Context: Patient-controlled analgesia (PCA) is commonly used for postoperative pain control. Although widely used, intravenous (IV) morphine PCA may not be suitable for all patients. Sufentanil sublingual tablet system (SSTS) PCA is a recent technique that has had success as a safe and effective alternative for acute pain management.Aims: This study aims to compare both the efficacy and safety of SSTS PCA versus IV morphine PCA in postoperative pain control and the quality of recovery in adult patients following scheduled gynecological or orthopedic surgery.Settings and design: Open-label, parallel-group, randomized controlled trial with 54 patients. The primary outcome was postoperative pain control, while the secondary outcomes included adverse effects associated with two analgesic modalities, total opioid dose required, patient satisfaction, and impact on the quality of postoperative recovery.Methods and material: Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 . The chi-squared test was used in categorical variables. When distribution was normal, T-student (mean ± standard deviation) was used in continuous variables. In contrast, when distribution was not normal, the Mann-Whitney test ) was used.Results: The results showed that there was a statistically significant difference in the total dose of opioid used by patients at 24 hours postoperatively, with patients receiving SSTS PCA requiring a higher total dose when compared to those receiving IV morphine PCA. However, there were no statistically significant differences in pain scores, adverse events, or patient satisfaction.Conclusions: The study suggests that both IV morphine and sublingual sufentanil are safe and effective for postoperative pain management. Patient-controlled analgesia (PCA) is a widespread and frequently used pain management method in hospitalized patients. Intravenous (IV) morphine PCA is commonly used in postoperative pain control, but it requires IV access and can lead to associated complications -3. SufenThe study was a single-center, open-label, parallel-group, randomized controlled trial and followed the 2010 Consolidated Standards of Reporting Trails (CONSORT) statement guidelines  and numeric rating scale (NRS) -10. SecoClinicalTrials.gov (ID NCT05259098). The study was conducted in Funchal Hospital and data was collected between November 2019 and June 2020. The inclusion criteria were signed informed consent, 18+ years, physical status according to the American Society of Anesthesiologists (ASA) 1-3, and undergoing scheduled open hysterectomy, total knee arthroplasty, or total hip arthroplasty, while the exclusion criteria were refusal to participate, not of legal age or legally dependent of thirds, neurological or psychiatric pathologies or an altered state of consciousness that does not allow for the PCA strategy, documented drinking habits and/or consumption of illicit drugs, diagnosis of opioid use disorder, tolerance to opioid therapy , obstructive sleep apnea syndrome (OSAS) documented, patients on long-term oxygen therapy, intraoperative use of intrathecal morphine, and current usage of any anesthetic techniques that provide postoperative analgesia . Data was collected in the anesthesia department and at the bedside of patients, while medical records were assessed in the institutional information system. A permuted block randomization with 1:1 allocation ratio was performed using an online software. A total of 10 blocks were created, consisting of seven blocks with six and three blocks with four participants.The study was approved by the Funchal Central Hospital Ethics Committee  and registered in The primary outcome was postoperative pain control measured at 24 hours and 48 hours using the NRS. In contrast, the secondary outcome assessed adverse effects associated with both analgesic modalities measured every eight hours by the nursing team , required dosage of opioid in each strategy, patients' satisfaction, and the impact of the treatment on the quality of postoperative recovery using the validated Portuguese version of the Quality of Recovery-15 (QoR-15) questionnaire .Preemptive analgesia included the use of oral gabapentin (100 mg) administered one hour before the procedure, and IV ketorolac (30 mg) at the beginning of the surgery. Intraoperatively, nociception was controlled with fentanyl in boluses. At the end of the procedure, 1 g of IV paracetamol was administered. In the postoperative period, patients were admitted to the post-anesthetic care unit (PACU) for initial recovery. While there, they received comprehensive instructions on the appropriate use of PCA devices. It was not necessary to administer any bolus in the PACU by the nursing staff, as the pain was under control, allowing the patient to be taught how the machine works. The morphine PCA was Smiths Medical CADD Model 2020® , programmed 1 mcg IV morphine on demand, 10 minutes lockout, maximum 6 mcg per hour, while the SSTS was Zalviso® machine , programmed 15 mg sublingual sufentanil, 20 minutes lockout, maximum 45 mg per hour. All patients were prescribed a combination of analgesics that included both IV paracetamol (1 g every eight hours), IV non-steroidal anti-inflammatory drugs (ketorolac 30 mg every eight hours), and oral gabapentin . All patients had also prescribed a fixed antiemetic medication .Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 . The chi-squared test was used in categorical variables. When distribution was normal, T-student (mean ± standard deviation) was used in continuous variables. In contrast, when distribution was not normal, the Mann-Whitney test ) was used.Statistical analysis was performed to compare the effectiveness of IV morphine PCA with SSTS PCA in postoperative pain management. There was no difference in demographic characteristics between the two groups Table .With regard to the primary outcome, no statistically significant differences were identified in the pain scores between the two groups at point in time. The median of NRS at 24 hours at rest was 1 (0-8) for the morphine group and 1.5 (0-7) for the sufentanil group. At 24 hours postoperative, patients reported moderate pain during movement with a median score of 5 (2-9) and 5.5 (0-9) for morphine and sufentanil, respectively. At 48 hours postoperative, the mean pain score for both groups at rest was 0 and 3 during movement  compared to that of morphine (6 mg per hour). Despite the difference, we wanted to test these treatment regimens since they are the ones that are protocolled in our department. Regardless of the difference in dosage, the side effects (which can be dose dependent) were similar between both groups, confirming findings of other studies .Although there was no statistically significant difference in pain relief and patient satisfaction between the two groups, the small sample size could have affected the results.Generalizations of this study are limited by the specific inclusion and exclusion criteria, which targeted patients undergoing scheduled hysterectomy, total knee arthroplasty, or total hip arthroplasty and excluded patients with certain medical conditions or using certain analgesic techniques. Additionally, the study was conducted at a single institution, which may limit the generalizability of the findings to other settings.A strong point of the study is the following of the CONSORT guidelines, recognized standards for reporting randomized controlled trials. Additionally, the study used validated outcome measures, and the sample size calculation was based on an a priori power analysis.However, the study has some limitations. With regard to the exclusion criteria, we considered a dose to exclude patients with chronic opioid use; however, we did not consider the duration of prior use. It was an open-label study, which means that both the patients and clinicians were aware of the treatment allocation, and this may have introduced bias. Additionally, the study did not assess long-term outcomes beyond the first 48 hours after surgery. Another concern is that sufentanil is more lipophilic, is more potent, and has a faster onset of action than morphine, which raises the question of it being associated with a higher risk of addiction.This study suggests that both IV morphine and sublingual sufentanil are effective and safe options for postoperative pain management. However, clinicians should consider the total dose required to achieve pain relief when choosing between the two medications. Future research could explore other factors that may influence the effectiveness and safety of these medications in specific patient populations. However, further studies with larger sample sizes are needed to confirm these findings.


The pathogenesis of concomitant continuous pain remains unclear and is worthy of further study. In this clinical study, we aimed to explore the potential role of a narrow foramen ovale in the development of concomitant continuous pain.A total of 108 patients with classical trigeminal neuralgia affecting the third branch of the trigeminal nerve and 46 healthy individuals were enrolled in this study. Three-dimensional reconstructed computerized tomography images of all participants were collected, and the morphometric features of the foramen ovale were examined by two investigators who were blinded to the clinical data of the patients.p = 0.015) and responded more poorly to medication  than patients without concomitant continuous pain. While no significant differences regarding the mean length  and area  were observed between patients with and without concomitant continuous pain, the mean width of the foramen ovale on the affected side in patients with concomitant continuous pain was significantly narrower than that in patients without concomitant continuous pain .In this cohort, patients with concomitant continuous pain suffered from more sensory abnormalities (18.4% vs. 2.9%, This neuroimaging and clinical study demonstrated that the development of concomitant continuous pain was caused by the compression of the trigeminal nerve owing to a narrow foramen ovale rather than responsible vessels in classical trigeminal neuralgia. Trigeminal neuralgia (TN) is one of the most torturous pain conditions and is characterized by recurrent episodes of unbearable and electric-shock-like pain restricted to the territory of the trigeminal nerve , 2. In aThe pathogenesis of TN is complicated and has not been completely elucidated. To date, neurovascular compression (NVC) is the most convincing theory and is supported by the high rate of pain relief by microvascular decompression (MVD) . NeverthThe foramen ovale (FO), through which the third branch of the trigeminal nerve (V3) and several small vessels travel, is an important bony aperture in the middle cranial fossa , 31. In A total of 257 consecutive patients with TN diagnosed as TN according to ICHD-3 13.1.1 in our institute from January 2019 to January 2023 were screened in the study (All obtained high-resolution head computed tomography (CT) images were transferred to the Picture Archiving and Communicating System and a 3-dimensional (3D) reconstruction was then created on a postprocessing workstation . The width and length of each FO were measured on the 3D-CT image, and the area was measured on the corresponding axial CT image by a self-contained measuring tool . The detp value of <0.05 was defined as statistically significant. The study was reviewed and approved by our institutional review board.Statistical analyses were performed using SPSS . Continuous and categorical variables are presented as medians and numbers (percentages), respectively. An independent-sample T test or Wilcoxon signed-rank test was used for the comparison of continuous data, and a Chi-square test or Fisher exact test was used for the comparison of categorical data. A p = 0.459), sex (p = 0.088), side (p = 0.476), pain duration (p = 0.223) or distribution (p = 0.943). Age of disease onset was most commonly between 50 and 70 years, and pain tended to occur in female patients in both patient groups. In all patients in whom V3 was affected, the combination of V2 and V3 being affected was more frequent, followed by V3 alone. The distribution of CCP was consistent with the divisions of paroxysmal pain. Pain duration ranged from 1 month to 11 years (mean 3.9 years) in patients with CCP and from 1 month to 20 years (mean 5.0 years) in patients without CCP. Of the 38 patients with CCP, 26 (68.4%) had this continuous pain at disease onset; in the remaining 12 (31.6%) patients, CCP developed after a mean period of 2.1 years (range 6 months–10 years). Almost all patients with CCP described the pain as burning, dull, and not as severe as paroxysmal pain.Patients with TN were divided into two groups according to the presence of CCP. The two patient groups did not differ in age (p = 0.018) in patients with CCP. Although the response rate was high in both groups (91.9% vs. 74.3%) at onset, when visiting our center, the response rate decreased to 37.1% and 18.4%. Regarding sensory abnormalities, a small proportion of CTN patients developed abnormalities before surgery. Nevertheless, sensory abnormalities were much more prevalent in patients with CCP .Conversely, the differences in response to medication and sensory abnormalities were statistically significant between groups. Owing to the impairment of the kidney and liver and other side effects, 3 patients with CCP and 8 patients without CCP did not receive the medication. The response to medication, such as carbamazepine, was poorer . No significant differences in any parameters of FOs between the left and right sides in either patient group were found  . In contrast, no difference in the size of FOs between the painful and painless sides in CTN patients without CCP was observed (p > 0.05) (p = 0.003). Likewise, there were no significant differences in the area and length between the two patient groups  . In pati > 0.05) . Furthert groups .With the deepening understanding of the pathogenesis of the characteristic paroxysmal pain, great strides in the treatment of TN have been made in recent decades. However, the underlying mechanisms causing CCP are still unknown. Furthermore, TN patients with CCP respond poorly to current available therapies, including pharmacological and surgical treatments . TherefoThe hypothesis that a narrow FO compressing the trigeminal nerve secondarily could cause TN on the basis of the neurovascular compression theory was first proposed in 2005 by Neto et al. . Since tp = 0.018). In addition, a small percentage of patients presented with sensory abnormalities in addition to pain. The uncomfortable sensation was much more prevalent in patients with CCP . Hitherto, no reasonable explanation accounts for the abovementioned phenomena.CCP occurred in 38 (35.2%) patients among the 108 CTN patients and was described as burning and throbbing but less intense than paroxysmal pain. The proportion and characteristics of CCP were similar to those reported in previous studies , 43. AppIn this paper, we found no significant differences in the parameters of FOs between the left and right sides, suggesting that FOs exhibited bilateral symmetry. The average width and area of FOs on the affected side in CTN patients were significantly smaller than those on the painless side in HCs. The difference in the length was not significant. The results suggested that a narrow FO may be associated with the occurrence of CTN. Previous studies reached the same conclusion , 39. To Previous clinical studies could also provide some evidence to support our hypothesis. First, it has been demonstrated that sensory abnormalities and abnormal trigeminal reflex testing were more prevalent in patients with CCP than in patients without CCP, suggesting that the trigeminal nerve of patients with CCP may be damaged by factors other than NVC , 44. TheOur findings on the role of a double crush mechanism in CCP may have treatment implications. The optimum surgical treatment for CCP is still an open issue. On the basis of the aforementioned results, we suggest that it is necessary for surgeons to measure the parameters of the FOs on the symptomatic side for patients with CCP. Percutaneous procedures and gamma-knife radiosurgery may be considered the first choices for patients with a narrow FO. Future randomized controlled trials are needed to explore treatment strategies for achieving long-term pain relief in CTN patients with CCP.Our study has several limitations. First, the retrospective design may affect the generalizability of results. Second, all parameters were measured manually and volume effects may lead to variable measurements. Finally, this study is hypothesis generating and need further validation by pathological and clinical studies.The findings of our clinical and neuroimaging study suggested that the width of FOs on the painful side in patients with CCP was significantly narrower, which demonstrated that a narrow FO may be involved in the occurrence of CCP and that the double crush theory may be the main mechanism of CCP. This paper may eventually help neurosurgeons select the optimum way to treat continuous pain in CTN patients.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving humans were approved by Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The ethics committee/institutional review board waived the requirement of written informed consent for participation from the participants or the participants’ legal guardians/next of kin because the nature of this study is retrospective.SL: Writing – original draft. CL: Data curation, Investigation, Methodology, Writing – review & editing. XY: Resources, Software, Supervision, Writing – review & editing. WZ: Resources, Supervision, Validation, Visualization, Writing – review & editing.


Musculoskeletal conditions, including osteoarthritis (OA), are a leading cause of disability and chronic pain, and are associated with high rates of comorbid depression. However, signs of depression are often masked by pain. The aim of this study was to determine the prevalence and severity of depression and pain in individuals awaiting specialist orthopaedic consultation. A secondary objective was to determine the relationship between pain and depression, irrespective of demographic factors and clinical diagnosis.Cross-sectional analysis of individuals awaiting orthopaedic consultation at a public hospital in Melbourne, Australia. Relevant data were extracted from medical records and questionnaires. Descriptive statistics were used to summarise participant characteristics. The patient health questionnaire (PHQ-9) was used to assess depression and a numerical rating scale (NRS) was used to assess pain severity. Multiple linear regression analyses were used to establish the relationship between pain and depression.2 = 0.13, P < 0.001), and this relationship remained significant after accounting for gender, age, education and employment status, OA status, number of joints affected and waiting time .Nine hundred and eighty-six adults  participated in the study. OA was present in 56% of the population and 34% of the entire population had moderate depression or greater, 19% of which met the criteria for major depressive disorder. Moderate-to-severe pain was present in 79% of individuals with OA and 55% of individuals with other musculoskeletal complaints. Pain was significantly associated with depression scores (β = 0.84, adjusted RDepression affects one-third of individuals on an orthopaedic waitlist. A strong link between pain and depression in patients awaiting specialist orthopaedic consultation exists, indicating a need for an integrated approach in addressing pain management and depression to manage this complex and comorbid presentation. Approximately one third of Australians report having arthritis or other musculoskeletal conditions . MusculoChronic pain is often the catalyst that leads individuals with musculoskeletal problems to seek medical care . ChronicIndividuals affected by OA are nearly three times more likely to report very severe pain, and two times as likely to report high levels of psychological distress compared to those without OA . HoweverParticipants were recruited from the orthopaedic outpatient waitlist at Western Health, a metropolitan public tertiary teaching hospital in Melbourne, Australia. Recruitment began August 2021 and is ongoing. All patients placed on the waitlist between the 1st of January 2018 and the 1st of June 2022 who were 18 years of age or older were invited to participate. Participants were excluded if they had a cognitive impairment, or if they had a specialist appointment scheduled.This study is part of a larger research project which is collecting longitudinal data examining the health and wellbeing of individuals on the orthopaedic waitlist in order to determine their needs and develop effective interventions. The study was approved by Melbourne Health Human Research Ethics Committee (2021.055) and site specific approval was granted by Western Health. Eligible patients were contacted via telephone call. Three attempts were made to contact patients. Those unable to be contacted after three attempts were recorded as non-responders. Interested patients were sent a survey package via email or mail, or completed over the phone. For patients preferring an electronic survey, a link to a secure website (REDCap) where patients could complete the survey was provided. For patients that preferred hard-copy, surveys were mailed out with an addressed, prepaid envelope. If patients elected to complete the survey over the phone, the survey questions and response options were read to them and the response was recorded on their behalf. Informed consent was obtained prior to data collection.For all patients on the waitlist, data were extracted from their medical records and entered into a secure online database (REDCap). Extracted data included date of birth, postcode, age, date that the GP referral was triaged by the hospital, number of joints affected, location/s of affected joint/s and whether osteoarthritis is present or suspected. Participants completed a survey comprising a range of self-report questionnaires including demographics, medical history and health status, pain and psychological wellbeing. The questionnaires were in English, however, if patients were unable to understand or read English well, their next of kin was contacted for assistance.Patients were listed as having OA if it was listed on their referral, or if they met the three clinical criteria; (1) over the age of 45 years; (2) has activity-related joint pain; and (3) has no morning joint-related stiffness, or morning stiffness that lasts no longer than 30 min , determiThe Patient Health Questionnaire (PHQ-9) was used to assess patients’ level of depression over the previous two weeks . The PHQPain intensity was self-rated by participants using the numeric rating scale (NRS). The NRS is an 11-point numerical scale ranging from 0 (no pain) to 10 (worst possible pain) . Various2 (57) = 56.0, P = 0.513), therefore, missing data were deleted pairwise. The Kolmogorov–Smirnov test was used to assess normal distribution of data. Data were deemed to be normally distributed with the exception of wait time and a square root transformation was performed for analysis. To test differences amongst the OA and non-OA subgroups for the total score of the survey items, t-test were used. Chi-squared test of independence was used to test for differences between categorical variables for the OA and non-OA subgroups. A simple linear regression was conducted to determine the relationship between pain and depression scores. Multiple linear regression analyses were used to identify whether pain and demographic characteristics were associated with depression scores (model 1) and lastly, to determine whether pain, demographic characteristics and joint specific factors were associated with depression scores (model 2). Collinearity statistics were used to evaluate the variation inflation factor (VIF). The VIF values were less than 3 indicating no problematic multi-collinearity [All statistical analyses were conducted using R version 4.1.2  in RStudio . Descriptive statistics such as mean and standard deviations (SD), and percentages were used to characterise the sample. Patterns of missing data were examined using the naniar package  and Littinearity . StatistOf the 4,709 patients contacted, 46.3% agreed to participate n = 2,180), of which 45.2% (n = 986) signed consent. Of the patients contacted, 22.4% refused participation, 21.7% did not respond and 9.6% were deemed ineligible. Participant flow is detailed in Fig. 80, of whFigure legends.Demographic characteristics are presented in Table X2 (4) = 0.440, P = 0.979). The proportion of individuals in each category are presented in Fig. The mean depression scores were 7.9 ± 6.6 and 7.9 ± 6.7 for the OA and non-OA subgroups, respectively. The mean depression scores did not differ significantly between groups , nor did the proportion of individuals’ per category (X2 (3) = 82.15, P < 0.001. The proportion of individuals in each category is presented in Fig. The mean pain scores were 6.4 ± 2.5 and 4.6 ± 2.8 for the OA and non-OA subgroups, respectively. Scores differed significantly between groups, with higher pain scores in the OA group , as did the proportion of individuals per category, 2 = 0.13, F). Following this, multiple linear regression was performed to test whether the addition of age, gender, employment status, education level and country of birth better explained the variance in depression scores (model 1). The overall regression was statistically significant ), with higher pain, older age, being a man, and not having employment all being significantly associated with higher depression scores  = 23.71, P < 0.001)) and none of the additional variables were statistically significantly (Table Initially, univariate linear regression analysis determined that higher pain scores were significantly associated with higher depression scores (β = 0.84 adjusted RWe report that a large proportion of individuals on an orthopaedic waitlist have high scores of depression, with 34% meeting the criteria for diagnosable depression and approximately one-fifth of the population meeting the criteria for major depressive disorder. Individuals with and without OA had high rates of moderate-to-severe pain, however, individuals with OA report significantly higher pain scores compared to those without. Amongst all individuals on the waitlist, pain was a significant predictor of depression scores, accounting for 13% of the variation in depression scores.Approximately 34% of individuals on the orthopaedic waitlist had diagnosable depression according to scores from the PHQ-9, 19% of which met the criteria for major depressive disorder . These rOur finding that moderate-to-severe pain was reported in 66% of individuals on the orthopaedic waitlist is problematic given the significant health and economic burden to the individual, and the healthcare system. In Australia in 2018, chronic pain was estimated to cost ~$139 billion, mostly attributed to loss of productivity and reduced quality of life . A natioPain and depression are closely correlated and often co-occur . High raStrengths of this study include the large sample size, which included a broad range of individuals from diverse backgrounds and the use of the PHQ-9 which is a validated, reliable measure and is considered the gold standard for determining depression symptom severity. Limitations of this study include the lack of patient response with less than 25% of approached patients choosing to participate, the cross-sectional nature, and that patients were surveyed after varying lengths of time on the wait list. We were also unable to specify and account for reasons for referral in patients that did not have OA. In addition, the questionnaires were only provided in English. Future studies should endeavour to survey patients in their preferred language and from the time that patients are placed on the waitlist.In conclusion, a large proportion of individuals on an orthopaedic waitlist are affected by depression. This indicates a need for action in assessing and addressing both the physical and mental health concerns of individuals whilst they are awaiting consultation. It was also noted that pain is significantly associated with depression and we recommend that the two be addressed simultaneously to reduce the risks associated with depression, and reduce the burden on the individual and the healthcare system.


The treatment of acute pain over the years has changed with increasing alternative therapies and increased scrutiny of opioid prescriptions. Shared Decision Making (SDM) has become a vital tool in increasing patient engagement and satisfaction in treatment decisions. SDM has been successfully implemented in the management of pain in a variety of settings; however, information regarding the use of SDM for treating acute pain in patients with a history of opioid use disorder (OUD) remains scarce. Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR), we conducted a review to understand how SDM is used in acute pain management in patients with OUD. We searched Medline, Embase, CINAHL, and PsychInfo databases for relevant articles. Articles were screened and SDM outcomes of eligible articles were charted. The results were grouped by sub-theme based on a 1997 SDM model. There were three original research studies and one quality improvement study. The remaining articles were split evenly between reviews and reviews of clinical guidelines. Four themes emerged from the review: prior judgment and stigma related to OUD, trust and sharing of information, clinical tools, and interprofessional teams. This scoping review consolidated and expounded the current literature on SDM in the management of acute pain in patients with OUD. More work is needed to address prior judgments by both providers and patients and to build greater dialogue. Clinical tools may aid this process as well as the involvement of a multidisciplinary team. Since the 1987 World Health Organization (WHO) analgesic ladder was first published, knowledge of pain physiology and the clinical management of pain has evolved ,3. With Shared Decision Making has also been utilized in a variety of pain conditions including musculoskeletal pain, cancer pain, and palliative medicine patients ,11,12. SWhen treating pain, it can be challenging to develop and sustain a therapeutic atmosphere as there may be disagreements regarding pain etiology. In addition, the use of opioids, a mainstay of pain treatment, has become controversial considering the ongoing opioid epidemic. Efforts to curb this national crisis via the implementation of prescription drug monitoring programs have shown reductions in the national opioid prescribing rate of 20.7% and 22.8% among oncologists and non-oncologists, respectively, between the years 2013 and 2017 . Some paFurthermore, patients with OUD being treated for acute pain may have several worries including fears of withdrawal, relapse into unrestricted opioid use, feeling their pain may be undertreated, or fears of discrimination based upon prior substance use history. Physicians treating patients with OUD, especially those not familiar with MOUD, may also have concerns about the fabrication of pain, risk of opioid diversion, or overtreatment resulting in opioid-induced respiratory depression . In suchCompared to systematic reviews, scoping reviews are used to identify gaps in knowledge and examine research questions related to a particular theme. The protocol for this study has not previously been published. The research topic was explored with a medical librarian to develop the search strategy across multiple databases, and the Preferred Reporting Items for Systematic Reviews and the Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) checklist was used to record the workflow  21]. . 21]. Research question: how is shared decision making used for pain management within the patient population with opioid use disorder? The initial research strategy was developed for Ovid MEDLINE and then translated to PsychInfo, Embase, and CINAHL. The selection of search terms was iterative and included the summation of three search categories: “opioid use disorder”, “acute pain”, and “shared-decision making”. A combination of MeSH, EMTREE/Subject Headings, and keywords were included. The full search strategy for Ovid MEDLINE can be found in Articles were included if they involved patients with OUD or substance use disorder (SUD), discussed pain management in an acute setting, were peer-reviewed, and were original research, reviews, or reviews of clinical guidelines. Articles were excluded if they focused on the prevention of first-time OUD treatment, chronic pain, palliative care, or were oncology related. ASC and AM screened the initial list of records. Eligible abstracts were then reviewed for full-text and those that, upon further review, did not meet the criteria were excluded. Records where there was agreement to include or exclude were kept in their respective assignment; for records where there was disagreement or uncertainty based on the title/abstract, the articles were kept in the search. When there was a disagreement in final eligibility, a third author (TCL) handled the dispute. The final set of articles was reviewed, charted, and the study details were extracted. Three authors  extracted article details including authors on the publication, year of publication, article type, population, treatment setting, and relevant findings. ASC grouped the articles by subtopics and the groupings were validated by the initial reviewers . Articles were grouped into subtopics based on the components of SDM described by the 1997 model developed by Charles et al. . The initial search retrieved 523 articles. Of these, 130 were found through Medline, 14 through PsychInfo, 99 through CINAHL, and 280 through EMBASE. After removing duplicates, 296 articles were reviewed. A total of 2 articles were excluded that were animal studies, 12 that did not focus on pain or pain management, 258 that did not focus on the correct population, and 8 records that were abstracts, dissertations, and educational material. A full review was performed on the remaining 16 articles. The complete search strategy is shown in There were four (40%) original research/work articles, three (30%) reviews, and three (30%) clinical guidelines. Of the original research/work studies, one was a quality improvement intervention, two were surveys , and one was a case study. Two of the studies focused specifically on acute pain in the setting of endocarditis in patients with active intravenous drug use. Of the reviews and clinical guidelines, three were focused on patients receiving MOUD, two were focused on pain in patients with a history of SUD, and the last focused on pain management in patients with OUD in the critical care setting. Four themes emerged from the review: prior judgment and stigma related to OUD, trust and sharing of information, clinical tools, and interprofessional teams. A detailed summary of the results is presented in Both the Butt et al. 2022 study and the review of clinical guidelines by Mefford and Donaldson discuss how prior experiences and existing stigma hinder SDM in pain management in patients with OUD ,28. StumIn addition to education and a general understanding of the population, trust and the patient–physician relationship are essential for SDM. This theme is illustrated in several ways throughout the literature with an overlap across articles. First, Stumbo et al. illustrate the importance of patients sharing their history of substance use and how providing discrete details identifies patient perceptions relevant to treatment barriers and suitable options for controlling pain . Second,There are several clinical tools with potential benefits in SDM. Broughton-Miller and Urquhart published the results of their institution’s quality improvement (QI) initiative for trauma patients on MOUD . Their QThe last subtopic of SDM explored in this scoping review was interprofessional care between providers and healthcare workers. This was a recurrent theme across several articles. Collaboration during the acute pain episode between the attending doctor and clinical care team  led to increased communication with the patient in the Broughton-Miller and Urquahart study . MeffordThis scoping review consolidated and expounded the current literature on SDM in the management of acute pain in patients with OUD, the observed effects on clinical management, and specific challenges that providers may face in its execution. Our review found the various components of SDM, as described by Charles et al., across the 10 articles . The theThe discussion of prior judgment and existing stigma related to OUD is well established in the initial decision of a provider to prescribe opioids. Some of the barriers related to this component of SDM include generalized and blanketed approaches, uninformed consent, fear of opioids or pain, mental health disorders, lack of agency, lack of choice, and increased stigma regarding addiction. These barriers appear to be common across multiple specialties, including primary care, telemedicine, perinatal, postpartum, and cancer management ,35,36,37Trust and information sharing is a key component in shared decision making. A study by Ritter et al. showed that a 2-h training plus the use of an SDM protocol discussing patient efficacy, provider’s experience, and patient’s values increased standardized patients’ comfort with the discussion . In partResearch has shown success in the use of decision aids or clinical tools to support SDM. A study by Aarts et al. on women with heavy menstrual bleeding and/or uterine fibroids showed that training of clinicians and the use of the “Option Grid encounter” decision aids yielded higher SDM scores based on the patient self-reported collaboRATE 3-question measure . A meta-Although uncertainty exists with respect to the type of decision aids to use and is an area of future research, one area of shared decision making that appears consistent across the literature is the use of a multidisciplinary team. This aspect of SDM reoccurred frequently in our review. In the area of critical care, Smith et al. discuss the need for regular patient monitoring and for communication with the patient when possible . KrashinThe use of a multidisciplinary team in shared decision making has been seen in other areas of medicine. A 2018 publication by Quinn et al. discusses their team’s implementation of a multidisciplinary decision-making process among clinicians followed by shared decision making with the patient/caregiver in the pre-operative oncology setting . NanapraIn the setting of acute pain management for patients with OUD or with a history of OUD, there is the opportunity to do the same. SDM has the potential to be a valuable skill. Our research shows that although some work has been conducted in this field, more is necessary. Increased efforts are needed to continue to reduce stigma, increase provider and patient education, and build trust . ClinicaOur scoping review has several limitations. Although our focus was on OUD, there were articles within our search on SUD that we opted to include although not in our original question. Although SUD includes OUD, these articles may have been referencing situations not related specifically to OUD. Additionally, unlike a traditional scoping review, we had a framework around SDM that we were attempting to address through the literature. This may have prevented us from analyzing the data in a different way, possibly leading to other factors that may be significant in SDM in this population. Finally, the inclusion of reviews of clinical guidelines in a scoping review is atypical. Our decision to include these articles was based on (1) the limited literature we expected to find and (2) a route to understanding how clinical guidelines impact providers in the SDM process.Despite our limitations, to our knowledge we offer the first scoping review that explores the relationship between SDM and the management of acute pain in patients with OUD. Using several databases, we were able to pull data relating to physicians in various settings as well as nurses, pharmacists, and other healthcare professionals. We were also able to explore the various components that impact SDM including the individual, clinical guidance, and actual execution of the process.There is an insidious stigma that goes beyond patients and extends to providers with direct patient care, influencing systemic utilities of pharmacies, insurance, housing, and transportation, among others, which creates further barriers for patients with OUD. This creates an additional barrier for those who are actively seeking treatment for OUD. Clinical utilities used during clinical visits have shown usefulness in SDM. Using a risk assessment, a shared decision-making tool, a provider’s checklist, and team engagement have all established guidelines to diagnose, treat, and monitor OUD. Without these tools, meticulous management and record-keeping would not be plausible, leaving room for errors.Increased patient participation is always desired during treatment. Collaboration between the attending doctor and the clinical care team leads to increased communication with the patient, promoting care, and understanding among all parties. Increased pharmacist–physician communication also provides clear education and increases treatment adherence for patients and physicians. Having dedicated addiction, mental health, and pain specialists increases resources and decreases barriers to accessing treatment for patients with OUD. More importantly, access to discharge planning coordination with various providers, including social workers, discharge planning staff, outpatient pain clinicians, and outpatient providers will improve treatment outcomes.


Percutaneous ethanol injection (PEI) is an alternative to surgery for the treatment of thyroid nodules (TNs). However, size reductions of treated (TTNs) and untreated TN (UTNs) have not been compared. Volumetric reductions in TTNs with PEI were evaluated by comparing TTNs and UTNs in the same patient, and independent variables predicting good post-PEI outcomes were analyzed.Overall, 282 patients with multinodular goiters were selected. Two nodules located in different lobes were compared for common disease behaviors. Overall, 150 nodules were selected from 75 patients (6 M: 69 F) with a mean age of 50.1 ± 17.4 years. This prospective nonrandomized intervention study prioritized treating TNs of greater volume or single hyperfunctioning TNs. A single observer experienced in PEI and an ultrasound specialist performed the interventions.TTNs (mean volume: 14.8 ± 16.2 mL) were reduced by 72.6 ± 27.3% of their initial volume, while UTNs increased by a mean of 365.7 ± 1.403.8% (p < 0.00001). The patients underwent a mean of 4.0 ± 3.1 outpatient PEI sessions without relevant complications. Logistic regression analysis showed that the magnitude of the PEI induced reduction was associated with the number of treatment sessions  and not with ultrasonographic characteristics of the nodules. Each PEI session increased the rate of TN reduction by a factor of 6.7.PEI is a well-tolerated outpatient procedure that effectively reduces the volume of TNs and is noticeably superior to conservative treatment for all ultrasonographic classifications. Many studies have reported a high frequency of thyroid nodules (TNs) in autopsies of people without thyroid dysfunction –3. More Benign TNs are managed through observation, leading to good outcomes . SurgicaThis prospective nonrandomized intervention study used convenience sampling and a nonrandomized control group due to ethical considerations. The largest (dominant) or hyperfunctioning nodule was treated to respect this clinical interest.The multinodular goiter patients had a PEI-treated (case) and a PEI-untreated (control) nodule. These were in different lobes to avoid confounding treated and untreated TNs. A volume reduction below 0.7% between sessions represented no reduction .In total, 282 patients were treated using PEI between May 2001 and August 2017, initially at Professor Edgar Santos University Hospital and subsequently at São Rafael Hospital . Of these initial 282, 75 patients with multinodular goiter (two TNs) were selected, totaling 150 nodules evaluated. The inclusion criteria were older than 16 years of age, nodules diagnosed as benign by two puncture aspirations, and no family history of thyroid cancer. Thyroid hormone treatment for the sole purpose of reducing TN volume, a protocol no longer recommended by the American Thyroid Association , when excess thyroid hormone and absent antithyroid antibodies suggested a hyperfunctioning TN. Patients with a heterogeneous pattern on thyroid ultrasound, characteristic of thyroiditis, were excluded to avoid confounding TN and thyroiditis pseudonodules.The patients underwent clinical and laboratory evaluation, including 99mTechnetium-sestamibi thyroid scintigraphy and a radioactive iodine uptake test (provided by The ALOKA SSD 1700 software DYNAVIEW II® Doppler ultrasound scanner with a 7.5-MHz transducer was used for the ultrasonographic study to classify the TNs as follows: 1) solid, 2) predominantly solid with cysts, 3) mixed, when it was not possible to measure cysts dispersed in solid areas, 4) predominantly cystic, and 5) cystic.Both treated (TTNs) and untreated (UTNs) TNs were measured at their largest diameter, and their volume was calculated using height, width, and anteroposterior diameter multiplied by a constant (0.52). Absolute (99.6 GL) and sterile ethanol (v/v)  were added to 10 mL ampoules using 5 mL and 10 mL disposable syringes. The ethanol dose injected percutaneously during each PEI session was not previously defined, as it was based on the level of patient acceptance and specific TN characteristics. In cystic lesions, the volume of ethanol injected was approximately the same as the volume of liquid content aspirated. The procedure was performed by the same professional (Daysi Alcântara-Jones) experienced with this technique since 2001.Vf is the final volume (after treatment) and Vi is the initial volume (before treatment). The degree of TN reduction in the largest diameter was calculated by Mf is the largest diameter of the nodule after PEI and Mi is the largest diameter before PEI. The TNs that grew were registered with negative values to indicate a negative reduction. To understand the relationship between the number of PEI sessions and TN reduction, the variable “number of sessions” was stratified into “one session”, “two to four sessions” and “five sessions or more”.The degree of TN volume reduction was calculated using the equation: 3 or 1.3 cm in its largest diameter; increased consistency, which made ethanol injection difficult; and absence of vascularization in a previously solid TN under treatment. The treatment was also discontinued when the needle was obstructed in solid nodules with calcification foci.The criteria for evaluating completion of treatment were as follows: nodule size smaller than 0.5 cmDemographic data are expressed as the mean, median, and standard deviation. Thyroid-stimulating hormone (TSH) levels were stratified as hyperthyroidism, subclinical hyperthyroidism, and euthyroidism. The normality of the measurement distributions was assessed using the Shapiro-Wilk test. The paired t-test was used to compare the volume, largest diameter, and degree of reduction in TTNs and UTNs, and the Wilcoxon test was used to compare nonparametric variables. The Kruskal-Wallis test was used to assess the degree of TTN reduction by ultrasound classification. The statistical software R version 3.6.3 was used for logistic regression analysis, which assessed which independent variables influenced TN reduction. A p-value < 0.05 was considered significant for all analyses. All volunteers signed the informed consent form after full explanation of the purpose and nature of all procedures used. The authors ensured that research involving human subjects complied with the Declaration of Helsinki, and the study was approved by the Research Ethics Committee (REC) of São Rafael and of Edgard Santos University Hospital  in 2003, which was updated in the Plataforma Brasil database in 2017 (registration number: 2.597.674).L mean ± SD (ng/dL): 1.3 ± 1.0). There were 12 hyperfunctioning TNs: 4 (6.5%) hyperthyroidism and 8 (13.1%) subclinical hyperthyroidism. Ultrasonographic standards of TTNs were as follows: solid: 29 (39.1%), predominantly solid: 12 (16.2%), predominantly cystic: 11 (14.9%), cystic: 9 (12.2%), and mixed: 13 (17.5%). Ultrasonographic standards of UTNs were as follows: solid: 32 (47.0%), predominantly solid: 10 (14.7%), predominantly cystic: 4 (5.9%), cystic: 13 (19.1%), and mixed: 9 (13.2%). There was loss of information on the ultrasound pattern of one TTN and seven UTNs. TTN localization was as follows: right side: 44 (58.7%), left side: 30 (40.0%), and isthmus: 1 (1.3%). UTN localization was as follows: right side: 33 (44.0%), left side: 35 (46.7%), and isthmus: 7 (9.3%).One hundred fifty patients , with ages ranging between 16 and 84 years, participated in the study. No hypothyroidism cases were diagnosed during selection or after treatment (TSH mean ± SD (μIU/mL): 1.3 ± 1.1, T4-12) and similar to the degree of reduction in the largest diameter of TTNs (43.2 ± 28.3 [mean ± SD]) compared to UTNs (-85.4 ± 251.6 [mean ± SD]) . The UTNs, unlike the TTNs, grew during the observation period but developed no clinical signs due to their small size . The percentages of the mean reduction in TTNs distributed by each ultrasound standard are shown in The number of sessions was heterogeneous, ranging from one to eight sessions. The patients underwent 4.0 ± 3.0  PEI sessions, and the duration of treatment was 22.6 ± 27.6  months. No response to treatment was considered when the reduction was <40% of the initial volume . PartialPain in the jaw or tooth homolateral to the nodule being treated was a rare self-reported complaint at the time of the injection, that ceased in seconds. Younger patients often said, “it hurts like a puncture”, referring to puncture aspiration of the thyroid, or “it hurts like a tattoo”. A local burning sensation, discomfort, and eventually facial redness were reported. Sometimes, patients reported feeling nothing in one session and pain in another. They classified pain as grade 6 to 7 on the visual analog scale while smiling. Older patients may have complained of pain from the hyperextended neck position necessary during PEI. A patient who presented dysphonia in a PEI session reestablished her voice one week later.This work compared the degree of reduction in TTNs and UTNs in the same patient, which is considered an ideal comparison model since genetic and environmental patterns were the same for treatment and control. This model to assess this pathology has hitherto not been found in the literature with regard to comparing two usual behaviors in TN monitoring: observation ,12, whicThis study reported that while some UTNs may have grown, there was a statistically significant reduction in TTNs, similar to the percentages previously reported –15. It iSolid TNs developing over a long period often have gross calcification foci that can obstruct the needle during a PEI session. Immediate repuncture is not prudent, and interruption of the session is recommended to avoid ethanol leakage through the initial puncture. This condition can increase the number of total sessions during treatment. Solid TN should be frequently monitored, and early treatment is indicated once it may result in a substantial reduction with fewer PEI sessions, thereby improving PEI outcomes.PEI is recommended as a first-line treatment for cystic nodules . The comThere was a more uniform TN reduction response in relation to the number of sessions  considerThe results of the present study were underestimated because in 42.7% of cases, the treatment was discontinued, not due to technical criteria but for abandonment. Since the strength of the PEI session to reduce TNs has been proven, it is assumed that if the data from the last session were known, the results obtained in this study would be even better.Although solid and mixed TNs require more sessions, their response to PEI has been quite satisfactory ,18,19. IAdditionally, PEI sessions and puncture aspiration have similar costs ,25. PEI A lower cutoff point (currently 4 cm)  for beniIn conclusion, ethanol ablation is a proven method that significantly reduces TN volume and largest diameter both in solid and cystic nodules. It is a well-tolerated procedure, noticeably superior to conservative treatment for all ultrasonographic classifications and can be indicated as a first-line treatment for benign TN.


Low back pain (LBP) is a common musculoskeletal disorder that affects people of all ages. This study investigates the effects of the addition of hands-on procedures to McKenzie exercises on patients with LBP and derangement syndrome.Forty-eight female patients were randomly assigned to either the experimental group or control group. All the patients in both groups underwent McKenzie exercises, transcutaneous electrical nerve stimulation (TENS) and education for 35 min/session–45 min/ session, with three sessions/week for 2 weeks. Hands-on procedures were added to the McKenzie extension exercises only for the patients in the experimental group. A visual analogue scale (VAS), the Oswestry disability index (ODI), back range of motion (BROM) and body diagrams were used to measure pain, functional disability, BROM and the centralisation of symptoms, respectively.P < 0.05), whereas the results of repeated measures ANOVA and Mann-Whitney U tests showed statistically non-significant differences between the two groups (P > 0.05).The mean values of VAS, ODI and BROM significantly improved after the interventions in both groups (The addition of hands-on procedures to McKenzie exercises, TENS and education significantly alleviated back pain and functional disability and improved the back mobility and centralisation of symptoms in patients with LBP and derangement syndrome; however, these measures did not result in any significant additional benefits for such patients. Low back pain (LBP) is a common musculoskeletal disorder that affects people of all ages—almost 80% of people experience it at one point in their lives . It usuaLBP is considered the leading cause of activity restriction and work absenteeism across the world . It is aDerangement syndrome is a disturbance in the normal resting position of the joint surface that causes pain and restricts the mobility of the spine. Most patients who suffer from common mechanical spinal disorders fall under the category of derangement syndrome . This syPhysical therapists play an important role in the assessment and treatment of LBP, such as pain reduction, function improvements and patient education, to avoid or reduce additional pain recurrences . PhysicaManual therapy (MT) has been shown to have beneficial effects at all stages of LBP . The McKHands-on techniques are a combination of selected extension exercises and MT for certain areas of the spine . This maThe McKenzie method is slightly more effective than back school interventions for disability treatment but not for reducing pain intensity . In addihttps://clinicaltrials.gov/ct2/show/NCT03066674All procedures were approved by the Ethics Research Committee of the Institutional Review Board of Imam Abdulrahman bin Faisal University, Saudi Arabia. This study was conducted in accordance with the Declaration of Helsinki at the Rehabilitation Clinic, Anak General Hospital, Ministry of Health, Dammam, Saudi Arabia, between January 2016 and January 2017. All patients signed a consent form. They were informed that the gathered data would be submitted for publication. Clinical trial registration: All patients were randomised to either the experimental group (EG) or the control group (CG). Pieces of paper were numbered and placed in a closed box. Each patient was instructed to pick one piece of paper from the box. Those who picked odd numbers were assigned to the EG, whereas those who picked even numbers were assigned to the CG  Figure .https://www.stat.ubc.ca/~rollin/stats/ssize/n2.html website. The means and standard deviation (SD) of the pain measure ) were reported in a previous study  was applied to all participating patients by the primary investigator over the spinous process of each lumbar vertebra using a small amplitude (Grade I) from the prone position, starting with lumbar five and progressing to lumbar one . This moPain was measured using a visual analogue scale (VAS), which is a reliable measure for measuring the pain caused by musculoskeletal problems. Every patient placed a mark on the line representing their pain intensity level .The percentage of disability in patients with LBP was estimated using the Arabic version of the Oswestry Disability Index (ODI) , 30. Thewhere A is the pre-intervention value and B is the post-intervention value. A positive number indicates improvement, whereas a negative number indicates the opposite .Back range of motion (BROM) was measured using a universal inclinometer . Back forward flexion, extension and right- and left-side flexion were measured from the standing-erect position for every patient. The trunk’s right and left rotations were measured from the sitting position using a standard goniometer whose measurements were proven to be valid and reliable.The locations of the symptoms were recorded on the patients’ body diagrams to determine the extent of the symptoms. This method has been shown to have excellent reliability .Every patient underwent a therapeutic programme with the following components for 35 min/session–45 min/session, with three sessions/week for 2 weeks.Transcutaneous electrical nerve stimulation (TENS) was used as an analgaesic modality for back pain and applied from a prone lying position for 20 min at a frequency of 20 Hz–50 Hz and a wave duration of 50–100. Either two electrodes were placed on each side of the painful area, or two electrodes were placed on the painful area, and the other two electrodes were placed on the path of the radiating nerve . TENS isThe following three exercises were performed by every patient in three sets, with 10 repetitions for 10 min–15 min , 27.Extension in standing: Every patient was asked to lean backwards as far as possible from a well-balanced standing position and to let their head tip back after arching backwards and returning to the neutral standing position.Extension in lying with a partial range: This was done from the prone lying position, with the hands under the shoulders to elevate the trunk, as a push-up exercise.Extension in lying with a full range: This was similar to the previous exercise in the partial range, but the arms were fully extended to achieve the maximum possible tolerated extension range (sustained movement for 1 s–2 s).These are passive CPA procedures conducted over lumber spinous processes. They were applied only to the EG patients while performing the three afore mentioned extension exercises. The target was to improve the standardisation of the examiner’s exerted force according to Maitland grades . Grades Every patient was educated regarding the treatment programme and was given instructions for posture correction for 5 min/ session–10 min/session. The education included basic information about back pain, its causes and guidance for exercises at home  .Each patient received a brochure explaining the home exercise programme .Every CG patient applied all the EG therapeutic interventions except the addition of hands-on procedures while performing back extension exercises.t-test was used to compare the demographic data between the two groups. Repeated measures ANOVA was used to determine significant differences within each group and between groups for normally distributed variables, whereas McNemar and Mann-Whitney U tests were used to determine the significant differences within each group and between both groups for abnormally distributed variables. Statistical significance was set at (P < 0.05) with a confidence interval of 95%.The collected data were analysed using SPSS statistical software (version 25.0). All data were tested for normality using a Shapiro-Wilk’s test. An independent P > 0.05).Of the 90 female patients with LBP and derangement syndrome, 48 (53%) completed this study. The number of patients who had subacute and chronic LBP was 21 (44%) and 27 (56%), respectively. As shown in P < 0.05). The pre- and post-values of the median (interquartile range) for the centralisation of symptoms were 2(0) and 1(P < 0.001 for both). On comparing back pain and functional disability, the results of repeated measures ANOVA show statistically non-significant differences between the EG and CG patients , respectively. Furthermore, the results of Mann-Whitney U test show statistically non-significant differences in the centralisation of symptoms between EG and CG patients .The mean values of pain and the ODI  show staP < 0.05 for both). On comparison, the results of repeated measures ANOVA for back flexion and extension show that there were statistically non-significant differences between the EG and CG patients , respectively. In addition, there were non-statistically significant differences in the back-right and left rotations between the EG and CG patients , respectively.P < 0.05). On comparison of right-side flexion with left-side flexion, there were statistically non-significant differences between the EG and CG patients , respectively.Despite technological advancements in new treatment modalities for LBP, it is still a common musculoskeletal disorder that affects people of all ages. The results of the current study show that the age and gender of patients may contribute to increases in the incidence rate of LBP. These results are supported by Chowdhury et al. , who fouThe current study’s results show that the back pain and functional disability of the patients were alleviated in both groups, and their back mobility and the centralisation of symptoms improved significantly. The achieved percentages of pain reduction were 43.87% and 49.42% for the EG and CG patients, respectively. Both percentages are higher than the clinically important differences in pain reduction (30%) . These fThe ODI scores improved significantly in both groups after the interventions. The percentages of clinical improvement in ODI were 30% and 28% for the EG and CG patients, respectively. ODI score reduction usually represents a reduction in pain intensity parallel with increases in ROM and functional activities  . This isLBP is a serious health problem that imposes a huge burden on society. However, for its treatment, there are simple, low-cost and safe PT procedures, such as CPA spinal mobilisation and McKenzie exercises combined with other non-invasive interventions, such as TENS and education.The BROM, including flexion, extension and rotation to both sides, improved significantly after the interventions in both groups. The increases in back extension ROM in both groups were in agreement with the findings of Shah and Kage , who fouFinally, the results of the current study show that the addition of hands-on procedures to McKenzie exercises did not lead to any significant additional benefits in pain, functional disability, back mobility and the centralisation of symptoms for the EG patients. These results are in accordance with the findings of Goodsell et al.  and PaatContrary to our findings, Choi et al.  and HidaThe percentage of improvement in the centralisation of pain was 71% and 67% for the EG and CG, respectively, which is in good agreement with the clinical observations of McKenzie and May  and DoneThe addition of hands-on procedures to McKenzie exercises, TENS and education significantly alleviated back pain and functional disability and improved back mobility and the centralisation of symptoms in patients with LBP and derangement syndrome. However, it did not result in any significant extra benefits for such patients.As the current study had a small sample size and included only female patients with LBP, its findings are not generalisable. In addition, the short duration of the interventions (only 2 weeks) resulted in the inability to evaluate the long-term effects of the interventions.Further studies are needed to investigate the short- and long-term effects of the addition of hands-on procedures to McKenzie exercises on both genders to generalise the findings of the current study and to analyse the associated psychosocial factors in patients with LBP and derangement syndrome.


To evaluate the correlation between obstructive sleep apnea (OSA) and temporomandibular joint (TMJ) morphology, tooth wear condition, orofacial pain through a follow-up program.n = 23), moderate group (n = 24), and severe group (n = 24). All patients had OSA therapies around six months after confirm the diagnosis of OSA. The tooth wear score and orofacial pain condition of all patients were recorded via clinical examination. Cone beam computed tomography (CBCT) images were also taken when confirm the diagnosis of OSA (T0), 6 months after the diagnosis (T1), and 6 months after the OSA treatment (T2). Parameters indicating the condylar morphology and joint space were evaluated. The differences of clinical symptoms and TMJ conditions among T0, T1 and T2 time point were detected in the three groups respectively. The changes in T1-T0 and T2-T1 of all descriptions among three groups were also compared. The correlations between AHI and clinical symptoms were detected with Spearman correlation analysis.Seventy one OSA patients were divided into three groups according to their (apnea hypopnea index) AHI: mild group (P < 0.05). From T0 to T1, mild group displayed fewer decreases in the condylar volume and superficial area and fewer increases in wear score than that in moderate and severe group (P < 0.05). From T1 to T2, there was a greatest reduction in severe group for R value, and significant difference in the description of VAS and R value were found among the three groups. AHI was negatively correlated condylar volume and condylar superficial area, and was positively correlated with tooth wear score and VAS (P < 0.05).In mild group, there was no difference in all clinical symptoms and TMJ morphology among the three time points. Both in moderate and severe group, the condylar volume, superficial area, wear score, visual analogue scales (VAS), and R value (indicating condyle position) displayed significant differences among the three time points (Moderate to severe OSA will aggravate orofacial pain and tooth wear, affect TMJ volume and superficial area, even change the location of condyles. Appropriate OSA therapies may be effective ways to alleviate these adverse effects in long-term. Obstructive sleep apnea (OSA), affecting 9%—49% of the general population , is charIn addition to OSA, the disease sleep bruxism, orofacial pain and temporomandibular disorders (TMD) are also common in stomatological department , 11. TMDClinically, patients are usually diagnosed with two or more with above diseases, but clinicians sometimes take stopgap measures for them, such as one single elastic dental pad, physiotherapy, surgery, acupuncture, etc. In other word, such patients often fail to obtain standardized, comprehensive and complete treatment due to the single department they visited. There are problems in the outpatient clinic such as unclear treatment procedures and lack of standardized treatment system, which can only be solved through interdisciplinary diagnosis and sequence therapies.Interestingly, these diseases in fact interact with one another and reinforce one another. According to a recent investigation, chronic TMD patients had markedly impaired sleep quality than healthy controls . The preIn order to carry out the interdisciplinary evaluation and comprehensive treatment for these diseases, understanding the association between OSA and TMD, bruxism, orofacial pain is very important, which would help provide references with new treatment options, would also help prevent and treat possible complications of OSA. However, limited study focused on the four diseases simultaneously, and such associations need further investigation and scientific evidence. The aim of this study is to explore whether OSA will affect sleep bruxism, orofacial pain and TMJ morphology, to explore if considerable OSA therapies have benefit in alleviating bruxism, orofacial pain and TMD symptoms, providing references for clinical practitioners. The null hypothesis is that no association would be found between OSA and TMD, bruxism, orofacial pain.This retrospective study included the data from 122 consecutive adults  with OSA who received treatment from 2019 to 2023 at Ningbo Stomatological Hospital and Xiangya Stomatological Hospital, and the study was done at the Xiangya Stomatological Hospital of Central South University.Subjects were selected according to the following criteria: (1) 25 to 45-year-old adults who complain of snoring or feel suffocated while sleeping, (2) meeting the diagnostic criteria for OSA  by polysn = 23, aged 35.8 ± 3.2 years, 5 ≤ AHI < 15, AHI mean value = 11.1 ± 2.0, (2) moderate group: n = 24, aged 36.5 ± 3.6 years, 15 ≤ AHI < 30, AHI mean value = 22.4 ± 4.9 (3) severe group: n = 24, aged 36.9 ± 3.3 years, AHI ≥ 30, AHI mean value = 52.8 ± 6.7.Fifty-one subjects were excluded because of various reasons. 24 subjects treated their OSA less than 6 months from the diagnosis because of severe symptoms, the importance they attaching to the disease, and so on. 10 cases had not been treated since the diagnosis. 5 follow-up cases were lost 6 months after the OSA treatment. 7 cases relapsed 6 months after the treatment, and 5 subjects did not take CBCT scans when confirm the diagnosis of OSA, 6 months after the diagnosis, or 6 months after the OSA treatment under consistent shooting condition. Eventually, 71 subjects  who fulfilled the inclusion criteria were enrolled in the study  ventilation, loss weight , tonsillectomy and/or adenoidectomy, uvulo-palato-pharyngoplasty (UPPP), genioglossus advancement with hyoid suspension (GAHM), and orthognathic surgery. The type of OSA treatment chosen not only depended on the severity of OSA, but also need comprehensive consideration of patients' economic capacity, subjective wishes and tolerance to surgery. For instance, although CPAP is not standard procedure for mild OSA, it is one of treatment methods with quick return and low cost for the mild patients who had typical clinical symptoms. Specific treatment methods and efficiency of study groups are shown in Table T0), 6 months after the diagnosis (T1), and 6 months after the OSA treatment (T2). The subjects enrolled in our study didn’t receive the treatment within 6 months after confirm the diagnosis of OSA on account of neglect, busy job, procrastination, and expensive surgery, et al. Clinical data of 6 months after diagnosis and 6 months after OSA therapies were obtained through follow-up.The clinical data including CBCT scans, intraoral slides, and visual analogue scales (VAS) were obtained at three different periods: confirm the diagnosis of OSA  . AnterioT0, T1, and T2 of all subjects  of all patients were accessed with the teeth in centric occlusion at the end of swallowing to make an exact diagnosis and acquire the information of the morphology of TMJs, which were calibrated and obtained by the same observer.CBCTs of the three periods including Descriptions on CBCTs were designed to measure the width, length, height, volume, and superficial area of condyles, as well as the joint space and position. All of the descriptions were measured in Mimics 21.0 software . Head positions were standardized in CBCT according to the horizontal plane, positioned passing through the superior border of the external acoustic meatus and the inferior border of the infraorbital margin of both sides, and the sagittal plane, positioned passing through the anterior nasal spine, the internasal suture and the glabella. Detailed definition of condylar width, length, height, and joint space are shown in Table Approaches for assessing bruxism in this study include non-instrumental and instrumental. Self- reported assessment of sleep bruxism continues is one primary tool in this research . The patTooth wear was scored with a 5-point ordinal scale reported by Lobbezoo : 0 = no To reduce random errors, serial numbers were assigned at random to each participant. All teeth of the first and third quadrants were examined in participants whose serial number was odd, while the second and fourth quadrants were examined in participants with an even serial number . Wisdom Approaches for orofacial pain in this study include patient’s pain complaint and clinical examination. The clinical tests include pain with opening jaw movements and palpation under the palpation pressure with 1 kg for 2 s. The examination included joint  and masticatory muscle  palpation. The pain of temporalis, masseter, posterior mandibular region, submandibular region, lateral pterygoid area, and temporalis tendon were recorded, which replicated the patient's pain complaint .Patient’s pain complaint was quantified by VAS, which was used for subjective evaluation of the degree of orofacial pain, including masticatory and joint area  Fig. . The symT0, T1 and T2time points and among mild, moderate and severe groups. Correlations between AHI value and the clinical symptoms were assessed by Rho Spearman correlation analysis, and statistical significance was established at α = 0.05. To assess the reliability of these measurements, 30 subjects were randomly chosen. All measures were duplicated by the investigator R.N. An intraclass correlation coefficient (ICC) was used to determine the intra-observer reliability of the measurements through reliability analysis in SPSS. Reliability was divided into three categories: poor (ICC < 0.40), fair to good (0.40 ≤ ICC ≤ 0.75), and excellent (ICC > 0.75) [All data were analyzed by IBM SPSS Statistics 21 software. One- and two-way analysis of variance (ANOVA) with Tukey tests was used to detect descriptions changes among  > 0.75) .The intra-observer reliability of the measurements of all descriptions using SPSS software was from fair to good to excellent, with ICC’s ranging from 0.673 to 0.916.There were no significant differences in the age, type of OSA therapies and the interval of taking CBCTs among these three groups. However, gender and BMI of the study groups were significantly different. Severe group had the most percentage of male and fewest female, as well as the highest BMI index (30.6 ± 3.7). On the contrary, moderate group had the most percentage of female and fewest male, as well as the lowest BMI index (24.7 ± 3.5).P < 0.05). After OSA treatment, the AHI values of all cases enrolled in this study were under 5, and the mean value were 1.2 ± 0.4 in mild group, 1.3 ± 0.5 in moderate group, 4.7 ± 1.3 in severe group. In addition, the ODI values were under 3 with the mean value of 1.0 ± 0.2 in mild group, 1.1 ± 0.3 in moderate group, 3.0 ± 1.2 in severe group. Before OSA treatment, both mean and lowest SpO2 decreased from mild group to severe group (P < 0.05). After OSA treatment, the three groups all had favourable mean and lowest SpO2.Before OSA treatment, AHI and ODI increased gradually from mild group to severe group and the lowest cases with home bruxism (29.2%).T0 to T1 , and no difference was found between T1 to T2. Wear score showed an increasing trend from T0 to T1 , and no difference was found between T1 to T2. VAS value showed an increasing trend from T0 to T1 , a decreasing trend T1 to T2 .In mild group, there was no difference in teeth wear, orofacial pain, and TMJ morphology among the three time points. The severe group had the largest wear score and VAS value, and smallest condylar volume and superficial area. Both in moderate and severe group, the ANOVA and Tukey LSD analysis indicated that condylar volume, superficial area, wear score, VAS value, and R value showed statistically significant differences among the three time points Table . In bothT0 to T1, the amount of condylar volume and superficial area decreased in moderate and severe groups were significantly greater than that in mild group, and the amount of wear score and VAS value increased in moderate and severe groups were significantly greater than that in mild group. Besides there was no change for R value in three groups. From T1 to T2, R value increased in the moderate group (3.6 ± 2.8) and the severe group (10.4 ± 3.3), and significant difference in its changes was found between the mild group and the severe group (P = 0.001), between mild group and the moderate group(P = 0.025), as well as between the moderate group and the severe group (P = 0.002). Significant difference in the changes of VAS value was also observed among the three groups .From P = 0.013, 0.002). In addition, AHI value was positively correlated with tooth wear score and VAS value . The remaining descriptions was not statistically significant.Spearman correlation analysis displayed that AHI value was negatively correlated condylar volume and condylar superficial area (Rho Spearman = -0.34, -0.37; With the transformation of the traditional medical model to the bio-psycho-social medical model, the goal of oral disease treatment is to restore the morphology and function of the oromaxillofacial region to the best on the basis of multidisciplinary cooperation. Clinicians ought to provide patients with a suitable bite, to help them regain favorable chewing, swallowing, pronunciation and respiratory functions, while maintaining the continuous stability of the efficacy. OSA, TMD, bruxism, and orofacial pain are multidisciplinary and sometimes they may appear concomitantly without standardized, comprehensive and complete treatment. In order to explore comprehensive treatment for these diseases, understanding the association between OSA and TMD, bruxism, orofacial pain can help a lot, which would help provide references with new treatment options, or even prevent and treat possible complications of OSA.The pathogenesis of sleep bruxism has not been fully clarified, which is related to emotional stress, anxiety disorders, OSA, consumption of certain groups of drugs, tobacco, alcohol, or coffee, and so on . Long-teOne of the hypotheses connecting sleep bruxism and OSA is that bruxism at night plays a protective role against OSA by protruding the jaw and restoring upper airway patency , 45. TheChronic widespread pain with psychologic factors, increasing age, and female gender are risk factors for chronic orofacial pain , 49. OroA famous hypotheses connecting sleep pain and OSA is that sleep deprivation and recurring nocturnal hypoxemia in OSA individuals during sleep would enhance pain sensitivity, promote inflammation, and increase spontaneous pain –53, woulMain symptoms of TMD are pain, joint friction, irregular or limited mandibular function. The current mainstream non-surgical therapies of TMD include hard occlusal splint therapy, counselling, exercises, massage, manual therapy, and so on. Psychosocial factors, immunity, occupational strain, TMJ overload and its anatomical factors are recognized as important risk factors of TMD among adults . FurtherGender plays a controversial role in the occurrence and development of TMD. Although it is now generally accepted that TMD and orofacial pain are more common in female, several researches were inconsistent with such consensus. Razi et al. reported there was no significant relationship between condyle morphology and gender . GörürgöWe analyze that bruxism may be related in TMD occurrence and development. It is possible that in people with OSA, apnea and hypopnea resulted from the airway collapses and obstructs will produce an abnormal muscle environment and varying degrees of neuromuscular dysfunction. TMJ is subjected to abnormal stress and pulling force that is different from that of normal people under such neuromuscular dysfunction. By this time the fragile condyle, condylar neck, and joint disc may shift, finally leading to TMJ injury. Diatchenko  indicateThere are certain limitations of this follow-up analysis. Not every subject has been recorded with RMMAs during PSG examination, and no other bruxism instrumental method was performed. Only self-reported assessment was used in the study is a limitation; Gender and BMI have statistic differences in the three groups. Although we believe the impact of this point is small enough, whether the results dependent on gender and BMI will be investigated in our next study. However, despite causality couldn’t be inferred from observational data alone, the findings from this research could imply that OSA contributes to the onset of sleep bruxism and orofacial pain to some extent, which could still provide important clinical references.OSA, orofacial pain, sleep bruxism and TMD has become more common and problematic among the general individuals. The complexity of pathogenesis and anatomy at the orofacial region contributes to challenging diagnosis, differential diagnosis and treatment for clinicians. A better understanding of underlying physiological mechanisms on the associations among OSA, orofacial pain, sleep bruxism and TMD may help clinicians do differential diagnosis and provide them with new options of therapies.As there is no consensus on the treatment protocol for TMD, bruxism, and orofacial pain with OSA, it has not been definitively guided which disease should be treated first when two or more of these symptoms occur at the same time. In this context, clinicians need to consider bruxism, orofacial pain and TMD as clinical predictors for OSA, and ought to consider not only symptoms of bruxism, TMD and orofacial pain, but also OSA. Because OSA may influence mandibular function and cause the presence of secondary orofacial pain, bruxism and TMD. For example, clinicians can implement a sleep quality investigation for the patient to confirm if there is any secondary symptom, and the treatment of OSA may relief the clinical consequences of bruxism, orofacial pain or TMD if so. This strategy is not an overall solution to all situation, but a series of comprehensive one. In our opinion, it is more systematic than the specific but limited therapy.For a better management of patients with OSA, chronic orofacial pain, TMD or bruxism, comprehensive understanding of the correlative mechanism among these different conditions would be helpful. Interdisciplinary treatment including physicians, dentists and otolaryngologists is also very essential.Moderate to severe OSA is a risk factor for orofacial pain, sleep bruxism and condylar absorption, which affect condylar volume and superficial area. Appropriate OSA therapies may be effective ways to relieve orofacial pain, reduce tooth grinding at night, and prevent condylar absorption in the long run.


P = 0.001] and LFCN injury  were associated with postoperative dissatisfaction. LFCN injury and the postoperative VAS score for pain independently impacted postoperative dissatisfaction at 1 year after CPO.This study aimed to evaluate clinical outcomes based on patient-reported outcome measures and to analyze factors influencing patient dissatisfaction at 1 year after curved periacetabular osteotomy (CPO). This retrospective review involved 98 hips of 98 consecutive patients with symptomatic acetabular dysplasia who underwent CPO from March 2016 to June 2020. The clinical outcomes were evaluated based on the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, the Medical Outcomes Study 36-Item Short-Form Health Survey and the Harris Hip Score. Patients were divided into satisfied and unsatisfied groups according to the 85th percentile cut-off on the postoperative visual analog scale (VAS) for dissatisfaction. A multiple logistic regression analysis was performed to investigate the factors impacting patient dissatisfaction after CPO; the explanatory variables were age, body mass index, postoperative Tönnis grade of ≥2, postoperative VAS score for pain, lateral femoral cutaneous nerve (LFCN) injury and radiographic complications . The 85th percentile of the postoperative VAS score for dissatisfaction was 60 mm. The unsatisfied group comprised 15 patients at 1 year after CPO. The multiple logistic regression analysis results showed that the postoperative VAS scores for pain [odds ratio (OR), 1.064; 95% confidence interval (CI), 1.026–1.104;  Acetabular dysplasia of the hip is a cause of hip osteoarthritis . PeriacePatient satisfaction and patient’s quality of life have been the focus of more recent investigations, and patient-reported outcome measures (PROMs) have been used to indicate treatment outcomes. Increasing numbers of reports are using PROMs, and good results have been reported after PAO . A previThis study was approved by our institutional review board . We retrospectively evaluated 119 hips of 110 consecutive patients who underwent PAO for the treatment of symptomatic dysplastic hips from March 2016 to June 2020. The exclusion criteria were as follows: (i) the second operated side of patients who underwent bilateral CPO within the research period; (ii) the first operated side of patients who underwent contralateral CPO within 1 year of the initial PAO; (iii) a history of trauma or surgery (i.e. hip arthroscopy) of the hip on the operative side; (iv) cerebral palsy and (v) loss to follow-up.et al. [At our institution, CPO  has beenet al. . Indicatet al.  of <25° l-lactic acid screws without an iliac bone graft. The osteotomized ASIS was then repositioned and fixed with two titanium cannulated cancellous screws (An anterior incision was made from the anterior superior iliac spine (ASIS) and extended distally for ∼8 cm along the tensor fasciae latae muscle. The ASIS was osteotomized with the inguinal ligament, and the remaining sartorius muscle was attached and retracted medially. The iliopsoas muscle was partially detached around the inner table of the pelvis and retracted medially with the femoral artery, vein and nerve. A C-shaped osteotomy line was started proximal to the anterior inferior iliac spine and ended at the distal part of the quadrilateral surface. The ischium was osteotomized using image intensifier guidance. Osteotomy of the superior ramus of the pubis was performed just medial to the iliopubic eminence. The acetabular fragment was rotated laterally to make the weight-bearing area horizontal and fixed with three poly-s screws .Active motion exercises were started on the first postoperative day. Partial weight-bearing was started at 10 kg on the second postoperative day for patients treated before June 2017. Partial weight-bearing was started at 20 kg in the second postoperative week for patients treated after June 2017. Weight-bearing was increased by 10 kg every 2 weeks in both periods. This rehabilitation protocol was revised during the study period to prevent postoperative fracture at the posterior column. Full weight-bearing was allowed at 2–3 months postoperatively, and a return to heavy work and sports activities was allowed at 6 months postoperatively.A clinical assessment based on the HHS, the JHEQ and the SF-36 was conducted preoperatively and at 1 year after PAO. The HHS (except the range of motion and deformation) had a total of 91 points, including 44 points for pain items and 47 points for function items. The JHEQ evaluates three categories using an 84-point scale: pain, motion and mental health with 7 items each, for a total of 21 items. The JHEQ also includes a visual analog scale (VAS) score for dissatisfaction and pain. Patients were divided into two groups: satisfied group and unsatisfied group according to 85th percentile cut-off on the postoperative VAS score for dissatisfaction. The SF-36 is a set of generic, coherent and easily administered measures of the quality of life. We used summary scores including the physical component score (PCS), mental component score and role component score . FurtherAP radiographs were assessed at preoperatively and 1 year postoperatively. AP radiographs were taken in the supine position and standardized by a tube-to-film distance of 120 cm, and the tube was oriented perpendicularly to the table. In addition, the central beam was directed toward the midpoint between the upper border of the symphysis and a horizontal line connecting the ASIS. Radiographically, acetabular dysplasia is defined as an LCEA of <25° . The Tönt-tests or the Wilcoxon signed-rank test. The Mann–Whitney U test was used to compare patients’ characteristics, clinical scores and radiographic data between the unsatisfied and satisfied groups. Pearson’s correlation coefficient was used to calculate the correlation between the postoperative VAS score for dissatisfaction and clinical evaluation findings. The minimal clinically important difference was calculated as 1/2 SD (baseline) according to the method of Norman et al. [P-value of <0.05 was considered statistically significant.The Tönnis grade was divided into categories and treated as a categorical variable. The chi-square test was used to compare categorical data such as sex, complications and the Tönnis grade. Comparisons between preoperative and postoperative values were tested using the paired-samples n et al. . Multipl2 , and the mean follow-up period was 12.4 months . All patients complained of hip pain at rest and during activity. According to the Tönnis grade, 79 hips were classified as Grade 1, 16 hips were classified as Grade 2 and 3 hips were classified as Grade 3. The original and revised rehabilitation protocols were used on 28 and 70 hips, respectively.For nine patients who underwent bilateral CPO within the research period, the second operated side (nine hips) was excluded. Furthermore, for four patients who underwent contralateral CPO within 1 year of the initial CPO, the first operated side (four hips) was excluded. One patient with cerebral palsy was excluded because this patient did not have classic dysplasia. Among the remaining 105 hips, 7 hips of 7 patients were lost to follow-up; 2 of whom moved to another prefecture, 1 of whom studied abroad, 1 of whom was admitted to another hospital for another disease and 3 of whom did not visit our institution during the study period. Finally, 98 hips of 98 patients were included. The follow-up rate was 93.3% (98/105) . No patiP < 0.001). The PCS and role component score of the SF-36 significantly improved from 34.4 to 45.6 points (P < 0.001) and from 42.9 to 49.3 points (P < 0.001), respectively. The mean HHS improved from 65.9 to 84.3 points (P < 0.001). The mean postoperative VAS score for dissatisfaction was 26.5 ± 24.7 mm . The 85th percentile of the postoperative VAS score for dissatisfaction was 60 mm.The preoperative and postoperative radiographic data and clinical evaluations are presented in l-lactic acid screw breakage. The incidence of posterior column fracture was 21.4% (6/28 hips) with the original protocol and 2.9% (2/70 hips) with the revised protocol. Of the six hips that demonstrated posterior column fracture with the original protocol, one case was revealed on CT 8 months after surgery due to hip pain. The other five cases with the original protocol and two cases with the revised protocol were all revealed on CT at 7 days postoperatively. The incidence of non-union of the ischium after posterior column fracture was 7.1% (7/98 hips), and the incidence of pubic non-union was 15.3% (15/98 hips). The incidence of ischial ramus stress fracture was 10.2% (10/98 hips). Delayed union was confirmed in two hips in the satisfied group at 1 year after PAO, but bone union was confirmed in the other eight hips. LFCN injury was observed in 35 of 98 (35.7%) patients at 1 year postoperatively.No patients developed surgical site infection, non-union of the ilium osteotomy site or poly-r = − 0.494, P < 0.001, and r = − 0.420, P < 0.001, respectively) and a very strong positive correlation between the postoperative VAS score for dissatisfaction and the postoperative VAS score for pain   were associated with postoperative dissatisfaction. The Hosmer–Lemeshow test showed adequate fitness , and the omnibus tests of model coefficients also showed that the model made sense overall  (There were no significant differences in any patient characteristics (age and BMI) or follow-up periods between the unsatisfied group and satisfied group . There w< 0.001) . The mul= 0.002) .This study based on PROMs showed improvements in pain, function, mental health and satisfaction. This result is similar to the results of other studies based on PROMs , 9, 10. LFCN injury and the postoperative VAS score for pain independently impacted postoperative dissatisfaction. Previous studies have shown that the incidence of LFCN injury after anterior-approach PAO was 65–74% at ∼2 weeks postoperatively, 48% at 1 year postoperatively and 30% at 7.4 years postoperatively , 24, 25.In this study, we were able to investigate the degree of postoperative pain using VAS scores, but we were not able to investigate the cause of pain in detail. The causes of pain after PAO include non-union of the ischium after posterior column fracture, non-union of the osteotomy site, stress fracture, progression of osteoarthritis, femoroacetabular impingement and muscle–tendon pain around the hip joint . The numThe present study has several limitations that should be noted. First, the level of evidence in this retrospective, single-center study is insufficient compared with prospective, multicenter studies. Second, the number of male patients was small because of the nature of the disease. Third, this study was designed based on a 1-year follow-up period, as a 1-year evaluation after surgery may be meaningful even for performing the longer-period follow-up study. The factors that impact patient satisfaction may change over time, and further research on medium- to-long-term outcomes would be useful. Finally, we did not investigate whether any treatment was given for postoperative pain. However, none of the patients underwent reoperation for postoperative pain within 1 year after CPO.This study based on PROMs showed that CPO was a satisfactory surgery that improved pain, motion and mental health. In contrast, LFCN injury and the postoperative VAS score for pain independently impacted postoperative dissatisfaction. These results suggest the importance of avoiding LFCN injury, posterior column fracture and pubic non-union, which cause postoperative pain, to improve patient satisfaction.