Arthroscopic TFCC Ulnar Bone Tunnel Foveal Repair in Adult Patients.

Triangular fibrocartilage complex (TFCC) tears may cause persistent ulnar-sided wrist pain, loss of grip strength, and associated loss of function. Although the majority of TFCC tears can be treated nonoperatively, surgical repair is considered when conservative measures fail. TFCC tears with foveal disruption and instability of the distal radioulnar joint (DRUJ) require direct repair of the TFCC to the ulnar fovea. The traditional method of foveal TFCC repair involves an open surgical approach through the floor of the 5th dorsal compartment. However, this open approach causes disruption of structures such as the dorsal ulnocarpal capsule, the extensor retinaculum, and, potentially, the distal radioulnar ligament (DRUL). This article describes, in detail, the recently developed arthroscopic assisted ulnar foveal bone tunnel repair. This method spares dorsal structures that may be disrupted during an open surgical approach and creates a robust repair of the TFCC deep fibers with restoration of DRUJ stability.

Innervated Dorsalis Pedis Advancement Flap for Burn Foot Contractures.

Dorsal foot burns in children often result in contractures with hyperextension of the toes and secondary gait disturbances. Skin grafting a wound bed after contracture release can result in early recurrence. Adequate contracture release often requires tenolysis and/or joint releases that may be prohibitive of skin grafting and require flap coverage. Local flaps are often dismissed as inadequate. Free flaps and distraction techniques have both been described as difficult in the pediatric foot. We describe a single-stage V-Y advancement dorsalis pedis (DP) based fasciocutaneous flap technique that releases dorsal foot contractures in children without donor sites by recruiting tissue from the anterior ankle to the dorsal forefoot. DP-based flaps have not been described before in forefoot burn contracture release. The flap is performed on three children (ages 4-9 years) with unilateral dorsal feet contractures. Each child suffered from gait disturbance due to toe hyperextension. Three to four centimeters of advancement was obtained with each child. Contractures involved all toes but were worst in the second toe for all patients. Extensor tenolysis and/or metatarsal joint releases were performed in each case. Surgeries were performed as an outpatient with minimal postoperative pain. Postoperative leg splinting was not performed. All patients' surgical sites healed without complication and with complete correction of contractures. Improved gait was noted postoperatively. The V-Y DP perforator advancement is a safe, effective, and reliable technique for dorsal foot burn contracture release in children without need for donor site or prolonged recovery.

Review of Operative Treatment of Delayed Presentation of Acute Cholecystitis.

Treatment of patients with delayed acute cholecystitis (AC) includes antibiotics and interval cholecystectomy based on proposed change at 72 hours from symptom onset to a chronic fibrotic phase with concern for increased complication rates. The purpose of our study was to compare the outcomes of patients undergoing laparoscopic cholecystectomy (LC) for AC before and after this golden 72-hour window. After institutional review board approval, a retrospective study was performed of patients presenting over two years with AC, who underwent LC during the index admission. A chart review was performed, and patients were divided into symptoms <72 hours (group A) and symptoms >72 hours (group B). Complications were defined as postoperative bleeding, return to operating room, and bile leaks. One hundred and eighty-four patients met the study criteria. Group A included 96 patients managed 5 to 71 hours after symptom onset, whereas Group B encompassed 88 patients with symptoms 72 to 336 hours. Both groups had similar baseline demographics and disease severity. No statistically significant differences were noted between the groups regarding overall complications or 30-day morbidity; however, Group B had an increased hospital stay length (P < 0.0001) and estimated blood loss(P = 0.028). LC seems safe despite duration of symptomatology and should be considered during the index admission in all AC patients.

The Feasibility and Time Required for Routine Health Literacy Assessment in Surgical Practice and Effect on Patient Satisfaction.

Patients with limited health literacy (HL) have higher likelihood of problems with communication and may decrease patient satisfaction. This study was performed to determine the time required for routine HL assessment and its effect on patient satisfaction. Retrospective review over four years of consecutive patients who attended a breast clinic who underwent HL assessment as part of routine care. A total of 3126 consecutive patients from 2010 to 2014. Of the 3126 patients (96.9%), 3030 of were capable of undergoing HL assessment. No patients refused assessment, but one patient was inadvertently missed [3029 of 3030 patients (99.9%)]. The average age was 45 years and 10.5 years of education. The average time required was 1:57 minutes. Only 19 per cent of patients had adequate HL. Per each 1000 patients the time decreased (2:07, 1:58, 1:47; P < 0.001). Newest Vital Sign score did not change with time (1.6, 1.8, 1.7; P = NS). Patient satisfaction ratings increased during each subsequent year of HL assessments (P = 0.002). Routine HL assessment is feasible in surgical practice. HL assessment allows for identification of patients at risk for miscommunication. Implementation of communication strategies as described on the AMA website can improve patient-clinician communication and improve patient satisfaction.

Does Self-Assessment Improve the Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital?

OBJECTIVE: To determine whether use of self-assessment (SA) questions affects the effectiveness of weekly didactic grand rounds presentations. DESIGN: From 26 consecutive grand rounds presentations from August 2013 to April 2014, a 52-question multiple-choice test was administered based on 2 questions from each presentation. SETTING: Community teaching institution. PARTICIPANTS: General surgery residents, students, and attending physicians. RESULTS: The test was administered to 66 participants. The mean score was 41.8%. There was no difference in test score based on experience with similar scores for junior residents, senior residents, and attending surgeons (43%, 46%, and 44%; p = 0.13). Most participants felt they would be most interested in presentations directly related to their surgical specialty. Participants, however, did not score differently on topics which were the focus of the program (40% vs. 42%; p = 0.85). Journal club presentations (39% vs. others 42%; p = 0.33) also did not affect the score. The Pearson correlation coefficient for attendance was 0.49 (p < 0.0001) demonstrated that attendance was very important. Participation in the weekly SA was significantly associated with improved score as those who participated in SA scored over 20% higher than those who did not (59% vs. 38%; p < 0.0001). Based on multiple linear regression for mean score, SA explained the variation in score more than attendance. CONCLUSIONS: The current study found that without preparation approximately 40% of material presented is retained after 10 months. Participation in weekly SA significantly improved retention of information from grand rounds presentations.