Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: A comparison between the out-of-plane versus the in-plane approaches | Revista Española de Anestesiología y Reanimación

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López-Herrera, J.C. Luis-Navarro, J.L. López-Romero" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "de la Matta-Martín" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "López-Herrera" ] 2 => array:2 [ "nombre" => "J.C." "apellidos" => "Luis-Navarro" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "López-Romero" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935613001680?idApp=UINPBA00004N" "url" => "/00349356/0000006100000002/v1_201401250029/S0034935613001680/v1_201401250029/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0034935613002211" "issn" => "00349356" "doi" => "10.1016/j.redar.2013.08.002" "estado" => "S300" "fechaPublicacion" => "2014-02-01" "aid" => "362" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2014;61:64-72" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1144 "formatos" => array:3 [ "EPUB" => 12 "HTML" => 807 "PDF" => 325 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Cerebral oxygenation in patients undergoing shoulder surgery in beach chair position: Comparing general to regional anesthesia and the impact on neurobehavioral outcome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "64" "paginaFinal" => "72" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Oxigenación cerebral en pacientes operados del hombro en posición sentada: comparación de anestesia general y regional e impacto en la respuesta neuroconductual" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 900 "Ancho" => 1609 "Tamanyo" => 124334 ] ] "descripcion" => array:1 [ "en" => "Mean arterial pressures (presented as mean values) are shown at different measurement point levels (heart level and acustic meatus level) for general anesthesia and regional anesthesia. The * indicate the statistical significant difference between the groups from anesthesia induction until surgery start (p<0.01). The dashed line indicates the times where MAP was significant lower compared to the respective baselines in both groups (p<0.05). BC: beach chair; GA: general anesthesia; MAP: mean arterial pressure; PACU: post anesthesia care unit; RA: regional p<0.05 vs. baseline anesthesia." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Aguirre, A. Borgeat, T. Trachsel, I. Cobo del Prado, J. De Andrés, P. Bühler" "autores" => array:6 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Aguirre" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Borgeat" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Trachsel" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Cobo del Prado" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "De Andrés" ] 5 => array:2 [ "nombre" => "P." "apellidos" => "Bühler" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935613002211?idApp=UINPBA00004N" "url" => "/00349356/0000006100000002/v1_201401250029/S0034935613002211/v1_201401250029/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: A comparison between the out-of-plane versus the in-plane approaches" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "73" "paginaFinal" => "77" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Ruiz, X. Sala-Blanch, J. Martinez-Ocón, M.J. Carretero, G. Sánchez-Etayo, A. Hadzic" "autores" => array:6 [ 0 => array:3 [ "nombre" => "A." "apellidos" => "Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "X." "apellidos" => "Sala-Blanch" "email" => array:2 [ 0 => "xsala@clinic.ub.es" 1 => "xavi.sala.blanch@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Martinez-Ocón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M.J." "apellidos" => "Carretero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "G." "apellidos" => "Sánchez-Etayo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Hadzic" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Anaesthesia, St Luke's – Roosevelt Hospital Center, University Hospital of Columbia University, New York, USA" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Incidencia de inserción intraneural en bloqueo femoral guiado por ecografía: comparación entre los enfoques en plano y fuera de plano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1394 "Ancho" => 2167 "Tamanyo" => 216330 ] ] "descripcion" => array:1 [ "en" => "Demonstration of the needle placement and location of the injection with in-plane (A) and out-of-plane (B) needle insertion." ] ] ] "textoCompleto" => "IntroductionThe femoral nerve block is widely used for regional anesthesia because it is simple and highly effective.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> The femoral nerve is separated from the femoral artery by the fibrous aponeurotic union of the fascia iliaca and the fascia lata, an elastic structure which presents resistance to needle passage.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> However, once the needle crosses the fascial layers, the loss of resistance and consequent further advancement may result in needle-nerve contact or impalement of the femoral nerve.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>We hypothesized that the incidence of needle-nerve contact is higher with the out-of-plane approach (insertion needle into the fascia at the midpoint over the femoral nerve) than with the in-plane approach (insertion needle lateral to the femoral nerve). Incidence of needle-nerve contact during femoral nerve block was compared between the two approaches in patients undergoing hip replacement surgery.Patients and methodsAmerican Society of Anaesthesiologists (ASA) physical status I to III patients with a diagnosis of trochanteric or cervical hip fracture and referred for hip replacement under spinal anesthesia were enrolled. Patients under the age of 65 years or over the age of 90 years were excluded. The study was approved by the ethics committee of the Hospital Clínic de Barcelona (ref: R-6345) and registered at <a id="intr0005" class="elsevierStyleInterRef" href="http://www.clinicaltrial.gov/">www.clinicaltrial.gov</a> identifier <a id="intr0010" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT01554722">NCT01554722</a>. All patients gave their written informed consent to participate in the study.Prior to seating the patients for spinal puncture, an ultrasound-guided femoral nerve block (SonoSite Turbo Ultrasound machine; SonoSite, Bothell, WA, USA) was performed by means of a multifrequency probe (6–12MHz). A short-axis view of the femoral nerve in the center of the screen just distal to the inguinal ligament was obtained. Femoral nerve depth (distance from skin to nerve) was measured. Patients were randomly assigned to either the out-of-plane (n=22) or the in-plane (n=22) approach by means of sealed envelopes. In the out-of-plane group, the needle was inserted 1cm caudad to the midpoint of the ultrasound probe just over the femoral nerve, at an angle between 45° and 60°, according to nerve depth; the needle was advanced until it was seen and felt to cross the iliac fascia iliaca. In the in-plane group, the needle was inserted 0.2–0.4cm from the external side of the probe and advanced through the tissues to a position lateral to the femoral nerve, then advanced through the fascia iliaca.After the needle crossed the fascia iliaca, a nerve stimulator (Stimuplex NHS, B. Braun, Melgunsen, Germany) was set to a frequency of 2Hz to deliver a stimulus of 0.1ms. The intensity was gradually increased until 1mA or until a motor response (sartorius or quadriceps muscle contraction with evident movement of the vastus medialis, vastus lateralis or rectus femoris) was observed. One milliliter of a 5% dextrose solution was administered. Anesthesiologist performing the block assessed the distribution of the fluid, anterior or posterior to the nerve.If injection of the solution occurred posterior to the nerve, indicating that needle has crossed the femoral nerve (needle-nerve contact), the needle was withdrawn slowly and sited anterior to the nerve and 10mL of 0.75% ropivacaine were injected. The depth of the needle's tip was recorded just before the start of the injection.The extent of sensory-motor blockade was recorded at 20min by an anesthesiologist who was not aware of the study group. Sensory block was assessed by skin-prick test over the patella and distal third of the anterior aspect of thigh (response scale, 1–3), whereas, motor block was assessed on the Oxford scale (1–3). The severity of the hip pain during positioning for spinal anesthesia was assessed using a verbal numerical scale (1–10). Spinal anesthesia was performed at the L3-L4 interspace; a 26-gauge Quincke spinal needle (BD Spinal Needle®; Becton Dickinson SA, San Agustín de Guadalix, Madrid, Spain) was used to inject 11mg of 0.5% bupivacaine with 10μg of fentanyl.Twenty-four hours after block placement, skin sensory perception was assessed by skin-prick test above the patella, motor response (knee extension) was assessed on the Oxford scale, and pain was assessed using the numerical scale. All patients were prescribed a combination of intravenous paracetamol (1g per 8h) and intravenous dexketoprofen (50mg/8h) for postoperative analgesia. Onset or persistence of sensory-motor symptoms, as reported by the patients, or neurologic deficits during exam, were recorded.Sample size was estimated to identify a 40% difference in the incidence of needle-nerve contact (incidence estimated at 50% for the out-of-plane group and at 10% for the in-plane group) with an alpha error of 5% and power 80%. Forty-four patients (22 per group) were needed. Data are expressed as mean (± SD) for continuous variables, and number (%) for categorical variables. The t test for independent samples or the chi square test of proportions (or Fisher test, as appropriate) was used to test differences between the groups. A p-value<0.05 was considered statistically significant. Risk was estimated by the odds ratio (OR) with 95% confidence interval (CI). Analyses were performed using the Statistical Package for the Social Sciences (SPSS for Windows, version 15.0.1, 2006, Chicago, IL, USA).ResultsThe groups were similar regarding ASA physical status, surgical procedure, depth of the femoral nerve, and in length of needle advanced (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The proportion of patients with needle-nerve contact was higher in the out-of-plane group (14/22, 64%) than in the in-plane group (2/22, 9%), (p<0.001). Risk for needle-nerve contact was higher with the out-of-plane approach than with the in-plane approach (OR=17.5, 95% CI 4–79). The overall incidence of paraesthesia when the needle crossed the fascia iliaca was similar in the two groups (out-of-plane group, 10 patients [46%]; in-plane group, 12 patients [55%]; p=0.76). Eighteen patients in the out-of-plane group (82%) and all patients in the in-plane group (100%) had a motor response to nerve stimulation after the needle passed through the iliac fascia (p=0.1) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In patients who had motor response to nerve stimulation, the median intensity of stimulus was 0.5 (IQR, 0.45–0.6mA), with no between-group differences (out-of-plane group 0.5mA [IQR, 0.4–0.6mA]; in-plane group 0.5mA [IQR, 0.5–0.6mA]) (p=0.77).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Effectiveness of the block for pain during positioning for spinal anesthesia was similar in the two groups. Mean pain assessment scores were similar after 20min of femoral nerve block in the two groups, at rest (1.4 [± 0.9] for the out-of-plane group and 1.3 [± 1] for the in-plane group; p=0.76) and during the sitting maneuverer (4 [± 0.9] for the out-of-plane group and 4.1 [± 1] for the in-plane group; p=0.64). Knee movement against resistance was observed in 32% of patients in the in-plane group vs. none in the out-of-plane group (p=0.008) at 20min. However, normal sensory perception at 24h was more often observed in the in-plane group than in out-of-plain group (77% vs. 36%; p=0.014) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). No patients reported neurologic symptoms or had signs of neurologic dysfunction during examination at 24h after the block.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionUnder the conditions of our study, the incidence of needle-nerve contact (as defined in the Methods section) was significantly higher with the out-of-plane approach to femoral nerve block, in which the needle is inserted through the fascia directly over the femoral nerve at an angle≥45°.The traditional femoral nerve block, using feedback provided by nerve stimulation, begins by identifying the femoral artery pulse in order to take an anterior approach to the nerve. In this approach, the puncture site use to be just lateral to the pulse of the femoral artery.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Of note, this approach is similar to the ultrasound-guided out-of-plane approach we used in our study. However, the incidence of needle-nerve contact (needle passage through the nerve) appears to be high after passing the fascia, whose elastic/dense characteristics resist further needle advancement.<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a> Thus using the in-plane technique may reduce the incidence of needle-nerve contact. This approach, similar to that of Dalens in pediatric patients,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> minimizes the incidence of needle transversing the nerve because the needle does not find the femoral nerve immediately upon traversing the fascia (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>We found a high incidence of femoral needle-nerve contact even though no clinical evidence of nerve injury was detected in our patients. One case of injection of the anesthetic into the femoral nerve, without further nerve damage, has been reported,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> but the incidence of intraneural puncture or injection inside the nerve has not been previously assessed in relation to different approaches to the femoral nerve. The structural characteristics of the femoral nerve at this level<a class="elsevierStyleCrossRef" href="#bib0005">1</a> probably decrease the risk for damage caused by the needle or injection into the nerve, as has been reported for the sciatic nerve.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> However, some cases of neurologic complications, presumably due to needle trauma to the femoral nerve have been reported<a class="elsevierStyleCrossRef" href="#bib0050">10</a> and this event may be under-reported.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>In conclusion, our study suggests that needle-nerve contact may be more likely with an out-of-plane than with an in-plane needle insertion during US-guided FNB. Introducing the needle in-plane through the fascia iliaca lateral to the nerve results in similar nerve block quality may reduce the risk for nerve puncture.Conflict of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres305316" "titulo" => array:5 [ 0 => "Abstract" 1 => "Background" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec288465" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres305315" "titulo" => array:5 [ 0 => "Resumen" 1 => "Antecedentes" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec288464" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-06-26" "fechaAceptado" => "2013-09-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec288465" "palabras" => array:3 [ 0 => "Femoral nerve blockade" 1 => "Nerve puncture" 2 => "Ultrasound-guided" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec288464" "palabras" => array:3 [ 0 => "Bloqueo del nervio femoral" 1 => "Punción nerviosa" 2 => "Guiado por ecografía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "BackgroundThe optimal method of ultrasound-guided femoral nerve block (in-plane vs. out-of-plane) has not been established. We tested the hypothesis that the incidence of needle-nerve contact may be higher with out-of-plane than with in-plane needle insertion. MethodsForty-four patients with hip fracture (American Society of Anaesthesiologists physical status I–III) were randomized to receive the femoral block with an out-of-plane approach (needle inserted at a 45–60° angle 1cm caudal to the midpoint of the ultrasound probe just above the femoral nerve) or with an in-plane technique (needle inserted 0.2–0.4cm from the side of the probe lateral to the femoral nerve). Data collected included depth of needle insertion, response to nerve electric stimulation, and distribution of the injected volume in relation to the nerve (anterior vs. posterior, the latter assuming needle-nerve contact). The sensory block onset was tested at 20min and block recovery and any neurologic symptoms were evaluated at 24h. ResultsThe incidence of needle-nerve contact was significantly higher with the out-of-plane approach (14/22 patients [64%]) than with the in-plane approach (2/22 patients [9%]) (p<0.001) (OR=17.5, 95% CI: 4–79). The rate of paraesthesia on crossing the fascia iliaca was similar in the two groups. All blocks uneventfully regressed; and no patient developed neurologic symptoms. ConclusionsUnder the conditions of our study, needle-nerve contact during femoral nerve block occurs frequently with the out-of-plane approach. An in-plane approach results in an equally effective femoral block and less incidence of needle-nerve contact." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "AntecedentesNo ha quedado establecido un método adecuado para el bloqueo femoral guiado por ecografía (en plano frente a fuera de plano). Probamos la hipótesis de que la incidencia del contacto entre la aguja y un nervio puede ser mayor en la inserción fuera de plano que en el abordaje en plano. MétodosCuarenta y cuatro pacientes con fractura de cadera (estadio i-iii según la Sociedad Americana de Anestesiólogos) recibieron de manera aleatorizada un bloqueo femoral con un enfoque fuera de plano (inserción de la aguja en ángulo de 45-60° y 1cm caudal a la sonda de ecografía sobre el nervio femoral) o con una técnica en plano (inserción de la aguja 0,2-0,4cm desde el lado de la sonda lateral al nervio femoral). Entre los datos recopilados se incluían la profundidad de inserción de la aguja, la reacción a la estimulación nerviosa y la distribución del volumen inyectado en función del nervio (anterior comparado con posterior, este último con contacto entre la aguja y un nervio). Se analizó el inicio del bloqueo a los 20min y se evaluaron la recuperación del bloqueo y los síntomas neurológicos después de 24h. ResultadosLa incidencia del contacto entre la aguja y los nervios fue significativamente mayor con el enfoque fuera de plano (14/22 pacientes [64%]) que con el abordaje en plano (2/22 pacientes [9%]) (p<0,001) (OR=17,5 [95%]; IC: 4-79). El grado de parestesia en aponeurosis fue similar en ambos grupos. Se revirtieron todos los bloqueos sin incidentes; ningún paciente desarrolló síntomas neurológicos. ConclusionesEn las condiciones de nuestro estudio, el contacto entre la aguja y un nervio durante el bloqueo femoral sucede a menudo con el enfoque fuera de plano. Un abordaje en plano tiene como resultado un bloqueo femoral igualmente efectivo, y una incidencia menor del contacto entre la aguja y un nervio." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1197 "Ancho" => 2083 "Tamanyo" => 143518 ] ] "descripcion" => array:1 [ "en" => "Incidence of paraesthesia and motor response to nerve stimulation. Data are reported as number of patients, n(%). (*) p<0.001." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1394 "Ancho" => 2167 "Tamanyo" => 216330 ] ] "descripcion" => array:1 [ "en" => "Demonstration of the needle placement and location of the injection with in-plane (A) and out-of-plane (B) needle insertion." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ASA indicates American Society of Anesthesiologists; M, male; F, female.Data are reported as number, or as mean (SD)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Anterior, out-of-plane (n=22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Lateral, in-plane (n=22) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ASA status I, II, III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1, 11, 10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2, 10, 10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex, M/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6/16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6/16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (SD), yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight (SD), kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 (11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Height (SD), cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">165 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">166 (7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of prosthetic surgery</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moore \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dynamic hip screws \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biarticular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total hip replacement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Depth of femoral nerve (SD), cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9 (0.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Depth of needle advanced (SD), cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.6 (0.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.2 (0.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab451903.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Data in no. of patients (percentage)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">OOP group (n=22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">IP group (n=22) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20min</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PPT<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> 1/2/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17/5/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13/7/2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(77/23/0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(59/32/9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">OS<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> 1/2/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11/11/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7/8/7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(50/50/0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(32/36/32) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24h</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PPT<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> 1/2/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/14/8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/5/17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(0/64/36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(0/23/77) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">OS<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> 1/2/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/19/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5/15/2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(14/86/0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(23/68/9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab451902.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Pin-prick test: 1, touch noted but not painful; 2, discomfort or slight pain; 3, normal sensitivity." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Oxford scale: 1, no movement; 2, movement against gravity; 3, movement against resistance." ] ] ] "descripcion" => array:1 [ "en" => "Assessment of sensory and motor function of femoral nerve after 20min and 24h." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomy–ultrasound correlation for selected peripheral nerve blocks" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "X. Sala-Blanch" 1 => "A. Carrera" 2 => "P. Hurtado" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Tech Reg Anesth Pain Manage" "fecha" => "2008" "volumen" => "12" "paginaInicial" => "146" "paginaFinal" => "152" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fascicular anatomy of human femoral nerve: implications for neural prostheses using nerve cuff electrodes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.J. Gustafson" 1 => "G.C. Pinault" 2 => "J.J. Neville" 3 => "I. Syed" 4 => "J.A. Davis Jr." 5 => "J. 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Original

Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: A comparison between the out-of-plane versus the in-plane approaches

Incidencia de inserción intraneural en bloqueo femoral guiado por ecografía: comparación entre los enfoques en plano y fuera de plano

A. Ruiza, X. Sala-Blancha,

Corresponding author

xsala@clinic.ub.es
xavi.sala.blanch@gmail.com

Corresponding author.

, J. Martinez-Ocóna, M.J. Carreteroa, G. Sánchez-Etayoa, A. Hadzicb

a Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain

b Department of Anaesthesia, St Luke's – Roosevelt Hospital Center, University Hospital of Columbia University, New York, USA

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        "titulo" => "Incidencia de inserci&#243;n intraneural en bloqueo femoral guiado por ecograf&#237;a&#58; comparaci&#243;n entre los enfoques en plano y fuera de plano"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Demonstration of the needle placement and location of the injection with in-plane &#40;A&#41; and out-of-plane &#40;B&#41; needle insertion&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The femoral nerve block is widely used for regional anesthesia because it is simple and highly effective&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The femoral nerve is separated from the femoral artery by the fibrous aponeurotic union of the fascia iliaca and the fascia lata&#44; an elastic structure which presents resistance to needle passage&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> However&#44; once the needle crosses the fascial layers&#44; the loss of resistance and consequent further advancement may result in needle-nerve contact or impalement of the femoral nerve&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We hypothesized that the incidence of needle-nerve contact is higher with the out-of-plane approach &#40;insertion needle into the fascia at the midpoint over the femoral nerve&#41; than with the in-plane approach &#40;insertion needle lateral to the femoral nerve&#41;&#46; Incidence of needle-nerve contact during femoral nerve block was compared between the two approaches in patients undergoing hip replacement surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">American Society of Anaesthesiologists &#40;ASA&#41; physical status I to III patients with a diagnosis of trochanteric or cervical hip fracture and referred for hip replacement under spinal anesthesia were enrolled&#46; Patients under the age of 65 years or over the age of 90 years were excluded&#46; The study was approved by the ethics committee of the Hospital Cl&#237;nic de Barcelona &#40;ref&#58; R-6345&#41; and registered at <a id="intr0005" class="elsevierStyleInterRef" href="http://www.clinicaltrial.gov/">www&#46;clinicaltrial&#46;gov</a> identifier <a id="intr0010" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT01554722">NCT01554722</a>&#46; All patients gave their written informed consent to participate in the study&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Prior to seating the patients for spinal puncture&#44; an ultrasound-guided femoral nerve block &#40;SonoSite Turbo Ultrasound machine&#59; SonoSite&#44; Bothell&#44; WA&#44; USA&#41; was performed by means of a multifrequency probe &#40;6&#8211;12<span class="elsevierStyleHsp" style=""></span>MHz&#41;&#46; A short-axis view of the femoral nerve in the center of the screen just distal to the inguinal ligament was obtained&#46; Femoral nerve depth &#40;distance from skin to nerve&#41; was measured&#46; Patients were randomly assigned to either the out-of-plane &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41; or the in-plane &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41; approach by means of sealed envelopes&#46; In the out-of-plane group&#44; the needle was inserted 1<span class="elsevierStyleHsp" style=""></span>cm caudad to the midpoint of the ultrasound probe just over the femoral nerve&#44; at an angle between 45&#176; and 60&#176;&#44; according to nerve depth&#59; the needle was advanced until it was seen and felt to cross the iliac fascia iliaca&#46; In the in-plane group&#44; the needle was inserted 0&#46;2&#8211;0&#46;4<span class="elsevierStyleHsp" style=""></span>cm from the external side of the probe and advanced through the tissues to a position lateral to the femoral nerve&#44; then advanced through the fascia iliaca&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">After the needle crossed the fascia iliaca&#44; a nerve stimulator &#40;Stimuplex NHS&#44; B&#46; Braun&#44; Melgunsen&#44; Germany&#41; was set to a frequency of 2<span class="elsevierStyleHsp" style=""></span>Hz to deliver a stimulus of 0&#46;1<span class="elsevierStyleHsp" style=""></span>ms&#46; The intensity was gradually increased until 1<span class="elsevierStyleHsp" style=""></span>mA or until a motor response &#40;sartorius or quadriceps muscle contraction with evident movement of the vastus medialis&#44; vastus lateralis or rectus femoris&#41; was observed&#46; One milliliter of a 5&#37; dextrose solution was administered&#46; Anesthesiologist performing the block assessed the distribution of the fluid&#44; anterior or posterior to the nerve&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">If injection of the solution occurred posterior to the nerve&#44; indicating that needle has crossed the femoral nerve &#40;needle-nerve contact&#41;&#44; the needle was withdrawn slowly and sited anterior to the nerve and 10<span class="elsevierStyleHsp" style=""></span>mL of 0&#46;75&#37; ropivacaine were injected&#46; The depth of the needle&#39;s tip was recorded just before the start of the injection&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The extent of sensory-motor blockade was recorded at 20<span class="elsevierStyleHsp" style=""></span>min by an anesthesiologist who was not aware of the study group&#46; Sensory block was assessed by skin-prick test over the patella and distal third of the anterior aspect of thigh &#40;response scale&#44; 1&#8211;3&#41;&#44; whereas&#44; motor block was assessed on the Oxford scale &#40;1&#8211;3&#41;&#46; The severity of the hip pain during positioning for spinal anesthesia was assessed using a verbal numerical scale &#40;1&#8211;10&#41;&#46; Spinal anesthesia was performed at the L3-L4 interspace&#59; a 26-gauge Quincke spinal needle &#40;BD Spinal Needle<span class="elsevierStyleSup">&#174;</span>&#59; Becton Dickinson SA&#44; San Agust&#237;n de Guadalix&#44; Madrid&#44; Spain&#41; was used to inject 11<span class="elsevierStyleHsp" style=""></span>mg of 0&#46;5&#37; bupivacaine with 10<span class="elsevierStyleHsp" style=""></span>&#956;g of fentanyl&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Twenty-four hours after block placement&#44; skin sensory perception was assessed by skin-prick test above the patella&#44; motor response &#40;knee extension&#41; was assessed on the Oxford scale&#44; and pain was assessed using the numerical scale&#46; All patients were prescribed a combination of intravenous paracetamol &#40;1<span class="elsevierStyleHsp" style=""></span>g per 8<span class="elsevierStyleHsp" style=""></span>h&#41; and intravenous dexketoprofen &#40;50<span class="elsevierStyleHsp" style=""></span>mg&#47;8<span class="elsevierStyleHsp" style=""></span>h&#41; for postoperative analgesia&#46; Onset or persistence of sensory-motor symptoms&#44; as reported by the patients&#44; or neurologic deficits during exam&#44; were recorded&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Sample size was estimated to identify a 40&#37; difference in the incidence of needle-nerve contact &#40;incidence estimated at 50&#37; for the out-of-plane group and at 10&#37; for the in-plane group&#41; with an alpha error of 5&#37; and power 80&#37;&#46; Forty-four patients &#40;22 per group&#41; were needed&#46; Data are expressed as mean &#40;&#177; SD&#41; for continuous variables&#44; and number &#40;&#37;&#41; for categorical variables&#46; The <span class="elsevierStyleItalic">t</span> test for independent samples or the chi square test of proportions &#40;or Fisher test&#44; as appropriate&#41; was used to test differences between the groups&#46; A <span class="elsevierStyleItalic">p-value</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered statistically significant&#46; Risk was estimated by the odds ratio &#40;OR&#41; with 95&#37; confidence interval &#40;CI&#41;&#46; Analyses were performed using the Statistical Package for the Social Sciences &#40;SPSS for Windows&#44; version 15&#46;0&#46;1&#44; 2006&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The groups were similar regarding ASA physical status&#44; surgical procedure&#44; depth of the femoral nerve&#44; and in length of needle advanced &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The proportion of patients with needle-nerve contact was higher in the out-of-plane group &#40;14&#47;22&#44; 64&#37;&#41; than in the in-plane group &#40;2&#47;22&#44; 9&#37;&#41;&#44; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Risk for needle-nerve contact was higher with the out-of-plane approach than with the in-plane approach &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#46;5&#44; 95&#37; CI 4&#8211;79&#41;&#46; The overall incidence of paraesthesia when the needle crossed the fascia iliaca was similar in the two groups &#40;out-of-plane group&#44; 10 patients &#91;46&#37;&#93;&#59; in-plane group&#44; 12 patients &#91;55&#37;&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;76&#41;&#46; Eighteen patients in the out-of-plane group &#40;82&#37;&#41; and all patients in the in-plane group &#40;100&#37;&#41; had a motor response to nerve stimulation after the needle passed through the iliac fascia &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;1&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In patients who had motor response to nerve stimulation&#44; the median intensity of stimulus was 0&#46;5 &#40;IQR&#44; 0&#46;45&#8211;0&#46;6<span class="elsevierStyleHsp" style=""></span>mA&#41;&#44; with no between-group differences &#40;out-of-plane group 0&#46;5<span class="elsevierStyleHsp" style=""></span>mA &#91;IQR&#44; 0&#46;4&#8211;0&#46;6<span class="elsevierStyleHsp" style=""></span>mA&#93;&#59; in-plane group 0&#46;5<span class="elsevierStyleHsp" style=""></span>mA &#91;IQR&#44; 0&#46;5&#8211;0&#46;6<span class="elsevierStyleHsp" style=""></span>mA&#93;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;77&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Effectiveness of the block for pain during positioning for spinal anesthesia was similar in the two groups&#46; Mean pain assessment scores were similar after 20<span class="elsevierStyleHsp" style=""></span>min of femoral nerve block in the two groups&#44; at rest &#40;1&#46;4 &#91;&#177; 0&#46;9&#93; for the out-of-plane group and 1&#46;3 &#91;&#177; 1&#93; for the in-plane group&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;76&#41; and during the sitting maneuverer &#40;4 &#91;&#177; 0&#46;9&#93; for the out-of-plane group and 4&#46;1 &#91;&#177; 1&#93; for the in-plane group&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;64&#41;&#46; Knee movement against resistance was observed in 32&#37; of patients in the in-plane group vs&#46; none in the out-of-plane group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41; at 20<span class="elsevierStyleHsp" style=""></span>min&#46; However&#44; normal sensory perception at 24<span class="elsevierStyleHsp" style=""></span>h was more often observed in the in-plane group than in out-of-plain group &#40;77&#37; vs&#46; 36&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; No patients reported neurologic symptoms or had signs of neurologic dysfunction during examination at 24<span class="elsevierStyleHsp" style=""></span>h after the block&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Under the conditions of our study&#44; the incidence of needle-nerve contact &#40;as defined in the Methods section&#41; was significantly higher with the out-of-plane approach to femoral nerve block&#44; in which the needle is inserted through the fascia directly over the femoral nerve at an angle<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>45&#176;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The traditional femoral nerve block&#44; using feedback provided by nerve stimulation&#44; begins by identifying the femoral artery pulse in order to take an anterior approach to the nerve&#46; In this approach&#44; the puncture site use to be just lateral to the pulse of the femoral artery&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Of note&#44; this approach is similar to the ultrasound-guided out-of-plane approach we used in our study&#46; However&#44; the incidence of needle-nerve contact &#40;needle passage through the nerve&#41; appears to be high after passing the fascia&#44; whose elastic&#47;dense characteristics resist further needle advancement&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> Thus using the in-plane technique may reduce the incidence of needle-nerve contact&#46; This approach&#44; similar to that of Dalens in pediatric patients&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> minimizes the incidence of needle transversing the nerve because the needle does not find the femoral nerve immediately upon traversing the fascia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">We found a high incidence of femoral needle-nerve contact even though no clinical evidence of nerve injury was detected in our patients&#46; One case of injection of the anesthetic into the femoral nerve&#44; without further nerve damage&#44; has been reported&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> but the incidence of intraneural puncture or injection inside the nerve has not been previously assessed in relation to different approaches to the femoral nerve&#46; The structural characteristics of the femoral nerve at this level<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> probably decrease the risk for damage caused by the needle or injection into the nerve&#44; as has been reported for the sciatic nerve&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However&#44; some cases of neurologic complications&#44; presumably due to needle trauma to the femoral nerve have been reported<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and this event may be under-reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; our study suggests that needle-nerve contact may be more likely with an out-of-plane than with an in-plane needle insertion during US-guided FNB&#46; Introducing the needle in-plane through the fascia iliaca lateral to the nerve results in similar nerve block quality may reduce the risk for nerve puncture&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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            2 => "Ultrasound-guided"
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            0 => "Bloqueo del nervio femoral"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The optimal method of ultrasound-guided femoral nerve block &#40;in-plane vs&#46; out-of-plane&#41; has not been established&#46; We tested the hypothesis that the incidence of needle-nerve contact may be higher with out-of-plane than with in-plane needle insertion&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Forty-four patients with hip fracture &#40;American Society of Anaesthesiologists physical status I&#8211;III&#41; were randomized to receive the femoral block with an out-of-plane approach &#40;needle inserted at a 45&#8211;60&#176; angle 1<span class="elsevierStyleHsp" style=""></span>cm caudal to the midpoint of the ultrasound probe just above the femoral nerve&#41; or with an in-plane technique &#40;needle inserted 0&#46;2&#8211;0&#46;4<span class="elsevierStyleHsp" style=""></span>cm from the side of the probe lateral to the femoral nerve&#41;&#46; Data collected included depth of needle insertion&#44; response to nerve electric stimulation&#44; and distribution of the injected volume in relation to the nerve &#40;anterior vs&#46; posterior&#44; the latter assuming needle-nerve contact&#41;&#46; The sensory block onset was tested at 20<span class="elsevierStyleHsp" style=""></span>min and block recovery and any neurologic symptoms were evaluated at 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The incidence of needle-nerve contact was significantly higher with the out-of-plane approach &#40;14&#47;22 patients &#91;64&#37;&#93;&#41; than with the in-plane approach &#40;2&#47;22 patients &#91;9&#37;&#93;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#46;5&#44; 95&#37; CI&#58; 4&#8211;79&#41;&#46; The rate of paraesthesia on crossing the fascia iliaca was similar in the two groups&#46; All blocks uneventfully regressed&#59; and no patient developed neurologic symptoms&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Under the conditions of our study&#44; needle-nerve contact during femoral nerve block occurs frequently with the out-of-plane approach&#46; An in-plane approach results in an equally effective femoral block and less incidence of needle-nerve contact&#46;</p>"
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      "es" => array:2 [
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">No ha quedado establecido un m&#233;todo adecuado para el bloqueo femoral guiado por ecograf&#237;a &#40;en plano frente a fuera de plano&#41;&#46; Probamos la hip&#243;tesis de que la incidencia del contacto entre la aguja y un nervio puede ser mayor en la inserci&#243;n fuera de plano que en el abordaje en plano&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cuarenta y cuatro pacientes con fractura de cadera &#40;estadio <span class="elsevierStyleSmallCaps">i</span>-<span class="elsevierStyleSmallCaps">iii</span> seg&#250;n la Sociedad Americana de Anestesi&#243;logos&#41; recibieron de manera aleatorizada un bloqueo femoral con un enfoque fuera de plano &#40;inserci&#243;n de la aguja en &#225;ngulo de 45-60&#176; y 1<span class="elsevierStyleHsp" style=""></span>cm caudal a la sonda de ecograf&#237;a sobre el nervio femoral&#41; o con una t&#233;cnica en plano &#40;inserci&#243;n de la aguja 0&#44;2-0&#44;4<span class="elsevierStyleHsp" style=""></span>cm desde el lado de la sonda lateral al nervio femoral&#41;&#46; Entre los datos recopilados se inclu&#237;an la profundidad de inserci&#243;n de la aguja&#44; la reacci&#243;n a la estimulaci&#243;n nerviosa y la distribuci&#243;n del volumen inyectado en funci&#243;n del nervio &#40;anterior comparado con posterior&#44; este &#250;ltimo con contacto entre la aguja y un nervio&#41;&#46; Se analiz&#243; el inicio del bloqueo a los 20<span class="elsevierStyleHsp" style=""></span>min y se evaluaron la recuperaci&#243;n del bloqueo y los s&#237;ntomas neurol&#243;gicos despu&#233;s de 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La incidencia del contacto entre la aguja y los nervios fue significativamente mayor con el enfoque fuera de plano &#40;14&#47;22 pacientes &#91;64&#37;&#93;&#41; que con el abordaje en plano &#40;2&#47;22 pacientes &#91;9&#37;&#93;&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#44;5 &#91;95&#37;&#93;&#59; IC&#58; 4-79&#41;&#46; El grado de parestesia en aponeurosis fue similar en ambos grupos&#46; Se revirtieron todos los bloqueos sin incidentes&#59; ning&#250;n paciente desarroll&#243; s&#237;ntomas neurol&#243;gicos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En las condiciones de nuestro estudio&#44; el contacto entre la aguja y un nervio durante el bloqueo femoral sucede a menudo con el enfoque fuera de plano&#46; Un abordaje en plano tiene como resultado un bloqueo femoral igualmente efectivo&#44; y una incidencia menor del contacto entre la aguja y un nervio&#46;</p>"
      ]
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Incidence of paraesthesia and motor response to nerve stimulation&#46; Data are reported as number of patients&#44; <span class="elsevierStyleItalic">n</span>&#40;&#37;&#41;&#46; &#40;&#42;&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46;</p>"
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      1 => array:7 [
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        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Demonstration of the needle placement and location of the injection with in-plane &#40;A&#41; and out-of-plane &#40;B&#41; needle insertion&#46;</p>"
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      2 => array:7 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ASA indicates American Society of Anesthesiologists&#59; M&#44; male&#59; F&#44; female&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Data are reported as number&#44; or as mean &#40;SD&#41;&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Anterior&#44; out-of-plane &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#47;16&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moore&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dynamic hip screws&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total hip replacement&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46;2 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">OOP group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">IP group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">20</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PPT<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> 1&#47;2&#47;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">17&#47;5&#47;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">13&#47;7&#47;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Article information

ISSN: 00349356
Original language: English

DOI:10.1016/j.redar.2013.09.023

The statistics are updated each day

Year/Month	Html	Pdf	Total

2021 September	3	2	5
2019 October	1	2	3
2019 July	1	0	1
2018 June	1	0	1
2017 July	22	4	26
2017 June	28	4	32
2017 May	33	0	33
2017 April	36	4	40
2017 March	33	11	44
2017 February	27	7	34
2017 January	14	0	14
2016 December	34	3	37
2016 November	19	2	21
2016 October	53	10	63
2016 September	37	5	42
2016 August	37	5	42
2016 July	25	1	26
2016 June	32	8	40
2016 May	25	4	29
2016 April	15	6	21
2016 March	17	2	19
2016 February	16	5	21
2016 January	14	3	17
2015 December	23	6	29
2015 November	18	3	21
2015 October	30	7	37
2015 September	31	7	38
2015 August	43	5	48
2015 July	32	3	35
2015 June	25	4	29
2015 May	31	7	38
2015 April	26	11	37
2015 March	16	11	27
2015 February	18	1	19
2015 January	0	3	3
2014 October	0	1	1
2014 September	1	0	1
2014 August	1	0	1
2014 July	0	1	1
2014 May	1	0	1
2014 April	0	3	3
2014 March	2	5	7
2014 February	5	8	13
2014 January	1	5	6

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