Semi-quantitative arthroscopic scoring system is related to clinical outcomes in patients after medial meniscus posterior root repair.

BACKGROUND: Different methods are available to assess the healing status of repaired root for medial meniscus posterior root tears (MMPRT) using second-look arthroscopy. However, few studies are comparing them or validating their usefulness. Therefore, it was hypothesized that the semi-quantitative arthroscopic score might correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. METHODS: Data of 61 patients who underwent MMPRT pullout repair and second-look arthroscopy were retrospectively evaluated. The semi-quantitative arthroscopic scoring system was divided into three evaluation criteria: scores from 0 to 10 points include the width of the bridging tissue, stability of the repaired root, and synovial coverage. The qualitative evaluation was classified into 4 status; complete healing, lax healing, scar tissue healing, and failed healing according to the stability and mobility of the repaired root. Multivariate linear regression analyses were used to identify predictors of 1-year postoperative clinical outcomes, including Knee Injury and Osteoarthritis Outcome, Lysholm, or International Knee Documentation Committee scores. Spearman's correlation analysis was used to analyze the correlation between second-look arthroscopic score/qualitative evaluation and 1-year postoperative clinical outcomes. In addition, the optimal cutoff point of semi-quantitative arthroscopic score was determined by receiver operating characteristic (ROC) curve. The Mann-Whitney U test was used to compare clinical outcomes between patients with semi-quantitative arthroscopic scores ≥8 and scores <8. RESULTS: All clinical scores significantly improved at 1 year postoperatively. A good correlation was observed between the semi-quantitative score and clinical scores, but none between qualitative evaluation and clinical scores. The optimal cutoff point of semi-quantitative second-look arthroscopic score was 8 points. Significantly, better clinical outcomes were observed in patients with semi-quantitative scores ≥8 points. CONCLUSIONS: All 1-year postoperative clinical scores were significantly improved. The semi-quantitative arthroscopic scores correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. LEVEL OF EVIDENCE: IV case series study.

Does second-look endoscopy reduce the bleeding after gastric endoscopic submucosal dissection for patients receiving antithrombotic therapy?

BACKGROUND: In patients with average risk of bleeding, second-look endoscopy does not reportedly reduce bleeding after gastric endoscopic submucosal dissection. However, effectiveness of second-look endoscopy for patients with a high risk of bleeding, such as those who are taking antithrombotic agents, is unclear. Hence, this study aims to clarify the effectiveness of second-look endoscopy for patients with antithrombotic therapy. METHODS: We studied 142 consecutive patients with 173 gastric epithelial neoplasms who were routinely taking antithrombotic agents and were treated by endoscopic submucosal dissection at Tonan Hospital between November 2013 and December 2019. They were classified into two groups: those with second-look endoscopy (SLE group, 69 patients with 85 lesions) and those without second-look endoscopy (non-SLE group, 73 patients with 88 lesions). The incidence of post-endoscopic submucosal dissection bleeding was compared between the SLE and non-SLE groups. RESULTS: There were no statistical differences in the rate of patients undergoing single antiplatelet therapy, single anticoagulant therapy, and multiple therapy between the SLE and non-SLE groups (SLE group vs. non-SLE group; 32 [46.4%], 16 [23.2%], and 21 [30.4%] patients vs. 37 [50.7%], 20 [27.4%], and 16 [21.9%] patients, respectively; p = 0.50). Post-endoscopic submucosal dissection bleeding incidence was 21.7% (15/69) and 21.9% (16/73) in the SLE and non-SLE groups, respectively, and did not significantly differ between the two groups (p = 0.98). CONCLUSIONS: For patients taking antithrombotic agents, the incidence of post-endoscopic submucosal dissection bleeding was not reduced by second-look endoscopy.

Medial Meniscus Posterior Root Repair Using a Modified Mason-Allen Suture Can Prevent the Progression of Cartilage Degeneration on the Loading Surface of the Medial Compartment: A Second-Look Arthroscopic Evaluation.

The treatment of medial meniscus posterior root tears (MMPRTs) has evolved to include a variety of repair strategies. This study investigated the location of the articular cartilage degeneration during second-look arthroscopy after transtibial pullout repair with a modified Mason-Allen suture using FasT-Fix (F-MMA) in 22 patients with MMPRTs. Second-look arthroscopy was performed approximately 1 year postoperatively to eval-uate the healing status of the medial meniscus (MM). Articular cartilage degeneration was assessed using the International Cartilage Repair Society grade at primary surgery and again at second-look arthroscopy. Articular surfaces of the medial/lateral femoral condyles, the medial/lateral tibial plateaus, the patella and the trochlea were divided into several subcompartments (MF 1-9, LF 1-9, MT 1-5, LT 1-5, P 1-9, T 1-3). Clinical evaluations used the Japanese Knee Injury and Osteoarthritis Outcome, Lysholm, and International Knee Documentation Committee scores. Second-look arthroscopic findings showed complete healing of the MM posterior root in all patients. Significant differences between pullout repair and second-look arthroscopy were observed for MF 2 and 4, LF 7, and P 7. All clinical outcomes were improved. Our results indicate that this technique improves clinical outcomes postoperatively and may prevent the progression of cartilage degenera-tion on the loading surface of the medial knee compartment.

Bone marrow aspirate concentration provided better results in cartilage regeneration to microfracture in knee of osteoarthritic patients.

PURPOSE: To determine whether microfracture with bone marrow aspirate concentrate (BMAC) improves functional outcome and cartilage regeneration better than microfracture alone in patients undergoing high tibial osteotomy (HTO) for medial unicompartmental osteoarthritis (OA). METHODS: Among 436 patients treated with HTO for medial unicompartmental OA with varus deformity between 2010 and 2016, clinical outcomes were retrospectively compared between the microfracture alone group (group I, 43 cases) and microfracture with BMAC augmentation group (group II, 48 cases). Of these, 64 patients underwent a second-look arthroscopic assessment. Clinical outcomes were compared based on the Knee Society Score (KSS), International Knee Documentation Committee (IKDC) subjective score, and Western Ontario and McMaster Universities Arthritis Index (WOMAC). Cartilage regeneration was assessed according to Koshino's staging system and the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system. RESULTS: At the last follow-up, there were no significant intergroup differences in terms of KSS for pain and function (p > 0.05). Moreover, WOMAC scores were similar between the two groups (p > 0.05). Regarding second-look arthroscopy findings, according to Koshino's staging system, there was no significant intergroup difference in terms of defect coverage (p = 0.187). However, group II showed a significantly better mean CRA score than group I (p = 0.035). CONCLUSION: There were no significant differences in clinical outcomes and cartilage regeneration between the groups. However, the CRA score was significantly higher with BMAC augmentation and microfracture than microfracture alone. Therefore, BMAC augmentation had a synergistic effect for a better cartilage regeneration, although studies with a longer follow-up might help to confirm whether microfracture with BMAC augmentation would ensure better clinical outcomes than microfracture alone for the treatment of knee OA.

Patient-reported evaluation on giving way is important for return to preinjury activity level after Anterior Cruciate Ligament reconstruction.

PURPOSE: The present study evaluated the rate of returning to the preinjury level of competitive sports after ACLR and influential factors. METHODS: After excluding composite ligament injury cases, 96 patients with a Tegner activity score of ≥ 6 who were managed between April 2015 and March 2016 and had been followed for ≥ 2 years were included in the present study. The patients were evaluated for instability, and the following data were collected: second-look arthroscopy findings, muscle strength, and International Knee Documentation Committee (IKDC) subjective score (follow-up rate: 88.1%). RESULTS: The rate of returning to the preinjury level of competitive sports was 62/96 (64.6%). Only the total IKDC subjective score (odds ratio, 1.052; 95% confidence interval 1.004-1.102; p = 0.035) and the subjectively evaluated item about giving way (odds ratio, 1.762; 95% confidence interval 1.066-2.911; p = 0.027) were independently associated with the returning to the preinjury level of competitive sports after ACLR in the logistic regression analysis. CONCLUSION: The rate of returning to the preinjury level of competitive sports after ACLR was 64.6%, even if a good knee stability and healing status of the sutured meniscus were acquired after ACLR. The IKDC subjective score, especially the item about giving way, was significantly associated with the returning to the preinjury level of competitive sports. The factors assessed by patient-reported evaluations concerning giving way that may be related to functional performance, including brain activity, are important to consider to improve the rate of returning to the preinjury level of competitive sports. LEVEL OF EVIDENCE: III.

Second-look surgery plus hyperthermic intraperitoneal chemotherapy versus surveillance in patients at high risk of developing colorectal peritoneal metastases (PROPHYLOCHIP-PRODIGE 15): a randomised, phase 3 study.

BACKGROUND: Diagnosis and treatment of colorectal peritoneal metastases at an early stage, before the onset of signs, could improve patient survival. We aimed to compare the survival benefit of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC), with surveillance, in patients at high risk of developing colorectal peritoneal metastases. METHODS: We did an open-label, randomised, phase 3 study in 23 hospitals in France. Eligible patients were aged 18-70 years and had a primary colorectal cancer with synchronous and localised colorectal peritoneal metastases removed during tumour resection, resected ovarian metastases, or a perforated tumour. Patients were randomly assigned (1:1) to surveillance or second-look surgery plus oxaliplatin-HIPEC (oxaliplatin 460 mg/m2, or oxaliplatin 300 mg/m2 plus irinotecan 200 mg/m2, plus intravenous fluorouracil 400 mg/m2), or mitomycin-HIPEC (mitomycin 35 mg/m2) alone in case of neuropathy, after 6 months of adjuvant systemic chemotherapy with no signs of disease recurrence. Randomisation was done via a web-based system, with stratification by treatment centre, nodal status, and risk factors for colorectal peritoneal metastases. Second-look surgery consisted of a complete exploration of the abdominal cavity via xyphopubic incision, and resection of all peritoneal implants if resectable. Surveillance after resection of colorectal cancer was done according to the French Guidelines. The primary outcome was 3-year disease-free survival, defined as the time from randomisation to peritoneal or distant disease recurrence, or death from any cause, whichever occurred first, analysed by intention to treat. Surgical complications were assessed in the second-look surgery group only. This study was registered at ClinicalTrials.gov, NCT01226394. FINDINGS: Between June 11, 2010, and March 31, 2015, 150 patients were recruited and randomly assigned to a treatment group (75 per group). After a median follow-up of 50·8 months (IQR 47·0-54·8), 3-year disease-free survival was 53% (95% CI 41-64) in the surveillance group versus 44% (33-56) in the second-look surgery group (hazard ratio 0·97, 95% CI 0·61-1·56). No treatment-related deaths were reported. 29 (41%) of 71 patients in the second-look surgery group had grade 3-4 complications. The most common grade 3-4 complications were intra-abdominal adverse events (haemorrhage, digestive leakage) in 12 (23%) of 71 patients and haematological adverse events in 13 (18%) of 71 patients. INTERPRETATION: Systematic second-look surgery plus oxaliplatin-HIPEC did not improve disease-free survival compared with standard surveillance. Currently, essential surveillance of patients at high risk of developing colorectal peritoneal metastases appears to be adequate and effective in terms of survival outcomes. FUNDING: French National Cancer Institute.

Use of an Intrauterine Foley Probe for Ultrasound-Assisted Hysteroscopic Resection of Complete Uterine Septum.

STUDY OBJECTIVE: To demonstrate our technique for hysteroscopic resection of the complete uterine septum. DESIGN: Step-by-step description and demonstration of the procedure using pictures and video (educational video). The video was approved by our hospital's Ethical Committee. SETTING: Uterine malformations represent a rare, yet usually asymptomatic condition that can be associated with poor obstetric outcomes. The European Society for Gynaecological Endoscopy(ESGE)/European Society of Human Reproduction and Embryology (ESHRE)classification is widely accepted for the description of female genital tract anomalies. Treatment of the uterine septum should be considered if fertility is desired, with hysteroscopic resection the gold standard procedure. INTERVENTION: A patient with a U2bC2V1 malformation according to the ESGE/ESHRE classification was treated with hysteroscopy. The procedure was performed in the operating room under general anesthesia using a 9-mm hysteroscope with a bipolar cutting loop. Surgery began with resection of the vaginal septum with monopolar electrosurgery until the cervix was visualized. A Foley probe was placed in 1 uterine hemicavity, and then hysteroscopy on the other hemicavity was performed. Transrectal ultrasound guidance was used to identify the limits of the septum and thereby enhance the safety of the procedure. Resection of the septum started in the upper part until the Foley probe was seen, then continued downward until internal cervical orifice was reached. In the hysteroscopic follow-up after 3 months, we visualized a small residual septum that was resected to fully restore the uterine cavity and improve the patient's obstetric outcomes. The procedure was completed without complications, and a second-look hysteroscopy showed a normal uterine cavity. CONCLUSION: The combination of real-time ultrasound guidance and placement of an intrauterine balloon through the cervix may increase safety during the procedure by providing clear visualization of the uterine cavity and septum border during resection.

Transtibial fixation for medial meniscus posterior root tear reduces posterior extrusion and physiological translation of the medial meniscus in middle-aged and elderly patients.

PURPOSE: To investigate changes in meniscal extrusion during knee flexion before and after pullout fixation for medial meniscus posterior root tear (MMPRT) and determine whether these changes correlate with articular cartilage degeneration and short-term clinical outcomes. METHODS: Twenty-two patients (mean age 58.4 ± 8.2 years) diagnosed with type II MMPRT underwent open magnetic resonance imaging preoperatively, 3 months after transtibial fixation and at 12 months after surgery, when second-look arthroscopy was also performed. The medial meniscus medial extrusion (MMME) and the medial meniscus posterior extrusion (MMPE) were measured at knee 10° and 90° flexion at which medial meniscus (MM) posterior translation was also calculated. Articular cartilage degeneration was assessed using International Cartilage Research Society grade at primary surgery and second-look arthroscopy. Clinical evaluations included Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee subjective knee evaluation form, Lysholm score, Tegner activity level scale, and pain visual analogue scale. RESULTS: MMPE at 10° knee flexion was higher 12 months postoperatively than preoperatively (4.8 ± 1.5 vs. 3.5 ± 1.2, p = 0.01). MMPE at 90° knee flexion and MM posterior translation were smaller 12 months postoperatively than preoperatively (3.5 ± 1.1 vs. 4.6 ± 1.3, 7.2 ± 1.7 vs. 8.9 ± 2.0, p < 0.01). Articular cartilage degeneration of medial femoral condyle correlated with MMME in knee extension (r = 0.5, p = 0.04). All clinical scores significantly improved 12 months postoperatively. However, correlations of all clinical scores against decreased MMPE and increased MMME were not detected. CONCLUSIONS: MMPRT transtibial fixation suppressed the progression of MMPE and cartilage degeneration and progressed MMME minimally in knee flexion position at 1 year. However, in the knee extension position, MMME progressed and correlated with cartilage degeneration of medial femoral condyle. MMPRT transtibial fixation contributes to the dynamic stability of the MM in the knee flexion position. LEVEL OF EVIDENCE: IV.

The role of the anterolateral ligament in knee's biomechanics: a case-control retrospective study.

PURPOSE: The aim of this study was to assess the functional and clinical results of patients who underwent ACL reconstruction surgery and were divided into subpopulations related to ACL-associated lesions and focused on ALL-associated lesion. METHODS: Our retrospective analysis included 62 patients who underwent standard ACL reconstruction surgery in our hospital from 2014 to 2016. The mean follow-up period was 21 months (range 11-35). We divided the sample into two subpopulations due to the presence or absence of ALL tear at the preoperative MRI. In 42 patients out of 62 (68%), ALL lesion was evident. We evaluated in both subpopulations the ACL failure rate, the functional outcomes rated with IKDC, KOOS, Lysholm scores and the clinical assessment of anteroposterior and rotatory instability with the Lachman test and pivot-shift test. RESULTS: The overall re-injury rate in our cohort of patients was 4.8% with a smaller but not a significant difference between the two groups. A statistically significant difference was observed for the three functional scores, favoring the isolated ACL-lesion group (p < 0.05). Similarly, a better Lachman score was observed in the isolated ACL-lesion group, without statistical significance (p = 0.77); overall, the rate of positive test was lower in the isolated ACL-lesion group. We observed a significant difference of residual rotatory instability (positive pivot-shift test) in the two subpopulations (p = 0.036), and 9% of patients in the ACL + ALL lesion group showed residual jerk or subluxation. CONCLUSION: The additional ALL reconstruction/repair surgery should always be considered in patients with evident ALL tear at the preoperative MRI.

Long-Term Efficacy of Lymph Node Reoperation for Persistent Papillary Thyroid Cancer: 13-Year Follow-Up.

BACKGROUND: Current recommendations for persistent or recurrent locoregional papillary thyroid cancer (PTC) include consideration of surgical resection versus active surveillance. The purpose of this study is to determine long-term outcomes after surgical resection of recurrent or persistent metastatic PTC in cervical lymph nodes after failure of initial surgery and radioactive iodine therapy using newer validated clinical outcomes measures. METHODS: Outcomes of 70 patients who underwent cervical lymphadenectomy (n = 110) from 1999 to 2013 for recurrent or persistent locoregional PTC metastases were reviewed. Measures included biochemical remission (BCR) based on Tg levels, American Thyroid Association classifications for response to treatment [biochemical incomplete response (BIR), structural incomplete response (SIR), indeterminate response (IR), and excellent response (ER)], need for reoperation, surgical complications, disease progression, and death. RESULTS: The median follow-up was 13.1 years, with only two additional reoperations since 2010, one of which had no metastasis on pathology with the other developing anaplastic thyroid cancer in background PTC. ER was achieved in 31 (44%) patients, all of whom remained in ER at time of last follow-up (median 14.1 years). There were no structural recurrences in patients with persistent BIR or IR after reoperation. Patients with SIR had stable disease, except for one who died due to anaplastic thyroid cancer. CONCLUSIONS: Patients who achieved ER after reoperation had no need for further treatment. Patients with persistent detectable Tg levels after reoperation rarely developed structural recurrence. ATA outcomes can be safely used to guide treatment decisions over a decade after reoperation for PTC.

Second and third look laparoscopy in pT4 colon cancer patients for early detection of peritoneal metastases; the COLOPEC 2 randomized multicentre trial.

BACKGROUND: Approximately 20-30% of patients with pT4 colon cancer develop metachronous peritoneal metastases (PM). Due to restricted accuracy of imaging modalities and absence of early symptoms, PM are often detected at a stage in which only a quarter of patients are eligible for curative intent treatment. Preliminary findings of the COLOPEC trial (NCT02231086) revealed that PM were already detected during surgical re-exploration within two months after primary resection in 9% of patients with pT4 colon cancer. Therefore, second look diagnostic laparoscopy (DLS) to detect PM at a subclinical stage may be considered an essential component of early follow-up in these patients, although this needs confirmation in a larger patient cohort. Furthermore, a third look DLS after a negative second look DLS might be beneficial for detection of PM occurring at a later stage. METHODS: The aim of this study is to determine the yield of second look DLS and added value of third look DLS after negative second look DLS in detecting occult PM in pT4N0-2 M0 colon cancer patients after completion of primary treatment. Patients will undergo an abdominal CT at 6 months postoperative, followed by a second look DLS within 1 month if no PM or other metastases not amenable for local treatment are detected. Patients without PM will subsequently be randomized between routine follow-up including 18 months abdominal CT, or an experimental arm with a third look DLS provided that PM or incurable metastases are absent at the 18 months abdominal CT. Primary endpoint is the proportion of PM detected after a negative second look DLS and will be determined at 20 months postoperative. DISCUSSION: Second look DLS is supposed to result in 10% occult PM, and third look DLS after negative second look DLS is expected to detect an additional 10% of PM compared to routine follow-up alone in patients with pT4 colon cancer. Detection of PM at an early stage will likely increase the proportion of patients eligible for curative intent treatment and subsequently improve survival, given the uniformly reported direct association between the extent of peritoneal disease and survival. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03413254 , January 2018.

Intraperitoneal (IP) port cytology after completion of primary therapy for advanced stage ovarian cancer: A novel approach to a "second look".

OBJECTIVE: To determine whether IP port cytology predicts early recurrence and/or poor prognosis in patients with ovarian cancer who have completed primary therapy. METHODS: A prospective study of patients with advanced stage ovarian cancer undergoing IP port removal after debulking followed by IV/IP chemotherapy was performed. Ports were flushed with 10 cc of normal saline into ThinPrep fixative to be analyzed for cytology. Results were correlated with clinical factors and cancer outcomes. Survivals were calculated using Kaplan-Meier curves and compared using log-rank analysis. RESULTS: Effluent from 53 IP ports was analyzed, and patients were followed for a median of 62 months. Mean age was 58.5, with the majority of patients being white (90%), with stage 3 (62%), serous histology (87%). Seven (13.2%) patients had positive IP cytology. POS and NEG groups were similar with regard to age, BMI, stage, grade, and GOG status. Patients with POS results had increased risk of recurrence HR 3.2 (95%CI 0.4, 28.9), and death HR 6.5 (95%CI 0.7, 58.8), and were more likely to recur before 12 months, 71% vs. 22% (p = 0.007). Compared to NEG, POS conferred a shorter median survival with PFS of 32 vs. 7 months (p = 0.02) and OS of 84 vs. 42 months (p = 0.04). CONCLUSIONS: IP port cytology is predictive of recurrence and survival in patients with ovarian cancer. This inexpensive test may serve as an adjunct to imaging and tumor markers to determine disease status at the completion of treatment. Further study should investigate how this may impact management.

Thoracoscopic truncal vagotomy versus surgical revision of the gastrojejunal anastomosis for recalcitrant marginal ulcers.

INTRODUCTION: Marginal ulcer is a common complication following Roux-en-Y gastric bypass with incidence rates between 1 and 16%. Most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. Revision of the gastrojejunal (GJ) anastomosis carries significant morbidity with complication rates ranging from 10 to 50%. Thoracoscopic truncal vagotomy (TTV) may be a safer alternative with decreased operative times. The purpose of this study is to evaluate the safety and effectiveness of TTV in comparison to GJ revision for treatment of recalcitrant marginal ulcers. METHODS: A retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from 1 September 2012 to 1 September 2017. All underwent medical therapy along with lifestyle changes prior to intervention and had preoperative EGD that demonstrated a recalcitrant marginal ulcer. Revision of the GJ anastomosis or TTV was performed. Data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate. RESULTS: Twenty patients were identified who underwent either GJ revision (n = 13) or TTV (n = 7). There were no 30-day mortalities in either group. Mean operative time was significantly lower in the TTV group in comparison to GJ revision (95.7 ± 16 vs. 227.5 ± 89 min, respectively, p = 0.0022). Recurrence of ulcer was not significant between groups and occurred following two GJ revisions (15%) and one TTV (14%). Complication rates were not significantly different with 62% in the GJ revision group and 57% in the TTV group. Approximately 38% (5/13) of GJ revisions and 28% (2/7) of TTV patients experienced complications with Clavien-Dindo scores > 3. There was no difference in postoperative symptoms between both groups. CONCLUSIONS: Our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. However, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups.

Predictive Factors for Patellofemoral Degenerative Progression After Opening-Wedge High Tibial Osteotomy.

PURPOSE: To identify risk factors for patellofemoral degenerative progression after opening-wedge high tibial osteotomy (HTO) and to investigate the effect of patellofemoral degeneration on the patellofemoral specific patient-reported outcomes. METHODS: Between March 2010 and June 2016, 94 knees (86 patients) underwent hardware removal with second-look arthroscopy at 21.4 months after opening-wedge HTO with first-look arthroscopy (mean follow-up duration, 49.8 months). Predictive factors for patellofemoral degeneration, including demographics, preoperative and postoperative mechanical axis (MA) of the lower limb (positive and negative MA indicating varus and valgus, respectively), tibial slope, and modified Blackburne-Peel ratio, were evaluated. Patients were divided into the progression and nonprogression groups according to their patellofemoral degenerative progression from first to second arthroscopy. Clinical outcomes, including the Kujala score and Knee Injury and Osteoarthritis Outcome Score, and radiographic outcomes were compared between the 2 groups. RESULTS: Postoperative MA (adjusted odd ratio, 0.62; P < .001) was the most significant predictive factor for progressive change in the patellofemoral joint (Rn2 = 0.31). Twenty-eight knees (30%) showed patellofemoral degenerative progression. Mean postoperative Kujala score (progression group 60.5 vs nonprogression group, 72.3; P = .005) and Knee Injury and Osteoarthritis Outcome Score scales (except for the symptom subscale) were lower in the progression group. Postoperative MA was significantly more corrected in the progression group (progression group -5.1° ± 2.7° vs nonprogression group -2.4° ± 2.3°; P < .001). CONCLUSIONS: Postoperative MA, which might be related to overcorrection, is correlated with patellofemoral degenerative progression after opening-wedge HTO. Patients with patellofemoral degenerative progression showed inferior patient-reported outcomes. LEVEL OF EVIDENCE: Level IV, case series with subgroup analysis.

The Clinical Outcome of Arthroscopic Versus Open Popliteal Tendon Reconstruction Combined With Posterior Cruciate Ligament Reconstruction in Patients With Type A Posterolateral Rotational Instability.

PURPOSE: To compare the objective and subjective clinical outcomes of arthroscopic versus open popliteal tendon (PT) reconstruction combined with posterior cruciate ligament reconstruction in patients with type A posterolateral corner injury. METHODS: From January 2012 to March 2016, patients were eligible for inclusion in this study if they (1) had type A posterolateral rotational instability according to Fanelli's classification, (2) underwent arthroscopic (group A) or open PT (group B) reconstruction, and (3) were followed for a minimum of 2 years with second-look arthroscopic findings. For evaluation, this study used subjective scoring systems (Lysholm, Tegner, and International Knee Documentation Committee subjective scores), knee stability examinations (side-to-side differences of tibial external rotation angle by dial test and posterior and varus stress radiographs), and second-look arthroscopic lateral gutter drive-through tests during hardware removal operations. RESULTS: A total of 38 patients were included in the study. The mean follow-up period was 31.0 ± 5.8 months in group A (n = 21) and 34.8 ± 12.7 months in group B (n = 17). At the final follow-up, all subjective and objective evaluation results were significantly improved compared with the preoperative condition. There were no significant intergroup differences in Lysholm score (group A, 72.7 ± 17.2; group B, 67.2 ± 14.2; P = .818), Tegner score (group A, 2; group B, 2; P = .710), or International Knee Documentation Committee subjective score (group A, 73.0 ± 13.8; group B, 69.7 ± 20.7; P = .561) at the final follow-up. In terms of objective evaluations, there was no difference in side-to-side difference of posterior stress radiography (group A, 4.0 ± 3.2 mm; group B, 5.0 ± 2.9 mm; P = .336) or lateral gutter drive-through test positive rate (group A, 1/21, 4.8%; group B, 2/17, 11.8%; P = .426). CONCLUSION: Both arthroscopic and open PT reconstruction significantly improved the knee stability and subjective outcome of patients with type A posterolateral rotational instability. In comparison with the open procedure, the arthroscopic PT reconstruction showed similar subjective and objective clinical outcomes. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Reoperation after Ladd's procedure in the neonatal period.

AIM OF THE STUDY: To investigate (1) the indications for reoperation after neonatal Ladd's procedure, (2) the type of reoperation and (3) its outcome. METHODS: We reviewed all neonatal Ladd's procedures in our hospital from 2003 to 2017 and the outcomes of reoperation in these patients. MAIN RESULTS: 252 neonates had Ladd's procedure: 59 were laparoscopic (23.4%) and 193 open (76.6%). 15 (6.0%) required reoperation with no difference between laparoscopic and open (p = 0.12). Overall, the indications for reoperation were: adhesive intestinal obstruction (n = 10, 4.0%), recurrent midgut volvulus (n = 4, 1.6%), and missed diagnosis of associated anomaly (n = 1, 0.4%). The incidence of recurrent midgut volvulus was higher after laparoscopic Ladd's procedure (3/59; 5.1%) compared to open Ladd's procedure (1/193; 0.5%) (p = 0.04). Adhesive intestinal obstruction developed after both open (8/193, 4.1%) or laparoscopic Ladd's procedure (2/59, 3.3%). The duration of reoperation and the length of post-operative hospital stay were 63.4 ± 27.1 min and 10.1 ± 5.2 days, respectively. After reoperation, there were no post-operative complications. All children were well at follow-up (6 months-14 years). CONCLUSIONS: In neonates, laparoscopic Ladd's procedure compared to the open Ladd's procedure is associated with a significantly higher risk of recurrent volvulus. The risk of developing this potentially dangerous complication after laparoscopic Ladd's procedure raises doubts about the effectiveness and safety of the laparoscopic approach in neonates.

Second-look arthroscopy after anatomic anterior cruciate ligament reconstruction: Bone-patellar tendon-bone versus hamstring tendon graft.

PURPOSE: The purpose of this study was to compare the morphological and clinical outcomes between anatomic rectangular tunnel (ART) ACL reconstruction with a BTB graft and anatomic triple-bundle (ATB) ACL reconstruction with hamstring tendon (HST) grafts. METHODS: The anatomic ACL reconstructions were performed on 467 patients; 233 patients with ART technique and 234 with ATB procedure. ART procedure was predominantly indicated for athletes with higher motivation to return to sports and aggressiveness for muscle training. A total of 113 patients, with a mean age of 20.7 years, had consented to undergo second-look arthroscopy. The average time from ACL reconstruction to the second-look was 10.0 months. This study included 56 ART techniques and 57 ATB procedures. The grafts underwent meticulous probing, and were evaluated based on tension, graft damage, and synovial coverage. Moreover, the femoral tunnel aperture was also observed in detail to assess the space between the femoral tunnel and the graft. As clinical evaluation, knee effusion, range of motion, Lachman test, pivot shift test, KT side-to-side difference, and Lysholm score were assessed. RESULTS: There was no significant difference in graft tension between two procedures, while HST graft in ATB procedure had more cases with graft damage (p = 0.05). Good synovial coverage was found in 98% in ART procedure and 70% in ATB procedure, showing a significant difference (P < 0.001). At femoral tunnel aperture, there were no cases with the space around BTB graft, while 33% showed the space around HST graft, again showing a significant difference (P < 0.001). There were no significant differences in clinical outcomes. CONCLUSION: BTB graft with the ART procedure was superior to HST graft with the ATB procedure in morphology at second-look arthroscopy, while there was no significant difference in clinical outcomes between two procedures.

Incidence of reoperation and wound dehiscence in patients treated for peroneal tendon dislocations: comparison between osteotomy versus soft tissue procedures.

PURPOSES: There is a lack of substantial clinical evidence endorsing the clinical outcomes of osteotomy for peroneal tendon dislocations. The aim of this study was to compare the post-operative reoperation rates following osteotomy techniques and soft tissues procedures using large database in order to investigate the efficacy of bony techniques. METHODS: Patients who underwent osteotomy and soft tissue procedures for peroneal tendon dislocations were identified and subsequently analysed using the United Healthcare Orthopedic and the Medicare datasets (PearlDiver Patient Record Database, PearlDiver Technologies Inc., Fort Wayne, IN). The investigated period was from 2005 to 2012. The annual incidence, gender distribution, and incidences of reoperation and wound dehiscence following primary operative procedures were determined in these cohorts. RESULTS: Of 6122 patients who received operative treatment for peroneal tendon dislocations, 1416 patients (23.1%) received the osteotomy technique, while 4706 (76.9%) were treated with the soft tissue techniques. The incidence of these operative procedures did not change significantly over the time periods of each database. In both databases, reoperation rates were 2.8% (40/1416) for osteotomy patients and 3.4% (158/4706) for soft tissue repair patients, with no statistical difference (2.8 vs. 3.4%. odds ratio 0.8, 95% confidence interval [CI] 0.6-1.2, [n.s.]) between them. Based on both databases, wound dehiscence occurred in 2.6% (37/1416) of the osteotomy patients and 2.3% (110/4706) of soft tissue repair patients with no statistical difference (2.6 vs. 2.3%, odds ratio 1.1, 95% CI 0.8-1.6, [n.s.]) between the groups. CONCLUSION: The results of this study show that osteotomy techniques were frequently performed for patients with peroneal tendon dislocations. Nevertheless, osteotomy techniques for peroneal tendon dislocations are not associated with a lower risk of reoperation. In conclusion, soft tissue procedures offer a satisfactory method of treating peroneal tendon dislocations without any additional risk of reoperation when compared to osteotomy techniques that have potentially greater complication rates. LEVEL OF EVIDENCE: III.

Second look arthroscopic evaluation of repaired radial/oblique tears of the midbody of the lateral meniscus in stable knees.

BACKGROUND: Radial/oblique tears of the midbody of the lateral meniscus significantly impair the ability of the meniscus to withstand the tibiofemoral load, requiring meniscal repair. However, healing status after meniscal repair has not been fully elucidated. This study aimed to evaluate arthroscopic findings after inside-out suture repair for isolated radial/oblique tears of the midbody of the lateral meniscus. METHODS: From 2011 to 2015, 18 consecutive patients with isolated radial/oblique tears of the midbody of the lateral meniscus underwent arthroscopic inside-out repair with the tie-grip suture technique. All knees were stable with no previous surgery. All patients were evaluated by second-look arthroscopy at six months postoperatively. Activities including jogging were not allowed until meniscal status was evaluated arthroscopically. To analyze factors associated with healing rates, age, time from injury to initial surgery, and tear zone were compared. RESULTS: Second-look arthroscopy revealed complete healing in four (22%) patients, partial healing in seven (39%), and failure to heal in seven (39%). Significant differences were observed for tear zone (p < 0.0001), but not for age and timing of repair. CONCLUSIONS: Arthroscopic evaluation revealed that inside-out repair with the tie-grip suture technique for isolated radial/oblique tears of the midbody of the lateral meniscus achieved complete or partial healing only in 61% of patients. Satisfactory results were observed particularly in patients with tears extending to the vascular zone, whereas those with tears in the avascular zone failed to achieve healing. Therefore, the operative indication of inside-out repair for radial/oblique tears of the midbody of the lateral meniscus might be limited to tears extending into the vascular zone. Given that 39% of cases were arthroscopically considered a failure even if patients complained of no symptoms in daily life, decisions should be made carefully to allow patients to return to sports activities.

Why women bleed and how they are saved: a cross-sectional study of caesarean section near-miss morbidity.

BACKGROUND: Maternal deaths from 'bleeding during and after caesarean section' (BDACS) have increased in South Africa, and have now become the largest sub-cause of deaths from obstetric haemorrhage. The aim of this study was to describe risk factors and causes of near-miss related to BDACS and interventions used to arrest haemorrhage and treat its effects. METHODS: Cross-sectional prospective study in 13 urban public hospitals in South Africa, from July to December 2014. RESULTS: There were 93 cases of near-miss related and 7 maternal deaths related to BDACS. The near-miss rate was 2.1/1000 live births, and the case fatality rate was 3.5/10 000 caesarean sections. Associated near-miss risk factors were previous caesarean section in 60% of multiparas, pre-operative anaemia (55%), abruptio placentae (20%) and placenta praevia and/or accreta (20%). Atonic uterus (43%) was the most frequent anatomical cause of bleeding for near-miss, followed by surgical trauma (29%). The median duration of the operations resulting in near-miss was 90 min, with 81% noted as difficult by the surgeon. Interventions in cases of near-miss included second-look laparotomy (46%), hysterectomy (41%), B-Lynch brace suture (9%), intensive care unit admission (32%) and red cell transfusion ≥3 units (21%). CONCLUSION: Cases from maternal near-miss from BDACS were frequently associated with pre-operative risk factors. Extensive life-saving interventions were required during and after the operations. An important factor in initiating the sequence of interventions is the realisation by the surgeon that the caesarean section is difficult, so that the progression from uneventful operation to near-miss to death can be arrested.