Use of a perineural coiled catheter at the sciatic nerve in dogs after tibial plateau levelling osteotomy – preliminary observations

The analgesic effects of peripheral nerve blocks can be prolonged with the placement of perineural catheters allowing repeated injections of local anaesthetics in humans. The objectives of this study were to evaluate the clinical suitability of a perineural coiled catheter (PCC) at the sciatic nerve and to evaluate pain during the early post-operative period in dogs after tibial plateau levelling osteotomy. Pre-operatively, a combined block of the sciatic and the femoral nerves was performed under sonographic guidance (ropivacaine 0.5%; 0.3 mL kg−1 per nerve). Thereafter, a PCC was placed near the sciatic nerve. Carprofen (4 mg kg−1 intravenously) was administered at the end of anaesthesia. After surgery, all dogs were randomly assigned to receive four injections of ropivacaine (group R; 0.25%, 0.3 mL kg−1) or NaCl 0.9% (group C; 0.3 mL kg−1) every 6 h through the PCC. Pain was assessed by use of a visual analogue scale (VAS) and a multi-dimensional pain score (4Avet) before surgery (T-1), for 390 min (T0, T30, T60, T120, T180, T240, T300, T360 and T390) as well as 1 day after surgery (Day 1). Methadone (0.1 mg kg−1) was administered each time the VAS was ≥40 mm or the 4Avet was ≥5. At T390 dogs received buprenorphine (0.02 mg kg−1). Data were compared using Mann–Whitney rank sum tests and repeated measures analysis of variance. Regardless of group allocation, 55% of dogs required methadone. VAS was significantly lower at T390 (P = 0.003), and at Day 1 (P = 0.002) and so was 4Avet at Day 1 (P = 0.012) in group R than in group C. Bleeding occurred in one dog at PCC placement and PCC dislodged six times of 47 PCCs placed. Minor complications occurred with PCC but allowed four repeated administrations of ropivacaine or saline over 24 h in 91.5% of the cases.

Eighty percent of patients with surgical hip dislocation for femoroacetabular impingement have a good clinical result without osteoarthritis progression at 10 years

BACKGROUND We previously reported the 5-year followup of hips with femoroacetabular impingement (FAI) that underwent surgical hip dislocation with trimming of the head-neck junction and/or acetabulum including reattachment of the labrum. The goal of this study was to report a concise followup of these patients at a minimum 10 years. QUESTIONS/PURPOSES We asked if these patients had (1) improved hip pain and function; we then determined (2) the 10-year survival rate and (3) calculated factors predicting failure. METHODS Between July 2001 and March 2003, we performed surgical hip dislocation and femoral neck osteoplasty and/or acetabular rim trimming with labral reattachment in 75 patients (97 hips). Of those, 72 patients (93 hips [96%]) were available for followup at a minimum of 10 years (mean, 11 years; range, 10-13 years). We used the anterior impingement test to assess pain and the Merle d'Aubigné-Postel score to assess function. Survivorship calculation was performed using the method of Kaplan and Meier and any of the following factors as a definition of failure: conversion to total hip arthroplasty (THA), radiographic evidence of worsening osteoarthritis (OA), or a Merle d'Aubigné-Postel score less than 15. Predictive factors for any of these failures were calculated using the Cox regression analysis. RESULTS At 10-year followup, the prevalence of a positive impingement test decreased from preoperative 95% to 38% (p < 0.001) and the Merle d'Aubigné-Postel score increased from preoperative 15.3 ± 1.4 (range, 9-17) to 16.9 ± 1.3 (12-18; p < 0.001). Survivorship of these procedures for any of the defined failures was 80% (95% confidence interval, 72%-88%). The strongest predictors of failure were age > 40 years (hazard ratio with 95% confidence interval, 5.9 [4.8-7.1], p = 0.002), body mass index > 30 kg/m(2) (5.5 [3.9-7.2], p = 0.041), a lateral center-edge angle < 22° or > 32° (5.4 [4.2-6.6], p = 0.006), and a posterior acetabular coverage < 34% (4.8 [3.7-5.6], p = 0.006). CONCLUSIONS At 10-year followup, 80% of patients with FAI treated with surgical hip dislocation, osteoplasty, and labral reattachment had not progressed to THA, developed worsening OA, or had a Merle d'Aubigné-Postel score of less than 15. Radiographic predictors for failure were related to over- and undertreatment of acetabular rim trimming.

Nondermatomal somatosensory deficits in chronic pain are associated with cerebral grey matter changes

OBJECTIVES Widespread sensory deficits occur in 20-40% of chronic pain patients on the side of pain, independent of pain aetiology, and are known as nondermatomal sensory deficits (NDSDs). NDSDs can occur in absence of central or peripheral nervous system lesions. We hypothesised that NDSDs were associated with cerebral grey matter changes in the sensory system and in pain processing regions, detectable with voxel-based morphometry. METHODS Twenty-five patients with NDSDs, 23 patients without NDSDs ("pain-only"), and 29 healthy controls were studied with high resolution structural MRI of the brain. A comprehensive clinical and psychiatric evaluation based on Diagnostic and Statistical Manual was performed in all patients. RESULTS Patients with NDSDs and "pain-only" did not differ concerning demographic data and psychiatric diagnoses, although anxiety scores (HADS-A) were higher in patients with NDSDs. In patients with NDSDs, grey matter increases were found in the right primary sensory cortex, thalamus, and bilaterally in lateral temporal regions and the hippocampus/fusiform gyrus. "Pain-only" patients showed a bilateral grey matter increase in the posterior insula and less pronounced changes in sensorimotor cortex. CONCLUSIONS Dysfunctional sensory processing in patients with NDSDs is associated with complex changes in grey matter volume, involving the somatosensory system and temporal regions.

CT-guided infiltration saves surgical intervention and fastens return to work compared to anatomical landmark-guided infiltration in patients with lumbosciatica

BACKGROUND Infiltration procedures are a common treatment of lumbar radiculopathy. There is a wide variety of infiltration techniques without an established gold standard. Therefore, we compared the effectiveness of CT-guided transforaminal infiltrations versus anatomical landmark-guided transforaminal infiltrations at the lower lumbar spine in case of acute sciatica at L3-L5. METHODS A retrospective chart review was conducted of 107 outpatients treated between 2009 and 2011. All patients were diagnosed with lumbar radiculopathic pain secondary to disc herniation in L3-L5. A total of 52 patients received CT-guided transforaminal infiltrations; 55 patients received non-imaging-guided nerve root infiltrations. The therapeutic success was evaluated regarding number of physician contacts, duration of treatment, type of analgesics used and loss of work days. Defined endpoint was surgery at the lower lumbar spine. RESULTS In the CT group, patients needed significantly less oral analgesics (p < 0.001). Overall treatment duration and physician contacts were significantly lower in the CT group (p < 0.001 and 0.002) either. In the CT group, patients lost significant fewer work days due to incapacity (p < 0.001). Surgery had to be performed in 18.2 % of the non-imaging group patients (CT group: 1.9 %; p = 0.008). CONCLUSION This study shows that CT-guided periradicular infiltration in lumbosciatica caused by intervertebral disc herniation is significantly superior to non-imaging, anatomical landmark-guided infiltration, regarding the parameters investigated. The high number of treatment failures in the non-imaging group underlines the inferiority of this treatment concept.

Protrusio acetabuli: joint loading with severe pincer impingement and its theoretical implications for surgical therapy

Severe pincer impingement (acetabular protrusio) is an established cause of hip pain and osteoarthritis. The proposed underlying pathomechanism is a dynamic pathological contact of the prominent acetabular rim with the femoral head-neck junction. However, this cannot explain the classically described medial osteoarthritis in these hips. We therefore asked: (1) Does an overload exist in the medial aspect of the protrusio joint? and (2) What is the influence of three contemporary joint-preserving procedures on load distribution in protrusio hips? In vivo force and motion data for walking and standing to sitting were applied to six 3D finite element models (normal, dysplasia, protrusio, acetabular rim trimming, acetabular reorientation, and combined reorientation/rim trimming). Compared with dysplasia, the protrusio joint resulted in opposite patterns of von Mises stress and contact pressure during walking. In protrusio hips, we found an overload at the medial margin of the lunate surface (54% higher than normal). Isolated rim trimming further increased the medial overload (up to 28% higher than protrusio), whereas acetabular reorientation with/without rim trimming reduced stresses by up to 25%. Our results can be used as an adjunct for surgical decision making in the treatment of acetabular protrusio.

Surgical Technique: Reverse Periacetabular Osteotomy

Acetabular retroversion is the result of an externally rotated hemipelvis rather than a focal overgrowth of the anterior wall and/or hypoplasia of the posterior wall. Acetabular retroversion is a cause of pincer impingement which, if left untreated, can lead to hip pain and osteoarthritis. The causal surgical treatment in hips with acetabular retroversion is acetabular reorientation with a reverse periacetabular osteotomy (PAO). Indication is based on a positive correlation among symptoms (typically groin pain), physical findings on examination (positive anterior impingement test and decreased flexion and internal rotation), and radiographic signs for acetabular retroversion. These include a positive crossover, posterior wall, and ischial spine sign. A reverse PAO is performed with four osteotomies and a controlled fracture. Unlike reorientation of the acetabular fragment in dysplastic hips, correction for acetabular retroversion is achieved by a combined extension and internal rotation of the acetabular fragment. Typically, a small supra-acetabular wedge resection is required to allow sufficient extension of the fragment. The quality of acetabular reorientation is evaluated by intraoperative AP pelvic radiographs. In addition, intraoperative testing of range of motion following acetabular reorientation is mandatory. An arthrotomy and offset correction of the femoral head-neck area is indicated in hips with decreased internal rotation following acetabular reorientation. In a 10-year follow-up study of reverse PAO, a favorable outcome with preservation of all native joints was found. Correct acetabular orientation and, if necessary, a concomitant offset correction were the keys of successful outcome.

EACTS expert consensus statement for surgical management of pleural empyema

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preference.

How often parametrial involvement leads to post-operative adjuvant treatment in locally advanced cervical cancer after neoadjuvant chemotherapy and type C radical hysterectomy?

OBJECTIVE Parametrial involvement (PMI) is one of the most important factors influencing prognosis in locally advanced stage cervical cancer (LACC) patients. We aimed to evaluate PMI rate among LACC patients undergoing neoadjuvant chemotherapy (NACT), thus evaluating the utility of parametrectomy in tailor adjuvant treatments. METHODS Retrospective evaluation of consecutive 275 patients affected by LACC (IB2-IIB), undergoing NACT followed by type C/class III radical hysterectomy. Basic descriptive statistics, univariate and multivariate analyses were applied in order to identify factors predicting PMI. Survival outcomes were assessed using Kaplan-Meier and Cox models. RESULTS PMI was detected in 37 (13%) patients: it was associated with vaginal involvement, lymph node positivity and both in 10 (4%), 5 (2%) and 12 (4%) patients, respectively; while PMI alone was observed in only 10 (4%) patients. Among this latter group, adjuvant treatment was delivered in 3 (1%) patients on the basis of pure PMI; while the remaining patients had other characteristics driving adjuvant treatment. Considering factors predicting PMI we observed that only suboptimal pathological responses (OR: 1.11; 95% CI: 1.01, 1.22) and vaginal involvement (OR: 1.29 (95%) CI: 1.17, 1.44) were independently associated with PMI. PMI did not correlate with survival (HR: 2.0; 95% CI: 0.82, 4.89); while clinical response to NACT (HR: 3.35; 95% CI: 1.59, 7.04), vaginal involvement (HR: 2.38; 95% CI: 1.12, 5.02) and lymph nodes positivity (HR: 3.47; 95% CI: 1.62, 7.41), independently correlated with worse survival outcomes. CONCLUSIONS Our data suggest that PMI had a limited role on the choice to administer adjuvant treatment, thus supporting the potential embrace of less radical surgery in LACC patients undergoing NACT. Further prospective studies are warranted.

Surgical adjunctive procedures for accelerating orthodontic treatment

BACKGROUND A range of surgical and non-surgical techniques have received increasing attention in recent years in an effort to reduce the duration of a course of orthodontic treatment. Various surgical techniques have been used; however, uncertainty exists in relation to the effectiveness of these procedures and the possible adverse effects related to them. OBJECTIVES To assess the effects of surgically assisted orthodontics on the duration and outcome of orthodontic treatment. SEARCH METHODS We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 10 September 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 8), MEDLINE via OVID (1946 to 10 September 2014), EMBASE via OVID (1980 to 10 September 2014), LILACS via BIREME (1980 to 10 September 2014), metaRegister of Controlled Trials (to 10 September 2014), ClinicalTrials.gov (to 10 September 2014), and the World Health Organization (WHO) International Clinical Trials Registry Platform (to 10 September 2014). We checked the reference lists of all trials identified for further studies. There were no restrictions regarding language or date of publication in the electronic searches. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating the effect of surgical adjunctive procedures for accelerating tooth movement compared with conventional treatment (no surgical adjunctive procedure). DATA COLLECTION AND ANALYSIS At least two review authors independently assessed the risk of bias in the trials and extracted data. We used the fixed-effect model and expressed results as mean differences (MD) with 95% confidence intervals (CI). We investigated heterogeneity with reference to both clinical and methodological factors. MAIN RESULTS We included four RCTs involving a total of 57 participants ranging in age from 11 to 33 years. The interventions evaluated were corticotomies to facilitate orthodontic space closure or alignment of an ectopic maxillary canine, with the effect of repeated surgical procedures assessed in one of these studies. The studies did not report directly on the primary outcome as prespecified in our protocol: duration of orthodontic treatment, number of visits during active treatment (scheduled and unscheduled) and duration of visits. The main outcome assessed within the trials was the rate of tooth movement, with periodontal effects assessed in one trial and pain assessed in one trial. A maximum of just three trials with small sample sizes were available for each comparison and outcome. We assessed all of the studies as being at unclear risk of bias.Tooth movement was found to be slightly quicker with surgically assisted orthodontics in comparison with conventional treatment over periods of one month (MD 0.61 mm; 95% CI 0.49 to 0.72; P value < 0.001) and three months (MD 2.03 mm, 95% CI 1.52 to 2.54; P value < 0.001). Our results and conclusions should be interpreted with caution given the small number of included studies. Information on adverse events was sought; however, no data were reported in the included studies. AUTHORS' CONCLUSIONS This review found that there is limited research concerning the effectiveness of surgical interventions to accelerate orthodontic treatment, with no studies directly assessing our prespecified primary outcome. The available evidence is of low quality, which indicates that further research is likely to change the estimate of the effect. Based on measured outcomes in the short-term, these procedures do appear to show promise as a means of accelerating tooth movement. It is therefore possible that these procedures may prove useful; however, further prospective research comprising assessment of the entirety of treatment with longer follow-up is required to confirm any possible benefit.

Superior outcomes of decompression with an interlaminar dynamic device versus decompression alone in patients with lumbar spinal stenosis and back pain: a cross registry study.

INTRODUCTION Surgical decompression for lumbar spinal stenosis (LSS) has been associated with poorer outcomes in patients with pronounced low back pain (LBP) as compared to patients with predominant leg pain. This cross registry study assessed potential benefits of the interlaminar coflex® device as an add-on to bony decompression alone. METHODS Patients with lumbar decompression plus coflex® (SWISSspine registry) were compared with decompressed controls (Spine Tango registry). Inclusion criteria were LSS and a preoperative back pain level of ≥5 points. 1:1 propensity score-based matching was performed. Outcome measures were back and leg pain relief, COMI score improvement, patient satisfaction, complication, and revision rates. RESULTS 50 matched pairs without residual significant differences but age were created. At the 7-9 months follow-up interval the coflex® group had higher back (p=0.014) and leg pain relief (p<0.001) and COMI score improvement (p=0.029) than the decompression group. Patient satisfaction was 90% in both groups. No revision was documented in the coflex® and one in the decompression group (2.0%). DISCUSSION In the short-term, lumbar decompression with coflex® compared with decompression alone in patients with LSS and pronounced LBP at baseline is a safe and effective treatment option that appears beneficial regarding clinical and functional outcomes. However, residual confounding of non-measured covariables may have partially influenced our findings. Also, despite careful inclusion and exclusion of cases the cross registry approach introduces a potential for selection bias that we could not totally control for and that makes additional studies necessary.