Preoperative Anemia and Risk for Perioperative Neurocognitive Dysfunction in Cardiac Surgery Patients: A Retrospective Analysis.

OBJECTIVES: To evaluate whether there is a relationship between preoperative anemia and domain-specific cognitive performance in patients undergoing cardiac surgery. DESIGN: Retrospective analysis of data collected from a randomized study. SETTING: Tertiary care university hospital. PARTICIPANTS: A total of 436 patients age ≥55 years undergoing cardiac surgery. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Neuropsychological testing was performed before and one month after surgery, using a standard battery. Individual Z-scores calculated from the mean and standard deviation of tests at baseline were combined into domain-specific scores. Anemia (hemoglobin <130 g/L for men, <120 g/L for women) was present in 41% of patients. Preoperative anemia had little impact on preoperative cognition. There were no differences in the change in cognitive performance one month after surgery from baseline between patients with and without preoperative anemia. However, in a sensitivity analysis using multiple imputation for missing cognitive test scores, significant associations were observed between preoperative anemia and change in postoperative processing speed (p = 0.016), change in executive function (p = 0.049), and change in fine motor speed (p = 0.016). Nadir hemoglobin during cardiopulmonary bypass, which was lower in anemic than nonanemic patients, was associated with decrements in performance on tests of verbal fluency (p = 0.007), processing speed (p = 0.042), and executive function (p = 0.10) one month after surgery but not delayed neurocognitive recovery (p = 0.06). CONCLUSIONS: Preoperative anemia may be associated with impairment of selective cognitive domains after surgery. Any effect of preoperative anemia may have on cognition after surgery might be related to lower nadir hemoglobin during cardiopulmonary bypass.

Trends in Anterolateral Ligament Reconstruction and Lateral Extra-articular Tenodesis With ACL Reconstruction in Children and Adolescents.

Background: Anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET) show promise in lowering the risk of rerupture after anterior cruciate ligament reconstruction (ACLR), but there are little data on surgeon practices and preferences in children and adolescents. Purpose: To quantify surgeon practices regarding ALLR and LET in the pediatric population. Study Design: Cross-sectional study. Methods: An electronic survey was administered to 87 surgeons in the Pediatric Research in Sports Medicine society. The questionnaire asked several questions about surgeon and practice characteristics as well as indications, preferences, and techniques for ALLR or LET in the context of primary and revision pediatric ACLR. Chi-square and Fisher exact tests were used to evaluate factors that affect surgical preferences. Results: A total of 63 surgeons completed the survey, of whom 62% performed ≥50 pediatric ACLRs annually; 56% sometimes performed anterolateral augmentation with primary ACLR, and 79% with revision ACLR. The most common indications for ALLR or LET in the primary setting were high-grade pivot shift, knee hyperextension, generalized laxity, and type of sports participation. Surgeons whose practice was >75% sports medicine were more likely to perform ALLR or LET with both primary and revision ACLR (P = .005 and P < .001, respectively). Those who had completed a sports medicine fellowship were more likely to perform these procedures than those with only pediatric orthopaedic training, in both primary (68% vs 36%; P = .01) and revision scenarios (92% vs 60%; P = .002). Of the 28 respondents who did not perform ALLR or LET with primary ACLR, 75% cited insufficient evidence as the reason. However, 96% of surgeons who did perform these procedures expressed interest in studying them prospectively, and 87% were willing to randomize patients. Conclusion: Findings indicated that 56% of pediatric sports surgeons sometimes perform anterolateral augmentation with primary ACLR and 79% with revision ACLR. Surgeons with sports medicine fellowship training or a mostly sports practice were more likely to perform these procedures. Insufficient evidence was the most common reason given by surgeons who did not perform anterolateral augmentation. However, there was substantial willingness to prospectively study and even randomize pediatric patients to assess the impact of ALLR or LET in this population.

The Anterolateral Ligament of the Knee.

The femoral attachment of the anterolateral ligament (ALL) of the knee is still under debate, but the tibial attachment is consistently between Gerdy's tubercle and the fibular head. The structure is less identifiable and more variable in younger patients. The ALL likely plays a role in rotational stability, but its impact on anterior stability is less clear. Numerous ALL reconstruction techniques have been described. Biomechanical analysis of these techniques has not shown clear benefits, but this literature is limited by the heterogeneity of techniques, graft choices, and study methodology. Clinical studies of combined anterior cruciate ligament (ACL) and ALL reconstruction are few but promising in lowering the risk of an ACL reinjury. To our knowledge, there are no studies showing the clinical outcomes of combined ACL and ALL reconstruction in pediatric patients, who are at higher risk for ACL graft failure than adults.