Association Between Preoperative Patient Resilience and Patient-Reported Outcomes After Rotator Cuff Repair.

Background: Mental and emotional health can affect outcomes after orthopaedic surgery, and patient resilience has been found to be significantly related to postoperative functional outcomes. Purpose: To evaluate the relationship between preoperative patient resilience and 2-year postoperative patient-reported outcomes after rotator cuff repair (RCR). It was hypothesized that patients with low preoperative resilience will have worse patient-reported outcomes at 2 years after RCR versus those with high resilience. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent primary arthroscopic RCR in 2020 at a single institution and completed the Brief Resilience Scale (BRS) preoperatively were identified. Other inclusion criteria were American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores at the 2-year follow-up. Outcomes were compared in patients as divided into low resilience (BRS score >1 SD below the mean), normal resilience (BRS score ≤1 SD of the mean), and high resilience (BRS score >1 SD above the mean) groups. Results: Overall, 100 patients (52 male, 48 female; mean age, 60 ± 9 years) were included in this study. Mean BRS scores did not change significantly from preoperative to 2-year follow-up (3.8 ± 0.7 vs 3.9 ± 0.8, P = .404). All patients had preoperative ASES scores. Low-resilience patients (n = 17) had significantly lower preoperative ASES scores compared with normal (n = 64) and high resilience (n = 19) patients (35 vs 42 vs 54, respectively; P = .022). There were no significant group differences in postoperative outcomes (revision rate, ASES score, ASES score improvement from preoperative to 2-year follow-up, or SANE score). Multivariate analysis indicated that preoperative resilience was not significantly associated with ASES score improvement (ß estimate = -5.64, P = .150), while resilience at 2-year follow-up was significantly related to ASES score improvement (ß estimate = 6.41, P = .031). Conclusion: Patient-reported outcomes at 2-year follow-up did not differ based on preoperative patient resilience for arthroscopic RCR patients. Multivariate analysis also showed that preoperative resilience was not associated with improvement in ASES scores; however, resilience at 2-year follow-up was associated with ASES score improvement.

Patients' under 25 subjective readiness to return to sport after ACL reconstruction with bone-patellar-bone grafts: Autograft vs. allograft.

Purpose: To assess the difference in perceived readiness to return to sport (RTS) within the first year postoperative period between individuals undergoing anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) autografts or allografts. Methods: This was a prospective cohort study of patients undergoing primary ACL reconstruction done either with BTB autograft or allograft from 2010 to 2018. Skeletally mature patients aged 14 to 25 were eligible for inclusion. Patients completed the Marx Activity Rating Scale (MARS) questionnaire postoperatively evaluating perceived ability to perform various activities to compare subjective ability to RTS. Those patients who were outside outlined cohort age, failed to complete a single post-operative survey, underwent revision procedures, or underwent simultaneous or staged additional ligament surgery were excluded. Results: Fifty-nine patients (20.1 ± 3.19 years, 57.6 % Male) were included in the study. Sixteen patients underwent ACL reconstruction with allograft (19.8 ± 3.43 years) while 43 patients received autograft (20.2 ± 3.13). At 3 months autograft recipients reported higher perceived ability to cut (P = .003). At 6-months, allograft recipients reported higher perceived ability to run (P = .033), cut (P = .048), and decelerate (P = .008) as well as a higher overall perceived ability to RTS (P = .032). At all other times, there was no significant difference between cohorts' subjective readiness to perform activities. Conclusion: The results of this study indicate that at times within the first year of recovery following ACL reconstruction, patients who receive allografts and autografts may have significantly different perceived ability to perform activities or RTS. However, while present at various times throughout the first year of recovery, any difference in perceived ability to perform activities or in overall RTS is no longer present at 12 months. Level of evidence: Level II, Prospective cohort study.

Impact of Climate on Stress Ultrasound Findings of the Elbow Ulnar Collateral Ligament in Professional Baseball Pitchers: An 18-Year Study.

Background: The ulnar collateral ligament (UCL) is the primary soft tissue stabilizer to valgus stress in the elbow and is placed under this valgus stress during the throwing motion. Although there are known risk factors for UCL injury, it is unknown whether the UCL undergoes adaptive changes in athletes from different climates. Purpose: To compare elbow stress ultrasound (SUS) findings between professional baseball pitchers from warm climates versus cold climates and assess significant differences in adaptive and morphologic changes in the UCL. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Dynamic SUS evaluations were performed over 18 years on the dominant and nondominant arms of 643 professional pitchers from warm and cold climates as determined by the player's country/state of origin. Studies were compared with respect to relative UCL thickness (dominant arm vs nondominant arm), relative glenohumeral joint laxity (joint space distance under stress vs joint space distance at rest), and the presence of morphologic changes such as tears or calcifications. In addition, a subgroup analysis was performed to compare the progression of SUS findings over 3 years in players with sequential yearly data. Results: Players from warmer climates had significantly greater relative UCL thicknesses than players from colder climates (1.75 vs 1.50 mm, respectively; P = .047). There were no differences between these 2 groups in terms of relative ulnohumeral joint laxity (P = .201), presence of morphologic changes (P = .433), 3-year progression of relative UCL thickness (P = .748), or relative joint laxity (P = .904). Conclusion: Professional pitchers from warm climates had a greater side-to-side difference in UCL thickness between the dominant and nondominant arms. This may be due to the potential for year-round throwing among baseball players from warm climates. There was no difference in laxity, thickness progression, laxity progression, or the presence of additional morphologic changes.

Risk Factors Associated With Poor Outcomes After Quadriceps Tendon Repair.

Background: Ruptures of the quadriceps tendon present most frequently in older adults and individuals with underlying medical conditions. Purpose: To examine the relationship between patient-specific factors and tear characteristics with outcomes after quadriceps tendon repair. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review was conducted on all patients who underwent quadriceps tendon repair between January 1, 2016, and January 1, 2021, at a single institution. Patients <18 years and those with chronic quadriceps tendon tears (>6 weeks to surgery) were excluded. Information was collected regarding patient characteristics, presenting symptoms, tear characteristics, physical examination findings, and postoperative outcomes. Poor outcome was defined as a need for revision surgery, complications, postoperative range of motion of (ROM) <110° of knee flexion, and extensor lag of >5°. Results: A total of 191 patients met the inclusion criteria. Patients were aged 58.5 ± 13.2 years at the time of surgery, were predominantly men (90.6%), and had a mean body mass index (BMI) of 32.2 ± 6.3 kg/m2. Patients underwent repair with either suture anchors (15.2%) or transosseous tunnels (84.8%). Postoperatively, 18.5% of patients experienced knee flexion ROM of <110°, 11.3% experienced extensor lag of >5°, 8.5% had complications, and 3.2% underwent revision. Increasing age (odds ratio [OR], 1.03 [95% CI, 1.004-1.07]) and female sex (OR, 3.82 [95% CI, 1.25-11.28]) were significantly associated with postoperative knee flexion of <110°, and increasing age (OR, 1.08 [95% CI, 1.04-1.14]) and greater BMI (OR, 1.14 [95% CI, 1.05-1.23]) were significantly associated with postoperative extensor lag of >5°. Current smoking status (OR, 15.44 [95% CI, 3.97-65.90]) and concomitant retinacular tears (OR, 9.62 (95% CI, 1.67-184.14]) were associated with postoperative complications, and increasing age (OR, 1.05 [95% CI, 1.02-1.08]) and greater BMI (OR, 1.08 [95% CI, 1.02-1.14]) were associated with risk of acquiring any poor outcome criteria. Conclusion: Patient-specific characteristics-such as increasing age, greater BMI, female sex, retinacular involvement, and current smoking status-were found to be risk factors for poor outcomes after quadriceps tendon repair. Further studies are needed to identify potentially modifiable risk factors that can be used to set patient expectations and improve outcomes.

Dynamic Stress Ultrasound Assessment of Professional Baseball Players' Elbows After Ulnar Collateral Ligament Reconstruction.

BACKGROUND: There is a paucity of data analyzing dynamic stress ultrasound (SUS) findings in elite pitchers who have undergone ulnar collateral ligament (UCL) reconstruction (UCLR) and returned to sport. PURPOSE: To identify longitudinal, perioperative changes in the elbows of professional baseball pitchers who have undergone UCLR and to compare these findings with a matched cohort of healthy pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study used prospectively collected data from dynamic elbow SUS analyses of professional baseball pitchers within a single Major League Baseball organization. Pitchers were divided into 2 cohorts: a UCLR cohort and healthy cohort. The UCLR cohort eligibility included availability of (1) SUS from preseason of injury/UCLR and (2) SUS from ≥2 years after surgery. These players were 1:1 matched to players with no history of upper extremity injury to form the healthy cohort. Ligament thickness and ulnohumeral joint space at rest and under stress were directly measured. Joint laxity was calculated by subtracting joint space at rest from joint space under stress. The term "relative" was used to describe calculated differences where nondominant measurements were subtracted from dominant-side measurements. RESULTS: Eight pitchers were included in the UCLR group and matched to 8 healthy pitchers (mean age at initial SUS examination, 19.6 years). At a minimum follow-up of 2 years, there were no significant differences between groups in terms of relative or dominant arm rest space, stress space, or laxity. Longitudinally (final measurements - baseline measurements), the mean relative ulnohumeral rest space decreased in the UCLR group and increased in the healthy group (-0.36 mm vs +0.50 mm; P = .032). The finding of increased UCL thickness in the UCLR group was expected, as UCL grafts are typically thicker than native ligaments. CONCLUSION: Ulnhohumeral joint stability was achieved after UCLR as indicated by similar rest space, stress space, and joint laxity in dominant arms compared with a matched healthy cohort. A significant decrease in relative rest space after UCLR may represent the achievement of stability in surgery patients. Alternatively, the increase in ulnohumeral rest space seen in the healthy cohort may represent adaptive changes from pitching at a professional level.

The Most Impactful Articles on the Shoulder Labrum From the United States or Europe, and Decreased Level of Evidence Is Associated With Increased Altmetric Attention Score.

Purpose: To use the top 100 articles pertaining to the shoulder labrum to understand the impact that social medial platforms have on the dissemination of shoulder research and to highlight bibliometric factors associated with Altmetric Attention Scores (AAS) to offer insight into the impact that social media platforms have on the dissemination, attention, and citation of shoulder research publications. Methods: This was a cross-sectional study. In January 2023, the Altmetric database was searched using the PubMed Medical Subject Headings terms "shoulder labrum." Articles with the greatest AAS were screened to exclude other topics unrelated to the labrum of the shoulder. The top 100 articles that met inclusion criteria were used in the final analysis. Bibliometric factors pertaining to each study were collected for further analysis of article characteristics in accordance with previous studies. Results: The Altmetric Database query yielded 619 studies. The top 100 articles with highest AAS were identified, mean Attestation Score was 24.85 ± 55.51, with a range of 7 to 460. The included articles represented 35 journals, with 57 articles attributed to 3 journals: American Journal of Sports Medicine (AJSM; 29%), Arthroscopy: The Journal of Arthroscopic & Related Surgery (Arthroscopy; 19%), and the Journal of Shoulder and Elbow Surgery (JSES; 9%). There was a significant increase in AAS for every decrease in the numerical Level of Evidence value for a study (P = .011) but no association between score and citation rate (P > 005). Conclusions: Top articles on the shoulder labrum, as defined by high AAS score, are most commonly original clinical research published in 1 of 3 sports medicine journals and performed in the United States or Europe. A decreased numerical Level of Evidence is associated with an increase in AAS score, but there is no association between AAS score and citation rate. Clinical Relevance: The increasing amount of science and health information shared freely through open-access journals, online servers, and numerous social media channels makes it difficult to measure the impact of research. Using measures such as the Altmetric Attention Score, in isolation or addition to measures of researcher or journal impact, has the potential to provide comprehensive information about the impact of research in the modern world.

The Utility of Stress Ultrasound in Identifying Risk Factors for Elbow Ulnar Collateral Ligament Tear: A Longitudinal Study of 203 Professional Baseball Players.

BACKGROUND: Injuries to the medial ulnar collateral ligament (UCL) are common among baseball pitchers due to repetitive stress on the soft tissue stabilizers of the elbow during pitching. Dynamic stress ultrasound (SUS) can be used to evaluate the UCL and ulnohumeral joint to identify anatomic risk factors of those who will require UCL reconstruction (UCLR). PURPOSE: To determine whether any adaptive or morphological changes detectable on SUS can predict injury to the UCL in professional baseball pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 203 professional baseball pitchers who underwent SUS at preseason training sessions over the course of 18 years were categorized into 1 of 2 groups: those without a history of shoulder, arm, elbow, or forearm surgery or injuries (healthy cohort; n = 184) and those who underwent UCLR the same season as SUS (UCLR cohort; n = 19). Ligament thickness, joint spacing, and laxity were compared. An additional matched cohort analysis was conducted using 10 players from each group to detect differences in the progression of UCL and ulnohumeral joint measures in the year before injury. RESULTS: The UCLR cohort, when compared with the healthy cohort, had higher relative (ie, nondominant-side measurements subtracted from dominant-side measurements) resting ulnohumeral joint space (median, 0.50 vs 0.20 mm, respectively; P = .006) and higher rates of hypoechoic foci (57.9% vs 30.4%, respectively; P = .030). Players of both groups had similar dominant UCL thickness (P = .161), ulnohumeral joint space at rest (P = .321), space under stress (P = .498), and laxity (P = .796). Groups did not differ in terms of relative UCL thickness, ulnohumeral joint space under stress, or relative laxity. In the year before UCL injury, the UCLR cohort, compared with the matched healthy cohort, had a greater increase in mean dominant UCL thickness (0.94 vs -0.60 mm, respectively; P = .038) and a greater increase in relative median UCL thickness (1.35 vs -0.35 mm, respectively; P = .045). Players in the healthy cohort were statistically older than those in the UCLR cohort (23 vs 22 years, respectively; P = .004). No differences in ulnohumeral stress spacing or laxity were detected. CONCLUSION: SUS of players who underwent UCLR demonstrated a progressive increase in UCL thickness over 1 year, higher rates of hypoechoic foci, and increased ulnohumeral rest space compared with SUS of uninjured players.

Female Authorship Is Driving Studies of Female Athletes: A Systematic Review.

BACKGROUND: Patient sex is known to affect patient outcomes in sports medicine. Historically, many studies on athletes have focused on male athletes and been generalized to female athletes. HYPOTHESIS: Studies with female first or senior authors will isolate female athletes as study participants more frequently than studies with male first or senior authors. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocols, original research studies published between 2017 and 2021 that analyzed athletes were systematically screened from the 6 top sports medicine journals (British Journal of Sports Medicine; Arthroscopy: The Journal of Arthroscopic and Related Surgery; Knee Surgery, Sports Traumatology, Arthroscopy; American Journal of Sports Medicine; Orthopaedic Journal of Sports Medicine; Sports Health: A Multidisciplinary Approach). Articles were included for analysis if they met the following criteria: (1) original sports medicine research study, (2) analysis involving athletes, and (3) inclusion of ≥10 participants. Exclusion criteria included (1) review articles of any type and (2) cadaveric studies. The determination of author sex was completed using the name-to-gender assignment algorithm Genderize.io (https://genderize.io/). RESULTS: A total of 1146 studies were included in quantitative analysis. There were 246 studies with a female first author (21.5%) and 191 studies with a female senior author (16.7%). When looking at all authors (first, senior, and intermediate), 19.9% were female. Female first authors were over 4 times more likely to isolate female athletes in clinical research than male first authors (17.5% vs 3.8%, respectively; P < .001). Female senior authors were approximately twice as likely to isolate female athletes compared with male senior authors (11.5% vs 5.8%, respectively; P < .001). CONCLUSION: Female first authors were significantly more likely to perform research isolating female athletes. While improving the frequency of female athlete research is multifactorial, increasing the number of female researchers may have a direct effect on improving gender equality in sports medicine research.

Association Between Draft Order and Stress Sonography of the Ulnar Collateral Ligament of the Elbow in Professional Baseball Pitchers: An 18-Year Study.

BACKGROUND: The Major League Baseball (MLB) draft is a common route for players to enter professional baseball in the United States. Players taken in earlier rounds are typically higher-performing players. When looking at pitchers specifically, higher performance at the amateur level may be associated with an increased frequency of adaptive change in the throwing elbow. PURPOSE: To determine whether pitchers taken in earlier rounds of the MLB draft have a greater frequency or extent of pathological change in the elbow, as measured by dynamic stress ultrasound. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Dynamic stress ultrasounds (SUSs) were performed over 18 years on the dominant and nondominant arms of 651 professional pitchers. The 383 drafted players were grouped according to the round in which they were drafted (rounds 1-5, 6-10, 11-20, 21+). Groups were compared with respect to "relative" ulnar collateral ligament (UCL) thickness (dominant-nondominant), relative ulnohumeral joint laxity (joint space distance under stress minus joint space at rest), and the presence of pathology (calcifications, tears, hypoechoic foci, osteophytes). In addition, a subgroup analysis was done to compare the progression of SUS findings over 3 years in players for which data were available. RESULTS: Draft round groups did not differ by age, number of previous spring training, or handedness. Comparing baseline measurements, there was no significant relationship between draft round and relative UCL thickness (P = .932), relative laxity (P = .996), or presence of pathology detectable on SUS (P = .642). However, increased relative UCL thickness was significantly associated with the presence of pathology on SUS (odds ratio, 1.45; 95% CI, 1.26-1.69; P < .001). Longitudinally, there was no significant relationship between draft round and 3-year progression of relative laxity, relative UCL thickness, or clinical progression of pathology. CONCLUSION: Higher-performing pitchers are drafted earlier in the MLB draft. This may be attributable to peak pitch velocity, in-game performance, visibility gained during player showcases, or any number of other sport-specific variables. However, despite this, there was no significant relationship between draft round and adaptive changes to the elbow or specific properties of the UCL on stress ultrasound.

Lower Opioid Prescription Quantity Does Not Negatively Impact Pain Control or Patient Satisfaction After ACL Reconstruction: A Randomized, Prospective Trial.

BACKGROUND: The purpose of this study was to evaluate the effects of different quantities of prescribed opioid tablets on patient opioid utilization, postoperative pain and function, and satisfaction after anterior cruciate ligament reconstruction (ACLR). METHODS: This was a prospective, randomized trial enrolling patients undergoing primary ACLR. Patients were assigned to 1 of 3 prescription groups: 15, 25, or 35 tablets containing 5-mg oxycodone. Patients completed visual analog scale (VAS) pain and medication logs, opioid medication satisfaction surveys, and International Knee Documentation Committee (IKDC) questionnaires postoperatively. RESULTS: Among the 180 patients included in the analysis, there was no significant difference in VAS pain scores (p > 0.05), IKDC scores (p > 0.05), morphine milligram equivalents (MMEs) (p = 0.510) consumed, or patient satisfaction with regard to pain control (p = 0.376) between treatment groups. Seventy-two percent of opioids were consumed in the first 3 days postoperatively, and 83% of patients in the 15-tablet cohort felt that they received the "right amount" of or even "too many" opioids. CONCLUSIONS: The prescription of 15 opioid tablets resulted in equivalent pain control, patient satisfaction, and short-term functional outcomes as prescriptions of 25 or 35 opioid tablets after ACLR. Lower prescription quantities of opioid medication may provide equivalent postoperative pain and help to minimize the number of unused opioid doses at risk for possible diversion after ACLR. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Greater Patient Satisfaction With Use of Nonabsorbable Sutures Compared to Absorbable Sutures for Skin Closure Following Knee Arthroscopy: A Randomized Controlled Trial.

Purpose: The purpose of this study was to evaluate patient outcomes and satisfaction after arthroscopic portal closure with absorbable versus nonabsorbable sutures after knee arthroscopy. Methods: Patients undergoing primary knee arthroscopy were identified during procedure scheduling. Exclusion criteria included revision procedures, concomitant ligament reconstruction, or meniscal repair surgery. Before surgery, enrolled patients were randomly assigned to undergo closure with either 3-0 Monocryl absorbable or 3-0 nylon non-absorbable sutures. Postoperative evaluation at 2, 6, and 12 weeks included a Visual Analogue Cosmesis scale, a 10-point visual analogue scale (VAS) for pain, patient scar assessment, and customized questionnaire assessing scar satisfaction. Results: Between January 2019 and August 2022, 247 were included for analysis: 145 in the absorbable group and 129 in the non-absorbable group. There was no significant difference between groups in terms of age, sex, body mass index, race, smoking status, or laterality of procedure. Patients in the nonabsorbable group reported higher overall satisfaction at week 6 follow-up (9.12 ± 1.85 vs 8.44 ± 2.49, P = .019) and week 12 follow-up (9.13 ± 1.76 vs 8.54 ± 2.50, P = .048). There was no difference in pain, swelling, itching, numbness, incisional pain, or burning at any time. Patients in the nonabsorbable group observed more skin discoloration at 2 weeks (3.00 ± 2.33 vs 2.41 ± 1.80, P = .026) and 6 weeks (3.74 ± 2.82 vs 2.98 ± 2.45, P = .032) follow-up with no significant difference at 12 weeks. Conclusion: In this study, patients were more satisfied with nonabsorbable sutures for portal wound closure after knee arthroscopy despite early reporting of increased skin discoloration relative to absorbable sutures. Level of Evidence: Level I, randomized controlled trial.

Outcomes of Osteochondral Allograft Transplantation: A Comparative Study of BioUni and Snowman Techniques for Ovoid Lesions.

BACKGROUND: Treatment of large articular cartilage lesions of the knee includes surgical options one of which includes cartilage replacement therapies. Among these therapies include osteochondral allograft (OCA) transplantation, which can be performed utilizing a BioUni® (Arthrex BioUni® Instrumentation System; Arthrex, Naples, FL) replacement and a 'snowman' technique of repair. HYPOTHESIS/PURPOSE: To compare clinical and radiographic outcomes in patients who have undergone multiplug OCA transplantations utilizing a BioUni® replacement and a 'snowman' technique of repair. METHODS: Patients who underwent OCA transplantation utilizing a snowman technique or BioUni® replacement between January 1st, 2012 and December 31st, 2018, and who had a minimum 1-year follow-up at the same institution were identified for inclusion in this study via current procedural terminology (CPT) codes. Charts of included patients were reviewed for injury and treatment details as well as demographic information. Imaging studies and operative reports were reviewed and pre and postoperative subjective and objective outcome measures were recorded. RESULTS: Twenty-eight patients underwent OCA transplantation with either BioUni® replacement (n=5) or with snowman technique repair (n=23). Defects in both groups had similar characteristics including size, area, location, and classifications. Patient-reported outcomes using the Knee Injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), International Knee Documentation Committee (IKDC), and Physical Health Composite Score (PCS-12) were similar at baseline and increased post-operatively for both groups with no significant differences between techniques after a mean follow-up of 2.77 ± 0.83. Although it did not reach significance, the snowman group had higher rates of knee-related complications (13%) and need for revision surgery (22%) when compared to BioUni® (0% and 0%, respectively). CONCLUSION: The use of both BioUni® and snowman techniques for large, unicondylar articular cartilage lesions of the femoral condyle demonstrate improved patient-reported outcomes at short-term follow-up. The use of the snowman technique presents relatively higher rates of revision similar to previous studies with no statistical difference in patient-reported outcomes when compared to those of a single plug OCA using a BioUni® system.

Successful Neuromuscular Blockade Reversal Using Sugammadex and Neostigmine Failed to Prevent Myasthenic Crisis After Emergency Surgery: A Case Report.

Recent literature suggests that the use of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) reduces the risk of postoperative myasthenic crisis (MC) in patients with myasthenia gravis (MG), particularly after thymectomy, but studies are lacking on emergency surgeries. We achieved successful intraoperative reversal of neuromuscular blockade (NMB) using a combination of sugammadex and neostigmine (with glycopyrrolate). However, MC was not avoided and reintubation was required on postoperative day 1. A 65-year-old male with a longstanding history of MG presented to the emergency department with complaints of abdominal pain, diarrhea, vomiting, chills, and fatigue for three days. A computed tomography (CT) scan of the abdomen showed acute appendicitis, for which he underwent a laparoscopic appendectomy on hospital day 1. The patient received successful general anesthesia with a rapid sequence induction using a smaller than average dose of rocuronium, given his history of MG. At the conclusion of the case, sugammadex followed by neostigmine/glycopyrrolate and a subsequent dose of sugammadex were given, with reversal of NMB. The patient was successfully extubated but required reintubation on postoperative day 1 for hypercapnic respiratory failure. Our case report on this patient with MG yields two topics that have not been extensively examined. First, dual therapy with sugammadex and neostigmine/glycopyrrolate may provide significant clinical benefit over individual therapy for NMBA reversal, given that their mechanisms of action are different and particularly when sugammadex is given prior to neostigmine/glycopyrrolate. Second, anesthesia literature is lacking on MG patients undergoing emergency surgeries. While sugammadex has been promising in medically optimized non-emergent surgeries, we discuss here a case where sugammadex failed to prevent MC in the emergency surgery setting and a look into what may provide patients with the best chance for avoiding postoperative MC.