Surgical Management of a Torn ACL and Bucket-Handle Meniscal Tear in the Pregnant Patient: A Case Report.

CASE: A 36-year-old, 7-month pregnant woman presented to the office with a locked knee and a displaced bucket-handle medial meniscus tear, in the setting of chronic anterior cruciate ligament (ACL) insufficiency. After thorough discussion with the patient and her husband, the obstetrician, and the anesthesiologist, the patient was treated with left knee ACL reconstruction and medial meniscus repair. CONCLUSION: With sufficient preoperative planning and coordinated multidisciplinary care among orthopaedic, anesthesiologist, and obstetric specialists, elective knee surgery can be performed safely in time-sensitive situations during pregnancy.

Bilateral Knee Dislocations Treated with Acute, Single-Stage Multiligament Reconstructions.

Bilateral knee dislocations are exceedingly rare in orthopaedics. Managing these injuries presents a difficult task given their high complication rate and guarded prognosis. We report the case of a 21-year-old male who presented to our institution with bilateral knee dislocations sustained in a motor vehicle collision. The patient subsequently underwent multiligament knee reconstruction surgeries for each knee at one and three weeks following the initial injury. At one-year follow-up, the patient has achieved a successful outcome and has returned to regular activities which include hiking and exercising at the gym.

Validation of the Shin Pain Scoring System: A Novel Approach for Determining Tibial Bone Stress Injuries.

BACKGROUND: The incidence of adolescent overuse injuries, including bone stress injuries (BSIs), is on the rise. The identification of a BSI in the early stages is key to successful treatment. The Shin Pain Scoring System (SPSS) was developed to aid clinicians in identifying patients with a BSI. HYPOTHESIS: The SPSS will correlate with magnetic resonance imaging (MRI) grading of a BSI in an adolescent population. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Enrolled in this study were 80 adolescent high school athletes between the ages of 13 and 18 years participating in a variety of sports with more than 1 week of atraumatic shin pain. The SPSS questionnaire was completed for each participant, and physical examination findings were recorded. Each question and physical examination item was allotted a point value, which totaled 29 points. Radiographs and MRI scans of both lower legs were obtained for each participant. The SPSS score was statistically analyzed using logistic regression, a classification matrix, and a 2 × 2 contingency table to evaluate validity and predictability. RESULTS: Logistic regression analysis of our data determined that 3 categories of SPSS scores provided the highest diagnostic value when compared with MRI grading based on the Fredericson classification (0-4). The SPSS correctly identified 43.5% of injuries for category 1 (MRI grades 0-1), 62.5% for category 2 (MRI grade 2), and 50.0% for category 3 (MRI grades 3-4). Overall, the SPSS correctly identified the degree of BSI in 54.4% of all tibias studied. Binary analysis for validity demonstrated a sensitivity of 96%, specificity of 26%, positive predictive value of 76%, and negative predictive value of 71% for the SPSS relative to the "gold standard" MRI results. CONCLUSION: The SPSS is a potentially valid method to identify tibial BSIs, given the sensitivity and negative and positive predictive values. It also provides helpful categorization to alert clinicians to the presence of a BSI and direct further diagnostics and/or interventions. The SPSS should be considered as an additional tool to use when evaluating adolescents with atraumatic tibial BSIs.

Managing atraumatic meniscal tears in middle-aged patients.

What role does arthroscopic surgery have in the treatment of patients with atraumatic meniscal tears and osteoarthritis? The authors reviewed the literature to find out.

On becoming a physician.

Ken Swan practiced surgery for 46 years, serving with the US Army Medical Corps in both Vietnam and Desert Storm. After his army service, he joined the faculty of Rutgers Medical School, where he was director of the clinical clerkships at the time of his sudden death in 2014. Among his papers after his death, his son, Kenneth Jr. ("K. G."), found this address to incoming third-year medical students. At a symposium and gala honoring his dad in Newark on May 15, 2015, K. G. read it as a tribute to his father.

Students to Surgeons: Increasing Matriculation in Surgical Specialties.

Introduction Our nation suffers from a shortage in surgeons. This deficiency must be addressed at the medical student level. Increasing faculty and resident interaction with junior students augments surgical interest. Our surgical interest group has recently redefined its role to address these concerns. Methods A multifocal approach has been implemented to increase interest in the surgical specialties. Each academic year, senior students recruit first and second year students to our group to establish early exposure. Members receive didactic presentations from surgical faculty, addressing various topics, on a biweekly basis. In addition, scrubbing, knot-tying, and suturing workshops address technical skills throughout the semester. Membership and match data were collated and analyzed. Results Over the past 5 years, the enrollment in the student interest group increased significantly from 112 to 150. Accordingly, we have observed a parallel increase in the number of students who have successfully matched into surgical residencies. A record number of students (37) from the class of 2013 matched into surgical specialties, representing an 85% increase over the last decade. After creating bylaws and electing societal officers, the group has been recognized by the school's Student Council and given financial support. At present, the group is fiscally solvent with support from the institution, surgery department, and faculty. Conclusion As the demand for surgeons increases so too does the need to increase student interest in surgery. Our school has been successful because of our surgical interest group, and we encourage other schools to adopt a similar approach.

Ether in the developing world: rethinking an abandoned agent.

BACKGROUND: The first true demonstration of ether as an inhalation anesthetic was on October 16, 1846 by William T.G. Morton, a Boston dentist. Ether has been replaced completely by newer inhalation agents and open drop delivery systems have been exchanged for complicated vaporizers and monitoring systems. Anesthesia in the developing world, however, where lack of financial stability has halted the development of the field, still closely resembles primitive anesthetics. DISCUSSION: In areas where resources are scarce, patients are often not given supplemental intraoperative analgesia. While halothane provides little analgesia, ether provides excellent intra-operative pain control that can extend for several hours into the postoperative period. An important barrier to the widespread use of ether is availability. With decreasing demand, production of the inexpensive inhalation agent has fallen. Ether is inexpensive to manufacture, and encouraging increased production at a local level would help developing nations to cut costs and become more self-sufficient.

Niels thorkild Rovsing: the surgeon behind the sign.

Niels Thorkild Rovsing (1862 to 1927) was a Danish surgeon. His eponyms include the Rovsing sign of acute appendicitis, the Rovsing syndrome (abdominal pain in a horseshoe kidney), the Rovsing operation I (for polycystic kidney), and the Rovsing operation II (to separate a fused "horseshoe" kidney). He received his M.D. degree in 1885 and his Ph.D. in 1889 from Copenhagen University. Rovsing practiced surgery from 1892 to 1902 at the Queen Louise Children's Hospital and the Red Cross Hospital, both located in Copenhagen. He became Professor of Surgery in 1899 and Director of Surgery at the Royal Frederiks Hospital in 1904. Rovsing earned international recognition for his innovative urological surgery. Together with his colleague, Eilert A. Tscherning, Rovsing founded the Danish Surgical Society (Dansk Kirurgisk Selskap) in 1908. His advocacy for antisepsis and Listerism advanced his notoriety and exemplified his medical leadership. His clarion call for a modern hospital led to the construction of the Copenhagen University Hospital (Rigshospitalet) that opened in 1910. Rovsing was an Honorary Member of the Edinburgh Medico-Chirurgical Society and the Association of Surgeons of Great Britain and Ireland. Rovsing served briefly as Denmark's Minister of Education in 1920. He died in 1927 from cardiac failure and laryngeal cancer.

Francis Xavier Dercum: a man for all seasons.

Francis Xavier Dercum (1856-1931) is known primarily for his prominence in the field of neurology and for his identification of "Adiposis Dolorosa", known as Dercum's disease. His brilliance, however, extends well beyond neurology. Born and raised in Philadelphia to parents of American and European descent, Dercum's natural curiosity oriented his interests toward medicine and philosophy. His scholarship flourished, and much recognition came his way. He died in Benjamin Franklin's Chair, closing what would be his last session as President of the American Philosophical Society. From anatomy, histology, pathology, and neurology to teaching, writing, and philosophy, Dercum's life was that of a man for all seasons.

The Greater Metropolitan Medical Alumni Council (GMMAC): the realization of a need.

OBJECTIVE: The greater New York metropolitan area includes 8 medical schools. Their alumni association (AA) presidents formed a council 6 years ago, meeting 3 times a year to share ideas and identify best practices to solve mutual problems challenging students and alumni. METHODS: A survey of the 8 medical AAs was conducted; all responded, and the results constitute the data in this report. RESULTS: Mean AA membership was 2509 or 33% of mean alumni populations (7489). Two AAs conferred membership at graduation; hence, 100% of alumni were AA members. Omitting these 2 AAs reduced mean participation to 1722 or 23%. Alumni association support staff averaged 3.8 persons (range, 1-7 persons). The 2 most frequently cited AA challenges were membership and fund-raising. All AAs had annual or biennial reunions and considered the reunion to be a major commitment of resources. Despite this commitment, mean reunion attendance was only 242 alumni (range, 40-500 alumni) or 7.3% of alumni in anniversary years (5-year intervals). The mean number of alumni who contributed annually to their alma mater through its AA was 1936 alumni (range, 500-3500 alumni), or 26% (range, 5%-47%). Medical AAs reported mean assets of $2,755,000 (range, $6475-$11,000,000). The mean AA budget was $298,750, of which 65% (range, 13%-100%) was devoted to "medical student support". The most frequently cited student activities were "career night" (100%), "white coat ceremonies" (63%), medical equipment (stethoscopes, etc, 50%), and alumni host programs (38%). Eleven additional medical student activities received financial support from the 8 AAs in varying proportions. CONCLUSIONS: Each AA in the Greater Metropolitan Medical Alumni Council has derived significant benefit from the application of best practices to its individual problem set. In particular, a nascent AA developed significant momentum in its formation and development by its participation in the Greater Metropolitan Medical Alumni Council. Additionally, these data provide a foundation for the development of best practices within medical school AA for optimizing support of student programs and alumni participation. Stronger AAs will translate into enhanced support of educational programs for medical students. We urge formation of similar medical AA organizations in other metropolitan areas.

Increasing educational indebtedness influences medical students to pursue specialization: a military recruitment potential?

BACKGROUND: Cost of medical education and student indebtedness has increased dramatically. This study surveyed medical students on educational debt, educational costs, and whether indebtedness influenced career choice. Responses should impact (1) Department of Defense (DoD) recruitment of physicians and (2) future of primary care. METHOD: The authors surveyed 188 incoming medical students (University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Class of 2012) concerning educational indebtedness, perceptions about educational costs, and plans regarding loan repayment. Data were analyzed and expressed as mean +/- standard error. RESULTS: Students with loans anticipated their medical educational costs to be $155,993. 62% felt costs were "exorbitant," and 28% "appropriate." 64% planned to specialize, whereas only 9% chose primary care. 28% of students planning specialization said income potential influenced their decision. 70% of students said cost was a factor in choosing New Jersey Medical School over a more expensive school. Students anticipated taking about 10 years to repay loans. CONCLUSIONS: As medical educational costs and student indebtedness rise, students are choosing less costly education and career paths with higher potential future earnings. These trends will negatively impact health care availability, accessibility, and cost. DoD programs to provide financial assistance in exchange for military service are not well publicized. These findings should increase DoD recruitment opportunities.

Evolution and development of the Advanced Trauma Life Support (ATLS) protocol: a historical perspective.

The Advanced Trauma Life Support (ATLS) protocol is a successful course offered by the American College of Surgeons. Once based on didactic lectures and seminars taught by experts in the field, trauma training has evolved to become a set of standardized assessment and treatment protocols based on evidence rather than expert opinion. As the ATLS expands, indices to predict outcome, morbidity, and mortality have evolved to guide management and treatment based on retrospective data. This historical, perspective article attempts to tell the story of ATLS from its inception to its evolution as an international standard for the initial assessment and management of trauma patients.

Historical review of emergency tourniquet use to stop bleeding.

BACKGROUND: Although a common first aid topic, emergency tourniquets to stop bleeding are controversial because there is little experience on which to guide use. Absent an adequate historical analysis, we have researched development of emergency tourniquets from antiquity to the present. METHODS: We selected sources emphasizing historical development of tourniquets from books and databases such as PubMed. RESULTS: The history of the emergency tourniquet is long and disjointed, mainly written by hospital surgeons with little accounting, until recently, of the needs of forward medics near the point injury. Many investigators often are unaware of the breadth of the tourniquet's history and voice opinions based on anecdotal observations. CONCLUSIONS: Reporting the historical development of tourniquet use allowed us to recognize disparate problems investigators discuss but do not recognize, such as venous tourniquet use. We relate past observations with recent observations for use by subsequent investigators.

George Ryerson Fowler: Brooklyn's surgical pioneer: a biographical sketch based on historical documents.

The Fowler position, widely used in surgery and obstetrics for patient placement, marks a fraction of 19th-century Brooklyn surgeon George Ryerson Fowler's prodigious accomplishments. Fowler was a pioneer who refined the appendectomy, performed the first lung decortication, advocated for sterile techniques, introduced first aid in the US Army, and helped start a precursor to Annals of Surgery. His publications include the first US textbook on appendicitis--ironically, the disease that killed him.

Marjolin's warty ulcer.

Marjolin's ulcer refers to malignant change within burn scar. The French surgeon Jean-Nicolas Marjolin is honored with the eponym. Marjolin described the "warty ulcer" in the first edition of Dictionnaire de Medécine. In his description, Marjolin did not actually state that this ulcer represented malignant transformation. Credit for noting the specific association involved in Marjolin's ulcer belongs to Caesar Hawkins, an English Surgeon, who described skin cancer arising in burn and flogging scars.

Isolated anterior compartment syndrome after a bimalleolar-equivalent ankle fracture in a collegiate football player.

Compartment syndrome after an ankle fracture is an extremely rare and potentially devastating event. The authors report a case of an isolated anterior compartment syndrome in a college student athlete who suffered a bimalle olar ankle fracture dislocation. A review of the literature highlights the importance of vigilance when the sports medicine physician and the community orthopaedist are treating these seemingly basic orthopaedic injuries.