Background: The early diagnosis of endometriosis in adolescents is not developed. Objective: We aim to conduct clinical, imaging, laparoscopic and histological analyses of peritoneal endometriosis (PE) in adolescents in order to improve early diagnosis. Methods: In total, 134 girls (from menarche to 17 years old) were included in a case–control study: 90 with laparoscopically (LS) confirmed PE, 44 healthy controls underwent full examination and LS was analyzed in the PE group. Results: Patients with PE were characterized with heredity for endometriosis, persistent dysmenorrhea, decreased daily activity, gastrointestinal symptoms, higher LH, estradiol, prolactin and Ca-125 (<0.05 for each). Ultrasound detected PE in 3.3% and MRI in 78.9%. The most essential MRI signs are as follows: hypointense foci, the heterogeneity of the pelvic tissue  and sacro-uterine ligaments lesions (<0.05 for each). Adolescents with PE mostly exhibit initial rASRM stages. Red implants correlated with the rASRM score, and sheer implants correlated with pain (VAS score) (<0.05). In 32.2%, foci consisted of fibrous, adipose and muscle tissue; black lesions were more likely to be histologically verified (0.001). Conclusion: Adolescents exhibit mostly initial PE stages, which are associated with greater pain. Persistent dysmenorrhea and detected MRI parameters predict the laparoscopic confirmation of initial PE in adolescents in 84.3% , justifying the early surgical diagnostics and shortening the time delay and suffering of the young patients. According to different authors, endometriosis occurs in 10–16% of women of early reproductive age and frequently manifests with chronic pelvic pain and dysmenorrhea in adolescence . The exap < 0.0001) [Due to the growing recognition that endometriosis often manifests itself and progresses from adolescence, its early diagnosis is especially important ,9,10,11. 0.0001) . The dif 0.0001) . Ballweg 0.0001)  and even 0.0001) . The pre 0.0001) .In adult women, endometriosis most typically manifests with cyclic pelvic pains, whereas in adolescent patients, the pain can be both cyclic and acyclic ,15. In eMoreover, the stage of the disease does not clearly correlate with the presence or severity of symptoms, and reciprocally, none of the symptoms are endometriosis-specific . None ofAt the same time, instrumental diagnostics, concerning pelvic ultrasound, is still not accurate enough in the cases of superficial endometriosis ,18,19. THistologic verification after laparoscopic surgery remains the gold standard for confirming the diagnosis, although the results of these surveys do not always correlate ,13,21. IThe aim of the current study is to compare the clinical features, instrumental diagnostics and surgical and histological peculiarities in adolescent patients with peritoneal endometriosis. n = 90) and 24/26.7% of them also having diffuse adenomyosis. All participants underwent inpatient treatments in 2020–2022 in the Pediatric and Adolescent Gynecology Department at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia.The case–control study enrolled girls from menarche to 17 years old (16.0 (15.0–17.0)), with a confirmed diagnosis of peritoneal endometriosis (PE) ; laparoscopically confirmed diagnosis of peritoneal endometriosis; informed consent of the patient and her legal representative for participation in the research study. The indications for laparoscopy were as follows: unsuccessful empirical treatment  or persistent moderate/severe dysmenorrhea with negative imaging results, ultrasound or MRI signs of deep infiltrative endometriosis. The exclusion criteria were as follows: age over 18; aggravated chronic or acute diseases ; mental conditions; pelvic tumors; absence of dysmenorrhea and/or chronic pelvic pain (for the main group); hereditary syndromes and congenital malformations associated with menstrual outflow obstruction; lack of informed consent.The control group consisted of 44 healthy adolescent girls of the same age (16.0 (15.0–17.0)) with regular periods and no gynecological and endocrine pathologies in the absence of routine drug administration. The exclusion criteria were mostly the same with the main group: age over 18; an aggravation of chronic or acute somatic and/or infectious disease; mental illnesses; endocrine or gynecological disorders; tumors of the pelvic organs; oncological diseases; secondary dysmenorrhea and/or chronic pelvic pain; inherited syndromes and congenital malformations associated with an obstruction of menstrual blood outflow; lack of informed consent of the patient or her legal representative for participation in the research study.General clinical examination was performed for all participants. It included a detailed medical history, heredity peculiarities, anthropometric data  and menstrual cycle characteristics. Pain sensations were assessed using the visual analog pain rating scale (VAS)—a 10 cm horizontal straight segment with each centimeter adding a point from “no pain” (0 points) on the left to “unbearable pain” (10 points) on the right. The patients were asked to make a mark on the scale in order to rate their experience of pain intensity; the outcomes were classified as mild (0–2 points), moderate (2–4 points), severe (4–6 points), very strong (6–8 points) or unbearable (8–10 points).2+, Fe2+/3+ and highly sensitive C-reactive protein (CRP) in venous blood were determined for all participants. In the biochemical profile, the concentrations of total protein, uric acid, creatinine, direct and total bilirubin, glucose, CaOn the 3rd to 4th day of a spontaneous menstrual cycle, all girls included in the study were subjected to an extended analysis of the blood hormonal profile: The levels of luteinizing hormone (LH), thyroid-stimulating hormone (TSH), thyroxine, follicle-stimulating hormone (FSH), dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin (Prl), estradiol (E2), cortisol, testosterone (T), antibodies to thyroid peroxidase (AT-TPO) and sex hormone-binding globulin (SHBG) and tumor markers Ca-125 and Ca-19-9 were determined. Hormonal assays were carried out by electro- and immunochemiluminiscent methods on Cobas e 411 , Immulite 2000 and Immulite 1000  automatic analyzers using reagents of the same companies. The concentrations of anti-Mullerian hormone (AMH) and 17-OH-progesterone (17-OHP) were measured by the enzyme-linked immunoassay on the DYNEX DSX System analyzer and using the Diagnostic Products Corporation (DPC) system on the Immulite device .All girls underwent an ultrasound examination for the pelvic organs and mammary and thyroid glands on days 3–5 of a spontaneous menstrual cycle. The study was performed on a Vivid-q ultrasonic device from GE HEALTHCARE company  using a linear and convex probe with a frequency of 1.8–6.0 MHz. The study was conducted with a fully filled bladder using the transabdominal approach. The sonographic features, including the length, width and thickness  of the left and right ovaries, and uterine (U) measurements  were described.An MRI of the pelvic organs was performed shortly before menstruation . Imaging was carried out in GE Signa Excite 1.5T and GE Signa Architect 3.0T MRI systems. T2-weighted images (T2WIs) in sagittal, axial and coronal projections were obtained using a slice thickness of 0.3–0.6 cm and a field of view of 32–42 cm. T1WI and T1FS methods were applied to identify and compare hemorrhagic and fatty components, particularly in the areas of destructive changes. The scanning protocol involved a diffusion-weighted mode to detect ischemic/necrotic sites and hemorrhages and to exclude neoplastic processes. All images were analyzed by the same radiologist in the department of Radiology and Diagnostics at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology.Data from the laparoscopic picture in the main group included surgical diagnosis and the stage of endometriosis according to the revised American Society for Reproductive Medicine (rASRM) criteria ; the typ2 test. A comparison of variables with a normal distribution in two groups was performed by a parametric Student’s t-test, and a mean value (M) and a standard deviation (SD) were calculated. In multiple groups, an analysis of variance (ANOVA) was used. The parameters that did not fit the normal distribution were analyzed using a median (Me) and an interquartile range (Q25–75) and the Mann–Whitney U test. The adjusted odds ratio (OR) with a 95% confidence interval (CI) was evaluated using logistic regression methods to analyze the influence of various risk factors. Correlations were estimated using Spearman’s rank correlation coefficient. To evaluate the impact of a single categorical independent factor on a dependent variable, a one-way ANOVA was performed and factorial ANOVA was used to analyze the interactive effects of several categorical factors. The diagnostic accuracy was assessed with logistic regression models and using the receiver operator characteristic (ROC) curve, calculating the area under the curve (AUC).Statistical data analysis was performed using the Statistica 12 software from StatSoft Inc.  and IBM-SPSS Statistics for Windows version 26 . Categorical variables were evaluated with the χp < 0.001 by χ2 test) and pregnancy complications in mothers   compared to healthy controls . In particular, girls with PE were significantly younger at menarche  and often had irregular periods and/or heavy menstrual flow  of patients in the main group reported blood spotting that occurred mostly mid-cycle  and/or shortly before menses (the responders could choose more than one answer to this question). In 60.9% (14/23) of the cases, the spotting was brown; in the rest, it was scarlet  or dark red . Most patients with intermenstrual spotting  had PE combined to diffuse adenomyosis.p < 0.001, χ2-test), 15.9% (7/44) reported functional dysmenorrhea with occasional single cases of pain reaching 5–8 points on day 1, and these were effectively treated without recurrence by a single dose of NSAID, which can occur during the physiological menstrual cycle. Patients with PE reported pain of high intensity  that most often began 1 day before menses and lasted 3 days into menses . Smaller proportions of the patients reported mid-cycle pain , pain beginning 3–5 days before menses , daily pain  and menstrual pain spanning 3–5 days before and after menses  . Although none of the control group’s participants presented severe dysmenorrhea  .In 45.6% (41/90) of the patients, the pain was localized in the “lower abdomen” area, whereas 22.2% (20/90) reported pain in the “lumbar” area and 13.3% (12/90) complained of diffuse pain without clear localization. The patients also reported groin pain on the left , groin pain on the right  and pain in the perineum  or in the sacrum  (the responders were asked to recollect sensations experienced up to 3 months prior to the survey and could choose more than one answer).Most patients  experienced menstrual pain from menarche, and the rest attributed the time of pain onset to some period after menarche . Three pThe descriptions of painful sensations in the main group varied: 44.4% (40/90) of the patients described the pain as “aching, pulling”, 25.6% (23/90) described the pain as “cramping”, 20.0% (18/90) described the pain as “cutting, stabbing”, 10.0% (9/90) described pain as “pressing” and 1.1% (1/90) described pain as “baking (burning)” (the responders could choose more than one definition). In addition, 38.9% (35/90) of the patients had gastrointestinal symptoms  and 24.4% (22/90) reported urination disorders (dysuria and hematuria) associated with menstruation. The majority of patients  had reduced everyday activity on menstrual days because of pain, which is defined as weakness, decreased performance and physical activity.p = 0.005) and dysmenorrhea from menarche  as risk factors for juvenile PE. Among clinical and anamnestic factors, the highest diagnostic accuracy for PE in adolescents was shown for persistent dysmenorrhea  and VAS score . The ROC analysis revealed the sensitivity of 71.8% and a specifity of 79.2% for the cut-off VAS score in 6.50 points in the prediction of PE on laparoscopy   in close relatives  see . 8/L; 2.6 ± 2.2 vs. 1.9 ± 2.1, p = 0.04). The measured values of other inflammation markers including total WBC counts , sedimentation rate of erythrocytes (ESR)  and C-reactive protein  were similar.Routine blood tests revealed no between-the-group differences, apart from slightly higher eosinophil counts in patients with PE compared to healthy controls (10p < 0.001) as a risk factor for PE in adolescents.Hormone profiling revealed higher levels of LH, estradiol, 17-OH progesterone and prolactin in patients with PE compared to the control group, albeit within reference laboratory values . Multivap = 0.006), albeit not exceeding the upper reference limit; the differences for other tumor markers were non-significant.The levels of CA-125 in patients with PE were higher than in the control group  and thicker endometrium  compared to the control group, whereas ovarian morphologies were similar. The signs of PE and adenomyosis were encountered in only 3.3% (3/90) and 20.8% (5/24) of the cases with corresponding final diagnoses.In sonographic images, patients with PE presented with thicker uterine walls  and PE in 78.9% (71/90) of cases with corresponding final diagnoses . The othWe paid special attention to the analysis of the MRI’s description in the cases of PE . Of the We analyzed the significance of detected MRI signs in predicting the confirmation of PE according to laparoscopy in adolescents using factor analyses. The most essential MRI signs of PE appeared to be the following: heterogeneity of paraovarian, parametrial or paracervical tissue or/and hypointense foci in the pelvic tissue, thickening or flattening of the uterosacral ligaments or asymmetric nodular irregularity of ligaments, thickening of the peritoneum and/or heterogeneity of the tissue of the pouch of Douglas, the presence of a meager amount of free fluid in the rectouterine pouch, adhesions in the pelvis and fixation of the fallopian tube, intestine and/or ovaries see .p = 0.008; area under the curve (AUC) = 0.796, p < 0.05), which could be helpful in early diagnostics (p = 0.002) than with the use of each index separately; the ROC analysis is presented in One of two MRI signs for ligaments or/and for the heterogeneity of the pelvic tissue provides a diagnostic accuracy of PE in 74.7%  score was detected in the majority of adolescents ; the II stage—in almost one-third of patients ; and the III stage was observed in 7.8% cases due to endometriomas .According to laparoscopy, a different localization of PE foci was noted see . EndometA comparison of the data of MRI and laparoscopy in relation to PE localization in adolescents revealed that the MRI suggested the direct compartment of lesions in less than half of the cases  on the uterosacral ligaments and in one-third of cases on the peritoneum of the pouch of Douglas (in 30.0% (18/60). The visualization results almost matched for the lesions in the paraovarian tissue and the peritoneum of ovarian fossa . However, the MRI showed false-positive results when the lesions were located in the retrocervical area (27 cases from 24 due to LS) and the serosa of the uterus (13 from 2 cases) see .p = 0.017. Transparent lesions were associated with a higher VAS score . White foci correlated with prominent vasculature .In most cases, patients had transparent confluent foci ; in a third of patients, red  and black foci  and white fibrous foci  were observed. In 14.4% (13/90) of patients with prominent vasculature, adhesions  and serous hemorrhagic fluid in the pouch of Douglas  were observed. Schematically, the features of endometriotic foci are presented in Furthermore, the histological findings were evaluated. In 67.8% (61/90), lesions were represented by endometrial-like tissues ; in addition, the areas of fibrous (100%), adipose (44.4%), muscle (31.1%) tissue, hemorrhages (7.8%), vessels (7.7%), the areas of calcification (3.3%) and infiltration with polynuclear leukocytes (5.6%) were described. In one of the cases, a combination of endosalpingiosis and endometrial-like tissues was determined (2.2%). However, in 32.2% (29/90) of cases, endometrial-like tissues were not identified. In these cases, the foci of endometriosis were represented mainly by fibrous (73.3%), adipose (31.1%), muscle (21.1%) tissue and areas of hemorrhage (21.1%); in 20.0% (18/90) of cases, the tubal epithelium was visualized, which determined the histological conclusion of endosalpingiosis.p = 0.001). In addition, plethoric and developed vessels in the histological picture were associated with a higher rate of detection of polynuclear leukocytes . Black lesions were more likely to have histological verification , consistent with other studies, and evidenced a polygenic multifactorial inheritance pattern relative to endometriosis with a heritability of 51–71% [Endometriosis is the most common reason for persistent dysmenorrhea and chronic pelvic pain in adolescents. At the same time, there are very few clinical studies on endometriosis in adolescents in the available literature; thus, the management strategy and tactics are customarily extrapolated from data obtained in adults ,24. It ip < 0.001 by t-test).A meta-analysis of 18 publications investigating the association between menarcheal age and endometriosis revealed a weak positive correlation between endometriosis and early menarche , possiblThe relationship between menstrual cycle length and endometriosis is complex . Both loConcerning pelvic pain, it is reported that adolescents express severe dysmenorrhea and acyclic nonclassical pain mostly for a prolonged time from menarche ,28,29. OAn important developmental facet in endometriosis pathogenesis is linked to the maturation of hypothalamic–pituitary projections during puberty. The higher systemic levels of luteinizing hormone (LH) and prolactin observed in the main group of the study may serve as a predisposing factor in girls with the delayed maturation of the hypothalamic-–pituitary system and elevated volume/frequency of LH release. In addition, endometriosis is a hormone-mediated condition , and accAdolescent endometriosis is generally underestimated; as the imaging evaluation remains challenging, transvaginal ultrasound and vaginal examination could be contraindicated ,31. TherMRI, by contrast, provides rather accurate diagnostic means for endometriosis including deep infiltrative forms, and these are informative in terms of organ involvement and adhesive process severity . SuperfiLaparoscopic evidence provides a gold-standard verification for PE, determining the stage, spread and severity of the process . EndometThe majority of our patients presented with stage I or II of the disease , and a minority presented stage III 7.8%, 24.5 ± 7.5). The lesions were localized predominantly in uterosacral ligaments (84.4% of the cases) and the pouch of Douglas (66.7% of the cases). These data are consistent with other studies: Smorgick et al. reported early stages I/II in 76% of the patients, with the rest having advanced stages III/IV% [ ± 7.5. TBack in 1987, a study by Chatman and Zbella enrolling 115 patients with endometriosis observed that conspicuous, clinically and laparoscopically substantiated diagnoses (characteristic symptoms and macroscopic lesions) often fail to be supported histologically . In modep = 0.045) and AFS score . El Bishry G. et al. previously reported a correlation between histological compliance and severity [p = 0.626) probably due to the specific structure of the cohort . The lack of association between clinical stage and dysmenorrhea severity as assessed by VAS  is consistent with other studies [According to published evidence, the endometrial foci of white/mixed color are more likely to contain endometrial-like morphological patterns; accordingly, black or red lesions are less often confirmed histologically . In thisseverity ; howeverIt should be emphasized that the decision on pelvic laparoscopy in an adolescent is a fundamentally sensitive issue: on the one hand, such decisions should imply that all conservative options have been exhausted; on the other hand, postponing may lead to uncontrollable disease progression with disastrous consequences ,35.Considering the substantial impact of endometriosis on social and psychological well-being, as well as the progressive nature of the disease and its damaging effect on reproduction, early diagnosis and management are pivotal. Despite the lack of reliable biomarkers and noninvasive diagnostic criteria, a comprehension of family history, clinical status and MRI data by an experienced specialist can result in the recognition of juvenile endometriosis with high accuracy . Laparosp ≤ 0.005).A family history of endometriosis and dysmenorrhea from menarche increases the risks of peritoneal endometriosis (PE) in a girl, respectively, 5- and 20-fold with 95% CIs of 1.58–14.87 and 7.19–51.60  and VAS score  show the high diagnostic significance for PE in adolescents.The main endometriosis-associated complaints in adolescents are moderate–severe dysmenorrhea (VAS score 7.5 ± 2.1), decreased everyday activity/performance (75.6%), gastrointestinal (38.9%) or urinary (22.4%) symptoms and mid-cycle spotting (25.6%). Persistent dysmenorrhea . Ultrasonography has a low diagnostic potential for both PE and adenomyosis in adolescents.p = 0.008) diagnostic accuracy on their own. However, the fundamental limitations of MRI as (so far) the best diagnostic approach for the initial stages of peritoneal endometriosis motivate laparoscopic interventions upon the indication of persistent pelvic pain and severe dysmenorrhea in adolescents, at least in MRI-negative cases.Significant MRI signs for the peritoneal form of the disease include the heterogeneity of paraovarian or parametrial tissue and/or hypointense foci in the tissue and the pouch of Douglas and the thickening or nodular irregularity of uterosacral ligaments or uterine serosa (<0.05 for each). The positive MRI signs for ligaments and/or the pelvic tissue heterogeneity provided 74.7% (p = 0.007), rASRM score for severity  and degree of vascularization , respectively.The majority of adolescent patients with PE (64.4%) had stage I (rASRM score 3.1 ± 1.3), followed prevalently by stage II  and stage III . Peritoneal lesions were found predominantly in uterosacral ligaments and the pouch of Douglas . Clear vesical, red and white foci  correlated with the VAS score for pain intensity .The combination of persistent dysmenorrhea and MRI signs for ligaments and/or pelvic tissue heterogeneity provided high diagnostic accuracy for PE detection in adolescents (80.9%, χThe main conclusions from the study are formulated as follows:


Conclusions: Pre-operative intravenous administration of a single dose of dexamethasone may decrease opioid requirements for adequate pain control after knee arthroscopy.Background: Knee arthroscopy is a standard surgical procedure that is nowadays widely performed as day-case surgery. The aim of the study was to observe the effect of a single dose of intravenous corticosteroid on pain after undergoing knee arthroscopy for non-bony procedures. Methods: A prospective, double-blind study design was adopted. Patients undergoing knee arthroscopy for non-bony procedures were prospectively assigned into two equal groups: control (those who were not given steroids) and treatment (those who were given eight milligrams of dexamethasone intravenously 15 min prior to the inflation of the tourniquet). The pain was assessed pre-operatively on admission and on the first post-operative day during the morning round in five different movements using a visual analogue scale (VAS). Results: A total of 60 patients were included in the study. There was no significant difference in the pre-and post-operatively scores between both groups. The treatment group experienced a significant reduction in post-operative morphine requirements, with 80% of patients who did not receive dexamethasone requiring post-operative morphine compared to only 53.3% of patients who did ( Knee arthroscopy is one of the most common orthopedic procedures. It is used to treat an array of conditions, particularly the repair or debridement of meniscal tears, removal of loose bodies, synovectomy, ligament reconstruction, and meniscal transplantation . ArthrosKnee arthroscopic procedures are performed as day cases in many institutions. Adequate post-operative analgesia is even more crucial for day case procedures and should ideally have a prolonged duration of action with minimal side effects to allow the patient to return to regular activity after discharge. Many substances have been studied for this use, including steroids, opioids, local anesthetics, and combinations of the aforementioned, with some demonstrating clinical benefits and others failing to do so; however, there is no consensus between clinicians and researchers on the efficacy of these combinations or their possible side effect ,11,12,13Dexamethasone may reduce post-operative discomfort if added to the treatment strategy. Although dexamethasone does not contribute directly to pain pathways, it does reduce inflammatory markers, which can decrease pain levels and shorten hospital stays . SteroidAlthough knee arthroscopy is an extremely common surgery for a variety of conditions, there is no consensus on how to manage the pain and disability after these procedures with minimal side effects. The purpose of our study is to observe the effects of pre-operative corticosteroid administration on acute post-operative pain in patients after undergoing arthroscopic knee procedures. Taking into consideration that glucocorticoids, including dexamethasone, are sometimes used to relieve severe acute pain following orthopedic surgery, we hypothesized that the administration of a single intravenous dose of dexamethasone prior to surgery would reduce the number of opioids required for adequate pain management following knee arthroscopy.This prospective, double-blinded study involved patients who underwent knee arthroscopy for non-bony procedures from 2019 to 2022. A total of 60 patients were enrolled in this study from a single, 600-bed tertiary care teaching hospital during the duration of the study. Patients were eligible for participation if they were undergoing knee arthroscopy for non-bony or soft tissue procedures, were mobile, could cooperate and understand the visual analog score (VAS) scale, and had no contraindications for receiving the medications which included hypersensitivity to dexamethasone or any corticosteroids. Exclusion criteria were cases of soft tissue procedures that needed tunnel drilling of the bone, such as anterior cruciate ligament and collateral ligament surgery or osteochondral autologous transfer surgery (OATS), because they also needed bone drilling and raised pain and sensitivity levels. The primary objective of this study was to evaluate the effect of a single intravenous corticosteroid dose on pain and analgesia requirements after knee arthroscopy.Prior to the study’s beginning, the protocol was evaluated and approved by the Jordan University Hospital ethics committee, and the appropriate institutional review board (IRB) approved the study proposal . The Code of Ethics of the World Medical Association (Declaration of Helsinki) was followed while conducting the study. All patients participating in this study signed written informed consent.The data were collected on a pre-formed collection sheet that was developed and created by the authors. The sheet included four major sections: patient demographics, covering the patient’s age, weight, height, and BMI. The second section included the pain scores, which were recorded using two instruments twice by an observer who was blind to the chosen group: once a day before the surgery at the time of admission and once the next morning after surgery at the morning round around 9 a.m. . The first tool included a physical movement pain score ranging from 0 to 10, with 0 indicating no pain and 10 being extremely painful. Patients were asked by a senior orthopedic resident (5th year resident) to perform a set of five movements at the bedside that included a straight leg raise while lying supine, knee flexion with the patient lying supine, knee extension and flexion while sitting on the couch, and five steps of walking. We chose these 5 movements based on our experience (the most common movement on the knee that causes pain) and to unify the situations for which the pain score was recorded in order to make the pain comparison more objective. The scores were documented accordingly for each movement. A second tool that included a VAS score, which included faces with various expressions and a 0 to 10 pain scale, with 0 indicating no pain and 10 being extremely painful, was used as an additional pain assessment tool. The third section of the data sheet included operation details, considering that all patients underwent arthroscopy for non-bony procedures under spinal anesthesia and tourniquet control, mainly for soft tissue procedures including diagnostic arthroscopy, meniscectomy, or meniscal repair. The fourth section contained additional details regarding any procedures performed, the need for analgesia or opioids within the last 24 h pre-operatively, intraoperatively, or post-operatively, and the dosage details  mixed with 25 µg Fentanyl (0.5 mL) and administered intrathecally using a 25 G pencil-point spinal needle under a complete septic technique. The level and potency of the block were assessed before starting the procedure. No local anesthetic intra-articular injections were performed. For intraoperative increases in heart rate or systolic blood pressure greater than 20% above baseline levels, fentanyl was administered in a dose of 50 μg. In the postanesthesia care unit, patients were evaluated for pain using the VAS and numeric pain score, and if the pain score exceeded 4 out of 10, patients were given 1g of IV paracetamol, and if was more than 6 out of 10, morphine, of 2 mg IV every 10 min, was given until the pain score was less than 4.The surgical technique involves standard knee arthroscopy with three portals: a medial supra-patellar for normal saline inflow, an antero-lateral (AL) for the arthroscope, and an antero-medial (AM) for instruments.Patients were assigned by the operating surgeon into two groups: one group received eight milligrams of dexamethasone intravenously (IV) 15 min before inflation of the tourniquet (treatment group) and the other group did not (control group). For convince purposes, the patients were assigned to each group in order of their presentation to the hospital after being determined to be eligible for the study, with the first 30 eligible patients placed in the control group and the following 30 eligible patients assigned to the treatment group. The process was blinded for both the patients and the data collection team to limit the bias, whereas the operating surgeon, the anesthesiologist, and the statistician were not blinded. In addition, all these procedures were performed by a single professional and expert sports medicine surgeon of the knee according to the same protocol, with a torniquet time and procedure time not exceeding 1 h at maximum, and under the supervision of the same senior anesthesiologist.Both groups were managed post-operatively using the same pain management protocol, including a regular one-gram acetaminophen IV every eight hours and, as needed, intramuscular (IM) morphine according to the patient’s weight (0.5 milligrams per kilogram and a maximum dose of 5 to 6 g). The frequency of ordering pain medication and the dosages were recorded in the data collection sheet. There were no surgical site infections or wound healing complications in any of the cases after two weeks, when patients presented for removing the sutures, or at least after a three-month follow-up period.U test was performed to compare the visual analogue scale between groups. All the underlying assumptions were met, and a p value of 0.05 was adopted as a significant threshold.Statistical analysis was performed using SPSS version 23.0 , and both the mean ± standard deviation and count (frequency) were used to describe continuous variables  and nominal variables , respectively. Further, an independent sample t-test was used to analyze the mean difference between each group and continuous scale measurements , where data were represented using the mean ± standard deviation. Chi-square testing was used to analyze the difference in morphine and acetaminophen use among each group. To compare the pain score and visual analogue scores between both groups, the difference was calculated by subtracting the pre-operative score from the post-operative score. Subsequently, a Mann–Whitney A total of 60 patients were included in this study, with a mean age of 34 ± 11.04 years. Of these patients, 73.3% were men and 26.7% were women. Half of the patients (n = 30) received dexamethasone pre-operatively, whereas the other half did not. There were no significant differences between both groups when comparing the demographic characteristics, as shown in p = 0.027). When looking at the pain management effect, a significant difference was found regarding morphine use, where 80% of patients who did not receive dexamethasone required post-operative morphine compared to only 53.3% of patients who did (p = 0.056). There was no significant difference in the pre- and post-operatively mean score between both groups among the physical movement pain scale scores, as shown in Regarding the use of IV acetaminophen, there was no significant difference (Our data showed that a single pre-operative IV dexamethasone injection helped achieve adequate post-operative pain control while significantly decreasing post-operative morphine requirements. The control group achieved comparable post-operative pain control; however, with significantly higher morphine requirements. This is explained by the fact that 80% of the control group requested morphine for pain control, compared to only 53% of the treatment group. There was no significant difference in the dosages of post-operative acetaminophen between the patients who were administered perioperative dexamethasone and those who were not.Uncontrolled pain is an undesirable effect of orthopedic procedures. This could lead to an increased duration of hospital stay and more prolonged time to start rehabilitation, leading to more post-operative complications and subsequently more readmissions, and a higher cost of care ,25. A raIdeally, pain management regimens should be efficacious and have minimal side effects. The use of multimodal pain management has been shown to serve this purpose, particularly in orthopedic surgical cases ,27. DexaSurgical patients undergoing surgery under general anesthesia were found to benefit from a single IV perioperative dose of dexamethasone, which could lead to reduced post-operative pain, lower need for post-operative opioids, longer time to take their first analgesia dosage, less rescue analgesia, and decreased time spent in the post-anesthesia care unit . RegardiA study that included 78 patients by Moyano et al. found that IV dexamethasone during the intraoperative period had no significant clinical impact on post-operative pain intensity during the first 48 h after arthroscopic knee surgery when given in conjunction with another anti-inflammatory . NeverthThere are some limitations to this study. First, the relatively small sample size reduces statistical power and makes it difficult to identify differences between the groups. Because there were no differences between the two groups’ demographic, the likelihood of a type I error was low. Second, this study may have been affected by regional ethnic sample biases because all patients were recruited from a single center. Third, it should be mentioned that it is important to keep in mind the possibility that even a single dose of dexamethasone may cause side effects. However, our study had several strengths. This includes the prospective nature of the study and the specific movements for which pain scores were recorded, which makes them more objective. We used a double-blind design to ensure that neither the experimenter nor the participants could be biased. Furthermore, all of the operations were performed by the same experienced orthopedic surgeon using the same protocol to avoid any element of variation across patients. Therefore, we believe that our findings provide preliminary evidence that offers a rationale for future clinical studies with a larger sample size. Moreover, we recommend future researchers to also study the effect of dexamethasone on postoperative nausea and vomiting, which could be an additional advantage of using it, as it was previously reported that 4 mg of dexamethasone given pre-operatively reduced significantly the risk of postoperative nausea and vomiting .The results of this study showed that pre-operative administration of a single dose of intravenous dexamethasone decreased the need for opioids required for adequate post-operative pain control. Further studies on larger samples may be required.


A numerical rating scale (NRS) to assess expectations for treatment was similar before hydrodissection and immediately after hydrodissection was 8.4  in the visual feedback and 5.9  in the visual feedback. The proportion of increased expectations immediately after hydrodissection was 90.8% (95% CI: 83.7–97.9) in visual feedback group and 38.0% (95% CI: 26.7–49.3) in non-visual feedback group (p < 0.001). In the visual feedback group, 67.7% of patients showed improvement in pain numerical rating scale score by 50% or more at day 14, whereas such improvement was observed in only 36.6% of the non-visual feedback group (p < 0.001). Based on path analysis, the visual feedback had the greatest influence on pain numerical rating scale reduction at 14 days, indirectly due to increased expectations for treatment as a mediator (β = 0.434). However, the adjusted R2 values, which is the overall fit of the model, was low at 0.298. Visual feedback during ultrasound-guided hydrodissection increases the expectations for treatment immediately after hydrodissection, which could be one of the related factors for pain reduction in patients with myofascial pain syndrome.Expectations for treatment have a favorable effect on the subsequent course of pain and behavior in patients. It is not known whether receiving hydrodissection while patients view their ultrasound image with doctors  is associated with positive treatment expectations. This was an exploratory, prospective, observational clinical trial. We explored the possibility that visual feedback immediately after ultrasound-guided hydrodissection increases the expectations for treatment, which could be one of the related factors for pain reduction. Treatment expectations were set as mediators of pain using path analysis. The primary endpoint was the numerical rating scale to assess expectations for treatment immediately after hydrodissection, between with and without the visual feedback. During 2019 and 2020, 136 outpatients received ultrasound-guided hydrodissection for myofascial pain syndrome. Of these, 65 (47.8%) patients received visual feedback during ultrasound-guided hydrodissection. Compared with the non-visual feedback group, the visual feedback group had higher expectations for treatment immediately after hydrodissection, and their expectations were maintained at day 14 of treatment ( According to the United States Centers for Disease Control and Prevention, the three main conditions that cause daily life disability are heart disease, arthritis, and chronic back pain . MyofascUltrasound-guided hydrodissection has recently been receiving increased attention as a therapy for treating MPS , 10. In We previously reported that MPS is a clinical symptom of psychosomatic disorder that occurs in approximately half of cancer patients. The results from a randomized controlled study suggested that biofeedback therapy, a psychosocial approach, is helpful in the treatment of MPS in cancer patients . ClinicaExpectations for treatment have a favorable effect on the subsequent course and behavior in patients. A systematic review has suggested that positive expectations for treatment are related to good health outcomes . FurtherWe hypothesized that visual feedback immediately after hydrodissection would raise patients’ expectations for pain treatment, which could be one of the related factors for pain reduction. To the best of our knowledge, there have not been any reports that have investigated the effect of visual feedback during ultrasound-guided hydrodissection for MPS.The objective of this study was to explore the possibility that visual feedback immediately after hydrodissection increases the expectations for treatment, which could be one of the related factors for pain reduction.This was an exploratory, prospective, observational clinical trial that explored the effects of visual feedback during ultrasound-guided hydrodissection. Visual feedback was defined as hydrodissection administration while patients viewed the ultrasound image with their doctor. Expectations for treatment were set as mediators of pain using path analysis.The study received approval from the Medical Ethics Committee of Kansai Medical University on March 6, 2019 (reference number: 2018177). Informed consent was not obtained in this study because usual clinical practice was observed, including assessments and treatment. An opt-out method was used so that patients and their families could refuse to participate in the study. The procedures performed in this study were in accordance with the Declaration of Helsinki (as revised in 2013). This study was registered with the University hospital Medical Information Network Clinical Trials Registry  on January 28, 2021 (retrospectively registered).This study was conducted from March 2019 to March 2020 at two facilities in Japan: Kansai Medical University Hospital and Omotesando Pain Clinic. During this period, we continuously enrolled outpatients who received ultrasound-guided hydrodissection for MPS of the upper back. MPS was diagnosed based on the following criteria: (1) a tender spot located with palpation, with or without referral of pain; (2) recognition of symptoms by the patient during palpation of the tender spot; and (3) at least three of the following: (a) muscle stiffness or spasm, (b) limited range of motion (ROM) of an associated joint, (c) pain worsening with stress, and (d) palpation of a taut band and/or nodule associated with the tender spot . The uppThe exclusion criteria were: (1) patients who were younger than 20 years and (2) patients who had any comorbid psychiatric disease or condition that made communication difficult, such as cognitive impairment or delirium.Hydrodissections  were administered by a doctor at each institution to four bilateral upper and lower sites at the boundary between the levator scapulae and trapezius muscle. Doctors used ultrasound to confirm the following points in real-time: (1) boundary between the levator scapulae and trapezius muscle; (2) position of the needle tip; (3) saline injection; and (4) removal of the fascia . A singlBefore starting treatment, a doctor at each institution verbally explained the ultrasound-guided hydrodissection procedure  to the patients. Patients were then asked whether they would like to request to view the real-time ultrasound images during the procedure. The merits and demerits of visual feedback were not shared with the patients. Patients who viewed the real-time ultrasound images were defined as the visual feedback group, and patients who did not view the real-time ultrasound images were defined as the non-visual feedback group. The visual feedback group received the doctor’s explanation of the procedure and ultrasound images with viewing the real-time ultrasound images; the non-visual feedback group received the doctor’s explanation of the procedure and ultrasound images without viewing the ultrasound images. Both groups spent equal amounts of time in each session. After the ultrasound-guided hydrodissection, patients were instructed to perform two 3-min sessions of a self-stretching exercise  per day. Assessments were carried out by a doctor in the outpatient department or clinic of each institution on the following days: before intervention (T0), the day of the hydrodissection (T1), and 14 days after the hydrodissection (T2).Clinical demographic information was obtained from all subjects and included age, sex, institution , primary illness (cancer or non-cancer), pain numerical rating scale (NRS) before the hydrodissection, NRS to assess expectations for treatment before hydrodissection, and analgesic drug use.Expectation intensity was determined using an NRS to assess expectations for treatment, which ranged from 0 (no expectations) to 10 (highest expectations). The questionnaire was self-administered and contained the following question: “How well do you expect this treatment to reduce pain?” The validity of this questionnaire is not clear, but it has frequently been used in research , 14. TheAverage pain intensity was assessed using an 11-point NRS for pain, which ranged from 0 (no pain) to 10 (worst possible pain) . The queCervical ROM for flexion, extension, lateral flexion, and rotation were measured using a goniometer , which is an objective and reliable method . All meaThe primary endpoint was the NRS to assess expectations for treatment immediately after ultrasound-guided hydrodissection, between with and without the visual feedback. The secondary outcomes were the proportion of increased expectations immediately after hydrodissection, NRS score change for expectations for treatment and pain, the proportion of pain reduction at T2 after hydrodissection, cervical ROM, correlation between increased expectations and pain NRS reduction using path analysis, and adverse events.Because previous studies on this subject are limited, sample size calculation was performed based on a report using similar therapeutic methodologies . The priData are reported as means and standard deviations, medians with interquartile ranges, or frequencies (%), as appropriate. When participants provided missing data, we used the worst scores in the data.t-tests were used for comparisons of the independent variables of age, pain NRS score before hydrodissection, and NRS score for expectations for treatment before hydrodissection. Pearson’s chi-square tests were used to analyze the independent variables of sex, institution, primary illness (cancer), and analgesic drug use. The proportion of study participants with visual feedback, increased expectations immediately after hydrodissection, and pain reduction at T2 after hydrodissection for each group among all participants were estimated using a chi-square test, including the exact 95% confidence intervals (95% CI).The study participants were classified into two groups: the visual feedback and non-visual feedback groups. Unpaired Changes in the course  of NRS scores for expectations for treatment, pain NRS scores, and cervical ROM scores were analyzed using one-way repeated measures analyses of variance (ANOVA) for each group. To conduct comparisons between groups, time course was used as the within-subjects factor and group was used as the between-subjects factor in a two-way repeated measures ANOVA. Multiple comparisons were corrected using the Bonferroni method. If participants withdrew from the study, NRS scores after withdrawal were substituted with scores immediately before withdrawal. Change in analgesic drug use during the period and loss to follow up were classified as withdrawals from the study.p < 0.05, adjusting paths with reference to the modification index, repeating model correction while checking the goodness of fit index (GFI), and investigating correlations between factors specifying pain reduction at T2. To assess fit, we used model chi-square values, GFI, comparative fit index (CFI), root mean square error of approximation (RMSEA), and AIC. Smaller chi-square values, >0.95 for GIF and CFI values, and ≤0.08 RMSEA values indicate good model fit .A value of n = 5) and (2) had a comorbid psychiatric disease or condition that made communication difficult (n = 8). A total of 136 patients were selected as study participants.During the study period, 149 outpatients who received ultrasound-guided hydrodissection for MPS were enrolled. Of these 149 outpatients, 13 patients were excluded for the following reasons: (1) aged <20 years (n = 65) or non-visual feedback (n = 71) groups. Of the 136 patients, 47.8% (95% CI: 39.4–56.2) received visual feedback during ultrasound-guided hydrodissection. Patients were classified into the visual feedback (n = 3) or loss to follow up (n = 7). Of these patients, four were in the visual feedback group and six were in the non-visual feedback group.Ten patients withdrew from the study because of analgesic drug changes during the study period (p < 0.001).In the visual feedback group, a NRS to assess expectations for treatment at T0 was 5.7 , whereas it increased to 8.4  at T1. In the visual feedback group, a NRS to assess expectations for treatment at T0 was 5.9 , and at T1 was 5.9 . The proportion of increased expectations immediately after hydrodissection was 90.8% (95% CI: 83.7–97.9) in visual feedback group and 38.0% (95% CI: 26.7–49.3) in non-visual feedback group . There was no significant difference for T1 between the two groups (p = 0.186). The visual feedback group showed a significant decrease in NRS score at T2 . Overall, improvement was observed in 52.2% of patients (95% CI: 43.8–60.6).In the visual feedback group 67.7% of patients showed improvement in pain numerical rating scale score by 50% or more at day 14 (95% CI: 56.5–78.9), whereas such improvement was observed in only 36.6% in the non-visual feedback group  and left rotations  did not differ between patients who were and were not instructed to perform self-stretching exercises. These results indicated that in the visual feedback group, an increase in patients’ expectation for treatment immediately after the intervention led patients to adhere more to self-stretching.The second critical point was that the expectations for treatment could be one of the determining factors for pain reduction. The severity of upper back pain in MPS was 6.0 on the NRS, which reflects moderate pain . At 14 dVisual feedback had no direct effect on the subsequent course of pain. However, it had an indirect positive effect through increased expectations for treatment. We speculate that a placebo effect on pain in MPS patients was exerted by patients’ expectations for treatment. A previous study reported that opioid-naïve cancer patients with high expectations for pain reduction before morphine treatment had significantly lower pain intensities at 7 days after treatment . There hWe also speculate that in the visual feedback group, the immediate increase in patients’ expectations for treatment after the intervention increased the adherence rate of subsequent self-stretching, which resulted in MPS pain relief 14 days after the intervention. Efficacy of self-stretching on MPS in the plantar heel and stretching plus acupuncture on MPS in the upper back have been reported previously , 30.R2 value at 0.298, which measures the overall fit of the model. In other words, visual feedback and increased expectations explain only 30% of the pain reduction“Increased expectations” is the only one among several other factors associated with pain reduction.However, path analysis revealed a low adjusted The study has several limitations. First, self-selection bias was present because visual feedback was not allocated. Patients with high expectations for treatment may have requested visual feedback treatment. However, there was no significant difference between the two groups in NRS scores for expectations for treatment before hydrodissection. This study was an exploratory trial, and future randomized controlled trials with or without visual feedback with expectations for treatment as the primary endpoint are needed. Second, hydrodissection is a new treatment and has not been established as a standard treatment for MPS. Therefore, these results are limited to the method of this study. Third, our results may not generalize to the general population because there was a large proportion of cancer patients. Although a recent review reported a high frequency of MPS in cancer patients , cancer Visual feedback during ultrasound-guided hydrodissection increases the expectations for treatment immediately after hydrodissection, which could be one of the related factors for pain reduction in patients with myofascial pain syndrome.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of Kansai Medical University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.HH was responsible for the conception and design of this study, wrote the manuscript, and responsible for data analysis. HH and HO were responsible for data collection and for clinical evaluations. MF provided advice on the composition of the manuscript. All authors have approved the final version of this manuscript.


Arthroplasty for the hip/knee and surgeries for hip fractures are increasing worldwide. The aims of this study were to investigate changes in health-related quality of life (HRQOL) after surgery with an early mobility education program, and to explore their associations with pain and anxiety. Pain intensity and anxiety were assessed with the visual analogue scale (VAS) and Beck Anxiety Inventory (BAI), and HRQOL was assessed with the Short Form-36 (SF-36). The physical component summary (PCS) and mental component summary (MCS) and eight subscales of the SF-36 were calculated. At pre-operation, the patients suffered from moderate pain and mild anxiety, and their HRQOL scores were low . The pain, anxiety, and HRQOL improved after surgery and had moderate to large effect sizes at 6-month follow-up . Pain and anxiety were strongly correlated to HRQOL at each stage, with the maximum correlation (r = −0.34 to −0.93) reached at 6-month follow-up. The surgery effectively improves HRQOL, as the reduced pain and anxiety lead to better physical and mental HRQOL. The prevalence of arthroplasty for hip and knee joints is increasing worldwide, and the prevalence rises with age. At the end of 2016, for the age groups of 65 to 84 years and over 85 years, the overall prevalences were 13.3% and 22.5%, and about 3.4% of the total population had at least one joint replacement, as reported by a study in Australia [Degenerative arthritis and osteoporosis are common diseases in the lower extremities of the elderly. Pain due to arthritis and inactivity can significantly interfere with daily and social activities. Osteoporosis can easily lead to femoral neck fracture. Although fracture is not difficult to cure, patients commonly stay in bed for an extended period, which consequently induces many complications. Early activity after surgery needs to include education for patients with hip fracture and arthroplasty, such as getting out of bed as soon as possible and following a specific exercise plan. Furthermore, an education program focused on early activity could conserve medical resources and reduce the social burden.QOL is considered one of the main postoperative outcomes, and after arthroplasty, most patients report improved QOL . HoweverAlthough current evidence clearly shows that pre-operative pain and anxiety affect HRQOL, few studies explored changes in pain and anxiety during the subsequent stages, and no information is available on concurrent pain and anxiety associated with HRQOL in the follow-up stages. The aim of this study therefore was to investigate HRQOL at different stages and the associations of pain and anxiety at the same stages by providing an early activity education program for patients with TKR, THR, and hip surgery.A convenience sample of patients was recruited from the Department of Orthopedics of Kaohsiung Medical University Hospital. Patients were included if they met the following criteria: age of 18 years or older; scheduled THR or TKR surgery at the hospital or surgery due to hip fracture; the ability to read traditional Chinese; and the absence of physical limitations affecting the ability to complete the self-administered questionnaire. The exclusion criteria included history of knee or hip surgeries, other medical diseases, and psychiatric history. The primary diagnoses for arthroplasty included osteoarthritis, rheumatoid arthritis, traumatic arthritis, and avascular necrosis. After explanation of the research program, written informed consent was obtained from all patients. We expected the effect sizes to be large (0.8) and moderate (0.5) for physical and mental quality of life, respectively, between 6-month follow-up and pre-operation. The sample sizes were estimated with a two-sided significance of 0.05 and a power of 0.8; a total of 15–34 patients was required . Considering the attrition effect of long-term follow-up, the total sample size in the study was 100.After receiving an explanation of the research program, each patient was asked to complete a questionnaire booklet containing the visual analog scale (VAS) for pain severity, the Beck Anxiety Inventory (BAI) for anxiety, the MOS Short Form 36 (SF-36) for HRQOL, and demographic questions. Each patient was tested on their knowledge of arthroplasty or hip surgery before the education was provided. The test had 14 items with a score range of 0–14 (0 indicating poor knowledge). The tests for TKR, THR, and hip fracture were different. A one-on-one preoperative education program was provided before and after the surgery by a physiotherapist or nurse; a booklet and a video were used for education. At the discharge, the test of the knowledge of arthroplasty or hip surgery, VAS, and BAI were administered again, and the physiotherapist or nurse rechecked whether the patient well understood the education program. At 6 weeks and 6 months post-operation, we first contacted the patient by telephone and then mailed the questionnaire booklet to him/her. The booklet included the VAS, BAI, and SF-36 questionnaires.The purpose of the education project was to improve the early activities of patients with TKR, THR, and hip fracture. The project was reviewed and approved by the Health Promotion Administration, Ministry of Health and Welfare, in Taiwan. The details of the education program were developed by a multidisciplinary team including two orthopaedic physicians, three physiotherapists, an occupational therapist, a psychotherapist, a nutritionist, a social worker, and a nurse. We developed three booklets for patients with TKR, THR, and hip fracture, respectively. We developed videos in two spoken languages, Mandarin and Taiwanese; therefore, in all, six videos were designed for patients with TKR, THR, and hip fracture. The content of the booklets included the progress of a person undergoing hip or knee surgery, from home preparation to hospital stay; information on anatomy, surgery, and the prothesis for replacement; the clinical pathway; precautions following surgery; postoperative recovery; positioning; early activities; daily living activities; exercise; advice on diet, social services, and planning for discharge; and the outpatient clinic program. The video focused on the precautions and positions after surgery, exercise training, early activity training , and daily living activity training with equipment. The educational program was delivered by a trained physiotherapist and a nurse. The content of the booklet was verbally explained before the surgery. One day after the surgery, the patient watched the video and then was taught the exercises and activities through demonstration and practice.The pain intensity was assessed with the visual analogue scale (VAS). The VAS is a 10 cm horizontal line with “no pain” written at the left endpoint and “severe pain” written at the right endpoint . The patThe Beck Anxiety Inventory (BAI) is a 21-item self-report questionnaire measuring symptoms of anxiety . The BAIHRQOL was measured with the Medical Outcomes Study Short Form 36 (SF-36). The SF-36 has eight subscales: physical functioning (PF), role limitations due to physical health problems , bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitation due to emotional problems , and mental health (MH) . The traFor HRQOL, to determine the magnitude of deviation of the eight subscales of the patients from those of the general population, age-/sex-matched normative values were selected and coded according to the age and sex of each patient. The study stages included the pre-operation stage, discharge (without SF-36 data), post-operation 6-week follow-up, and post-operation 6-month follow-up. One-way analysis of variance (ANOVA) with post hoc analysis was used to analyze the difference among stages. The least significant difference (LSD) was used for post hoc analysis. The magnitude of change in scores was evaluated by calculating the effect size (ES). Glass’s ∆ (delta) was used to calculate the ES because the experimental manipulation potentially affected the standard deviation . The ES n = 64) outnumbered males (n = 36); most of them received arthroplasty  and 17 patients received hip surgery to treat fracture. The pain of the patients was moderate (mean VAS near to 5) and their anxiety was mild (mean BAI near to 8) before the operation. Before the operation, the scores of the SF-36 were low in both physical QOL (PCS = 35.4) and mental QOL (MCS = 48.2). The scores of the VAS, BAI, PCS, and MCS were not significantly different among subgroups  before the operation. The mean test scores for the patients’ knowledge were 8.2 ± 2.5 at the beginning of pre-education, and these scores improved to 11.7 ± 1.9 on the day of discharge (p < 0.001). The test scores at the beginning and discharge were not significantly different among subgroups. The mean hospital stay was 6.5 ± 1.8 days. The patients with hip fracture stayed about one day longer (7.4 ± 3.2) than the patients with THR/TKR  did; however, the difference was not significant (p = 0.074).The demographic data and clinical characteristics of the patients pre-operation are shown in = 0.81, 1.02, 1.21, and 0.96), indicating great improvements in HRQOL 6 months after the operation. The patients with THR had the greatest PCS effect sizes (∆ = 1.3), while those with TKR/fracture showed no significant improvement. At the 6-week follow-up, the PCS scores of the patients with THR (41.9 ± 9.1) were higher than those of the patients with TKR and hip fracture . At the 6-month follow-up, the scores of the PCS were not significantly different among subgroups. At both 6-week and 6-month follow-ups, the scores of the MCS were not significantly different among subgroups. The effect size of the MCS was moderate (∆ = 0.67) when compared between 6 months and pre-operation. The patients with TKR had larger MCS effect sizes (∆ = 0.73) than the patients with THR did (∆ = 0.66).The scores of the two summary measures at the three stages  and scores of the eight subscales of the age-/sex-matched normative values and the patients at the three stages are listed in p < 0.001). p < 0.05); however, RE and MH were higher than those normative values (p < 0.05). In the subgroup comparisons, only the SF subscale at the pre-operation stage was significantly different; the scores of the patients with TKR were higher (81.6 ± 21.4) than those of the patients with THR and hip fracture .In the pre-operation stage, five of the eight subscales were lower than the age-/sex-matched normative values  (p ≤ 0.001). Among subgroups, the patients with TKR reported more pain (VAS = 2.2 ± 2.6) than the patients with THR  at 6-week follow-up. BAI scores decreased by over 60% at 6-month follow-up as compared with discharge . The effect sizes of the VAS and BAI, which were compared between 6 months and pre-operation, were large (∆ = 1.23 and 0.88), indicating great improvements in pain and anxiety 6 months after the operation. Among subgroups, moderate to large effect sizes could be found, but the VAS had no significant improvements in patients with fracture  . The chafracture . For all= −0.34, −0.46, and −0.69), and BAI scores correlated well with the MCS  (= −0.69), but also with the MCS (r = −0.70). Similarly, at 6 months, BAI scores were highly correlated with the MCS (r = −0.74) and moderately correlated with the PCS (r = −0.46). Preoperative PCS scores were also moderately correlated with the 6-month follow-up VAS scores (r = −0.52). On the other hand, preoperative MCS scores were not correlated with the BAI scores at 6-month follow-up. For the subscales, VAS scores were moderately to highly correlated with the subscales (r from −0.56 to −0.93), and BAI scores were slightly lower but also moderately to highly correlated with the subscales (r from −0.34 to −0.74) at 6-month follow-up.In each stage, the VAS scores correlated well with the PCS (r d −0.74) . At the At the pre-operative stage, the patients had moderate pain, mild anxiety, and poor HRQOL. Over half of the subscales of the SF-36 had poor scores as compared with the normative values. After education and arthroplasty or hip surgery, the patients improved quickly, the average hospital day was short, and the pain and anxiety significantly decreased at discharge. Most of the subscale scores of the SF-36 continued to improve. The effect sizes between 6-month follow-up and pre-operation were large, in both the physical  and mental  domains. The scores of role emotional and mental health were even significantly better than the normative values. For each stage, the physical summary measure was correlated with pain severity, and the mental summary measure was correlated with anxiety. The associations  changed from moderate at pre-operation to high at 6-month follow-up.The surgery and education program decreased the pain and anxiety of the patients with TKR, THR, and hip fracture. The patient responses to the education programs were good. Especially after watching the video, patients immediately practiced the activities and exercises taught and demonstrated by the physiotherapist or nurse. We encouraged the patients to strive for early mobility and to do the exercises every day, as well as to learn the techniques for daily activities with or without assistive devices. The average hospital stay was only 6.5 days. A nationwide, population-based study from Taiwan showed that, from 2001 to 2005, the average lengths of stay were 8.4 and 8.9 days for THR due to osteoarthritis and rheumatoid arthritis, respectively, and 8.4 and 8.2 days for TKR due to osteoarthritis and rheumatoid arthritis, respectively . The mear changed from 0.28 to 0.48.Preoperative education resulted in a 5.1-point reduction  in preoperative anxiety as compared with usual care  in McDonald’s meta-analysis . Few stuBoth physical and mental HRQOL improved, with moderate to large ESs at 6 months post-operation. The ES of the PCS was larger than that of the MCS, and the ESs of many subscales were large, such as those of the physical functioning, bodily pain, and role emotional subscales  . Among tTo our best knowledge, only one study investigated the HRQOL of knee arthroplasty at 6 weeks post-operation, but not much change in the subscales was found in that study . Our stuA five-year follow-up study for THR showed that the greatest improvement was found at the six-month assessment . We suggThe associations between pain and HRQOL, as well as between anxiety and HRQOL, increased at different stages of assessment. Pain severity was correlated with physical HRQOL, and anxiety was correlated with mental HRQOL . This asMost previous research focused on pre-operative anxiety as a predictor of a poorer outcome and poor QOL . For exaWe also found that, at 6 weeks, the BAI was also moderately correlated with the PCS, and at 6 months, the VAS was also highly correlated with MCS and the BAI was still moderately correlated with the PCS. Therefore, the VAS and BAI were correlated with both the PCS and MCS at 6 months. Furthermore, the correlation became very strong. The possible reasons may be that the pain and anxiety of most of the patients decreased at 6 months , while the standard deviations of the pain and anxiety became relatively large  . BrieflyThe limitations of our study should be noted. The first is the generalizability of our findings. The study sample was a small number of patients with arthroplasty and hip fracture recruited from a single medical center. Multicenter studies are needed to improve the generalizability. We provided the norms (an age- and sex-matched group) to precisely reveal the conditions of our sample. The second is the follow-up period. This study explored only the short-term follow-up and could not provide information on mid-term and long-term follow-up. The third is the lack of a control group. The study was not a randomized trial design; therefore, some questions cannot be answered. Finally, many factors may be associated with HRQOL. However, this study assessed pain and anxiety at each stage and found high correlations with HRQOL. Other factors may also be associated with HRQOL and need to be studied in the future.In conclusion, education programs focused on early mobility were delivered by booklet and video for patients with knee/hip arthroplasty or hip fracture surgery. The patients had moderate pain and mild anxiety at pre-operation; after surgery, the pain and anxiety obviously decreased at 6 weeks and 6 months, respectively. Both physical and mental HRQOL were poor as compared with those of age- and sex-matched norms at pre-operation. The ES of the physical functioning subscale was large at 6 months, but the scores did not reach the normative values. The ESs of the role emotional and mental health subscales were large and moderate at 6 months, and the scores were even higher than the normative values. Pain and anxiety were highly and moderately correlated with physical and mental HRQOL. It is important for healthcare providers to consider pain and anxiety so as to improve the quality of life of patients with arthroplasty and hip surgery.


This study was designed to investigate the effects of arthrocentesis on the improvement of internal derangement symptoms and jaw function in a series of patients with anterior disc displacement and closed lockjaw.The study was based on a review of patients’ records before and after treatment using clinical examinations and radiographs. Visual analog scales were used to measure pain before and after arthrocentesis. Six patients (12 temporomandibular joints) with closed lock symptoms (2 cases) and internal derangements (4 cases) were treated at the Oswaldo Cruz Hospital. The mean follow-up was 11.5 months.The mean maximum vertical opening before treatment was 31.83 mm and after arthrocentesis was 36.50 mm. The visual analog scale for pain before treatment was 7 points (mean) and after arthrocentesis the mean was 4.3.Arthrocentesis was shown to be effective in reducing pain and increasing jaw motion in this series of cases. Temporomandibular joint (TMJ) arthrocentesis consists of lavage of the upper joint space of the TMJ done with no direct vision, aiming primarily to remove necrotic tissue, blood and pain mediators from the joint .Arthrocentesis has low morbidity, few risks and low cost compared to other TMJ surgical interventions, and may be conducted under local anesthesia in an outpatient clinic setting  presenting with pre-auricular pain, limited TMJ movements and closed lock were referred to the bucomaxillofacial surgery and trauma unit of the Oswaldo Cruz University Hospital in Recife, Pernambuco state.All patients had undergone prior medical treatment for TMJ dysfunction  for at least 6 months with no clinical improvement. Four out of six patients had joint pain and functional limitation and two patients had closed lock .Table 1EPreoperative data included the clinical history, a physical exam and radiograms. This included progression time of TMJ dysfunction, the presence of facial asymmetry, unilateral or bilateral involvement, the amplitude of mandibular movements , the presence of joint noises, deviation on maximum mouth opening, and pain on mandibular movements, which was catalogued according to the pain visual analog scale. Radiography included a maxillary panoramic radiogram and a TMJ specific panoramic radiogram to establish anatomical changes of the mandibular condyle and reduced joint space.The first surgical procedure was TMJ arthrocentesis. All procedures were done by a single surgeon. Procedures were done under local anesthesia and sedation. Postoperative follow-up for all patients was 11.5 months (6 to 17 months). Postoperative data were the same preoperative variables. This study was presented to and approved by the Pernambuco University Research Ethics Committee (number 004/04) and participants read and signed a free and informed consent form.Three patients presented joint noises on the preoperative clinical exam. At the end of treatment, two no longer had joint noises and one had a reduction in joint clicks.Every patient had moderate to severe preoperative pain. Preoperative pain visual analog scale scores averaged 7 ±1.78. On follow-up the pain score fell to an average 4.33 ±1.03. All patients reported an improved general clinical status and a reduction of internal derangement symptoms. Table 3PrMaximum mouth opening, right lateral movements and the pain visual analog scale were statistically significant (p < 0.05) based on the Wilcoxon test. Table 4StArthrocentesis is the most recent surgical approach for internal derangement of the TMJ. In the past many cases of anterior displacement of the disc or closed lock that did not improve with medical treatment  were initially treated with surgical repositioning of the disc and arthroplasty of the mandibular fossa. Arthrocentesis has an intermediate place between the medical and the surgical forms of treatment . Ease, lower cost of materials and excellent published results so far include this technique in the international protocol for the treatment of TMJ dysfunction .There are no longitudinal studies to compare the success and lack of success of this approach, and further studies are required to scientifically demonstrate the indication and predictability of results. Efficacy in various papers are: All patients had improvement in symptoms related to the intra-articular derangement and increased mandibular movements. These results are similar to published studies , increasing mandibular mobility by removing intra-articular adhesions , eliminating the negative pressure within the joint, recovering disc and fossa space , and impIn our study we observed that symptom reduction resulted in improved mandibular function without necessarily producing an anatomical relationship between the mandibular head, the articular disc and the glenoid cavity. Rather, improved mandibular function appeared to be due to the removal of intra-articular adhesions and the resulting increased mobility of the disc.The methodology used in this series showed effective improvement in the treatment by arthrocentesis of patients with mandibular internal derangement and closed lock.


Patients with bone metastasis often experience severe pain that is difficult to control and seriously affects quality of life. Radiotherapy is an effective way to relieve pain in these patients. Currently, there is no standard recommended range of radiotherapy targets for vertebral metastasis. The effect of radiotherapy on pain relief varies among patients, and some patients with metastases have serious side effects.This study aims to verify whether reducing the radiotherapy range for vertebral metastases can achieve the same effect as whole vertebral radiotherapy while minimizing side effects. Sixty-six patients with pain caused by vertebral metastasis were randomly divided into two groups. The study group is receiving partial vertebrae body radiotherapy at the regions of abnormal signal, suspected invasion, and adjacent subclinical focus of vertebral metastasis, and the control group is receiving the same dose of radiotherapy on whole vertebrae body where metastasis occurred. After radiotherapy, along-term follow-up of patients will determine pain relief and side effects.The expected results of this study are that local irradiation of vertebral metastases can achieve a palliative effect of pain control not less than total vertebral irradiation with fewer side effects.ChiCTR1900023401).This study was registered in the Chinese Clinical Trial Registry (No:  Patients with bone metastasis often present with severe pain that is difficult to control. The ASTRO guideline and its update recommend palliative analgesic radiotherapy for bone metastases , 2. HoweThe ISRC proposed dividing vertebral body into six parts in the target setting of spinal stereotactic radiosurgery, as shown in Fig. At present, there is a single-center phase II prospective cohort study comparing the effect on pain control of conventional radiotherapy and SBRT in patients with spinal metastasis. In both treatment groups, patients had a comparable decrease in pain and analgesic use in the 3 months following treatment , 5. Howe’s clinical target volume setting was according to the ISRC consensus guidelines that recommend the vertebral body be divided into six parts, which include the area of vertebral destruction and adjacent parts, and control group’s clinical target volume include the whole vertebral body, The two groups of clinical target volume settings are shown in Fig. This study was registered in the ChiCTR (No: ChiCTR1900023401). This is a multicenter, prospective, phase II randomized controlled clinical trial. Patients with solid tumors diagnosed pathologically at our hospital were collected. All patients had vertebral metastases and pain symptoms. Patients will be randomized into 2 groups: study groupBefore starting treatment, the qualified recruitment participants will explain the common ethical issues, objectives, design, description, implementation, requirements and schedule of this study to every potential study participant.The primary endpoint is pain relief rate. The secondary endpoints are the incidence and types of side effects.Aged 18-80 yearsPatients with vertebral metastasis of solid tumors confirmed by pathology and imaging, and a number of discontinuous vertebral metastases ≤ 3, who had no tumor tissue compressing the spinal cordECOG0-1No serious chronic diseases, such as severe hypertension, diabetes or heart diseaseThere was no contraindication to radiotherapy and no previous radiotherapy targeting a vertebral metastasisEstimated survival time ≥ 3 monthsThe patient or their family members sign the informed consent form and were willing to cooperate with the follow-upBone destruction in benign diseases and diffuse bone destruction, such as multiple myeloma, lymphoma, or leukemia with bone marrow infiltrationParticipated in other clinical trials of drug or physical therapy for target lesions in the past four weeksMyocardial infarction or myocardial ischemia and arrhythmia (≥ 2 levels of congestive heart failure according to the NYHA and QTc ≥ 480 ms)≥ CTCA Elevel 2 infection or long-term unhealed woundActive bleeding due to dysfunctional coagulationSystolic blood pressure greater than or equal to 180 mmHg and diastolic blood pressure greater than or equal to 110 mmHgAccording to the judgment of the researchers, the tumor invaded the large blood vessels and likely caused fatal bleeding during the treatmentUncontrolled and/or severe disease, including:Those who had a history of drug abuse and were unable to quit, or had mental disordersHad received surgery or radiotherapy for the target lesion in the past six monthsThe researcher judged that there were serious accompanying diseases that would endanger the safety of patients or affect the completion of the study.The withdrawal of the informed consent of patients.A decision by the researchers to discontinue the study to ensure patients’ safetyA decision by the researchers or patients to stop the research in case of toxic side effectsResearchers’ judgmentBefore radiotherapy, all patients received computed tomography (CT) scans with a thickness of 3 to 5 mm. These CT scans were used to contour the gross tumor volume (GTV), clinical target volume (CTV) and organs at risk (OARs). The GTV was profiled according to CT scans, MRI and ECT. The clinical target volumes include the area of vertebral destruction and adjacent parts (study group) or the whole vertebral body (control group). The planning target volume (PTV) include organ movement and a daily setting error of 0.3 cm based on the CTV. Radiotherapy will be performed as IGRT, which will be administered using a line accelerator (energy = 6MV) in 10fractions .This study will collect the patient’s name, age, gender, diagnosis of primary tumor, location and number of vertebral metastases, pain score and imaging findings. The above information will be recorded in a unique case report for each patient. These data will be input and saved in the electronic data management system established by Mianyang Central Hospital. The final data will be reviewed, locked and used for final data analysis by key researchers and statistical analysts.Pain relief will be assessed by patients using the numerical rating scale before radiotherapy, two weeks, three months, six months and every six months after radiotherapy. The pain relief rate is the primary endpoint of this study. The secondary endpoint was a follow-up on the occurrence of side effects and the positive results of imaging, such as radiation spinal cord injury and pathological fracture. The vertebral bodies will be scanned with CT to identify radiogenic injury of the spinal cord and vertebral compression fracture.Adverse events are being recorded in accordance with the requirements of the MedDRA. The classification of side effects was based on the CTCAE of National Cancer Institute.Δ = -0.15 using PearsonX2test, power = 0.809, H0: πt—πc ≤ -0.15, H1: πt—πc > -0.15.We estimate a loss to follow-up rate of 10% and the resultant required number of patients was 66. The rate of pain relief in patients with vertebral metastases receiving radiotherapy will be measured according to the results of previous trials including that by Howell et al. [We estimated the sample size based on paper of Fleiss, JL et al. . We perfThe number, proportion and 95% confidence interval of patients with pain relief will be reported. The related toxicity will analyze by Fisher exact test.The study was approved by the Ethics Committee of Mianyang Central Hospital (NO 2019YJ30). The ethics committee will supervise and administer the study.This trial was registered in the ChiCTR (NO: ChiCTR1900023401). The recruitment starts in January 2021 and is planned to be completed in two years.Approximately one-third of patients with advanced malignant tumors will experience bone metastasis, and the spine is the most common bone metastasis, especially the lumbar spine and thoracic , 10. PatThe 2017 ASTRO update on palliative radiotherapy for bone metastases continues to recommend that patients with bone metastases can be selectively treated with 8 Gy/1 f, 20 Gy/5 f, 2 Gy/6 f, or 30 Gy/10 f with four different fractionation methods –16. The According tothe2012 ISRC consensus guidelines on the target volume of spinal SRS, unless the spinous processes, lamina / bilateral pedicle and vertebral body are affected or there are extensive metastatic diseases around the epidural space, the circumferential TVs around the spinal cord should not be used. The guidelines emphasized that published guidelines on indications and practice patterns for spinal SRS are limited and there is no consensus on the definition of target volume [If this trial can prove that local irradiation is equivalent to whole vertebral body irradiation in terms of pain relief, then the next step will be to increase the irradiation dose on the reduced target area in order to achieve higher pain control rate of vertebral metastasis and improve the quality of life of patients with vertebral metastasis.


The aim of this study was to assess perioperative pain and mobilization after total hip arthroplasty (THA) using three different surgical approaches.This was a multisurgeon, prospective, single-center cohort study. A total of 188 patients who underwent hip arthroplasty (THA) between February 2019 and April 2019 were analyzed according to the surgical approach used . Outcome parameters were the daily walking distance during the inpatient stay, the pain level according to the visual analog scale (VAS) at rest and motion during the inpatient stay and at 6-week follow-up and the modified Harris Hips Score (mHHS) preoperatively and at 6 weeks.p < 0.001). The DAA and posterior approach patients had a significantly longer walking distance than the lateral approach patients on the third postoperative day . DAA and posterior approach patients reported significantly less pain during motion on the third postoperative day and at 6-week follow-up than the lateral approach patients . The mHHS demonstrated significant improvement within each group. However, lateral approach patients reported significantly less improvement than the DAA and posterior approach patients .The walking distance within the groups increased significantly during the inpatient stay (This study analyzed perioperative pain progression and short-term rehabilitation after THA according to the different surgical approaches. Direct anterior and posterior approaches have shown comparable improvements in pain, walking distance, and mHHS. Whether this effect persists over a longer period of time must be clarified in future studies.Prospective cohort study, level of evidence, 2. Coxarthrosis is a common disease of the hip joint and it is typically treated by total hip arthroplasty (THA) if conservative therapy is not successful. The majority of patients undergoing THA experience pain relief, improved mobility, enhanced functionality and the restoration of the quality of life , 2. MoreThe three most common methods used for THA are the anterior, lateral, and posterior approaches . HoweverThe present study comprises a consecutive series of 188 patients following cementless total hip arthroplasty performed in a single-center, multisurgeon series (7 surgeons) between February 2019 and April 2019. Patients were evaluated prospectively over the study period. The Corail Pinnacle Hip System  was used in all patients. Three groups were formed according to the approach used: Group 1, minimally invasive direct anterior approach (DAA); Group 2, transgluteal lateral approach; Group 3, piriformis muscle sparing posterior approach. Each surgeon performs THA with only one approach at high volumes (> 250/year). Thus, every patient of the respective surgeon was operated on using the same approach. The inclusion criteria consisted of primary cementless total hip arthroplasty and consent for general anesthesia. Exclusion criteria included revision surgery, the existence of chronic pain syndrome preoperatively or for the use of epidural anesthesia  to eliminate the bias of prolonged analgesia due to epidural anesthesia.A standardized pain management concept was applied for all patients: Preoperatively the patients received 90-mg etoricoxib, 50-mg pregabalin and 20-mg pantoprazole. During surgery, dexamethasone at a dosage of 0.1–0.2 mg/kg, ondansetron 4 mg and tranexamic acid 500 mg were administered intravenously. A propofol bolus of 1.5–2.5 mg/kg was used intravenously to induce anesthesia. In addition, fentanyl 0.2 mg and the muscle relaxant rocuronium 0.5–0.6 mg/kg, which is monitored and controlled by relaxometry during surgery, were injected. Anesthesia was maintained by a continuous propofol infusion device. Postoperative oral-controlled analgesia was applied at the ward. The patients received 500 mg of metamizole four times daily and 90 mg of etoricoxib once daily as the standard. During the first 2 days, the patients received an additional 10-mg Targin in the morning and evening. During pain peaks, 10-mg Sevredol was administered every 4 h as needed.Full weight-bearing was allowed in the immediate postoperative course. The initial mobilization of the patients was performed on the day of the operation as a standard, and patients also received physiotherapeutic treatment once a day from the day of the operation onwards. After discharge, pain-adapted full weight-bearing was further permitted. During the first 4 weeks, flexion over 90° and terminal rotational and adduction movements were prohibited. Ossification prophylaxis was given during the first 2 weeks, and thrombosis prophylaxis was given during the first 4 weeks postoperatively. The postoperative rehabilitation protocol was the same for all surgeons.As a matter of routine, patients were prospectively assessed preoperatively and at 6 weeks postoperatively using the modified Harris Hip Score (mHHS) , 19. TheThe ethics commission of the Landesaerztekammer Baden-Wuerttemberg, Germany approved all procedures (F-2019-006), and the study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2008. The study was registered in the German Registry of Clinical Studies (DRKS) with the approval number DRKS00016519 (WHO Register). All participants provided written informed consent.t test and a Wilcoxon signed-rank test. Differences between the groups were tested using ANOVA test with a Bonferroni correction for multiple repeated comparisons. Categorical variables were reported using the count and percentage. To compare percentages between groups, Fisher’s exact test was performed. Statistical analyses were conducted using SPSS statistical software .G*Power   points. The percentages of negative prognostic factors  did not differ significantly among the groups. The proportions of patients who underwent arthroplasty of the contralateral hip or knee joint did not differ significantly. Ninety-eight THAs were performed on the right side, and 90 were performed on the left side. A total of 132 patients were discharged on the fourth postoperative day, and 56 were discharged on the fifth postoperative day. A significant difference was found among the three groups regarding the respective operation time . In the post hoc pairwise comparisons (Bonferroni correction), we found statistically significant differences between groups 1 and 2 (p = 0.003) and groups 2 and 3 (p = 0.0019). No significant differences were found when comparing groups 1 and 3 (p = 0.356). Table A total of 188 patients met the inclusion criteria and were included in the analysis  . There was no difference between groups 1 and 3 (p = 0.832).A total of 185 (98%) patients could be mobilized on the day of surgery. In 3 2%) patients, the first mobilization was only on the first postoperative day. The reason for the delay in these patients was increased nausea and circulatory weakness. The walking distance within the individual groups increased significantly from day to day (% patientp < 0.001). However, there were differences regarding the different points of time. DAA patients reported significantly less pain at rest at 6 weeks than in the lateral and posterior approach groups . There were no differences among the groups during the inpatient stay for the pain level at rest.Pain was assessed preoperatively, as well as daily during the hospital stay and for 6 weeks of follow-up at rest and during motion. The pain level decreased significantly over time in each group   vs. follow-up 76.2 ± 15.8 (37.4–97.9), p < 0.00001; group 3: preoperative 34.8 ± 4.9 (24.0–45.0) vs. follow-up 85.4 ± 13.5 (41.8–100.0), p < 0.00001)  vs. follow-up 85.5 ± 14.6 (41.8–100.0), p < 0.033, ANOVA). In the post hoc pairwise comparisons (Bonferroni correction), we found statistically significant differences between groups 1 and 2 (p = 0.006) and groups 2 and 3 (p = 0.019). No significant differences were found when comparing groups 1 and 3 (p = 0.656). The lateral approach group showed significantly less improvement (Fig. A significant difference was found among the three groups regarding the respective change in the mHHS value (ent Fig. .Fig. 4PrThis study analyzed the influence of the surgical approach on perioperative pain and short-term rehabilitation after THA implantation. The main finding was that DAA patients reported the least pain on the third postoperative day and at the 6-week follow-up. In addition, patients treated with a DAA and posterior approach achieved a significantly longer walking distance and thus faster mobilization during the inpatient stay. Patients operated on with the lateral approach achieved the least improvement in the mHHS after 6 weeks. This is significant because, to the best of our knowledge, this is the first study comparing the perioperative effect of three different surgical approaches for THA.In modern endoprosthetics, the aim is to damage as little soft tissue as possible, which enables faster mobilization and rehabilitation. Most of our patients could already be mobilized on the day of surgery. For the first 2 postoperative days, there were no significant differences in the walking distance achieved in the group comparison. However, patients with the DAA and posterior approach had a significantly longer walking distance on the third postoperative day than those with the lateral approach. Thus, patients who underwent surgery with a minimally invasive approach achieved a longer walking distance by the discharge day. These results are in contrast with Barrett et al.’s study, which compared the anterior and posterior approaches. The DAA subjects walked further postoperatively on the day of surgery and the first and second days postoperatively . The reaAnother factor influencing perioperative mobilization is pain. Patients operated on with the DAA had significantly less pain at rest than the lateral and posterior approach patients at the 6-week follow-up. Regarding pain during motion, patients with the DAA and posterior approaches had significantly less pain on the third postoperative day and at the 6-week follow-up than patients with the lateral approach. The abductor complex is a pain generator following the direct lateral approach and this may explain differences in early pain perception between the groups . A recenCertain comorbidities have been identified in the literature that can negatively affect postoperative outcomes, especially pain. These factors include diabetes, depression, and chronic pain syndrome –23. In oOur study surveyed the mHHS as a PROM. We showed that the lateral approach resulted in a significantly lower improvement than the DAA or the posterior approach. The DAA and posterior approach showed similar improvements at the 6-week follow-up. These findings are consistent with other studies that found less improvements in PROMs for the lateral approach at short-term follow-up , 30. TheOne strength of this study is its prospective nature and the inclusion of a consecutive series of patients who received THA. Another advantage is that each surgery was performed by high-volume surgeons, each of whom had a high level of experience in THA.Our study is not free of limitations. First, we only report a short follow-up period of 6 weeks, so the consistency of the results cannot be assessed. Follow-up studies must, therefore, determine whether the differences found will have persisted. Second, the procedures were carried out by several surgeons, so that individual influences cannot be excluded, and therefore, a surgeon-related bias may exist. However, surgeon selection bias was likely not a factor, as each surgeon performed only the assigned approach during the study period. The lateral approach was performed by only one surgeon, so this group had a small size, which may have influenced the results.This study analyzed perioperative pain progression and short-term rehabilitation after THA according to the different surgical approaches. Direct anterior and posterior approaches have shown comparable improvements in pain, walking distance, and mHHS. Whether this effect persists over a longer period of time must be clarified in future studies.