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Background: The use of all-suture anchors for rotator cuff repair is increasing. Potential benefits include decreased bone loss and decreased damage to the chondral surface. Minimal evidence exists comparing outcomes among medial-row anchor fixation methods in double-row suture bridge rotator cuff repair. Purpose: To compare the clinical outcomes between all-suture and solid medial-row anchors in double-row suture bridge rotator cuff repair. Study Design: Case series; Level of evidence, 4. Methods: A total of 352 patients (mean age at surgery, 60.3 years) underwent double-row suture bridge rotator cuff repair at our institution. Patients were separated into 2 groups based on whether they underwent all-suture (n = 280) or solid (n = 72) anchor fixation for the medial row. Outcomes data were collected via an ongoing longitudinal data repository or through telephone calls (minimum follow-up time, 2.0 years; mean follow-up time, 3.0 years). Outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) standardized shoulder assessment form and the visual analog scale (VAS). The same rehabilitation protocol was administered to all patients. The proportions of patients meeting previously published Patient Acceptable Symptom State (PASS) thresholds were calculated for the outcome measures, and outcome scores and the proportions of patients meeting PASS thresholds between groups were compared using linear and logistic regression, respectively. Results: The groups did not differ in terms of age at surgery, sex distribution, rotator cuff tear size, or number of medial-row anchors used. The solid anchor group had a longer follow-up time compared with the all-suture anchor group (3.6 ± 0.7 vs 2.8 ± 0.8 years, respectively; P < .01). After controlling for follow-up time, the solid and all-suture anchor groups did not differ in ASES scores (89.6 ± 17.8 vs 88.8 ± 16.7, respectively; P = .44) or VAS scores (1.1 ± 2.1 vs 1.2 ± 2.1, respectively; P = .37). Similarly, after controlling for follow-up time, the solid and all-suture anchor groups did not differ in the proportions of patients meeting PASS cutoffs for the ASES (84.7% vs 80.7%, respectively; P = .44) or the VAS (80.6% vs 75.0%, respectively; P = .83). Conclusion: Double-row suture bridge rotator cuff repair using all-suture anchors for medial-row fixation demonstrated similar excellent clinical outcomes to rotator cuff repair using solid medial-row anchors.
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PURPOSE: Cranial Nerve Neuropathies (CNNs) often accompany Cavernous Sinus Meningioma (CSM), for which Stereotactic Radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSR) are established treatments. This study assesses CNNs recovery in CSM patients treated with LINAC, offering insight into treatment effectiveness. METHODS: This study was conducted on 128 patients with CSM treated with LINAC-based SRS/FSR between 2005 and 2020 at a single institution. 46 patients presented with CNNs. The study analyzed patients' demographics, clinical parameters, SRS/FSR treatment characteristics, post-treatment CNNs recovery duration, status, and radiological control on their last follow-up. RESULTS: The median follow-up duration was 53.4 months. Patients were treated with SRS (n = 25) or FSR (n = 21). The mean pretreatment tumor volume was 9.5 cc decreasing to a mean end-of-follow-up tumor volume was 5.1 cc. Radiological tumor control was achieved in all cases. CNN recovery was observed in 80.4% of patients, with specific nerve recoveries documented as follows: extra-ocular nerves (43.2%), trigeminal nerve (32.4%), and optic nerve (10.8%). A higher CNNs recovery rate was associated with a smaller pre-treatment tumor volume (p < 0.001), and the median time-to-improvement was 3.7 months. Patients with tumor volumes exceeding 6.8 cc and those treated with FSR exhibited prolonged time-to-improvement (P < 0.03 and P < 0.04 respectively). CONCLUSIONS: This study suggests that SRS/FSR for CSM provides good and sustainable CNNs recovery outcomes with excellent long-term radiological control. A higher CNNs recovery rate was associated with a smaller pre-treatment tumor volume. while shorter time-to-improvement was identified in patients treated with SRS compared to FSR, particularly in those with small pre-treatment tumor volume.
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BACKGROUND: Cervical cancer is a rare primary tumor resulting in metastases to the breast with few cases reported in literature. Breast metastases are associated with poor prognosis. The following case highlights the diagnostic challenges associated with metastatic cervical cancer to the breast along with individualized treatment. CASE SUMMARY: A 44-year-old G7P5025 with no significant past medical or surgical history presented with heavy vaginal to an outside emergency department where an exam and a pelvic magnetic resonance imaging showed a 4.5 cm heterogenous lobulated cervical mass involving upper two thirds of vagina, parametria and lymph node metastases. Cervical biopsies confirmed high grade adenocarcinoma with mucinous features. A positron emission tomography/computed tomography (PET/CT) did not show evidence of metastatic disease. She received concurrent cisplatin with external beam radiation therapy. Follow up PET/CT scan three months later showed no suspicious fluorodeoxyglucose uptake in the cervix and no evidence of metastatic disease. Patient was lost to follow up for six months. She was re-imaged on re-presentation and found to have widely metastatic disease including breast disease. Breast biopsy confirmed programmed death-ligand 1 positive metastatic cervical cancer. The patient received six cycles of carboplatin and paclitaxel with pembrolizumab. Restaging imaging demonstrated response. Patient continued on pembrolizumab with disease control. CONCLUSION: Metastatic cervical cancer to the breast is uncommon with nonspecific clinical findings that can make diagnosis challenging. Clinical history and immunohistochemical evaluation of breast lesion, and comparison to primary tumor can support diagnosis of metastatic cervical cancer to the breast. Overall, the prognosis is poor, but immunotherapy can be considered in select patients and may result in good disease response.
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Background: Few studies have examined the short-term clinical outcomes of rotator cuff repair (RCR) with all-suture anchors for medial row anchor fixation. Purpose: To evaluate clinical outcomes of double-row suture bridge RCR using a novel all-suture medial row anchor. Study Design: Case series; Level of evidence, 4. Methods: We enrolled 179 patients before double-row suture bridge RCR (mean age at surgery, 60.0 years; 63% male patients) at a single institution. All patients underwent RCR with all-suture anchor fixation for the medial row and solid anchor fixation for the lateral row. Preoperative (baseline) and follow-up (minimum follow-up time of 2 years; mean, 2.5 years) clinical outcomes were compared using the American Shoulder and Elbow Surgeons (ASES) score and a 10-point numeric pain rating scale (NPRS). We calculated the proportions of patients meeting previously published Patient Acceptable Symptom State (PASS) thresholds for the ASES (≥78.0) and NPRS (≤1.7). We further compared baseline and follow-up outcome scores and the proportions of patients meeting PASS thresholds using paired t tests and McNemar tests, respectively, and calculated effect size to quantify the magnitude of change from baseline to follow-up. Results: Values significantly improved from baseline to follow-up for ASES (from 45.3 ± 19.8 to 87.3 ± 17.1) and NPRS (from 5.2 ± 2.5 to 1.4 ± 2.1). The proportion of patients meeting PASS thresholds also significantly improved for the ASES (from 6% to 77%) and the NPRS (from 7% to 72%). The magnitude of baseline to follow-up change for all measures was large (all effect sizes ≥1.5). Conclusion: Our study demonstrated excellent short-term clinical outcomes and substantial improvements for patients undergoing double-row suture bridge RCR with all-suture anchors for medial row fixation.
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BACKGROUND: Esophageal dysmotility has been attributed to opioid use. The goal was to assess the differences in pre- and post-treatment timed-barium esophagram (TBE) barium heights at 1 and 5 minutes and symptomatic response to treatment in esophagogastric junction outflow obstruction (EGJOO) patients according to opioid use status. METHODS: We performed a retrospective cohort study. Consecutive patients with EGJOO were eligible for inclusion. Data were collected on demographics, pre and post-treatment 1 and 5 minutes TBE barium heights and symptom outcomes. Groups were compared according to opioid use. RESULTS: Thirty-one EGJOO patients met the inclusion criteria. All patients were treated with pneumatic dilation. Of the 31 patients, 11 (35%) had opioid exposure and 20 (65%) did not. The median follow-up post-treatment was two months (range 1-47 months). There was no statistically significant difference in post-treatment outcomes for opioid exposed vs. unexposed groups. The median per cent decrease in the TBE barium height at 1 minute was 100% for the opioid exposed vs. 71% for the unexposed group (p = 0.92). The median per cent decrease in the TBE barium height at 5 minutes was zero % for the opioid exposed and unexposed groups (p = 0.67). The incidence of symptomatic improvement was 82% (9/11) for the opioid exposed group vs 95% (19/20) for the unexposed group (p = 0.28). CONCLUSIONS: Patients with EGJOO seem to respond to treatment similarly regardless of being on opioids.
Subject(s)
Esophageal Achalasia , Esophageal Motility Disorders , Stomach Diseases , Humans , Analgesics, Opioid , Esophagogastric Junction , Retrospective Studies , Barium , Manometry , Esophageal Motility Disorders/diagnosis , Esophageal Achalasia/diagnosisABSTRACT
Purpose: Mortality rates following hip fracture surgery have been well-studied. This study was conducted to examine mortality rates in asymptomatic patients presenting for treatment of acute hip fractures with concurrent positive COVID-19(+) tests compared to those with negative COVID-19(-) tests. Materials and Methods: A total of 149 consecutive patients undergoing hip fracture surgery during the COVID-19 pandemic at two academic medical centers were reviewed retrospectively. Patients were divided into two groups for comparative analysis: one group included asymptomatic patients with COVID-19+ tests versus COVID-19- tests. The primary outcome was mortality at 30-days and 90-days. Results: COVID-19+ patients had a higher mortality rate than COVID-19- patients at 30-days (26.7% vs 6.0%, P=0.005) and 90-days (41.7% vs 17.2%, P=0.046) and trended towards an increased length of hospital stay (10.1±6.2 vs 6.8±3.8 days, P=0.06). COVID-19+ patients had more pre-existing respiratory disease (46.7% vs 11.2%, P=0.0002). Results of a Cox regression analysis showed an increased risk of mortality at 30-days and 90-days from COVID-19+ status alone without an increased risk of death in patients with pre-existing chronic respiratory disease. Conclusion: Factors including time to surgery, age, preexisting comorbidities, and postoperative ambulatory status have been proven to affect mortality and complications in hip fracture patients; however, a positive COVID-19 test result adds another variable to this process. Implementation of protocols that will promote prompt orthogeriatric assessments, expedite patient transfer, limit operating room traffic, and optimize anesthesia time can preserve the standard of care in this unique patient population.
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Scapulothoracic dissociation is a rare and devastating injury that is considered an orthopedic emergency. It is critical to recognize this injury early based on mechanism, physical examination, and radiographic parameters. Initial management should be focused on resuscitation and evaluation for potential limb-threatening ischemia.
Subject(s)
Brachial Plexus/injuries , Brachial Plexus/surgery , Scapula/injuries , Scapula/surgery , Shoulder Injuries , Shoulder Joint/surgery , Vascular System Injuries/surgery , Brachial Plexus/diagnostic imaging , Diagnostic Imaging , Humans , Plastic Surgery Procedures/methods , Scapula/diagnostic imaging , Shoulder Joint/diagnostic imaging , Vascular System Injuries/diagnostic imagingABSTRACT
BACKGROUND: Timed barium swallow (TBS) assesses esophageal emptying before and after therapy in patients with achalasia. Our aim was to compare the accuracy of percent change in barium height with traditional absolute cutoff of <5 cm on post-treatment TBS. MATERIALS AND METHODS: Consecutive patients with treatment naïve achalasia treated with either PD, HM, or POEM between 1/2012 and 7/2017 were eligible for inclusion. The accuracy of percent change in pre- and post-treatment barium height at 5 minutes versus an absolute <5 cm cutoff for assessing treatment response was assessed using the receiver operating curve analysis (ROC). RESULTS: Eighty-one patients met the inclusion criteria. The median percent change in barium heights at five minutes in patients who did not improve was 6 percent increase (n = 10; mean 10.6) versus 78 percent decrease (n = 71; mean 64) in patients who improved (P = 0.0001). The AUC for percent change in TBS 5 minutes height was 76% (95% CI 48% to 90%), and a 3% decrease from baseline as a cutoff had a sensitivity of 60% and specificity of 99%. The AUC for post-treatment TBS 5 minutes height was 79% (95% CI 53% to 91%), and the 5 cm cutoff had a sensitivity of 70% and specificity of 75%. CONCLUSIONS: The results show that 3% percent improvement in pre- and post-treatment barium height at 5 minutes rather than absolute cutoff value of <5 cm on post-treatment TBS is a better indicator of treatment success in achalasia patients. These findings indicate the need for reassessment of tools to identify treatment response.
Subject(s)
Barium Compounds , Deglutition , Esophageal Achalasia/diagnostic imaging , Esophageal Achalasia/surgery , Manometry , Radiography , Diagnostic Techniques, Digestive System , Dilatation , Esophageal Achalasia/physiopathology , Esophagoscopy , Female , Heller Myotomy , Humans , Male , Middle Aged , Myotomy , Treatment OutcomeABSTRACT
Microgallbladder is a nonsurgical medical condition characterized by chronic inflammation and atrophy of the gallbladder, which is considered a highly specific imaging finding unique to patients with cystic fibrosis (CF), and has been incidentally reported on abdominal imaging in up to 45% of cases with CF. The impairment of exocrine water efflux in CF leads to the production of hyperviscous biliary secretions, cholestasis, and transient cystic duct obstruction of the microgallbladder causing microcholecystitis-interestingly a self-remitting acute cholecystitis-like condition without surgical intervention. We present a case report of a 22-year-old male patient with history of CF with multiple hospital admissions for unexplained chronic abdominal pain found to be caused by microgallbladder, which was managed conservatively.
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INTRODUCTION: Paraesophageal hernia repairs are prone to recurrence and mesh reinforcement is common. Both biologic and prosthetic meshes have been used. We report a comparison of a new type of biologically derived graft, Gentrix Surgical Urinary Bladder Matrix (UBM). METHODS: The medical records of 65 patients who underwent paraesophageal hernia repair (PEHR) were reviewed. Primary data points included demographics, first-time or recurrent hernia, operative approach, graft or primary repair, operative time, and postoperative complications. Patients then underwent upper gastrointestinal series, completed the GERD-HRQL symptom severity questionnaire, and the SF-36 generic quality of life instrument. RESULTS: A total of 32 patients underwent graft-reinforced repair, 33 underwent primary repair. More patients in the UBM group were being treated for recurrent PEH. Demographic data and postoperative complications were similar. There was no difference in recurrence rates, size of recurrence, postoperative symptomatic or quality of life improvement. Patients who suffered recurrence in the primary repair group had more severe symptoms and a higher rate of dissatisfaction. Of the 3 patients with recurrences after Gentrix placement, reoperation demonstrated anterior failure where no reinforcement had occurred because of the posteriorly placed U-shaped graft. CONCLUSIONS: The use of UBM was not associated with an increased complications despite use in more difficult patients. Although there appeared to be no difference in recurrence rate or size, it was associated with less severe symptomatic recurrences. The U-shape configuration is prone to recurrence at the site of the repair not covered by the graft, suggesting that a keyhole configuration may be superior.
Subject(s)
Extracellular Matrix/transplantation , Hernia, Hiatal/surgery , Herniorrhaphy/methods , Surgical Mesh , Urinary Bladder/transplantation , Adult , Aged , Aged, 80 and over , Bioprosthesis , Female , Hernia, Hiatal/diagnostic imaging , Humans , Laparoscopy/methods , Laparotomy/methods , Male , Middle Aged , Quality of Life , Radiography , Suture Techniques , Thoracotomy/methods , Treatment OutcomeABSTRACT
OBJECTIVES: Timed barium swallow (TBS) assesses esophageal emptying in patients with achalasia and is considered the standard workup for patients with dysphagia. Our aim was to determine the usefulness of TBS in differentiating patients with achalasia (type 1-3), esophagogastric junction outflow obstruction (EGJOO), and non-achalasia dysphagia. METHODS: We performed a retrospective cohort study including consecutive patients who underwent TBS evaluation between May 2013 and September 2015. Patients were separated into untreated achalasia (n=117), EGJOO (n=46), and non-achalasia (n=146) groups. Diagnosis of achalasia/EGJOO was based on high-resolution manometry using Chicago Classification. Receiver operating characteristic (ROC) curve analysis was performed to determine the accuracy of TBS (barium height at 1 and 5 min and tablet retention) in identifying achalasia vs. EGJOO and non-achalasia. RESULTS: Barium column height of 5 cm at 1 min showed a sensitivity of 94% and specificity of 71% and barium column height of 2 cm at 5 min showed a sensitivity of 85% and specificity of 86% in differentiating untreated achalasia from EGJOO and non-achalasia. Combined liquid barium and tablet increases diagnostic yield from 79.5 to 100% in untreated achalasia patients and from 48.9 to 60% in EGJOO patients. CONCLUSIONS: TBS is a simple and useful test in differentiating untreated achalasia, EGJOO, and non-achalasia dysphagia. We propose that barium height >2 cm at 5 min be used as cutoff point for identifying achalasia. Combination of liquid barium and tablet increased the diagnostic yield of TBS in achalasia and EGJOO. Retention of barium tablet alone suggests functional/anatomic obstruction at the esophagogastric junction.
Subject(s)
Deglutition Disorders/diagnostic imaging , Esophageal Achalasia/diagnostic imaging , Esophagogastric Junction/diagnostic imaging , Gastrointestinal Motility , Aged , Barium Sulfate , Cohort Studies , Contrast Media , Deglutition Disorders/diagnosis , Esophageal Achalasia/diagnosis , Esophageal Diseases/diagnosis , Esophageal Diseases/diagnostic imaging , Esophageal Motility Disorders/diagnosis , Esophageal Motility Disorders/diagnostic imaging , Esophageal Stenosis/diagnosis , Esophageal Stenosis/diagnostic imaging , Female , Hernia, Hiatal/diagnosis , Hernia, Hiatal/diagnostic imaging , Humans , Male , Manometry , Middle Aged , Predictive Value of Tests , Radiography, Thoracic , Retrospective Studies , Sensitivity and Specificity , Time FactorsABSTRACT
Although intertrochanteric femoral fractures in elderly patients are common injuries that have been studied extensively, little has been reported about high-energy intertrochanteric fractures in younger patients. This study examined the injury characteristics and outcomes of high-energy intertrochanteric fractures in patients younger than 65 years treated with either sliding hip screws (SHSs) or cephalomedullary nails (CMNs). A total of 37 patients younger than 65 years (mean age, 45 years) with high-energy intertrochanteric fractures and mean follow-up of 34 weeks were identified; 21 patients were treated with SHSs, and 16 patients were treated with CMNs. All fractures were AO/ Orthopaedic Trauma Association (OTA) fracture type 31A1 or 31A2. Injury characteristics, measures of surgical quality, treatment outcomes, and complications were compared. Despite high-energy mechanisms of injury, 84% of patients had AO/OTA type 31A1 fractures, 60% presented with an Injury Severity Score of 17 or higher, and 78% sustained other injuries. There were no significant differences in tip-apex distance (TAD), reduction quality, blood loss, or surgical time (P>.05) for fractures treated with SHSs or CMNs. The overall rate of major complications requiring revision surgery was 13.5%; this difference was not statistically significant (P=.36). Young patients with intertrochanteric fractures often have multisystem trauma; these fractures are difficult to reduce by closed means, and young patients are more prone to complications than older patients. In particular, varus collapse occurred at a high rate in young patients with intertrochanteric fractures treated with SHSs despite relatively simple fracture patterns, satisfactory TAD, and satisfactory reduction quality. [Orthopedics. 2017; 40(2):e293-e299.].
Subject(s)
Bone Nails , Bone Screws , Hip Fractures/surgery , Orthopedic Procedures/adverse effects , Postoperative Complications/epidemiology , Female , Humans , Incidence , Injury Severity Score , Male , Middle Aged , Operative Time , Reoperation , Treatment OutcomeABSTRACT
Tibial stress fractures are common in the athlete. There are various causes of these fractures, the most common being a sudden increase in training intensity. Most of these injuries are treated conservatively; however, some may require operative intervention. Intervention is mostly dictated by location of the fracture and failure of conservative treatment. There are several surgical options available to the treating surgeon, each with advantages and disadvantages. The physician must understand the nature of the fracture and the likelihood for it to heal in a timely manner in order to best treat these fractures in this patient subset.
Subject(s)
Athletes , Athletic Injuries/therapy , Fracture Fixation/methods , Fractures, Stress/therapy , Tibial Fractures/therapy , HumansABSTRACT
A 50-year-old man with a history of epilepsy controlled with phenytoin presented for evaluation of dysphagia. History revealed the patient was taking his phenytoin daily without water. Barium esophagram showed severe stricturing of the mid-esophagus. Upper endoscopy revealed diffuse gross mucosal abnormality with a thick stricture and occasional exudate. Biopsies were consistent with a drug-induced injury with lymphocytic infiltration and epithelial cell necrosis.
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The purpose of this study was to determine if recent changes to the femoral component of a particular posterior-stabilized total knee prosthesis would affect the incidence of postoperative patellofemoral crepitance and patella clunk syndrome. One hundred eight total knee arthroplasties were performed with the conventional design; 136 were performed after the femoral component was changed. Complications were compared between the groups with an average follow-up of 17.7 months and 12.4 months, respectively. Thirteen knees with the conventional design (12%) were found to have patellofemoral complications; no complications were noted with the new design (P < .0001). Femoral components with a deep trochlear groove and smooth transition of the intercondylar box appear to better accommodate any peripatellar fibrous nodule that may form after total knee arthroplasty.