Search Results (391)

Background: Hip fractures represent a major clinical challenge, particularly in elderly and frail patients, where postoperative pain control must balance effective analgesia with motor preservation to facilitate early mobilization. Various regional anesthesia techniques are used in this setting, including the pericapsular nerve group (PENG) block, fascia iliaca compartment block (FICB), femoral nerve block (FNB), and quadratus lumborum block (QLB), yet optimal strategies remain debated. Objectives: To systematically review the efficacy, safety, and clinical applicability of major regional anesthesia techniques for pain management in hip fractures, including considerations of fracture type, surgical approach, and functional outcomes. Methods: A systematic literature search was conducted following PRISMA 2020 guidelines in PubMed, Scopus, Web of Science, and the virtual library of the Hospital Central de la Defensa “Gómez Ulla” up to March 2025. Inclusion criteria were RCTs, systematic reviews, and meta-analyses evaluating regional anesthesia for hip surgery in adults. Risk of bias in RCTs was assessed using RoB 2.0, and certainty of evidence was evaluated using the GRADE approach. Results: Twenty-nine studies were included, comprising RCTs, systematic reviews, and meta-analyses. PENG block demonstrated superior motor preservation and reduced opioid consumption compared to FICB and FNB, particularly in intracapsular fractures and anterior surgical approaches. FICB and combination strategies (PENG+LFCN or sciatic block) may provide broader analgesic coverage in extracapsular fractures or posterior approaches. The overall risk of bias across RCTs was predominantly low, and certainty of evidence ranged from moderate to high for key outcomes. No significant safety concerns were identified across techniques, although reporting of adverse events was inconsistent. Conclusions: PENG block appears to offer a favorable balance of analgesia and motor preservation in hip fracture surgery, particularly for intracapsular fractures. For extracapsular fractures or posterior approaches, combination strategies may enhance analgesic coverage. Selection of block technique should be tailored to fracture type, surgical approach, and patient-specific functional goals. Full article

Background: Plantar fasciitis (PF) is a common enthesopathy in patients with ankylosing spondylitis (AS). Shear wave elastography (SWE) and the Belgrade ultrasound enthesitis score (BUSES) may detect PF, but their comparative diagnostic performance is unclear. Objective: To compare SWE with the BUSES for identifying PF in individuals with and without AS. Methods: In this cross-sectional study, 96 participants were stratified into AS and non-AS populations, each further divided based on the presence or absence of clinical PF. Demographic data, the American Orthopedic Foot and Ankle Society Score (AOFAS), and the BASDAI score were recorded. All subjects underwent grayscale ultrasonography, the BUSES scoring, and SWE assessment of the plantar fascia. Logistic regression models were constructed for each population, controlling for age, body mass index (BMI), and fascia–skin distance. ROC curve analyses were performed to evaluate diagnostic accuracy. Results: In both AS and non-AS groups, SWE and the BUSES were significant predictors of PF (p < 0.05). SWE demonstrated slightly higher diagnostic accuracy, with area under the curve (AUC) values of 0.845 (AS) and 0.837 (non-AS), compared to the BUSES with AUCs of 0.785 and 0.831, respectively. SWE also showed stronger adjusted odds ratios in regression models. The interobserver agreement was good to excellent for both modalities. Conclusions: Both SWE and the BUSES are effective for PF detection, with SWE offering marginally superior diagnostic performance, particularly in AS patients. SWE may enhance the early identification of biomechanical changes in the plantar fascia. Full article

Introduction: Hip abductor strength is essential for pelvic stability, lower limb alignment, and injury prevention. Weaknesses of the gluteus medius and minimus contribute to various musculoskeletal conditions. Lateral band walks and monster walks are elastic resistance exercises commonly used to target the hip abductors and external rotators in functional, weight-bearing tasks. Therefore, the aim was to summarize the current evidence on the biomechanics, muscle activation, and clinical applications of lateral and monster band walks. Methods: This narrative review was conducted following the SANRA guideline. A comprehensive literature search was performed across PubMed, Scopus, Web of Science, and SPORTDiscus up to April 2025. Studies on the biomechanics, electromyography, and clinical applications of lateral band walks and monster walks were included, alongside relevant evidence on hip abductor strengthening. Results: A total of 13 studies were included in the review, of which 4 specifically investigated lateral band walk and/or monster walk exercises. Lateral and monster walks elicit moderate to high activation of the gluteus medius and maximus, especially when performed with the band at the ankles or forefeet and in a semi-squat posture. This technique minimizes compensation from the tensor fasciae latae and promotes selective gluteal recruitment. Proper execution requires control of the trunk and pelvis, optimal squat depth, and consistent band tension. Anatomical factors (e.g., femoral torsion), sex differences, and postural variations may influence movement quality and necessitate tailored instruction. Full article

Background and Clinical Significance: Serratus Anterior Muscle Pain Syndrome (SAMPS) is an underdiagnosed cause of anterior chest wall pain, often attributed to myofascial trigger points of the serratus anterior muscle (SAM) or dysfunction of the Long Thoracic Nerve (LTN), leading to significant disability and affecting ipsilateral upper limb movement and quality of life. Current diagnosis relies on exclusion and physical examination, with limited treatment options beyond conservative approaches. This case report presents a novel approach to chronic SAMPS, successfully diagnosed using Sonoguided Digital Palpation (SDP) and treated with ultrasound-guided hydrodissection of the LTN using 5% dextrose in water (D5W) without local anesthetic (LA), in a patient where conventional treatments had failed. Case Presentation: A 72-year-old male presented with a three-year history of persistent left chest pain radiating to the upper back, exacerbated by activity and mimicking cardiac pain. His medical history included two percutaneous coronary interventions. Physical examination revealed tenderness along the anterior axillary line and a positive hyperirritable spot at the mid axillary line at the 5th rib level. SDP was used to visualize the serratus anterior fascia (SAF) and LTN, and to reproduce the patient’s concordant pain by palpating the LTN. Ultrasound-guided hydrodissection of the LTN was then performed using 20–30cc of D5W without LA to separate the nerve from the surrounding tissues, employing a “fascial unzipping” technique. The patient reported immediate pain relief post-procedure, with the pain reducing from 9/10 to 1/10 on the Numeric Rating Scale (NRS), and sustained relief and functional improvement at the 12-month follow-up. Conclusions: Sonoguided Digital Palpation (SDP) of the LTN can serve as a valuable diagnostic adjunct for visualizing and diagnosing SAMPS. Ultrasound-guided hydrodissection of the LTN with D5W without LA may provide a promising and safe treatment option for patients with chronic SAMPS refractory to conservative management, resulting in rapid and sustained pain relief. Further research, including controlled trials, is warranted to evaluate the long-term efficacy and generalizability of these findings and to compare D5W to other injectates. Full article

In recent years, the concept of the myofascial network has transformed biomechanical understanding by emphasizing the body as an integrated, multidirectional system. This study advances that paradigm by applying graph theory to model the osteo-myofascial system as an anatomical network, enabling the identification of topologically central nodes involved in force transmission, stability, and coordination. Using the aNETomy model and the BIOMECH 3.4 database, we constructed an undirected network of 2208 anatomical nodes and 7377 biomechanical relationships. Centrality analysis (degree, betweenness, and closeness) revealed that structures such as the sacrum and thoracolumbar fascia exhibit high connectivity and strategic importance within the network. These findings, while derived from a theoretical modeling approach, suggest that such key nodes may inform targeted treatment strategies, particularly in complex or compensatory musculoskeletal conditions. The proposed concept of a polyconnective skeleton (PCS) synthesizes the most influential anatomical hubs into a functional core of the system. This framework may support future clinical and technological applications, including integration with imaging modalities, real-time monitoring, and predictive modeling for personalized and preventive medicine. Full article

Background/Objectives: Hip fractures are highly prevalent worldwide, primarily affecting frail elderly patients. Frailty increases the risk of complications like postoperative delirium, which negatively impacts outcomes, including morbidity and mortality. Current recommendations favor a multidisciplinary approach and effective pain control, often using preoperative peripheral nerve blocks. We aimed to evaluate a multimodal approach’s efficacy in reducing postoperative delirium and complications in geriatric hip fracture patients. Methods: This study was conducted between March 2020 and June 2022. A total of 144 patients evaluated prior to the implementation of an optimized clinical pathway protocol (OCPP) were compared to 117 patients evaluated following its implementation. The protocol included early preoperative evaluation, streamlined medication adjustments, prompt surgical intervention and fascia iliaca compartment block (FICB) for analgesia. In addition, early patient mobilization and resumption of oral intake were promoted. The primary outcome was the incidence of delirium during hospitalization. Secondary outcomes were a composite of 30-day mortality or major complications, duration of stay, hospital readmission after discharge and 1-year mortality. Results: The OCPP intervention significantly reduced the incidence of postoperative delirium from 44% to 29% (a 33% relative reduction; p = 0.017), the rate of major complications or death was 14.5% in OCPP group and 25.7% in the control group (p = 0.02). Significantly more patients in the OCPP group were mobilized within 24 h (74.4% vs. 41.3% in the control group, p < 0.001). The median time to ambulation was also shorter in the OCPP group: 65 h (IQR: 39–115) compared to 72 h (IQR: 48–119.75) in the control group (p = 0.028). No differences were observed on hospital stay and 1-year mortality. Conclusions: Among patients undergoing hip fracture repair the implementation of a OCPP significantly reduced the incidence of postoperative delirium and the rate of major complications or death. This improvement was associated with significantly earlier patient mobilization and ambulation. The OCPP was not associated with a lower hospital stay and lower rate of one-year mortality. Full article

This study characterized collagen remodeling in an electron-beam-sterilized porcine acellular dermal matrix (E-PADM) by evaluating host response kinetics during wound healing. E-PADM (n = 6 lots/time point) was implanted in an abdominal wall bridging defect in nonhuman primates (N = 24). Histological, immunohistochemical, and biochemical assessments were conducted. Pro-inflammatory tissue cytokines peaked 1 month post-implantation and subsided to baseline by 6 months. E-PADM-specific serum immunoglobulin G antibodies increased by 213-fold from baseline at 1 month, then decreased to <10-fold by 6–9 months. The mean percentage tissue area staining positively for matrix metalloproteinase-1 plateaued at 3 months (40.3 ± 16.9%), then subsided by 6 months (16.3 ± 11.1%); tissue inhibitor matrix metalloproteinase-1 content plateaued at 1 month (39.0 ± 14.3%), then subsided by 9 months (13.0 ± 8.8%). Mean E-PADM thickness (1.7 ± 0.2 mm pre-implant) increased at 3 months (2.9 ± 1.5 mm), then decreased by 9 months (1.9 ± 1.1; equivalent to pre-implant). Histology demonstrated mild inflammation between 1–3 months, then a peak in host tissue deposition, with ≈75%–100% E-PADM collagen turnover, and fibroblast infiltration and neovascularization between 3–6 months. Picrosirius red staining revealed that mature E-PADM collagen was replaced by host-associated neo-collagen by 6 months. E-PADM implantation induced wound healing, which drove dermal E-PADM collagen remodeling to native, functional fascia-like tissue at the implant site. Full article

Background: Sternal wound infections (SWIs) remain a significant complication following cardiac surgery. Inflammatory and nutritional status are increasingly recognized as key contributors to their development. This study aimed to investigate the predictive utility of immunonutritional biomarkers and to evaluate the protective effect of combining sternal irrigation with an antibiotic-impregnated membrane. Methods: This retrospective cohort study included 480 patients undergoing off-pump coronary artery bypass grafting. Patients were categorized based on sternal management strategy (standard closure or local prophylaxis using gentamicin-enriched irrigation combined with an antibiotic-impregnated fascia lata membrane) and according to the severity of SWIs, classified as superficial or deep. Inflammatory and nutritional markers—including C-reactive protein (CRP), neutrophils, lymphocytes, albumin, neutrophil-to-lymphocyte ratio (NLR), C-reactive protein-to-albumin ratio (CAR), and prognostic nutritional index (PNI)—were assessed at three time points: preoperatively, on postoperative day 3, and after week 1. Results: SWIs were observed in 93 patients, including 75 superficial and 18 deep infections. The combined prophylactic approach was associated with a nearly 1.8-fold reduction in deep SWIs (OR: 0.55; 95% CI: 0.15–0.87) and a modest reduction in superficial infections (OR: 0.89; 95% CI: 0.5–1.3; p = 0.061). Threshold values of 3.75 for preoperative NLR, 9.8 for ΔNLR, and 16.7 for ΔCAR demonstrated strong predictive capacity for identifying patients at increased risk of developing deep SWIs. Patients receiving local prophylaxis exhibited significantly lower CRP, NLR, and CAR values and higher PNI levels at all time points. Conclusions: The combination of sternal irrigation and local antibiotic prophylaxis appears to confer protection against SWIs, potentially by mitigating postoperative inflammation. Immunonutritional biomarkers offer a promising means for early risk stratification. To confirm their clinical utility and broader applicability, these results should be validated in prospective, multicenter studies encompassing a wider range of cardiac surgical procedures. Full article

This update is aimed at various specialists who deal with fractures, such as emergency physicians, general practitioners, orthopedists, and sports medicine physicians. The Global Burden of Disease 2019 Fracture Collaborators estimated the worldwide incidence to be at 178 million, i.e., 2.2 fractures per 1000 people per year. Traditionally, X-rays are the first choice for suspected fractures. However, many fractures can also be detected or excluded with ultrasound. This option is especially attractive when available at the “point of care,”, i.e., at the patient’s bedside in the ambulatory or emergency setting. Point-of-care ultrasound provides clinicians with a simple, cost-effective imaging tool without radiation and complex infrastructure. The evidence suggests that ultrasound has high diagnostic sensitivity and can reliably rule out many fractures with a high degree of certainty. When applied correctly, it could potentially save millions of radiographs and, in some cases, even compete with the accuracy of X-rays and CT scans. These findings suggest a potential paradigm shift. This update discusses the advantages of ultrasound, its examination technique, sonoanatomy of fractures, and relevant indication groups, including its application for analgesia through nerve, fascia, and fascial plane blocks. Ultrasound’s diagnostic value supports its integration into routine fracture assessment, particularly in emergency and ambulatory care settings Full article

Background/Objectives: The accurate localization of interfascial planes is critical for effective regional anesthesia, yet current techniques relying on ultrasound guidance can be challenging, especially in obese or pediatric patients. Previous cadaveric and clinical studies have suggested that injection pressure varies depending on needle placement relative to fascial and neural structures. This pilot study aimed to evaluate whether the continuous monitoring of injection pressure can reliably differentiate interfascial spaces from surrounding anatomical structures in a porcine tissue model. Methods: A custom-built pressure monitoring system was used to continuously measure saline injection pressure during regional block procedures performed on porcine thighs. Injections were guided by ultrasound and conducted using an infusion pump. Needle positions were classified as intramuscular, resting on fascia, or interfascial. Statistical comparisons of pressure levels, variability, and temporal trends were conducted using Wilcoxon signed-rank tests and regression analysis. Results: Mean intramuscular pressure was significantly higher than the mean interfascial pressure (p < 1 × 10⁻¹³). Interfascial injections demonstrated lower pressure variability (p = 2.1 × 10⁻⁴) and an increasing trend in pressure over time (p = 2.1 × 10⁻⁴), whereas intramuscular injections exhibited a decreasing pressure trend (p = 3.15 × 10⁻³). Conclusions: Continuous pressure monitoring effectively distinguishes interfascial from intramuscular and fascial penetration phases during regional anesthesia. The method demonstrates potential as a real-time, objective tool for enhancing needle guidance and improving the safety and accuracy of interfascial plane blocks. Further cadaveric and clinical studies are warranted to validate these findings. Full article

The effectiveness of ultrasound (US)-guided compared with blind corticosteroid injections for the treatment of plantar fasciitis (PF) remains uncertain. This meta-analysis aimed to evaluate the clinical benefits of US-guided over blind injections in patients with PF. A systematic search of PubMed, Embase, Web of Science, and Scopus was conducted, collecting articles published up to 20 April 2025. Randomized controlled trials comparing US-guided and blind corticosteroid injections for PF were included. The extracted outcome measures, i.e., visual analog scale (VAS), heel tenderness index (HTI), tenderness threshold (TT), and plantar fascia thickness, were assessed at short- (2–6 weeks) and long-term (≥12 weeks) follow-ups. Compared with the blind injection group, the US-guided group showed significantly greater improvement in TT at both short- and long-term follow-ups, as well as a greater reduction in plantar fascia thickness. However, no significant differences were found between the two groups in VAS and HTI scores. US-guided corticosteroid injections provide superior clinical benefits compared with blind injections in patients with PF, particularly in enhancing mechanical pain tolerance and reducing plantar fascia thickness. Nevertheless, these findings should be interpreted with caution due to the limited methodological quality of the included studies. Full article

Background and Objectives. Umbilical hernia is particularly common among patients with liver cirrhosis, affecting about 20% of this group, compared to 3–8.5% in healthy individuals. This increased prevalence is mainly due to weakened abdominal fascia, elevated intra-abdominal pressure, and malnutrition. The rapid progression of umbilical hernias often leads to complications such as skin necrosis, perforation, and strangulation. Historically, patients with liver cirrhosis and complicated umbilical hernia have faced high morbidity and mortality rates. However, recent advancements in perioperative management, especially in controlling ascites, have improved outcomes in elective treatments. Despite these advancements, managing patients with decompensated liver cirrhosis and complicated umbilical hernia in emergency settings remain a significant surgical challenge. Materials and Methods: We conducted a retrospective review of patients treated for complicated umbilical hernia at the University Medical Centre Ljubljana from 2015 to 2024, using prospectively collected data. This analysis involved implementing hernioplasty combined with incisional negative pressure wound therapy (iNPWT) as part of the surgical protocol. The primary endpoint of our study was the rate of local complications, while the secondary endpoints included the rate of systemic complications and 90-day mortality. Results: We treated 28 consecutive patients with complicated umbilical hernia and liver cirrhosis. Local wound complications were observed in three (10.7%) patients. Systemic complications developed in 10 patients (35.7%). The median duration of hospitalization was 8 days (range: 5–29), and no readmissions were recorded within the 30-day period. Two (7.1%) patients died within 90 days. Conclusions: Our experience indicates that iNPWT, when combined with surgical repair, can be safely utilized, yielding outcomes comparable to elective hernia repairs, even in emergency contexts. Further randomized controlled trials are necessary to validate these findings and optimize treatment protocols. Full article

Background and Objectives: The technique of complete mesocolic excision (CME) for colonic cancer is being advocated to improve the local control of the disease and increase the long-term survival. However, even with an open approach, CME is a complex technique and has not yet been adopted as standard care. Laparoscopy has been proven to bring significant advantages to colorectal surgery but performing a laparoscopic CME (Lap-CME) for colonic cancer is even more technically demanding than CME in open surgery. The purpose of this study is to evaluate whether Lap-CME can be offered as a standard procedure for patients with colonic cancer and to compare the results with those obtained after a conventional, open technique. Materials and methods: This study included 100 consecutive patients with colonic cancer, who were operated on by the same surgical team using a standardized medial-to-lateral open or laparoscopic complete mesocolic excision technique. The perioperative data was prospectively recorded in a database and retrospectively analyzed with the aim of identifying the proportion of patients that received Lap-CME, to evaluate the success rate of the procedure and to identify whether there are differences in the oncological quality of CME between the laparoscopic and open surgery groups. Results: Most of the patients enrolled in this study were in the advanced stages of the disease, with the incidence of pT3 tumors being 67% and the mean tumor size averaging 4.5 cm. Laparoscopic CME was performed in 39% of cases overall, with 41.4% being right colectomies, 42.5% being left colectomies and 16.1% being transverse colectomies. All of the parameters relevant to the oncological quality of resection, namely total lymph node count, resection margins, or the completeness of resection, were similar between the open and laparoscopic groups both when analyzed for the entire cohort or when analyzed for specific subgroups according to the tumor location (right, transverse, or left colon) or stage of the disease (pT3 or stage III). Conclusions: Laparoscopic complete mesocolic excision for colonic cancer can be offered as a standard procedure by experienced surgical teams in carefully selected patients and provides oncological results similar to those obtained with open surgery. Full article

Background/Objectives: We aimed to review pediatric patients who underwent surgical treatment for posterior fossa tumors and to share our experience with the various types of dural grafts used in these patients. Methods: We carried out a retrospective study on pediatric patients who received surgical treatment for posterior fossa tumors and underwent duraplasty using either an autograft or a xenograft from January 2018 to December 2022. Data were gathered from patients’ medical records, encompassing demographic details. Additional information included tumor locations and the extent of resection. Factors such as postoperative complications like meningitis, pseudo-meningocele, and hydrocephalus were also noted. Results: Our cohort included 50 patients, 13 of whom underwent surgeries with autografts and 37 had xenografts. The patients’ tumors were in various areas, including intraventricular or those extending into the ventricle (31) and intracerebellar (17) and extra-axial (2) cases. Subtotal resection occurred in 8 cases, near-total resection in 9, and gross-total resection in 33. Postoperatively, meningitis occurred in 12 patients, pseudo-meningocele in 13, and hydrocephalus in 10, with 9 requiring V/P placement. Conclusions: In conclusion, techniques for dural closure hold great significance in neurosurgery, particularly during pediatric posterior fossa surgeries. Although the modest size of the autograft cohort limited statistical power, our epidural onlay fascia lata autograft produced fewer postoperative complications than the bovine xenograft and achieved outcomes comparable to those reported for watertight closure. Full article

Background/Objectives: Plantar fasciitis is the most common cause of heel pain, affecting 4–7% of the general population. Physiotherapy is a key component of conservative management. However, there is limited evidence on how physiotherapists in Saudi Arabia manage this condition. This study aimed to investigate current physiotherapy practices for plantar fasciitis in Saudi Arabia and assess their alignment with international clinical guidelines. Methods: A cross-sectional survey was conducted among licensed physiotherapists practicing in Saudi Arabia who had treated patients with plantar fasciitis. An online questionnaire, adapted from a validated UK-based survey, gathered data on participant demographics, service characteristics, diagnostic criteria, treatment goals, outcome measures, and intervention strategies. Descriptive statistics were used for analysis. Results: A total of 399 physiotherapists participated. Diagnosis was mainly based on clinical signs such as pain during plantar fascia stretch (72.9%), early morning pain (70.4%), and medial heel tenderness (69.4%). Common goals of intervention included pain reduction (93.4%), functional improvement (69.9%), and patient education (57.3%). Pain scales (74.9%) and functional tests (49.1%) were the most frequently used outcome measures. Interventions such as exercise therapy (92.0%), stretching (89.4%), and strengthening (84.7%) were widely used. More advanced modalities like shockwave therapy and dry needling were less frequently reported. Conclusions: Physiotherapy practices largely align with international guidelines. However, variation in outcome assessments and underuse of advanced modalities indicate the need for national clinical guidelines and targeted training programs. These steps may promote more consistent, evidence-based care and improve patient outcomes in Saudi Arabia. Full article