Monique Christakis

Sonographically Guided Ilioinguinal Nerve Block

Objective. The aim of this study was to describe a sonographically guided ilioinguinal nerve block in adults. Methods. We developed a useful step‐by‐step technique of sonographically guided ilioinguinal nerve block based on visualization of abdominal muscles, fascial planes, and the branch of the deep circumflex iliac artery. Results. We performed 9 sonographic examinations with subsequent blockade of the ilioinguinal nerve. All injections resulted in a clinically successful sensory block. Conclusions. This technique is reliable and reproducible. The block is achievable by a low‐volume local anesthetic injection. Visualization of the intestines and blood vessels in the abdominal wall may help prevent an inadvertent injury.

Impact of prosthetic design on clinical and radiologic outcomes of total shoulder arthroplasty: a prospective study

BACKGROUND This prospective longitudinal study compared clinical and radiologic outcomes of total shoulder arthroplasty (TSA) using 3 different prosthetic designs, the Neer II system, the Bigliani-Flatow (BF), and a stemless prosthesis, the Total Evolutive Shoulder System (TESS). MATERIALS AND METHODS Patients with advanced osteoarthritis of the glenohumeral joint who underwent TSA were followed up for 2 years. Four patient-oriented disability outcomes were used. The clinical data collected before surgery and at follow-up assessments during a 2-year period included active range of motion (ROM) in 6 directions and strength. Radiographic signs of glenoid and humeral component loosening were recorded. The incidence of humeral head subluxation was documented. RESULTS Seventy-four patients completed the study. There was a significant improvement in the 4 disability measures, ROM, and strength at 2 years in all 3 groups (P < .0001). Active external rotation at 90° abduction was statistically significantly lower in the Neer II group (P = .001). The incidence of lucent lines around the glenoid component was higher in the Neer II group (P = .0002). No statistically significant relationship was seen between type of prosthesis and patient satisfaction (P > 0.05). CONCLUSIONS The 3 types of TSA prostheses used in this study all provided significant improvement in pain and function and were associated with high patient satisfaction. The Neer II was associated with less active external rotation and more lucent lines.

The Role of Plain Radiographs in Management of Bone Metastases

Approximately 50% of patients with cancer will develop skeletal metastases, which often lead to significant pain. When a patient complains of pain, a bone scan and/or plain x-rays are ordered as investigations. X-rays necessitate a 1-cm diameter mass and 50% bone mineral loss at minimum for detection. Up to 40% of lesions will be unidentified by x-rays, presenting false-negative results. Computed tomography (CT) scans can recognize a bony metastatic lesion up to 6 months earlier than an x-ray. However, plain x-rays can also lead to rare false-positive results. We present a case with a false-positive result in a patient with lung cancer.

Correlation of Computed Tomography Imaging Features With Pain Response in Patients With Spine Metastases After Radiation Therapy

PURPOSE To correlate computed tomography (CT) imaging features of spinal metastases with pain relief after radiotherapy (RT). METHODS AND MATERIALS Thirty-three patients receiving computed tomography (CT)-simulated RT for spinal metastases in an outpatient palliative RT clinic from January 2007 to October 2008 were retrospectively reviewed. Forty spinal metastases were evaluated. Pain response was rated using the International Bone Metastases Consensus Working Party endpoints. Three musculoskeletal radiologists and two orthopaedic surgeons evaluated CT features, including osseous and soft tissue tumor extent, presence of a pathologic fracture, severity of vertebral height loss, and presence of kyphosis. RESULTS The mean patient age was 69 years; 24 were men and 9 were women. The mean worst pain score was 7/10, and the mean total daily oral morphine equivalent was 77.3 mg. Treatment doses included 8 Gy in one fraction (22/33), 20 Gy in five fractions (10/33), and 20 Gy in eight fractions (1/33). The CT imaging appearance of spinal metastases included vertebral body involvement (40/40), pedicle involvement (23/40), and lamina involvement (18/40). Soft tissue component (10/40) and nerve root compression (9/40) were less common. Pathologic fractures existed in 11/40 lesions, with resultant vertebral body height loss in 10/40 and kyphosis in 2/40 lesions. At months 1, 2, and 3 after RT, 18%, 69%, and 70% of patients experienced pain relief. Pain response was observed with various CT imaging features. CONCLUSIONS Pain response after RT did not differ in patients with and without pathologic fracture, kyphosis, or any other CT features related to extent of tumor involvement. All patients with painful spinal metastases may benefit from palliative RT.

Impact of Platelet-Rich Plasma on Arthroscopic Repair of Small- to Medium-Sized Rotator Cuff Tears: A Randomized Controlled Trial

Background: Increased interest in using platelet-rich plasma (PRP) as an augment to rotator cuff repair warrants further investigation, particularly in smaller rotator cuff tears. Purpose: To examine the effectiveness of PRP application in improving perioperative pain and function and promoting healing at 6 months after arthroscopic repair of small- or medium-sized rotator cuff tears. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a double-blinded randomized controlled trial of patients undergoing arthroscopic repair of partial- or full-thickness rotator cuff tears of up to 3 cm who were observed for 6 months. Patients were randomized to either repair and PRP application (study group) or repair only (control group) groups. The patient-oriented outcome measures utilized were the visual analog scale (VAS), the Short Western Ontario Rotator Cuff Index (ShortWORC), the American Shoulder and Elbow Surgeons (ASES) form, and the Constant-Murley Score (CMS). Range of motion (ROM) and inflammatory and coagulation markers were measured before and after surgery. Magnetic resonance imaging was used at 6 months to assess retear and fatty infiltration rate. Results: Eighty-two patients (41 males) with a mean age of 59 ± 8 years were enrolled; 41 patients were included in each group. Both the PRP and control groups showed a significant improvement in their pain level based on the VAS within the first 30 days (P < .0001), with the PRP group reporting less pain than the control group (P = .012), which was clinically significantly different from days 8 through 11. The PRP group reported taking less painkillers (P = .026) than the control group within the first 30 days. All outcome measure scores and ROM improved significantly after surgery (P < .0001), with no between-group differences. No differences were observed between groups in inflammatory or coagulation marker test results (P > .05), retear (14% vs 18% full retear; P = .44), or fatty infiltration rate (P = .08). Conclusion: The PRP biological augmentation for repair of small- to medium-sized rotator cuff tears has a short-term effect on perioperative pain without any significant impact on patient-oriented outcome measures or structural integrity of the repair compared with control group.

Immediate Pain Relief and Improved Structural Stability after Percutaneous Vertebroplasty for a Severely Destructive Vertebral Compression Fracture

Approximately 10% to 30% of patients with cancer have metastases to the spine that require treatment. Spinal metastases can cause acute and chronic pain, compression fractures, spinal instability, and neurologic deficits. Vertebral compression fractures can be a significant cause of pain and impaired function. Radiation therapy is the standard treatment for patients with spinal metastases. However, this may not be the optimal treatment by itself for some patients when immediate pain relief is desirable. Percutaneous vertebroplasty is a mildly invasive treatment which involves the injection of cement, polymethylmethacrylate (PMMA) into a diseased vertebral body. We report a patient who presented with a severely destructive lesion and compression fracture at T9 with severe pain and impaired mobility. Percutaneous vertebroplasty provided immediate pain relief and restored structural stability of the diseased vertebra.

Rare bone metastases of the olecranon.

Abstract Bone metastases are prevalent in patients with cancer, especially with primary lung, breast, renal cell, thyroid, and prostate carcinomas. When looking specifically at primary renal cell carcinoma, approximately 40% of patients will develop bone metastases during the course of their disease. However, distal bony involvement to the appendicular skeleton occurs less frequently, developing below the elbow and knee in approximately 7% of metastatic renal cell carcinoma patients. The incidence of olecranon metastasis is extremely rare in all cancers and so far only two cases have been reported in literature. We report the third case of an olecranon metastasis in a patient with renal cell carcinoma.

Efficacy of postoperative radiation treatment for bone metastases in the extremities

BACKGROUND AND PURPOSE Impending or pathological fractures due to bone metastases may require surgical fixation. Postoperative radiation is often recommended to reduce local progression and prevent prosthesis displacement, hence reducing the need for second surgery. The objectives of this study were to investigate the need for second surgery, and to report on rates of re-irradiation, tumor progression and prosthesis displacement following postoperative radiation. MATERIALS AND METHODS Data were collected from 65 patients who received postoperative radiation to 74 sites in the extremities in a palliative radiation clinic between January 2009 and January 2017. Descriptive statistical analyses were performed. RESULTS Only 2 patients required a second surgery (2.7%) at 9 and 10months after postoperative radiation. Increase in pain requiring re-irradiation was reported in 7 patients (9.5%), at a median time of 9.3months after the delivery of radiation. Of the 47 patients who had radiological imaging available post-radiation, local progression of bone metastases was seen in 8 patients (17.0%) and displacement of the prosthesis in 1 patient (2.1%). CONCLUSION Rates of prosthesis displacement and progression of bone metastases at site of surgery were low after postoperative radiation. There were few incidences of second surgery and re-irradiation observed in the cohort. These findings provide support for the benefit of postoperative radiation.

Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist's Approach

Purpose: Recent care innovations using advanced-practice physical therapists (APPs) as alternative health care providers are promising. However, information related to the clinical decision making of APPs is limited with respect to ordering shoulder-imaging investigations and the impact of these investigations on patient management. The purpose of this study was twofold: (1) to explore the clinical decision making of the APP providing care in a shoulder clinic by examining the relationship between clinical examination findings and reasons for ordering imaging investigations and (2) to examine the impact on patient management of ordered investigations such as plain radiographs, ultrasound (US), magnetic resonance imaging (MRI), and magnetic resonance arthrogram (MRA). Method: This was a prospective study of consecutive patients with shoulder complaints. Results: A total of 300 patients were seen over a period of 12 months. Plain radiographs were ordered for 241 patients (80%); 39 (13%) received MRI, 27 (9%) US, and 7 (2%) MRA. There was a relationship between clinical examination findings and ordering plain radiographs and US (ps=0.047 to <0.0001). Plain radiographs ordered to examine the biomechanics of the glenohumeral joint affected management (χ2 1=8.66, p=0.003). Finding a new diagnosis was strongly correlated with change in management for all imaging investigations (ps=0.001 to <0.0001). Conclusion: Skilled, extended-role physical therapists rely on history and clinical examination without overusing costly imaging. The most important indicator of change in management was finding a new diagnosis, regardless of the type of investigation ordered.