The Evolution of Pituitary Gland Surgery from the Ancients to the Millennials.

Located at the base of the skull, the pituitary gland has a long and controversial history, not only in terms of its anatomy, but especially in the functions it performs and in the attempt to approach it surgically. Considered by Galen of Pergamon to have a role in releasing waste products of the brain, a theory accepted until the 17th century, the pituitary gland became a separate entity once with the anatomical descriptions of the famous Andreas Vesalius. At the beginning of the 18th century, researches of the time began to be more and more interested in this gland, trying to identify its functions, and at the same time correcting the traditional theories that were wrong or incomplete. Later, they turned their attention to experimental animal studies that represented the germinal nucleus for the transcranial and endoscopic pituitary surgery. In this review, an attempt has been made to record the entire history of anatomy, physiology and surgery of the pituitary gland, from antiquity to the current day's surgical techniques.

Proprioception Analysis following Anterior Cruciate Ligament Reconstruction using Stabilometry: A Prospective, Longitudinal Study / Análise de propriocepção por estabilometria após a reconstrução do ligamento cruzado anterior: Um estudo prospectivo e longitudinal

Abstract Objective Commonly used methods for measuring proprioception have resulted in conflicting reports regarding knee proprioception with anterior cruciate ligament (ACL) rupture and the influence of ACL reconstruction. Methods One hundred subjects (50 patients with radiologically and arthroscopically confirmed unilateral ACL rupture and 50 normal controls) were assessed with regards to proprioception using dynamic single-leg stance postural stabilometry. Instrumented knee ligament laxity and knee outcome scores were also measured. Of the 50 patients in the ACL group, 34 underwent reconstruction and were reassessed postoperatively. Results There was a significant proprioceptive deficiency in the ACL group compared with their contralateral knee ( p < 0.001) and to the control group ( p = 0.01). There was asignificant improvement in knee proprioception following ACL reconstruction compared to preoperative findings ( p = 0.003). There was no correlation between ligament laxity measurements and outcome scores. A significant correlation was found preoperatively between outcome scores and proprioception measurements. This correlation was not found post-operatively. Pre-operative proprioception testing had asignificant correlation (r = 0.46) with post-operative proprioception ( p = 0.006). Conclusion Patients with an ACL rupture had a proprioceptive deficit which improved following ligament reconstruction. Knee outcome scores had a better correlation with proprioception than ligament laxity. Proprioception may be a superior objective measure than ligament laxity in quantifying functional knee deficits and outcomes in patients with ACL ruptures. Level of Evidence III Therapeutic Study; Prospective Longitudinal Case-Control Study.

Resumo Objetivo Os métodos comumente usados para medir a propriocepção resultaram em relatos conflitantes sobre a propriocepção do joelho com ruptura do ligamento cruzado anterior (LCA) e a influência da reconstrução do LCA. Métodos A propriocepção de 100 indivíduos (50 pacientes com ruptura unilateral do LCA confirmada à radiologia e artroscopia e 50 controles normais) foi avaliada por estabilometria postural dinâmica em apoio unipodal. A lassidão ligamentar do joelho instrumentado e suas pontuações de desfechos também foram medidas. Dos 50 pacientes do grupo LCA, 34 foram submetidos à reconstrução e reavaliados no período pós-operatório. Resultados O grupo LCA apresentou deficiência proprioceptiva significativa em relaçãoaojoelho contralateral ( p < 0,001) e ao grupo controle ( p = 0,01). A propriocepção do joelho melhorou de maneira significativa após a reconstrução do LCA em relação aos achados pré-operatórios ( p = 0,003). Não houve correlação entre as medidas de lassidão ligamentar e as pontuações de desfechos. Além disso, observamos uma correlação significativa entre as pontuações de desfechos e as medidas de propriocepção antes da cirurgia. Essa correlação não foi detectada no período pós-operatório. O teste pré-operatório de propriocepção teve correlação significativa ( r = 0,46) com a propriocepção pós-operatória ( p = 0,006). Conclusão Os pacientes com ruptura do LCA apresentaram déficit proprioceptivo que melhorou após a reconstrução ligamentar. As pontuações de desfecho do joelho tiveram melhor correlação à propriocepção do que a lassidão ligamentar. A proprio-cepção pode ser uma medida objetiva superior à lassidão ligamentar na quantificação de déficits funcionais e desfechos do joelho em pacientes com ruptura do LCA. Nível de Evidência III Estudo Terapêutico; Estudo de Caso-Controle Longitudinal Prospectivo.

Clinical Outcome Measures in Arthroscopic Meniscectomy: Clinician versus Patient Completed Knee Scores / Medidas de desfechos clínicos na meniscectomia artroscópica: Pontuações de joelho segundo médicos e pacientes

Abstract Objective The aim of the present study was to investigate the difference between clinician-completed and patient-completed outcome scores in detecting improvement following arthroscopic meniscectomy in patients with meniscal tears of the knee. Methods Thirty-four patients with meniscal tears were prospectively assessed using 9 clinical outcome measures. The five clinician-completed knee scores included the Tegner Activity Score, the Lysholm Knee Score, the Cincinnati Knee Score, the International Knee Documentation Committee (IKDC) Examination Knee Score, and the Tapper and Hoover Meniscal Grading Score. The four patient-completed knee scores included the IKDC Subjective Knee Score, the Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS), the Short Form-12 Item Health Survey (SF-12), and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Twenty-nine of the 34 patients underwent an arthroscopic meniscectomy and were reassessed with all 9 outcome scores upon their follow-up review. Results A significant longitudinal improvement was observed in 4 of the 5 clinician-completed scores (Tegner [p< 0.001], Lysholm [p= 0.004], Cincinnati [p = 0.002] and Tapper and Hoover [p< 0.001], but not in the IKDC Examination [p= 0.332]. However, the IKDC Subjective score (p= 0.021) was the only patient-completed score to demonstrate significant improvement postoperatively. Conclusion Overall, clinician-completed scoring systems were found to be inconsistent with those of patient-completed instruments. The mode of administering outcome measures can have a significant influence on the outcome results both for research and for clinical practice. A combination of both a clinician-completed with a patient-completed instrument may be a more balanced approach to assessing and quantifying meniscus tears and the outcome following arthroscopic meniscectomy.

Resumo Objetivo O objetivo do presente estudo foi investigar a diferença entre instrumentos de desfechos preenchidos por médicos e pacientes na detecção de melhora após a meniscectomia artroscópica para tratamento de rupturas de menisco. Métodos Trinta e quatro pacientes com rupturas de menisco foram avaliados de forma prospectiva usando 9 medidas de desfechos clínicos. Os cinco instrumentos de avaliação de joelho respondidos por médicos foram o Escore de Atividade de Tegner, o Escore de Joelho de Lysholm, o Escore de Joelho de Cincinnati, o Escore de Exame do Joelho do International Knee Documentation Committee (IKDC, na sigla em inglês) e o Escore de Classificação do Menisco de Tapper e Hoover. Os quatro instrumentos de avaliação do joelho respondidos por pacientes foram o Escore Subjetivo do Joelho do IKDC, a Pesquisa de Desfecho de Joelho - Escala de Atividades de Vida Diária (KOS-ADLS, na sigla em inglês), o Formulário Curto de Pesquisa em Saúde de 12 Itens (SF-12, na sigla em inglês) e o Escore de Desfecho de Osteoartrite e Lesões no Joelho (KOOS, na sigla em inglês). Vinte e nove dos 34 pacientes foram submetidos a uma meniscectomia artroscópica e reavaliados com todos os 9 instrumentos na sua consulta de acompanhamento. Resultados Uma melhora longitudinal significativa foi observada em 4 dos 5 instrumentos respondidos por médicos (Tegner [p< 0,001], Lysholm [p= 0,004], Cincinnati [p= 0,002] e Tapper e Hoover [p< 0,001], mas não no IKDC [p= 0,332]). Por outro lado, o Escore Subjetivo do Joelho do IKDC (p= 0,021) foi o único instrumento respondido por pacientes a demonstrar melhora pós-operatória significativa. Conclusão De modo geral, os instrumentos respondidos por médicos foram considerados inconsistentes em relação àqueles respondidos por pacientes. O modo de administração dos instrumentos pode ter influência significativa nos resultados, tanto para fins de pesquisa quanto para a prática clínica. A combinação de um instrumento respondido pelo médico com um instrumento respondido pelo paciente pode ser uma abordagem mais equilibrada para a avaliação e a quantificação das rupturas do menisco e do desfecho após a meniscectomia artroscópica.

PERFECTED enhanced recovery pathway (PERFECT-ER) versus standard acute hospital care for people after hip fracture surgery who have cognitive impairment: a feasibility cluster randomised controlled trial.

OBJECTIVES: Assess feasibility of a cluster randomised controlled trial (RCT) to measure clinical and cost-effectiveness of an enhanced recovery pathway for people with hip fracture and cognitive impairment (CI). DESIGN: Feasibility trial undertaken between 2016 and 2018. SETTING: Eleven acute hospitals from three UK regions. PARTICIPANTS: 284 participants (208 female:69 male). INCLUSION CRITERIA: aged >60 years, confirmed proximal hip fracture requiring surgical fixation and CI; preoperative AMTS ≤8 in England or a 4AT score ≥1 in Scotland; minimum of 5 days on study ward; a 'suitable informant' able to provide proxy measures, recruited within 7 days of hip fracture surgery. EXCLUSION CRITERIA: no hip surgery; not expected to survive beyond 4 weeks; already enrolled in a clinical trial. INTERVENTION: PERFECT-ER, an enhanced recovery pathway with 15 quality targets supported by a checklist and manual, a service improvement lead a process lead and implemented using a plan-do-study-act model. PRIMARY AND SECONDARY OUTCOME MEASURES: Feasibility outcomes: recruitment and attrition, intervention acceptability, completion of participant reported outcome measures, preliminary estimates of potential effectiveness using mortality, EQ-5D-5L, economic and clinical outcome scores. RESULTS: 282 participants were consented and recruited (132, intervention) from a target of 400. Mean recruitment rates were the same in intervention and control sites, (range: 1.2 and 2.7 participants/month). Retention was 230 (86%) at 1 month and 54%(144) at 6 months. At 3 months a relatively small effect (one quarter of an SD) was observed on health-related quality of life of the patient measured with EQ-5D-5L proxy in the intervention group. CONCLUSION: This trial design was feasible with modifications to recruitment. Mechanisms for delivering consistency in the PERFECT-ER intervention and participant retention need to be addressed. However, an RCT may be a suboptimal research design to evaluate this intervention due to the complexity of caring for people with CI after hip fracture. TRIAL REGISTRATION NUMBER: ISRCTN99336264.

Patient reported outcome measures in meniscal tears and arthroscopic meniscectomy: The value of outcome score prediction.

BACKGROUND: There are several clinical outcome scores relating to meniscal injuries reported in the literature. However, the result of one scoring system is often different from that of the others even when assessing the same group of patients. This makes the comparison of results of studies who have used different outcome measures restrictive and difficult. HYPOTHESIS: Statistically derived formulae can be used to predict the outcome of one knee scoring system when the result of another is known in patients with meniscal tears before and after arthroscopic meniscectomy. PATIENTS AND METHODS: Thirty-four patients with meniscal tears were evaluated using nine clinical outcome scores. These included Tegner Activity Score, Lysholm Knee Score, Cincinnati Knee Score, International Knee Documentation Committee (IKDC) Objective Knee Score, Tapper and Hoover Meniscal Grading Score, IKDC Subjective Knee Score, Knee Outcome Survey-Activities of Daily Living Scale, Short Form-12 Item Health Survey (SF-12) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Twenty-nine patients underwent an arthroscopic meniscectomy and were reassessed 3 months post-operatively. RESULTS: There were considerable differences between the mean total of each of the nine outcome measures. Significant correlations and regressions were found between most of the outcome scores and were stronger following surgery. The strongest correlation was found between IKDC Subjective and SF-12 Physical Component Summary sub-score (r=0.94, P<0.001). The strongest regression formula was found between IKDC Subjective and KOOS (R2=0.93, P<0.001). DISCUSSION: The outcome of one knee score can be predicted when the results of the other are known through formulae calculations produced from this study. This could facilitate the conduct of systematic reviews and meta-analysis in research pertaining to meniscal injuries by allowing the pooling of substantially more data. LEVEL OF EVIDENCE: II; prospective non-randomized trial.

Clinical outcome measures in anterior cruciate ligament reconstruction: Clinician vs patient completed knee scores.

INTRODUCTION: Clinical outcome measures are important in both the conduct of clinical research and evaluation of knee surgery in every day clinical practice. A wide variety of validated outcome scores are available in the literature. The objective of this study was to investigate if there is a difference between clinician-completed and patient-completed outcome scores in detecting improvement following anterior cruciate ligament (ACL) reconstruction. METHODS: Fifty patients with ACL rupture were prospectively evaluated using nine clinical outcome measures. Five clinician-completed knee scores included Tegner Activity Score, Lysholm Knee Score, Cincinnati Knee Score, International Knee Documentation Committee (IKDC) Objective Knee Score and Tapper and Hoover Meniscal Grading Score. Four patient-completed knee scores included IKDC Subjective Knee Score, Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS), Short Form-12 Item Health Survey (SF-12) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Thirty-four of the 50 patients underwent an ACL reconstruction and were reassessed with all nine outcome scores upon their follow-up review 3 months post-operatively. RESULTS: A significant longitudinal improvement was observed of all five clinician-completed knee scores including Tegner (3.3-4.1 (p = 0.006)), Lysholm (71.7-85.3 (p < 0.001)), Cincinnati (62.6-75.9 (p < 0.001)), IKDC Objective (Abnormal to Nearly Normal (p = 0.001)) and Tapper and Hoover (Fair to Good (p < 0.001)). However, none of the four patient-completed knee scores revealed a statistically significant improvement post-operatively. CONCLUSIONS: Results of clinician-completed scores were found to be inconsistent with those of patient-completed instruments. It's important to consider the mode of administering outcome measures either for research or clinical practice as it can have a significant influence on the end results. The use of both a clinician-completed and a patient-completed instrument maybe the more prudent approach to assessing and quantifying ACL injuries and the outcome post-operatively. Ultimately, better methods of objectively evaluating surgical interventions of the knee are required.

Knee Dislocation with Ipsilateral Tibial Fracture Treated with an Intramedullary Locked Nail and Simultaneous Transtibial Tunnel Knee Ligament Reconstruction: A Case Report of Autografts and Limited Resources.

Knee dislocations associated with ipsilateral tibial shaft fracture represent one of the most challenging injuries in trauma surgery. This injury occurs in only 2% of all tibial fractures in several series. With the use of intramedullary nail (IMN) of the tibia, current practice paraments suggest that transtibial tunnels should be avoided and ligamentous knee surgery be delayed until healing of the shaft fracture occurs. We report a novel case which was successfully managed by delayed IMN and multiligamentous transtibial posterior cruciate ligament (PCL) and posterolateral corner (PLC) autograft reconstructions. A 27-year-old male sustained a Gustilo-Anderson grade IIIa tibial shaft fracture and a Schenck IIIL knee dislocation (KD3L) in the ipsilateral knee. At 2 weeks, the patient was then taken back to the operating theater to undergo definitive bone fixation and ipsilateral simultaneous knee ligamentous reconstruction. The knee was stabilized by open reconstruction of the PCL under fluoroscopic control using an ipsilateral quadriceps autograft fixed with metallic interference screws. The PLC was reconstructed with ipsilateral semitendinosus autograft harvested through a separate 1.5-cm standard anteromedial incision using the technique described by Stannard et al. After graft fixation, the 90 degree posterior and posterolateral drawer and 0 and 30 degrees varus stress tests were negative. After 12 months follow-up, the patient had no complaints regarding pain or instability. The tibial fracture had healed and no knee axis deviation could be noted. The patient had returned to recreational low demand activities and motorcycle riding. Treatment of a combined tibial shaft fracture with an ipsilateral knee dislocation may be satisfactorily accomplished with an IMN for the tibia and transtibial tunnel fixation for knee ligament reconstruction allowing for a single rehabilitation course and a shorter recovery without having to use a third stage for knee ligamentous reconstruction.

Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations.

PURPOSE: To plan for the continuance of elective hip and knee arthroplasty during a resurgence or new wave of COVID-19 infections. METHOD: A systematic review was conducted using the terms "COVID-19" or "SARS-Cov-2" and "second wave". No relevant citations were found to inform on recommendations the plan. Therefore, an expert panel of the European Hip Society and the European Knee Associates was formed to provide the recommendations. RESULTS: Overall, the recommendations consider three phases; review of the first wave, preparation for the next wave, and during the next wave. International and national policies will drive most of the management. The recommendations focus on the preparation phase and, in particular, the actions that the individual surgeon needs to undertake to continue with, and practice, elective arthroplasty during the next wave, as well as planning their personal and their family's lives. The recommendations expect rigorous data collection during the next wave, so that a cycle of continuous improvement is created to take account of any future waves. CONCLUSIONS: The recommendations for planning to continue elective hip and knee arthroplasty during a new phase of the SARS-Cov-2 pandemic provide a framework to reduce the risk of a complete shutdown of elective surgery. This involves engaging with hospital managers and other specialities in the planning process. Individuals have responsibilities to themselves, their colleagues, and their families, beyond the actual delivery of elective arthroplasty.

Proprioception deficiency in articular cartilage lesions of the knee.

PURPOSE: The purpose of this study is to investigate the proprioceptive function of patients with isolated articular cartilage lesions of the knee as compared to normal controls. METHODS: The Cartilage group consisted of eight subjects with radiologically and arthroscopically confirmed, isolated, unilateral, articular cartilage lesions of the knee (Outerbridge grade III or IV). They were compared to 50 normal controls. Knee proprioception was assessed by dynamic postural stabilometry using the Biodex Balance SD System. Patient-reported outcome measures (PROMs) were used to evaluate all subjects. RESULTS: Proprioception of the injured knee of the Cartilage group was significantly poorer compared to that of the control group (p < 0.001). A significant proprioceptive deficit also was observed when the uninjured knees of the Cartilage group were compared to those in the Control group (p = 0.003). There was no significant proprioceptive difference between the injured and the contra-lateral uninjured knee of the Cartilage group (p = 0.116). A significant correlation was found between the proprioception measurements of the injured and uninjured knee of the Cartilage group (r = 0.76, p = 0.030). A significant difference was observed in all PROMs (p < 0.001) between the Cartilage and Control groups. CONCLUSIONS: Patients with isolated articular cartilage lesions of the knee had a significant proprioceptive deficit as compared to normal controls. The deficiency was profound and even affected the proprioceptive function of the contra-lateral uninjured knee. This study has shown that articular cartilage lesions have a major influence on knee proprioception. However, it remains uncertain as to whether a proprioceptive deficit leads to osteoarthritis or is a consequence of it.

Tudor military surgery and the management of Sir Martin Frobisher's gunshot wound: Comparison with current treatment.

Sir Martin Frobisher (ca 1535-1594), the famous Elizabethan explorer and privateer, sustained a bullet to the outer plate of his ilium from a low-velocity bullet wound fired at close range from an arquebus, an early form of musket. The bullet was removed, but he subsequently died from gas gangrene. This paper looks at the management of this injury in Tudor times and compares it to current practice. The arrival of gunpowder and the seriousness of the resulting injuries spurred innovation in surgical practice, such that at the time of Frobisher's death, the Tudor military surgeon had considerable expertise and skill. The wound, treated properly, was not serious, but his first surgeon failed to remove the wadding that the bullet took with it. This was recognised as an error at the time. A Tudor surgeon today would note that the surgical management has not really changed since their time, even though they did not understand infection and bacterial contamination. Guidelines on managing gunshot wounds, and most research, is focussed on high-velocity injuries where removal of foreign material (clothing) is mentioned. Low-velocity injuries are treated as "outpatients" and the importance of removing foreign material, especially when the bullet is left in situ, is not mentioned. The inexperienced surgeon of today risks making the same error as Frobisher's surgeon.

Patient-directed self-management of pain (PaDSMaP) compared to treatment as usual following total knee replacement; a randomised controlled trial.

BACKGROUND: Self-administration of medicines by patients whilst in hospital is being increasingly promoted despite little evidence to show the risks and benefits. Pain control after total knee replacement (TKR) is known to be poor. The aim of the study was to determine if patients operated on with a TKR who self-medicate their oral analgesics in the immediate post-operative period have better pain control than those who receive their pain control by nurse-led drug rounds (Treatment as Usual (TAU)). METHODS: A prospective, parallel design, open-label, randomised controlled trial comparing pain control in patient-directed self-management of pain (PaDSMaP) with nurse control of oral analgesia (TAU) after a TKR. Between July 2011 and March 2013, 144 self-medicating adults were recruited at a secondary care teaching hospital in the UK. TAU patients (n = 71) were given medications by a nurse after their TKR. PaDSMaP patients (n = 73) took oral medications for analgesia and co-morbidities after two 20 min training sessions reinforced with four booklets. Primary outcome was pain (100 mm visual analogue scale (VAS)) at 3 days following TKR surgery or at discharge (whichever came soonest). Seven patients did not undergo surgery for reasons unrelated to the study and were excluded from the intention-to-treat (ITT) analysis. RESULTS: ITT analysis did not detect any significant differences between the two groups' pain scores. A per protocol (but underpowered) analysis of the 60% of patients able to self-medicate found reduced pain compared to the TAU group at day 3/discharge, (VAS -9.9 mm, 95% CI -18.7, - 1.1). One patient in the self-medicating group over-medicated but suffered no harm. CONCLUSION: Self-medicating patients did not have better (lower) pain scores compared to the nurse-managed patients following TKR. This cohort of patients were elderly with multiple co-morbidities and may not be the ideal target group for self-medication. TRIAL REGISTRATION: ISRCTN10868989 . Registered 22 March 2012, retrospectively registered.