The Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) evaluates the patient-reported quality of pain management in adults. A validated APS-POQ-R is pivotal to guide effective pain management with better patient satisfaction. Previous studies revealed that subscales of “patients’ perception of pain management” were unstable cross-culturally. This study aims to evaluate the construct validity of the APS-POQ-R in gynecological postoperative patients with a multi-cultural background using confirmatory factor analysis to allow comparisons among different a priori models at the latent factor level.Patients aged 18 years old or above and who were scheduled for gynecology surgery were selected. Three different models with a combination of latent factors were based on a priori hypotheses from previous studies. The root-mean-squared error of approximation, comparative fit index, Tucker-Lewis Index, Chi-squared test, and change in Chi-squared statistic given a change in degrees of freedom between models were used to assess the model fit to the present data.A total of 302 patients completed the questionnaire. The five-factor model which was based on Gordon’s study has an acceptable fit for the data and was superior when compared to the one-factor baseline model. Although the four-factor model, which originated from Botti’s study, also demonstrates a good model fit, the “perception of care” construct was excluded in this model. The “perception of care” construct is conceptually important as patient-centered care has become the focus of quality improvement of pain service.The APS-POQ-R is easy to administer and is useful for quality evaluation in postoperative pain management. The present study demonstrates that a five-factor structure of the APS-POQ-R is the best fitting model in our patient sample. The results of this study provide further evidence to support the use of APS-POQ-R as a measurement tool for pain management evaluation in acute postoperative patients with a multi-cultural background. Pain is an inevitable consequence of surgery, and managing pain is a challenging task as pain is a subjective experience and multi-dimensional . PostopeThe Acute Pain Society Patient Outcome Questionnaire (APS-POQ) was first developed in 1991 , and wasBotti et al. divided the primary questionnaire items that were amenable to psychometric testing into two main categories based on their face meaning; namely, pain experience and patients’ perception of pain management. The “pain experience” category measures the pain severity, interference of physical and psychological well-being due to pain, and the “patients’ perception of pain management” category evaluates patients’ participation in decision making and their satisfaction . The autThis finding was echoed in a study by Zoega et al. who evaluated the Icelandic version of the APS-POQ-R . AlthougFrom the literature, the models that were proposed for APS-OQ-R may have three-, four-, or five-factor structures. The differing patterns of item distribution and removal of items in previous studies render the questionnaire difficult to compare findings between cohorts , 9. In tThis cross-sectional study was carried out at the University of Malaya Medical Centre (UMMC), a tertiary university hospital in Kuala Lumpur, Malaysia. The present study complies with the Declaration of Helsinki and the study protocol was approved by the UMMC Medical Research and Ethics Committee , as well as the International Medical University Joint Committee on Research and Ethics , Kuala Lumpur, Malaysia. Written informed consent from patients was obtained before their participation.In our center, postoperative pain management is managed by both the Acute Pain Service (APS) team, and the primary surgical team. The usual postoperative multimodal analgesia regimens are a combination of opioids and non-opioid analgesics. The commonly used opioids include fentanyl, morphine, and oxycodone; while non-opioid analgesics are paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetic agents. Regional anesthetic techniques will be considered if indicated.Patients aged 18 years old or above and who were scheduled for elective gynecological surgery were eligible to be enrolled in this study. All elective surgeries were scheduled via the hospital’s online operation booking system in our center. A total of 320 patients were identified from the booking system. The investigator who was not directly involved in the management of the patients would communicate with them and introduce the APS-POQ-R questionnaire after they agreed to participate. A patient’s participation was voluntary, and standard care was ensured for all patients. We excluded the patients who had unexpected postoperative complications or intensive care admission as they were unable to answer the questionnaire.The APS-POQ-R measures the quality of postoperative pain management among adults in the first 24 h of in-hospital patient care, and the questionnaire can be administered by interview or self-completion . This quThe questionnaire contains a total of 23 items which include 18 primary items (P1 – P9) and 3 secondary or information items (P10 – P12). The first three primary items (P1 – P3) measure patients’ pain intensity. Patients are asked to rate the least and the worst pain that they have in the first 24 h postoperatively on a numerical rating scale (NRS) ranging from 0  to 10 (the worst pain possible). Meanwhile, item P3 examines the amount of time that patients experienced pain on a 0 to 100% scale during their first postoperative day.Item P4 of the APS-POQ-R examines the interference of postoperative pain on patients’ routine functioning which includes activities in and out of bed, as well as the impact of pain on their sleep. Also, item P5 assesses the effects of pain that may result in anxiety, depression, fright, or helplessness on postoperative patients. Treatment-related adverse effects are an important component of pain management. Item P6 elicits the severity of side effects associated with analgesics. Insights regarding the side effects associated with postoperative pain management will help identify areas of improvement in the current practice.Patients’ participation in the management of their care is of paramount importance to ensure comfort and to reduce potential complications . The patThe additional assessments on non-pharmacologic pain management include the items that evaluate whether the patients receive any information about other options for pain treatment, and how useful the information is to them (Item P9). The use of non-pharmacologic methods to relieve pain, and whether a nurse or a doctor encourages the patients to use non-pharmacologic methods are assessed in Item P10 and Item 11, respectively. These items give secondary information and are not included in the psychometric testing. The information on the patient characteristic profile is also obtained from the questionnaire.The study was carried out between June 2017 and June 2018 using APS-POQ-R (English version). An investigator would approach potential study subjects preoperatively to obtain their informed consent. On a postoperative day, the consented patients were then asked to recall the pain management that they received in the first 24 h postoperatively. The demographic and clinical data of these patients were retrieved from their respective electronic medical records.We used confirmatory factor analysis (CFA) to evaluate the construct validity of the APS-POQ-R. The CFA was computed using maximum likelihood estimation in AMOS version 26™ . Confirmatory factor analysis is a subset of structural equation modeling (SEM), whereby it focuses on analyzing the extent to which the observed variables are related to the latent factors (measurement model); while SEM analyzes the causal relationship between observed variables and latent factors  . PreviouMulti-trait multimethod matrix (MTMM) is another statistical tool to evaluate construct validity. This analysis is used when the data set involves multiple constructs that are measured by different methods, such as self-report questionnaires, investigators’ observation, and so on . Our stuThe models tested were based on the a priori hypothesis from previous studies , 6. FourModel II, the original classification by Gordon et al. , was a fThe assessment of model fit was based on several fit indices to test the best CFA model that describes the present data set and theoretical considerations. These indices include the root-mean-squared error of approximation (RMSEA), comparative fit index (CFI), Tucker-Lewis Index (TLI), Chi-squared test, and a change in Chi-squared statistic given a change in degrees of freedom between models. The RMSEA values closer to 0 with a threshold of less than 0.08 represent a good model fit . The CFIThere is no easy number that one can use as a “large enough” sample size for structural equation modeling. Some rules of thumb are used; based on Kline et al., 100–200 observations are considered a medium sample size . DiffereDescriptive statistics were used to describe the demographic data, and to report the results of the questionnaire items. Descriptive statistics were performed by using the Statistical Package for the Social Sciences, version 21.0 , and MS Excel (2013).Of the 320 eligible patients in this study, 11 patients refused to participate, and seven returned questionnaires were incomplete. This gave a response rate of 94.4% (302/320). A flowchart of the patient recruitment process based on STROBE guidelines [2/df) is small (2.47), while the Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) are within an acceptable range. The root-mean-squared error of approximation (RMSEA) of this model also indicates an adequate fit.The fit statistics of all models are shown in Table 2/df (2.40), CFI of 0.922, TFI of 0.895, and RMSEA of 0.068. The fit indices for the three-factor model (Model IV), however, were not acceptable based on this dataset  of the pain scores are shown in Table The present study examines the construct validity of the APS-POQ-R using confirmatory factor analysis, in contrast to the use of exploratory factor analysis in previous studies. Our findings support the five-factors structure that was hypothesized by Gordon et al.  in a mulThe psychometric evaluation of APS-POQ-R has been performed in adult inpatients across different cultures using an exploratory factor analysis approach , 8, 21. Among the hypothetical models tested in this study, two models (model II and model III) demonstrate acceptable fit indices and are superior to the one-factor model. Although Model III was based on the study by Botti et al.  has an oIn recent years, patient-centered care has been a focus in the healthcare system, and patients’ needs are considered in the decision-making process . PatientFor Model II, the item “participation in decision making of pain treatment” has a standardized factor loading of less than 0.3 in our cohort. The interpretation of “participation in pain management” may be different among individuals. McTier et al. reported that most patients tended to report their pain severity rather than participating in decision-making on the treatment options . Some paThe “affective” and “adverse effects” subscales are stable across previous studies . The staThe satisfaction score among our participants was high, with a mean value of 8.05. The influence on the level of satisfaction of postoperative pain management could be multifactorial. The level of patient satisfaction does not only depend on the effectiveness of pain relief but is also determined by the care from the healthcare providers. An opportunity to participate in pain treatment and to gain better knowledge about the pain care that they are receiving may contribute to higher patient satisfaction , 25.Our findings support the APS-POQ-R as a QI tool for pain management evaluation in this setting. This validated questionnaire can be used as a standard tool to provide a benchmark for the comparison of pain management quality within the measured patient cohort. Besides, the different subscales of the questionnaire allow clinicians or researchers to identify areas for improvement more effectively. Of note, we plan to utilize this questionnaire for our postoperative patients to enable continual evaluation and reassessment of the construct stability over time. The use of patient-reported pain experience measures will also encourage patients’ engagement in their pain care. In the future, the psychometric testing of APS-POQ-R using the CFA approach should be performed in other clinical settings such as medical patients who receive pain care to establish a standardized QI instrument for comparison of the quality of pain care.Our study has a few limitations. First, the patients may suffer from the lingering effects, such as dizziness and sleepiness of anesthesia in the postoperative period. Hence, the recall of postoperative pain experience may be affected. Second, we recruited only gynecological patients who represent one of the main surgical subspecialties in our center. Recruitment of patients from different subspecialties in the future would enable the generalization of the study results to other surgical patients.The psychometric testing of a measurement instrument is important to support its use in research or clinical practice. The present study has demonstrated that a five-factor structure of the APS-POQ-R is the best fitting model in our multi-ethnic patient sample. This study results provide further evidence to support the use of APS-POQ-R as a measurement tool for pain management evaluation.


There have been several reports of instrumentation failure after three-column resections such as total en bloc spondylectomy (TES) for spinal tumors; however, clinical outcomes of revision surgery for instrumentation failure after TES are seldom reported. Therefore, this study assessed the clinical outcomes of revision surgery for instrumentation failure after TES.This study employed a retrospective case series in a single center and included 61 patients with spinal tumors who underwent TES between 2010 and 2015 and were followed up for > 2 years. Instrumentation failure rate, back pain, neurological deterioration, ambulatory status, operation time, blood loss, complications, bone fusion after revision surgery, and re-instrumentation failure were assessed. Data were collected on back pain, neurological deterioration, ambulatory status, and management for patients with instrumentation failure, and we documented radiological bone fusion and re-instrumentation failure in cases followed up for > 2 years after revision surgery.n = 2) and delayed wound healing (n = 1). At the final follow-up, bone fusion was observed in all patients. No re-instrumentation failure was recorded.Of the 61 patients, 26 (42.6%) experienced instrumentation failure at an average of 32  months after TES. Of these, 23 underwent revision surgery. The average operation time and intraoperative blood loss were 204 min and 97 ml, respectively. Including the six patients who were unable to walk after instrumentation failure, all patients were able to walk after revision surgery. Perioperative complications of reoperation were surgical site infection (Bone fusion was achieved by revision surgery using the posterior approach alone. Total en bloc spondylectomy (TES) was developed for complete surgical resection for spinal tumors , 2. TES Since 2010, instead of harvesting autografts from the ilium or fibula, the resected lamina and vertebral body from the TES are frozen in liquid nitrogen and used as grafted bone for spinal reconstruction. This technique has the following benefits: no pain at the bone harvest site, shortened operative time, decreased blood loss, and additional antitumor immune response . In thisDespite the fact that several studies have examined instrumentation failure after TES –14, therThis retrospective study was approved by our institutional review board, and informed consent was obtained from all patients. Between 2010 and 2015, 114 patients with primary or metastatic spinal tumors underwent TES at our institute. Of these, 33 patients died within 2 years, and 20 patients were lost to follow-up. Finally, 61 patients (53.5%) who could be followed up for > 2 years after TES were included and comprised 35 men and 26 women, with a mean age of 52.6 (range 14–73) years. The mean follow-up period was 60 (range 24–101) months. Of the 61 patients, 10 had primary malignant tumors, 10 had primary aggressive benign tumors, and 41 had metastatic tumors. In 41 patients with metastatic disease, metastases were diagnosed as having oligometastatic cancer. The thoracic, thoracolumbar, and lumbar spines were affected in 27, 27, and seven patients, respectively.Primary surgery (TES) consisted of en bloc laminectomy after transpedicular osteotomy, subsequent en bloc corpectomy, and spinal reconstruction , 20. AftRevision surgery after instrumentation failure was performed via the posterior approach alone in all cases. Broken rods and broken or loosening pedicle screws were replaced. In some patients, segmental fixation was extended to increase stability. In most patients, a fresh autologous bone strut graft harvested from the iliac crest was placed on the scar tissue of the resected vertebral area to form a bridge between the adjacent laminae Fig. a, b. In Instrumentation failure was determined based on follow-up plain radiographs. In cases of instrumentation failure, computed tomography (CT) was performed to determine the details of instrumentation failure. Back pain, neurological deterioration, ambulatory status, and management (conservative or revision surgery) were recorded. Operative time, intraoperative blood loss, and complications of the revision surgery were documented. Finally, we evaluated the extent of radiological bone fusion using multiplanar reconstruction CT in cases of re-instrumentation failure that could be followed up for > 2 years after revision surgery. The graft bone in the cage was continuous with the upper and lower adjacent vertebral bodies, and a cage filled with bone tissue was considered bone fusion within the cage.Of the 61 patients, 26 (42.6%) experienced instrumentation failure at an average of 32  months after TES. The mean body mass index of the patients who experienced instrumentation failure was 23.4 . Of the 26 patients who experienced instrumentation failure, 4 (15.3%) underwent radiation therapy for spinal tumors before TES. Ten patients had primary tumors, comprising giant cell tumor in 3 patients, chondrosarcoma in 1, epithelioid sarcoma in 1, liposarcoma in 1, Ewing’s sarcoma in 1, synovial sarcoma in 1, chordoma in 1 and aggressive hemangioma in 1. Sixteen patients had metastatic tumors from renal cell carcinoma in 4 patients, breast cancer in 3, thyroid cancer in 2, lung cancer in 2, hepatocellular carcinoma in 1, esophageal cancer in 1, parotid cancer in 1, leiomyosarcoma in 1, unknown primary squamous cell carcinoma in 1. Rod breakage was observed in 20 patients, screw breakage in two patients, rod and cage breakage in two patients, cage breakage in one patient, and screw and cage breakage in one patient. However, no evidence of local recurrence was found at the surgical site throughout the follow-up period in any patient. Of the 26 patients, 19 (73.1%) experienced back pain, 8 (30.8%) had lower-extremity neurological deterioration, and 6 (23.1%) were unable to walk because of these symptoms (Table Eighteen patients could be followed up for > 2 years after revision surgery (average follow-up period: 41 months) by radiological evaluation. At the last follow-up, bone fusion was achieved within the anterior cage and at the posterior bone graft in 11 patients, within the anterior cage in two patients, and at the posterior bone graft in five patients. There was no re-instrumentation failure after revision surgery . An autologous strut bone graft was placed on the scar tissue of the resected L1 lamina area and the adjacent T12 and L2 laminae. The posterior instrumentation was adjusted to slightly compress the inserted vertebral cage. No perioperative complications occurred. The patient re-acquired ambulatory function, without aid, 1 week after the revision surgery. At 42 months after the revision surgery, bone fusion within the cage and at the posterior bone graft was observed on CT  was 17.0% (8/47) ; in the In the present study, back pain and neurological deterioration caused by instrumentation failure developed in 19 (76.1%) and 8 (30.8%) patients, respectively. Matsumoto et al.  reportedInstrumentation failure is caused by delayed union between the cage and the vertebral body , and revIn the present study, 13 (72.2%) of 18 patients with > 2 years of follow-up after revision surgery achieved bone fusion within the cage, but the remaining 5 (27.8%) did not achieve bone fusion; nevertheless, bone resorption within the cage improved. We believe that robust restabilization of the posterior instrumentation increased the stability of the spine, which facilitated bone fusion within the cage. In addition, bone fusion at the posterior aspect of the spine, which could not be applied in the primary surgery without the scar tissue of the resected vertebral area, was achieved earlier than that within the cage in cases where posterior bone grafting was performed. We believe that attaining bone fusion at the posterior aspect further increased the stability of the spine and favored bone fusion within the cage. This finding indicates that replacement of the cage using the anterior approach is unnecessary when the cage is restabilized using a stiffer construction by exchange and supplement of posterior instruments. Our recommended revision procedure is to perform posterior restabilization with three or four cobalt chromium rods and posterior bone grafting. In cases with a severely damaged cage (not observed in this study cohort), cage replacement using the anterior approach should be considered.This study has some limitations. The small and heterogenous cohort with several tumor histologies and adjuvant therapies and the retrospective manner of data collection can introduce bias and errors. This retrospective study included various reconstruction procedures  differed depending on the time of surgery. The follow-up time was limited as well. Longer follow-up is required to determine the accurate incidence of instrumentation failure after revision surgery. Although all patients were diagnosed as having oligometastatic cancer in the present study, the indications for TES remain controversial because less invasive surgeries (e.g. separation surgery) have shown significant results recently. Despite these limitations, this study demonstrated the rate of instrumentation failure after TES with reconstruction using frozen autografts treated by liquid nitrogen and described a relatively simple and effective strategy for revision surgery and its favorable outcomes. The results obtained from this study will contribute to revision surgery for instrumentation failure after TES.In patients with instrumentation failure after TES, posterior instrumentation replacement and posterior bone grafting were performed during revision surgery. In this study, bone fusion was observed in all patients with > 2 years of follow-up after revision surgery, and no re-instrumentation failure was observed during follow-up. Our findings suggest that bone fusion can be achieved by revision surgery using the posterior approach.


Background and Objectives: Temporomandibular joint disorders (TMJDs) are associated with pain and reduced jaw mobility. The aim of this study was to compare the outcome of patients with TMJ arthralgia when submitted to four different treatment modalities, in some cases using intra-articular injections of substances with anti-inflammatory properties and in others, a more conservative approach consisting only of a bite splint. Materials and Methods: The sample was made up of 80 patients, randomly distributed into 4 groups of 20 patients each. Each patient was given a nocturnal bite splint. One of the groups was treated with the bite splint only, while each patient in the other 3 was injected with betamethasone, sodium hyaluronate, or platelet-rich plasma in addition to using the bite splint. Two variables were assessed, namely pain intensity between 0 to 10 according to the visual analogue scale and maximum pain-free mouth opening in mm. The patients were evaluated at four different points: at the beginning of the treatment, as well as one week, one month and six months after initiation. Results: The results showed that maximum pain-free mouth opening improved in all the groups that made up the sample, with either a reduction in pain severity or with no pain. However, the group injected with platelet-rich plasma yielded the best results after six months, while patients treated with sodium hyaluronate or betamethasone obtained the best results at the end of the first week. Conclusions: We concluded that all the treatments used caused a reduction in pain and increased pain-free mouth opening. The splint combined with the platelet-rich plasma injection achieved long-term success. The term temporomandibular joint disorders (TMJDs) covers a broad spectrum of clinical issues related to joints and muscles in the orofacial area. These dysfunctions are mainly characterized by pain, joint sounds and irregular or limited jaw function. TMJDs are considered a distinct subgroup of musculoskeletal and rheumatoid disorders and represent the most common cause of orofacial pain of non-dental origin ,2. TMJDs are the most common chronic orofacial pain conditions and are often compared with cervical pain, back pain and headache. This is because of the intensity, persistence and fundamentally psychological impact on the patient of such pain. TMJDs are also known to be rare in children prior to puberty .In the adult population, incidences of temporomandibular joint pain (TMJP) vary between 9% to 15% for women and 3% to 10% for men. TMJP seems to be 1.5 to 2 times more common in women than in men, although certain studies report a greater difference of up to 4.1. Similarly, in all studies where there was a clear age pattern, the age range where TMJP was more prevalent was between 35 and 45 years ,7. This The most common intraoral treatment for pain associated with TMJDs is the use of occlusal splints (bite splints), which are designed to cover the occlusive surfaces of the upper or lower teeth and thus reduce strain on the temporomandibular joint. There is a general consensus that the use of a bite splint should never promote permanent changes in teeth or jaw position ,9,10. CuOn the other hand, intra-articular injections with corticosteroids have also been successfully used for different TMJ conditions, despite their potential adverse effects such as progression of a pre-existing joint lesion ,15,16,17Another compound used in TMJ intra-articular injections is sodium hyaluronate, used to either promote viscosity supplementation or act as an anti-inflammatory agent, which is currently reporting very promising results ,22,23,24Platelet-rich plasma (PRP) is a therapeutic agent consisting essentially of a platelet concentrate and associated growth factors taken and centrifuged from a sample of the patient's blood. It was initially introduced in the fields of stomatology, maxillofacial/plastic surgery and reconstructive surgery in the 1990s and its clinical use is due to its potential healing properties through cell recruitment, proliferation, differentiation and consequently, tissue remodeling. It has been found to have several advantages over the use of corticosteroids in the treatment of TMJ degenerative and inflammatory conditions, the most remarkable being its lack of serious and/or irreversible adverse effects. Treatment with PRP injections has reported anti-inflammatory, analgesic and antibacterial properties and, at the same time, restores intra-articular levels of hyaluronic acid, increases glycosaminoglycan chondrocyte synthesis, balances joint angiogenesis and induces stem cell migration .The aim of this study was to compare the outcome of patients with TMJ arthralgia regarding pain and mouth opening. Treatment consisted of a bite splint (control) or a bite splint in combination with corticoid (betamethasone) injections, sodium hyaluronate injections or PRP injections. This investigation took place in order to determine which treatment would be the most successful in improving the study variables.A sample of 80 patients diagnosed with TMJ arthralgia, according to the original version of the diagnostic criteria for temporomandibular disorders (DC/TMDs) were recruited from consultations framed in the Course of Occlusal Rehabilitation at the University of Coimbra, organized by the School of Medicine. All patients agreed to participate in the research and signed the informed consent form. This study was conducted in compliance with the Declaration of Helsinki and was approved by the ethics committee of the School of Medicine of the University of Coimbra . This study was approved on 25 June 2017 by the institutional review board (IRB 06-2017-096).Patients who met all the following requirements were included in the study: a clinical history of over 6 months of TMJP that modifies with mandibular movement in function or parafunction; pain present in a clinical examination at opening, laterality or palpation; and no previous treatment. Exclusion criteria: patients who had received previous treatment for TMJ dysfunction; patients suffering from any rheumatic pathology such as rheumatoid arthritis or psoriatic arthritis (including juvenile arthritis); hypnosis patients; pregnant or breastfeeding women; and those who were under 18 years old.n = 20): patients receiving bite splint therapy only (BS); patients using a bite splint and receiving betamethasone (BS + B); patients using a bite splint and treated with sodium hyaluronate (BS + SH); and patients using a bite splint and undergoing PRP treatment (BS + PRP).Patients were randomly assigned to four groups, each of them including 20 patients  and adrenaline (10 µg/mL). A 23-gauge needle was used to inject 1 mL of betamethasone (Diprofos Depot 7 mg/mL) and 1 mL of sodium hyaluronate . The exact puncture point was determined by drawing the canthal-tragus line and measuring 10 mm from the tragus and 2 mm below the line. The zygomatic arch was palpated and the patients were asked to open their mouths to move the condyle anteriorly. The position of the needle should be from the outside in, from top to bottom and from back to front. Patients were evaluated one week after the beginning of the treatment, one month later and six months later. They were informed that they could experience discomfort in the region. No analgesic or anti-inflammatory drugs were prescribed. Throughout the process, all patients were always followed by the same practitioner. On the other hand, after signing the informed consent, the patients were randomly assigned to the respective treatment group. Treatment for each patient was assigned by a randomization list automatically generated prior to the start of the study in which the treatment approach was determined. In the BS + PRP group, the injections were preceded by the collection of the patient's peripheral blood from the ulnar vein into a glass tube with sodium citrate as an anticoagulant. After mixing the blood with the citrate, using rotating movements, the tubes were centrifuged at 3200 rpm for 12 min. After careful aspiration of platelet-rich plasma into a syringe, 2mL of PRP were injected into the TMJ following the previously described procedure for BS + B and BS + HS injections.Pain was evaluated as previously described using a visual analogue scale . In brieTo assess the pain-free mouth opening variable, a ruler was used to measure the distance between the patients’ incisors and the results were entered into an Excel datasheet.The descriptive statistics of the demographic data were carried out according to the groups studied. Gender was described in terms of absolute and relative frequency. Age was described using the mean and the standard deviation from the mean. Differences between groups were assessed using a three-way repeated measures ANOVA. The measures were time, the repeated factor, and the group defining the type of therapy and the gender were the other two factors. Differences at the initial moment were assessed using one-way ANOVA. The rates of change of pain and mouth opening were evaluated using linear regressions that were fitted in each group. The independent variable was time and this was expressed in weeks. In one case, pain was used as the dependent variable whereas pain-free mouth opening was used in the other case. As the slope (regression coefficient) of each linear regression represented the rate of change, the comparison between groups was direct and their confidence intervals (CI) allowed the assessment of statistical significance by considering the lack of overlapping between CIs.® v24 platform  and a significance level of 0.05 was adopted.The statistical analyses were carried out on the IBM SPSSThe average age of the sample population was of 43.1 (SD 17.7) and the sex proportions were 20% for men and 80% for women. Sex distribution and age in the treatment groups yielded no significant differences. Supplementary p = 0.325). p < 0.001), but there was no statistical evidence to establish differences between groups  = 2.376; p = 0.077) and gender  = 2.042; p = 0.257). Regression analysis evaluating pain variation over time showed that pain decreased significantly in all the groups treated with injections (p < 0.001), a decrease that was lower in the bite splint group with an average rate of 0.05 on the pain scale per week, and higher in the splint + PRP group, with an average rate of 0.172 per week. Results of the regression analyses regarding the pain are shown in There were no differences in pain intensity among the groups at the beginning of the study  = 1.174; p = 0.400). Subsequently, according to our linear regression analysis and ANOVA, pain-free mouth opening significantly increased over time in all four groups  = 107.017), p < 0.001). The bite splint group had a smaller average rate of 0.219 per week, whereas the splint + PRP group had a larger average rate of 0.676 per week, as shown by the regression coefficients (B) in Variations in the patient’s maximum pain-free mouth opening over time with the different treatments were then analyzed . At the The aim of this research was to assess the effectiveness of treatment with intra-articular injections of betamethasone, hyaluronic acid and platelet-rich plasma in combination with the nocturnal use of a bite splint compared with the isolated use of the splint.In the current literature, there are several studies that have compared the outcome of the use of hyaluronic acid and corticosteroids ,30,31,32It should be noted that, as demonstrated in several previous studies, the use of bite splint shows a high efficacy , as wellTreatment with a bite splint is one of the four therapeutic approaches included in this work and is also the one most commonly used, for the longest time around the world. It is known that in patients with temporomandibular disorders , the vast majority of patients present a good response to the treatment, but there was a minority, no less important, that had no response . Thus, fIn this study, the group that only used the bite splint was the one that showed the least improvement compared to their initial condition in terms of maximum pain-free mouth opening and reduction in pain intensity. Regarding pain, values started at an average of 6.4 and ended with 4.3 after six months, representing an average decrease of 0.05 per week. The most marked period of pain reduction that took place was within the first week, an average value of 4.8. Regarding mouth opening, the results were very similar to those obtained for pain intensity, ranging from an average value of 26.8 mm and ending with 35.6 mm. Thus, a 6 mm increase in the mean was achieved at the end of the first week.The fact that the bite splint group’s model has not been statistically significant could be due to the large dispersion of observed values.In other studies, it has been reported that both intra-articular corticosteroid and sodium hyaluronate injections have a potent anti-inflammatory effect on synovial tissue and are known to reduce effusion, decrease pain and increase the range of motion of the synovial joints ,32.In this work, we found that treatment with sodium hyaluronate and betamethasone reported similar effectiveness. In terms of pain intensity, the patients initially reported an average of 5.8 and 7.1 for sodium hyaluronate and betamethasone use, respectively. The final values were 0.7 and 0.9, respectively, with both groups experiencing a drastic decrease in pain over the first week. Similarly, maximum pain-free mouth opening values started at 26.1 for sodium hyaluronate and at 22.2 for betamethasone, and after six months, very close values of 44 mm and 43.6 mm were reached, which are within normal opening values. Of note, PRP injections are widely used to treat different diseases in other joints of the human body due to their analgesic, anti-inflammatory and healing properties. However, there is a lack of studies which show these forms of treatment being used on TMJP . First of all, it is important to mention that there are few studies involving the use of platelet-rich plasma in the treatment of TMJ arthralgia followed or not by arthrocentesis. Our results revealed an improved response to BS + PRP treatment compared to the previously commented therapies. A recent narrative review shows encouraging results for the use of platelet-rich plasma against other therapeutic approaches .In the present study, the group that received platelet-rich plasma intra-articular injections benefited the most of the four groups studied, starting from pre-treatment pain intensity values of 5.9 and obtaining mean values of 0.2 after six months of treatment. This means that values decreased by 0.172 each week. Patients also started with maximum pain-free mouth opening values of 25.8 mm and these improved to 46.8 mm. However, it should be noted that, although there was a decrease in pain intensity over the first week to a value of 3.3 and an increase in pain-free mouth opening to 33.6 mm, these values fall behind those obtained for sodium hyaluronate and betamethasone.We can conclude that all the therapeutic approaches in this study lead to significant improvements both in maximum pain-free mouth opening and in pain intensity reduction. The treatment with platelet-rich plasma and bite splint yielded the greatest results after six months. However, further study on the topic and new experimental designs are required to achieve a greater understanding of these results and to improve treatments.


Rebound pain after a single-shot nerve block challenges the real benefit of this technique. We aimed to investigate whether perineural dexamethasone addition decreased the incidence of rebound pain after a single-shot nerve block.We randomly allocated 132 patients scheduled for open reduction internal fixation of an upper extremity closed fracture under single-shot peripheral nerve block and sedation into two groups. Patients in the dexamethasone group received nerve block with 0.375% ropivacaine and 8 mg dexamethasone, while those in the control group received ropivacaine only. Sixty-three patients in the dexamethasone group and 60 patients in the control group were analyzed for the incidence of rebound pain 48 h after block administration, which was the primary outcome. The secondary outcomes included the highest self-reported numeric rating scale (NRS) pain score, and NRS at 8, 12, 24, and 48 h after the block, sufentanil consumption, sleep quality on the night of surgery, patient satisfaction with the pain therapy, blood glucose at 6 h after the block, pain and paresthesia at 30 days after surgery.p = 0.001]. Dexamethasone decreased opioid consumption in 24 h after surgery (p < 0.001) and improved the sleep quality score on the night of surgery (p = 0.01) and satisfaction with pain therapy (p = 0.001). Multivariate logistic regression analysis showed that only group allocation was associated with the occurrence of rebound pain . Patients in the dexamethasone group reported later onset pain  and lower peak NRS scores  than those in the control group.The incidence of rebound pain was significantly lower in the dexamethasone group (7 [11.1%] of 63 patients) than in the control group , The perineural administration of 8 mg dexamethasone reduces rebound pain after a single-shot nerve block in patients receiving ORIF for an upper limb fracture.ChiCTR-IPR-17011365) on May 11th, 2017.This study was retrospectively registered in the Chinese Clinical Trial Registry (The online version contains supplementary material available at 10.1186/s12871-021-01267-z. Peripheral nerve block (PNB) plays an essential role in anesthesia and multimodal postoperative analgesia in extremity surgeries. It provides multiple benefits, including reducing opioid consumption, better early postoperative pain control and faster hospital discharge –3. HowevUncompliant bridging therapy is supposed to be the main reason for the rebound phenomenon during PNB wear off. However, based on the duration of action of ropivacaine or bupivacaine, the most commonly used local anesthetics for nerve block, there is a chance that the pain burst happens at night when the patient cannot take bridging medicine beforehand. The continuous infusion of local anesthetics through the perineural catheter may reduce the incidence of rebound pain . NeverthThis single-center, randomized, double-blind controlled study was approved by the Ethics Committee of Zhongshan Hospital, Fudan University (B2016-079R). Written informed consent was obtained from patients before study enrollment by the investigator. This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines.We enrolled patients scheduled for open reduction internal fixation (ORIF) of a closed fracture in the upper extremity under single-shot peripheral nerve block and sedation at Zhongshan Hospital, Fudan University between November 2016 and February 2018. The inclusion criteria were patients aged over 18 years with an ASA physical status of 1 or 2 who had adequate Chinese language skills and a clear understanding of the numerical rating scale (NRS) of pain. The exclusion criteria included patients who refused, those with multiple injuries requiring other surgeries or pain medications, those with preoperative nerve injury, those with a known allergy to ropivacaine or dexamethasone and those with chronic analgesic use. The patients were randomly assigned in a 1:1 ratio to one of two groups (the Dexamethasone and Control groups) according to a computer-generated random number table with SPSS version 23.0 . This allocation was concealed using a sealed opaque envelope that was opened only after the patients were enrolled. Regional medications were prepared by a research nurse who was not involved in the follow-up or care of the patients. The patients, anesthesiologists and outcome assessors were blinded to the group allocation. The physician in charge of generating the allocation sequence and concealment (Fang Du) was not directly involved in the treatment administration or data collection.n = 66) and with 40 mL 0.375% ropivacaine alone in the Control group (n = 66). Premedication included midazolam 1–2 mg i.v. and fentanyl 50 μg i.v. The same regional anesthetist performed the ultrasound-guided nerve block using a high-frequency linear ultrasound probe. The timing of block administration was recorded. Surgeries for lateral third of clavicle and proximal humeral fractures were performed under combined superficial cervical plexus with interscalene or supraclavicular brachial plexus block. Forearm fracture surgeries involving the musculocutaneous nerve innervation area were performed under axillary brachial plexus block combined with musculocutaneous nerve block in the fascial plane between the biceps and the coracobrachialis muscle. For the combined blocks, 40 mL local anesthetic were divided into 10 mL for the superficial cervical plexus block or musculocutaneous nerve block and 30 mL for the brachial plexus block. The effect of the block was evaluated based on the sensation of pin prick 30 minutes after the block.The patients received ultrasound-guided single-shot nerve block with 40 mL 0.375% ropivacaine and 8 mg dexamethasone in the Dexamethasone group  drip and parecoxib 40 mg i.v. were given 30 min before the end of surgery.Standard monitoring was applied, including ECG, BP, HR and SpO− 1 background infusion of sufentanil, 4 μg per bolus, and a lockout time of 6 min as well as parecoxib 40 mg i.v. every 12 h. The patients were instructed to push the self-control button when they felt the numbness of the arm waning. The background infusion was set to maintain a stable blood concentration of sufentanil when rebound pain broke through.Postoperative multimodal analgesia included patient control intravenous analgesia (PCIA) with 2 μg·hOne of our investigators blinded to the allocation details followed the patients’ pain intensity evaluated by NRS 0–10) at 8, 12, 24, and 48 h after the block and asked them to describe their experience when the block wore off. To avoid interrupting the patients’ night sleep, if the prescheduled follow-up time point fell between 9 pm and 8 am, the patient recorded a pain dairy  to 5 (strongly satisfied), blood glucose at 6 h after the block, and pain and paresthesia at 30 days after surgery followed by phone call.The sample size calculation was based on our preliminary observational results that 60% of patients suffered from severe pain (NRS ≥ 7) after ORIF with a single-shot nerve block. We assumed that a 22% decrease in rebound pain incidence with the addition of dexamethasone was clinically significant. With 80% power, 61 patients in each group were required to detect this difference at a significance level of 0.05. We recruited 132 patients with 66 patients per group to compensate for the potential drop out.p < 0.05, and 95% confidence intervals were calculated for the primary outcome measures. We performed a preliminary explanatory analysis to examine the relationships between potential covariates and the dependent variable, rebound pain, as well as the independent variable, group allocation. The Mann-Whitney U test was used for the continuous variables, including days after injury, sleep quality score the night before surgery and patients’s satisfactory score. Based on the type of the distribution; chi-square tests were used to assess the associations between the categorical covariates, including surgeon, block type (single or combined approach), fracture location, brachial nerve approach and use of tourniquet. The variance analysis of repeated measurements was used for the NRS socres before and after the surgery.Statistical analysis was conducted using SPSS version 23.0 . Continuous data are expressed as the median and interquartile range unless the data was verified to have a normal distribution. The level of significance was set at If the prescheduled follow-up time point fell between 9 pm and 8 am, we used the following data reconciliation strategy for the NRS score: according to the patient’s pain diary, if the follow-up time point was before the first reported pain appeared, the resting and exercise NRS scores at that time point were considered to be 0; if the follow-up time point was later than when the initial pain appeared and earlier than the most severe pain that happened, the NRS score at this point was considered to be the mean value of the first NRS higher than 0 and the highest NRS score (rounded down); if the follow-up time point was later than the most severe pain that happened and the patient described that the pain did not alleviate, the highest pain score was taken as the NRS at that point. If the patient did not describe when the pain was relieved, the data at that time point were considered missing.We assessed 140 patients for eligibility; of these, eight patients declined to participate and were thus excluded. In total, 132 patients were enrolled and randomized. The CONSORT flow diagram is shown in Fig. The baseline demographic, anesthetic and surgical characteristics of both groups were comparable, with no statistically significant differences Table . The PNBp = 0.001.The incidence of rebound pain was significantly lower in the dexamethasone group [7 (11.1%) of 63 patients] than in the control group [28 (48.8%) of 60 patients]; the relative risk (RR) was 0.238, 95% CI 0.113–0.504, p < 0.001). The patients in the dexamethasone group reported the highest pain score at 19.7 ± 6.6 h (mean ± SD) since block administration, while those in the control group reported the most severe pain at 14.7 ± 4.8 h (mean ± SD) after block administration.The patients in the two groups showed different pain profiles when the block wore off. The highest self-reported NRS score and the onset time since PNB administration according to the patients’ pain diary of all the participants are shown in Fig. p = 0.000), block type , brachial nerve block approach (p = 0.070), usage of tourniquet (p = 0.070), NRS pain score with movement (p = 0.047) before block administration and sleep quality score on the night before surgery (p = 0.066) were found to be significantly associated with rebound pain ; thus, we included these factors and fracture location (p = 0.430) in multivariate logistic regression analysis. Finally, only group allocation was found to be significantly related to the occurrence of rebound pain . For the NRS scores at postoperative follow-up time points, a significant difference between the groups existed only at 12 h after block administration, both at rest (p = 0.006) and during activity (p = 0.001) . No difference was found in opioid consumption between the two groups 48 h after block administration  during the block effect wear off . We did It is challenging to define rebound pain after nerve block. Williams BA et al.  describeAlthough dexamethasone is one of the most common additives to a nerve block, there are still some safety concerns. Desmet  reportedThere are limitations to our study. We did not investigate the effect of intravenous dexamethasone on rebound pain occurrence. Therefore, we cannot determine whether the reduction in the rebound phenomenon is due to perineural or systemic effects from the absorption of dexamethasone. The comparison of intravenous and perineural dexamethasone showed conflicting results regarding whether the prolongation of the nerve block is of systemic or perineural origin. The results from a meta-analysis showed that for bupivacaine, the addition of perineural dexamethasone leads to a statistically significant prolongation of analgesic duration by 21% compared with intravenous administration. For ropivacaine, the mean duration of analgesia was increased by 12% with perineural dexamethasone compared with systemic dexamethasone, which did not reach statistical significance. The author concluded that the finding of equivalence between both routes of administration remains underpowered for ropivacaine, and a total of 1124 patients would be needed before suggesting a definitive conclusion . BecauseThis single-center, randomized, double-blind controlled study revealed that the addition of 8 mg dexamethasone to ropivacaine provides the benefit of reducing rebound pain after a single-shot nerve block in patients receiving ORIF for an upper limb fracture. It also reduces opioid consumption 48 h after the block and decreases the pain intensity at the point patients describe as the most severe pain after the block. Dexamethasone addition improves sleep quality on the night of surgery and patients’ satisfaction with postoperative pain therapy.Additional file 1.Additional file 2.


Pain catastrophizing, anxiety, and depression are risk factors for poor functional outcomes and worse post-treatment pain that can be treated alongside physical care given to orthopedic patients. While these factors have been shown to be common in patients with hip pathology, there is limited literature that follows these conditions throughout treatment. The purpose of this study was to track psychological factors in patients with various hip pathology to determine if they improved alongside functional measures following treatment.rs), was conducted to evaluate the relationship between change in psychological factors with change in functional outcomes.Patients presenting to a specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, depression, and hip function. Pre- and post-treatment assessments were undertaken: Pain Catastrophizing Scale, the Hospital Anxiety Depression Scale, the Hip Outcome Survey, and Hip Disability and Osteoarthritis Outcome Score (HOOS). Patient characteristics were recorded. A correlation analysis, using the Spearman partial correlation coefficient (n = 35), femoroacetabular impingement (n = 35), lateral trochanteric pain syndrome (n = 9), osteoarthrosis (n = 109), and avascular necrosis of the hip (n = 13). Statistical analysis revealed a significant negative relationship between change in function level (as measured by HOOS ADL) and change in pain catastrophizing , depression , and anxiety . Pain catastrophizing, depression, and anxiety improved with function. Spearman correlation coefficients also revealed that pain catastrophizing, HADS anxiety, and HADS depression improved with improvement in other patient-reported functional outcomes.A total of 201 patients  with a mean age of 53.75 ± 18.97 years were included, with diagnoses of hip dysplasia (Patients with hip pathology often exhibit pain catastrophizing, anxiety, and depression, but improvements in hip functionality are associated with decreased severity of these psychological comorbidities. Exploring this connection demonstrates the correlation between musculoskeletal impairment and psychosocial outcomes and mental health. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care.The online version contains supplementary material available at 10.1186/s12891-021-04001-5. Hip pain contributes to reductions in physical function and ability, but pain is a subjective experience that represents a confluence of biological, social, and psychological factors. The development of hip pain is multifactorial, affected by pathologic factors like hip morphology, arthrosis, and musculotendinous injury, as well as externally-related contributors like BMI, comorbid conditions, and mental health –5. Pain rumination, magnification, and helplessness [Pain catastrophizing is defined as an exaggerated negative mental set that arises in response to present or anticipated pain, broken down into subcategories of lessness . It is alessness , 9. Anxilessness . Depresslessness . Each pllessness .Patients with hip pathology often exhibit levels of pain catastrophizing, anxiety, and depression at the time of presentation . These pWe prospectively evaluated patients presenting at a single academic hip clinic, with the main complaint of hip pain, between August 2017 and November 2019. These patients underwent assessment using validated scales following Institutional Review Board approval. They included the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), a visual analogue pain scale (VAS), the Hip Outcome Survey (HOS), and the Hip Disability and Osteoarthritis Outcome Score (HOOS) , 12–18. All patients in the study presented with hip pain and diagnostic evaluation including: clinical and radiological examination by an orthopedic surgeon specializing in hip preservation and reconstruction. DDH was diagnosed based on physical and radiological examination with a lateral center-edge Wilberg angle < 20° –23. FAI Patients received either operative or non-operative treatment with non-operative being physical therapy or medication/injection. The surgeries included in the operative treatment group consisted of a range of procedures tailored to the specific diagnosis and symptom severity of each patient. These operations included total hip arthroplasty, periacetabular and femoral osteotomy, and minimally invasive hip arthroscopy. Those patients treated with physical therapy were given specific physical therapy scripts including strengthening and range of motion exercises. Medications included anti-inflammatories like steroid injections and NSAIDs. Length of treatment was recorded.n = 1269). These five diagnoses were chosen due to the prevalence of these conditions in the clinic’s patient population as well as clinical expertise of the senior author/diagnosing physician. However, because this aim of this study was to track functional and psychological outcomes longitudinally, only data from patients who had completed the above-mentioned assessments prior to and once after treatment were used in this study (n = 410). Furthermore, because all of the patient-reported data required scoring the assessments that were completed by the patients themselves, all patients with surveys deemed to be incomplete were excluded, leading to our final cohort size of 201 patients with complete pre/post data. This selection process is depicted in Fig. The responses from 201 patients with the diagnosis of DDH, FAI, LTP, OA, or AVN were used in this study, and sample selection was primarily determined by availability of complete pre/post assessments. All patients who presented with hip pain and were ruled to have one of these five diagnoses were eligible for inclusion (2), diagnosis, and treatment protocol  included: sex, age, body mass index , dThe primary outcomes were patient-reported pain catastrophizing, anxiety, depression, and hip function pre/post-treatment. Assessments were gathered using validated questionnaires completed by patients during clinic office visits both before and after treatment, with the follow-up timepoint occurring about six months on average after the completion of treatment. The PCS consists of 13 items, with scores for each question ranging from zero to four. The total score was calculated as the sum of the values of the 13 items, ranging from zero to 52. Higher scores correspond to higher levels of pain catastrophizing. A total score > 30 is considered clinically significant. HADS is a reliable patient-reported measure assessing symptoms of anxiety and depression , 13. EacMeasures of patient symptoms and hip function were also included. Patient-perceived level of function was quantified using the HOS and the HOOS scores , 17. Thers), was conducted to evaluate the relationship between change in self-reported pain catastrophizing , HADS depression, and HADS anxiety with change in patient-reported functional outcome measures, while controlling for age, BMI, and time in days from pre- to post-treatment assessment.Demographic and clinical characteristics for the sample of 201 patients with a range of hip pathology were described using the sample mean and standard deviation for continuous variables and the frequency and percentage for categorical variables. The mean level of pain catastrophizing, anxiety, depression, and functional outcome measures at pre and post-treatment was compared using the dependent samples t-test. Next, a correlation analysis, using the Spearman partial correlation coefficient . The level of significance was set at α = 0.05 (two-tailed). We implemented the False Discovery Rate (FDR) procedure to control false positives over the multiple tests .2. The surgical group included 168 patients, while the non-operative group included 33 patients . The mean time in days from pre- to post-treatment assessment was 187.36 ± 125.19 days (range = 28 to 725 days). The sample included 35 DDH patients, 35 with FAI, 9 with LTP, 109 with OA, and 13 with AVN. Demographic and clinical characteristics are shown in Table The sample of 201 patients were 61.19% female, mean age of 53.75 ± 18.97 years (range = 14 to 89 years). Mean BMI was 27.24 ± 5.48 kg/mp < 0.0001), anxiety (p < 0.0001), depression (p < 0.0001), and functional outcomes (p < 0.0001) from pre- to post-treatment for patients with adverse hip conditions , change in HADS depression , and change in HADS anxiety , while controlling for age, BMI, and time in days from pre- to post-treatment assessment. Pain catastrophizing, depression, and anxiety improved as level of function (ADL) improved. Spearman correlation coefficients revealed that pain catastrophizing, HADS anxiety, and HADS depression improved with improvement in the other patient-reported functional outcomes  and change in pain catastrophizing  and we statistically controlled for length of time from pre-to-post treatment, the wide range in time elapsed between pre/post assessments and the varying treatment modalities may confound our results. However, we also note that the varying treatment modalities along with the time elapsed between assessments represent a real-life clinic setting—not an artificially-controlled setting—which bolsters the external validity of the current study.Finally, concern regarding the validity and reliability of using self-report measures to evaluate musculoskeletal complaints has been documented in previous literature , 51. We In conclusion, we found that improvements in pain catastrophizing, depression, and anxiety are associated with better patient-reported hip function. Patients who originally presented with clinically significant levels of pain catastrophizing, anxiety, and depression demonstrated a decreased severity of these mental health conditions following treatment that improved their hip function. Additionally, our results show the effect that functional improvements may have on psychological factors; conversely, it may also be true that improvements in patients’ psychology and mental outlook may contribute to achieving optimal functional improvements for various musculoskeletal and orthopedic conditions. Because of the association between psychological factors and hip function, we believe that mental health factors may represent an important treatment target to consider as part of a multidisciplinary approach toward treatment of orthopedic hip conditions.Additional file 1. Pain Catastrophizing Scale (PCS).Additional file 2. Hospital Anxiety and Depression Scale (HADS).Additional file 3. Visual Analogue Pain Scale (VAS).


Nerve identification is recommended in inguinal hernia repair to reduce or avoid postoperative pain. The aim of this prospective observational study was to identify nerve prevalence and find a correlation between neuroanatomy and chronic neuropathic postoperative inguinal pain (CPIP) after 6 months.A total of 115 patients, who underwent inguinal hernia mesh repair (Lichtenstein tension-free mesh repair) between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%). Furthermore, these patients were undergoing Dermatome Mapping Test in preoperatively and postoperatively 6 months evaluation.Identification rates of the iliohypogastric (IH), ilioinguinal (II) and genitofemoral (GF) nerves were 72.2%, 82.6% and 48.7% respectively. In the analysis of nerve prevalence according to BMI, the IH was statistically significant higher in patients with BMI < 25 than BMI ≥ 25 P (< 0.05). After inguinal hernia mesh repair, 8 patients (6.9%) had chronic postoperative neuropathic inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome. The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542).The anatomy of inguinal nerve is very heterogeneous and for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms. Dermatome Mapping Test in an easy and safe method for preoperative and postoperative 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified. Cutaneous incision about 1 cm above and parallel to the inguinal ligament, beginning from the pubic tubercle and extending 5–6 cm laterally.Opening of the subcutaneous fat.Opening of the Scarpa fascia until the external oblique aponeurosis with accurate visualization of the external inguinal ring and of the lower border of the inguinal ligament.Opening of the deep fascia of the thigh to check the femoral canal for a femoral hernia.Division of the external oblique aponeurosis from the external ring laterally, preserving the ilioinguinal nerve.Mobilization of the superior (protecting the iliohypogastric nerve) and inferior flaps of the external oblique aponeurosis.Mobilization of the spermatic cord, along with the cremaster, including the ilioinguinal nerve, the genitofemoral nerve, and the spermatic vessels.Opening of the coverings of the spermatic cord and identification and isolation of the hernia sac.Inversion (preferred), division, resection, or ligation of the sac, as indicated.Placement and fixation of mesh to the edges of the defect or weakness in the posterior wall of the inguinal canal to make a new artificial internal ring.Mandatory resection of any nerves that are injured or of doubtful integrity.Gentle pulling of the testes back down to their normal scrotal position.Closure of spermatic cord layers, the external oblique aponeurosis, subcutaneous tissue, and the skin.The operative site is cleaned and a sterile dressing applied. Local infiltration of bupivacaine or ropivacaine may be useful.Neuroanatomy of inguinal canal is characterized by great variability . Nerve iThe European Hernia Society recommends that in cases where an open approach is indicated (as in case of recurrence after a laparoscopic procedure), the Lichtenstein technique be utilized as the preferred method . Mesh athttps://www.clubdaysurgery.it/).Based on these premises, the first aim of this prospective observational study was to identify inguinal nerves during surgery, searching for significant correlations between identification rates during hernia repair and CPIP. The research was undertaken according to the Italian Privacy Laws concerning collection, storage, and analysis of private data. A formal Institutional Research Ethics Board  approval was not required because of the non-interventional, retrospective, and anonymous study design; however, a signed consent for the treatment and the analysis of data for scientific purpose was obtained from all patients or relatives either at admission or as soon as they could give it. The protocol of the study was accepted from Scientific Committee of SICADS  and published in the CUDS’ (Club Unità Day Surgery) ; chronic use of analgesics, antidepressants, anxiolytics, anticonvulsants, abuse of alcohol and drugs; fibromyalgia, herpes zoster.Primary outcomes: intraoperative identification of the inguinal nerves.Secondary outcomes: chronic postoperative inguinal pain after 6 months.All the interventions were performed according to the Lichtenstein technique with a light macroporous mesh in polipropilene. Modification to the original technique consisted in prophylactic inguinal neurectomy (IIN) and mesh fixation with fibrin glue.Before surgery, demographics and anamnesis/comorbidities, which could influence sensitivity for local pain, were collected in an excel table. Furthermore, patients signed an informed consent for the procedure. In addition, they were asked to describe local symptoms and the investigator performed a physical examination. Preoperative pain was localized according to the dermatomal distribution of the three inguinal nerves (Dermatome Pain Mapping Test) Fig. . Pain seFollow-up was set at the sixth postoperative month. Data on local symptoms were collected through a physical examination and by IPQ administration, which was completed in presence of the investigator in order to help with an explanation of the questions . In the Primary outcomes: Nerve identification rates, separated according to the hernia dimension above-mentioned dichotomous variables, were analyzed with the Chi Square test, setting the confidence interval (CI) to 95% (P < 0.05). The Levene test for the homogeneity of the variance (CI 95%) and Student’s T Test were used to verify the equality of the above-mentioned methods.Secondary outcomes: Preoperative pain and postoperative (6 months) symptoms were analyzed separately. Sample means of preoperative pain (IPQ scores) were calculated for each nerve separately in the presence (identification) and absence of the nerves, respectively. The Levene test (CI 95%) and Student’s-T Test were used. Correlations between hernia dimension, IPQ score and nerve dimension were tested by Pearson's test.A total of 115 patients, who underwent inguinal hernia mesh repair between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%) (Table Many of the patients were in the age range of between 75 and 84 years (27%), while the 72% of the total were between 55 and 84 years old. Twelve patients (10.4%) were lost to follow-up.The II was the most frequently identified nerve . The prevalence of the IH nerve  and GF  was lower   had preoperative groin pain. Prevalence of pain during activity and rest, which impaired activities, was 65.4% and 35% respectively. This was prevalent in II/GF dermatome , IH  and IH + II/GF dermatomal distribution (11.5%) (Table Out of three patients with diffuse pain only one had pain influencing activities (IPQ > 3). Pain at rest was prevalent in II/GF dermatome (44%) followed by IH + II/GF localization 15%). Pain during activity resulted more prevalent in II/GF dermatome (57%). Pain with IPQ ≤ 3 prevailed in II/GF region (54%) while IPQ > 3 was less prevalent in this region (48%) in favor of IH + II/GF dermatomes (14%) (Table %. Pain dFifteen patients (13%) had chronic postoperative inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome (66%). In eight patients’ pain was probably of neuropathic origin (DN4 > 3) 53%). Five of these patients presented preoperative pain in the same region and had pain with IPQ > 3. In the other patients pain was probably of nociceptive origin (DN4 ≤ 3) . When the IH nerve was missing, prevalence of pain was lower (6% vs 12%) and prevalence of hypoesthesia was similar (12–13%). Both the mentioned symptoms prevailed in absence of the IH nerve (6% vs 1%).The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542). Narrative analysis is in accordance with the literature since the II resulted the most identified nerve (82.6% in our series vs 84.3% in the literature) and the association of this nerve with pain has been extensively studied. Indeed, prevalence of chronic pain resulted noticeably higher when the II nerve was missing (20% vs 8%): about double the overall incidence of the whole series. Prevalence of the hypoesthesia was slightly higher after neurectomy (13% vs 10%). Both the above-mentioned symptoms were prevalent in the absence of the nerve (5% vs 2%). Most of the patients who resulted negative at follow-up underwent II neurectomy.Hypoesthesia was detected in 17 patients (14.8%). No cases of severe hypoesthesia compromising quality of life occurred. This complication was prevalent in II/GF dermatomal distribution (10 pts).Inguinal nerves have a superficial course and they are exposed to risk of iatrogenic injuries ; nerve iRecently, a systematic review and meta-analysis of worldwide literature reported the identification rates of the inguinal nerves both during open inguinal hernia repair and during cadaveric dissections . OverallIn the present study, pain was classified by dermatomal localization through the Dermatome Inguinal Mapping Test and its severity that took into consideration both intensity and impact on activities as well as quality of life with the Inguinal Pain Questionnaire (IPQ) . We aimeChronic neuropathic pain is defined as a pain, which lasts beyond the third postoperative month . A systeThe same review reported that the prevalence of chronic (probable) neuropathic postoperative pain was about 31% . In our The identification of inguinal nerves is very heterogeneous , for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms, in effect this pain prevailed pain at II/GF dermatome and in 1/3 of cases there is a neuropathic groin pain. Furthermore, Dermatome Mapping Test in an easy and safe method for preoperatively and postoperatively 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified.


Short tapered stem placement has been extensively employed in total hip arthroplasty (THA). Suboptimal fixation tends to cause postoperative complications, such as thigh pain. However, it remains unclear whether poor seating/alignment of short tapered stems contributes to thigh pain. In this study, we retrospectively examined the factors that might be associated with thigh pain.Medical records of 230 patients who had undergone THAs at our hospital were reviewed retrospectively. All patients received the same mediolateral (ML) short tapered femoral stems. The association between thigh pain and patients’ demographics, radiographic findings, or the type of fitting of the femoral stems was investigated.x2 = 6.706, p = 0.01). In addition, hip anteroposterior radiographs exhibited that the stem angulation (mean 2.52°), the variation in angulation (mean 1.32°), and the extent of femoral stem subsidence (mean 0.29 cm) were greater in patients with thigh pain than in their counterparts without thigh pain .In our cohort, 68 patients (27.8%) presented with thigh pain. Among 203 type I fit patients, 62 (30.5%) developed thigh pain, while only 6 out of 43 (12.2%) type II fit patients had thigh pain, with the differences being statistically significant (Malalignment and improper seating of short tapered stems could be at least one of the reasons for post-THA thigh pain. The distal contact between the stem tip and the medial femoral cortex might result in thigh pain. Our study suggested that distal implant contact should be avoided, and stem alignment should be meticulously performed in the placement of ML short tapered femoral stems for THA. Total hip arthroplasty (THA) represents one of the most successful and cost-effective operations of modern medicine . In spitAlthough short tapered stems were reportedly performed as well as standard ones, with equally good functional improvement, pain relief, and implant survival, mounting evidence still shows that thigh pain remains a common complication after THA , 7, 8. FSo far, no consensus has been reached regarding the optimal seating of short tapered stems in the femoral metaphysis. Compared to conventional stems, it is more difficult to ensure appropriate alignment and seating of short tapered stems. Apart from implant/bone contact at the metaphysis, to ensure stability, the distal contact between the stem tip and the medial femoral cortex is required in most cases. The operation, in turn, might lead to misalignment of the stem to some extent. Unfortunately, it remains unclear whether poor seating/alignment of short tapered stems causes thigh pain. In this study, we retrospectively investigated the factors that might be associated with thigh pain after THA with short tapered stem.Upon approval by the institutional review board of our hospital, we performed a retrospective analysis of relevant data from our electronic medical record system. Included in the analysis were 289 patients (322 hips) who had undergone primary THA from October 2015 to August 2018. Of them, 230 patients (involving 252 hips) had complete follow-up data. The stem used in this study was titanium, circumferentially and proximally coated mediolateral (ML) taper short femoral stem , and was implanted with a 32- or 36-mm modular ceramic femoral head (BIOLOX Delta). The stem length (95–119 mm) increased with ML size. The acetabular component was implanted with the Pinnacle acetabular component  in all hips. Ceramic liners (BIOLOX Delta) were used in all hips.The inclusion criteria for this case series study were patients who had undergone THA due to osteoarthritis, acute fracture , developmental dysplasia (Crowe I or II), aseptic necrosis, avascular necrosis, drug-induced necrosis, and post-traumatic arthritis, among others. The exclusion criteria were patients who were diagnosed as having hemophilic arthritis and had undergone intramedullary nailing or total knee arthroplasty. Patients with any comorbidities causing thigh pain before the THA were not included.All procedures were performed by three surgeons via a direct anterior (32 hips), anterior-lateral (142 hips), or minimal invasive posterolateral approach (78 hips). The stem was inserted with a broach-only technique, and a similar broaching technique was used across the 3 surgeons. For all cases, the acetabulum was reamed to 1 mm less than the diameter of the component used. Dome screws were used to augment fixation at the surgeon’s discretion. Patients were allowed to progress to full weight bearing as tolerated, typically transitioning from a walker or crutches to a cane to no support over a period of 4 weeks.Among the selected cases, the mean age of the patients at the time of the primary THA was 61 years (range 23–84 years), and there were 72 men and 158 women. Clinical follow-up lasted for a mean time of 2.7 years . Follow-up evaluation covered the Harris Hip Score (HHS) , 17. TheRadiographs were taken within 3 days before surgery and 1 day, 6 weeks, 3, 6 months, 1 year after surgery, and then on annual basis. Patients returned to the clinic for follow-up. If they were unable to return, radiographs were taken elsewhere and were sent to us for evaluation. The radiographs included anteroposterior (AP) views of the pelvis that involved the tip of the femoral prosthesis and AP and lateral views of the femur that included the hip.d) metaphyseal diameter 2 cm above the level of the lesser trochanter midpoint, (e) isthmus diameter which represents the width of the narrowest part of the proximal femoral canal, (f) diameter of the femoral shaft which was measured 10 cm distal to the center of the small trochanter, and (g) internal width of the medullar canal which was measured 10 cm distal to the center of the small trochanter. Femoral flare index (FFI) was obtained through the ratio between the metaphyseal diameter 2 cm above the level of the lesser trochanter midpoint (d) and isthmus diameter (e). Femoral cortical index (FCI) was obtained through the ratio between the thickness of cortical bone  and the diameter of the femoral shaft (f) measured 10 cm distal to the center of the small trochanter.Preoperative AP radiographs of the hip Fig. a: (d) meh) the width of the stem which was measured at the proximal end of stem tip arc; (i) the internal width of medullar canal, which was measured at the proximal end of tip arc; (j) the width of the stem, which was measured at the distal end of porous coating; (k) the internal width of medullar canal, which was measured at the distal end of porous coating; (α1) coronal stem angulation (CSA), which represents the angle between the stem axis and the femur axis at the first follow-up; (α2) CSA, which is representative of the angle between the stem axis and the femur axis measured at the last follow-up; (s1) distance between the major trochanter apex and the stem shoulder perpendicular to the femoral stem axis measured at the first follow-up; and (s2) distance between the major trochanter apex and the stem shoulder perpendicular to the femoral stem axis at the last follow-up. Stem-intramedullary canal diameter ratio (S-ICDR) at the proximal end of the stem tip arc is the ratio between the diameter of stem (h) and the diameter of intramedullary canal (i) at the proximal end of the stem tip arc. S-ICDR at the distal end of porous coating is the ratio between the diameter of stem (j) and the diameter of intramedullary canal (k) at the distal end of porous coating. Femoral stem subsidence (FSS) from the first to last follow-up visits is the difference between the distance at the first follow-up (s1) and the distance at the last follow-up (s2). Variation in coronal stem angulation (VCSA) from the first to last follow-up visits was obtained by subtracting the stem angulation at the first follow-up (α1) from the stem angulation at the last follow-up (α2).Postoperative AP radiographs of the hip Figs. b ,a, c: β) sagittal stem angulation (SSA), which represents the angle between the stem axis and the femur axis at the first follow-up.Postoperative lateral radiographs of the hip Figs. c and b: All preoperative and postoperative radiographs were retrospectively analyzed, and radiological parameters were measured and checked by two authors. The following parameters were collected Figs.  and 2:PStem subsidence was diagnosed when a stem subsided more than 4 mm, as measured on a perpendicular line drawn from the greater trochanter to the lateral border of the implant. And implant loosening was diagnosed when a stem sunk more than 4 mm and/or varus/valgus migration range was greater than 5° . Stem alIn previous studies, the implant fit was evaluated on the basis of the amount of implant/bone engagement as described by Faizan et al. . In thist tests for continuous variables, and logistic regression for risk factor analysis. All statistical analyses were conducted using SPSS version 20.0. A p value < 0.05 was considered statistically significant.Pearson chi-square was used for categorical variables, Student Of the 230 patients (252 hips) included in the study, 72 31%) were male and 158 (69%) were female. Twenty-two patients underwent bilateral THAs, with a mean age of 61 ± 11 years at the surgery. The preoperative diagnoses included osteoarthritis in 82 (32.5%) hips, acute fracture in 54 (21.4%) hips, developmental dysplasia in 42 (16.7%) hips, aseptic necrosis in 33 (13.1%) hips, avascular necrosis in 25 (9.9%) hips, drug-induced necrosis in 11 (4.4%) hips, and post-traumatic arthritis in 5 (2.0%) hips. There existed no statistically significant differences in demographics or diagnoses between the two groups (Table % were map < 0.01). There were 15 intra-operative calcar fractures, which were stabilized with one or two wires and were managed with the same recovery protocol. Two of 15 calcar fracture cases complained of temporary thigh pain. No femoral components were revised for aseptic loosening, periprosthetic joint infection, or prosthetic dislocation. Two patients had delayed wound healing. They were treated conservatively and recovered eventually.The preoperative HHS was 44.8 (± 14), and at the last follow-up, the mean HHS was 89.2 (± 12), indicating that significant improvement was achieved  reported thigh pain after THA. As shown in Fig. x2 = 6.707, p = 0.01). The implant fit was associated with a clinically significant postoperative thigh pain  were identified to be type I fit, while more type II fits were observed in the pain-free group , with the difference being statistically significant (p = 0.525 and p = 0.575), and femoral anatomical variation could not explain the thigh pain. Nonetheless, the mean CSA was 2.52° ± 1.84° and the mean SSA was 4.63° ± 1.83° in the pain group, while the CSA and SSA were 1.65° ± 1.42° and 3.96° ± 2.01°, respectively, in the pain-free group. We also found that the stem alignment was more valgus and retroverted in the pain group, since the CSA and SSA were more positive in this group than in the pain-free group . In addition, there was a significant difference in VCSA scores between the pain and pain-free groups . Moreover, the FSS ranges averaged 0.29 cm ± 0.22 cm and 0.12 cm ± 0.12 cm in the pain and pain-free groups, respectively (p < 0.001). These significant differences suggest that the type I fit might be less stable than the type II fit. Collectively, our results indicated that the type I fit might bear an association with thigh pain.In our study, no significant differences were found in FFI and FCI  who had received ML short tapered femoral stems, with an attempt to understand the relationship between thigh pain and THA with short tapered stems. We compared the proximal and femoral anatomical structures , stem position relative to adjacent femoral cortical bone, and femoral stem fits in patients with and without thigh pain.In our study, after the placement of short tapered stems, thigh pain developed in 27%  of the patients about 1.5–4.6 years after surgery. Crawford et al. found that 15% 218 in all) of such patients reported anterior thigh pain and 15% complained of lateral thigh pain . Richard8 in all p = 0.000 and p = 0.004, respectively)  Table . MoreoveIn fact, the biomechanical and pathological mechanisms of postoperative thigh pain remain unclear. Khanuja et al.  reportedIn summary, a more varus/valgus stem alignment, a suboptimal stem fixation, and a higher proportion of type I fits were associated with thigh pain. We suggest that the type I fit, featuring distal contact between the stem tip and the medial femoral cortex, to some extent, is indicative of the malalignment of the implant, which, in turn, compromises implant stability, increases regional stress, and causes thigh pain.This study has several limitations. First, this is a case series where three surgeons performed the surgery with different operative approaches, and outcomes (such as the thigh pain) might vary with different surgeons and operator bias might result. Second, although patients were asked specifically if they had “thigh pain,” it was difficult for some subjects to differentiate hip pain, lumbar spine radicular pain, pain resulting from trochanteric bursitis, and abductor tendonitis, especially when the survey was conducted over the phone. Despite all the efforts made to rule out non-implant-related causes, thigh pain could be caused by numerous causes such as undetectable neurological pathology or muscle strain. These might result in an overestimation of thigh pain. Third, the study especially lasted for a relatively short time, especially for a THA follow-up, and thigh pain may modulate over time. Forth, we focused on only one specific type of stem, and the conclusion should be extrapolated to other stems with caution. Finally, this study has similar limitations as all other radiographic studies of THA, i.e., having inter- and intra-observer variability of radiographic measurements.Our clinical and radiological analyses showed that short tapered stems could attain evident functional improvement in terms of HSS. However, stem malalignment and the distal contact between the stem tip and the medial femoral cortex might cause thigh pain. It is essential that distal implant contact be avoided and stem alignment be meticulously executed during surgical procedure. Future studies with longer follow-up and larger cohorts will provide more valuable information.