Surgical trends of groin hernia repairs performed for recurrence in medicare patients.

BACKGROUND: The recurrence rate after groin hernia repair (GHR) has been estimated to be between 1-10% in adult patients. Neither national rates nor trends in recurrence over time have been reliably established for Medicare patients in the USA. MATERIALS: We evaluated patients undergoing GHR (inguinal = IHR; femoral = FHR) from 2011 to 2014 from the Medicare Provider Analysis and Review database. Patients were identified using ICD-9 diagnosis and ICD-9 and CPT procedure codes, stratified both by primary vs. recurrent hernia repair and by sex. One-tailed Cochran-Armitage tests evaluated trends over time and a generalized estimating equation model estimated factors associated with recurrent IHR or FHR. RESULTS: We identified 407,717 patients (87.0%, ≥ 65 years) who underwent an IHR and 11,578 (91.0%, ≥ 65 years) who underwent a FHR. The proportion of IHRs for recurrence decreased statistically from 14.3% in 2011 to 13.9% in 2014 (p < 0.01) in males and was increased, but not statistically so (7.0-7.4%) in females (p = 0.08). The proportion of FHRs for recurrence was decreased, but not statistically so (16.3-14.8%, p = 0.29) in males and increased in females (5.3-6.3%, p = 0.02). On multivariable analysis, males were more than twice as likely as females to undergo recurrent repair (IHR or FHR, both p < 0.01). CONCLUSIONS: Within the Medicare population, recurrence rates after groin hernia repairs were found to be higher than previously reported but have remained clinically stable over time. Establishing and reducing this rate is important for patient outcomes and expectations.

Proportion of femoral hernia repairs performed for recurrence in the United States.

PURPOSE: Recurrence rates after femoral hernia repair (FHR) have not been reliably established in the USA. We sought to determine this trend over time. METHODS: The proportion of primary and recurrent FHRs was determined for patients age ≥ 18 from: ACS-NSQIP (1/2005-12/2014), Premier (1/2010-09/2015), and institutional (1/2005-12/2014) data. Trends were analyzed using a one-tailed Cochran-Armitage test. RESULTS: In the NSQIP database, 6649 patients underwent a FHR. In females, the proportion of FHRs performed for recurrence decreased from 14.0% in 2005 to 6.2% in 2014, p = 0.02. In males, there was no change: 16.7-16.1% 2005-2014 (p = 0.18). The Premier database included 4495 FHRs and our institution 315 FHRs. There was no difference for either gender over time in either data source, all p > 0.05. CONCLUSIONS: The proportion of femoral hernia repairs performed for recurrence in the USA remained relatively constant in males in two large national databases between 2005 and 2015. In females, a decrease was seen in one of the large national databases.

First Report of Syzygites megalocarpus (Mucorales) Web Mold on the Commercial Portabella Button Mushroom Agaricus bisporus in North America.

Agaricus bisporus (Lange) Imbach mushrooms, which are cultivated commercially under environmentally controlled conditions, are the most valuable crop in Pennsylvania. In August 2011, we first observed a mucoraceous mold colonizing primordia and mature basidiocarps of a new brown portabella strain of A. bisporus at two commercial mushroom farms in Chester County, PA. This strain is a hybrid between a commercial strain producing white basidiocarps and a brown wild type isolate of A. bisporus. Mushrooms mature in weekly "flushes". By third flush, 25% of the production surface at both farms was colonized by a fast growing mycelium that was initially white, subsequently yellow to golden brown, and finally grayish. Mushrooms colonized by the mold showed pitting, discoloration, and necrosis. Two pure cultures of the mold were obtained by the hyphal tip method from mature, necrotic basidiocarps at each farm. These isolates were accessioned in the ARS Culture Collection (NRRL, Peoria, IL) as NRRL 54814 to 54815 and 54818 to 54819. The cultures produced abundant aerial sporangiophores that branched dichotomously on potato dextrose agar. Light microscopic examination revealed that each branch terminated in a globose, multispored sporangium with a conspicuous columella. Individual cultures of NRRL 54818 and 54819 produced large (175 to 250 × 200 to 250 µm), barrel-shaped, dark brown to black zygosporangia between opposed suspensors, indicating they were homothallic. Morphological and cultural characteristics of the mold matched the description of Syzygites megalocarpus (3), a member of the Mucorales reported to colonize diverse, mostly fleshy basidiomycetes (2), including cultivated matsutake (Tricholoma matsutake) in Korea (1). Molecular phylogenetic confirmation of the morphological identification was obtained by PCR amplifying and sequencing domains D1 and D2 at the 5' end of the nuclear ribosomal large subunit (LSU rDNA). The four isolates shared an identical LSU rDNA allele. A search of the NCBI nucleotide database, using a partial LSU rDNA sequence from NRRL 54814 as the BLAST query, revealed that it shared 99.5% identity with AF157216.1, a reference isolate of S. megalocarpus NRRL 6288 (3). To assess whether cultures of S. megalocarpus could induce the disease, caps of portabella and white button mushrooms were inoculated with 3.7 × 106 sporangiospores. When incubated in moist chambers at 21 to 22°C with a 12-h photoperiod, disease symptoms developed in 2 to 3 days on portabella that included discoloration and pitting at the site of inoculation. S. megalocarpus was reisolated from the symptomatic mushrooms and produced a colony identical to the original. By comparison, white button mushrooms inoculated with S. megalocarpus, using the same method, only showed minor pitting and discoloration. Disease symptoms were not observed on mushrooms inoculated with water as a negative control. Although development of new commercial varieties derived using "wild" genetically diverse stocks is an effective way to introduce desirable traits into cultivated mushrooms, it carries the risk of introducing new diseases into the industry. References: (1) K.-H. Ka et al. Korean J. Mycology 27:345, 1999. (2) R. L. Kovacs and W. J. Sundberg. Trans. Il. State Acad. Sci. 92:181, 1999. (3) K. O'Donnell. Zygomycetes in culture. Palfrey Contributions in Botany. No. 2. Department of Botany, University of Georgia, Athens, 1979.

Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff.

SUMMARY: The purpose of this article is to describe the outcome of an arthroscopic examination and the pathology in symptomatic shoulders of 41 professional overhand throwing athletes. With the arm in the position of the relocation test, 100% of the subjects had either contact between the rotator cuff undersurface and the posterosuperior glenoid rim or osteochondral lesions. Other key findings included undersurface cuff fraying in 93%, posterosuperior labral fraying in 88%, and anterior labral fraying in 36% of the subjects. This study supports the concept of impingement of the posterior cuff undersurface with the posterosuperior glenoid rim in the overhand throwing athlete with shoulder pain.

A pitfall of coronal computed tomographic imaging in evaluation of calcaneal fractures.

Computed tomographic (CT) coronal images of the posterior talocalcaneal joint were compared with lateral radiographic views and intraoperative findings in 35 patients with 36 intra-articular calcaneal fractures. The severity of articular incongruity and rotational displacement of the posterior facet fragment were not well appreciated in coronal CT images of nine patients, although Bohler and Gissane angles were significantly decreased in lateral radiographs. This disparity between the radiographic and coronal CT scans can be explained by the intraoperative finding of rotation of the fractured central or lateral portion of the convex posterior calcaneal facet along a horizontal axis in the coronal plane.

Comparison of bone contusion seen by MRI in partial and complete tears of the anterior cruciate ligament.

OBJECTIVE: Bone contusions are frequently found in association with complete tears of the anterior cruciate ligament (ACL) and can be a helpful secondary sign in diagnosis. We compare the frequency, location, and significance of bone contusions in complete and partial ACL tears. MATERIALS AND METHODS: Twenty-nine patients with complete and 42 patients with incomplete tears of the ACL were examined by MRI for the presence of accompanying bone contusions within 1 month of injury. RESULTS: Bone contusions were found in 72% of the complete ACL tears but in only 12% of the partial tears. Of the partial ACL tears with accompanying contusions, 80% were high grade injuries that eventually went on to complete rupture within 6 months. Only 16% of the partial ACL injuries without bone contusion progressed to complete rupture at 1-2 year follow-up. There was no difference between the bone contusions of partial and complete tears in terms of general appearance and location. They were predominantly in the lateral compartment (90%) and had a specific predilection for the mid portion of the lateral femoral condyle and the posterior portion of the lateral tibial plateau, often occurring in tandem. CONCLUSION: Bone contusions occur with much less frequency in partial ACL tears than in complete tears but their presence in partial rupture favors a high grade tear that is likely to become complete.

Spontaneous tibial compartment syndrome: case report.

We report the case of an obese 34-year-old woman who spontaneously developed compartment syndrome in her right calf. The patient was treated with four-compartment fasciotomy and debridement of necrotic tissue. Four months after treatment she was ambulating without the use of aids and had full range of motion and muscle strength.

Severe displacement of a calcaneal apophyseal fracture.

Calcaneal apophyseal fractures are rare injuries. Careful review of radiographs are necessary to make the correct diagnosis and initiate prompt treatment. The authors report the case of an adolescent with a severely displaced calcaneal apophyseal fracture that was missed on initial evaluation due to significant soft tissue swelling and misinterpretation of radiographs.

Transportation of children with special seating needs.

As of 1986, all 50 states had implemented mandatory child restraint laws. When used correctly, restraint systems have been proven to reduce the number of fatalities, hospitalizations, and injuries. To date, there is little information regarding compliance with restraint systems for disabled children. There are no data available on fatalities of or injuries to disabled children. This study assessed the restraint system (if any) used in the transportation of disabled children with special restraint needs. We conducted a survey to determine the restraint practices used in transporting these children to school, to our outpatient clinic, and around home. Our survey found that two thirds of the handicapped children reviewed were transported unsafely in at least one mode of transportation. We recommend that health care providers review the transportation needs of their handicapped patients in order to ensure safe transportation.

Penetration of the distal femur by the distal locking device of Brooker Wills interlocking nail.

Of seven patients with complications caused by penetration of the distal locking device through the distal femur, three had penetration of the distal locking device into the knee joint. Two patients had penetration into the patellofemoral joint. One patient had penetration into the lateral cortex of the distal femur and another patient had penetration into the medial cortex of the distal femur. All but one patient required removal of the rods and/or the distal locking device. The main causes of complications include rod rotation, previous surgery, preexisting deformity of the femur, and failure to insert the rod into its proper location distally.

Comminuted fracture of the calcaneus associated with subluxation of the talus.

Two cases of complex fracture dislocation of the calcaneus having an unusual pattern of injury are described. The cases exhibit the following special characteristics: (1) fracture dislocation of the calcaneus where the primary fracture line separates the calcaneus into an anteromedial fragment that maintains its normal relationship to the talus and a posterolateral fragment that is dislocated from the subtalar joint. This posterolateral fragment moves laterally and lies adjacent to the fibula; (2) a secondary fracture line separating the lateral portion of the posterior facet from the tuberosity of the calcaneus. Both fragments are dislocated from their normal anatomical position; (3) talar tilt as shown on AP view of the ankle caused by inversion of the talus due to rupture of the lateral collateral ligament. Also, the posterolateral fragments impinging on the fibula pushes the heel downward and contributes to the talar tilt; (4) involvement of the calcaneocuboid joint; (5) dislocation of the peroneal tendons. This fracture pattern is unusual and has not been described before. Recognition of this unusual injury with subsequent and proper management may prevent major disability to the patient. Conservative treatment by casting or early range of motion is contraindicated. Closed reduction should be attempted immediately, and if not successful, a lateral approach with open reduction and internal fixation is the treatment of choice for this complex injury.

Case report 802: Ewing's tumor of the proximal phalanx of the third finger with radiographic progression documented over a 6-year-period.

In summary, a case of Ewing's tumor of the proximal phalanx of the long finger of the right hand was presented. This case is unusual because of its location as well as the unusually long clinical course before the correct diagnosis was made. The major point to be stressed is that Ewing's tumor may initially present with a "benign" appearance mimicking a bone cyst [17] or angioma [12]. Timely follow-up of so-called benign lesions, particularly when recurrent swelling occurs, would help in avoiding prolonged delays in diagnosis.