Assessing the Quality of Postoperative Recovery: A Guide for Making Adjustments in Anesthesia Delivery.

PURPOSE: The purpose of this project was to develop a plan and then implement a process for improving anesthesia delivery at a surgery center in the Southeast United States over a 2-month period. DESIGN: The design of the project was based on utilization of the instrument QoR-15 (Quality of recovery - 15 item questionnaire). This tool is a valid and reliable instrument for the measurement of postoperative outcomes. The QoR-15 includes 15 questions that can each be scored on a 10-point scale. METHODS: Methods included a literature search, collecting pre-assessment data, making phone calls to patients utilizing QoR-15 tool, analyzing data, presenting findings to stakeholders, creating a plan of future anesthesia care adjustments. FINDINGS: The results revealed the following outcome data: a total of 183 postoperative phone calls were successfully performed. The calls were completed on the first postoperative day during the months of July and August 2021. There were 459 total cases during this 2-month period with 113 successful patient contacts (24.6 % successful contact rate). Mean scores of the QoR-15 data for the total population were above 9 for all 15 items. The data was then analyzed according to surgical specialty. The category of moderate pain scores in patients from the General and Ophthalmology surgical specialties were 7.9 and 7.8 respectively. General surgery patients also had one of the highest scores in severe pain with a mean of 8.7. CONCLUSIONS: In conclusion, the leadership team at the ASC received a formal presentation of the results and recommendations for future adjustments that could be potentially implemented in anesthesia care. The benefits of regional anesthesia were suggested to help achieve better patient pain outcomes in both the General and Ophthalmologic surgical populations.

Pituitary Society Delphi Survey: An international perspective on endocrine management of patients undergoing transsphenoidal surgery for pituitary adenomas.

PURPOSE: In adults and children, transsphenoidal surgery (TSS) represents the cornerstone of management for most large or functioning sellar lesions with the exception of prolactinomas. Endocrine evaluation and management are an essential part of perioperative care. However, the details of endocrine assessment and care are not universally agreed upon. METHODS: To build consensus on the endocrine evaluation and management of adults undergoing TSS, a Delphi process was used. Thirty-five statements were developed by the Pituitary Society's Education Committee. Fifty-five pituitary endocrinologists, all members of the Pituitary Society, were invited to participate in two Delphi rounds and rate their extent of agreement with statements pertaining to perioperative endocrine evaluation and management, using a Likert-type scale. Anonymized data on the proportion of panelists' agreeing with each item were summarized. A list of items that achieved consensus, based on predefined criteria, was tabulated. RESULTS: Strong consensus (≥ 80% of panelists rating their agreement as 6-7 on a scale from 1 to 7) was achieved for 68.6% (24/35) items. If less strict agreement criteria were applied (ratings 5-7 on the Likert-type scale), consensus was achieved for 88% (31/35) items. CONCLUSIONS: We achieved consensus on a large majority of items pertaining to perioperative endocrine evaluation and management using a Delphi process. This provides an international real-world clinical perspective from an expert group and facilitates a framework for future guideline development. Some of the items for which consensus was not reached, including the assessment of immediate postoperative remission in acromegaly or Cushing's disease, represent areas where further research is needed.

One normal void and residual following MUS surgery is all that is necessary in most patients.

INTRODUCTION AND HYPOTHESIS: There is considerable variation worldwide on how the assessment of voiding function is performed following midurethral sling (MUS) surgery. There is potentially a financial cost, and reduction in efficiency when patient discharge is delayed. Using our current practice of two normal void and residual (V&R) readings before discharge, the aim of this retrospective study was to evaluate the likelihood of an abnormal second V&R test if the first V&R test was normal in order to determine if a policy of discharge after only one satisfactory V&R test is reasonable. METHODS: Data from 400 patients who had had MUS surgery with or without other procedures were collected. Our unit protocol included two consecutive voids of greater than 200 ml with residuals less than 150 ml before discharge. The patients were divided into the following groups: MUS only, MUS plus anterior colporrhaphy (AR) plus any other procedures (MUS/AR), and MUS with any non-AR procedures (MUS+). RESULTS: Complete datasets were available for 335 patients. Once inadequate tests (low volume voids <200 ml) had been excluded (28% overall), the likelihood of an abnormal second V&R test if the first test was normal was 7.1% overall, but 3.6% for MUS, 11.5% for MUS/AR and 8.6% for MUS+. CONCLUSION: The findings in the MUS-only group indicate that it is probably safe to discharge patients after one satisfactory V&R test, as long as safety measures such as 'open access' are available so that patients have unhindered readmission if problems arise.

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot.

OBJECTIVE: Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice. METHODS: The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement. RESULTS: In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation. CONCLUSIONS: Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.

Wide Variation in Post-Void Residual Management after Urogynecologic Surgery: A Survey of Urogynecologists' Practices.

To date there is no standardized regimen or evidence-based practical guideline concerning post-void residual (PVR) measurement after urogynecologic surgeries. This survey aimed to evaluate current practice patterns and the approach taken among urogynecologists surrounding PVR measurement. An online survey was sent to members of several urogynecologic societies assessing pre- and postoperative management of patients undergoing urogynecologic surgery. A total of 204 urogynecologists from 21 countries participated in the survey. The vast majority of urogynecologists perform some kind of voiding trial to assess voiding function postoperatively. The cut-off values to perform catheterization, the methods of measurement, and the number of successfully passed voiding showed strong differences. Only 34.4% of the respondents consider routine PVR measurement after urogynecologic surgery to be evidence-based. PVR measurement after urogynecologic surgeries is widely performed and if pathological, it almost always provokes invasive treatment. However, there is a wide variation of implemented strategies, methods, and cut-off values. Scientific societies are challenged to devise a standardized regimen based on evidence for the management of urinary retention after urogynecologic surgery.

The hind- and midfoot alignment computed after a medializing calcaneal osteotomy using a 3D weightbearing CT.

PURPOSE: A medializing calcaneal osteotomy (MCO) is a surgical procedure frequently performed to correct an adult acquired flatfoot (AAFD) deformity. However, most studies are limited to a 2D analysis of 3D deformity. Therefore, the aim is to perform a 3D assessment of the hind- and midfoot alignment using a weightbearing CT (WBCT) preoperatively as well as postoperatively. METHODS: Eighteen patients with a mean age of 49.4 years (range 18-67) were prospectively included in a pre-post-study design. A MCO was performed and a WBCT was obtained pre- and postoperative. Images were converted into 3D models to compute linear and angular measurements, respectively, in millimeters (mm) and degrees (°), based on previously reported landmarks of the hind- and midfoot alignment. A regression analysis was performed between the displacement of a MCO and the obtained postoperative correction. RESULTS: The mean 3D hindfoot angle improved significantly preoperative compared to postoperative (p < 0.001). This appeared according to a linear relation with the amount of medial translation in a MCO (R2 = 0.84, p < 0.001). The axes of the tibia showed significant coronal as well as axial changes (p < 0.05). Analysis of the midfoot showed significant changes in the navicular height and rotation as well as the Méary angle (p < 0.05). Additionally, a linear trend between the midfoot measurements and amount of medial translation in a MCO was observed, but not significant (p > 0.05). CONCLUSION: This study demonstrates an effective 3D correction of an AAFD by a MCO according to a linear relationship. The concomitant formula can be used to perform a preoperative planning. The novelty is the comparative 3D weightbearing CT assessment of both the computed hind- and midfoot alignment after a medializing calcaneus osteotomy. This could improve accuracy of the currently performed preoperative planning in clinical practice.

Evaluation of computed tomography post-processing images in postoperative assessment of Lisfranc injuries compared with plain radiographs.

BACKGROUND: The objective of this study is to evaluate the value of computed tomography (CT) post-processing images in postoperative assessment of Lisfranc injuries compared with plain radiographs. METHODS: A total of 79 cases with closed Lisfranc injuries that were treated with conventional open reduction and internal fixation from January 2010 to June 2016 were analyzed. Postoperative assessment was performed by two independent orthopedic surgeons with both plain radiographs and CT post-processing images. Inter- and intra-observer agreement were analyzed by kappa statistics while the differences between the two postoperative imaging assessments were assessed using the χ 2 test (McNemar's test). Significance was assumed when p < 0.05. RESULTS: Inter- and intra-observer agreement of CT post-processing images was much higher than that of plain radiographs. Non-anatomic reduction was more easily identified in patients with injuries of Myerson classifications A, B1, B2, and C1 using CT post-processing images with overall groups (p < 0.05), and poor internal fixation was also more easily detected in patients with injuries of Myerson classifications A, B1, B2, and C2 using CT post-processing images with overall groups (p < 0.05). CONCLUSIONS: CT post-processing images can be more reliable than plain radiographs in the postoperative assessment of reduction and implant placement for Lisfranc injuries.

Accuracy of leg alignment measurements from antero-posterior radiographs.

After a knee replacement procedure, postoperative radiological assessment is carried out to evaluate outcome and predict procedure success. For this assessment, long-standing load-bearing antero-posterior radiographs are used to carry out manual identification of anatomic landmarks. These landmarks are subsequently used to estimate leg alignment. The positions of the landmarks in the radiographs are affected by the patient pose and the X-ray projection center. Although there is some past work exploring the impact of patient pose on the landmarks in the radiographs, there is no previous work on the impact of the X-ray projection center on the estimated leg alignment. In this work, we carried out a study of the impact of patient foot rotation, and X-ray projection center on landmark measurement errors, and estimation of leg alignment. In this evaluation, landmarks were first identified in three-dimensional computed tomography scans. Digitally reconstructed radiographs were then obtained from these scans under varying rotation and projection centers. Subsequently, landmarks were manually identified in these radiographs and leg alignment was estimated from these landmarks. We found that foot rotation leads to increased errors in certain landmarks. We also found that variations in the X-ray projection center do not lead to significant (p<0.01) errors in landmark measurements. Also, errors as large as 13.1 mm for the femoral knee center and 13.6 mm for the lateral malleolus led to a maximum error of 1.46° for the femoral mechanical axis and 0.66° for the tibial mechanical axis.

Incidence, degree, and development of graft hypertrophy 24 months after matrix-induced autologous chondrocyte implantation: association with clinical outcomes.

BACKGROUND: Graft hypertrophy is a common occurrence after periosteal, collagen-covered and matrix-induced autologous chondrocyte implantation (MACI). PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the incidence, development, and degree of graft hypertrophy at 24 months after MACI. The hypothesis was that graft hypertrophy would not be associated with clinical outcome at 24 months. STUDY DESIGN: Case series, Level of evidence, 4. METHODS: This study was undertaken in 180 consecutive patients (113 male, 67 female) after MACI in the knee. All patients were assessed clinically using the Knee injury and Osteoarthritis Outcome Score (KOOS) and underwent magnetic resonance imaging (MRI) at 3, 12, and 24 months after surgery. The incidence of hypertrophy relevant to anatomic graft site was investigated, as was the progressive change in hypertrophic studies postoperatively. The degree of tissue overgrowth in hypertrophic cases was investigated, as was its association with patient clinical outcome at 24 months after surgery. RESULTS: Of the 180 patients, 50 demonstrated a hypertrophic graft at 1 or more postoperative time points. This included 9 grafts (5.0%) at 3 months and 32 grafts (18.7%) at 12 months. At 24 months, 47 grafts (26.1%)-43 (32.1%) tibiofemoral and 4 (8.7%) patellofemoral-were hypertrophic. Patients with hypertrophic grafts at 24 months (n = 47) were younger (P = .051), they had a lower body mass index (BMI; P = .069), and significantly fewer of them had patellofemoral grafts (P = .007) compared with patients who had grafts with full (100%) tissue infill (n = 61). There were no significant differences in any of the KOOS subscales between patients with graft hypertrophy or full (100%) tissue infill at 24 months after surgery, while the severity of graft hypertrophy was not associated with KOOS subscales at 24 months. CONCLUSION: Hypertrophic grafts after MACI were common and continued to develop through to 24 months after surgery. Hypertrophic growth was associated with being younger and having a lower BMI, was more common on the femoral condyles, and overall was not associated with clinical outcome at 24 months after surgery. However, further research with longer term follow-up is required to evaluate the effect of persistent hypertrophy on graft stability and to assess the use of early surgical intervention to prevent such failure.

Non-inferiority of retrospective data collection for assessing perioperative morbidity.

Background. Postoperative morbidity has immediate and delayed consequences for surgical patients, including excess risk of premature death. Capturing these data objectively and routinely in large electronic databases using tools such as the Postoperative Morbidity Survey (POMS) would offer tremendous clinical and translational potential. However, POMS has thus far only utilised prospective data collection by research staff. We hypothesised that retrospective data collection from routinely collated hospital data from paper and electronic charts, medical and nursing notes was non-inferior to prospective data collection requiring research staff capturing POMS-defined morbidity in real-time. Methods. Morbidity was recorded by a trained investigator as defined by POMS prospectively on postoperative days 3 and 7. Separately, an independent investigator blinded to prospectively acquired data retrospectively assessed the same patients' morbidity as defined by POMS criteria, using medical charts, nursing summaries and electronic data. Equivalence was accepted when the confidence limits for both modes of data collection fell completely inside the equivalence bounds, with the maximum equivalence difference (i.e., the largest value of the difference in sensitivities deemed to reach a conclusion of equivalence) set a priori at 0.2. Differences for confidence limits between retrospective and prospective data collection were based on Nam's RMLE method. The relationship between morbidity on postoperative day 3 as recorded by each data collection method on time to become morbidity free and length of hospital stay was compared using the log-rank test. Results. POMS data from 85 patients undergoing elective or emergency surgery were analyzed. At postoperative day 3, POMS-defined morbidity was similar regardless of whether data were collected prospectively or retrospectively (95% CI [-0.13-0.013]; p < 0.001). Non-inferiority for sensitivity was observed for all other POMS domains and timepoints. Time to become morbidity free Kaplan-Meier plots were indistinguishable between POMS obtained prospectively or retrospectively (hazard ratio: 1.09 (95% CI [0.76-1.57]); p = 0.33, log rank test). Similarly, the mode of data collection did not alter the association between early postoperative morbidity on postoperative day 3 and delayed hospital discharge. Conclusions. Postoperative morbidity as defined by the Post Operative Morbidity Survey can be assessed retrospectively. These data may therefore be easily captured using electronic patient record systems, thereby expanding the potential for bioinformatics approaches to generate new clinical and translational insights into recovery from surgery.

Role and efficacy of picture archiving and communication system-assisted preoperative planning in total knee arthroplasty / 中国组织工程研究

BACKGROUND: In clinical application, Picture Archiving and Communication System gradually replaces the traditional preoperative planning mode of acetate template measurement on film, which can accurately obtain the parameters needed in the operation of total knee arthroplasty. OBJECTIVE: To evaluate the usage of Picture Archiving and Communication System in planning and assessment pre- and post-operatively in total knee arthroplasty. METHODS: Severe knee osteoarthritis patients who undertook total knee arthroplasty in Wuxi People's Hospital affiliated to Nanjing Medical University from March 2016 to March 2018 were included in the study. The patients were randomly divided into two groups. In the trial group (n=32), osteotomy was performed by Picture Archiving and Communication System, and then patients were implanted with knee prosthesis. In the control group (n=32), the osteotomy was performed according to the X-ray film, and then the artificial knee joint prosthesis was implanted. The trajectory of the tibia was tested during the operation. Anteroposterior and lateral X-ray films of the knee and the whole length films of the lower limbs were reexamined postoperatively. Tibial plateau inclination angle and valgus or varus angle were measured through Picture Archiving and Communication System. Recovery of lower limb alignment was assessed. Hospital for special surgery knee score on the affected side was analyzed to evaluate the recovery of joint function at postoperative 1, 3 and 12 months. This study was approved by the Ethics Committee of Wuxi People's Hospital affiliated to Nanjing Medical University. RESULTS AND CONCLUSION: (1) The satisfaction rate of lower limb alignment and the excellent and good rate of patellar movement trajectory were higher in the trial group than in the control group (100%, 91%; 100%, 94%, P 0. 05). (2) Hospital for special surgery knee score was higher in the trial group than in the control group at postoperative 1 and 3 months [(80. 5±9. 06), (74. 0±6. 42), P 0. 05). (3) No complications or adverse reactions related to implant occurred after operation. (4) Results indicated that personal osteotomy data can be obtained through Picture Archiving and Communication System in the total knee arthroplasty so as to improve the accuracy of osteotomy, better correct the lower limb alignment, obtain excellent patellar trajectory, and obtain better early curative effect of operation. The follow-up results within 1 year were satisfactory. The long-term effect remains to be further observed.

Degree of preoperative subchondral bone edema is not associated with pain and graft outcomes after matrix-induced autologous chondrocyte implantation.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects. While a number of factors may affect the clinical outcome, little is known about the influence of subchondral bone abnormalities at the time of surgery on pain and graft outcomes after MACI. PURPOSE: To investigate the association between subchondral bone marrow edema within 3 months before MACI surgery on preoperative and postoperative reported pain and symptoms as well as postoperative graft outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This retrospective study was undertaken in 56 patients undergoing MACI with clinical and radiological assessments before surgery and at 3, 12, 24, and 60 months after surgery. Patients were assessed using the Pain and Symptoms subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS). High-resolution magnetic resonance imaging (MRI) was used to evaluate the severity of preoperative subchondral bone marrow edema, while graft infill and an MRI composite graft score were evaluated after surgery via the magnetic resonance observation of cartilage repair tissue (MOCART) scoring system. Linear regression utilizing generalized estimating equations was used to investigate the association between preoperative subchondral bone marrow edema scores and preoperative and postoperative KOOS subscores as well as postoperative MRI-based scores of graft repair. RESULTS: The degree of preoperative subchondral bone marrow edema was not significantly associated with postoperative outcomes, whereby there was no evidence of a difference between edema subgroups over all time points for the KOOS-Pain subscore (P = .644), KOOS-Symptoms subscore (P = .475), or MRI composite score (P = .685) after adjustment for potential confounders of age, body mass index, defect size, and defect location. CONCLUSION: No association was demonstrated between the severity of preoperative subchondral bone marrow edema with postoperative patient-reported knee pain or symptoms or postoperative graft repair assessed via MRI.

Correlation Between Clinical and Radiological Outcomes After Matrix-Induced Autologous Chondrocyte Implantation in the Femoral Condyles.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects, although the correlation between clinical and radiological outcomes after surgery is poorly understood. PURPOSE: To determine the correlation between clinical and radiological outcomes throughout the postoperative timeline to 5 years after MACI. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: This retrospective study was undertaken in 83 patients (53 male, 30 female) with complete clinical and radiological follow-up at 1, 2, and 5 years after MACI. The mean age of patients was 38.9 years (range, 13-62 years), with a mean body mass index (BMI) of 26.6 kg/m(2) (range, 16.8-34.8 kg/m(2)), mean defect size of 3.3 cm(2) (range, 1-9 cm(2)), and mean preoperative duration of symptoms of 9.2 years (range, 1-46 years). Patients indicated for MACI in this follow-up were 13 to 65 years of age, although they were excluded if they had a BMI >35 kg/m(2), had undergone prior extensive meniscectomy, or had ongoing progressive inflammatory arthritis. Patients were assessed clinically using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Magnetic resonance imaging (MRI) was used to evaluate the graft using a 1.5-T or 3-T clinical scanner; the MRI assessment included 8 parameters of graft repair (infill, signal intensity, border integration, surface contour, structure, subchondral lamina, subchondral bone, and effusion) based on the magnetic resonance observation of cartilage repair tissue (MOCART) score as well as an MRI composite score. The degree of an association between the MRI parameters and the KOOS subscales at each postoperative time point was assessed with the Spearman correlation coefficient (SCC), and significance was determined at P < .05. Ethics approval was obtained from the appropriate hospital and university Human Research Ethics Committees, and informed consent was gathered from all patients. RESULTS: The only MRI parameter displaying consistent evidence of an association with the KOOS subscales was effusion, with a pattern of increasing strength of correlations over time and statistically significant associations at 5 years with KOOS-Pain (SCC, 0.25; P = .020), KOOS-Activities of Daily Living (SCC, 0.26; P = .018), and KOOS-Sport (SCC, 0.32; P = .003). Apart from a significant correlation between subchondral lamina and KOOS-Sport at 1 year (SCC, 0.27; P = .016), no further significant findings were observed. CONCLUSION: Apart from some consistent evidence of an association between the KOOS and effusion, this analysis demonstrated a limited correlative capacity between clinical and radiological outcomes up to 5 years after surgery.

Developing a strategy to identify and treat older patients with postoperative delirium.

Postoperative delirium is one of the most common adverse outcomes in elderly patients undergoing surgery and is associated with increased morbidity, length of stay, and patient care costs. The purpose of this quality improvement project was to evaluate the effectiveness of a multicomponent strategy to identify and treat general surgical patients 65 years of age or older at risk for and who develop postoperative delirium at Cape Cod Hospital, a community hospital in southern New England. We evaluated 96 patients using the Mini-Cog assessment tool preoperatively and the Confusion Assessment Method (CAM) delirium screening tool or CAM-Intensive Care Unit (CAM-ICU) assessment tool postoperatively. Patients who tested positive during preoperative assessment underwent a postoperative delirium management protocol. We summarized data using descriptive statistics. The results showed an association between compliance and outcomes. High compliance with implementation of CAM and CAM-ICU assessment tools resulted in increased identification of postoperative delirium in the older surgical population. The use of screening tools helped facilitate early identification of postoperative delirium in elderly surgical patients.

Factors predictive of outcome 5 years after matrix-induced autologous chondrocyte implantation in the tibiofemoral joint.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (MACI) has become an established technique for the repair of full-thickness chondral defects in the knee. However, little is known about what variables most contribute to postoperative clinical and graft outcomes as well as overall patient satisfaction with the surgery. PURPOSE: To estimate the improvement in clinical and radiological outcomes and investigate the independent contribution of pertinent preoperative and postoperative patient, chondral defect, injury/surgery history, and rehabilitation factors to clinical and radiological outcomes, as well as patient satisfaction, 5 years after MACI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study was undertaken in 104 patients of an eligible 115 patients who were recruited with complete clinical and radiological follow-up at 5 years after MACI to the femoral or tibial condyles. After a review of the literature, a range of preoperative and postoperative variables that had demonstrated an association with postoperative clinical and graft outcomes was selected for investigation. These included age, sex, and body mass index; preoperative 36-item Short Form Health Survey (SF-36) mental component score (MCS) and physical component score (PCS); chondral defect size and location; duration of symptoms and prior surgeries; and postoperative time to full weightbearing gait. The sport and recreation (sport/rec) and knee-related quality of life (QOL) subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used as the patient-reported clinical evaluation tools at 5 years, while high-resolution magnetic resonance imaging (MRI) was used to evaluate graft assessment. An MRI composite score was calculated based on the magnetic resonance observation of cartilage repair tissue score. A patient satisfaction questionnaire was completed by all patients at 5 years. Regression analysis was used to investigate the contribution of these pertinent variables to 5-year postoperative clinical, radiological, and patient satisfaction outcomes. RESULTS: Preoperative MCS and PCS and duration of symptoms contributed significantly to the KOOS sport/rec score at 5 years, while no variables, apart from the baseline KOOS QOL score, contributed significantly to the KOOS QOL score at 5 years. Preoperative MCS, duration of symptoms, and graft size were statistically significant predictors of the MRI score at 5 years after surgery. An 8-week postoperative return to full weightbearing (vs 12 weeks) was the only variable significantly associated with an improved level of patient satisfaction at 5 years. CONCLUSION: This study outlined factors such as preoperative SF-36 scores, duration of knee symptoms, graft size, and postoperative course of weightbearing rehabilitation as pertinent variables involved in 5-year clinical and radiological outcomes and overall satisfaction. This information may allow orthopaedic surgeons to better screen their patients as good candidates for MACI, while allowing treating therapists to better individualize their preoperative preparatory and postoperative rehabilitation regimens for a best possible outcome.

Validación posoperatoria en la selección asistida por computadora de aloinjertos de fémur distal / Postoperative assessment in computer assisted selection of femur osteoarticular allograft

El objetivo de nuestro trabajo fue comparar dos grupos de pacientes tratados con trasplantes osteoarticulares del fémur distal en términos de evaluar: 1) el volumen del fémur distal del receptor y del trasplante, 2) la superficie articular de contacto del fémur distal del receptor y del trasplante, 3) el ángulo del valgo anatómico femoral del fémur distal del receptor y del trasplante. Materiales y métodos: se realizó una búsqueda retrospectiva entre 2002 y 2012 analizando a pacientes tratados con un trasplante osteoarticular de fémur distal. Se incluyó un total de 32 pacientes. Estos fueron divididos en dos grupos de acuerdo con el método de selección del trasplante: Grupo 1, conformado por 16 pacientes con trasplantes seleccionados mediante tomografía 2D y Grupo 2, 16 pacientes con trasplantes seleccionados a través de un método 3D. La evaluación fue realizada por un observador independiente y ciego para los dos grupos. Resultados: las diferencias en las pruebas de estimación de volumen y superficie articulares entre el donante y el receptor no fueron estadísticamente significativas (p>0,05). Sin embargo, la diferencia entre los ángulos de valgo del fémur receptor y el fémur donante, seleccionados por el método 2D fue significativa (p<0,05), mientras que la diferencia de estos ángulos en el método 3D no lo fue (p>0,05). Conclusión: el método de selección de un aloinjerto, mediante la utilización de un banco de huesos virtual 3D para la reconstrucción con un trasplante osteoarticular de femur distal, permite obtener una mejor alineación del miembro comparado con aquellos seleccionados solo con un método bidimensional. (AU)

The aim of our study was to compare two groups of patients treated with distal femur osteoarticular allograft in terms of: 1) the volume of the distal femur of the allograft and patient, 2) the articular surface contact, 3) the anatomical femoral valgus angle. Material and methods: a retrospective review was performed between 2002 and 2012 and all patients with an osteo-articular allograft of the distal femur were analysed. A total of 32 patients were included in the study. Patients were divided into two groups according to the selection method of the allograft: Group 1, 16 patients with allograft selected by 2D (CT) and Group 2, 16 patients selected through a 3D method. The evaluation was done by an independent and blind observer. Results: the differences in terms of volume estimation and joint surface contact between the donor allograft and patient distal femur were not statistically significant (p>0.05). However, the difference between the valgus angle showed significant differences between donor and patient femurs selected by the 2D method (p<0.05) but no difference in the group of patients selected by 3D method (p>0.05). Conclusion: the 3D method for allograft selection of the distal femur showed better results in limb alignment compared to 2D selection method. (AU)