Surgical Efficiency of Anterior Cruciate Ligament Reconstruction in Outpatient Surgical Center Versus Hospital Operating Room.

Anterior cruciate ligament (ACL) reconstructions are complex orthopedic procedures in which a proficient team is of vital importance. Outpatient surgical centers (OSCs) often provide orthopedic-specific teams; however, hospital operating rooms (ORs) commonly rotate staff. The purpose of this study was to compare the efficiency of pediatric ACL reconstructions between a surgical center and a hospital OR owned and directed by a single institution. Cases examined involved pediatric patients, aged 12 to 18 years (mean age, 15.9±1.5 years), who underwent ACL reconstructions by a single orthopedic surgeon from 2009 to 2014. Procedural efficiency was defined as shorter total OR time, less total staff, and fewer support staff changes. Total OR time was also broken into 3 distinct time periods: in-room to incision time, total procedure time, and stop time to out-of-room time. A total of 49 ACL reconstructions were performed in healthy athletes, with 28 surgeries at the OSC (mean age, 15.7±1.3 years) and 21 surgeries in the hospital OR (mean age, 16.1±1.8 years). Overall efficiency was higher at the OSC, with total OR time improved by 30 minutes on average (P=.0001) with less total staff (P=.0002). Surgical technician and nursing changes occurred 6 and 2.5 times more often in the hospital OR, respectively. Procedural efficiency was greater at the OSC. The provision of consistent and experienced orthopedicspecific teams allows for improvement in OR efficiency, cost, and value. [Orthopedics. 2017; 40(5):297-302.].

Reduction and circumferential fusion for low-grade slips and intermediate-grade slips in pediatric spondylolisthesis.

Uninstrumented in-situ fusion of pediatric spondylolisthesis harbors a significant risk of suboptimal outcome. We suggest that reduction and instrumented fusion with deliberate protective measures against neurologic insult should be considered for the treatment of low-grade slips to intermediate-grade slips. This retrospective review of the clinical and radiographic data of 13 consecutively treated pediatric patients describes our experience with this approach. Eleven patients were pain free at the most recent follow-up and showed an average sustained correction in percent slip of 39%. This technique provides a safe alternative to in-situ fusion with the potential for improved outcomes.

Ceramide mediates vascular dysfunction in diet-induced obesity by PP2A-mediated dephosphorylation of the eNOS-Akt complex.

Vascular dysfunction that accompanies obesity and insulin resistance may be mediated by lipid metabolites. We sought to determine if vascular ceramide leads to arterial dysfunction and to elucidate the underlying mechanisms. Pharmacological inhibition of de novo ceramide synthesis, using the Ser palmitoyl transferase inhibitor myriocin, and heterozygous deletion of dihydroceramide desaturase prevented vascular dysfunction and hypertension in mice after high-fat feeding. These findings were recapitulated in isolated arteries in vitro, confirming that ceramide impairs endothelium-dependent vasorelaxation in a tissue-autonomous manner. Studies in endothelial cells reveal that de novo ceramide biosynthesis induced protein phosphatase 2A (PP2A) association directly with the endothelial nitric oxide synthase (eNOS)/Akt/Hsp90 complex that was concurrent with decreased basal and agonist-stimulated eNOS phosphorylation. PP2A attenuates eNOS phosphorylation by preventing phosphorylation of the pool of Akt that colocalizes with eNOS and by dephosphorylating eNOS. Ceramide decreased the association between PP2A and the predominantly cytosolic inhibitor 2 of PP2A. We conclude that ceramide mediates obesity-related vascular dysfunction by a mechanism that involves PP2A-mediated disruption of the eNOS/Akt/Hsp90 signaling complex. These results provide important insight into a pathway that represents a novel target for reversing obesity-related vascular dysfunction.