Background Postoperative pain after major knee surgery can be severe. Our aim was to compare the outcomes of epidural analgesia and peripheral nerve blockade (PNB) in patients undergoing total knee joint replacement (TKR). Moreover, we aimed to compare outcomes of adductor canal block (ACB) with those of femoral nerve block (FNB) after TKR.Methods We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; and the Cochrane Central Register of Controlled Trials (CENTRAL). We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above databases. Pain intensity assessed on visual analogue scale (VAS), nausea and vomiting, systolic hypotension, and urinary retention was the reported outcome parameters. Results:We identified 12 randomised controlled trials (RCTs) comparing outcomes of epidural analgesia and PNB reporting a total of 670 patients. There was no significant difference between two groups in VAS scores at 0-12 h (MD -0.48; 95 % CI -1.07-0.11, P = 0.11), 12-24 h (MD 0.04; 95 % CI -0.81-0.88, P = 0.93), and 24-48 h (MD 0.16; 95 % CI -0.08-0.40, P = 0.19). However, epidural analgesia was associated with significantly higher risk of postoperative nausea and vomiting (RR 1.65; 95 % CI, 1.20-2.28, P = 0.002), hypotension (RR 1.76; 95 % CI, 1.26-2.45, P = 0.0009), and urinary retention (RR 4.51; 95 % CI, 2.27-8.96, P<0.0001) compared to PNB. Moreover, pooled analysis of data from 6 RCTs demonstrated no significant difference in VAS score between ACB and FNB at 24 h (MD -0.00; 95 % CI, -0.56-0.56, P = 0.99) and 48 h (MD -0.06; 95 % CI, -0.14-0.03, P = 0.23).Conclusions: PNB is as effective as epidural analgesia for postoperative pain management in patients undergoing TKR. Moreover, it is associated with significantly lower postoperative complications. ACB appears to be an effective PNB with similar analgesic effect to FNB after TKR. Future RCTs may provide better evidence regarding knee range of motion, length of hospital stay, and neurological complications.

PurposeA meta-analysis was performed to assess the outcomes following surgical intervention for medial knee plica.Materials and MethodsA literature search of Medline, EMBASE, CINAHL and Cochrane CENTRAL was performed using relevant key words. The primary outcome was patient-reported postoperative scores of “good” and “excellent”. Meta-analyses were performed using a random effects model.ResultsThe literature search identified 731 articles. After removing duplicates and those not meeting the inclusion criteria, 12 articles reporting on a total of 643 knees were included for analysis, and of these, 7 articles including 235 knees were used for meta-analysis. The overall rate of good and excellent outcomes following surgery was estimated at 84.2% (95% confidence interval [CI], 72.8–91.4). In those cases that had non-surgical therapy prior to surgery, the rate of good and excellent outcomes of surgery was estimated at 76.1% (95% CI, 60.1–87).ConclusionsArthroscopic surgical management of symptomatic medial knee plica results in favourable outcomes. Our results suggest that arthroscopic surgical excision should be considered as a treatment modality in patients with pathological medial plica disease of the knee either as a first-line treatment or when symptoms have not responded to non-surgical interventions.Level of EvidenceIV

Non-steroidal anti-inflammatory drugs (NSAIDs) can produce diaphragm disease where multiple strictures develop in the small bowel. This typically presents with anaemia and symptoms of small bowel obstruction. The strictures develop as a result of circumferential mucosal ulceration with subsequent contraction of rings of scar tissue. We report a case of a 47-year-old woman with a 6-month history of NSAIDs abuse who presented with subacute small bowel obstruction 1 year after stopping NSAIDs. CT and MRI showed multiple ileal strictures with florid locoregional lymphadenopathy. A malignant diagnosis such as lymphoma was considered likely as florid mesenteric lymphadenopathy has not been previously reported in diaphragm disease. Laparotomy with small bowel resection was therefore performed. Histology showed diaphragm disease with the enlarged mesenteric nodes having reactive features. Gross locoregional lymphadenopathy should not deter a diagnosis of diaphragm disease in cases of multiple small bowel strictures where there is a strong history of NSAIDs use.

Lymph nodes (LNs) are believed to be the first organs targeted by colorectal cancer cells detached from a primary solid tumor because of their role in draining interstitial fluids. Better detection and assessment of these organs have the potential to help clinicians in stratification and designing optimal design of oncological treatments for each patient. Whilst highly valuable for the detection of primary tumors, CT and MRI remain limited for the characterization of LNs. B-mode ultrasound (US) and contrast-enhanced ultrasound (CEUS) can improve the detection of LNs and could provide critical complementary information to MRI and CT scans; however, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines advise that further evidence is required before US or CEUS can be recommended for clinical use. Moreover, knowledge of the lymphatic system and LNs is relatively limited, especially in preclinical models. In this pilot study, we have created a mouse model of metastatic cancer and utilized 3D high-frequency ultrasound to assess the volume, shape, and absence of hilum, along with CEUS to assess the flow dynamics of tumor-free and tumor-bearing LNs in vivo. The aforementioned parameters were used to create a scoring system to predict the likelihood of a disease-involved LN before establishing post-mortem diagnosis with histopathology. Preliminary results suggest that a sum score of parameters may provide a more accurate diagnosis than the LN size, the single parameter currently used to predict the involvement of an LN in disease.