Arthroscopic Meniscus Trephination: A Novel Technique for the Treatment of Symptomatic Meniscal Degeneration: Surgical Technique and Literature Review.

Introduction: Meniscal pathology constitutes a major reason for a vast number of patients suffering from knee pain. It is, in general, attributed either to meniscal tearing or degeneration. Debridement and partial meniscectomy, or repair, when possible, is the mainstay surgical approach for refractory knee pain from meniscal degeneration or tears. Sometimes, the patient has clinical symptoms of meniscal pathology, but despite those highly suggestive clinical symptoms, the patient turns out, during knee arthroscopy, to have meniscal degeneration and hardening of the meniscus without frank tearing of the meniscus. Surgical Technique: To initiate meniscal trephination, we first conduct a diagnostic knee arthroscopy to examine the suprapatellar space, the gutters, and the anterior knee space for any pathologies. Following this, both menisci are inspected for any signs of tearing or hardening. For the purposes of our study, the medial meniscus is considered pathological if it shows signs of degeneration or hardening, which then justifies our intervention. An 18-gauge spinal needle, manually bent for the procedure, is inserted through the portal to perform trephination on the hardened menisci. Care is taken to adequately space the needle insertion points to prevent accidental tearing. Our trephination technique aims to soften the meniscus, facilitating its ability to compact and compress when patients ambulate. Additionally, the needle insertion points help attract blood flow to the meniscus, thereby enriching it with growth factors and stem cells that may aid in improving the degenerative condition. Conclusion: Meniscal trephination is benign and effective for meniscal degenerative pathologies. The procedure allows for a healthier meniscus, free from degeneration, that would otherwise disable patients. The intervention does not have long-term adverse effects. To this end, more comparative trials are required to confirm the effectiveness of the technique and to ensure minimal to no associated side effects.

Association of Hip Fracture With the Use of Walking Assistance Devices Post-surgery: A Retrospective Study Comparing Intertrochanteric and Subtrochanteric Hip Fractures.

Background Hip fractures, including intertrochanteric and subtrochanteric fractures, are among the most common types of fractures. The dynamic hip screw (DHS) and the cephalomedullary hip nail (CHN) are the two main techniques used for the fixation of these types of fractures. This study aims to explore the association of the fracture type with the use of walking assistance devices post-surgery, regardless of the fixation technique. Methodology This study is a retrospective study based on the review of de-identified patient data from the American College of Surgeons National Surgical Quality Improvement Program database. Patients aged 65 years old or above who underwent fixation procedures for intertrochanteric or subtrochanteric fractures using CHN or DHS techniques were included in this study. Results A total of 8,881 patients were included and divided into the following two groups: 876 (9.9%) patients treated for subtrochanteric fracture, and 8,005 (90.1%) patients treated for intertrochanteric fracture. No statistical significance was detected in the use of mobility aid postoperatively between the two groups. When compared to CHN, DHS was noted to be the most employed fixation technique among patients with intertrochanteric fractures. One main finding was that patients who underwent surgery using DHS for intertrochanteric fractures were more likely to use walking assistance devices postoperatively compared to those with subtrochanteric fractures treated with the same fixation technique. Conclusions Findings suggest that the use of walking assistance devices post-surgery is independent of the type of fracture and potentially dependent on the fixation technique employed. Future studies focused on the difference in the use of walking assistance devices based on fixation techniques for patients with distinctive sub-types of trochanteric fractures are highly encouraged.

Predictors of postoperative pain, opioid consumption, and functionality after arthroscopic shoulder surgery: A prospective observational study.

PURPOSE: This study aims to identify predictors of postoperative pain and opioid consumption after shoulder surgery to help optimize postoperative pain protocols. STUDY DESIGN: Observational cohort study. METHODS: One thirty-four patients undergoing arthroscopic shoulder repair were included. Variables related to the patient, surgery and anesthesia were collected and correlated with postoperative pain intensity, analgesic consumption, and functionality up to 1-month post-surgery. We used mixed-effect linear models to estimate the association of gender, interscalene block (ISB), preoperative shoulder pain, non-steroidal anti-inflammatory drugs (NSAIDs) consumption before surgery, and type of surgery with each of the following outcomes: postoperative pain scores, opioid consumption, and functionality. We further analyzed the data for pain scores and opioid consumption per body weight using the multiple linear regression analysis to demonstrate the aforementioned associations specifically at 1 h, 6 h, 12 h, 24 h, 72 h, 1 week and 1 month after surgery. RESULTS: Omitting the ISB was associated with higher postoperative pain and cumulative opioid consumption over the first 24 h after surgery. Rotator cuff repair and stabilization surgeries were found to be predictive of higher postoperative pain at 24 h, 72 h, and 1 week and lower functionality at 1 week after surgery. Preoperative shoulder pain and NSAIDs consumption were also predictive of postoperative pain and cumulative opioid consumption. CONCLUSION: Omitting a single shot ISB is a strong predictor of postoperative pain and opioid consumption in the early postoperative phase, beyond which the type of surgery, particularly rotator cuff repair and stabilization surgery, emerges as the most important predictor of postoperative pain and functionality.

Complete distal deltoid muscle detachment: a case report.

BACKGROUND: The deltoid is a large triangular muscle at the shoulder. It attaches proximally to the clavicle, acromion and scapula, while distally it attaches to the lateral deltoid tuberosity. Ruptures are rare, and the literature only reports cases of proximal detachment. In this article, we report the first case of distal traumatic deltoid muscle detachment and its successful management. CASE: A young female sustained a traumatic injury following a Jet Ski accident with loss of consciousness. A complete distal rupture of the deltoid muscle was diagnosed after the basic functions were regained and a thorough musculoskeletal examination could be conducted. A conservative approach helped her to regain an acceptable shoulder function, but there was persistent pain upon activity and cosmetic scarring. The patient underwent surgical reconstruction. Postoperatively, she recovered satisfactorily. DISCUSSION: Distal detachment of the deltoid muscle is rare. The choice for surgical treatment may be undertaken based on several factors including functional status and patient-based assessment.

The association of anaemia and its severity with composite morbidity after total hip arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is a common orthopaedic procedure and is expected to increase with an increasing elderly population. Many of these patients suffer from chronic diseases which might be associated with anaemia. Anaemia, by itself, increases the risk of morbidity. We aimed to delineate relationship between preoperative anaemia and postoperative composite morbidities in patients undergoing primary THA. METHODS: A cohort study analysed the data from the American College of Surgeons National Surgical Quality Improvement Program 2008-2014 database. Adult patients who underwent unilateral primary THA were included and divided into 3 groups: no anaemia, mild anaemia, and moderate-to-severe anaemia. Thirty-day mortality and morbidity were recorded as adverse events. The associations between anaemia, baseline characteristics, and adverse events were analysed after adjusting for confounders. RESULTS: Moderate-to-severe anaemia patients were at increased risk for composite morbidity (adjusted odds ratio, 1.43 [1.17-1.74]) when compared to non-anaemics. The stratification revealed a significant effect of younger age, male gender, white race, obesity, general anaesthesia, and mean operative time >120 minutes in patients with moderate-to-severe anaemia. These patients were also at a higher risk of developing several specific morbidities. CONCLUSION: Moderate-to-severe anaemia increases the risk for composite morbidities, but not mortality in patients undergoing primary THA. Further studies are needed to assess whether preoperative management of moderate-to-severe anaemia would improve outcomes in patients undergoing THA.

Utility of liver function tests in acute cholecystitis.

BACKGROUNDS/AIMS: Common bile duct stones (CBDS) affect the management of acute cholecystitis (AC). This study aims to investigate the utility of liver function tests (LFTs) in predicting the presence of CBDS in AC patients. METHODS: Retrospective cohort study of adult patients with AC found in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2016. Patients were classified into two groups, without CBDS (AC-) and with CBDS (AC+). LFT results namely total bilirubin, SGOT and ALP were collected and categorized into normal and abnormal with the cut-offs of 1.2 mg/dl for total bilirubin, 40 U/L for SGOT and 120 IU/L for ALP. Measures of diagnostic accuracy for individual and combinations of LFTs were computed. RESULTS: A total of 32,839 patients were included in the study, with 8,801 (26.8%) AC+ and 24,038 (73.2%) AC- patients. Their mean age was 52.4 (±18.6) years and over half (59.1%) were females. Mean LFT results were significantly higher in the AC+ group for total bilirubin (1.82 vs 0.97), SGOT (110.9 vs 53.3) and ALP (164.4 vs 102.3) (p<0.0001). The proportions of abnomal LFTs were significantly higher in the AC+ group for total bilirubin (47.7% vs 20.2%), SGOT (62.8% vs 27.1%) and ALP (56.6% vs 21.0%) (p<0.0001). Among AC+, the odds of having abnormal results for bilirubin, SGOT and ALP were found to be 3.61, 4.54 and 4.90 times higher than among AC-, respectively. CONCLUSIONS: Abnormal LFTs are strong predictors for the presence of CBDS in patients with AC. Normal LFTs should be interpreted with caution as some patients with AC and CBDS might not present with characteristic abnormalities in results.

Effect of Gender on Postoperative Morbidity and Mortality Outcomes: A Retrospective Cohort Study.

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons' National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89-0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14-1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10-1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08-1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04-1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96-1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

Comparison of Early Adverse Events After Operative Treatment of Bimalleolar and Trimalleolar Fractures Versus Pilon Fractures.

Ankle fractures requiring open reduction and internal fixation vary in severity from unimalleolar fractures to bimalleolar/trimalleolar (BT) fractures to pilon fractures. Consequently, the postoperative outcomes with these surgeries can vary. Most previous studies of these injuries had small sample sizes, studied a single risk factor or adverse event, or did not compare different injuries by severity. The purpose of the present study was to describe and compare the patient characteristics and postoperative outcomes of 2 high-energy ankle fractures: BT and pilon fractures. The relevant patients were identified from the American College of Surgeons National Surgical Quality Improvement Program database using the Current Procedural Terminology codes for BT and pilon fractures. Patient demographics, characteristics, comorbidities, and 30-day mortality and adverse events were recorded and compared between the 2 types of ankle fractures. More than 45% of patients with these fracture types were aged 40 to 65 years. Pilon fractures occurred more frequently in younger patients, were more likely to occur in men, required a longer hospital stay and operative time, were less likely to occur in patients with a body mass index of >30 kg/m2, and conferred a greater risk of wound complications (odds ratio 1.76; p = .048) compared with BT fractures. The findings from the present study help us understand the differences in patient characteristics and potential early adverse events after open reduction and internal fixation of BT fractures versus pilon fractures.

PECTUS CARINATUM: A NOVEL METHOD OF STERNAL FIXATION.

The traditional method for fixing the sternum during surgical repair of pectus carinatum is through the use of a stainless steel bar (Adkin's strut). In this article we describe a new method of sternal fixation using nonabsorbable sutures which are placed in a transverse and crossed fashion anterior to the sternum. This method provides stable sternal fixation and spares the patient a second operation to remove the steel bar. The absence of metallic implants allows clearer view of the thoracic structures in future X-rays, CT scans and MRI, and is likely to be more acceptable to patients than the implantation of a metallic strut in their chest. In addition, it is less costly.

Preoperative INR and postoperative major bleeding and mortality: A retrospective cohort study.

Little research has been done on the current cut-off international normalized ratio (INR) value of 1.5 for patients undergoing surgery. The objectives of this study are to assess the association between INR and postoperative major bleeding and mortality in patients undergoing surgery and to identify an ideal pre-operative INR for surgical patients. We analyzed data from the American College of Surgeons' National Surgical Quality Improvement Program database between 2008 and 2011 (636,231 patients). The primary outcomes were major bleeding and mortality at 30 days postoperatively. Multivariate logistic regression analyses were carried out to assess these associations. Compared to an INR of <1, the adjusted odds ratio (aOR) for major bleeding was 1.22 (95 % CI 1.18-1.25) for INR 1-1.49, 1.48 (95 % CI 1.40-1.56) for INR 1.5-1.9, and 1.49 (95 % CI 1.39-1.60) for INR ≥2. The aOR for mortality at 30 days post-operation compared to INR of <1 was 1.51 (95 % CI 1.41-1.62), 2.31 (95 % CI 2.12-2.52), and 2.81 (95 % CI 2.56-3.10) for INR 1-1.49, 1.5-1.9, and ≥2, respectively. The ideal pre-operative INR value to predict an increased risk for major bleeding was 1.10 and 1.13 for mortality. In conclusion, preoperative INR is significantly and independently associated with postoperative major bleeding and mortality.

The Association of Anemia and Its Severity with Cardiac Outcomes and Mortality After Total Knee Arthroplasty in Noncardiac Patients.

BACKGROUND: The purpose of this study is to assess whether an association exists between preoperative anemia and postoperative cardiac events or death in patients undergoing unilateral primary total knee arthroplasty (TKA) with no prior cardiac history. METHODS: Data from the 2008-2012 American College of Surgeons National Surgical Quality Improvement Program database were analyzed. Patients aged ≥18 years undergoing unilateral primary TKA were included. We divided the patients into 4 groups: no anemia, any anemia, mild anemia, and moderate-severe anemia. Associations between anemia and different characteristics as well as cardiac outcomes and death were studied, after adjusting for all potential confounders. RESULTS: In the nonanemic group, the occurrence of myocardial infarction, cardiac arrest, and death were 61 of 34,661 (0.18%), 23 of 34,661 (0.07%), and 30 of 34,661 (0.09%), respectively. The numbers in the anemia group were 23 of 6673 (0.34%), 9 of 6673 (0.13%), and 14 of 6673 (0.21%). These were not statistically different. The anemic group had higher odds for respiratory and renal morbidities and for receiving transfusions. CONCLUSION: We found no association between preoperative anemia or its severity and myocardial infarction, cardiac arrest, or death up to 30 days postoperatively. This could potentially lower the bar for safe preoperative hematocrit levels for elective TKA, theoretically increasing the percentage of anemic patients undergoing the procedure. This, however, is at the expense of potential respiratory and renal insults.

Posterior dislocation of a discoid meniscus in a child: a case report.

Discoid meniscus of the knee is a well-known anatomic and congenital variant of the lateral meniscus. It is often asymptomatic, but can be associated with knee pain and other symptoms. Posterior dislocation of the discoid meniscus is an extremely rare finding; to the best of our knowledge, only one case has been reported in the literature. Here, we report a case of 10-year-old girl who presented with right knee pain with no history of trauma. The radiograph of her right knee was negative but MRI showed bilateral lateral discoid menisci with posterior dislocation in the right knee and some subluxation in the left. She underwent right knee arthroscopic lateral meniscoplasty with excellent outcome. This case demonstrates the possibility of torn and dislocated discoid lateral menisci management through arthroscopic reduction and repair.

Quality of life following proximal femoral replacement using a modular system in revision THA.

BACKGROUND: Proximal femoral replacement using a segmental modular system is one option for revision THA in the presence of severe bone loss or periprosthetic fracture. While many papers report function in these patients, they do not describe the quality of life. QUESTIONS/PURPOSES: We evaluated the quality of life in patients undergoing proximal femoral replacement using a segmental modular system for severe bone loss. PATIENTS AND METHODS: We retrospectively reviewed 63 patients undergoing complex revision THA using a modular replacement system for nonneoplastic conditions between April 1996 and June 2006. Average age was 73 years (range, 23-94 years). Twenty-one patients were lost to followup and six patients died before 2-year minimum followup. The remaining 36 patients were followed for an average of 3.2 years (range, 2-10 years). Study patients were matched by age-decade to a control group of patients undergoing conventional revision THA. At baseline, both groups were comparable with respect to age, comorbidities, and quality-of-life scores. RESULTS: At last followup, the modular system group showed improvement in WOMAC function, WOMAC pain, Oxford score, and the SF-12 mental component. Compared to the control group, the modular system group scored lower on WOMAC function and Oxford scores, but there were no differences in any other scores. CONCLUSIONS: In patients with severely compromised bone stock, a segmental modular replacement system can improve the quality of life. Special attention should be given to the stability of the hip intraoperatively and a constrained acetabular liner should be used when the risk of postoperative dislocation is high. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Injury patterns to the posteromedial corner of the knee in high-grade multiligament knee injuries: a MRI study.

Injury patterns to the posteromedial corner of the knee have not been previously studied in the context of multiligament knee injuries. We performed a retrospective magnetic resonance imaging and clinical review of a consecutive series of 27 dislocatable knees presenting to a single level-one trauma center from 2005 to 2008. Post-injury magnetic resonance imaging studies were reviewed by two fellowship-trained musculoskeletal radiologists to assess injury patterns to the posteromedial corner. In our series, injury to at least one structure within the posteromedial corner was observed in 81% (22/27) of cases while injury to the superficial medial collateral ligament alone was seen in 63% (17/27) of cases. Furthermore, injuries to the posterior horn of the medial meniscus were associated with a tear of the meniscotibial ligaments in all cases and with a tear of the posterior oblique ligament in 67% of cases. All patients with grade III laxity (>10 mm medial opening) under an examination under anesthesia had a complete tear of the posterior oblique ligament and meniscotibial ligament in addition to a medial collateral ligament injury. Injury to the semimembranosus attachment alone was not associated with clinically significant laxity under an examination under anesthesia. Our findings demonstrate that injuries to the posteromedial corner are common in the setting of traumatic knee dislocations. Interestingly, high-grade medial instability during an examination under anesthesia and injury to the posterior horn of the medial meniscus may be important indicators for further posteromedial corner injury.