Posterior Endoscopic Cervical Decompression in Metastatic Cervical Spine Tumors: An Alternative to Palliative Surgery.

Metastatic spinal cord compression of the cervical spine is a well-known consequence of cancer that generally manifests as an oncological emergency. This study presents and describes an alternative to the minimally invasive posterior full-endoscopic approach for direct decompression and tumor debulking from the metastasis of hepatocellular carcinoma (HCC) in the cervical spine. A 54-year-old man presented with progressive cervical radiculopathy that had persisted for 3 months. The underlying disease was HCC. Radiographic examination revealed evidence of metastatic spinal cord compression with an epidural mass at the C4-C5 levels, which compressed the C4-C5 spinal cord without bony destruction. The modified Tomita score was 6 to 8 points based on palliative surgery. A posterior full-endoscopic approach to remove the tumor from the metastasis of HCC in the cervical spine was done. A postoperative radiographic study revealed adequate tumor mass resection and spinal decompression. The patient was extremely satisfied with this alternative treatment and achieved complete neurologic recovery at 1 month and no recurrent symptoms at the 6-month follow-up. The technique of posterior full-endoscopic decompression of cervical metastasis causing unilateral radiculopathy, presented in this study, is feasible. This surgical intervention seems to be optional minimally invasive and acts as an alternative to palliative surgery.

Does the intramedullary femoral canal plug reduce blood loss during total knee arthroplasty?

INTRODUCTION: The benefit of the femoral canal bone plug during total knee arthroplasty (TKA) in reducing blood loss has never been proven. The aim of this meta-analysis was to determine whether the femoral canal bone plug significantly reduces blood loss in primary TKA. METHOD: All studies published before December 2021 were searched. The inclusion criteria were randomized controlled trials comparing blood loss between TKA with plugged and unplugged femoral intramedullary canal, respectively. The primary outcome was postoperative hemoglobin reduction. RESULTS: Five studies with a total of 717 patients (361 in the plugged group, 356 in the unplugged group) met the criteria for inclusion in the meta-analysis. The mean difference in hemoglobin level between the two groups was 0.92 g/dL, with significantly less hemoglobin reduction in the plugged group (95% confidence interval [CI] - 1.64 to - 0.21, p = 0.01). The patients in the plugged group also had a significantly lower risk of receiving a blood transfusion (risk ratio 0.58, 95% CI 0.47-0.73, p < 0.00001). CONCLUSIONS: This meta-analysis demonstrates that using a femoral canal bone plug can significantly reduce blood loss and lower the risk ratio of blood transfusion in patients undergoing TKA.

Low urine output during the first twenty-four hours after total knee arthroplasty.

BACKGROUND: Low urine output (LUO) for six hours is defined as the stage that is at risk of acute renal failure. Major surgeries with a bloodless field, such as total knee arthroplasty (TKA), may be associated with LUO; however; there has been no study addressing this point. The present study evaluated the incidence of LUO and the effect of fluid balance on LUO in TKA patients during the first 24 hours after surgery. MATERIAL AND METHOD: The authors retrospectively evaluated 257 uncomplicated patients undergoing unilateral TKA during the first 24 hours after surgery. Patients' demographic data, intra-operative intravenous (IV) fluid replacement, postoperative IV fluid replacement, oral fluid intake, total fluid intake, postoperative urine output, blood collected from the drain, and the total visible fluid output during the first 24 hours after surgery were collected and evaluated. RESULTS: The incidence of LUO was 19.1% (49/257) in the studied group. There were no significant differences in patients' demographic data between the LUO and normal urine output (NUO) groups. Comparing the LUO and NUO groups, the LUO group had a lower volume of intra-operative fluid replacement, with statistical significance. There were no differences in postoperative IV fluid replacement and postoperative oral fluid intake between groups. Although 80.5% of the studied group had LV fluid replacement at a less than ideal level, at discharge there was no patient suffering from renal complications related to LUO. DISCUSSION AND CONCLUSION: Urine output is one of the common monitoring parameters of fluid balance in the perioperative period; it should be ≥ 0.5 mL/kg/h. Prolonged low urine output for six hours and for 12 hours are categorized as causing risk and injury to the kidney, respectively. The incidence of LUO at our institution during the first 24 hours after TKA is not uncommon and is significantly related to intra-operative fluid replacement. Fortunately, all LUO patients had further fluid replacement, resulting in no renal complications at discharge. As eighty percent of patients had less than ideal fluid replacement, and patients having LUO during the first 24 hours had a significantly lower volume of intra-operative fluid replacement, the authors propose reconsidering perioperative fluid replacement in TKA patients, especially intra-operative IV fluid to avoid LUO.

Prospective randomized trial comparing the efficacy of single 6-ml injection of hylan G-F 20 and hyaluronic acid for primary knee arthritis: a preliminary study.

OBJECTIVE: To compare the efficacy of single 6-ml intraarticular injection between hylan G-F 20 and hyaluronic acid (HA) for knee osteoarthritis. MATERIAL AND METHOD: Thirty-two patients with primary knee arthritis, who were randomly received single intraarticular injection of 6-ml hylan G-F 20 (Synvisc) or HA (Hyalgan), were prospectively evaluated for clinical outcomes at a minimum 26-week follow-up. The parameters, including visual analog scale (VAS) during walking, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and Short-Form 36 (SF-36) questionnaires, were evaluated at pre-injection, then at 1 week, 4 weeks, 8 weeks, 12 weeks and 26 weeks, post-injection. RESULTS: There were 15 patients in both groups who were available for final follow-up with no statistical differences in demographic data, VAS during walking, WOMAC score and SF-36 score at pre-injection. There was no adverse event related to viscosupplementation using in is better than of both agents. At 26-week follow-up, patients in both groups had significantly improved VAS during walking (p < 0.01), WOMAC score (p < 0.01) and SF-36 (p < 0.05) with no statistical differences between groups. However the cost of hylan G-F 20 was much more expensive than that of HA (534 USD vs. 252 USD). CONCLUSION: A single intraarticular injection of both hylan G-F 20 and HA for primary knee arthritis had no adverse event related to 6-ml volume. At 26-week follow-up of the present preliminary study, both groups had similarly improved clinical outcomes post-injection. Further study in larger population is required. As the cost of hylan G-F 20 was 2 times higher than HA, a single 6-ml intraarticular injection of HA (Hyalgan) provided better cost-effectiveness than hylan G-F 20 (Synvisc).

Contemporary pain management in total knee arthroplasty.

Pain management has become a very important part of postoperative care for total knee arthroplasty patients. Contemporary pain control has evolved from high-dose opioid in the past to state-of-the-art multimodal regimens. These include multiple non-opioid medication such as NSAIDs, COX-2 inhibitors, and gabapentinoid, and novel anesthetic techniques such as preemptive analgesia and ultrasound-guided peripheral nerve blocks. Another method which is gaining popularity is intraarticular injection of anesthetic cocktail during surgery. Pre-op education can also help patients cope with their pain better.