PurposeThe study aimed to examine associations between the 36-item short form health survey (SF-36) in clinical and neurophysiological measures to identify its predictors in patients with knee osteoarthritis (KOA) in a rehabilitation program.MethodsWe analyzed data from our cohort study (DEFINE cohort). We analyzed data from our KOA arm, with 107 patients, including clinical assessments, demographic data, pain scales, motor function (Timed Up and Go Test (TUG), 10 meters walk test, and 6-minute walk), balance (BBS), sleepiness (ESS), and Transcranial Magnetic Stimulation (TMS) and Electroencephalography (EEG).ResultsOur results showed 83.19% of patients were female with an average age of 68.6 years and an average number of days of pain was 96 days; around 31.86% were using more than five medications per day. Regarding the multimodal model to explain SF-36, the main variables relevant to the quality of life (QoL) were related to emotional aspects, such as anxiety and depression. Moreover, our study added findings with polymorphism (OPRM1/rs1799971) predicting mental aspects. Cognitive variables were important in predicting the mental health, emotional, and social support dimensions of the SF-36. In the physical domain, pain-related variables predominantly predicted QoL in these relationships. The domain of vitality significantly predicted all dimensions studied, except for mental and general health.ConclusionThe results help in understanding the aspects that contribute to QoL and are discussed considering the general literature on physical rehabilitation and specific to this clinical group. Furthermore, the statistical methods allowed us to explore and effectively understand the dimensions related to QoL. Osteoarthritis is a cartilage disease caused by multifactorial aspects with little understanding of the molecular mechanisms of initiation and progression . MoreoveKnee osteoarthritis (KOA) clinical symptoms vary among individuals but typically become severe, frequent, and more debilitating over time. Although medications help to slow the progression, there are no proven agents for the treatment , and it Although in 2001, a science conference, organized and sponsored by the Kessler Medical Rehabilitation Research and Education Corporation, in conjunction with federal and private, set QoL as a measure of rehabilitation, it is important to better understand the benefits of rehabilitation . MoreoveAs QoL cannot be directly measured, but under one aspect, the health-related quality of life (HRQOL) as a subset, it usually is converted into components that can be quantified . Thus, tFor easy interpretation, a higher score indicates better health status . SimilarThe physical functioning dimension questions aimed to measure the impact of physical limitations of everyday life on HRQOL. The questions focused on aspects, such as reduction of the amount of work or other activities, limitations of activities performed, and reduced accomplishments resulting from physical limitations. Those on emotional role limitations were about the reduction of work or daily activities due to emotional problems. In vitality, dominions have questions about energy and fatigue levels.The mental health dominion questions were about happiness, cheer, peace, and negative affect for the last two weeks. Social aspects capture social activities regarding quantity and quality activities and the impact of physical and emotional problems on them. Regarding mental health, the questions include concepts of anxiety, depression, loss of behavioral or emotional control, and psychological well-being, which inspire us to be careful about potential risk to overlapping mainly to analyze mental health impact  in our rIn Brazil, the SF-36 was standardized by Laguardia et al. , and it Hence, it is important to know the aspects that most influence the domains that are related to QoL to be more assertive during rehabilitation and related aspects to promote a positive impact on QoL. Therefore, the purpose of this study is to identify predictors of SF-36 in KOA patients in a rehabilitation program.The data are obtained from a cohort study whose protocol was previously published by Simis et al. . We focuSampling methods and participants The sample size of 107 patients was determined by the fact that the main design of the study was observational. Participants were recruited from the rehabilitation program at the Lucy Montoro Rehabilitation Institute (LMRI), which is in the city of São Paulo, as part of the Institute of Physical Medicine and Rehabilitation (IPMR) of the Clinics Hospital of the University of São Paulo Medical School. We included patients aged over 50 years with clinical and radiological diagnosis (Kellgren and Lawrence) of primary osteoarthritis of the knee and gonalgia for three months or more. Those with the following characteristics were excluded: i) pregnancy; ii) active osteoarthritis with clinical manifestations other than the knee; and iii) occurrence of other clinical and/or social conditions that hinder the subject's participation in the rehabilitation treatment. All participants were included from December 2018 to January 2020, and a total of 113 participants completed the study. Notably, all participants were evaluated before the global pandemic crisis, so the results found do not represent the scenarios during COVID-19.Screening and assessment of severityThe patients went through clinical assessment and screening. All screenings were conducted by physicians trained to diagnose KOA, and they performed radiological bilateral knees. The visual analog scale (VAS), timed up and go (TUG), Berg Balance Scale (BBS), Western Ontario and McMasters University Osteoarthritis Index (WOMAC), Epworth sleepiness scale (ESS), and 10 meters walk test along with sociodemographic data collection and use of medications were performed by a physical therapist from the research center with previous experience. The Pain Catastrophizing Scale, McGill scale, Hamilton, hospital anxiety and depression (HAD) scale, and Montreal cognitive assessment (MoCA) were used by psychologists. To assess the severity of KOA, Kellegren-Lawrence was used in both knees where the radiograph had a grade (0 to 4), which correlated with increasing severity of KOA with grade 0 referring to no presence of OA, and grade 4 signifying severe OA. A detailed and complete description of each investigated instrument can be found in Simis et al. .Neurophysiological markersFollowing the study protocol of this project , TMS meaGenetics analysis Blood was collected from patients (5 mL) in EDTA (Ethylenediaminetetraacetic acid) and DNA (deoxyribonucleic acid) was isolated by the salting-out process  and storStatistical analysisStatistical analyses were performed using Stata software . For these cross-sectional analyses, as aforementioned in the description of the instruments section, the SF-36 data were analyzed considering their division into the eight dimensions constituting this instrument , with the data from each considered as the dependent variable and those from the other instruments in the data bank as the independent variable. Notably, all variables included in the univariate analysis were selected based on a criterion and biological relevance or plausibility. Thus, only the variables that were relevant for evaluation were analyzed.First, to ensure the normal distribution of the data, normality tests were conducted using histograms. Next, we initially ran a bivariate analysis to reveal which independent variables had a significant relationship with the SF-36 dependent variables and to determine the values of the unadjusted β coefficients or odds ratios (OR) and 95% confidence intervals (CI). Next, we built the models for the multivariate analyses, based on theoretical relevance and on variables that had a p-value <0.2, thus avoiding the inclusion of potential confounding factors that did not reach the significance level of 0.05 in the univariate analysis. Variables that were not statistically significant were excluded from one of the models (backward stepwise regression), a method that is typically adopted based on the procedure’s validity in its ability to avoid suppressor effects. To guarantee the statistical quality of the models presented, the four assumptions defended by Osborne & Waters (2002) were adoEthical aspectsThis study was approved by the Ethics Committee of the Clinics Hospital of the University of São Paulo Medical School (CAAE: 86832518.7.0000.0068). All participants signed the ICF before starting the assessments according to Brazilian research regulations (Resolution no.466) and the Declaration of Helsinki 1964) [64 [19].ParticipantsThe study included 107 patients with KOA after excluding those with missing data. Among them, 83.19% were female with a mean age of 68.6 years, and an average number of days of pain was 96 days; around 31.86% were using more than five medications per day even though regarding pain measure (WOMAC and VAS), the sample showed moderate pain  with around 96 days of pain, as shown in Table  Considering our variable of main interest, Table Bivariate analysisFirst, bivariate analysis was performed for each domain with the following variables: WOMAC total, pain, stiffness, and difficulty, KL, BBS, TUG, six-meter walk test, 10-meter walk test, Hamilton scale, HAD scale , ESS, VAS, Mcgill scale pain intensity, pain threshold, MoCA, and conditioned pain modulation (CPM). Descriptive variables were used in the bivariate analysis: gender, years of study, age, treatment time, time of pain, body mass index, and ethnicity . They were tested for the bivariate model, but some were tested in the multi-model to test confounders for the analysis. Regarding neurophysiological measures in TMS, we used bivariate MEP, short-latency intracortical inhibition, and intracortical facilitation as bilateral averages. Regarding EEG measures, all analyses were performed by the frontal, central, and parietal regions to band delta, theta, alpha, beta, and gamma in resting time. It is important to highlight that for EEG and TMS variables, we did not find a correlation between any model and the SF-36. Multivariate analysisAs presented in the data analysis section, regarding the multivariate analysis described below, only the variables that presented the necessary criteria to be included in the models were adopted for the analyses of the respective dimensions of the SF-36. For each model, four assumptions were checked: normality, linearity, homoscedasticity, and independence.1) Physical FunctioningRegarding functional capacity, we found that WOMAC pain , KL , TUG (p = 0.022), and anxiety (p = 0.001) were the best predictors of functional variation (approximately 51%). The Breusch-Pagan test also showed adequate homoscedasticity, and the model met the prerequisites of linearity and independence. All independent variables have a negative correlation with functional capacity.2) Physical Role LimitationsRegarding physical aspects, WOMAC pain , ESS , and Hamilton Scale  explained approximately 24% of the variability of physical aspects in the SF-36, as in the previous domain, all correlations were negative.3) Emotional Role LimitationsThe emotional model, ESS (p = 0.016), Hamilton scale (p = 0.000), and MoCA attention score (p = 0.001) explained approximately 38% of the variability in the variable-dependent emotional domain of the SF-36. As the MoCA test could be influenced by years of study, we also used it, but it did not show any influence in this model. The final model was MoCA attention with positive relation, which means that the higher the emotional score, the better attention score.4) VitalityAge (p = 0.010), BBS (p = 0.005), and HAD (anxiety p = 0.000 and depression p = 0.000) better explain the vitality domain. For vitality, the HAD scale (anxiety and depression) had a negative correlation, as depression and anxiety scores were higher and lower vitality scores and physical disposition. Regarding the age and BBS scale, the relationship with vitality was positive and age seemed to act as a confounder. For this model, the independent variables explain approximately 51% of the variability of vitality. 5) Mental HealthAnxiety , MoCA total score , and OPRM1(rs1799971)A/G polymorphism (p = 0.039)explained approximately 49% of the variability in the mental health dimension. Moreover, we ran the model with education because of its possible influence on the MoCA total score result, but it does not influence it. 6) Social FunctioningSocial aspects were related to anxiety (p = 0.000), McGill intensity of current pain (p = 0.003), and MoCA total score (p = 0.006). The final model could explain approximately 38% of the variability in social functioning, and education did not show any relevant influence. 7) Bodily Pain Variability in pain dimension may also be explained by depression, measured using the Hamilton scale , ESS , VAS , and MoCA abstraction sub-scale (0.010); only this variable had a positive correlation with bodily pain. Although two of the predictors also measured some aspects of pain, in the linearity test, it was appropriate.8) General Health PerceptionsAll the correlations to general health status were negative, with higher depression and pain catastrophizing, and lower good general health perception. Regarding significance, HADS depression has a p-value of 0.000 and pain catastrophizing scale p-value of 0.001, explaining 43% of the variability in perceptions of general health. Inhibitory markers from TMS and EEGAll the variables indexing inhibitory activity, such as SICI and CSP, and also some EEG oscillatory frequencies such as Theta, Delta and Beta were not significantly associated with QOL either in the univariate and also multivariate analysis.Mediation and moderation analysisFrom the predictive models, we created eight diagrams, one for each, in which we presented our hypotheses about how each independent variable would behave within the model. The diagrams were built from theoretical assumptions and from the results of bivariate regression analyses between all the independent variables of each model, thus allowing us to understand how the interactions took place. Figure As shown in Table Finally, regarding the moderation analyses, significant moderation in the models could be observed: i) TUG moderating KL → Physical Functioning ; ii) HAD Anxiety moderating McGill → Social Functioning ; iii) MoCA total moderating McGill → Social Functioning ; and iv) MoCA abstraction moderating VAS Pain → Pain . The other models did not show any significant interactions . Generally, higher levels of anxiety measured by the HAD instrument are related and predict lower scores of functionalities, mental health, social functioning, and vitality.Specifically, regarding the patient's functionality, some studies show that although anxiety symptoms are not associated with physical performance, they are associated with declines in self-reported functioning, which for patients in rehabilitation is the most harmful . NotablyRegarding mental health, anxiety levels were expected to significantly predict the mental health dimension and depression levels measured by the same scale (HAD). This relationship was expected in the literature relating to these measures , which wOur results are consistent with the literature, which showed that anxiety is negatively related to social interaction and vitality. Despite this compatibility, the results are innovative, as they exclusively concern KOA patients. Moreover, the strong emotional aspect influences the HRQOL in this group, perhaps reinforcing the need for interventions focused on this perspective, such as those conducted . FurtherFinally, it is important to mention that the anxiety variable was not excluded as a predictor of mental health. The main explanation is the fact that in the emotional aspects model, the anxiety of the HAD scale does not show multicollinearity and it justifies keeping with depression in the same model  because even though there is an overlap of clinical symptoms and pathophysiological processes, both are separate syndromes , seeing Regarding the variables measuring depression levels, we used two relevant measures, the HAD and Hamilton scales, to measure differences between the instruments. Moreover, we found that the HAD scale of depression is significant in predicting the dimensions of general health and vitality, and the Hamilton scale is a predictor of the dimensions of emotional aspects, physical aspects, and pain. In addition, as the mental health domain in the SF-36 approaches the impact of symptoms of depression in daily life, we expected that the multicollinearity tests for this domain would point to the model's lack of redundancy in these aspects. Overall, both scales predict five of the eight dimensions of HRQOL. Among the main differences between both, it can be highlighted that HAD scale can be used to measure anxiety and depression and is a valid and reliable measure of overall emotional distress, as indicated together with the SF-36 to assess patients with chronic pain , while tNotably, depression levels, whether measured on HAD or Hamilton scale, predict different dimensions of HRQOL, corroborating the literature but specifically regarding KOA patients. That is, we observed in the results that the dimensions of general health perceptions, vitality, physical functioning, and emotional role limitations and that of pain in KOA patients, can be predicted by the depression levels, as observed in the healthy population. Moreover, the SF-36 could detect major depression and demonstrate a dose-effect relationship between depression type (severity) and HRQOL in chronic pain patients . NonetheAs observed for the anxiety variable HAD in the predictive model of emotional aspects and of mental health, we excluded the depression variable HAD for presenting high collinearity with anxiety HAD, but less significant for the statistical model. Even so, this variable has a high predictive value for SF-36 mental health levels, as observed in the bivariate analysis.Both depression variables were present in the mediation model. It was observed that the predictive character of the levels of depressive symptoms in emotional role limitations, pain, and general health perceptions, were significantly mediated by the attention levels, VAS pain, and catastrophic thoughts, respectively. That is, the depression levels impact these dimensions of HRQOL through these mediators.Finally, the last emotional variable worth highlighting its role in HRQOL models is catastrophic thinking, which significantly predicts the general health model. This finding can be explained by the fact that typically catastrophic thinking is positively related to increased intensity and exaggerated pain behavior, decreasing physical function, and prolonged disability . FurtherCognitive variablesOur analysis revealed that the main cognitive variables, which have a predictive character, were the total levels of the MoCA instrument, predicting the dimensions of mental health and social support for HRQOL in SF-36 and the sub-aspect of attention of the MoCA instrument related to the dimension of emotional aspects and MoCa abstraction related to bodily pain model and MoCa total score for mental health and social support functioning.Initially, regarding the total levels of the MoCA instrument, higher scores on this measure were related to greater mental health and greater social support. This result is consistent with the previous literature, as it is typically observed that, regardless of the sub-aspect, cognition levels are related to greater social adaptation and mental health . The resIn all four statistical models, which included the MoCA instrument variables, we also included the education variable to reveal or control the possible confounding impact of education on the predictive value of cognition under the HRQOL. Thus, education was included in the initial mental health, social functioning, emotional role limitations, and pain models. Education does not appear as a confounder but contaminated the model, not contributing to the predictive value as a whole and decreasing the weight of the contribution of variables such as total MoCA levels and anxiety levels; hence, it was excluded from the final model. We also found a significant impact of MoCA abstraction in the bodily pain model, explaining the cognitive face of pain that is widely known, in which pain tends to guide poorer cognitive functioning, even though it was found in domains of attention and executive function of MoCA, not in abstraction . Our modPain-related variablesRegarding the related pain measures, pain catastrophizing is widely known in the health behaviors impacting physical activities, and the fear-avoidance caused by them might result in slowing the rehabilitation process and becoming a cycle of pain-related fear, impairment, and disability. Nonetheless, pain is a floating measure and context-specific, which makes it more important for factors that could contribute to daily fluctuations in joint pain among patients with KOA . RegardiRegarding CPM, a significant measure related to endogenous pain-inhibitory capacity, it does not have a predictive impact in any model, even in bivariate analysis, which may be because the biggest part of our sample efficiency responds to it (pain threshold variation greater than 10%). In KOA, these variables will be more important when we perform longitudinal analysis where we expect that patients with higher CPM at baseline may show a higher reduction in pain after treatment or rehabilitation, as seen in another study .Functional/vitality variablesRegarding the functional and vitality domains, the independent variables understood that ESS, age, BBS, and KL, assess aspects that could affect execution. Previous studies  have shoConsidering the BBS, our predictive results may be consistent with the literature, since it contributes to mobility limitations and difficulties in daily life . The samGenetic polymorphismThe last topic relevant to this discussion concerns the genetic polymorphism of OPRM1/rs1799971. As aforementioned, the data presented in this paper are part of a large, ongoing study, described in detail by Simis et al. , which uNeurophysiological biomarkersThe neurophysiological measures  in this dataset were collected to be tested as predictors of other dependent variables, such as pain and motor . Our inStrengthens and LimitationsThe strengths of this study are its large number of patients compared with other similar studies and the use of different instruments to measure the same aspects, such as pain and depression, which makes the analysis more complex and appropriate for modeling a construct multicausal as HRQOL. A limitation is that it did not include patients’ information before rehabilitation, such as data on anxiety and depression.This work revealed the main predictors of eight aspects of HRQOL in KOA patients in a physical rehabilitation hospital. Among the main relevant variables, emotional aspects such as anxiety and depression were present in all evaluated dimensions. Cognitive variables were significant, specifically regarding mental health, emotional aspects, and social support dimensions. As expected, pain-related variables predominantly predict the HRQOL regarding functionality and patient pain. Finally, variables related to the functionality and vitality of patients significantly predicted all dimensions studied, except for mental and general health. To the best of our knowledge, this is the first study to describe physical, cognitive, pain-related, and functional predictors of HRQOL in patients with KOA. The results contribute to the general literature on physical rehabilitation and are specific to this clinical group. Moreover, our study added findings with polymorphism regarding the mental aspect, predicting the dimension of the SF-36, which strengthens the study by including an objective measure among the many subjective ones.


Background: Inguinal hernia repair is one of the most common operations performed in general surgery. Lichtenstein mesh hernioplasty is a commonly practiced technique for open inguinal hernia repair. Out of many other complications postoperatively, chronic groin pain is one of the patients' most common postoperative complaints. There is no direct evidence to explain the cause of post-mesh hernioplasty pain. Only a few studies have been done to judge the effect of suture material used for mesh fixation on chronic groin pain.Aims and objectives: To compare the postoperative groin pain level in mesh hernioplasty using nonabsorbable versus absorbable sutures for mesh fixation at predetermined intervals using a visual analog scale (VAS) score.Methods: A prospective, single-center, non-randomized, observational study was conducted. All patients per inclusion and exclusion criteria of inguinal hernia planned for surgery were admitted electively on the day of surgery and were operated on in minor OT under local anesthesia for open mesh hernioplasty. The VAS score assessed the postoperative pain level.Results: This observational study was done to look for any difference in postoperative chronic groin pain after mesh fixation with either nonabsorbable, prolene sutures (PS) or absorbable vicryl sutures (VS). One hundred and ten patients fulfilling the department of general surgery inclusion criteria were admitted to the study. In our study, postoperatively, the incidence of chronic groin pain was assessed and followed up to six months. After six months, 25%of patients had pain. Of this 25%, the majority (70%) of patients had mild pain, 15% had moderate pain, and 15% had severe pain. There was no statistically significant difference between the two groups of mesh fixation by nonabsorbable versus absorbable sutures.Conclusion: Inguinal hernia is one of the most typical conditions seen in general surgery clinics with male predominance. Definitive management of inguinal hernia is surgery. There is no difference in postoperative chronic groin pain with either type of suture material i.e., nonabsorbable or absorbable (prolene vs vicryl) sutures. To conclude, fixation material for mesh does not influence chronic inguinodynia. However, further studies are required for the same. Inguinal hernia repair is a frequently performed operation in general surgery. And the Lichtenstein mesh hernioplasty is a commonly practiced technique for open inguinal hernia repair . Among mSince many studies have yet to be taken to study the prevalence of inguinal hernia in developing countries, the assumption is that hernia affects 15% to 20% of the general population; the prevalence of inguinal hernia in India is estimated to be 1.5 to 2 million . The preIn this study, we observed the effect of the suture material used for mesh fixation on postoperative chronic groin pain.Aims and objectivesHere, we compare the postoperative groin pain level in mesh hernioplasty using nonabsorbable versus absorbable sutures for mesh fixation at predetermined intervals using a visual analog scale (VAS) score. This is a prospective, single-center, non-randomized, observational study that was conducted after seeking permission from the institutional human ethics committee of All India Institute of Medical Sciences, Bhopal, India  for the duration of the follow-up, which is a minimum of six months from the date of surgery. The proposed sample size was calculated to obtain a power of 80% with a confidence interval of 95%. Based on this, fifty-one is required in each of these two groups. Thus, a total of 110 patients with 55 in each group were recruited for the study.Inclusion & exclusion criteriaThe sampling method used was purposive sampling. All patients ranging from 18 to 65 years who planned for elective inguinal hernia repair were included in the study. Patients with recurrent inguinal hernia, incarcerated hernia, physical or mental disorders that could interfere with the evaluation of pain scores, impaired cognition, those on daily analgesics for any other illness, those that refused to consent to participate in the study, and those with a history of surgery in the groin area were excluded from the study.Study procedureAll patients with inguinal hernias visiting our institute  were thoroughly examined in the outpatient department. A complete history was taken, followed by a clinical examination of the patient, and findings were methodically noted.Preoperatively, patients were assessed for groin pain on a numerical rating scale of 1 to 10 using the visual analog scale (VAS). Pain gradation into four categories depending on the VAS scores as follows: nil=VAS score 0, mild=VAS score 1-3, moderate=VAS score 4-6, severe=VAS score >6. Patients using analgesics preoperatively for pain were also noted.After taking informed consent, patients who were planned for surgery were admitted electively on the day of surgery and were operated on in the minor operation theatre under local anesthesia.This observational study looked for any difference in postoperative chronic groin pain after mesh fixation with either a nonabsorbable prolene suture (PS) or an absorbable vicryl suture (VS). As per the inclusion and exclusion criteria, 110 patients were recruited for the study from the department of general surgery. After thorough clinical evaluation and investigations, all the patients were operated on, and all of them underwent surgery under local anesthesia. Intraoperatively, the type of suture used to fix the mesh was noted down. Patients of all ages as per inclusion and exclusion criteria were included in the study.Age distributionIn our study, 20.9% of patients were between 21 to 30 years, 20% were between 41 and 50 years, and 39% were >50 years. As per the inclusion criteria age, those aged less than 18 years and more than 65 years were not included in the study. Hence the classic bimodal distribution of hernia patients wasn’t obtained. The mean age was 44±15 years. The age of patients ranged from 18 to 67 years. The mean age in the PS group was 40+15 years and in the VS group was 48+14 yrs. The equality of means (t-test) was calculated for these two groups and was found to have a significant difference in age distribution between the groups. This difference might be due to the non-randomization of the study. Table Sex ratioIn this study, 97% of patients were males, and 3% were females. The male:female ratio was 32:1. Table Preoperative pain VAS score was mild in 51% of patients and of moderate nature in 49% of patients. The distribution of such patients in both groups was not statistically significant as tested by the Pearson chi-square test  after hernia repair was 25%. Around 75% were completely free of pain, 17% had mild pain, 4% had moderate pain, and 4% had severe pain. Further distribution of patients in respective groups in each category has been shown in the table. There was no statistically significant difference between the two groups. Table Pain at Rest at Six MonthsIn this series, 8% of patients had pain at rest during the six-month follow-up Table .Pain During an Activity at Six MonthsBoth groups had no difference in pain during an activity at six months. Overall, 7% of patients had pain during an activity at six months. Table Mean of Pain VAS Score and p-valueOn calculating each group's VAS score means and the p-value (Mann Whitney U test), the p-value was insignificant for 24 hours, seven days, and six months. For one month, the p-value was significant, but Pearson's chi-square of mild, moderate, and severe categories at one month was insignificant. The p-value at six months was also insignificant. So, this significance doesn't have much importance Table .Pain VAS Score at Six Months and Preoperative Pain RelationshipOn cross-tabulation between pain VAS score at six months and preoperative pain, there was no significant association or relationship in the Pearson chi-square test Table .Chronic inguinodynia is a groin pain that develops post-hernia repair and lasts more than three months. It can be classified as nociceptive and neuropathic pain. Nociceptive pain is either somatic or visceral in origin and is due to the periosteal reaction, scar tissue, and mechanical pressure caused by folded mesh called 'meshoma'. The cause of neuropathic pain is unintended entrapment of nerve in suture or mesh, perineural fibrosis, partial division, crushing of nerve, or diathermy burns, all leading to chronic nerve irritation . Of thesThere have been studies comparing glue vs absorbable sutures for mesh fixation in Lichtenstein hernioplasty. A randomized control trial by Paajanen et al. concluded that rates of foreign body sensation, acute and chronic pain, and recurrence rates were similar in both absorbable and nonabsorbable groups . JeroukhIn our study, postoperatively, the incidence of chronic groin pain after six months was 25%. Of this 25%, around 70% had mild pain, 15% had moderate pain, and 15% had severe pain. In 25% of the patients with groin pain, 13.6 % were on analgesics, 3.6% needed painkillers daily for pain management, and 10% required analgesics sometimes only. The incidence of postoperative chronic groin pain after six months was statistically insignificant in both groups. Therefore in our study, the fixation of mesh with either absorbable or nonabsorbable sutures doesn’t influence the incidence of chronic groin pain.This was also concluded in the study by Paajanen et al., where it was studied if absorbable sutures caused less pain than continuous polypropylene fixation of the mesh in the Lichtenstein operation. Study results concluded that absorbable suture material does not appear to cause less neuropathic pain than nonabsorbable sutures . In a coTo conclude, further randomized studies with larger sample sizes and longer follow-ups are required to provide level 1 evidence. Also, studies depicting the pathophysiological mechanisms causing chronic groin pain and interactions between the mesh materials and host tissue are suggested, which might help to understand chronic groin pain better. Also, there is a need for mesh material that balances both recurrence and chronic groin pain.Inguinal hernia is one of the most prevalent conditions seen in general surgery clinics, predominantly in males. The definitive management of inguinal hernia is surgery. Fixation material for mesh does not influence chronic inguinodynia and recurrence rates. Further randomized studies with larger sample sizes and longer follow-ups are required to provide level 1 evidence in this regard. Also, studies depicting the pathophysiological mechanisms causing chronic groin pain and interactions between the mesh materials and host tissue are suggested for a better understanding of chronic groin pain. The surgery for hernia repair has evolved with many changes, modifications, and concepts to decrease the incidence of recurrence.


BackgroundAcute postoperative pain after breast cancer surgery adversely affects recovery and is an independent predictor of chronic postsurgical pain in these patients. Serratus plane blocks have been found to provide analgesia to the anterior hemithorax. However, trials comparing superficial serratus plane block and deep serratus block in breast cancer surgery patients are sparse.MethodologyA total of 74 female patients with American Society of Anesthesiologists physical status I and II scheduled for elective modified radical mastectomy for breast cancer were randomized into two groups. Group A patients received a superficial serratus plane block with 30 mL of 0.25% bupivacaine, and group B patients received a deep serratus plane block with 30 mL of 0.25% bupivacaine. Postoperatively, the Numerical Rating Scale (NRS) score was measured during the immediate postoperative period, after 30 minutes and at one, four, eight, 16, and 24 hours, as well as on the second and third day. After discharge, the NRS scores were recorded in the second and third weeks and then monthly once for three months. All patients received patient-controlled analgesia with intravenous (IV) morphine. The duration of analgesia, pain scores, and 24-hour morphine consumption were also noted.ResultsIn group A, the mean duration of analgesia (hours) was 5.51 ± 1.42, whereas in group B the mean duration of analgesia (hours) was 6.69 ± 1.18 (p < 0.01). NRS scores for pain during rest at 12 and 16 hours and NRS scores for pain during cough at eight, 12, and 16 hours, as well as at the third month were significantly lower in group B. However, morphine consumption was comparable between the groups.ConclusionsDeep serratus plane block was associated with better NRS scores for pain on rest and coughing and prolonged duration of analgesia after a modified radical mastectomy. We conclude that the deep serratus plane block provides superior and extended analgesia than the superficial serratus plane block after a modified radical mastectomy. The mainstay of treatment in breast cancer is the surgical removal of the neoplasm. However, pain after breast cancer surgery poses significant problems in these patients. Acute postoperative pain can affect up to 60% of women undergoing mastectomy, with 10% of women developing chronic pain which can persist up to 6-12 months after surgery [The serratus anterior muscle can be easily visualized by sonography, and there are two potential compartments, namely, superficial and deep to the serratus anterior muscle. The description and clinical use of serratus anterior plane block (SAPB) were first done by Blanco et al. . They deIn this study, we compared the effect of superficial and deep SAPB on immediate postoperative pain relief, consumption of analgesia, and pain scores in breast cancer patients who underwent a modified radical mastectomy. Our primary objective was to compare the postoperative pain scores using the Numerical Rating Scale (NRS) score at 30 minutes postoperatively during rest.We included 74 female patients planned for a modified radical mastectomy during the period between April 2019 and March 2020 after obtaining clearance from the Institute Ethics Committee for human studies . This trial was registered prospectively with the Clinical Trial Registry of India (CTRI/2019/03/018202). Only patients belonging to the American Society of Anesthesiologists (ASA) physical status classification I and II and above 18 years of age were included and those with an allergic history of local anesthetic drugs, coagulopathy, and infection at the site of intervention were excluded. Patients were enrolled after obtaining written informed consent. Randomization was done in the preoperative holding area, and 74 patients were randomized into two groups consisting of 37 patients each by block. Group A patients received superficial serratus anterior plane block, while group B patients received deep serratus anterior plane block. Group allocation was done by picking serially numbered opaque sealed envelopes by a resident who did not participate in the study, and blinding was not done. The primary objective was to study and compare the postoperative pain scores using the NRS score at 30 minutes postoperatively during rest. Secondary objectives were NRS pain scores at the immediate postoperative period, 30 minutes, first, fourth, eighth, 12th, 16th, 24th hours, second and third day, at the second and third week, followed by monthly once for the first three months postoperatively during rest and coughing. Secondary outcomes were the duration of analgesia in the postoperative period, postoperative analgesic consumption, procedure-related complications, and incidence of opioid-related side effects.Patients were taught about self-assessment of pain using the NRS scale ranging from 0 to 10 , usage of patient-controlled analgesia, and their overall satisfaction using the Likert scale. All patients were premedicated with oral diazepam 5 mg on the previous night. After arriving at the operation theater, one hour before the scheduled time of the operation, all patients were shifted to the pre-anesthesia room, and peripheral venous access was secured using an 18-gauge intravenous (IV) cannula. Standard monitoring devices including non-invasive blood pressure, pulse oximetry, and five-lead electrocardiography were attached. All patients received premedication with IV midazolam 1 mg before the procedure. For performing block, all patients in both groups were placed in the lateral decubitus position placing the side to be blocked above with the arm abducted, and a linear transducer (8-13 MHz) ultrasonography (USG)  probe was used under aseptic precautions by trained anesthesiologists. The USG probe was placed over the mid-clavicular region of the thoracic cage on the operating side in a sagittal plane. By counting the ribs inferiorly and laterally in the mid-axillary line, the fourth and fifth ribs were identified. In group A, patients received superficial SAPB as follows: the latissimus dorsi and serratus muscle were identified, and after infiltration of the skin with 2% lignocaine, a 22-gauge echogenic needle was introduced in-plane with respect to the USG probe from the caudal to cranial direction till the tip of the needle was placed between the two muscles and the position was confirmed by injecting saline. After confirming the plane between the two muscles with hydrodissection by saline, 30 mL of 0.25% bupivacaine was injected. In group B patients, deep SAPB was given by injecting 30 mL of 0.25% bupivacaine in the fascial plane between the serratus anterior and the intercostal muscles.The sensory level of the block was assessed by an anesthesiologist not involved in the study, with a pin-prick sensation every five minutes in each dermatomal distribution from T2 to T6 in the mid-clavicular, mid-axillary, and mid-scapular lines. The total number of dermatomes with no pain to pinprick compared with the opposite side was noted. The block was considered a failure if the pinprick sensation did not decrease in any segment for up to 30 minutes. Block-related complications such as pneumothorax, hypotension, and vascular injury were noted.After confirming the sensory level of the block, all patients in both groups were shifted to the operating room, and general anesthesia was induced using a standard protocol. All patients were shifted to the post-anesthesia care unit at the end of surgery.The postoperative pain was assessed using the NRS scale  by an independent observer not involved in the study. The vital parameters and pain scores at rest and on coughing were noted at the following timelines: immediate postoperative period, 30 minutes, first, fourth, eighth, 12th, 16th, and 24th hours. All patients in both groups received patient-controlled analgesia with IV morphine in the postoperative period for 24 hours using the following settings: demand dose of 1 mg morphine with a lockout time of 15 minutes. The time from the administration of the serratus plane block to the time of administration of the first dose of patient-controlled morphine by the patient in the postoperative period was considered as the duration of analgesia. The total morphine consumed in the first 24-hour postoperative period was also noted. Other parameters such as postoperative nausea and vomiting (PONV) and complications were noted. NRS scores for pain were assessed daily until the third day and thereafter at the second and third week and monthly for three months over the telephone. The overall satisfaction with analgesia was assessed using the Likert scale.Okmen et al. found reduced Visual Analog Scale (VAS) scores 1.8 ± 0.76) with serratus plane block compared to conventional analgesia in thoracotomy patients [6 with seAmong the demographic parameters, age, height, weight, ASA physical status classification, and duration of surgery were not statistically significant, as shown in Table NRS pain scores at rest analyzed using two-way repeated measures of the analysis of variance method were significantly higher at the following timelines: in group A - one hour, 12 hours, and 16 hours, as shown in Table The postoperative morphine consumption was not statistically significant between the groups. However, the duration of analgesia was significantly longer in group B, as shown in Table Our study results show that deep SAPB is associated with lesser pain scores for acute postoperative pain and chronic pain three months after surgery. Further, deep SAPB prolonged the duration of analgesia significantly.Breast cancer surgery involves extensive dissection and resection of major muscles and nerves, causing severe pain postoperatively which may progress to chronic pain. Serratus plane block was first described by Blanco et al. as a regional analgesic technique to provide analgesia to the hemithorax , and it Abdallah et al. found that deep serratus plane block was associated with non-inferior but not superior pain scores in ambulatory breast surgery . EdwardsAlthough the duration of analgesia was significantly prolonged with deep SAPB, the total patient-controlled morphine consumption in the postoperative period was insignificant between the two groups. This contrasted with the findings of Edwards et al. who observed that deep serratus block patients required lesser oral morphine postoperatively . Our stuBhoi et al in a case series including 20 patients compared the superficial and deep blocks and found no significant difference in NRS scores and fentanyl consumption . This waAll 36 patients in group B expressed “extreme satisfaction” on the Likert scale compared to group A (27 out of 37 patients), which was statistically significant. This was in contrast to the study by Edwards et al. who found no significant difference in the satisfaction score between the superficial and deep blocks . None ofOur study had certain limitations. First, the sample size was smaller. Second, we did not perform postoperative dermatome mapping which would have helped in assessing the spread of the block over time. Third, we did not record the hemodynamic response to surgical incision. Fourth, NRS pain scores may not be optimal to study chronic pain, and further trials are needed to study the impact of serratus plane block on chronic pain and functional status after breast cancer surgery.Deep SAPB is associated with better NRS scores for pain on rest and coughing in the initial 24 hours of the postoperative period after a modified radical mastectomy. Further, deep serratus block provides a longer duration of analgesia and better patient satisfaction. We conclude that the deep serratus plane block provides superior and extended analgesia than the superficial serratus plane block after modified radical mastectomy for breast cancer. Further trials are required to study the effect of serratus plane blocks on chronic pain and functional assessment.


The modified Broström operation (MBO) has found widespread use in the therapy of lateral chronic ankle instability (CAI). However, alternative surgical techniques like the open reconstruction using a periosteal flap (RPF) are still an important part of the surgical treatment of lateral CAI. Both procedures differ in terms of the reconstruction material used and the surgical procedure. Comparative studies on the surgical therapy of CAI are limited and generally refer to similar surgical procedures. Aim of this study was to compare the arthroscopic MBO and the RPF.We retrospectively analysed 25 patients with lateral CAI after a tear of the anterior talofibular ligament (ATFL). 14 patients received arthroscopic MBO and 11 patients received RPF. We compared the postoperative outcome between both groups with respect to subjective instability, the number of ankle sprains, pain, complications and follow-up operations as well as the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score.Both surgical procedures resulted in a significant improvement in pain, in subjective instability, in the reduction in the frequency of ankle sprains and improvement in the AOFAS ankle-hindfoot score one year postoperatively. Three months postoperatively, the values for pain and instability of the MBO group were significantly better compared to the RPF. One year after the operation, these differences were evened out. Also in terms of complications and follow-up operations, no significant difference was found between the two procedures.Both surgical procedures give very good results one year postoperatively in terms of pain, instability, function and complication rate. With significantly better results regarding pain and instability three months postoperatively, the MBO allows a faster recovery in patients operated with this technique. Ligament lesions, especially ankle sprains are one of the most common injuries in sports and daily activities. A recent meta-analysis from Doherty et al. described ankle sprain incidences of 13.6 in women and 6.94 in men per 1000 exposures . In 80% A good clinical result without pain or compromised range of motion can only be achieved if the function of the original ligaments is somehow restored.In 1966 Broström et al. already described a surgical technique for the treatment of CAI with a direct augmentation and gathering of the torn ligaments . This teAlthough the MBO seems to be becoming the standard procedure for this condition, there are also alternative techniques to successfully address lateral CAI. In 1997 Rudert et al. treated 94 patients with lateral CAI performing reconstruction with a local periosteal flap (RPF) achieving good or excellent results. This periosteal technique allows anatomical reconstruction without sacrificing other ligaments or tendons . To the The aim of the present study was to compare the outcome after arthroscopic MBO and the open RPF regarding instability, pain, postoperative ankle sprains, and function.We hypothesized that both methods show comparable results in terms of stability and function. Due to the minimally invasive procedure of the arthroscopic MBO, we expected a faster recovery of the patients treated with this procedure.We performed a retrospective study comparing the two different operative techniques explained below. All patients received an operative treatment with either a reconstruction with arthroscopic MBO or RPF. Patients were treated in the Department of Orthopaedic Surgery of the University Hospital of Tübingen and in the Praxisklinik Straubing.Since the study was designed retrospectively, the patients had no choice which surgical method to receive. All operations were carried out by experienced senior physicians.Inclusion criterion was a performed stabilization operation of the lateral ligaments with either the MBO or the RPF. Diagnosis and indication for surgery were based on medical history, clinical examination and further radiographic imaging including conventional X-ray in 2 planes and MRI imaging from each patient. Indication for surgery was a lateral CAI with repeated ankle sprains and failure of conservative treatment, e.g. physiotherapy or braces. The minimum duration of failed conservative treatment before considering surgery was 3 months. Exclusion criteria were a medical history with a chronic pain disorder, therapeutic anticoagulation and unsteady gait caused, for example, by underlying neurological diseases.The arthroscopic MBO was performed using the Arthrex Broström Repair implant system . A standard anteromedial arthroscopic portal and a secondary anterolateral portal with the protection of neuro-vascular structures are established. Viewing from the anteromedial aspect of the joint a debridement is performed with special attention paid to the preparation of the anterior aspect of the distal fibula with the anatomical origin of the ATFL. Through the anterolateral portal onto the inferior aspect of the fibula a SutureTak drill guide and drill bit are used to create two bone tunnels 5 mm and 10 mm proximal to the tip of the distal fibula. These two drill holes are armed with a 3 mm Biocomposite SutureTak anchor. 15 mm ventrodistally from the tip of the fibula 4 exit points for the suture are marked. Using a Micro SutureLasso, all four sutures are shuttled through the marked points. In the next step, all four sutures are passed subcutaneously through the anterolateral arthroscopic portal. While holding the foot in slight eversion, the sutures are fastened down to the fibula thus sewing the inferior extensor retinaculum to the periosteum of the lateral malleolus  ranging from 0 with “no pain” to 10 “greatest imaginable pain”. We also used the AOFAS ankle-hindfoot score with a maximum score of 100 evaluating pain (40 points), functional status (50 points) and alignment of the foot with the ground (10 points). The functional dimension of the AOFAS ankle-hindfoot score comprises functional limitation, use of supports, distance covered, ground characteristics, step alterations and sagittal movements. Furthermore, previous operations and follow-up operations were recorded, too.Statistical analyses were conducted using IBM SPSS Version 20  and Microsoft Excel . Distributions of variables within the groups were assessed by histograms and a non-parametric approach was chosen. Continuous variables are presented as medians and ranges, and categorical variables as frequencies. Comparison between groups was performed by Mann–Whitney U-test, Wilcoxon-test or Chi-Square-test as appropriate. All reported p-values are two-sided, with a significance level of 0.05, and have not been adjusted for multiple testing. Power analyses were conducted using G*Power Version 3.1.9.6.The analysed collective consisted of 25 patients (22 women and three men), 14 of whom received an arthroscopic MBO and 11 a RPF. The operations were carried out between 2002 and 2018. Median patient age at the time of operation was 35 years (range 17—54 years). Two patients from the RPF group had previously been operated on in the operating area . There was no statistically significant difference between the two groups for any of the above-mentioned characteristics (Table p = 0.199). In total, five patients had to undergo revision (three patients with MBO (21%) and two patients with RPF (18%), p = 0.840). In the MBO group, the revisions consisted of a cheilectomy, resection of suture material granuloma and neurolysis. Revisions in the RPF group included one scar revision and one implant removal.Complications occurred in six patients (24%) of the whole collective. In the MBO group, one suture granuloma and one nerve damage were observed (14% complication rate). In the RPF group, three patients had nerve damage and one patient suffered from wound healing disorders (complication rate 36%) (p < 0.001) and one year (p < 0.001) postoperatively. In the RPF group, the median pain was reduced from 5 preoperatively to 3 three months (p = 0.261) and 0 one year (p = 0.012) postoperatively. Pain reduction was thus significantly greater in the MBO group when compared to the RPF group (p = 0.029) at three months postoperatively. One year postoperatively, pain levels were similar in both groups  at three months and of 93 (range 53 – 100) (p = 0.002) at one year postoperatively was documented. The median score of the RPF group was 81 (range 47 – 96) preoperatively. In this group, too, the score improved significantly in the postoperative follow-up with a value of 96 (range 60 – 100) (p = 0.004) at three months and a value of 100 (range 71—100) (p = 0.01) at one year postoperatively. In direct comparison, the RPF shows significantly better absolute values both preoperatively and at both points in time postoperatively  .To retrospectively assess function, we used the AOFAS ankle-hindfoot score. The patients of the MBO group preoperatively presented with a median score of 61 (range 29—81). A significant improvement to a median score of 82 (range 53 – 100) (81 range 7 – 96 prp = 0.037)  still reported a feeling of instability at three months postoperatively and one patient (9%) one year postoperatively. In comparison, the MBO group thus showed significantly better stability three months postoperatively (37) Fig. .Fig. 5Rep = 0.065)  and pain (p = 0.029). The arthroscopic MBO, therefore, appears to offer a faster pain reduction than the RPF. Rudert et al. (1997) were able to show for the RPF that pain was postoperatively never present in the majority of patients or only after greater exertion [One year postoperatively, both groups showed good improvement in function and a significant reduction in pain, subjective instability and the number of ankle sprains with no significant difference between both groups one year postoperatively. However, patients treated with the MBO recovered faster with significantly greater improvement in the feeling of instability  was more than twice as high as in the MBO group 14%). The most common complications reported in the literature are nerve injuries, wound healing problems and suture material complications, which is consistent with the data of the present study , 34, 35.4%. The mThe successful conservative therapy of ankle sprains with only very few patients requiring surgical treatment leads to the problem of small sample sizes in studies looking into surgical strategies of CAI , 14, 35.The statistical power of certain tests in our study can be classified as small to medium thus being underpowered. This is why results showing no difference could be false negatives in the sense of a type II error. This fact can largely be attributed to the limited sample size. Although the descriptive data for both procedures at one year postoperatively do not suggest a clinically relevant difference, these findings need to be interpreted with caution. Since a large body of research in the CAI field consists of studies with smaller sample sizes, our data may also contribute to future meta-analyses improving our perspective on these procedures.When interpreting the results of our study it needs to be pointed out that we compared one minimally invasive procedure (MBO) with an open surgical technique (RPF). Although no minimally invasive procedure is available for the RPF it would still have been interesting to also compare the RPF with an open MBO. Looking at other comparative studies of open versus minimally invasive techniques, similar results with less pain and faster recovery for minimally invasive techniques can be seen , 31. It One methodical limitation is that the AOFAS ankle-hindfoot score is not recommended by the AOFAS anymore because of several flaws inherent to the questionnaire . As therThe MBO and the RPF are surgical techniques that yield a comparable clinical outcome one year postoperatively. Pain, function, instability and the frequency of ankle sprains improve significantly with both procedures and do not differ significantly from one another. The arthroscopic MBO appears to have the advantage of faster recovery through significantly faster pain reduction and improvement of instability.From our point of view, RPF can be seen as a good alternative therapy, which can be carried out if the MBO is not technically feasible or available.


Lumbar Disc Degeneration (LDD) is associated with recurrent low back pain (LBP) (symptomatic). However, in some instances of LDD, people do not experience LBP (asymptomatic).As a step towards understanding why some people with LDD experience LBP and others do not, the primary aim of this study was to examine differences in anticipatory (APA) and compensatory postural adjustments (CPA), between symptomatic LDD patients (LDD pain) and asymptomatic LDD controls (LDD no pain) during postural perturbation. The secondary aim was to determine simultaneous differences in mental health, disability and quality of life status.U test was conducted to examine group differences in sagittal spine and lower limb kinematics , anxiety, depression, disability and quality of life.3 T MRI was used to acquire T2 weighted images (L1-S1) from LDD no pain (n = 34) and LDD pain groups (n = 34). In this observational study, responses to predicted and unpredicted forward perturbations were examined using three dimensional motion capture. A Mann Whitney The LDD pain group exhibited lower hip and knee displacements (p = 0.049−0.040) than the LDD no pain group during predicted and unpredicted perturbation. The LDD pain group also exhibited higher compensatory lumbar displacement than the LDD no pain group (p = 0.040−0.005) in the predicted condition but there was no difference observed in the unpredicted condition. The LDD pain group experienced higher levels of depression, anxiety and disability (p < 0.0001) and lower quality of life (p = 0.0001) than LDD controls.Symptomatic LDD patients are different from LDD controls; they exhibit different kinematic strategies, levels of disability, anxiety, depression and quality of life. Effective care may benefit from evaluating and targeting these differences. CurrentFunctional task analysis has been used to successfully discriminate between asymptomatic controls and LBP patients using three-dimensional motion capture (3DMC). However, findings seem contradictory and inconclusive due to the established heterogeneity of this population . In addiImpaired postural control is frequently associated with LBP . TherefoThe primary objective of this study was to examine differences in sagittal trunk and lower limb displacements between symptomatic LDD patients (LDD pain) and asymptomatic LDD controls (LDD no pain) in the APA and CPA phases of predicted and unpredicted forward postural perturbation using 3DMC. Since patients with LBP commonly experience psychological changes and disability, the secondary objective was to simultaneously examine these differences between the same groups using validated self-report questionnaires.22.1Ethical approval was granted from the NHS Health Research Authority . A priori analysis confirmed that a minimum total sample size of fifty-eight subjects (29 per group) would be required to deliver sufficient power (0.80) (α = 0.05) . Patients were recruited from primary and secondary care and healthy controls through local advertisement as part of a larger study and provided informed consent (n = 97). Since preliminary findings determined that significant differences in motor control lay between LDD pain and LDD no pain groups, these groups (sixty-eight participants (34 per group) became the primary focus of this study. LDD is common, with a prevalence of 40 % of subjects under 30 years of age, increasing to 90 % at 50–55 years . Therefo2.2A 3 T Verio MRI scanner  was used to acquire supine T2 weighted sagittal lumbar spine images (L1-L5/S1)  from healthy controls and patients as part of their consented involvement in the study and routine NHS care respectively.st and 5th metatarsals and calcanei), 3 triads   . In addiThe spine, pelvis and bilateral lower limbs were modelled as 10 rigid segments according to identifiable anatomical landmarks. The upper thoracic (UT) segment (T1-T6) was defined with its origin in T6, vertical axis from T6 to T1 (+y) and horizontal axis through T6 (+z to the right). The lower thoracic (LT) segment (T7-T12) was defined with its origin in T12, vertical axis from T12 to T7 (+y) and horizontal axis through T12 (+z to the right). The lumbar (L) segment (L1-L5) was defined with its origin in L5, vertical axis from L5 to L1 (+y) and horizontal axis through L5 (+z to the right).Pelvic, thigh, shank and foot local co-ordinate systems were defined ,31 and rThe anatomical frames of the pelvis, thigh and shank were then referenced to the corresponding technical frames in the static calibration trial such that anatomical markers  could be removed prior to dynamic trials, permitting freedom of movement. All trials were recorded at 100 Hz using a 10-camera 3DMC system (Vicon Nexus (T160), Oxford Metrics Ltd., Oxford, UK) .2) with the acceleration profile designed to simulate a train on the London Underground . Pa. Pa34]. 2.3The onsets of kinematic signals were synchronised with the onset of platform perturbation. An in-house constructed accelerometer (1000 Hz) was attached directly to the platform. The onset of perturbation was verified by a combination of visual verification and a computer algorithm reflecting the Shewart protocol . In the The baseline joint displacement was calculated within the -500 to −450 ms window prior to perturbation (0 ms). This baseline was subtracted from all outputs in order to ensure that the results were due to true differences and not differences in baseline . Since eDifferences in kinematic strategy were defined as differences in integrated sagittal spine  and/or lower limb  displacement waveforms between groups during specific APA and CPA phases. Since there is a known 50 ms electromechanical delay between the onset latency of skeletal muscle and the tension development within a muscle , each phThere was no learning effect observed with respect to the three repeated perturbation trials. Therefore, the median of three predicted and unpredicted forward perturbation trials was calculated for each participant. Three trials were excluded due to a stepping response.2.4U test, the data from both groups were automatically ordered in ascending fashion and ranked between 1 and 68. The distributions of the ranks were assessed by visual inspection of a population pyramid (histogram) produced in SPSS . Since the distributions of the two groups of the independent variable were not the same (i.e. different shapes), the Mann-Whitney U test was used to determine if there were statistically significant differences in the mean ranks of the dependent variable  between LDD pain and LDD no pain groups [Statistical analysis was performed using SPSS statistical package  and Microsoft Excel . Normality of the data was determined using QQ plots, histogram and Shapiro Wilks test. In order to perform a Mann-Whitney n groups . Higher 3Two groups were identified LDD pain (n = 34) and LDD no pain (n = 34). Age was not statistically significant between groups (p = 0.35). BMI was significantly higher in the LDD pain group than the LDD no pain group . However3.1In the predicted condition, integrated hip and knee displacements were smaller in the LDD pain group  than the LDD no pain group  . In the unpredicted condition, smaller integrated knee displacements were similarly observed in the LDD pain group (mean rank: left knee CPA2 = 27.80) when compared with the LDD no pain group (mean rank: left knee CPA2 = 37.50)  . However, in the CPA phases, lumbar displacement was notably higher in the LDD pain group  than the LDD no pain group  . In the unpredicted condition, there was no significant differences in spinal segment displacement during the APA and CPA phases (p = 0.28−0.89).These findings corresponded to a significant difference in compensatory lumbar strategy between groups in response to predicted forward perturbation with no significant difference in the unpredicted condition . There were no significant correlations in the unpredicted condition (p > 0.05).In the predicted condition, there was a significant negative correlation observed between bilateral hip APAs and self-reported pain (NRS)  than the LDD no pain group (mean ranks 17.69–24.80) . The LDD pain group had significantly lower mean ranks in terms of quality of life (mean ranks = 16.73–23.60), when compared to the LDD no pain group (mean ranks = 39.64–45.88) . This indicated that the LDD pain group experienced higher levels of depression, anxiety and disability and lower quality of life than the LDD no pain group.4The evaluation of kinematic strategy is frequently described in the literature when investigating differences between LBP and healthy controls during functional tasks . HoweverHealthcare professionals routinely use gait and STS tasks to assess LDD patients  as theseA recent systematic review, comparing anticipatory and compensatory responses to postural perturbation, found a lack of conclusive evidence to support kinematic differences between people with or without chronic LBP . DefinitIt is proposed that stereotyped lower limb displacements enhance postural recovery during mechanical perturbations on a flat surface . HoweverAlthough motor control impairments of the lower limb are typically described, significant differences in spinal strategy are documented. Healthy adults appear more adaptable than LBP patients, using an unrestricted repertoire of multiple joint segment motion in response to perturbation . HoweverAlthough, we cannot presume a causal effect, it seems that such differences in the postural chain are more likely to be uncovered through the comprehensive examination of both the spine and lower limbs. Since the postural strategy adopted by the LDD pain group involved joints proximal (lumbar) and distal (hip and knee) to the site of reported LBP, this may reflect a centrally mediated change or a change within the nervous system associated with task prediction . This reIn response to unpredictable perturbations there was no difference in lumbar and hip displacements between groups. These findings are noteworthy for two reasons. Firstly, although ‘trunk stiffening’ has been reported to result from similarly unpredictable perturbation scenarios in LBP patients , a recenA strength of this study was that the a priori sample size estimate was exceeded (34 per group). In addition, potential confounders such as age, sex, BMI and task related pain changes were not found to influence results. However, the ‘Imperial Spine’ marker set ,27 was u4.1In this study it was observed that significant differences in kinematic strategy are not exclusive to the trunk but also occur in the lower limbs. This suggests that a comprehensive examination of the trunks and bilateral lower limbs of LDD patients is required in clinical research and practice, in order to prevent the potential underestimation of motor control deficits.The kinematic differences observed between the LDD pain and LDD no pain groups in this study appear similar to those previously reported between people with LBP (for whom the cause of LBP has not been determined) and healthy controls ,49. UndeCorrelation analysis in symptomatic LDD patients revealed a negative correlation between bilateral hip APAs and self-reported pain (NRS) in the predicted condition. It is of note that, in the same predicted condition, the same parameters (left and right hip APA2) were also observed to be significantly different between the LDD pain and LDD no pain groups. A recent systematic review highlighted that the effect of LBP on APAs and CPAs is unclear, with authors proposing a link between impaired limb motor control and the risk of injury proximal or distal to the affected trunk or lower limb segments . Therefo5Symptomatic LDD patients exhibit different kinematic strategies to their asymptomatic LDD counterparts. Strategic differences are dependent upon task predictability and are not restricted to the lumbar region, confirming the need for future 3DMC studies to use marker sets, such as the ‘Imperial Spine’, which include bilateral lower limb segments. Differences in functional ability, mental health and quality of life also reflect underlying complexity. Therefore, effective rehabilitation for symptomatic LDD patients will require a multi-faceted approach. Evaluation of spine and lower limb kinematics under destabilising conditions, in addition to self-reported clinical outcomes, may prove a better indicator of LBP and/or risk of recurrence than LDD itself.The authors report no declarations of interest.


To assess the value of a morphine Patient Controlled Intravenous Analgesia (PCIA) after Tonsillectomies (TE).30 adult patients were treated with oral analgesics (protocol group) and compared to 30 patients treated with a morphine PCIA for the first 3 Postoperative Days (PODs) after TE. Average and maximum pain severities  on PODs 1–3, analgesic score, quality of life, patient satisfaction and side effects were defined as outcome measures.p = 0.68], POD2: 4.75 vs. 4.22 [p = 0.32] and POD3: 4.44 vs. 4.25 [p = 0.71]). Maximum pain intensities on POD1 (p = 0.92), POD2 (p = 0.51) and POD3 (p = 0.36) were also comparable between both groups. Patients with a PCIA consumed significantly more opioids (p = 0.001) without significant more side-effects.Average pain severities of the protocol and the PCIA group were of similar magnitude (NRS) (POD1: 4.48 vs. 4.71 [The PCIA did not provide a superior pain control compared to oral analgesics. In view of the considerable effort and the high opioid consumption, it cannot be recommended as a standardized application for pain control after TE. Postoperative pain intensities following Tonsillectomy (TE) regularly reach high levels affecting especially the first four Postoperative Days (PODs) and so far, there is no effective evidence-based treatment concept.Consequently, aiming at quality improvement of our postoperative pain treatment we hypothesized that a routine application of a PCIA with morphine combined with opioid-sparing peripherally acting analgesics may improve pain treatment after TE.This prospective study was approved by the Ethics Committee of the University of Cologne (application number: 16–190), registered in the German Clinical Trials Register (DRKS) (application number: DRKS00011092), was conducted according to the Declaration of Helsinki and followed the STROBE guidelines.2. Exclusion criteria were: single sided and partial TE, TE à chaud, oncologic TE, pre-existing opioid-dependent pain, central nervous system disease and Obstructive Sleep Apnoea (OSA). OSA was excluded on the basis of medical history. Patients were specifically asked about symptoms of OSA, previous sleep medical diagnosis and possible nocturnal CPAP therapy. Patients were also monitored in the recovery room for several hours after surgery. If saturation drops had occurred postoperatively, the patients would not have received PCIA with opioids.A total of 60 consecutive patients presenting for elective bilateral TE at the Department of Otorhinolaryngology-Head and Neck Surgery of the University of Cologne between September 1st, 2016 and November 1st, 2018 were included in the study. The following inclusion criteria were applied: bilateral total TE due to chronic recurrent tonsillitis following the criteria of the S2k guideline “Inflammatory diseases of the palatine tonsils/tonsillitis, therapy”,−1) and Fentanyl (2–3 µg × kg−1) and maintained with Sevoflurane (1.7–2.0 vol%) in an air-oxygen mixture combined with Fentanyl (1 µg × kg−1bolus as required). In case of infection, antibiotics were administered during POD 1–3   . Postopee daily) . SubsequPain perception  and pain tolerance  were surveyed twice daily. Health-related quality of life was evaluated preoperatively and on POD3 using the “acute version” of the validated Short Form Survey (SF-36).Patient satisfaction and involvement in the analgesic treatment NRS 0–10) were surveyed using the “Quality Improvement in Postoperative Pain Management” (QUIPS) questionnaire. were surt-tests, where applicable . Numerical values are presented as mean values ± standard deviation (SD). p-Values of <0.05 were considered statistically significant.Mixed-model ANOVAs with the between-factor “group” and the within-factor “time” computed the pain intensity related to treatment group. Paired or unpaired t-tests served as post-hoc tests with Bonferroni correction. Side effects were analysed using Chi-square, Fisher’s exact and unpaired Sample size estimation was performed for the primary endpoint maximum and average pain perception and was based on Gostian et al. (2020).The study included 60 out of 64 eligible candidates. Two patients withdrew their initial consent, one patient discharged himself earlier and for one patient clinical data was incomplete. Demographic and clinical characteristics revealed no statistically significant differences between both patient groups .p = 0.04). As a consequence, the average opioid consumption over all three PODs was significantly higher in the PCIA group (43.99 ± 34.80 mg) compared to the protocol group  = −3.46, p = 0.001). p = 0.28 with POD1: t(58) = −0.420, p = 0.676, POD2: t(58) = 1.011, p = 0.316 and POD3: t(58) = 0.374, p = 0.710). Similarly, maximum pain intensities were independent of the application of the PCIA  = 0.45, p = 0.64 with POD1: t(58) = 0.098, p = 0.922, POD2: t(58) = 0.663, p = 0.510 and POD3: t(58) = 0.919, p = 0.362)  = 2.216, p = 0.031) only.Opioids were applied to 22 patients of the protocol group (73.3%) and to all 30 patients of the PCIA group (100%) (= 0.362) . Patient2(1) = 5.55, p = 0.02) at a similarly low level compared to patients of the protocol group (t(32) = 1.39, p = 0.17). Furthermore, incidences and severities of the surveyed treatment related side effects were comparable in both patient groups (Patients receiving a PCIA complained more often of obstipation (χt groups .Table 2I(57) = 0.802, p = 0.426; POD3: 36.23 ± 9.41 vs. 34.8 ± 10.21; t(58) = 0.671, p = 0.505) and psychological scores  = 0.135, p = 0.893; POD3: 49.17 ± 9.5 vs. 48.69 ± 11.09; t(58) = 0.135, p = 0.893) indicated that health-related quality of life was irrespective of the applied treatment  = −1.63, p = 0.11) and were comparably satisfied with their analgesic treatment  = −0.90, p = 0.38).All surveyed patients felt equally involved in their pain management (protocol group: 8.43 ± 1.68 vs. PCIA group: 7.66 ± 1.99; tThis study shows that mean values of the reported average and maximum pain intensities did not differ significantly between both analgesic treatments. This is all the more surprising since patients of the PCIA group consumed twice as much opioids compared to the protocol group as expected and known from various PCIA applications, where in contrast to our study, pain scores were usually lower with higher analgesic use.Apparently, average and maximum pain levels were rather high throughout all days. Numerous studies have already demonstrated that pain intensities after TE regularly reach very high intensities.Still, the results in pain relief after TE remained unsatisfactory. This may be attributed to the lack of knowledge on the exact cause of this severe pain. It is assumed to be either of inflammatory and/or neuropathic origin and there might be a pain component that is non-opioid sensitive. In this regard, further studies in order to identify the underlying pathophysiological mechanism of pain after TE and to implement potential new therapeutic targets are desperately needed in order to improve the unsatisfactory issue of pain treatment after TE.Our work is in line with the study of Kelly et al., where it was demonstrated that using morphine after TE in children did not lead to a superior pain control but to an increase in serious and dangerous side effects in children.Receiving a PCIA pump for pain relief was assessed positively by the patients but did not lead to a higher patient satisfaction compared to oral analgesics. It is known that there seems to be only a weak correlation between analgesia and patient satisfaction and patients rate their satisfaction high despite of having substantial pain.Limitations of our study are based on the missing randomization. We still believe that both groups were highly comparable, since both treatment groups were similar in regard to demographic and clinical factors out of which female gender, preoperative chronic pain and younger age contribute to increased postoperative pain sensation.In conclusion, this pioneer survey on the efficacy of morphine PCIA to treat postoperative pain after TE in adults shows that opioids are not a necessary and effective therapeutic option. Further studies in order to identify the underlying pathophysiological mechanism of pain after TE and possible new therapeutic targets are desperately needed in order to improve the unsatisfactory issue of pain treatment after TE.The authors declare no conflicts of interest.


The optimal analgesia for total knee arthroplasty (TKA) requires excellent analgesia while preserving muscle strength. This study aimed to determine the hypothesis that continuous adductor canal block (CACB) combined with the distal interspace between the popliteal artery and the posterior capsule of the knee (IPACK) block could effectively alleviate the pain of the posterior knee, decrease opioids consumption, and promote early recovery and discharge.Patients undergoing unilateral, primary TKA were allocated into group CACB+SHAM (receiving CACB plus sham block) or group CACB+IPACK (receiving CACB plus IPACK block). The primary outcome was cumulative opioid consumption. Secondary outcomes included the incidence of postoperative pain originated from the posterior knee, visual analogue scale (VAS) score, range of motion, ambulation distance, and satisfaction for pain management.p = 0.019), 8 hours , and 24 hours  after TKA. The VAS scores of the posterior knee were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours , 8 hours , and 24 hours  after TKA. The overall VAS scores were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours  and 8 hours  at rest and 4 hours , 8 hours , 24 hours  during active flexion after TKA. The range of motion  and ambulation distance  were superior in group CACB+IPACK than that of the group CACB+SHAM in postoperative day 1. The satisfaction for pain management was higher in group CACB+IPACK than that of the group CACB+SHAM . There was no difference in term of cumulative opioids consumption between group CACB+IPACK and group CACB+SHAM .The incidence of moderate-severe pain of the posterior knee was lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours .This study was registered at Chinese Clinical Trial Registry ( Knee Osteoarthritis, as one of the most common forms of knee disease, is widely found in the elderly population. Total knee arthroplasty (TKA) has been recognized as an effective therapy for patients with end-stage knee osteoarthritis. However, patients underwent TKA usually experience excruciating postoperative pain which decreases patient satisfaction, hampers early mobilization, prolong hospital stay, and worsen postoperative function. Therefore, anesthesiologists and surgeons are consistently seeking ways to effectively manage the postoperative pain. Recent studies found that the pain after TKA could be controlled by femoral and sciatic nerve blocks , 2. HoweThe ideal postoperative analgesia management strategy of TKA requires not only providing adequate postoperative analgesia but also retaining the muscle strength of the limb at most. Adductor canal block (ACB) was a motor-sparing nerve block that provides an analogous analgesic effect to femoral nerve block –5. Howevhttp://www.chictr.org.cn/). Patients who were scheduled for primary unilateral TKA were recruited. Subjects with chronic kidney disease or cardiac insufficiency, chronic use of analgesics  or psychotropics, allergy to ropivacaine, contraindication to nerve block, inability to comprehend or cooperate to accomplish this study were excluded. The written informed consent was obtained from all subjects. Subjects were randomly allocated into the CACB+SHAM group (receiving CACB plus sham block) and the CACB+IPACK group (receiving CACB plus IPACK block) with a 1:1 ratio based on a computer-generated randomization sequence. Random allocation was carried out using a sealed envelope containing numbered card which was not opened until the nerve block was implemented.The prospective randomized double-blind controlled study complied with the Declaration of Helsinki and obtained the approval from the Ethical Committee of the First Central Hospital of Baoding (NO. [2020] 092). This study was registered at Chinese Clinical Trial Registry  score. All nerve block procedures were performed by the same senior anesthesiologist before anesthesia induction, whereas assessment was accomplished by junior anesthesiologists. Except for the nerve block team including a senior anesthesiologist and an anesthesia nurse, other participants including junior anesthesiologists participating in assessment, nurses on the floor, surgeons and patients were blinded to randomization.All patients received a CACB as our previously reported Fig. a. FifteePatients assigned to group IPACK received a distal IPACK in a posterior approach, according to the method reported by Kampitak W et al. Fig. b 9]. In. In9]. IAnesthesia induction was performed after confirming the effect of nerve block. Propofol, remifentanil, sevoflurane, and cisatracurium were used for anesthesia induction and maintenance. Ventilation by laryngeal mask, end-tidal carbon dioxide was maintained at 35 to 40 mmHg. During the operation, bispectral index was maintained at 45 to 55, and the fluctuation of mean arterial pressure and heart rate were not more than ±10% of the baseline value. To reduce bleeding, tranexamic acid was administered intravenously at 0.5 h before surgery for all patients. All TKA with similar surgical steps and same prosthesis were accomplished by the same surgeon. To assess the analgesic effect of IPACK and ACB, periarticular infiltration, nonsteroidal anti-inflammatory drug(s) and paracetamol were not used in the present research. When the VAS score was more than 4, morphine, oxycodone, or hydromorphone, as a remedy, was administered.https://globalrph.com/medcalcs/opioid-pain-management-converter-advanced/. Secondary outcomes, including the incidence of postoperative moderate-severe pain originated from the posterior knee, the postoperative pain score originated from the posterior knee and the overall postoperative pain score, were assessed at 4, 8, 24, 48 and 72 h after surgery. Postoperative pain was measured by VAS . The range of motion and ambulation distance were assessed in postoperative 1–3 days. The satisfaction for pain management was assessed at 72 h after surgery.The primary outcome was cumulative opioid consumption. To facilitate comparison, opioid consumption was converted to oral morphine equivalents (OME). The following conversion equivalents were used: 5 mg morphine (PO) = 3.33 mg oxycodone (PO) = 1.25 mg hydromorphone (PO) = 1.67 mg morphine (IV/IM/SC) = 0.25 mg hydromorphone (IV) based on the recommendations of According to Patterson ME’s research, 64 patients would have 80% power of detecting a difference at a 5% level of significance, using a confidence interval of 95% . To prevt test. VAS score, opioids consumption and satisfaction for pain management were shown as median (interquartile range) and tested by Mann-Whitney U test. Gender and incidence of moderate-severe posterior knee pain were shown as number (%) and tested by χ2 test. P < 0.05 was considered statistically significant.SPSS 16.0 was used for statistical analysis. The Kolmogorov-Smirnov test was used for testing normal distribution of data. Age, height, weight, body mass index, length of surgery, range of motion and ambulation distance were shown as mean ± standard deviation and tested by P > 0.05).Seventy-two patients were initially enrolled, and seventy of them completed the research Fig. . Patientp = 0.019), 8 hours , and 24 hours  after TKA  vs. 3 (2–4); p = 0.001], and 24 hours  after TKA  vs. 3 (2–4); p = 0.032] at rest and 4 hours , 8 hours , and 24 hours  during active flexion after TKA (Table p = 0.000) and ambulation distance  were superior in group CACB+IPACK than that of the group CACB+SHAM in postoperative 1 day (Table p = 0.024] (Table p = 0.835] (Table The incidence of moderate-severe pain of the posterior knee was lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours (17.1% vs. 42.8%; The study was to observe the analgesic effect and early functional rehabilitation of CACB combined with distal IPACK for patients undergoing TKA. Patients who received distal IPACK combined with CACB for postoperative analgesia had lower incidences of moderate-severe posterior knee pain and lower pain score over 24 hours after the operation. Meantime, CACB combined with distal IPACK could improve the overall VAS score. Moreover, the addition of distal IPACK could facilitate patients’ early activity and improve patients’ satisfaction with pain management. However, postoperative opioids consumption was not decreased by CACB combined with IPACK.The optimal analgesia for TKA requires excellent analgesia while preserving muscle strength. ACB was a motor-sparing nerve block for postoperative analgesia following TKA –13. HoweIn this study, the combination of CACB and distal IPACK block could improve range of motion in postoperative day 1 and ambulation distance in postoperative day 1, which were consistent with Eccles’s findings . The injThere are several limitations to this study. First, the sample size of the study is relatively small, therefore, the outcome may have some limitations. To a certain degree, it is possible that some undesirable complication of IPACK may be neglected, such as bleeding, infection, falls in-hospital and etc. Second, to assess the analgesic effect of IPACK combined with CACB, multimodal analgesic strategy was not implemented in the present research, which might cause insufficient analgesia. Third, the patients were followed for only 72 hours after surgery. In the further, more studies are needed to assess the effect of IPACK block on long-term analgesia and functional exercise after TKA.It is concluded that the combination of CACB and distal IPACK block could decrease the incidences of moderate-severe posterior knee pain, improve the postoperative pain over the first 24 hours for after TKA, as well as promoting recovery of motor function. However, the opioids consumption was not decreased by the addition of IPACK to CACB.