As diferenças do Doppler espectral,na artrite psoriática e onicomicose

ObjectiveTo evaluate the use of the spectral Doppler (SDoppler) to quantify inflammatory activity and to detect nail echotextural differences in patients with psoriatic arthritis and onychomycosis.MethodsTwo patients, one with psoriatic arthritis but with no joint pain nor nail clinical change and the other with onychomycosis and rheumatoid arthritis were included. The gray scale ultrasound study, showed changes in the regular presence of echotexture at the nail insertion, thickening of the nail bed and loss of trilaminar nail pattern. The spectral Dopplerresistance index (RI), detects the inflammatory process in nail entheses.ResultsSeven distal interphalangeal (DIP) joints in both patients were evaluated in two planes, getting nine RI. In the patient with psoriatic arthritis the author found: loss of normal trilaminar nail plate aspect, and nail beds and DIP joint capsules preserved. The spectral Doppler showed RI < 1, with mean ± SD = 0.50 ± 0.75 in the microcirculation at nail entheses, with characterization of a bone erosion in the third left DIP joint, with RI = 0.38 and 0.63 in transverse and longitudinal planes, respectively. The patient with onychomycosis showed the following changes: hypoechogenicity at nail insertion; loss of nail shape, and spectral Doppler in nail entheses with RI > 1, with mean ± SD = 1.71 ± 0.98.ConclusionThe use of ultrasound can detect changes in the nail beds in these diseases. Future studies will further characterize these changes.     

Can we improve the diagnosis of spondyloarthritis in patients with uncertain diagnosis? The EchoSpA prospective multicenter French cohort

Power Doppler ultrasound (PDUS) has proved to be a highly sensitive tool for assessing enthesitis in spondyloarthritis (SpA). In patients with a suspected SpA, diagnosis could be improved by detecting enthesitis with PDUS.ObjectiveTo evaluate the performance of PDUS for the diagnosis of SpA alone or combined with other clinical, laboratory and imaging findings in patients consulting for a suspected SpA.MethodsProspective, multicenter French cohort study (Boulogne-Billancourt, Brest, Caen, Grenoble, Marseille and Nancy). Outpatients consulting for symptoms suggestive of SpA (inflammatory back pain [IBP], arthritis or inflammatory arthralgia [IA], enthesitis or dactylitis [ED], HLA-B27 positive uveitis [B27+U], familiarity for SpA [Fam]) were recruited and followed up for at least 2 years. Sample size was set to 500 patients (for estimated prevalence of SpA of 30 ± 5% after 2 years). At baseline, patients were submitted to standardized physical examination, pelvic X-ray, sacroiliac joints magnetic resonance imaging (MRI), HLA-B typing, and other tests judged useful for diagnosis. For each patient, a blinded PDUS examination of 14 enthesitic sites was performed at baseline and at years 1 and 2. Patients were planned to be followed during 5 years. The diagnosis of SpA ascertained by an experts’ committee, blind to PDUS results, after at least 2 years of follow-up, with a revaluation of doubtful patients at 5 years will be used as gold standard for evaluating the diagnostic performance of PDUS and the best diagnostic procedure by combining PDUS, clinical symptoms and other tests.ResultsBetween January 2005 and September 2007, 489 patients were included (96% of the target population). Nineteen patients (0.2%) retired their informed consensus or were lost to follow-up immediately after their inclusion. At baseline, mean age of the 470 remaining patients was 40 years, mean duration of symptoms was 6.1 years; 42% of them were HLA-B27+ and 63% were female. Primary inclusion criterion was IBP in 53%, IA in 27%, ED in 9%, B27+U in 8% and Fam in 4%. Follow-up is still ongoing.ConclusionWe have set up a unique diagnostic cohort which includes the entire spectrum of SpA manifestations. By using PDUS we expected to improve the diagnostic procedure of SpA.     

Is there a link between inflammation and abnormal lipoprotein profile in Sjögren's syndrome?

ObjectivesTo investigate the lipoprotein profile of patients with primary Sjögren's syndrome (pSS) and its association with laboratory tests, including markers of inflammation.MethodsThis is a cross-sectional study among patients with pSS and healthy controls. We analyzed the lipoprotein profile of 73 pSS patients compared to 65 healthy individuals in the control group. We further evaluated possible associations between dyslipidemia in pSS patients and laboratory parameters including: hypergammaglobulinemia, autoantibodies [antinuclear antibodies (ANA), rheumatoid factor (RF), anti-Ro, anti-La], and acute-phase reactants [C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)].ResultsPatients and controls were comparable regarding the demographic variables. Lipoprotein profile was similar between pSS patients and controls: total cholesterol (204.0 ± 43.39 versus 206.5 ± 42.76 mg/mL, P = 0.73), LDL fraction (131.6 ± 37.38 versus 130.62 ± 38.24 mg/dL, P = 0.88) and HDL fraction (49.7 ± 13.5 versus 51 ± 11.5 mg/dL, P = 0.56), triglycerides (129.3 ± 81.0 versus 116.8 ± 53.5 mg/dL, P = 0.29). However, patients with pSS had a strong trend to present dyslipidemia when compared to healthy individuals (76.7% versus 61.5%, P = 0.06). The presence of dyslipidemia in pSS was associated with increased ESR (44.05 ± 28.07 versus 28.28 ± 18.00, P = 0.03), but not with other laboratory markers of the disease and inflammation.Discussion/ConclusionpSS patients frequently present abnormal lipid profile, which are associated with higher levels of ESR. Thus, similar to other systemic inflammatory diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), lipid profile should be evaluated in pSS patients, with the aim of initiating specific therapeutic strategy for prevention of cardiovascular events.     

Avaliação de entesopatia em pacientes com fibromialgia por meio do novo índice ultrassonográfico de entesite

ObjectiveThe aim of the present study is to determine the frequency of enthesopathy in fibromyalgia (FM) by using a newly developed ultrasonography (US) method, the Madrid Sonography Enthesitis Index (MASEI).MethodsThis study was conducted on 38 consecutive patients with FM and 48 healthy sex- and age-matched controls. Six entheseal sites (olecranon tuberosity, superior and inferior poles of patella, tibial tuberosity, superior and inferior poles of calcaneus) on both lower limbs were evaluated. All US findings were identified according to MASEI. Scores of patients and controls were compared by Student's t-test and Mann-Whitney U-test. Validity was analysed by receiver operating characteristic curve. Values of P < 0.05 were considered significant.ResultsTotal enthesitis score was 7.39 ± 4.99 (mean ± SD) among FM patients and 3.7 ± 3.22 among healthy controls (P < 0.001). The receiver operating characteristic curve established an ultrasound score of > 3.5 in the FM group as the best cut-off point to differentiate between cases and controls. No statistically significant correlation was found between the MASEI score and the FM disease duration, and the location of the tender points.ConclusionsMisdiagnoses of FM are harmful to patients and the community, and the presence of enthesopathy among FM patients increases. Its detection with the MASEI score may help to discriminate FM patients presenting with ill-defined symptoms and signs, in order to prevent mistreatment.     

Minimally invasive distal first metatarsal osteotomy can be an option for recurrent hallux valgus

BackgroundRecurrence rate of surgical treatment of hallux valgus ranges in the literature from 2.7% to 16%, regardless of used procedure. In this study, long-term results of a minimally invasive distal osteotomy of the first metatarsal bone for treatment of recurrent hallux valgus are described.Methods32 consecutive percutaneous distal osteotomies of the first metatarsal were performed in 26 patients for treatment of recurrent hallux valgus. Primary surgery had been soft tissue procedures in 8 cases (25%), first metatarsal or phalangeal osteotomies in 19 cases (59.4%) and Keller procedures in 5 cases (15.6%).ResultsPatients were assessed with a mean follow-up of 9.8 ± 4.3 years. All patients reported the disappearance or reduction of the pain. The mean overall AOFAS score improved from 46.9 ± 17.8 points to 85.2 ± 14.9 at final follow-up. The mean hallux valgus angle decreased from 26.1 ± 9.1 to 9.7 ± 5.4°, the intermetatarsal angle decreased from 11.5 ± 4.5 to 6.7 ± 4.0°. No major complications were recorded with a re-recurrence rate of 3.1% (1 case).ConclusionsPercutaneous distal osteotomy of the first metatarsal can be a reliable and safe surgical option in the recurrent hallux valgus with low complication rate and the advantages of a minimally invasive surgery.Levels of evidence: IV, Retrospective Case Series.     

Ultrasonography of shoulders in spondyloarthritis and rheumatoid arthritis: A case-control study

IntroductionShoulders are often involved in spondyloarthritis (SpA) and rheumatoid arthritis (RA). The diagnosis of peripheral SpA and its differential diagnosis with RA could be challenging. A recent ultrasound study showed that ultrasonography (US) of the hands might differentiate psoriatic arthritis to RA. The aim of the study was to compare different US features in SpA, RA and healthy controls.MethodsA total of 38 SpA and 43 RA patients with clinical involvement of shoulders were included and compared to 33 controls. One blinded rheumatologist performed US examinations. The following items were assessed: gleno-humeral effusion, long-head biceps tendon tenosynovitis, subacromial and subdeltoid bursitis, acromio clavicular (AC) synovitis and humeral bone erosion.ResultsThirty-eight SpA (mean age: 49.9 ± 15.4 years, 58% of male), 43 RA patients (52.9 ± 16.6 years, 26% of male) and 33 controls (55.2 ± 16.9 years, 42% of male) were assessed. In comparison to RA, SpA patients had higher frequency of AC synovitis (66% vs 5%, P < 0.0001) but lower prevalence of subacromial and subdeltoid bursitis (39% vs 67%, P = 0.015), gleno-humeral effusion (5% vs 28%, P = 0.008) and humeral bone erosion (10% vs 56%, P < 0.0001). Unilateral abnormalities were found more frequently in SpA patients than in RA (64% vs 26%, P < 0.0001).ConclusionOur results suggest that AC synovitis is highly evocative of SpA in patients with inflammatory painful shoulders. Thus, US might help to diagnose SpA and to differentiate with RA.     

Ultrasound guided transversus abdominis plane block versus local wound infiltration in children undergoing appendectomy: A randomized controlled trial

BackgroundThe transversus abdominis plane block (TAP) has been described for pain management following abdominal surgery in adults, but there are only few reports on its use in pediatrics. The aim of this study was to evaluate the analgesic effect of ultrasound guided TAP block in patients scheduled for open appendectomy versus an active comparator (wound infiltration).MethodsForty-four children aged 4–16 years (ASA 1–2) were enrolled. Patients were randomized into two groups (22 in each). Patients in group (T) were assigned to receive ultrasound guided TAP block using 0.4 ml/kg of bupivacaine 0.25%, and those in group (L) were assigned to receive local infiltration by the surgeon. Maximum pain scores, the time to the first analgesic requirement and the number of analgesic requirements were recorded over 48 h.ResultsThe ultrasound guided TAP block increased the mean time to the first analgesic requirement (10.4 ± 1.5 h) in comparison with the local infiltration group (5.4 ± 1.5). The cumulative number of doses of analgesic was significantly lower in TAP group than in local infiltration group (3.7 ± 1.1 versus 5.3 ± 2.1) and the Pain Scale score was significantly lower in the TAP group over the study period. Besides, there were no complications attributable to the ultrasound guided TAP block.ConclusionUltrasound-guided TAP block with (0.4 ml/kg) 0.25% bupivacaine provides prolonged postoperative analgesia and reduced analgesic use without any clinical side-effects after appendectomy in children.     

Treatment of Trigger finger by ultrasound-guided needle release of a1 pulley: A series of 105 cases

IntroductionWe aimed to evaluate the efficacy and tolerance of A1 pulley release using the needle technique, under ultrasound guidance, in patients with symptomatic trigger finger.MethodsAll patients with symptomatic trigger finger underwent A1 pulley release using an intramuscular 21 gauge (G) needle. Quinnell grade (I-IV), Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score (0–100) and pain score on a visual analog scale (VAS: 0–10 mm) were recorded at inclusion. The primary endpoint was complete resolution of the trigger finger at 6 months.ResultsEighty-four patients totaling 105 treated digits were included. Mean age was 63.3 ± 10.7 years. Prior to treatment, mean VAS pain score was 5.8 ± 2.6 mm, and mean QuickDASH score was 44.3 ± 19.1. At 6 months, disappearance of symptoms was achieved in 85 of 91 digits with follow-up (93.4%), and in 85.7% at 12 months. The absolute reduction in VAS pain and QuickDASH scores at 6 months was respectively 4.1 ± 3.1 (P < 0.001) and 36.1 ± 20.7 (P < 0.001), and 90% of patients reported being satisfied or very satisfied at 6 months. Long duration of symptoms was significantly associated with persistent trigger finger at 6 months after intervention. Complications were rare and minor. Tenosynovitis occurred in 5.7% of cases, for which a corticosteroid injection into the tendon sheath rapidly led to favorable resolution.ConclusionTreatment of trigger finger by release of the A1 pulley under ultrasound guidance using the needle technique is a mildly invasive technique that yields rapid and effective symptom resolution with good tolerance up to 12 months.     

Synthetic MRI is not yet ready for morphologic and functional assessment of patellar cartilage at 1.5 Tesla

PurposeThe purpose of this study was to compare morphologic assessment and relaxometry of patellar hyaline cartilage between conventional sequences (fast spin-echo [FSE] T2-weighted fat-saturated and T2-mapping) and synthetic T2 short-TI inversion recovery (STIR) and T2 maps at 1.5 T magnetic resonance imaging (MRI).MethodThe MRI examinations of the knee obtained at 1.5 T in 49 consecutive patients were retrospectively studied. There were 21 men and 28 women with a mean age of 45 ± 17.7 (SD) years (range: 18–88 years). Conventional and synthetic acquisitions were performed, including T2-weighted fat-saturated and T2-mapping sequences. Two radiologists independently compared patellar cartilage T2-relaxation time on conventional T2-mapping and synthetic T2-mapping images. A third radiologist evaluated the patellar cartilage morphology on conventional and synthetic T2-weighted images. The presence of artifacts was also assessed. Interobserver agreement for quantitative variables was assessed using intraclass correlation coefficient (ICC).ResultsIn vitro, conventional and synthetic T2 maps yielded similar mean T2 values 58.5 ± 2.3 (SD) ms and 58.8 ± 2.6 (SD) ms, respectively (P = 0.414) and 6% lower than the expected experimental values (P = 0.038). Synthetic images allowed for a 15% reduction in examination time compared to conventional images. On conventional sequences, patellar chondropathy was identified in 35 patients (35/49; 71%) with a mean chondropathy grade of 4.8 ± 4.8 (SD). On synthetic images, 28 patients (28/49; 57%) were diagnosed with patellar chondropathy, with a significant 14% difference (P = 0.009) and lower chondropathy scores (3.7 ± 4.9 [SD]) compared to conventional images. Motion artifacts were more frequently observed on synthetic images (18%) than on conventional ones (6%). The interobserver agreement was excellent for both conventional and synthetic T2 maps (ICC > 0.83). Mean cartilage T2 values were significantly greater on synthetic images (36.2 ± 3.8 [SD] ms; range: 29-46 ms) relative to conventional T2 maps (31.8 ± 4.1 [SD] ms; range: 26-49 ms) (P < 0.0001).ConclusionDespite a decrease in examination duration, synthetic images convey lower diagnostic performance for chondropathy, greater prevalence of motion artifacts, and an overestimation of T2 values compared to conventional MRI sequences.     

Accuracy of medial-side cutting guide compared to anterior cutting guide in distal femoral osteotomy of total knee arthroplasty

IntroductionMinimally invasive surgery (MIS) in total knee arthroplasty has the benefits of less postoperative pain and a faster recovery time. An MIS instrument was designed to help surgeons perform this procedure under reduced visualization conditions. A medial cutting guide of the distal femur is used to cut the distal femoral bone without patella subluxation. This study aimed to compare the accuracy of the distal femoral bone cut between the medial and standard anterior cutting guides.Materials and methodsTwo orthopedic surgeons, who specialize in total knee arthroplasty and are familiar with both of these cutting guides, performed the procedures. Forty-eight synthetic saw bones were used, and five-degree valgus medial and anterior cutting guides were randomly assigned to the surgeons. After the osteotomies were performed, the synthetic saw bones were investigated via plain radiographs. Two independent radiologists measured the medial distal femoral angle (MDFA) and the posterior distal femoral angle (PDFA).ResultsThe MDFA in the medial cutting group was statistically significantly different from that of the anterior cutting group (94.18° ± 1.47° vs. 94.98° ± 1.14°, P = 0.041). However, the PDFA was not different between the two groups. Likewise, the number of outliers was not different between the groups when a ± 2° error was defined as an outlier (P = 0.609 for MDFA and P = 0.359 for PDFA). Moreover, a high degree of reliability was found in both MDFA and PDFA measurements (intraclass correlation coefficients = 0.813 and 0.824, respectively).ConclusionsIn this experimental study, the MIS medial cutting guide was less accurate than the standard cutting guide in the distal femoral cut.     

Efficacy of ultrasound-guided transversus abdominis plane blocks for post-cesarean delivery analgesia: a double-blind,dose-comparison,placebo-controlled randomized trial

BackgroundThe analgesic benefit of TAP (transversus abdominis plane) blocks for cesarean delivery pain remains controversial. We compared the analgesic efficacy of two doses of local anesthetic for TAP blocks after cesarean delivery.MethodsSixty women having cesarean delivery under spinal anesthesia were randomized to receive ultrasound-guided TAP blocks using either high-dose ropivacaine (3 mg/kg), low-dose ropivacaine (1.5 mg/kg) or placebo. Patients received intrathecal 0.75% bupivacaine 10–12 mg, fentanyl 10 μg and morphine 150 μg and standard multimodal analgesia. The primary outcome was the difference in pain with movement using a numeric rating scale at 24 h. Other outcomes included time to first request for analgesia, pain scores at 6, 12, 36, 48 h and at 6 and 12 weeks, opioid consumption, adverse effects, quality of recovery, and satisfaction.ResultsThere were no differences between groups in the primary outcome. Mean ± SD pain scores (0–10) with movement at 24 h were: high-dose ropivacaine 3.6 ± 1.5, low-dose ropivacaine 4.6 ± 2.1 and placebo 4.1 ± 1.7. With respect to secondary outcomes, the mean ± SD pain scores at 6 h were lower in the high-dose group 2.0 ± 1.8 compared to the low-dose 3.4 ± 2.7 and placebo groups 4.2 ± 2.0 (P = 0.009). Pain scores at 12 h were also lower in the high-dose group 2.2 ± 2.0 compared to the low-dose group 4.1 ± 2.7 and placebo group 4.0 ± 1.3 (P = 0.011). There was no difference in other outcomes between groups.ConclusionsNeither high- or low-dose TAP blocks as part of a multimodal analgesia regimen including intrathecal morphine improved pain scores with movement at 24 h after cesarean delivery when compared to placebo TAP blocks. High-dose TAP blocks may improve pain scores up to 12 h after cesarean delivery.     

Assessment of calcific tendonitis of rotator cuff by ultrasonography: Comparison between symptomatic and asymptomatic shoulders

ObjectiveCalcific tendonitis of rotator cuff is observed on plain radiographs in 10% of adults, but remains asymptomatic in half these cases. We looked for differences on ultrasound (US) and power Doppler findings between symptomatic and asymptomatic cases of shoulder calcific tendonitis.MethodsUS was performed in 62 patients (81 shoulders) with symptomatic (n = 57) or asymptomatic (n = 24) calcific tendonitis. Calcific plaque morphology, power Doppler signaling, and widening of the subacromial-subdeltoid bursa (SSB) were recorded. US-guided steroid injection into the SSB (n = 21) or needle puncture of calcific deposits (n = 29) was performed at the end of US evaluation in 50 of the 57 patients, and a questionnaire was sent to each patient after 11 ± 6 months.ResultsLarger (p = 0.0015) and fragmented (p = 0.01) calcifications were associated with pain. A power Doppler signal and a widening of the SSB was identified in 21 and 17 of the 57 symptomatic calcification respectively, but in none of the cases of asymptomatic calcification (p < 0,005). At least one of these signs was present in 31 of the 57 (54%) symptomatic shoulders (p < 0.001). Long-term outcome was favourable for 60% of our patients after steroid injection. The presence of a SSB widening before bursal steroid injection was associated with an improvement of the symptoms (p = 0.06).ConclusionPositive power Doppler signal within the calcific deposit and SSB widening are US features strongly associated with pain. Moreover, larger calcifications are also more symptomatic. According to these results, US can help physicians to confirm that calcification is responsible for shoulder pain.     

Ultrasound to identify the lumbar space in women with impalpable bony landmarks presenting for elective caesarean delivery under spinal anaesthesia: a randomised trial

BackgroundUltrasound can facilitate neuraxial blockade in patients with poorly defined anatomical surface landmarks, but there are no studies comparing an ultrasound-guided technique with landmark palpation for spinal anaesthesia. The objective of this study was to compare pre-procedural lumbar ultrasonography with landmark palpation to locate the needle insertion point in women with impalpable lumbar spinous processes presenting for caesarean delivery.MethodsAfter institutional ethics committee approval, 20 women with impalpable lumbar spinous processes presenting for elective caesarean delivery were recruited. Patients were randomised to palpation or ultrasound. The primary outcome of the study was the number of needle passes to achieve lumbar puncture. Secondary outcomes were the overall procedural time and patient satisfaction score.ResultsThere was no difference in mean (±SD) body mass index of both groups (ultrasound 39.1 ± 5.02 kg/m² vs. palpation 38.3 ± 3.77 kg/m²). There were significantly fewer needle passes in the ultrasound group (median 3 [IQR 1.8–3.2]) compared to the palpation group (median 5.5 [IQR 3.2–7.2] (P=0.03)). More time was required to locate the needle insertion point in the ultrasound group (ultrasound 91.8 ± 30.8 s vs. palpation 32.6 ± 11.4 s, P <0.001). There was no difference in the total procedural time between groups (ultrasound 191.8 ± 49.4 s vs. palpation 192 ± 110.9 s, P=0.99).ConclusionThe use of ultrasonography to locate the needle insertion point reduced the number of needle passes in women with impalpable lumbar spinous processes undergoing elective caesarean delivery under spinal anaesthesia. Its use did not prolong overall procedural time.     

The contribution of periapical nerve block in transrectal ultrasound-guided prostate biopsy: Results from a prospective randomized trial

ObjectivePeriprostatic nerve block has been shown to be the most effective method to reduce pain during transrectal ultrasound (TRUS) guided prostate biopsy, but the ideal technique remains controversial. The aim of this study was to compare pain control between bilateral basal block (BBB) alone and BBB combined with periapical nerve block (PNB).Patients and methodsFrom November 2007 to May 2009, 182 consecutive patients with abnormally elevated serum prostate-specific antigen (PSA) or suspicious digital rectal examination (DRE) underwent TRUS-guided needle biopsy of the prostate. The patients were prospectively randomized after informed consent had been obtained. Group 1 (n = 90) underwent bilateral basal block (BBB) with periprostatic infiltration of 8 ml 1% lidocaine into the neurovascular bundle at the prostate-seminal vesicle junction on each side. Group 2 (n = 92) underwent BBB with the addition of periapical nerve block (PNB) using 2 ml 1% lidocaine per side. A visual analog scale (VAS) was used to evaluate the patient's perception of pain during the biopsy.ResultsThe mean patient age was 64.6 ± 8.2 years and the average VAS was 1.9 ± 2.0. The mean VAS was lower in Group 2 compared with Group 1, 1.6 ± 1.9 versus 2.2 ± 2.0 (p = 0.026). In the subgroup aged 56–65 years the mean VAS was 1.26 ± 0.6 in Group 1 versus 2.46 ± 0.5 in Group 2 (p = 0.001), and in the subgroup aged 66–87 years it was 1.41 ± 0.5 in Group 1 versus 1.66 ± 0.75 in Group 2 (p = 0.554).ConclusionsBBB combined with PNB seems to be more effective to BBB alone to reduce pain during TRUS-guided prostate biopsy and may be of maximum benefit for younger patients.     

Nerve and tendon injury with percutaneous fibular pinning: A cadaveric study

ObjectiveThe purposes of this study were to measure the average distance from a percutaneous pin in each quadrant of the distal fibula to the sural nerve and nearest peroneal tendon, and define the safe zone for percutaneous pin placement as would be used during surgery.MethodTen fresh-frozen cadavers underwent percutaneous pin fixation into four quadrants of the distal fibula. The sural nerve and peroneal tendon were identified as they coursed around the lateral ankle. Distances from the K-wire in each quadrant to the anatomic structure of interest were measured.ResultsAverage distances (mm) from the K-wire to the sural nerve in the anterolateral, anteromedial, posterolateral, and posteromedial quadrants were 19.1 ± 8.9 (range, 5.1–35.5), 12.8 ± 8.2 (range, 0.3–27.8), 12.6 ± 6.8 (range, 3.0–27.8), and 5.9 ± 5.5 (range, 0.1–19.9), respectively. Average distances from the K-wire to the nearest peroneal tendon in the anterolateral, anteromedial, posterolateral, and posteromedial quadrants were 15.7 ± 4.4 (range, 9.5–23.1), 11.9 ± 5.2 (range, 3.2–21.7), 6.3 ± 3.9 (range, 0.1–14.4), and 1.0 ± 1.6 (range, 0–5.6), respectively.ConclusionsPercutaneous pinning of distal fibula fractures is a successful treatment option with minimal complications. Our anatomical study found the safe zone of percutaneous pin placement to be in the anterolateral quadrant. The sural nerve can be as close as 5.1 mm and the peroneal tendons as near as 15.7 mm. In contrast, the posteromedial quadrant was associated with the greatest risk of injury to both the sural nerve and peroneal tendons.     

Eficácia do bloqueio do plano do músculo eretor da espinha guiado por ultrassom para analgesia após colecistectomia laparoscópica: um estudo controlado randômico

Background and objectivesThe primary aim of this study is to assess the effect of ultrasoung‐guided erector spinae block on postoperative opioid consumption after laparoscopic cholecystectomy. The secondary aims are to assess the effects of erector spinae plane block on intraoperative fentanyl need and postoperative pain scores.MethodsPatients between 18‐70 years old, ASA I‐II were included in the study and randomly allocated into two groups. In Group ESP, patients received bilateral US‐ESP with 40 ml of 0.25% bupivacaine at the level of T7, while in Group Control, they received bilateral US‐ESP with 40 ml of saline before the induction of anesthesia. Then a standard general anesthesia procedure was conducted in both groups. NRS scores at the postoperative 15th, 30th, 60th minutes, 12th and 24th hours, intraoperative fentanyl need and total postoperative tramadol consumption were recorded.ResultsThere were 21 patients in Group ESP and 20 patients in Group Control. Mean postoperative tramadol consumption was 100 ± 19.2 mg in Group ESP, while it was 143 ± 18.6 mg in Group Control (p < 0.001). The mean intraoperative fentanyl need was significantly lower in Group ESP (p = 0.022). NRS scores at the postoperative 15th, 30th min, 12th hour and 24th hour were significantly lower in ESP group (p < 0.05). According to repeated measures analysis, NRS score variation over time was significantly varied between two groups (F[1,39] = 24.061, p < 0.0005).ConclusionsBilateral US‐ESP block provided significant reduction in postoperative opioid consumption, intraoperative fentanyl need and postoperative pain scores of patients undergoing laparoscopic cholecystectomy.     

Associations between ocular and extra-ocular assessment in primary Sjögren's syndrome*

ObjectivesTo assess associations between ophthalmological features and the main systemic biomarkers of primary Sjögren's Syndrome (pSS), and to identify systemic biomarkers associated with severe keratoconjunctivitis sicca (KCS) in pSS patients.MethodsIn this cross-sectional study, data was retrospectively extracted from the monocentric cohort of the French reference centre for pSS. We analysed data from the initial visit of patients admitted for suspicion of pSS and included patients validating pSS ACR/EULAR classification criteria. Ophthalmological assessment included Schirmer's test, tear break-up time, ocular staining score (OSS), and visual analogue scale (DED-VAS) for dry eye disease (DED) symptoms. Results of minor salivary gland biopsy, unstimulated whole salivary flow rate, anti-SSA/Ro antibodies, anti-SSB/La antibodies, and rheumatoid factor (RF) were collected.ResultsA total of 253 patients (245 females) with confirmed pSS, aged 56.6 ± 13.0 years, were included, among which 37% had severe KCS. Multivariate analysis showed that the presence of anti-SSA/Ro antibodies, anti-SSB/La antibodies and RF were associated with conjunctival OSS (odds ratio–OR– = 1.25 per OSS unit increase; confidence interval–CI–95% = 1.05–1.49; P = 0.01; OR = 1.31 per OSS unit increase; CI95% = 1.09–1.58, P = 0.002, and OR = 1.34 per OSS unit increase; CI95% = 1.12–1.59; P = 0.001, respectively). Both anti-SSB/La antibodies and DED-VAS ≥ 5 were significantly associated with severe KCS (OR = 2.03; CI95% = 1.03–4.00; P < 0.05 and OR = 2.52, CI95% = 1.31–4.90; P < 0.01, respectively).ConclusionAssociation between conjunctival OSS and systemic biomarkers of pSS indicate the crucial importance of conjunctival staining when pSS is suspected as a cause of DED. Conversely, patients with anti-SSB and DED-VAS ≥ 5 features should be prioritized for extensive evaluation by an ophthalmologist due to their association with severe KCS.     

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

IntroductionThe number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.AimTo investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.Patients and methodsIn this randomised controlled trial involving patients aged ≥70 years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.ResultsThe study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9) years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12 h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12 h compared with controls (p < 0.001 and p = 0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3 ± 4.0 vs. 5.7 ± 5.2 mg, p < 0.001) and in the subgroup with dementia (2.1 ± 3.3 vs. 5.8 ± 5.0 mg, p < 0.001).ConclusionPatients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.     

Biomechanical comparison of conventional versus modified technique in distal chevron osteotomies of the first metatarsal: A cadaver study

BackgroundDistal chevron osteotomy can be performed using a conventional or a modified technique. The aim of this biomechanical study was to compare the stability of the two techniques.MethodsEighteen first metatarsals from nine pairs of fresh frozen human cadaver feet were used. A distal chevron osteotomy was performed using the conventional technique in group 1 (n = 9) and using the modified technique in group 2 (n = 9). The head of the first metatarsals was loaded in two different configurations (cantilever and physiological), using a materials testing machine.ResultsIn the cantilever configuration, the relative stiffness of the osteosynthesis in comparison with intact bone was 60% (±21%) in group 1 and 65% (±25%) in group 2 (p = 0.61). In the physiological configuration, it was 47% (±29%) in group 1 and 47% (±21%) in group 2 (p = 0.98). The failure strength in the cantilever configuration was 235 N (±128 N) in group 1 and 210 N (±107 N) in group 2 (p = 0.47).ConclusionsThe conventional and the modified technique for distal chevron osteotomy in the treatment of hallux valgus show a comparable biomechanical loading capacity in this cadaver study.     

Bloqueo axilar ecoguiado: variaciones anatómicas de la disposición de los 4 nervios terminales del plexo braquial en relación con la arteria humeral

ObjectivesTo describe the distribution of the terminal branches of the brachial plexus at the axillary level and define distribution patterns after ultrasound evaluation.Material and methodFifty volunteers underwent ultrasound bilateral axillary brachial plexus scanning exploration. Nerve distribution around the humeral artery was described and the distance between each nerve and the center of the artery was measured. The distance and relationship between the ulnar nerve and the humeral vein were also recorded.ResultsThe median nerve was located in the anterolateral quadrant (−29 ± 40°) and at a mean distance of 2.1 ± 0.9 mm from the artery (85%). The ulnar nerve was found at 53 ± 26° and at 4.2 ± 2.1 mm from the artery in the anteromedial quadrant (90%), anterolateral to the vein in 46% of cases, and deep to it in 54%. The radial nerve was at 122 ± 38° and at 3.3 ± 1.7 mm from the artery in the posteromedial quadrant (86%). The musculocutaneous nerve was found at −103 ± 22° and 9.3 ± 5.6 mm from the artery in the posterolateral quadrant (90%) and in the anterolateral quadrant (−55 ± 16°) at 4.8 ± 2.7 mm (10%). There were no differences regarding laterality, gender or overweight patients.ConclusionsOur results allow defining four different anatomical patterns, two based in the position of the musculocutaneous nerve and two based on the disposition of the ulnar nerve with respect to the humeral vein. These patterns were not related to laterality, gender or body weight.