Review of Ultrasound-Guided Procedures in the Management of Chronic Pain.

This article summarizes clinical expert recommendations and findings for the application of ultrasound-guided procedures in chronic pain management. Data on analgesic outcomes and adverse effects were collected and analyzed and are reported in this narrative review. Ultrasound guidance offers opportunities for the treatment of pain, with focus in this article on greater occipital nerve, trigeminal nerves, sphenopalatine ganglion, stellate ganglion, suprascapular nerve, median nerve, radial nerve, ulnar nerve, transverse abdominal plane block, quadratus lumborum, rectus sheath, anterior cutaneous abdominal nerves, pectoralis and serratus plane, erector spinae plane, illioinguinal/iliohypogastric/genitofemoral nerve, lateral femoral cutaneous nerve, genicular nerve, and foot and ankle nerves.

Scaphoid Malunion: Incidence, Predictors, and Outcomes.

Background Scaphoid malunion is rarely reported. Previous literature has attributed loss of carpal height and degenerative changes to scaphoid malunion, but the percentage of asymptomatic malunions remains unknown. Purpose The authors of this study aim to define predictors of malunion and outcomes associated with scaphoid malunion. Methods Institutional board review was obtained prior to evaluating medical records of patients 18 years and older who were treated for scaphoid fractures and/or nonunion between 2000 and 2020. The following data were collected for each patient: age, gender, fracture location, surgical technique, time to union, and whether malunion resulted. Malunion was defined using a lateral intrascaphoid angle (LISA) >45 degrees and height-to-length ratio (HLR) >60. Pain scores, range of motion (ROM), and secondary surgery were also evaluated. Results Overall, 355 scaphoid injuries, including 196 acute fractures and 159 nonunions, were evaluated in this analysis. Of these, 55 scaphoids (15%) met the definition of malunion. Of these patients, 23% were female. The mean age at the time of injury was 29 years. Nonunion cases were more likely than acute cases to be associated with malunion. Proximal pole fractures were more likely to associated with malunion than waist fractures. When controlling for nonunion and fracture location, malunited scaphoids were not associated with any significant difference in pain score, ROM, or secondary surgery, compared with nonmalunion cases. A total of 10 patients (3.3%) without malunion and 2 patients (3.6%) with malunion went on to a secondary surgery. Final extension/flexion was 67/67 degrees and 56/59 degrees in nonmalunion and malunion groups, respectively, but these differences were not significant. Conclusion Compared with scaphoid injuries that do not result in malunion, scaphoid injuries that heal into malunion have similar outcomes. While scaphoid malunion in a single case or series may be associated with poor outcomes, this study suggests that scaphoid malunions do not have worse functional outcomes. Level of Evidence This is a Level IV study.

Pill Ingestion and Caustic Laryngeal Injury.

OBJECTIVE: To highlight an unusual mechanism of laryngeal injury. METHODS: Case report and literature review. RESULTS: A 66-year-old male ingested an over-the-counter preparation of bile acids as a dietary supplement. The capsule lodged in the patient's pharynx, and he sustained a caustic injury to the supraglottic and glottic larynx. His injury was managed conservatively, and his symptoms gradually resolved over a period of 8 weeks. A follow-up laryngoscopy at 8 weeks and 6 months showed no signs of injury. A barium swallow at 8 weeks was normal at that time and videostroboscopy results normalized with resolution of the injury as well. CONCLUSIONS: Caustic injury to the upper aerodigestive tract from pill ingestion is uncommon, and laryngeal injury even less so. Urgent evaluation should be undertaken, and appropriate therapies instituted promptly. Laryngeal injury can respond to conservative therapy, but there is a lack of clinical information to evaluate optimum treatment of this unusual injury.

Drilling the cement mantle in well-fixed periprosthetic femur fractures is not associated with arthroplasty-related complications.

OBJECTIVE: To determine if screw fixation across a cement mantle is safe and effective during plate fixation of well-fixed periprosthetic femur fractures. DESIGN: Retrospective cohort study. SETTING: Academic Level I Trauma Center. PATIENTS: Twenty-eight patients with AO/OTA 32A[B1] or 32A[C] periprosthetic femur fractures treated with open reduction and internal plate and screw fixation after cemented or uncemented hip arthroplasty. INTERVENTION: Screw placement into the cement mantle during internal fixation. OUTCOME MEASUREMENTS: Primary outcome was revision arthroplasty for aseptic loosening. Secondary outcomes included radiographic evidence of aseptic loosening, infection, nonunion, implant failure, and overall reoperation rate. RESULTS: There were 28 patients who met inclusion criteria. A total of 9 patients had screws placed in the cement mantle while the remaining 19 patients had screws placed around an uncemented stem. At a mean of 3.7-year follow-up, there were no cases of revision arthroplasty or aseptic loosening in either group. There were no significant differences in rates of infection, nonunion, implant failure, or reoperation rate between patients who had screw placement into a cement mantle vs around an uncemented stem. CONCLUSION: Drilling into the cement mantle during fixation of a periprosthetic femur fracture around a well-fixed cemented hip stem appears safe and effective. When possible, surgeons can consider bicortical screws around a cemented stem, given the biomechanical advantages over unicortical screw or cerclage fixation. Larger prospective trials confirming the safety of this technique are warranted prior to routine implementation. LEVEL OF EVIDENCE: III.

Association of Severe Obesity and Chronic Obstructive Pulmonary Disease With Pneumonia Following Non-Cardiac Surgery.

Background: Pneumonia is the third most common surgical complication after urinary tract infection and wound infections. In addition to increased mortality, patients who develop postoperative pneumonia have a higher risk of prolonged hospital stay, intensive care unit (ICU) admissions, and higher healthcare costs. Obesity and chronic obstructive pulmonary disease (COPD) are both independent risk factors for the development and severity of postoperative pneumonia, although the combined effect of these comorbidities is unknown. Therefore, we evaluated whether the combination of severe obesity and COPD is associated with an increased risk of postoperative pneumonia. Methods: We performed a multicenter retrospective cohort study of 365,273 patients aged 18 - 64 years who were either severely obese (body mass index (BMI) ≥ 40 kg/m2) or normal-weight (BMI between 18.6 and 24.9 kg/m2) and underwent general surgery, orthopedic surgery, neurosurgery, otolaryngology surgery, urology surgery, and vascular surgery in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participating hospitals from 2014 to 2018. We evaluated the combined effect of COPD and severe obesity on the risk for postoperative pneumonia, unplanned tracheal reintubation, and extended length of stay. Results: The co-occurrence of severe obesity and COPD appeared to have a protective effect on the risk of postoperative pneumonia. In the presence of COPD, patients with severe obesity were 14% less likely to develop pneumonia compared to their normal-weight counterparts (2.9% vs. 4.4%; adjusted relative risk (RR): 0.76; 95% confidence interval (CI): 0.60, 0.95). In addition, in the presence of COPD, severe obesity conferred a lower risk for requiring an extended length of stay (37.6% vs. 47.9%; adjusted RR: 0.83; 95% CI: 0.78, 0.89). Conclusions: Counterintuitively, the co-occurrence of severe obesity with COPD appeared to buffer the negative impact of COPD on postoperative pneumonia, unplanned tracheal reintubation, and prolonged hospital stay after noncardiac surgery. These findings are consistent with the obesity paradox and warrant further investigations.

Countersinking the Lag Screw or Blade During Cephalomedullary Nailing of Geriatric Intertrochanteric Femur Fractures: Less Collapse and Implant Prominence Without Increased Cutout Rates.

INTRODUCTION: The lag screw or helical blade of a cephalomedullary nail facilitates controlled collapse of intertrochanteric proximal femur fractures. However, excessive collapse results in decreased hip offset and symptomatic lateral implants. Countersinking the screw or helical blade past the lateral cortex may minimize subsequent prominence, but some surgeons are concerned that this will prevent collapse and result in failure through cutout. We hypothesized that patients with countersunk lag screws or helical blades do not experience higher rates of screw or blade cutout and have less implant prominence after fracture healing. METHODS: A retrospective review of 175 consecutive patients treated with cephalomedullary nails for AO/OTA 31A1-3 proximal femur fractures and a minimum 3-month follow-up and 254 patients with a 6-week follow-up at a single US level I trauma center. Patients were stratified based on countersunk versus noncountersunk lag screw or helical blade in a cephalomedullary nail. The primary outcome was the cutout rate at minimum 3 months, and the secondary outcome was radiographic collapse at minimum 6 weeks. RESULTS: Cutout rates were no different in patients with countersunk and noncountersunk screws and blades, and countersinking was associated with less collapse and less implant prominence at 6 weeks. DISCUSSION: Surgeons can countersink the lag screw or blade when treating intertrochanteric proximal femur fractures with a cephalomedullary nail without increasing failure rates and with the potential benefits of less prominent lateral implants and decreased collapse.

Impact of policy-based and institutional interventions on postoperative opioid prescribing practices.

BACKGROUND: We assessed the impact of policy-based and institutional interventions to limit postoperative opioid prescribing. METHODS: Retrospective cohort study of patients who underwent laparoscopic/open appendectomies, laparoscopic/open cholecystectomies, and laparoscopic/open inguinal hernia repair during a 6-month interval in 2018 (control), 2019 (post-policy intervention), and 2020 (post-institutional intervention) to assess changes in postoperative opioid prescribing patterns. A survey was collected for the 2020 cohort. RESULTS: Comparing the 762 patients identified in 2018, 2019, and 2020 cohorts there was a significant decrease in mean opioid tabs prescribed (23.5 ± 8.9 vs. 16.2 ± 7.0 vs. 12.8 ± 4.9, p < 0.01) and mean OME dosage (148.0 ± 68.0 vs. 108.6 ± 51.8 vs. 95.4 ± 38.0, p < 0.01), without a difference in refill requests. Patient survey (response rate 63%) indicated 91.4% of patients reported sufficient pain control. CONCLUSION: Formalized opioid-prescribing guidelines and statewide regulations can significantly decrease postoperative opioid prescribing with good patient satisfaction. Surgeon education may facilitate efforts to minimize narcotic over-prescription without compromising pain management.

Cephalomedullary helical blade is independently associated with less collapse in intertrochanteric femur fractures than lag screws.

OBJECTIVES: Excessive fracture site collapse and shortening in intertrochanteric femur fractures alter hip biomechanics and patient outcomes. The purpose of the study was to compare extent of collapse in cephalomedullary nails with blades or lag screws. We hypothesized that there would be no difference in collapse between helical blades and lag screws. DESIGN: Retrospective cohort study. SETTING: Single U.S. Level I Trauma Center. PATIENTS: 171 consecutive patients treated with cephalomedullary nails with either lag screw or blade for AO/OTA 31A1-3 proximal femur fractures and minimum 3-month follow-up. INTERVENTION: Lag screw or helical blade in a cephalomedullary nail. OUTCOME MEASURES: The primary outcome was fracture site collapse at 3 months. RESULTS: There was a significantly higher proportion of reverse-oblique and transverse intertrochanteric femur fractures (31-A3) in the lag screw group (15/42 vs 25/129). A3 patterns were associated with more collapse. There was significantly less collapse in the blade group (median 4.7 mm, inter-quartile range 2.5-7.8 mm) than the screw group (median 8.4 mmm, inter-quartile range 3.7-11.2 mm, p 0.006). Median collapse was no different between blades and screws when comparing stable and unstable patterns. However, blades were independently associated with 2.5 mm less collapse (95%CI - 4.2, - 0.72 mm, p 0.006) and lower likelihood of excessive collapse (> 10 mm at 3 months, OR 0.3, 95% CI 0.13-0.74, p 0.007), regardless of fracture pattern. CONCLUSIONS: Helical blades are independently associated with significantly less collapse than lag screws in intertrochanteric proximal femur fractures, after adjusting for unstable fracture patterns. In fracture patterns at risk for collapse, surgeons can consider use of a helical blade due to its favorable sliding properties compared to screws.

Perioperative aspiration events in children: A report from the Wake Up Safe Collaborative.

BACKGROUND: Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death. AIM: We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration. METHODS: The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments. RESULTS: Analysis included 2 440 810 anesthetics administered involving patients ≤18 years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA ≥ 4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%). CONCLUSION: Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.

Sugammadex for Reversal of Neuromuscular Blockade in a Patient With Renal Failure.

Residual neuromuscular blockade following the use of non-depolarizing neuromuscular blocking agents (NMBAs) can lead to postoperative respiratory complications, including oxygen desaturation, atelectasis, and pneumonia. Sugammadex rapidly reverses steroidal NMBAs by encapsulating them in a highly stable water-soluble complex. This NMBA-sugammadex complex then undergoes renal elimination. In patients with renal insufficiency or failure, concern has been expressed regarding the elimination of the NMBA-sugammadex complex. We present a 19-year-old patient with renal failure who received sugammadex for reversal of neuromuscular blockade. The use of sugammadex in patients with renal dysfunction is discussed and safety concerns are reviewed.

Hyperphosphorylation of CDH1 in Glioblastoma Cancer Stem Cells Attenuates APC/CCDH1 Activity and Pharmacologic Inhibition of APC/CCDH1/CDC20 Compromises Viability.

Glioblastoma (GBM) is the most common and lethal primary brain tumor and remains incurable. This is in part due to the cellular heterogeneity within these tumors, which includes a subpopulation of treatment-resistant cells called cancer stem-like cells (CSC). We previously identified that the anaphase-promoting complex/cylosome (APC/C), a key cell-cycle regulator and tumor suppressor, had attenuated ligase activity in CSCs. Here, we assessed the mechanism of reduced activity, as well as the efficacy of pharmacologically targeting the APC/C in CSCs. We identified hyperphosphorylation of CDH1, but not pseudosubstrate inhibition by early mitotic inhibitor 1 (EMI1), as a major mechanism driving attenuated APC/CCDH1 activity in the G1-phase of the cell cycle in CSCs. Small-molecule inhibition of the APC/C reduced viability of both CSCs and nonstem tumor cells (NSTCs), with the combination of proTAME and apcin having the biggest impact. Combinatorial drug treatment also led to the greatest mitotic arrest and chromosomal abnormalities. IMPLICATIONS: Our findings demonstrate how the activity of the APC/CCDH1 tumor suppressor is reduced in CSCs and also validates small-molecule inhibition of the APC/C as a promising therapeutic target for the treatment of GBM.