Surgical pain is managed with multi-modal anaesthesia in total hip replacement (THR) and total knee replacement (TKR). It is unclear whether including local anaesthetic infiltration before wound closure provides additional pain control.We performed a systematic review of randomised controlled trials of local anaesthetic infiltration in patients receiving THR or TKR. We searched MEDLINE, Embase and Cochrane CENTRAL to December 2012. Two reviewers screened abstracts, extracted data, and contacted authors for unpublished outcomes and data. Outcomes collected were post-operative pain at rest and during activity after 24 and 48 hours, opioid requirement, mobilisation, hospital stay and complications. When feasible, we estimated pooled treatment effects using random effects meta-analyses.In 13 studies including 909 patients undergoing THR, patients receiving local anaesthetic infiltration experienced a greater reduction in pain at 24 hours at rest by standardised mean difference (SMD) -0.61  and by SMD -0.43  at 48 hours during activity.In TKR, diverse multi-modal regimens were reported. In 23 studies including 1439 patients undergoing TKR, local anaesthetic infiltration reduced pain on average by SMD -0.40  at 24 hours at rest and by SMD -0.27  at 48 hours during activity, compared with patients receiving no infiltration or placebo. There was evidence of a larger reduction in studies delivering additional local anaesthetic after wound closure. There was no evidence of pain control additional to that provided by femoral nerve block.Patients receiving local anaesthetic infiltration spent on average an estimated 0.83  and 0.87  fewer days in hospital after THR and TKR respectively, had reduced opioid consumption, earlier mobilisation, and lower incidence of vomiting.Few studies reported long-term outcomes.Local anaesthetic infiltration is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Studies should assess whether local anaesthetic infiltration can prevent long-term pain. Enhanced pain control with additional analgesia through a catheter should be weighed against a possible infection risk. Total hip replacement (THR) and total knee replacement (TKR) are widely used to treat diseased and damaged joints. In 2012 there were 75,366 primary THR and 76,497 primary TKR procedures recorded in the National Joint Registry for England, Wales and Northern Ireland [Pain is the primary indication for THR and TKR and many preparatory, surgical and rehabilitation strategies target reduction in pain. However, both short- and long-term pain after THR and TKR are common -5. Peri-Pain management by infusion of local anaesthetic into wounds has been evaluated in diverse surgical procedures. In their systematic review, Liu and colleagues noted improved pain, reduced opioid use and side effects, increased patient satisfaction, and shorter hospital stay in patients receiving local anaesthetic infiltration . Only onUsing systematic review methods and meta-analysis, our objective was to synthesise evidence from randomised controlled trials (RCTs) evaluating the effectiveness of peri-operative local anaesthetic infiltration for pain control in patients with THR and TKR. Pain outcomes were considered along with post-operative opioid requirement, mobilisation, hospital stay and complications.We identified RCTs using methods described in the Cochrane handbook of systematic reviews of interventions . The revth December 2012. The search strategy covered RCTs, anaesthesia and analgesia, and THR and TKR terms ; additional intervention group treatments; and control group treatment including placebo and alternative analgesia regimens.Outcomes studied were pain at rest or during activity at 24 and 48 hours after surgery, opioid consumption, mobilisation, length of hospital stay in days, and long-term pain and function. Serious complications recorded were altered state of consciousness, cardiovascular complications requiring treatment, central nervous system toxicity, dysarthria, dyspnoea, major surgical complications, pneumonia, pulmonary embolism, respiratory depression, seizures, and swollen knee; or complications relating to deep infection. Adverse events were vomiting and nausea.Potential sources of bias were recorded in a Cochrane risk of bias table . We consWe conducted meta-analyses for pain at rest and during activity at 24 and 48 hours, length of hospital stay, and complications. Data collected on mobilisation, long-term pain and function outcomes were not suitable for meta-analyses and results were summarised using a descriptive narrative.Follow-up times were approximated to the closest timing. When not specified, we assumed measurements were taken at rest. Analyses were carried out in Stata 12 and Review Manager 5 and results are reported with 95% confidence intervals. Funnel plots were inspected to assess small study effects . Given tIn meta-analysis, means and standard deviations of continuous variables such as pain intensity are required for intervention and control groups. Pain outcomes are sometimes reported as medians and inter-quartile ranges due to the recognised ceiling effects of pain measures after successful pain management. However this is less of an issue during early recovery. Kerr and Kohan presented distributions of pain intensity scores at rest and during walking on the first and second day after THR or TKR . The proAssuming a normal distribution, we estimated means and standard deviations from medians and inter-quartile ranges . If no mAs pain scores are reported on different scales we used the standardised mean difference (SMD) as our measure of treatment effect in meta-analyses . To helpFor length of hospital stay, we compared means and medians in studies reporting both, and examined individual level data provided by some authors. Distributions were right-skewed and followed a lognormal distribution. Some studies reported means and standard deviations directly. For studies that reported medians and inter-quartile ranges, or ranges, we estimated means and standard deviations on the log scale and then back-transformed them to the natural (unlogged) scale . We repoNot all studies compared a local anaesthetic infiltration intervention with no intervention or placebo. Thus meta-analyses are reported separately for different regimen comparisons, which we label A-E. These are summarised in Figure THR studies were grouped into comparisons A and B; we and also report the combined comparison (A + B).For TKR studies, we initially report results from a combined meta-analysis across the first two subgroups (A + B), comparing local anaesthetic infiltration with or without further post-closure intervention against control. Further analyses report the comparisons C, D and E.2 and I2 statistics [We quantified the differences in treatment effects between groups using meta-regression. Heterogeneity within meta-analyses was quantified using the τatistics . SensitiSearches identified 839 articles of which 33 described 36 RCTs evaluating local anaesthetic infiltration in THR or TKR. The flow diagram in Figure Inspection of funnel plots for each meta-analysis gave no strong indication of publication bias or small study effects, but numbers of studies in individual analysis groups were small such that it was difficult to assess asymmetry.Details of 13 studies including 909 patients with THR ,27-37, oResults of meta-analyses including up to 12 studies -29,31-37In seven studies with no additional post-closure analgesia through a catheter or injection (A), patients receiving local anaesthetic infiltration reported lower pain at 24 hours at rest by SMD -0.63 , equivalent to an average of 12 points lower pain. However, there was no strong evidence that the intervention had an effect during activity or at 48 hours.In five studies where patients received further post-closure analgesia (B), pain was reduced on average at 24 hours during activity by SMD -1.38 , equivalent to a 40 point decrease on a 100 point scale. Pain at 48 hours was reduced, on average, at rest by SMD -0.49  and during activity by SMD -0.6  equivalent to 8 and 14 point decreases, respectively.In one study, control patients received an epidural analgesia infusion . Pain wa2 and τ 2 statistics was high, and separating the analysis for A and B groups did not appear to reduce this heterogeneity. Restricting the analysis to studies with low risk of bias gave a marginally smaller estimate of reduction in pain at 24 hours at rest by an average of SMD -0.49 , but during activity average pain reduction appeared greater at SMD -0.99 , corresponding to 28 points on a 100 point scale.Heterogeneity measured by the IIn all 11 studies reporting an outcome, opioid consumption was reduced in patients receiving local anaesthetic infiltration compared with controls ,27,30-37In the studies where control patients received epidural or intrathecal analgesia, patients receiving local anaesthetic infiltration consumed 20% and 12% less morphine, respectively.Several different measures of mobilisation were reported. In three studies patients receiving local anaesthetic infiltration with no additional post-operative component achieved a straight leg raise earlier than control patients ,29,32. MIn one study, 35% of patients receiving local anaesthetic infiltration were able to walk after 8 hours compared with 87% of control patients receiving an epidural infusion. In the study where control patients received intrathecal morphine, 33% of these patients could walk further than 5 metres on the first post-operative day compared with 71% of patients receiving local anaesthetic infiltration.2 = 84%), mainly in studies with additional post-operative analgesia.As shown in Table When the comparison group received an epidural infusion , patientThe Peto OR for a major complication in patients with local anaesthetic infiltration compared with controls was 0.30 , but this is weak evidence, based on five major complications in 896 patients. Five deep infections were reported, four in local anaesthetic infiltration patients and one in controls, Peto OR 3.47 . Four infections occurred in the 218 patients who received post-closure delivery of infiltrate through a catheter.The incidence of vomiting was reduced in patients receiving local anaesthetic infiltration in five studies with 309 patients with data, Peto OR 0.46 .Five studies reported long-term outcomes. Andersen and colleagues reported a trend for improved Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores at six weeks in local anaesthetic infiltration patients compared with controls . At eighOverall there were 23 studies including 1,439 patients with TKR ,28,38-56As shown in Table Heterogeneity was moderate to low. When we restricted analyses to studies assessed as low risk of bias, pain outcome estimates were slightly attenuated towards zero.We additionally performed separate analyses according to whether additional analgesia was delivered after wound closure through a catheter or injection. In the six studies with no further analgesia (A studies) -42,47,52In six studies with additional analgesia delivered after wound closure (B studies) ,46,48,51In six studies comparing local anaesthetic infiltration with or without additional post-closure analgesia against femoral nerve block, there was no evidence for improvement in pain at any time point ,50,55,56In eight comparisons between local anaesthetic infiltration with controls ,48,49,51In four studies, control patients received either an epidural infusion ,48,49 orIn all four studies reporting opioid consumption, this was reduced by 35–40% in patients receiving wound infiltration with no additional post-closure analgesia ,42,47,52In six studies where the control group or both groups received femoral nerve block, there was little difference in opioid consumption between randomised groups ,45,50,53In four studies where patients receiving wound infiltration with further post-closure analgesia were compared with patients receiving epidural anaesthesia, there was no consistent difference between groups ,48,49.Nineteen studies reported a mobilisation outcome. In four studies, patients receiving local anaesthetic infiltration had reduced time to achieve a straight leg raise by an estimated 44–50% ,47,52 orIn four out of five studies, patients receiving local anaesthetic infiltration achieved better knee flexion ,40,47,54Improvements to diverse walking goals were reported in patients receiving local anaesthetic infiltration in three studies where some or all of the comparison group patients received epidural analgesia ,49. WhenData on length of hospital stay were available for 8 studies comparing local anaesthetic infiltration with controls ,48,49,51In three studies where the comparison group received femoral nerve block ,45,55, tIn four studies where the control group received epidural analgesia ,48,49, lBased on 11 events, the Peto OR for a major complication was 1.17  in patients receiving local anaesthetic infiltration compared with controls. There were two deep infections in intervention patients ,44, and Excluding one intervention with additional morphine , there wFive studies reported outcomes measured at six weeks ,45, or tCarli and colleagues reported poorer WOMAC scores after 6 weeks in patients receiving local anaesthetic infiltration compared with the control group who received femoral nerve block .Our systematic review and meta-analyses represent a comprehensive overview of evaluations of the effectiveness of peri-operative local anaesthetic infiltration in THR and TKR. Systematic reviews allow for a more objective appraisal than traditional narrative reviews , which aIn conducting this systematic review we recognised the problems that can arise when small studies are included in meta-analyses . In thisPain after THR was reduced for patients receiving local anaesthetic infiltration, with patients experiencing less pain at rest at 24 hours and during activity at 48 hours equivalent to about 12 and 10 points on a 100 point pain intensity scale. In musculoskeletal settings, VAS pain changes of 11 , and 14 Pain after TKR was also reduced for patients receiving local anaesthetic infiltration compared with controls, with less pain at rest at 24 hours and after 48 hours during activity, equivalent to reductions of about 10 and 8 points on a 100 point pain intensity scale. Opioid consumption was reduced compared with untreated control patients and there was a general observation of early mobilisation, reduced vomiting and nausea, and early hospital discharge. Inclusion of the non-steroidal anti-inflammatory agent ketoralac in the infiltrate seemed to enhance post-operative pain relief.When compared with alternative regimens, results were not so clear. Pain levels after TKR were broadly similar when femoral nerve block was included in the general analgesia regimen or as a comparator. Likewise, opioid consumption was similar. There was some suggestion of benefit for earlier mobilisation, but length of hospital stay was not reduced in patients receiving local anaesthetic infiltration. Femoral nerve block is a well established method of providing analgesia after TKR and is associated with reduced opioid requirement and thus fewer side effects such as nausea and vomiting. However, femoral nerve block is associated with decreased quadriceps function for a time and an increased risk of falls ,65.In studies in patients receiving TKR where control groups received epidural or intrathecal analgesia, benefit was observed for reduced pain in patients receiving local anaesthetic infiltration. Opioid consumption did not differ between groups but mobilisation and hospital discharge were achieved earlier in patients receiving local anaesthetic infiltration.The improvement in pain control and shorter hospital stay was greatest for patients receiving additional analgesia through a catheter or by injection. However, we observed a small but potentially important increase in rates of serious infection, particularly in patients receiving further infiltrate through a catheter post-wound closure. Across THR and TKR studies, there were eight cases of deep infection requiring surgical debridement or revision. Six of these were in patients randomised to wound infiltration analgesia with additional analgesia through a post-surgical catheter. Indeed, all patients with deep infection had been randomised to receiving a catheter although researchers reported that catheters in control groups were not inserted into the joint capsule. The overall rate of infection in patients with THR or TKR randomised into wound infiltration analgesia studies was 0.34% and in patients receiving an active catheter the rate was 1.4%.Few studies in patients with THR or TKR reported long-term follow up of patients and results were equivocal. Acute post-operative pain is an important risk factor for long-term pain ,67, and Our study has limitations. Although meta-analyses performed were enhanced by extensive contact with authors, imputation was required for some measures of variability. The skewed nature of hospital stay required transformation under assumptions of a lognormal distribution . For opiA further limitation of meta-analyses in a highly active field of research such as wound infiltration analgesia is that they may become out of date quickly. Their value is emphasised, however, in a widely cited example when studies of streptokinase in acute coronary heart disease were conducted long after a critical mass of evidence had been obtained from meta-analysis showing benefit for patients . Prior tOur results show that local anaesthetic infiltration is effective in reducing short-term pain after THR and TKR when compared with no anaesthetic infiltration. The effect of local anaesthetic infiltration is enhanced with the addition of post-closure analgesia, although this needs to be considered in light of the infection risks associated with catheters . In TKR,Our systematic review and meta-analysis shows that inclusion of local anaesthetic infiltration in a multi-modal anaesthesia regimen is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Enhanced pain control was observed when additional analgesia was provided after wound closure through a catheter but benefit should be weighed against a possible infection risk. For patients with TKR, inclusion of the non-steroidal anti-inflammatory agent ketoralac in the infiltrate seemed to enhance pain relief. There was no evidence of pain control additional to that provided by femoral nerve block in patients receiving TKR. Few studies reported long-term outcomes and future research should assess whether local anaesthetic infiltration can affect the development of long-term post-surgical pain.THR: Total hip replacement; TKR: Total knee replacement; RCT: Randomised controlled trial; SMD: Standardised mean difference; MD: Mean difference; VAS: Visual analogue scale; OR: Odds ratio; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index.The authors declare that they have no competing of interests.ADB, EM, AWB and MP designed the study and produced the search strategy. EM and ADB performed the systematic review as second and first reviewers respectively, conducted the searches, screened abstracts and titles, assessed inclusion and exclusion criteria, produced data collection forms and extracted data, assessed study quality and contacted authors. AWB and MP advised on inclusion/ exclusion criteria and subgroup analyses. HEJ provided statistical guidance. EM and HEJ performed meta-analyses of continuous and skewed outcomes (pain and length of stay). KTE and ADB collected complications data and performed meta-analyses of complications. EM, ADB and HEJ drafted the article with critical revisions from AWB, MP and KTE. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/15/220/prepubPRISMA checklist.Click here for fileCochrane risk of bias table .Click here for file


Botulinum toxin type A (BTX-A) has been reported to have analgesic effects independent of its action on muscle tone, mostly by acting on neurogenic inflammatory mediators and controlling the neurotransmitter release of sensory and autonomic nerve terminals that are involved in many chronic painful conditions as chronic intractable trigeminal neuralgia (TN).The aim of our work was evaluating the efficacy, safety, and tolerability of BTX-A for the treatment of intractable idiopathic TN.This was a randomized, single-blinded, placebo-control study carried out on 20 Egyptian patients with intractable TN. Patients received a one-time subcutaneous administration of BTX-A using “follow the pain” method. The primary efficacy measure was reduction in pain severity on the 10-cm VAS score as well as in paroxysms frequency from the baseline to week 12 (endpoint last observation carried forward [LOCF]). Secondary efficacy measures included QoL assessment and number of acute medications received from baseline to the endpoint.Pain reduction at the 12-week endpoint was significant in BTX-A group ; VAS scores at endpoint LOCF relative to baseline for BTX-A group showed a decrease of 6.5 compared with a decrease of 0.3 for placebo, also there was a significant decrease in the number of acute medications and an increase in QoL functioning scale.These results indicate that BTX-A has a direct analgesic effect in patients with TN and can represent a therapeutic option for intractable cases. Trigeminal neuralgia (TN) is defined as a unilateral, abrupt, brief electric shock-like pain, that is limited to the distribution of one or more divisions of the trigeminal nerve .The chronic and recurrent pain imposes a substantial burden on patients’ quality of life (QoL) . Other cThe analgesic effect of BTX-A has been investigated through a series of open-labeled studies as well as a few randomized controlled trials (RCTs) -11, withThis is a randomized controlled study aiming at evaluating the efficacy and tolerability of botulinum toxin type A (Botox®) for the treatment of intractable idiopathic trigeminal neuralgia.This is a randomized, double-blinded, placebo-control study.Eligible subjects had idiopathic TN according to IHS criteria . In all Patients who responded to medical treatments, pregnants, symptomatic TN  and patient with possibility of lack of coherence during follow up.The study was designed according to the recommendations of the IHS, and was approved by Neurology Department Review Board in Cairo University. A written informed consent was obtained from all participants prior to study commencement.From March, 2010 to June, 2012, 20 consecutive Egyptian patients who fulfilled inclusion criteria were recruited.Every patient was assessed clinically and by MRI brain. The MRI scans of all patients were normal as a prerequisite for inclusion even for those patients who were subjected to surgery for their idiopathic neuralgias. Thereafter, all patients were requested to complete a baseline, pre-treatment questionnaire to assess pain intensity using VAS, average paroxysms frequency per day, precipitants, associated symptoms, trigger areas, drug compliance, and number of weekly acute medications in the last 3 months. Initially, 24 patients were recruited; 2 of them were excluded as they had difficulty in complying the follow up visits (they were from upper Egypt), one patient withdrew his informed consent and one patient failed to complete the screening questionnaire Figure . After tEvery patient received either BTX- A (Botox®)  or placebo (2 mL 0.9% NaCl). Eligible patients were allocated to one of the two treatment arms in a randomized (1:1), double-blind fashion using a computer-generated randomization to receive either arm with 12 weeks follow up period.Injection points were detected using “follow the pain” method, especially in the trigger zones and each point had received 5 units of BTX-A / or 0.1 ml placebo subcutaneously. In patients with mandibular root involvement, a larger dose of the toxin was injected posteriorly in the masseter to avoid undesired cosmetic effects. Patients were evaluated every 2 weeks for 12 weeks by using the VAS. The number of painful paroxysms and the need of any acute medications were reported.Assignment to either Botox or placebo was blinded to participants, treating physicians (injectors) and investigators who assessed the patients in follow up visits. Every effort was made to maintain strict blinding; the only unblinded physician (G.R) was the one who performed randomization and prepared the syringes in the injection session. He was trained to perform Botox preparation for injection and he was not involved in any other study procedures. It is worth noting that, this blindness was not maintained after the first 2 weeks assessment in some patients who developed facial asymmetry following BTX-A injection, however, the follow up assessment scales were presented in a structured interview that minimized biased investigator’s impression.The primary efficacy measures were pain severity reduction in the 10-cm VAS score and paroxysms frequency from the baseline to week 12 (endpoint last observation carried forward [LOCF]). Secondary efficacy measures included QoL scale and number of weekly acute medications received from baseline to the endpoint.Any adverse event that a subject reported during the study was recorded by the investigators, graded for severity , and assessed for its relationship to study treatment . A serious adverse event was defined as one that was fatal, life-threatening, permanently disabling, or required admission to hospital.Data management was carried out with the Statistical Package for Social Sciences . Simple descriptive analysis in the form of means and standard deviations were calculated for numerical data, qualitative data were described using percent distribution. Efficacy and safety measures were assessed for all patients based on intention to treat. Comparison of Botox and placebo groups in efficacy measures at endpoints using the LOCF was conducted using an analysis of covariance (ANCOVA) model. Correlation was conducted using bivariate Pearson correlation coefficient. The level of significance was set at 0.05.A total of 20 Egyptian patients were randomized. Their age ranged from 27 to 72 years (mean age: 45.95 ± 10.02 years). They were 9 males (45%) and 11 females (55%), the mean duration of the disease was 5.33 ± 1.52 years (range from 3 to 9 years). Pain affected one root in 8 patients, while two roots were affected in 12 patients . The overall injected doses ranged from 40 units (8 injection points) to 60 units (12 points) (mean ± SD was 48 ± 5.87).The mean baseline pain scores in placebo group and BTX-A group were 8.5 and 8.3 respectively on the VAS score with no significant difference. Pain reduction at the 12-week endpoint was significant in BTX group (P < 0.0001), VAS scores at endpoint LOCF relative to baseline for BTX-A group showed a decrease of 6.5 compared with a decrease of 0.3 for placebo. This significant reduction in the mean VAS scores were recorded in BTX-A group in week 2 and maintained over the follow up visits  or paroxysms frequency .Treatments were generally tolerated, no systemic reactions were noted and there were no serious injections-related adverse events. The reported side effects were facial asymmetry, hematoma at the site of injection, itching and pain at the site of injection Table . All theThe role of BTX-A in the treatment of drug-refractory trigeminal neuralgia has been evaluated by some authorities ,13,14, aThe mechanism by which BTX-A exerts its antinociceptive effect is poorly understood; whether or not BTX-A can change sensory perception in those patients remains unknown . Cui et The results of the current study support the possible role of BTX-A in pain alleviation, evidenced by the significant reduction in the mean VAS scores as well as the paroxysms frequency in BTX group in week 2 which continued till the endpoint LOCF, in addition to the significant increase in QoL functioning scale compared to the placebo group. Similar to our data, Pioversan et al.  reported2 was injected with a mean total dose of 48 units. In Pioversan et al. [2. An open label study assessed the clinical effects of BTX-A injections in 12 patients with otherwise unresponsive idiopathic trigeminal neuralgia. Patients were infiltrated with 20–50 units of BTX-A in trigger zones. The patients were assessed on a weekly basis using the Visual Analogic Scale for pain. Ten patients reported a significant benefit from BTX-A injections, with reduction or even disappearance of pain, and remained pain free for as long as 60 days [In our series a mean of 5 units /cmn et al.  study, t 60 days . In anot 60 days . In our Regarding safety of the BTX-A in the current study, side effects were generally tolerated and were mostly related to the injection sites, 4 cases developed mild facial asymmetry which was self limited and did not impose much impact on the patients especially in the setting of reduced pain. However, this adverse event could be overcome by a more posterior injection approach.Subcutaneous BTX-A injection can result in relieving pain in intractable cases with TN with minimal adverse reactions and can be an effective treatment option.The authors declare that they have no competing interests.HS, MEl-T, and NS participated in the pre-injection assessment and in injection as a team, whereas, GR participated in post-injection assessment. All authors read and approved the final manuscript.


Introduction. The purpose of this study is to investigate chest pain evaluations after initial coronary computed tomography angiography (CCTA) based upon coronary artery disease (CAD) burden. Methods. CCTA results of 1,518 patients were grouped based on the CCTA results into no CAD, nonobstructive CAD , or obstructive CAD (≥50% stenosis). Chest pain evaluation after initial CCTA and rates of major adverse cardiovascular events (MACE) defined as the incidence of all-cause mortality, nonfatal MI, ischemic stroke, and late revascularization (>90 days following CCTA) were evaluated. Results. MACE rates were higher with obstructive CAD compared to nonobstructive CAD and no CAD . One hundred seventy-four patients (11.5%) underwent evaluation for chest pain after index CCTA with rates significantly higher with obstructive CAD compared to both nonobstructive CAD and no CAD . The incidence of repeat testing was more frequent in patients with obstructive CAD . Conclusion. Absence of obstructive disease on CCTA is associated with lower rates of subsequent evaluations for chest pain and repeat testing with low MACE event rates over a 22-month followup. Coronary CT angiography (CCTA) has emerged as an effective tool for both outpatient and emergency department (ED) evaluation of low to intermediate risk patients presenting with acute chest pain syndromes –6. CCTA Recurrent chest pain presentations often lead to repeat testing and recurrent hospitalizations. Recurrent emergency department evaluations and hospitalizations for chest pain have been reported previously without commenting on CCTA disease burden , 12. We Coronary CT angiography (CCTA) results from January 2005 until July 2012 at a high volume, single center tertiary referral hospital were retrospectively reviewed. A study population of 1518 patients evaluated in emergency department (ED), inpatient, or outpatient setting for the indications of chest pain, dyspnea, syncope, evaluation of graft/stent patency, or possible anomalous coronary artery was identified. Patients were grouped based on the CCTA results demonstrating either no CAD, nonobstructive CAD , or obstructive CAD (≥50% stenosis). Recurrent chest pain was determined based on ICD-9 codes. Rates of major adverse cardiovascular events (MACE) were abstracted.CCTA images were analyzed by a cardiologist with level III ACC/ACR certified imaging expert in accordance with SCCT guidelines . From JaThe primary endpoint was recurrent chest pain evaluation. Recurrent chest pain evaluations were identified initially by searching ICD-9 codes for atypical chest pain (786.59), chest pain (786.5), and angina (413) both in the inpatient and outpatient setting. All identified chest pain diagnoses after initial CCTA were manually adjudicated by per patient chart review. Any additional invasive or noninvasive cardiac risk stratification testing performed after the initial CCTA was documented, including multiple testing when applicable. Centers for Medicare and Medicaid Services (CMS) reimbursement rates, released in December 2013, were used to calculate per patient cost for additional risk stratification testing following CCTA. The composite secondary outcome was MACE, defined as all-cause mortality, stroke, nonfatal MI, and late revascularization, defined as revascularization performed within 90 days of CCTA with CAC imaging. ICD-9 codes for all-cause mortality , stroke , nonfatal MI (410.0–410.9), and late revascularization with PCI  or CABG  were used for initial data extraction followed by Department of Defense (DOD) outpatient and inpatient electronic medical records (EMR) verification of events. We determined mortality using the social security death index (SSDI) followed by reverification using EMR for last visit date as well as Tricare Healthcare Informatics Division verification. All events identified by ICD-9 code were adjudicated.P values <0.05 considered statistically significant. Kaplan-Meier method was used to demonstrate chest pain-free survival in the recurrent chest pain population as well as total survival free from MACE in the total population with a log rank value <0.05 considered statistically significant.Statistical analysis was performed using IBM SPSS version 19.0 . Continuous variables are presented as means ± standard deviation. Categorical variables are presented as frequencies with percentages. Comparison of means between the various CCTA groups was performed using one-way ANOVA with P < 0.001). CCTA evaluation in these 1518 patients at index evaluation demonstrated obstructive CAD, nonobstructive CAD, and no CAD in 11.5%, 43.1%, and 45.4%, respectively. Patients with obstructive CAD on CCTA were more likely to have documented diabetes mellitus (P < 0.001) and hypertension (P < 0.001). Obstructive CAD and nonobstructive CAD patients were more likely to have hyperlipidemia than no CAD CCTA patients (P < 0.001). Of the 174 patients with obstructive disease, single-vessel, 2-vessel, and 3-vessel obstruction was found in 64.5%, 32.3%, and 3.2%, respectively. All-cause mortality was rare in this patient population with 3 total deaths and was not statistically different stratified by CAD burden. Stroke, nonfatal MI, late revascularization, and composite MACE rates were significantly higher in the obstructive CAD cohort  with overall low event rates.One thousand five hundred eighteen patients underwent CCTA in an ED, inpatient or outpatient setting. P < 0.001). The mean age at the time of reevaluation differed amongst the groups; however the nonobstructive CAD patients tended to be older at time of reevaluation . The incidence of repeat testing (P = 0.015). This correlated with increased frequency of hospitalizations at initial reevaluation amongst the groups with 34.6%, 53.8%, and 58.1% of patients in the no CAD, nonobstructive CAD, and obstructive CAD groups, respectively (P = 0.046). There was no difference observed with respect to the mean duration of time between index CCTA and reevaluation for chest pain (P = 0.938) nor the length of stay (LOS) during hospitalization at first reevaluation (P = 0.810). At the time of reevaluation, review of initial CCTA results was significantly correlated with time free of recurrent chest pain with those having no CAD having a longer chest pain-free survival period with log rank showing P < 0.001  overall. Fifty-two patients with no CAD, 91 patients with nonobstructive CAD, and 31 patients with obstructive CAD  presente testing  was more < 0.001 . Health  < 0.001 .P = 0.032), high per patient cost in repeat testing (P = 0.019), higher all-cause mortality (P < 0.001), and composite MACE rates (P < 0.001). There was no difference between nonobstructive LM CAD, obstructive LM CAD, and no LM CAD with respect to chest pain reevaluations . Nonobstructive LM CAD was associated with longer hospital LOS (1.8 ± 1.3 days) when compared with no LM CAD and obstructive LM CAD .Outcomes and ability to predict recurrent chest pain evaluations and MACE were broken down into individual major epicardial coronary vessels and analyzed with respect to CAD burden. Obstructive LM CAD  on initiP < 0.001), hospitalization at reevaluation (P < 0.001), repeat testing at the time of reevaluation (P < 0.001), average per patient testing and cost (P < 0.001 for both), rates of myocardial infarction (P = 0.006), late revascularization (P = 0.006), and composite MACE (P = 0.005).Obstructive LAD CAD  was assoP = 0.048), hospitalization at reevaluation (P = 0.039), repeat testing at the time of reevaluation (P = 0.003), average per patient testing (P = 0.001), average per patient cost for repeat testing (P < 0.001), all-cause mortality (P = 0.027), stroke (P = 0.003), late revascularization (P = 0.020), and composite MACE (P < 0.001). Any degree of CAD in the LCX was associated with higher rates of MI than no LCX disease (P = 0.001).Obstructive LCX CAD  was founP = 0.016). Nonobstructive RCA CAD was also associated with higher rates of repeat testing (P < 0.001), average tests performed per patient (P = 0.001), and per patient testing cost (P < 0.001). Obstructive RCA CAD was associated with higher rates of hospitalization at time of reevaluation (P = 0.014), hospital LOS (P = 0.018), stroke (P < 0.001), MI (P = 0.001), late revascularization (P < 0.001), and composite MACE (P < 0.001).Nonobstructive CAD in the RCA  was assoP < 0.001). Male predominance was observed in patients with 3-vessel disease when compared to the other two groups (P = 0.041). Reevaluations for chest pain were found more commonly in patients with 2-vessel CAD when compared to 1-vessel and 3-vessel . This increased incidence of reevaluation did not translate into a difference with regard to frequency of hospitalization, hospital LOS, frequency of repeat ischemic testing, or total number of repeat tests ordered per group. Additionally, the time to reevaluation and the incidence of morbidity and mortality were not different between the three groups. Within the obstructive disease cohort, twenty-one patients underwent repeat testing at the time of reevaluation when compared with 10 patients where testing was deferred (67.7% versus 32.3%). No difference was observed with regard to stroke , MI , late revascularization , and composite MACE  whether additional testing was performed or not . P = 0.001). However, once patients were selected to undergo additional testing, there was no difference amongst the groups with regard to the average number of tests ordered per patient in the obstructive, nonobstructive, and no CAD groups . Hospital LOS was not different between the groups and thus was not included in the cost analysis. Outcomes were not different in the 90 patients that underwent repeat testing at time of reevaluation for chest pain when compared to the 84 patients where testing was deferred (P = 1.0), MI , late revascularization , and composite MACE  were not different in the repeat testing and no repeat testing groups, respectively.Testing frequency also appeared to be affected by CCTA disease burden. When comparing all patients with reevaluation for chest pain, the average number of total tests ordered was higher in the patients with obstructive disease (0.8 ± 0.7) when compared to patient with nonobstructive CAD or no CAD  presentations and return visits are common; therefore, an effective strategy to curtail these recurrent presentations is vital. CCTA has proven to be an effective means to evaluate patients with possible ACS in the emergency department who have low to intermediate risk of CAD . CurrentGiven the high costs associated with recurrent ED evaluations and inpatient admissions for chest pain, a more definitive strategy of excluding significant CAD was needed and CCTA seems to be providing this necessity. A recently published study comparing CCTA to standard evaluation in the emergency department triage of low-risk chest pain revealed that CCTA led to a statistically significant decrease in admission rates, and return visits to the ED for recurrent chest discomfort were 5 times more likely within 30 days in the standard evaluation arm . The staFurther studies have been done comparing CCTA to myocardial perfusion imaging in the evaluation of acute, low-risk chest pain patients in the ED. A recent multicenter randomized trial showed that compared to MPI, CCTA resulted in a statistically significant reduction in time to diagnosis and decreased health care costs without a difference in major adverse cardiac events after normal index findings .CCTA not only allows prognostication based on presence or absence of obstructive disease but also allows for determination of plaque characterization that may reveal future presentations for chest pain due to acute coronary syndromes (ACS) . These cIndividual epicardial vessel CAD burden in this study demonstrated predictive utility for predicting repeat chest pain evaluations with the exception of LM obstructive disease. While this finding is unanticipated, it likely represents the very small number of patients  in the study cohort with obstructive LM CAD. Additionally, nearly all of these patients went on to coronary artery bypass graft (CABG) surgery within 30 days of initial CCTA. Thus with complete revascularization, lower recurrence rates for angina would be expected. An unpublished analysis by our group demonstrated the presence of LM coronary artery calcium (CAC) may predict MACE events to include stroke above that which would be predicted by total CAC score alone in a symptomatic cohort of patients. Indeed this current analysis also suggests the presence of obstructive LM disease predicts higher MACE rates to include mortality, stroke, MI, and late revascularization.Absence of obstructive disease on CCTA is associated with much lower rates of subsequent evaluations for chest pain and repeat testing with associated low MACE event rates over 6-year review period and median followup of 22 months.


There is a limited information about the role of Substance P (SP) in acute pain nociception following surgical stimulation in patients with a chronic inflammatory state not to mention the link between this neuropeptide level changes and intensity of pain. The goal of the research was to find the correlation between SP level changes and acute pain intensity in patients with rheumatoid arthritis undergoing elective orthopedic surgery.Patients with rheumatoid arthritis (RA) were enrolled in the study. The correlation between acute pain intensity and concentration of SP in serum as well as in drainage fluid from postoperative wound was assessed in patients with RA who underwent Total Knee Replacement (TKA) under spinal anesthesia.In patients with RA a correlation between intensity of acute pain and serum SP was found postoperatively, whereas there was no correlation between intensity of acute pain and concentration of SP in drainage fluid.1. The correlation between acute pain intensity and SP serum concentration was found postoperatively in patients with RA. 2. The correlation between acute pain intensity and SP concentration in drainage fluid was not found postoperatively in patients with RA. A great deal of recent evidence suggests that SP and its receptors are involved in joint inflammation and associated with some aspects of the pathophysiology of RA , 2]..2].Total Knee Arthroplasty (TKA) is a useful surgical procedure for pain relief, which much improves the patient’s life comfort.The acute postoperative pain is the direct consequence of the knee surgery following nociceptors excitation inside injured tissue.There is a limited information describing the role of SP during acute nociception following surgical stimulation in patients with a chronic inflammatory state. Therefore, the correlation between the intensity of pain and systemic or local SP concentrations was studied in patients with RA who experienced an acute postoperative pain following orthopedic surgery.The main objective of the research was to evaluate the link between intensity of acute pain in patients with RA undergoing elective orthopedic surgery and serum concentration of SP.In addition, SP concentration in drainage fluid collected from postoperative wounds was measured.Patients with RA were randomly enrolled in the study.All patients were diagnosed according to the criteria of the American Rheumatism Association .Exclusion criteria included:Contraindications to spinal anesthesia ASA physical status > IIISevere liver or kidney diseasesHistory of opioids dependenceThe presence of other inflammatory diseasesThe intensity of acute pain in correlation with the concentration of SP in serum and drainage fluid from postoperative wound was examined postoperatively.2  were continuously monitored throughout surgery in all patients. None of the patients received opioids during surgery. For postoperative pain relief, the patients were given opioids and paracetamol. The venous blood samples were collected just before surgery (0 h) as well as 6 (6 h), 24 (24 h), 36 (36 h) hours postoperatively.All patients underwent Total Knee Arthroplasty under spinal anesthesia. The classic cardiopulmonary parameters including ECG, BP , SpOThe disease activity was assessed with subjective and objective methods in all patients with RA. DAS 28 (Disease Activity Score) according to four variables with DAS 28 formula by DAS 28 Calculator v1.1-beta (Alfons & Michiel) was estimated.The intensity of pain was evaluated using a numeric pain scale (NPS) from 0 to 5 where 0 corresponds with no pain, 1 –slight, 2 –moderate, 3 –intensive, 4 –severe and 5 –worst imaginable pain. The evaluation was done by patients.The concentrations of SP in blood and drainage fluids samples were measured. The 4–5 ml venous blood samples were collected into the serum test- tubes, delivered to an analytical laboratory and centrifuged (2000 rpm/10 min). The sera were placed into 200 μl test- tubes and stored at -70°C. The 4–5 ml drainage fluid samples were collected postoperatively with a sterile syringe directly from postoperative wound drainage and the supernatants were aliquoted and stored the same as sera. The concentration of SP was measured with Substance P Immunoassay Test (R&D System) according to manual. The minimum detectable level for this assay was 8,0 pg/ml.P values <0.05 were considered significant.STATISTICA v.10 was used to carry out statistical analysis. For the tests performed at the time the repeated measures analysis was used. The sphericity assumption was estimated by Mauchly’s test. If the analysed variables did not correspond with the sphericity assumption then, for the result of the variance analysis, the more conservative Greenhouse-Geisser correction was used to adjust the degree of freedom associated with the F-value for repeated measure data the univariate and multivariate ANOVA tests were used. Correlation analyses were performed with the Spearman rank correlation test. Factor analysis was performed to find patterns among the measured variables. Factor loadings > 0.70 were considered. The factor analyses were performed with Varimax, with Kaiser normalisation as a rotation method. In order to identify interdependencies (their power was checked by the Snedecor F test) further tests were made to find a regression function, The protocol was approved by the medical Ethics Committee of Institute of Rheumatology in Warsaw. The experiments were conducted according to the principles expressed in the Declaration of Helsinki.A written, informed consent was obtained from all patients.The correlation between acute postoperative pain and SP serum was examined in 23 RA patients who underwent elective orthopedic surgeries. More women than men were enrolled in the study (22/1) at average age 59±10 years. The average RA disease duration was 21±8.7 years. The average DAS was 4.9±0.9, which indicates high disease activity. The SP drainage concentration (SP dr) and serum SP concentration were examined in 14 patients at the same time.2(5) = 8.63, P = 0.125, but for SP and NPS have been violated; χ2(9) = 51.03, P < 0.001 and χ2(5) = 13.33, P = 0.020 respectively. Because the sphericity assumption for SP dr has been fulfilled, then we can apply the one-dimensional approach. The analysis of variance results for repeated measures effects allow the conclusion that changes in SP dr subsequent measurements are statistically non significant . Again as the epsilon values are less than 0.80 .Mauchly’s test indicated  that thehan 0.80  thus morhan 0.80 . There aP-values than the adjusted one if the sphericity condition is not satisfied. Instead of using the univariate method, we can confidently use the multivariate test for repeated measures data as it does not require a specific covariance structure. Multivariate tests—Pillai’s Trace, Hotelling’s Trace, Wilk’s Lambda and Roy’s Largest Root confirmed the previous results in terms of statistically significant differences (P << 0.05) of repeated measures of SP and NPS in time . In postoperative NPS values we observed a difference between the first measurement and the following ones (P = 0.010). For SP dr however this difference was not statistically significant (P = 0.806).The difference between SP value measured before the operation and SP values measured in the next hours after the surgery was important  at a given time (P = 0.008).Having found correlation between the variables an attempt to extract a functional dependence was conducted and a regression analysis for this purpose was performed . Based oP = 0.907 and P = 0.087. Therefore, using the module forward stepwise regression, the latter two quantities have been removed, and the results of the regression analysis are shown in 2 = 0.8499. However, it cannot be directly compared with the previous value, because in this case has been removed from the equation, moving the graph up the value. Based on the test regression analysis  of the dynamics of change in pain intensity was high, and was 0.25 points out of 100 pg/ml, and after exceeding a value of 200 pg/ml the increase of pain was reduced almost twice in the value of 0125 points in 100 pg/ml.At 36 h after surgery patients complained of more severe pain (2.5–3.0 points) even at low values of the concentration of substance P and were more sensitive to it. Along with increasing concentrations of substance P in a smaller range of values, for the value of 200 pg/ml the intensity of the pain reached the level of 3 points. For SP value about 380 pg/ml, the pain was already estimated at 3.5 point. These differences can be observed on the width of the contour lines in the The high preoperative serum concentration of SP in all studied patients was found. However, it is directly related with chronic, advanced, ongoing, auto immunological disease.The link between serum concentration of SP and the intensity of acute pain postoperatively was assessed. Therefore, significant correlation between the intensity of acute pain and serum SP level changes in RA patients in accordance with the results given by Michaels et al. was found  In contrThe correlation between the postoperative concentration of plasma SP and the labor pain among pregnant and non-pregnant healthy women enrolled in the study by Conversely, Dalby et al.  were notAdditionally, different factors combined with nociceptive stimulation could have an influence on serum SP concentration. The type of anesthesia is one of them. The systemic SP concentration mainly depends on neuronal nociceptive transmission, which is blocked by spinal anesthesia. However, the SP concentration in drainage fluid depends on inflammatory mediators release triggered by mastocytes degranulation. As the immediate result of the sensory blockade, the SP concentration increase and respectively IL-10 decrease was found postoperatively in wound surrounding tissue as the example of imbalance among pro- and anti-inflammatory components .The spinal anesthesia with bupivacaine does not seem to influence the concentration of SP in serum or wound fluid. Although the results reported by Carvalho et al. show that the local application of bupivacaine resulted in an increased concentration of SP wound exudates .Knee joint replacement as a major orthopedic surgery causes significant postoperative pain that can be relieved by opioids administration.The postoperative measurement of average consumption of opioids was done additionally. Nevertheless, the long-term morphine analgesia might influence SP concentration. The postoperative analgesia was provided with morphine at a dose 10 mg or pethidine at a dose 1 mg/kg administered subcutaneously every 4–6 hrs. Additionally, 1 g of paracetamol intravenously three times per day for all the patients was administrated. None of the patients received intrathecal opioids and tramadol IV/IM. The mean morphine consumption was about 70 mg MF and 350 mg pethidine during the 36—hour study period. This treatment is optimal for effective pain relief. It is known that opioids cause the presynaptic attenuation of neurotransmitter release from sensory neurons . The subOn the other hand, there was not any correlation between the SP concentration in drainage fluid and postoperative acute pain severity. The SP concentration in drainage fluid however was hundredfold higher than in the serum. Sahbaie et al. have reported that the high concentration of SP in drainage may contribute to the development of hyperalgia or allodynia in the skin surrounding the wound . None ofThe next factor that could have influenced the level SP drainage was the use of a tourniquet to prevent bleeding during surgery. SP is known as one of many pro inflammatory components in reperfusion injury due to tourniquet ischemia . The timThe administration of cytokine antagonist is beneficial in RA therapy. The multimodal action of NK-1 and NK-2 receptors allows to use their antagonists in the therapy of different disorders moreover the use of the SP antagonist might be beneficial in degenerative joint disease therapy. The anti nociceptive action of the substance P antagonists was confirmed to be beneficial in therapy of acute pain because it inhibits the development of opioid anti nociceptive tolerance , 16]..16].The new opioid peptide analogue, which acts as an agonist for opioid receptors as well as an antagonist for the NK1 receptor by Matalinska et al., was found. Additionally, its anti proliferative properties were confirmed which is advantageous in the cancer pain therapy .The correlation between acute pain and SP serum concentration is a new approach for further research about the usefulness of NK-1 receptor antagonists or SP as a new kind of analgesics, which need to be proven.The correlation between acute pain intensity and SP serum concentration was found postoperatively in patients with RA.The correlation between acute pain intensity and SP concentration in drainage fluid was not found postoperatively in patients with RA.


Postoperative analgesia for the knee surgery in children can be challenging. Meanwhile acute pain management in pediatric patients is still often undertreated due to inadequate pain assessment or management.We reported the ultrasound-guided single-injection adductor canal block (ACB) with 0.2% ropivacaine and dexmedetomidine (0.5 μg/kg) in addition in a series of 6 children. Patients’ age was range from 7 to 15 years old with right or left habitual patellar dislocation needing an open reduction and internal refixation. Pain assessments using Numeric Rating Scale scores on the operative limb were made preoperatively and at 12, 24, 36, and 48 h postoperatively at rest. Medication consumption was calculated as well. The possible complications, such as hemodynamic changes, nausea, vomiting, and dysesthesia, were also recorded at 12, 24, 36, and 48 h postoperatively at rest.The pain scores were low, and analgesic medication consumption was minimal. Meanwhile, no adverse events were recorded in any of the subject.Single-injection ACB might be an optimal analgesia strategy for patellar dislocation surgery in pediatric patients. Pediatric regional anesthesia seem to be safety and an ideal method to minimize postoperative pain evidently.5 The adductor canal block (ACB) is a relatively new block providing analgesia for knee surgery, which not only blocks the largest sensory branch of the femoral nerve but also results in less reduction of quadriceps muscle strength, compared with the femoral nerve block (FNB) in adult patients.7 Dexmedetomidine (DEX) as an additive to local anesthetic provides a significantly longer postoperative analgesia with comparable adverse effects and hemodynamic changes, when compared with local anesthetics alone in pediatric regional anesthesia.8 We report 6 cases in which we successfully performed ultrasound-guided a single dose of local anesthetic with DEX in the adductor canal releasing postoperative pain of patellar dislocation surgery in children. Committee of Kunming General Hospital of Chengdu Military Command approved this study (2015031).However, the knee surgery in children or teenager is not common,From April 2015 to July 2015, 6 pediatric patients who had undergone elective, unilateral open reduction and internal refixation, received postoperative analgesia using ultrasound-guided a single dose of local anesthetic with DEX in the adductor canal. This study was approved by Committee of Kunming General Hospital of Chengdu Military Command (2015031).6 The adductor canal was identified in short-axis view approximately at the mid-thigh level. A 0.5 × 35 mm needle was inserted in plane with the transducer with the tip of the needle located anterior to the superficial femoral artery, deep to the sartorius muscle, between the vastus medialis of the quadriceps muscle and the adductor longus muscle. All blocks were performed during real-time ultrasonography by J-YC and NL.After induction of general anesthesia, patient received a single-injection ACB on operative leg with 0.2% ropivacaine and dexmedetomidine (0.5 μg/kg) in addition (10 mL). The blocks were performed during real-time ultrasonography using a color Doppler ultrasound machine  with a high-frequency linear transducer as previous described.Pain assessments using Numeric Rating Scale (NRS) scores on the operative limb were made preoperatively and at 12, 24, 36, and 48 h postoperatively at rest. Medication consumption (MC) was calculated as well. The possible complications, such as hemodynamic changes, nausea, vomiting, and dysesthesia were also recorded at 12, 24, 36, and 48 h postoperatively at rest by J-YC.Subject 1 is a 7-year-old girl, 15 kg with right habitual patellar dislocation needing an open reduction and internal refixation. After induction of general anesthesia, patient received a single-injection ACB on right leg with 0.2% ropivacaine and dexmedetomidine 7.5 μg (0.5 μg/kg) in addition (10 mL).Subject 2 is an 8-year-old girl, 22 kg with left habitual patellar dislocation needing an open reduction and internal refixation. After induction of general anesthesia, patient received a single-injection ACB on left leg with 0.2% ropivacaine and dexmedetomidine 11 μg (0.5 μg/kg) in addition (10 mL).Subject 3 is an 8-year-old boy, 21.5 kg with right habitual patellar dislocation needing an open reduction and internal refixation. After induction of general anesthesia, patient received a single-injection ACB on right leg with 0.2% ropivacaine and dexmedetomidine 10.75 μg (0.5 μg/kg) in addition (10 mL).Subject 4 is an 11-year-old girl, 36 kg with left habitual patellar dislocation needing an open reduction and internal refixation. After induction of general anesthesia, patient received a single-injection ACB on left leg with 0.2% ropivacaine and dexmedetomidine 18 μg (0.5 μg/kg) in addition (10 mL).Subject 5 is a 12-year-old boy, 50 kg with right habitual patellar dislocation needing an open reduction and internal refixation. After induction of general anesthesia, patient received a single-injection ACB on right leg with 0.2% ropivacaine and dexmedetomidine 25 μg (0.5 μg/kg) in addition (10 mL).Subject 6 is a 15-year-old girl, 52 kg with left habitual patellar dislocation needing an open reduction and internal refixation. After induction of general anesthesia, patient received a single-injection ACB on left leg with 0.2% ropivacaine and dexmedetomidine 26 μg (0.5 μg/kg) in addition (10 mL).Pain scores and MC are presented in Table 9 reported that peripheral nerve block found to be superior to systemic opioids for postoperative pain relief. Another study showed the effect of peripheral nerve block was similar to that caused by epidural analgesia.10 The complications of the systemic opioids and epidural analgesia, such as hypotension, respiratory depression, nausea/vomiting, and urinary retention, were not exclusive to the peripheral nerve block.12Peripheral nerve block thought to be effective and safe method for postoperative analgesia and has attained wide use even in pediatric patients. Lee et al6 The most important finding was the ACB preserved the ability to ambulate better than the FNB.7 The study showed that the ACB only reduced the quadriceps muscle strength by 8% compared with baseline. In comparison, the FNB reduced the quadriceps strength by 49% compared with baseline.7 To our knowledge, there have been no published reports of management postoperative pain with ACB in pediatric patients.The patellar surgery is associated with intense postoperative pain in pediatric patients. The challenge of treating postoperative pain after patellar surgery in pediatric patients is using easier analgesia method to provide optimal analgesia with preserved muscle function and minimal side effect. Single-shot analgesia might be better management than continuous catheter analgesia after surgery in pediatric patients. The ACB is a relatively new block. The largest sensory branch of the femoral nerve (the saphenous nerve), the medial femoral cutaneous nerve and probably articular branches of the obturator nerve and the nerve to the vastus medialis, a motor nerve but also the second largest sensory branch of the femoral nerve, are traversing the adductor canal.17 However, there are presently insufficient safety data to support the use of perineural dexmedetomidine in the clinical setting.13 In pediatric patients, adjunct use of dexmedetomidine is associated with prolonged block duration following ilioinguinal/iliohypogastric nerve block. Furthermore, dexmedetomidine significantly reduces early break-through pain in the PACU.18 A meta-analysis shows that dexmedetomidine as an additive to local anesthetic provides a significantly longer postoperative analgesia with comparable adverse effects and hemodynamic changes, when compared to local anesthetics alone.8 In this study, we use 0.5 μg/kg dexmedetomidine in addition. Almost all subjects showed satisfactory score except subject 6 at 12 and 24 h postoperatively at rest. Even more, subject 1 to 4 showed low NRS scores at 36 and 48 h postoperatively at rest and did not require the supplemental analgesia within 48 h postoperatively. However, we do not establish the control group which did not add dexmedetomidine, the 6 subjects showed acceptable NRS scores and no adverse events during 48 h after surgery. Subjects 5 and 6 showed comparatively high scores at 24 and 36 h after surgery. Andersen et al took a study in the spread of injectate during saphenous nerve block at the adductor canal on adult cadavers. They recommend 15 ml could be an optimal dosage to spread throughout the adductor canal and beyond both proximally and distally.19 So we presume that might be a low volume reason for over 50 kg patients which resulted in insufficient pain management.Dexmedetomidine as a perineural adjuvant can prolong the durations of both sensory and motor block.20 Single-injection adductor canal blockades may be superior for postoperative ambulation, knee flexion, and providing similar pain control and analgesics requirements. Our limitation is that this study is just a case-series report. Whether dexmedetomidine could prolong the durations of postoperative analgesia using single-injection ACB and the safety dosage need further clinical trials study.A retrospective study hints that single-injection ACB offered similar pain control and earlier discharge compared to continuous femoral nerve catheter in patients undergoing total knee arthroplasty (TKA).We successfully performed ultrasound-guided single shot of local anesthetic with DEX in the adductor canal releasing postoperative pain of patellar dislocation surgery in 6 pediatric patients. The patients and their parents reported comparatively satisfactory scores. Further study is needed to determine more widespread application of this technique.


The aim of this study was to evaluate and compare the difference in the level of pain using the visual analog scale (VAS) between cases treated with the edgewise appliance and Invisalign. In addition, the cause of pain and discomfort in the Invisalign cases was identified.n = 55), Invisalign group , and edgewise and Invisalign group . VAS scores were collected during the first three stages  and at the end of the treatment . Evaluation of the cause of pain was categorized into three different types of problem . Statistical comparison of VAS scores between groups was performed by two-way analysis of variance.The sample consisted of 145 cases for the edgewise group (EG; A significantly higher VAS score was observed at 3 and 4 days after, at 1, 2, and 3 days after, and at 2 and 3 days after in stages 1, 2, and 3, respectively, in EG compared to EIG and IG. A significant difference was observed in overall VAS scores between EG and IG in intensity of pain, number of days that pain lasted, and discomfort level. Only intensity of pain resulted in a significant difference between EG and EIG. Most of the causes of problem in the Invisalign cases were deformation of the tray.Invisalign may offer less pain compared to the edgewise appliance during the initial stages of treatment. In the use of Invisalign, deformation of tray must be carefully checked to avoid pain and discomfort for the patients. Pain and discomfort during orthodontic tooth movement are the most negative concerns for treatment . In geneThere have been several studies that have analyzed the level of pain in different types of orthodontic appliances. In most of the past studies, there was no significant difference in the level of pain treated between fixed appliances such as with self-ligation, lingual, or conventional brackets ,7. On thIn recent years, aligners  have becTherefore, we evaluated the level of pain using the visual analogue scale (VAS) between groups that were treated with the conventional edgewise appliance (EG), Invisalign (IG), and both the edgewise appliance and Invisalign (EIG). Furthermore, we identified the cause of pain and/or discomfort in the Invisalign groups. Our hypothesis was that there would be a significant difference in the level of pain between these groups.EG consisted of 55 adult patients , IG consisted of 38 adult patients , and EIG consisted of 52 adult patients . Consecutive patients were prospectively collected from one private orthodontic clinic. Exclusion criteria were as follows: under 18 years of age, complex or surgery cases, and cases that were only treated in one jaw. This study was approved by the Ethics in Research Committee of the University of Tottori. All patients received informed consent and understood and agreed to the purpose of this study.In EG, all cases were treated with a straight wire appliance with .018 slot edgewise brackets. In IG, only Invisalign aligners were used for the treatment. Patients were instructed to wear the aligner for a minimum of 20 h per day. In EIG, all cases had experienced both the straight wire edgewise appliance and Invisalign aligners. The percentage of extraction cases was 23.6% (13/55), 18.4% (7/38), and 18.5% (10/52) for EG, IG, and EIG, respectively.Subjects were instructed to mark their level of pain on a 10-cm VAS during the three stages of treatment. The mark was measured in millimeters with a 10-cm ruler from the left side. Each millimeter was given a VAS score of 1 such that a score of 0 at the left end of the scale indicated no pain, a score of 100 at the right end of the scale indicated maximum pain, and a score of 50 in the center of the scale indicated moderate pain. This was explained to each patient before the study.The first stage of collecting the VAS score was at 60 s, at 6 and 12 h, and at 1, 2, 3, 4, 5, 6, and 7 days after the appliance delivery (changing wires in EG and new trays in IG). The second stage was at 3 weeks after the appliance delivery, and the patients were also asked to mark from 60 s to 7 days after. The third stage was at 5 weeks after the appliance delivery. We changed the wire in a 2-week interval instead of 4 weeks  in order to match the treatment interval with that of IG. For EIG, the average VAS score was measured after the delivery of both appliances  during the first three stages of each treatment. All cases in EIG initially had edgewise treatment followed by Invisalign treatment. The overall VAS score was also taken immediately after the treatment was finished in all three groups. Since patients in EIG have experienced both appliances, we also collected the overall VAS score for both the edgewise appliance and Invisalign at the end of the treatment.In addition, we have analyzed the reasons for the pain or discomfort level beyond VAS score 50 (>moderate) and identified the common problems in IG. We divided the reasons for pain or discomfort into three categories   computer software for Windows. Non-significant values were defined as p < 0.05.Two-way analysis of variance (ANOVA) for repeated measures and Bonferroni At stage 1, the peak VAS score was observed at 24 h in all three groups and lasted for 4 days in EIG and IG and for 5 days in EG  Figure .Figure 8Approximately 11% (10/90 cases) of Invisalign cases complained significant pain or discomfort, and approximately 3%  of the total trays had problems. Reasons for pain or discomfort resulted in 23, 25, and 316 cases in categories 1, 2, and 3, respectively . During the initial stages of treatment, EIG resulted in a similar VAS score to that of IG. The combination approach by initial alignment with the edgewise appliance and later with Invisalign tends to have less pain than just with edgewise treatment. The overall VAS scores for EIG resulted in significantly less pain, duration, and discomfort during the Invisalign treatment period than during the initial edgewise treatment. Therefore, patients who experienced both appliances prefer Invisalign than edgewise treatment from a pain and discomfort point of view. However, the limitation of this result is that since all EIG patients experienced the edgewise appliance prior to Invisalign, the initial edgewise treatment may have masked the intensity of pain by the use of Invisalign. Thus, comparison of VAS between the group that has the edgewise appliance initially and the group that started with Invisalign must be performed to clarify this problem.Our overall results collected after the treatment also showed significantly more and long-lasting pain in EG than in IG. However, there was no significant difference in pain duration and discomfort between EG and EIG. Thus, patients may feel less pain with Invisalign, but the duration of pain and discomfort level seems to be the same. Since several patients complained of pain or discomfort, we further identified the problems with Invisalign trays. As a result, most of the reasons for pain or discomfort in the Invisalign cases were deformation of trays. Some patients experienced pain other than the four categories such as pain related to the change in the gingival morphology due to the eruption of third molars, swelling of the gingiva due to inefficient oral hygiene, and inefficient use of aligner (bad cooperation) which were not included in the present analysis. Recently, since there was a change in the material of the tray from EX30 to LE30, which is softer and has more flexibility, this problem should be greatly improved.One of the limitations of this study was the different extraction ratios among groups. The extraction ratio was quite similar between IG and EIG; however, EG has a higher extraction rate (approximately 5% higher) compared to the other two groups. Since extraction requires a surgical procedure, it might have resulted in higher VAS scores compared to non-extraction therapy. However, we suggest that a 5% difference would not have a significant impact on the results of our study. Future studies such as randomized clinical trials with more controlled selection of the sample are required to elucidate this problem.Brown and Moerenhout indicated that adolescents, pre-adolescents, and adults varied in their pain reports during orthodontic treatment, with adolescents reporting the most pain. In this study, the average age was very similar among the three groups; thus, there should not be any influence on our results on age among groups. On the other hand, the male:female ratio was 20:35, 10:28, and 19:33 for EG, IG, and EIG, respectively. IG had a higher female ratio (73.7%) compared to EG (63.6%) and EIG (63.5%). However, since a lower VAS score was observed in IG , we indicate that there was no significant impact on the results of our study.In conclusion, Invisalign results in less pain compared to the edgewise appliance approximately 3 days after delivery or adjustment during the initial stage (approximately 5 weeks) of the treatment. Overall, at the end of the treatment, patients also observed that less pain was felt with Invisalign treatment compared to the edgewise appliance. In addition, the major cause of pain or discomfort in the Invisalign cases is tray deformation. Thus, Invisalign offers less pain compared to the traditional edgewise treatment; however, problems such as tray deformation must be carefully checked in the use of Invisalign.


Background: Following breast reduction procedures, the level of postoperative pain can be severe, and sufficient pain control influences a patient's physiological, immunological, and psychological status. Objective: The aim of this study was to examine the use of intrathecal morphine (ITM) in breast reduction surgery with patient-controlled analgesia (PCA). Methods: Sixty-two female patients who underwent breast reductions with the same technique participated in this study. The study group (ITM + PCA) included 32 patients; a single shot (0.2 mg) of ITM and intravenous morphine with PCA were administered. In the control group, morphine PCA alone was intravenously administered to 30 patients. Comparisons between the groups of cumulative morphine consumption, visual analog scale scores, and patient satisfaction scores, which were the primary outcome measures, and adverse effects, which were the secondary outcome measures, were conducted. Results: The patients in the 2 groups had similar degrees of pain and satisfaction scores. The study group had lower cumulative morphine consumption (P = .001) than the PCA-only control group; there was no statistically significant difference in adverse effects between the 2 groups. Conclusion: Intrathecal morphine may effectively control pain with lower total morphine consumption following breast reduction surgery. Level of Evidence: Level II-6,6,11,Proper pain control following breast surgery can increase patient comfort and satisfaction. Most pain control publications have discussed pain control related to augmentation mammoplasty; however, reduction mammoplasty is associated with pain that is just as intense, due to the requirements for large incisions, extensive dissections, and a pronounced inflammatory response.1After institutional review board approval and informed consent were obtained, 62 patients  who had undergone reduction mammoplasty with the Wise pattern inferior pedicle technique participated in the study. This study was conducted at a single tertiary medical center between January 2010 and December 2014. The exclusion criteria were as follows: patients who required surgery other than the Wise pattern inferior pedicle breast reduction, patients who had a contraindication for spinal intervention or ITM, and patients who were unable to use a PCA pump. Other exclusion criteria included patients with a history of drug abuse or allergy to the study drugs. The day before surgery, the patients were instructed on the use of the PCA device and the method of reporting pain via a visual analog scale (VAS).n = 32) or the group receiving PCA with morphine . This study was conducted with approval from the Local Ethics Committee.A table of random sampling numbers was used to randomly allocated the patients into either the group receiving ITM combined with intravenous PCA  and oxygen (0.5 L/min) plus sevoflurane (1%–2%) after tracheal intubation. The same anesthesiologist performed lumbar punctures in the lateral decubitus position at the LOn arrival at the postanesthesia care unit, each patient received a PCA pump programmed to deliver an initial morphine bolus of 0.05 mg/kg without base flow if the patient's pain score was higher than 60 on a 100-mm VAS. Upon discharge from the postanesthesia care unit, the pump was reprogrammed to deliver a morphine bolus of 1 mg with an 8-minute lockout without base flow. Patient-controlled anesthesia was maintained during the first 48-hour postoperative period.no pain to 100 mm for the worst pain imaginable, and the satisfaction scores ranged from 0 mm for not satisfied to 100 mm for very satisfied. Degree of pain was documented at 30 minutes, 1, 3, 6, 12, 24, and 48 hours by the same trained plastic surgery assistant who was blinded to the study groups. Patient satisfaction scores were documented after 24 hours and again at 48 hours.A 100-mm VAS was used to evaluate degree of pain and patient satisfaction. The pain scores ranged from 0 mm for The patients were asked directly if they experienced vomiting, nausea, or pruritus. Intravenous antiemetics and antihistamines (4 mg of ondansetron and 20 mg of diphenhydramine HCl) were administered as rescue drugs at the patient's request. The number of patients with nausea, vomiting, and pruritus was recorded.Sedation was evaluated on a 5-point scale  at 30 minutes, 1, 3, 6, 12, 24, and 48 hours.Respiratory depression was evaluated using oxygen saturation and respiratory rate. When the degree of oxygen saturation was less than 90% as measured using a pulse oximetry device, and when the respiratory rate was less than 8, the patient was treated with supplemental oxygen and intravenous administration of 0.1 mg of naloxone repeated every 5 minutes until sufficient respiration was restored.2 test was used for categorical variables. The Student t test was used for continuous normally distributed data, and the Mann-Whitney U test was used for continuous abnormally distributed data. P < .05 was considered statistically significant.The SPSS statistical package (version 16.0) for Windows  was used for statistical analysis. Data are represented as mean ± SD and the number of patients. Data were tested for normality with the Kolmogorov-Smirnov normality test. A χSixty-two patients were randomly allocated to the 2 groups . Of the P = .001)  .The patient satisfaction scores at 24 hours were 66 ± 3 and 62 ± 2.9 mm in the PCA-only group and the ITM + PCA group, respectively; at 48 hours, the scores were 65 ± 3 and 64 ± 1.5 mm in the respective groups. There was no statistically significant difference between the 2 groups at either time point .The VAS scores of patients in the ITM + PCA group and the PCA-only group were similar, and there were no statistically significant differences at 30 minutes, 1, 3, 6, 12, 24, or 48 hours .There were also no statistically significant differences between the 2 groups with respect to nausea, pruritus, or the number of antiemetic drugs used in the postoperative period. Six of the 30 patients in the ITM + PCA group experienced nausea, 2 patients had pruritus, and 1 patient had used antiemetic drugs. Eight of the 30 PCA-only patients experienced nausea, 3 patients had pruritus, and 2 patients had used antiemetic drugs. There were no significant differences between the 2 groups.The sedation scores, pulse oximetry values, and respiratory rates were comparable in both groups’ at all postoperative periods . There wThis study demonstrated that the analgesic effect of a single ITM injection can reduce cumulative PCA morphine consumption and control acute postoperative pain effectively without differences in any of the adverse effects.-Surgical procedures for breasts vary from reduction to augmentation to breast cancer procedures. Pain control is a major concern among patients undergoing breast surgery. In most pain control studies, the main focus is on breast augmentation procedures.1,9Patient-controlled anesthesia with an intravenous opioid, such as morphine, is used effectively for pain management.6Because morphine has many different properties, including greater spinal bioavailability and therefore the ability to be administered neuraxially, it is a suitable choice for treating acute postoperative pain.Postoperative pain management is one of the greatest challenges for patients who have undergone reduction mammoplasty, and pain control devices tend to cause trouble for patients rather than benefit them. Kryger et alThe ITM dosages for some surgical procedures have been determined.It is well known that intrathecal administration of morphine causes nausea, vomiting, and pruritus more often than intravenous morphine does.Because morphine can cause sedation and respiratory depression, we monitored our patients closely postoperatively to watch for these adverse effects. There were no significant differences in sedation or oxygen saturation levels between the ITM + PCA and PCA-only groups. When adjusting the morphine dose in PCA, sedation and respiratory sedation dosages should be taken into account.It has been reported that ITM application does not carry a risk of respiratory depression, and it is used with an internalized intrathecal delivery system to control chronic cancer pain.This study had some limitations. While there were no differences in adverse effects between the 2 groups, more adverse effects were experienced in the ITM + PCA group. A possible reason for this finding is that our study did not have sufficient power for secondary outcome measures, such as adverse effects, and we did not perform intrathecal sham interventions in the PCA-only group. Therefore, the study was not double blinded.We think pain control is an important issue in breast reduction operations. A single-shot ITM was not superior to parenteral narcotics in reducing pain; however, it might be able to relieve pain symptoms with decreased cumulative morphine consumption, which has major implications in developing new strategies for pain management in breast reduction surgery.


The Gait Deviation Index summarizes overall gait ‘quality’, based on kinematic data from a 3-dimensional gait analysis. However, it is unknown which clinical outcomes may affect the Gait Deviation Index in patients with primary hip osteoarthritis. The aim of this study was to investigate associations between Gait Deviation Index as a measure of gait ‘quality’ and hip muscle strength and between Gait Deviation Index and patient-reported outcomes in patients with primary hip osteoarthritis.2) and with severe primary hip osteoarthritis underwent 3-dimensional gait analysis. Mean Gait Deviation Index, pain after walking and maximal isometric hip muscle strength  were recorded. All patients completed the ‘Physical Function Short-form of the Hip disability and Osteoarthritis Outcome Score  and the Hip disability and Osteoarthritis Outcome Score subscales for pain (HOOS-Pain) and quality-of-life (HOOS-QOL).Forty-seven patients , aged 61.1 ± 6.7 years, with BMI 27.3 ± 3.4 (kg/mr = 0.40), hip flexion strength , HOOS-Physical Function  HOOS-QOL , and negatively associated with HOOS-Pain after walking . Adjusting the analysis for walking speed did not affect the association.Mean Gait Deviation Index was positively associated with hip abduction strength (p<0.01, Patients with the strongest hip abductor and hip flexor muscles had the best gait ‘quality’. Furthermore, patients with higher physical function, quality of life scores and lower pain levels demonstrated better gait ‘quality’. These findings indicate that interventions aimed at improving hip muscle strength and pain management may to a moderate degree improve the overall gait ‘quality’ in patients with primary hip OA. Hip osteoarthritis (OA) is a leading cause of disability worldwide . PatientThree-dimensional gait analysis (3DGA) is an objective and detailed analysis of the walking pattern, with the possibility to measure a large number of discrete variables. Discrete variables are often measured at one time-point in the gait cycle, for example hip or knee extension at terminal stance or peak hip flexion and extension. However these discrete variables lack the ability to evaluate the overall gait pattern or gait ‘quality’ throughout the entire gait cycle . TherefoThe purpose of this study was to investigate potential associations between gait ‘quality’ measured by the GDI, hip muscle strength and PROs in patients with severe primary hip OA. We hypothesized that low hip muscle strength, high pain level and impaired self-reported physical function and quality of life would be associated with reduced GDI scores. The results from this study will provide a better understanding of the factors influencing the overall gait ‘quality’ and the way in which targeted rehabilitation may improve gait ‘quality’ for hip OA patients.This study was a cross-sectional analysis of explorative pre-operative data from a subsample of patients included in a randomized controlled trial. The trial is registered at ClinicalTrials.gov. No.:NCT01616667 and described in detail elsewhere .2) , if they were unable to walk without walking aid of any kind, if they had any neurological or medical disease compromising their walking ability, inability to read and understand Danish, or if they declined to participate. All patients were clinically and radio-graphically evaluated and diagnosed with primary OA and scheduled for THA. A convenience sample of 20 able-bodied adults aged 45 to 70 years was recruited to provide a reference group on kinematic data.Forty-seven patients were recruited from the outpatient clinic at the Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Svendborg Hospital (SvB), Denmark between May 2012 and May 2014. The inclusion criteria were patients aged 45–70 years with primary unilateral hip OA, scheduled for cementless THA. Patients were excluded if they had had prior THA or major lower limb surgery, BMI>35  had a mean age of 59.6 ±7.1 years and mean BMI of 25.6 ±2.9 (kg/m2), The trial complied with the Declaration of Helsinki. It was approved by the Danish Data Protection Agency and The Danish Regional Committee on Biomedical Research Ethics (Southern Denmark), Project-ID S-20120009. A written and orally informed consent was collected prior to the inclusion of all participants.3DGA data were collected using a six-camera motion capture system  and further processed in Nexus 1.7–8 , 26. Pri® program . The contraction with the highest peak moment (Nm) was selected and normalized according to body mass (Nm/kg). Only iMVC performed with the affected limb was used in the current study. iMVC in the standing position has shown acceptable validity [The muscle strength of the hip abductor, hip flexor and hip extensor muscles was measured with three consecutive isometric maximal voluntary contractions (iMVC) for each muscle group. Maximal hip muscle strength was recorded in the upright standing position, according to the protocol described by Jensen et al. . For eacvalidity  and highvalidity , 30.Pain was measured immediately after completion of the 3DGA using an 11-point (0–10) Numeric Rating Scale (NRS); where 0 represents ‘no pain’ and 10 represents ‘the worst possible pain’. The patients were asked to assess their hip pain intensity for the affected limb immediately after walking. A second pain intensity assessment was performed immediately after the last iMVC contraction. The NRS scores for the affected limbs recorded after walking were used in the association analyses. The NRS has been shown to be both valid and reliable in geriatric patients .We used the Hip disability and Osteoarthritis Outcome Score–Physical Function Short-form together with its subscales of Pain and Quality Of Life in HOOS 2.0 (HOOS-Pain and HOOS-QOL) to measure physical function, pain and quality of life, respectively. The total score for each of the three subscales ranges from 0 points (extreme symptoms) to 100 points (no symptoms). HOOS-Physical Function has shown good validity when compared with the HOOS subscale for Activity of Daily Living and high responsiveness in THA patients . HOOS 2.per se had an index value of 100. Finally, we calculated the GDI scores for the hip OA patients against our reference group data. mGDI scores based on five trials were calculated. We only used the mGDI of the affected limbs in the analyses. A GDI score of 100 or above represents no gait pathology. Each 10-point decrement from 100 indicates approximately one standard deviation from the normal gait pattern [The GDI is calculated for each limb using nine kinematic variables collected during 3DGA- namely, all three planes from the pelvis and hip, the sagittal plane from the knee and ankle and the foot progression . First,  pattern . GDI has pattern  and exce pattern , 21.Data were checked for completeness and normality (Q-Q plot). A one-sample t-test was used to test the difference between the patients’ mGDI and the reference group’s GDI of 100 points.r-value) and the determination coefficient (R2) were reported. The correlation coefficients were interpreted according to Dancey and Reidy [r-value of 0.1–0.3 was regarded as weak; 0.4–0.6 as moderate; 0.7–0.9 as strong and 1 as perfect correlation. The statistical analyses were performed using Stata 13.1  and we used a 0.05 significance level.We used Pearson’s correlation to investigate the associations between mGDI and continuous variables . Spearman correlation was used to investigate the association between mGDI and pain measured by the NRS . Preliminary analyses were performed to ensure all correlation analysis assumptions were fulfilled and data were checked for linearity and outliers . We also found a significant, albeit weak, association between hip flexion muscle strength and mGDI , but no association between hip extension muscle strength and mGDI . Adjusting for walking speed did not change the significance of the association between mGDI and hip muscle strength, Results from the unadjusted and adjusted associations between the mGDI scores and the independent clinical outcomes are summarized in r = -0.45; p<0.01), r = 0.41; p<0.01 and r = 0.41; p<0.01, respectively) were found. These moderately significant associations were also present after adjusting for walking speed, r = 0.18; p = 0.23).We found a moderately significant negative association between pain measured by NRS immediately after walking and mGDI . The discrepancy in our results could be explained by the way the two pain score are collected. The NRS score is directly connected to the pain level experienced by the patient at the time of walking, whereas the items in the HOOS-pain subscale cover several situations over the past week, not only related to the activity of walking. In accordance with our result, both Behery and Foucher 2014 and Zeni et al. 2014 , 12 inveThe moderate association between mGDI and self-reported physical function and quality of life is also in agreement with previous findings . AssociaAs recommended by ‘Outcome Measures in Rheumatology Clinical Trials’ , evaluatWe have also investigated the interaction between different domains in accordance with WHO International Classification of Functioning, Disability and Health (ICF) classification . The ICFWe conducted an explorative study on a well-defined patient group with unilateral hip OA, which supports the internal validity of the study. The use of the GDI as a measure of gait ‘quality’ has advantages over more common ways of reporting the results from 3DGA. Firstly, by reporting a single composite score rather than several discrete gait variables extracted at specific time points in the gait cycle, the GDI can be used as an overall score of gait pathology. Secondly, the GDI has shown previously to be a potentially useful classification and evaluation tool in different patients , 22, 53.Finally, the evaluation included the valid and reliable HOOS-questionnaire, pain measured directly related to the gait analysis session and measurement of hip muscle strength. Thus, our results may be one step towards providing ‘validity’ to the use of the GDI in hip OA patients.However, limitations of the current study should be mentioned. Firstly, limitations with regard to 3DGA methodology made strict inclusion criteria necessary . This caBetter hip flexor and hip abductor muscle strength were weakly to moderately associated with a better gait ‘quality’ in patients with hip osteoarthritis. Furthermore, patients with higher patient-reported physical function, quality of life and lower pain levels demonstrated better gait ‘quality’. Interventions aimed at improving hip muscle strength, especially hip abduction strength, and appropriate pain management may to a moderate degree improve the gait ‘quality’ in patients with severe hip osteoarthritis. This, however, needs to be confirmed in controlled intervention studies.S1 File(XLSX)Click here for additional data file.