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A continuous adductor canal block (cACB) for pain control in total knee arthroplasty (TKA) is always performed by an anesthesiologist. A surgeon-performed cACB during surgery is somewhat questionable in terms of feasibility, reproducibility, and efficacy. This study was divided into two phases. In Phase 1 study, an experimental dissection of 16 cadaveric knees to expose the saphenous nerve and related muscles around the adductor canal was conducted. The extent of dye after injection via a catheter inserted into the adductor canal at the time of TKA was evaluated. In Phase II, a randomized controlled trial study comparing clinical outcomes between surgeon-performed (Group 1) and anesthesiologist-performed cACB (Group 2) during TKA in 63 patients was evaluated. The visual analogue scale (VAS) at rest and during movement at several time points and functional outcomes during hospitalization were compared. The Phase I study demonstrated surgeon-performed cACB during surgery feasible and reproducible with consistent dye extension into the adductor canal after injection via a catheter. In the Phase II study, 29 patients of Group 1 and 30 patients of Group 2 completed the evaluation with no differences in baseline parameters. The VAS during movement at 24 and 36 hours, quadriceps strength, time up and go test, and knee motion at different time points, and total morphine consumption showed no differences between both groups. There were no procedure-related complications. The surgeon-performed cACB during surgery was feasible and reproducible with similar VAS scores and functional outcomes during hospitalization to anesthesiologist cACB. Level of evidence is Level I, prospective randomized trial.

We compared two and four intra-articular injections of platelet-rich plasma (PRP) in terms of changes of synovial cytokines and clinical outcomes. One hundred twenty-five patients having knee OA underwent leukocyte-poor PRP with a 6-week interval. Before each PRP injection, synovial fluid aspiration was collected for investigation. Patients were divided into two or four intra-articular PRP injections (group A and B, respectively). Changes in synovial cytokines and growth factors were compared with the baseline levels of both groups, and clinical outcomes were evaluated until one year. Ninety-four patients who had completed synovial fluid collection were included for final evaluation, 51 in group A and 43 in group B. There were no differences in mean age, gender, BMI, and OA grading. The average platelet count in PRP was 430,000/µL. There were no changes of synovial inflammatory cytokines (IL-1ß, IL-6, IA-17A, and TNF-alpha), anti-inflammatory cytokines (IL-4, IL-10, IL-13, and IL-1RA), and growth factors (TGF-B1, VEGF, PDGF-AA, and PDGF-BB) between baseline levels and six weeks in group A, and 18 weeks in group B. Both groups had significantly improved clinical outcomes from six weeks including visual analog scale (VAS), patient-reported outcome measure (PROM; WOMAC and SF-12), with a significant delayed improvement of performance-based measure [PBM; time up and go (TUG), 5-time sit to stand test (5×SST), and 3-minute walk test (3-min WT)]. In conclusion, two- or four-PRP injection at a 6-week interval for knee OA demonstrated no changes of synovial cytokines and growth factors but similarly improved clinical outcomes from 6 weeks until one year.

Background Peripheral nerve block and local infiltration analgesia (LIA) have an increasing role as part of multimodal analgesia for enhanced recovery after total knee arthroplasty (TKA). We hypothesized that the combination of obturator nerve block (ONB) and tibial nerve block (TNB) would reduce pain and opioid consumption more than ONB or TNB alone when combined with continuous adductor canal block and LIA. Methods Ninety patients were recruited into the study and received spinal anesthesia, LIA, and continuous adductor canal block. They were further randomized to receive either an ONB (group 1), a TNB (group 2), or both (group 3). The primary outcome was total morphine consumption over the postoperative 24 hours. The secondary outcomes included visual analog scale scores, time to first and total dosage of rescue analgesia, Timed Up and Go test, range of motion, muscle strength test, hospital stay, and patient satisfaction. Results Eighty-nine patients completed analysis. The median total morphine consumption during the first 24 postoperative hours was 2 mg (interquartile range [IQR] 0-4) in group 3, 4 mg (IQR 2-8) in group 2, and 6 mg (IQR 6-14) in group 1 (P Conclusion The combination of triple nerve block was superior to double nerve block in improving analgesia and functional outcomes in the immediate postoperative period after total knee arthroplasty, when combined with LIA.

Introduction: Total knee arthroplasty (TKA) is associated with intense postoperative pain for which effective analgesia is essential to facilitate early postoperative recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) have become increasingly involved in postoperative pain management after TKA. We aimed to compare their efficacy and outcomes in patients undergoing TKA. Materials and Methods: Sixty patients undergoing unilateral TKA were randomized to receive either postoperative single-injection ACB (Group A) or LIA (Group L) during the operation. All patients received spinal anaesthesia. Primary outcome was total morphine consumption over postoperative 24 hours. Visual analog pain scale, time to first and total dosage of rescue analgesia, performance-based evaluations [timed-up and go (TUG) test, quadriceps strength], side-effects, length of hospital stay and patient satisfaction were measured. Results: Fifty-seven patients were available for analysis. Median total morphine consumption over 24 and 48 postoperative hours of Group A were significantly less than Group L (6/10 mg vs 13/25 mg, p, 0.008 and 0.001, respectively). Similarly, Group A had significantly lower VAS at postoperative 6, 12 and 18 hours, VAS at ambulation on postoperative (POD) 1-3, better TUG tests on POD 2 and during POD 3 than those of Group L. However, quadriceps strength and patient satisfaction were not different between both groups. Conclusion: Patients undergoing TKA with single-injection ACB required less postoperative opioids than those with LIA. Furthermore, multimodal analgesia using ACB provided better postoperative analgesia, as well as performance-based activities, than those with LIA.

Background Currently Minimally Invasive Plate Osteosynthesis (MIPO) technique for tibial shaft fracture management has gained wide attention. However, an increased intracompartmental pressure after the plate insertion may result in postoperative acute compartment syndrome. We reported the difference of immediate effect of percutaneous plate insertion using 2 approaches of MIPO technique on anterior compartment pressure of the legs. Materials and methods Eight soft cadaveric legs (one female and three males) without previous history of skeletal trauma or surgery were infused with normal saline to create the sustained intracompartmental pressure of 20 mm Hg in all four compartments. The Synthes® 4.5 mm 11-hole Narrow Locking Compression Plate was inserted via anteromedial and anterolateral approach. Anterior compartment pressure was measured by portable digital monitoring device through side-port needle (Stryker® Intracompartmental Monitoring Device) before and after plate insertion for each approach. Results By using anteromedial approach, a mean of anterior compartment pressure was increased by 0.375 mm Hg after plate insertion (5 of 8 legs had no change in pressure and the remaining 3 resulted in 1 mm Hg pressure elevation). For anterolateral plate insertion, all of the 8 legs had an elevation of anterior compartment pressure with a mean of 3.5 mm Hg (ranged from 2 to 6 mm Hg). Conclusions When both approaches were compared to each other, the anterolateral plate insertion resulted in higher intracompartmental pressure elevation of the anterior compartment than the anteromedial approach. Surgeon should be more aware of acute compartment syndrome when considering the anterolateral approach in treating close tibial fracture. However, in patients with suspected acute compartment syndrome, close observation and continuous monitoring of the intracompartmental pressure is still imperative for all healthcare provider.

Background Skin numbness after total knee arthroplasty (TKA) was reported in relation to injury of the infrapatellar branch of saphenous nerve (IPBSN). Methods Phase I study: A nonrandomized and nonconsecutive selection of 30 patients undergoing unilateral TKA, using minimally invasive surgery approach, and 30 patients having standard approach were included. Area of skin numbness was periodically evaluated and compared until 1-year follow-up (FU). Phase II study: we dissected 15 normal cadaveric knees and followed the course and distribution of IPBSN. Results Twenty-nine predominantly female patients in each group completed 1-year FU with no differences in demographic data. Both the groups had significantly improved Knee Society Score clinical and function scores with no statistical differences. The numb areas in both the groups similarly decreased from 2 weeks (51.7 cm 2 vs 51.1 cm 2 ) to 1 year (2.1 cm 2 vs 2.4 cm 2 ) with similar percentages of no skin numbness at 1 year (69% vs 65%). The IPBSN branched from saphenous nerve before exiting the adductor canal and ran longitudinally and obliquely. It was found as a single nerve in 20%, a 2-branch nerve in 67% and a 3-branch nerve in 13%. All branches crossed the knee midline between superior patellar pole and tibial tubercle. Conclusion Clinical study showed that TKA using minimally invasive surgery approach provided similar area of skin numbness to standard approach. Numbness area gradually decreased at serial FUs in both the groups. The cadaveric study demonstrated that the IPBSN consistently gave no branch passing the knee midline above superior patellar pole.

The aim of the present study was to investigate the neutrophil-to-lymphocyte ratio (NLR) level in children with cerebral palsy (CP) living at home or the rehabilitation center. The correlation of NLR with different severities of motor impairment was assessed. This was a single-center, cross-sectional, observational study. A total of 80 CP children who were either living at home (n=34) or at the rehabilitation center (n=46) were included. Demographic characteristics, anthropometric parameters and complete blood counts were recorded, and the NLR values were calculated. The severity of motor impairment was evaluated and categorized according to the Gross Motor Functional Classification System (GMFCS) level. The mean age of CP participants was 8.52±1.92 years. The percentage of children with CP who were malnourished (underweight, stunted and wasted) was higher amongst those at the rehabilitation center compared with those living at home. The mean NLR of children with CP in the rehabilitation center was significantly higher compared with the patients living at home (P=0.003). Participants from the rehabilitation center had severe motor impairment (GMFCS levels IV-V) and significantly higher NLR values than those with mild motor impairments (GMFCS levels II-III; P=0.006). However, there were no differences in NLR values in relation to severity of motor impairment in CP children living at home. CP children had some degree of neuroinflammation and systemic inflammation. NLR may be a potential simple inflammatory parameter that may be used to predict the severity of the motor impairment, particularly in CP children living at a rehabilitation center.

Purpose We compared a single-injection adductor canal block (ACB) with or without local infiltration analgesia (LIA) for accelerating functional recovery and reducing postoperative pain after total knee arthroplasty (TKA). Materials and methods Sixty-two patients undergoing TKA with simple spinal analgesia and ACB were randomized to receive either LIA (group A+L) or placebo LIA (group A). Postoperative visual analog scale (VAS) score for pain, Timed Up and Go (TUG) test and quadriceps strength, total dosage of rescue analgesia, time to first rescue analgesia, and adverse events were serially evaluated from postoperative day 1 to 3 months. Results There were no differences between both groups in pre- and postoperative VAS, TUG test, quadriceps strength 2 days, 3 days, 2 weeks, 6 weeks, and 3 months postoperatively. There were no differences in Knee Society clinical and function scores at 6 months and 1 year. However, group A+L had a significantly longer time for postoperative rescue analgesia (491 minutes vs. 143 minutes, p=0.04) with less patients requiring rescue analgesia during 6 hours after surgery (16.7% vs. 43.3%, p=0.024). Both groups had similarly high rates of patient satisfaction with low adverse event rates. Conclusions Combined ACB and LIA in TKA enhanced early ambulation with reduced and delayed rescue analgesia.

El recorrido del nervio cutaneo antebraquial medial (NCAM) proporciona la inervacion sensorial medial del antebrazo. Su anatomia se ha descrito en parte, porque los datos relativos a su patron de ramificacion y distancias a puntos de referencia adyacentes son insuficientes. El proposito de este estudio fue proporcionar datos morfometricos sobre la anatomia del NCAM, comparando entre lados y sexos. Se disecaron 96 miembros superiores de 26 hombres y 22 mujeres. Se encontro que 5 ramos del NCAM traspasaron la fascia profunda y llegaron 4 hasta la linea interepicondilar (LIE). Presencia de 2 y 3 ramos se encontro en la mayoria de los casos (>80%). Las distancias de estos ramos a los puntos anatomicos variaron considerablemente. En caso de ausencia de ramos, la distancia medial al epicondilo medial (EM) y arteria braquial (AB) fueron de aproximadamente 1,5 cm, mientras que a la vena basilica (VB) fueron 0,7 cm en ambos sexos. Independientemente del patron de ramificacion, el NCAM podria pasar sobre o cerca (a menos de 0,5 cm ) del EM, VB y AB. Asimetria en el patron de ramificacion se encontro en 50% de las muestras. Diferencias en algunos de los parametros de medicion se observaron segun sexo, pero no por lado. Estos datos son relevantes para localizar el NCAM durante el bloqueo del nervio y la toma de injertos, sino tambien para evitar la lesion del nervio durante los procedimientos quirurgicos.

Objective The incidence of obesity is increasing, including children with cerebral palsy (CCP). Purposes were to determine the association of serum adipokine levels, anthropometrics and biomarkers measurements with bodyweight and functional status in CCP. Methods Seventy-two CCP (age 8.7 ± 1.9 years) were enrolled. They were classified by body mass index (BMI) into thinness, normal and overweight and were characterized by the Gross Motor Function Classification System (GMFCS). Serum levels of adipokines (leptin, adiponectin and resistin) were analyzed. A multivariate regression model was used to examine variables associated with BMI and GMFCS. Correlations between serum adipokines, BMI and GMFCS classifications were evaluated. Results The CCP with overweight had the prevalence of 24% and had remarkably higher levels of serum leptin (p Conclusions The treatment for CCP should aim to control weight in order to balance adipokine and functional levels and reduce risks of subsequent metabolic disorders.

Adequate nutrition is crucial for children with cerebral palsy (CCP). However, conventional nutritional assessments may be inadequate for defining undernourished CCP. Leptin, an adipocyte hormone controlling energy expenditure, could be a useful marker. Objectives of this cross-sectional analytic study were to explore correlations between serum leptin level and nutritional status, anthropometric measurements, and biochemical parameters in 86 CCP (aged 9 ± 2 years). Subscapular (SST) and triceps (TST) skinfold thicknesses, weight, and calculated height were obtained. Body mass index and weight-for-height (WH) Z-scores were calculated. Complete blood count and serum levels of leptin and albumin were collected. CCP were classified as undernourished if their WHZ was < -2 according to the World Health Organization criteria. Correlations between anthropometric measurements, biochemical data, and serum leptin levels were evaluated. From 86 CCP, 11 (12%) children were undernourished, and SST, hemoglobin, and hematocrit were significantly lower. Serum leptin levels of nourished and undernourished CCP were 5.4 ± 6.2 and 2.9 ± 1.6 ng/mL (p < 0.001), while the reported value from normal children was 4.9 ng/mL. Serum leptin levels demonstrated a significant correlation with SST and TST (r = 0.83 and 0.72; p < 0.001). Serum leptin was the only marker significantly correlated with WHZ (r = 0.45, p < 0.001) while adjusting for covariates. A serum leptin level of 2.2 ng/mL was the optimal cutoff point for defining adequate nutritional status (WHZ ≥ -2). The measurement of serum leptin should be included in a care scheme of CCP especially during surgical evaluation.

The lateral antebrachial cutaneous nerve (LACN) is the terminal sensory branch of the musculocutaneous nerve supplying the lateral aspect of forearm. Because of its close proximity to the biceps brachii tendon (BBT), the lateral epicondyle (LE), and the cephalic vein (CV), surgery and venipuncture in the cubital fossa can injure the LACN. Measurement data regarding the relative anatomy of LACN are scarce. We, therefore, dissected 96 upper extremities from 26 males and 22 females to expose the LACN in the cubital fossa and forearm. The LACN consistently emerged from the lateral margin of BBT. It then pierced the deep fascia distal to the interepicondylar line (IEL) in 84.4% with mean distances of 1.8 ± 1.1 and 1.2 ± 0.9 cm (male and female, respectively). At the level of IEL, the LACN in all cases was medial to the LE (5.9 ± 1.1 cm male and 5.2 ± 0.9 cm female). Two types of branching were observed: single trunk (78.1%) and bifurcation (21.9%). Asymmetry in the branching pattern was observed in 6 males and 1 female. Concerning the relationship to the CV, the LACN ran medially within 1 cm at the level of IEL in 78.7%. Moreover, in 10 specimens, the LACN was directly beneath the CV. In the forearm, the LACN tends to course medial to the CV. Significant differences in the measurement data between genders but not sides were found in some parameters. These data are important for avoiding LACN injury and locating the LACN during relevant medical procedures.

Lateral femoral cutaneous nerve (LFCN) generally emerges from the pelvis behind the inguinal ligament (IL) to the thigh. Because of its proximity to the anterior superior iliac spine (ASIS) and hip joint, the LFCN is prone to injuries during various procedures. Anatomy of this nerve is highly variable among studies. Moreover, measurement data regarding its branches including the differences between genders and sides are still lacking. This study was, therefore, done to clarify these issues. Eighty-five thighs from 43 cadavers of both genders were dissected at the inguinal region. Distances from each branch of the LFCN to palpable landmarks: the ASIS, pubic tubercle (PT) and femoral artery (FA) were measured along the IL. Up to four branches of the LFCN were found; however, the single trunk was the most common form (>65%). The common site of this pattern on the IL was within 2 cm medial to the ASIS but could be present at over 6 cm. The distances in case of bifurcation were mostly comparable to those of the single trunk. In contrast, the values varied considerably in the cases with three or more branches (three cases). Regarding side and gender, asymmetry in the branching pattern was found in one fourth of specimens. However, only some minor differences between genders or sides in the measurement data were seen. These findings suggest that asymmetry and multiple branches of the LFCN should be concerned. The measurement data are also useful for localizing the LFCN with higher accuracy.