Endonasal septal perforation repair using posterior and inferiorly based mucosal rotation flaps.

IMPORTANCE: Repair of nasal septal perforations is challenging regardless of surgical technique due to their location and the health of surrounding tissue. There is currently no surgical procedure which is completely effective in the treatment of anteriorly located perforations. OBJECTIVE: To report a novel method of closing anterior septal perforations using an inferiorly based mucosal rotation flap and an acellular dermal interposition graft, as well as expand upon a previous series. DESIGN: The study includes patients who underwent surgical repair for septal perforations by the senior author between 2003 and 2015. SETTING: The study took place at MetroHealth Medical Center in Cleveland, Ohio. PARTICIPANTS: Thirty-nine patients (15 male) with septal perforations of various size and etiology underwent endonasal repair using rotation flaps. The average age of patients was 42-years old (range 10-67years). INTERVENTION FOR CLINICAL TRIALS OR EXPOSURE FOR OBSERVATIONAL STUDIES: Five patients had perforations such that we used inferiorly based flaps, while 35 cases utilized posteriorly based flaps. Acellular dermis was used in addition to a unilateral rotation flap. MAIN OUTCOMES AND MEASURES: The primary outcome desired was a complete closure of the septal perforation. The success, or lack thereof, was monitored after healing from surgery. RESULTS: Thirty-seven of the forty surgical procedures demonstrated complete closure of the perforation, a 92.5% success rate. Perforations were separated based upon size. Small perforations (<1cm) had a 93.3% success rate, medium (1-2cm) 88.9%, and all seven large perforations (>2cm) were closed successfully. In addition, all five of the inferiorly based procedures resulted in complete closure of the perforation. Of the failed repairs, one required revision surgery to repair a recurring perforation, while the other two were asymptomatic following the procedure. CONCLUSIONS AND RELEVANCE: Endonasal repair using inferiorly based mucosal rotation flaps coupled with an acellular dermal interposition graft is a valid technique for the repair of septal perforations. Posterior rotation flaps are preferred due to major septal blood supply from branches of the sphenopalatine artery, but inferiorly based flaps are also viable options for repair for perforations located in the anterior septum.

Outcomes in Pediatric Hip FAI Surgery: a Scoping Review.

PURPOSE OF REVIEW: Femoracetabular impingement (FAI) is a common source of hip pain in children and adolescents. While nonoperative therapies and open surgical procedures can be effective, hip arthroscopy is a minimally invasive treatment option with substantial benefit. The purpose of this paper is to evaluate the current role of hip arthroscopy in treating FAI within the pediatric population. This article examines its efficacy through a review of hip arthroscopy outcomes in the contemporary orthopaedic literature. RECENT FINDINGS: Morphologic changes in the acetabulum and proximal femur seen in FAI can be attributed to a multitude of etiologies-including idiopathic FAI, Legg-Calve-Perthes, and slipped capital femoral epiphysis. In general, arthroscopic treatment of FAI secondary to these conditions leads to statistically significant improvements in pain and patient-reported outcomes in the short and long term. In the pediatric athlete, repetitive stress on the hip perpetuates FAI and can drastically hinder performance. Hip arthroscopy allows for a high rate of return to sport with minimal morbidity in this population. Overall, pediatric hip arthroscopy is effective in treating FAI secondary to a wide variety of conditions. Despite its clinical benefits, patients and their families should be counseled regarding alternative treatments, potential complications, and return to play.

Reduced Opioid Prescription After Anterior Cruciate Ligament Reconstruction Does Not Affect Postoperative Pain or Prescription Refills: A Prospective, Surgeon-Blinded, Randomized, Controlled Trial.

PURPOSE: To investigate opioid utilization after anterior cruciate ligament (ACL) reconstruction in the setting of a multimodal pain regimen and assess the feasibility of prescribing fewer opioids to achieve adequate postoperative pain control. METHODS: Patients undergoing ACL reconstruction in conjunction with a multimodal approach to pain control were randomized to receive either 30 or 60 tablets of hydrocodone (10 mg)-acetaminophen (325 mg). Patients were contacted at multiple time points up to 21 days after surgery to assess opioid utilization and medication side effects. We compared the mean number of tablets used between groups as the primary outcome. Preoperative variables associated with an increased risk of higher opioid pain medication requirements were also assessed. RESULTS: The final analysis included 43 patients in the 30-tablet group and 42 in the 60-tablet group. There was no significant difference between groups in the number of tablets consumed (9.5 vs 12.2, P = .22), number of days opioids were required (4.5 vs 6.2, P = .14), 3-month opioid refill rates (12% vs 7%, P = .48), or postoperative pain control at any point up to 21 days after surgery. The 30-tablet group had a significantly smaller proportion of unused tablets compared with the 60-tablet group (69% of prescribed tablets [910 tablets] vs 80% of prescribed tablets [2,027 tablets], P < .001). Opioids were required after surgery by 91% of patients (n = 77), and 81% could have had their pain medication requirements met with a prescription for 15 tablets. Risk factors for increased postoperative opioid use included a family history of substance abuse (ß = 14.1; 95% confidence interval, 5.7-22.4; P = .0014) and increased pain score at 2 hours after surgery (ß = 1.07; 95% confidence interval, 0.064-2.07; P = .037). CONCLUSIONS: Orthopaedic surgeons may significantly reduce the number opioid tablets prescribed after ACL reconstruction without affecting postoperative pain control or refill rates. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Can preoperative magnetic resonance arthrography accurately predict intraoperative hip labral thickness?

OBJECTIVE: There is limited literature investigating the reliability of magnetic resonance-based assessments of labral size. The goal of this study was to validate the reliability of magnetic resonance arthrography-based labral size measurements with intra-operative arthroscopic measurements. METHODS: Patients undergoing hip arthroscopy for femoroacetabular impingement and labral tears were prospectively enrolled. Preoperative magnetic resonance arthrograms were used to determine labral size at the anterior-superior portion (zone 2), mid-superior portion (zone 3), and posterior-superior portion (zone 4). Intra-operative labral widths were measured at the same anatomical zones of the acetabulum using an arthroscopic probe. Mean labral size was determined for each location and a Pearson correlation was used to determine the correlation between imaging-based measurements and intra-operative measurements. RESULTS: 117 patients were enrolled with 70% being female, an average age of 39.1 ± 13.3, and an average body mass index was 26.5 ± 5.4. The average labral sizes based on intraoperative measurements were 6.85 mm in zone 2, 7.45 mm in zone 3, and 7.29 mm in zone 4. The average labral sizes based on MRA were 6.95 mm in zone 2, 7.24 mm in zone 3, and 6.71 mm in zone 4. There was a poor correlation between MRA and intraoperative measurements in zones 2 and 3 (zone 2: R = 0.171, p = 0.065; zone 3: R = 0.335, p = 0.00022) and no correlation in zone 4 (R = -0.22, p = 0.82). CONCLUSION: This study demonstrates a poor correlation in labral measurements between magnetic resonance arthrogram imaging and intraoperative measurements, suggesting that this imaging modality may be insufficient in providing accurate measurements of labral size.

Thursday Night Football's impact on all-cause injuries in NFL players during 2012 - 2017.

Objectives: This study sought to determine whether shortened recovery periods between regularly scheduled Sunday NFL games and Thursday Night Football games significantly increased the incidence of injury in NFL players. Methods: NFL injury reports and injury reserve data were collected for every NFL player, on all 32 NFL teams, for each week during the regular season, for the 2012-2013, 2013-2014, 2014-2015, 2015-2016, and 2016-2017 NFL seasons. Injuries were defined as any reported injury, not previously documented in an injury report prior to said injury. Calculated injury rates per 1000 athletic exposures for Sunday and Monday night games versus Thursday night games was used to generate relative risk of injury using 95% confidence intervals. Results: The all-cause injury rate during NFL Sunday and Monday Night Football games was found to be 7,598 per 1000 athletic exposures, while the all-cause injury rate during Thursday Night Football games was found to be 6,072 per 1,000 athletic exposures. The relative risk of injury during Thursday Night Football games was calculated to be 0.97 compared to Sunday and Monday night games. Therefore, the rate of injury during Thursday Night Football games was significantly less than the rate of injury during Sunday and Monday night games, despite the lack of additional recovery time. Conclusion: This study suggests that eliminating Thursday Night Football is unlikely to improve the statistical injury rate among NFL players.