Anatomical and surgical considerations of the pectoralis muscle.

Introduction: The pectoralis major (PM) muscle is the largest and most superior muscle of the anterior chest wall. The PM plays an important role in flexion, adduction, and internal rotation of the arm. The pectoralis major's size, strength, and anatomical location make it an excellent candidate in transfer surgeries due to its ability to restore balancing forces that may be lost in scapular winging and subscapularis tears. Each of these injuries and pathologies involves the PM muscle in some way, and careful consideration of its anatomy and physiology is necessary. This review article aims to provide a comprehensive overview of the anatomy, physiology, and surgical considerations of the pectoralis muscle with a specific focus on the surgical techniques involving the muscle. Methods: A comprehensive literature search using a combination of the following terms: pectoralis major, rupture, transfer, chronic subscapularis tear, pectoralis surgery, anatomy, scapular winging, and long thoracic nerve anatomy. There were no limitations with regards to article type or publishing date, but article language was limited to only English. Conclusion: The pectoralis muscle is an important muscle when it comes to function of the upper extremity primarily or through transfer procedure. Injuries and impairments of the pectoralis major or other muscles of the upper extremity can significantly impact an individual's quality of life, limiting their ability to perform activities of daily living. A thorough understanding of anatomical, functional, and surgical purposes of the pectoralis muscle is crucial for achieving optimal outcomes and avoiding complications.

Comparison of true blood loss between short and long cephalomedullary nail fixation of geriatric hip fractures, a retrospective cohort study.

PURPOSE: Existing literature is discrepant on the differences in blood loss and need for transfusion between short and long cephalomedullary nails used for extracapsular geriatric hip fractures. However, prior studies used the inaccurate estimated rather than the more accurate 'calculated' blood loss based on hematocrit dilution (Gibon in IO 37:735-739, 2013, Mercuriali in CMRO 13:465-478, 1996). This study sought to clarify whether use of short nails is associated with clinically meaningful reductions in calculated blood loss and resultant need for transfusion. METHODS: A retrospective cohort study using bivariate and propensity score-weighted linear regression analyses was conducted examining 1442 geriatric (ages 60-105) patients undergoing cephalomedullary fixation of extracapsular hip fractures over 10 years at two trauma centers. Implant dimensions, pre and postoperative laboratory values, preoperative medications, and comorbidities were recorded. Two groups were compared based on nail length (greater or less than 235 mm). RESULTS: Short nails were associated with a 26% reduction in calculated blood loss (95% confidence interval: 17-35%; p < 10-14) and a 24-min (36%) reduction in mean operative time (95% confidence interval: 21-26 min; p < 10-71). The absolute reduction in transfusion risk was 21% (95% confidence interval: 16-26%; p < 10-13) yielding a number needed to treat of 4.8 (95% confidence interval: 3.9-6.4) with short nails to prevent one transfusion. No difference in reoperation, periprosthetic fracture, or mortality was noted between groups. CONCLUSION: Use of short compared to long cephalomedullary nails for geriatric extracapsular hip fractures confers reduced blood loss, need for transfusion, and operative time without a difference in complications.

Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study.

OBJECTIVE: Multiple comorbidities in hip fracture patients are associated with increased mortality and complications. The goal of this study was to characterize the relationship between specific patient factors including comorbidities and outcomes in geriatric hip fractures, including length of stay, unplanned ICU admission, discharge disposition, complications, and mortality. METHODS: This is a retrospective review of a trauma database from five Level 1 and Level 2 trauma centers of patients with hip fractures of the femoral neck and intertrochanteric region who underwent treatment using hip pinning, hemiarthroplasty, total hip arthroplasty, cephalomedullary nailing, or dynamic hip screw fixation. Mortality was the primary outcome variable (including in-hospital mortality, 30-day mortality, 60-day mortality, and 90-day mortality). Secondary outcome variables included in-hospital adverse events, unplanned transfer to the ICU, postoperative length of stay, and discharge disposition. Regression analyses were used for evaluation of relationships between comorbidities as independent variables and primary and secondary outcomes as dependent variables. RESULTS: Two thousand three hundred patients were included. The mortality was 1.8%, 7.0%, 10.9%, and 14.1% for in-hospital, 30-day, 60-day, and 90-day mortality, respectively. Diabetes and cognitive impairment present on admission were associated with mortality at all-time intervals. COPD was the only comorbidity that signaled in-hospital adverse event with an odds ratio of 1.67 (P = 0.012). No patient factors, time to surgery, or comorbidities signaled unplanned ICU transfer. Patients with renal failure and COPD had longer hospital stays after surgery. CONCLUSION: Geriatric hip fractures continue to have high short-term morbidity and mortality. Identifying patients with increased odds of early mortality and adverse events can help teams optimize care and outcomes. Patients with diabetes, cognitive impairment, renal failure, and COPD may benefit from continued and improved medical optimization during the perioperative period as well as being more closely managed by a medicine team without delaying time to the operating room.

The geriatric distal femur fracture: nail, plate or both?

Surgical fixation of distal femur fractures in geriatric patients is an evolving topic. Unlike hip fractures, treatment strategies for distal femur fractures are ill-defined and lack substantive high-quality evidence. With an increasing incidence and an association with significant morbidity and mortality, it is essential to understand existing treatment options and their supporting evidence. Current fixation methods include the use of either retrograde intramedullary nails, or plate and screw constructs. Due to the variability in fracture patterns, the unique anatomy of the distal femur, and the presence or absence or pre-existing implants, decision-making as to which method to use can be challenging. Recent literature has sought to describe the advantages and disadvantages of each, however, there is currently no consensus on a standard of care, and little randomized evidence is available that directly compares intramedullary nails with plating. Future randomized studies comparing intramedullary nails with plating constructs are necessary in order to develop a standard of care based on injury characteristics.

Nutritionist Referral Modestly Improves Weight Loss and Increases Surgery Rate in Obese Patients Seeking Total Joint Arthroplasty.

Background: Obesity is associated with increased complications after total joint arthroplasty (TJA), leading some surgeons to recommend nutrition counseling and weight loss. We aim to evaluate the effect of preoperative nutritionist referral on weight loss and likelihood of surgery in obese patients seeking primary TJA. Methods: A retrospective cohort of patients seeking primary TJA who were referred to a licensed nutritionist for weight loss was matched by age, sex, and body mass index (BMI) to an unreferred control group. BMI change was compared between groups up to 1 year of follow-up. Differences were determined using 2-tailed t-tests and chi-squared tests with a significance cutoff of P < .05. Results: A total of 274 referred patients and 174 controls were included in our analysis. Patients who were referred to a nutritionist achieved significantly greater average BMI change (-1.5 kg/m2) than controls (-0.8 kg/m2) by 6 months after first contact (P = .01) although significance was lost at 1 year after first contact (P = .21). Thirty-eight percent of referred patients went on to TJA compared with 28% of controls (P < .01). Conclusions: Referral to a licensed nutritionist modestly improves early weight loss and is associated with a higher rate of surgery in obese patients seeking primary TJA.

Validation of a prospective mortality prediction score for hip fracture patients.

PURPOSE: Although mortality prediction tools are the subject of significant interest as components of comprehensive hip fracture protocols, few have been applied or validated to prospectively inform ongoing patient management. Five regional hospitals are currently generating real-time mortality risk scores for all adults at the time of admission using available laboratory and comorbidity data (Cowen et al. J Hosp Med 9(11):720-726, 2014). Although results for aggregated conditions have been published, the primary aim of this study is to determine how well prospectively calculated scores predict mortality for hip fracture patients specifically. METHODS: Using a five-hospital database, 1376 patients who were prospectively scored on admission were identified from January 2013 to April 2017, cross-referencing ICD9/10 diagnosis and procedure codes for AO/OTA 31A1 through 31B3 fractures. Prospective mortality scores have been previously divided into 5 risk categories to facilitate ease of clinical use. Vital status was determined from hospital data, Social Security and Michigan Death Indices. RESULTS: Prospective scores demonstrated good mortality prediction, with AUCs of 0.80, 0.73, 0.74 and 0.74 for in hospital, 30-, 60- and 90-day mortality, respectively. Patients in the top 2 mortality risk categories represented 30% (410/1376) of the cohort and accounted for 78% (25/32) of the inpatient and 59% (57/97) of the 30 day deaths. CONCLUSIONS: Implementation of this real-time mortality risk tool is feasible and valid for the prediction of short- to medium-term mortality risk for hip fracture patients, and potentially offers valuable information to guide ongoing patient management decisions such as admitting service or level of care.

Effects of an anesthesia perioperative surgical home for total knee and hip arthroplasty at a Veterans Affairs Hospital: a quality improvement before-and-after cohort study.

BACKGROUND: A perioperative surgical home, the Anesthesia Perioperative Care Service (APCS), was created to execute enhanced recovery after surgery pathways for total knee and total hip arthroplasty patients at the Tennessee Valley Health System Nashville VA Medical Center. We hypothesized that the APCS would be associated with reduced length of stay, in-hospital and post-discharge opioid exposure, costs, and hospital readmissions. METHODS: Data were collected for all patients admitted to the Nashville VA Medical Center following their respective surgery, for 400 days after the initiation of the APCS and for a 400-day period prior. This cohort study was based on a quality improvement project set up at the initiation of the service. The adjusted effect on each quantitative outcome was evaluated using proportional odds logistic regression methods. In addition, each regression analysis was performed in segmented regression fashion to identify changes in the outcomes over time. RESULTS: We included 282 patients in our cohort-96 prior and 186 post-implementation. Median hospital length of stay, intravenous (IV) and per os (PO) inpatient opioid administration, outpatient opioid quantity, and total days of supply were all reduced in the cohort cared for by the APCS. After adjusting for potential cofounders and evaluated outcome over time, the APCS remained independently associated with a reduction of hospital length of stay of one day (95% confidence interval, 0.09 to 1.97; P = 0.05) and with decreased IV and PO inpatient opioid administration, while continuing to show no increase in hospital readmissions. CONCLUSIONS: This cohort study showed significant improvements in important post-surgical outcomes after total knee and hip arthroplasty that were associated with the implementation of an APCS.

RéSUMé: CONTEXTE: Un centre de soins chirurgicaux périopératoires (perioperative surgical home), le Service de soins périopératoires en anesthésie (SSPA), a été créé pour mettre en œuvre des trajectoires de soins de récupération rapide après la chirurgie pour les patients ayant subi une arthroplastie totale du genou ou de la hanche au centre médical Tennessee Valley Health System Nashville VA Medical Center. Nous avons émis l'hypothèse que le SSPA serait associé à une réduction de la durée du séjour, de l'exposition aux opioïdes à l'hôpital et après le congé, ainsi qu'à une diminution des coûts et des réadmissions à l'hôpital. MéTHODE: Les données ont été recueillies pour tous les patients admis au centre médical Nashville VA Medical Center après leur chirurgie respective, pendant 400 jours avant et après la création du SSPA. Cette étude de cohorte se fondait sur un projet d'amélioration de la qualité mis en place lors de l'inauguration du service. L'effet ajusté sur chaque résultat quantitatif a été évalué à l'aide de méthodes de régression logistique proportionnelles. De plus, chaque analyse de régression a été effectuée de façon segmentée afin d'identifier l'évolution des résultats au fil du temps. RéSULTATS: Nous avons inclus 282 patients dans notre cohorte ­ 96 avant et 186 après la mise en œuvre. La durée médiane du séjour à l'hôpital, l'administration d'opioïdes par voie intraveineuse (IV) et per os (PO) pendant le séjour hospitalier, la quantité d'opioïdes en ambulatoire et sa durée en jours ont tous été réduites dans la cohorte prise en charge par le SSPA. Après avoir procédé à des ajustements pour tenir compte des facteurs de confusion potentiels et évalué l'évolution des résultats au fil du temps, le SSPA est demeuré indépendamment associé à une réduction de la durée de séjour à l'hôpital d'un jour (intervalle de confiance 95 %, 0,09 à 1,97; P = 0,05), à une réduction de l'administration d'opioïdes IV et PO durant le séjour, et il n'y a eu aucune augmentation des réadmissions à l'hôpital. CONCLUSION: Cette étude de cohorte a montré des améliorations significatives en matière de résultats post-chirurgicaux importants après une arthroplastie totale du genou et de la hanche associés à la mise en œuvre d'un SSPA.

Role of Moderate Hypothermia and Antegrade Cerebral Perfusion during Repair of Type A Aortic Dissection.

The goal of this study was to compare early postoperative outcomes and actuarial survival between patients who underwent repair of acute type A aortic dissection with deep or moderate hypothermia. A total of 132 consecutive patients from a single academic medical center underwent repair of acute type A aortic dissection between January 2000 and June 2014. Of those, 105 patients were repaired under deep hypothermia (< 24 C°), while 27 patients were repaired under moderate hypothermia (≥24 C°). Median ages were 62 years (range: 27-86) and 59 years (range: 35-83) for patients repaired under deep hypothermia compared with patients repaired under moderate hypothermia, respectively ( p = 0.451). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. Operative mortality was 17.1 and 7.4% in the deep and moderate hypothermia groups, respectively ( p = 0.208). Incidence of permanent stroke was 12.4% in the deep hypothermic circulatory arrest group and 0% in the moderate hypothermia group ( p = 0.054). Actuarial 5- and 10-year survival demonstrated a trend for lower long-term mortality with moderate hypothermia compared with deep hypothermia (69% 5-year and 54% 10-year for deep hypothermia vs. 79% 5-year and 10-year for moderate hypothermia, log-rank p = 0.161). Moderate hypothermia is a safe and efficient alternative to deep hypothermia and may have protective benefits. Stroke rate was lower with moderate hypothermia.

Analysis of Outcomes After TKA: Do All Databases Produce Similar Findings?

BACKGROUND: Use of large clinical and administrative databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and varies in their methodology of data acquisition, which makes it possible that similar research questions posed to different databases might result in answers that differ in important ways. QUESTIONS/PURPOSES: (1) What are the differences in reported demographics, comorbidities, and complications for patients undergoing primary TKA among four databases commonly used in orthopaedic research? (2) How does the difference in reported complication rates vary depending on whether only inpatient data or 30-day postoperative data are analyzed? METHODS: Patients who underwent primary TKA during 2010 to 2012 were identified within the National Surgical Quality Improvement Programs (NSQIP), the Nationwide Inpatient Sample (NIS), the Medicare Standard Analytic Files (MED), and the Humana Administrative Claims database (HAC). NSQIP is a clinical registry that captures both inpatient and outpatient events up to 30 days after surgery using clinical reviewers and strict definitions for each variable. The other databases are administrative claims databases with their comorbidity and adverse event data defined by diagnosis and procedure codes used for reimbursement. NIS is limited to inpatient data only, whereas HAC and MED also have outpatient data. The number of patients undergoing primary TKA from each database was 48,248 in HAC, 783,546 in MED, 393,050 in NIS, and 43,220 in NSQIP. NSQIP definitions for comorbidities and surgical complications were matched to corresponding International Classification of Diseases, 9 Revision/Current Procedural Terminology codes and these coding algorithms were used to query NIS, MED, and HAC. Age, sex, comorbidities, and inpatient versus 30-day postoperative complications were compared across the four databases. Given the large sample sizes, statistical significance was often detected for small, clinically unimportant differences; thus, the focus of comparisons was whether the difference reached an absolute difference of twofold to signify an important clinical difference. RESULTS: Although there was a higher proportion of males in NIS and NSQIP and patients in NIS were younger, the difference was slight and well below our predefined threshold for a clinically important difference. There was variation in the prevalence of comorbidities and rates of postoperative complications among databases. The prevalence of chronic obstructive pulmonary disease (COPD) and coagulopathy in HAC and MED was more than twice that in NIS and NSQIP (relative risk [RR] for COPD: MED versus NIS 3.1, MED versus NSQIP 4.5, HAC versus NIS 3.6, HAC versus NSQIP 5.3; RR for coagulopathy: MED versus NIS 3.9, MED versus NSQIP 3.1, HAC versus NIS 3.3, HAC versus NSQIP 2.7; p < 0.001 for all comparisons). NSQIP had more than twice the obesity as NIS (RR 0.35). Rates of stroke within 30 days of TKA had more than a twofold difference among all databases (p < 0.001). HAC had more than twice the rates of 30-day complications at all endpoints compared with NSQIP and more than twice the 30-day infections as MED. A comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of wound infections and deep vein thromboses is captured when data are analyzed out to 30 days after TKA (p < 0.001 for all comparisons). CONCLUSIONS: When evaluating research utilizing large databases, one must pay particular attention to the type of database used (administrative claims, clinical registry, or other kinds of databases), time period included, definitions utilized for specific variables, and the population captured to ensure it is best suited for the specific research question. Furthermore, with the advent of bundled payments, policymakers must meticulously consider the data sources used to ensure the data analytics match historical sources. LEVEL OF EVIDENCE: Level III, therapeutic study.

Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital.

Physician-led perioperative surgical home models are developing as a method for improving the American health care system. These models are novel, team-based approaches that help to provide continuity of care throughout the perioperative period. Another avenue for improving care for surgical patients is the use of enhanced recovery after surgery pathways. These are well-described methods that have shown to improve perioperative outcomes. An established perioperative surgical home model can help implementation, efficiency, and adherence to enhanced recovery after surgery pathways. For these reasons, the Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center created an Anesthesiology Perioperative Care Service that provides comprehensive care to surgical patients from their preoperative period through the continuum of their hospital course and postdischarge follow-up. In this brief report, we describe the development, implementation, and preliminary outcomes of the service.

Assessment of potential confounders when imaging pectus excavatum with chest radiography alone.

BACKGROUND: Chest radiography (CXR) has emerged as an attractive alternative imaging option for objective pre-operative assessment of pectus excavatum (PE) with comparable accuracy, reduced cost, and less radiation exposure when compared to computed tomography (CT). This study asked whether image quality, scoliosis, and asymmetry of the PE deformity would decrease the accuracy of CXR as compared to CT. METHODS: A database of PE patients receiving preoperative CXR and CT was created, and Haller-indices (HI) and correction-indices (CI) were calculated using each imaging modality. Each potential confounding variable were analyzed using Spearman correlations the Fisher r-to-z transformation test. RESULTS: The database was comprised of 77 patients. Image quality, scoliosis and the 'eccentric type' of asymmetry did not demonstrate any significant worsening of measurement accuracy. However, the correlation coefficients for CIs for those with and without the 'unbalanced type' of asymmetry were 0.593 and 0.890, respectively, with a Fisher r-to-z of 2.16 (p=.031). CONCLUSIONS: The accuracy of CXR-derived pectus indices remains quite favorable despite the heterogeneity from radiographic quality, scoliosis and chest wall asymmetry. Nonetheless, the unbalanced type of chest wall asymmetry did emerge as a significant confounder. As such, use of CXR alone in cases of gross chest wall asymmetry should be cautioned.

The case for using the correction index obtained from chest radiography for evaluation of pectus excavatum.

BACKGROUND: We previously reported the use of a computed tomography (CT)-based Correction Index (CI) as a more accurate assessment of pectus excavatum (PE) severity than the historically used Haller Index (HI). This study examines the diagnostic capabilities of the CI as assessed by lateral chest radiography (CXR). METHODS: A database of PE patients receiving preoperative CXR and CT was created. For each patient, a radiologist calculated a CT-based CI, while two pediatric surgeons independently calculated CXR CIs. RESULTS: The database was composed of 69 patients. Significant correlations were found between CXR CI estimates of the two observers and between the CXR and CT CI for each observer. Per our previous work, CT CIs were used in this study for identifying patients meeting surgical criteria (CT CI≥28%). Observed CXR CIs demonstrated good interrater reliability. The sensitivity (0.83) and specificity (0.77) of CXR in diagnosing severe PE (CT CI≥28%) was high. However, sensitivity (0.89) markedly improved when only considering measured CXR CIs≤26%, and combined specificity rose to 0.86 when only considering measured CXR CIs≥30%. CONCLUSIONS: We recommend the CI as measured by lateral CXR for the preoperative evaluation of PE, with CT used as a confirmatory test in patients measured to have a CXR CI between 26% and 30%.

Paracrine co-delivery of TGF-ß and IL-2 using CD4-targeted nanoparticles for induction and maintenance of regulatory T cells.

The cytokine milieu is critical for orchestration of lineage development towards effector T cell (Teff) or regulatory T cell (Treg) subsets implicated in the progression of cancer and autoimmune disease. Importantly, the fitness and survival of the Treg subset is dependent on the cytokines Interleukin-2 (IL-2) and transforming growth factor beta (TGF-ß). The production of these cytokines is impaired in autoimmunity increasing the probability of Treg conversion to aggressive effector cells in a proinflammatory microenvironment. Therapy using soluble TGF-ß and IL-2 administration is hindered by the cytokines' toxic pleiotropic effects and hence bioavailability to CD4(+) T cell targets. Thus, there is a clear need for a strategy that rectifies the cytokine milieu in autoimmunity and inflammation leading to enhanced Treg stability, frequency and number. Here we show that inert biodegradable nanoparticles (NP) loaded with TGF-ß and IL-2 and targeted to CD4(+) cells can induce CD4(+) Tregs in-vitro and expand their number in-vivo. The stability of induced Tregs with cytokine-loaded NP was enhanced leading to retention of their suppressive phenotype even in the presence of proinflammatory cytokines. Our results highlight the importance of a nanocarrier-based approach for stabilizing and expanding Tregs essential for cell-immunotherapy of inflammation and autoimmune disease.

Indications for tracheotomy in the pediatric intensive care unit population: a pilot study.

OBJECTIVE: To define the indications for tracheotomy in patients requiring prolonged intubation (>1 week) in the pediatric intensive care unit (PICU). DESIGN: Retrospective chart review and follow-up telephone survey. SETTING: A tertiary care center PICU. OUTCOME MEASURE: Tracheotomy or extubation. PATIENTS: All patients older than 30 days in the PICU intubated for longer than 1 week between 1997 and 1999. RESULTS: During the study, 63 total admissions required intubation for longer than 1 week. A tracheotomy was necessary in 14% of admissions (n = 9). The mean length of intubation before the tracheotomy was 424 hours, whereas the mean length of intubation without the need for tracheotomy was 386 hours. Length of intubation, age, and number of intubations did not increase the probability of having a tracheotomy. Of those requiring a tracheotomy, 2 had tracheomalacia, 1 had subglottic edema, 1 had plastic bronchitis, 1 had Down syndrome with apnea resulting in right heart failure, 3 required long-term ventilation after cardiopulmonary collapse, and 1 had mitochondrial cytopathy. Of these 9 children, 7 were successfully decannulated, 1 patient died of underlying disease, and 1 patient remained cannulated secondary to the mitochondrial cytopathy. Twenty families of the patients who did not undergo a tracheotomy were reached by telephone after discharge. Most of the families reported that their children were free of stridor and hoarseness after extubation. CONCLUSIONS: Children tolerate prolonged intubation without laryngeal complications. The consideration for tracheotomy in the PICU setting must be highly individualized for each child.