A Subdural Dissection of Cerebrospinal Fluid Causing Cauda Equina Centralization After Durotomy: A Case Report.

CASE: A 61-year-old woman with recurrent left L5 radiculopathy underwent revision L4-5 decompression complicated by incidental durotomy requiring primary repair. Postoperative course was complicated by wound drainage and headache. Repeat magnetic resonance imaging demonstrated cerebrospinal fluid dissecting a plane deep to the dura mater but superficial to the arachnoid, with the collection compressing the cauda equina in an atypical horizontal and linear fashion. Nonoperative treatment was ineffective, and she required revision decompression and dural repair. CONCLUSION: Spine surgeons should recognize this finding on postoperative imaging as a potential sign of an incomplete dural repair necessitating return to the operating room.

Comparison of a right versus left sided anterior approach to the thoracic and thoracolumbar spine: A case series.

Aims & objectives: Traditionally, a left sided anterior approach has been considered the safest way to access the thoracic and thoracolumbar spine due to avoidance of the inferior vena cava (IVC). We challenge this 'go from the left' dogma by presenting a series of patients who underwent a right sided approach to the thoracic and thoracolumbar spine. Materials & methods: 71 anterior thoracic fusion procedures treated with either a left or right sided approach were identified and retrospectively studied. Demographic information, indication for surgery, intra-operative time, estimated blood loss (EBL), hospital length of stay (LOS), and complications were collected. Patients were further sub divided into groups according to indication for surgery. Results: 57 cases with a right sided approach and 14 cases with a left sided approach were investigated. Four mortalities occurred, all within the right sided approach group among patients who were being for osteomyelitis/discitis. There were statistically significant differences between right and left sided approach groups for operative time and EBL when patients were analysed together favoring the left sided approach. However once subgroup analysis was performed, there were no statistically significant differences between right and left sided approach groups aside from operative time in the HNP group and LOS in the fracture group. Neither group had catastrophic intra-operative vascular injury. Perioperative complications occurred in 22.8% of right sided approach patients and 14% of left sided approach patients. Conclusions: Our results reinforce the fact that anterior thoracic fusion is a major surgical endeavor that is not without risk. Although there were differences in operative time and EBL between right and left sided approach groups when all patients were analysed together, these were no longer significant with subgroup analysis according to indication for surgery with two exceptions. This may be in part due to low sample size or confounding variables related to indication.

Cartilage and Meniscus Injuries Are More Common in Patients Undergoing Delayed Multiligament Reconstruction.

The purpose of this study was to describe the pattern of meniscus and cartilage pathology in multiligament knee injuries (MLKIs) and determine the relationship between surgical timing and injury mechanism with degree of intra-articular injury. Patients with surgically treated MLKIs over a 15-year period were retrospectively reviewed and grouped based on surgical intervention, time to intervention, and injury mechanism. The presence or absence of meniscus and chondral injury were recorded at the time of surgery. Surgical intervention within 6 weeks of injury was deemed acute, while surgery occurring more than 6 weeks from injury was classified as delayed. Over the 15-year study period, 207 patients with MLKIs were identified. Compared with acutely managed patients, the delayed intervention group had significantly more meniscus (p = 0.03) and cartilage (p < 0.01) pathology. Meniscus injury rates in MLKIs sustained during sporting activity did not differ from nonsporting injuries (p = 0.63). However, the nonsporting group had significantly more chondral injuries (p < 0.01). High-energy injury mechanism was associated with increased cartilage (p = 0.02), but not meniscus (p = 0.61) injury rates. In conclusion, surgical reconstruction of MLKIs delayed for more than 6 weeks was associated with increased meniscus and cartilage pathology.

Pregnancy and Parental Leave During Orthopaedic Surgery Residency.

Background: Gender diversity in the field of orthopedic surgery has lagged behind other surgical subspecialties. One potential barrier to the recruitment and retention of female orthopedic surgeons lies in controversies surrounding pregnancy and parental leave during residency training, for which no clear guidelines exist. Trainees and residency programs face the challenge of balancing clinical and surgical competency with the health and well being of the mother and her child. This article addresses the current policies, health considerations, perceptions of parental leave and future recommendations regarding pregnancy and parental leave for orthopedic residents. Level of Evidence: V.

Performance of the Patient-Reported Outcome Measurement Information System in Patients With Patellofemoral Instability.

BACKGROUND: The Patient-Reported Outcome Measurement Information System (PROMIS) was developed to improve patient-reported outcome measures (PROMs) and administration through a computer adaptive test (CAT). The PROMIS physical function-CAT (PF-CAT) has not been investigated in patients with patellofemoral instability (PFI). PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the construct validity of the PROMIS PF-CAT with previously validated tools for measuring PROMs in patients with a diagnosis of PFI. We hypothesized that the PF-CAT will have the strongest correlations with other PROMs that evaluated PF as well as moderate correlations with PROMs that measured other health domains. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients enrolled in this study who underwent operative intervention for PFI completed the following evaluations preoperatively: PROMIS PF-CAT, 36-Item Short Form Health Survey (SF-36), Knee injury and Osteoarthritis Outcome Score (KOOS), EuroQol-5 dimensions (EQ-5D), and Kujala Anterior Knee Pain Scale (AKPS). Correlation coefficients and the percentage of patients achieving the highest and lowest possible outcome score of each instrument were calculated to assess floor and ceiling effects. Statistical significance was defined as P < .05. RESULTS: In total, 91 participants (63.7% females; mean age, 20.1 ± 7.2 years) completed the questionnaires. PF-CAT had the lowest number of questions (4.3 ± 1.1). The strongest correlations were between the PF-CAT and SF-36 PF subscale (r = 0.78; P < .01), AKPS (r = 0.68; P < .01), and KOOS Activities of Daily Living subscale (r = 0.68; P < .01). Correlation was moderate between the PF-CAT and the KOOS subscales of Sports/Recreation (r = 0.58; P < .01), Quality of Life (r = 0.53; P < .01), and Symptoms (r = 0.47; P < .01). The PROMIS PF-CAT demonstrated no floor or ceiling effects. CONCLUSION: In patients with PFI, construct validity of the PROMIS PF-CAT was supported by strong correlations demonstrated between the PF-CAT and PROMs evaluating PF and moderate correlations with those assessing other health domains. Our results demonstrated a low respondent burden and no floor or ceiling effects associated with the PROMIS PF-CAT. The PROMIS PF-CAT may be considered a beneficial alternative to previously established PF PROMs for preoperative evaluation of patients with PFI.

Preoperative opioid use is associated with inferior outcomes after patellofemoral stabilization surgery.

PURPOSE: The purpose of the study was to investigate the association between preoperative opioid use and persistent postoperative use, and determine the impact of preoperative opioid use on patient-reported outcomes (PROs) in patients undergoing patellofemoral stabilization surgery. METHODS: A retrospective analysis of 60 patients after patellofemoral stabilization surgery with a minimum of 2-year follow-up was performed using a prospectively collected patellar instability registry. Patients were categorized as opioid naïve (n = 48) or preoperative opioid users (n = 12). Postoperative opioid use was assessed for all patients at 2 and 6 weeks. Knee Injury and Osteoarthritis Outcome Score (KOOS) and Kujala questionnaires were administered at baseline, and 6 months and 2 years postoperatively. RESULTS: Preoperative opioid use was identified as an independent risk factor for postoperative opioid use at 2- and 6-weeks following surgery (p = 0.0023 and p < 0.0001, respectively). Preoperative opioid use was associated with significantly lower KOOS and Kujala scores at baseline, 6 months and 2 years postoperatively. Both groups significantly improved from baseline KOOS and Kujala scores at 6 months and 2 years postoperatively. Regardless of preoperative opioid use, opioid use at 6 weeks after surgery was associated with worse KOOS scores at 6 months and 2 years postoperatively. CONCLUSION: In patients undergoing patellofemoral stabilization surgery, preoperative opioid use was predictive of postoperative use. Additionally, preoperative opioid use was associated with worse PROs at 6 months and 2 years following surgery. LEVEL OF EVIDENCE: III.

Impact of a Standardized Multimodal Analgesia Protocol on Opioid Prescriptions After Common Arthroscopic Procedures.

BACKGROUND: Excessive prescription of opioids has become a national problem. Providers must attempt to decrease the amount of opioids prescribed while still providing patients with adequate pain relief after surgery. HYPOTHESIS: Implementing a standardized multimodal analgesic protocol will decrease the amount of opioids prescribed at the time of surgery as well as the total amount of opioids dispensed postoperatively. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who had undergone meniscectomy, rotator cuff repair (RCR), or anterior cruciate ligament (ACL) reconstruction at our institution were identified by Current Procedural Terminology code 12 months prior to and 6 months after the initiation of a standardized multimodal postoperative pain protocol. Records were reviewed to extract demographic data, amount of opioids prescribed at the time of surgery, amount and frequency of opioid refills, and call-ins regarding pain medication or its side effects. A Wilcoxon rank-sum test was used to evaluate differences in opioid prescriptions between pre- and postprotocol, and significance was set to P < .05. RESULTS: The mean amount of opioids prescribed at the time of surgery decreased from 63.5 to 22.3 pills (P < .0001) for meniscectomy, from 73.3 to 39.7 (P < .0001) for ACL reconstruction, and from 75.6 to 39.8 (P < .0001) for RCR. The percentage of patients receiving a refill of opioids during the postoperative period also decreased for all groups: from 13% to 4% (P = .0051) for meniscectomy, 29.2% to 11.4% (P = .0005) for ACL reconstruction, and 47.3% to 24.4% (P < .0001) for RCR. There was no significant difference in patient calls regarding pain medication or its side effects. CONCLUSION: Institution of a standardized multimodal analgesia protocol significantly decreased the amount of opioids dispensed after common arthroscopic procedures. This reduction in the amount of opioids given on the day of surgery did not result in an increased demand for refills. Our study also demonstrated that 20 opioid pills were adequate for patients undergoing meniscectomy and 40 pills were adequate for ACL reconstruction and RCR in the majority of cases. This protocol serves as a way for providers to decrease the amount of opioids dispensed after surgery while providing patients with alternatives for pain relief.

Anatomic Syndesmotic and Deltoid Ligament Reconstruction with Flexible Implants: A Technique Description.

The optimal fixation method for unstable syndesmosis (SYN) injuries remains a matter of debate between rigid screw fixation that stabilizes all three components of the syndesmosis but prohibits any motion, and flexible implants stabilizing by compression along the axis of the interosseous ligament. More recently additional repairs of the anterior or posterior SYN ligaments have been explored both clinically and biomechanically. The role for deltoid ligament (DL) repair or reconstruction in the setting of SYN injury remains controversial. However, the DL is increasingly recognized as having an important contribution to rotational stability of the ankle. A method of treatment is presented for unstable SYN injuries with flexible implants. An anatomic approach to reconstructing the DL with specific augmentation of the anterior and posterior bands of the deep deltoid ligament (DDL) is described for immediate restoration of medial ankle rotational stability. Level of Evidence: V.

Performance of the PROMIS After Operative Interventions for Shoulder Instability.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to capture patient-reported outcomes (PROs) in an efficient manner. Few studies have assessed this instrument postoperatively. PURPOSE: To compare the PROMIS Physical Function computer adaptive test (PROMIS PF CAT) and Upper Extremity (PROMIS UE) item bank to other previously validated PRO instruments and to evaluate ceiling and floor effects and construct validity responsiveness in patients who underwent operative interventions for shoulder instability. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 72 patients who underwent operative interventions for shoulder instability completed the American Shoulder and Elbow Surgeons (ASES) assessment form, Marx shoulder activity scale (Marx), 36-Item Short Form Health Survey physical function (SF-36 PF) and general health (SF-36 GH), Western Ontario Shoulder Instability Index (WOSI), PROMIS PF CAT, and PROMIS UE before surgery and then at 6 weeks and 6 months postoperatively. Correlation coefficients were calculated among these tools. The effect size of change was also calculated for each tool at each time point. A total of 91 patients who had also undergone surgery for shoulder instability completed these PRO instruments 2 years postoperatively. The percentage of patients hitting the ceiling and floor effects of each of the PRO instruments was calculated at all time points. RESULTS: The PROMIS PF CAT demonstrated excellent-good correlation with the SF-36 PF at all postoperative time points (0.61 at 6 weeks, 0.68 at 6 months, and 0.64 at 2 years; P < .01 for all). The PROMIS UE showed excellent correlation with the ASES at 6 weeks postoperatively (0.73, P < .01). Both the PROMIS PF CAT and PROMIS UE demonstrated the ability to detect change after surgical interventions with a medium to large effect size. The PROMIS UE demonstrated a ceiling effect at 6 months (68.1%) and 2 years (67.0%) postoperatively. The PROMIS PF CAT demonstrated no ceiling effect at any time point. CONCLUSION: The PROMIS PF CAT demonstrated good to excellent correlation with other previously validated PRO instruments that assess physical function in patients with shoulder instability postoperatively. The PROMIS UE demonstrated good correlation with other PRO tools but had a significant ceiling effect and is not recommended for this patient population. Both tools demonstrated an ability to detect change after surgical interventions with a good effect size.

Detailing postoperative pain and opioid utilization after periacetabular osteotomy with automated mobile messaging.

In the setting of periacetabular osteotomy (PAO), this investigation sought to (i) describe patient-reported pain scores and opioid utilization in the first 6 weeks following surgery and (ii) evaluate the effectiveness of postoperative communication using a robotic mobile messaging platform. Subjects indicated for PAO were enrolled from a young adult hip clinic. For the first 2 weeks after surgery, subjects received daily mobile messages inquiring about pain level on a 0-10 scale and the number of opioid pain medication tablets they consumed in the previous 24 h. Messaging frequency decreased to 3 per week in Weeks 3-6. Pain scores, opioid utilization and response rates with our mobile messaging platform were quantified for the 6-week postoperative period. Twenty-nine subjects underwent PAO. Twenty-one had concurrent hip arthroscopy. Average daily pain scores decreased over the first four postoperative days. Average pain scores reported were 5.9 ± 1.9, 4.1 ± 3.3 and 3.0 ± 3.5 on Day 1, Day 14 and Week 6, respectively. Reported opioid tablet utilization was 5.0 ± 3.2, 2.2 ± 2.0 and 0.0 ± 0.0 on Days 1 and 14 and at 6 weeks. Response rate for participants completing the 6-week messaging protocol was 84.1%. Patient-reported pain scores decreased over the first two postoperative weeks following PAO before plateauing in weeks 3-6. Opioid pain medication utilization increased in the first postoperative week before gradually declining to no tabs consumed at 6 weeks after PAO. Automated mobile messaging is an effective method of perioperative communication for the collection of pain scores and opioid utilization in patients undergoing PAO.

Single Forearm Vessel Injury in a Perfused Hand: Repair or Ligate? A Systematic Review.

Background: The purpose of this study was to systematically review available literature reporting vessel patency and how this correlates with cold symptoms following the treatment of a single forearm artery injury when the hand remains perfused. The outcomes of those treated by ligation were compared to those treated with vessel repair. Methods: Electronic databases including PubMed, Embase (Elsevier) and Cochrane Central Register of Controlled Trials (Willey) were searched for studies that reported the outcomes of patients who underwent either ligation or repair of single vessel injuries to hands that remained perfused at time of presentation. Level of evidence was determined by two independent reviewers. Studies were then sorted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and application of inclusion and exclusion criteria. A total of 19 studies were included for statistical analysis. The patency of repaired vessels was calculated (with comparison between those with radial versus ulnar repair) as was the prevalence of cold symptoms in both ligation (or repairs that went on to occlusion) and repair groups. Results: The average patency of radial and ulnar artery repairs was 68.39% and 65.56% respectively. There was no significant difference between the success rates of these repair groups (pooled estimates for odd ratios was 1.02, p=0.867). The average incidence of cold symptoms in those who underwent ligation (or repair that when on to occlusion) and those that had patent repairs were 19.82% and 17.27% respectively. There was no significant difference between the incidence of cold symptoms between these groups (pooled estimate for proportion of patients with cold symptoms was 0.223, p=0.573). Conclusions: This review showed there to be no significant difference in patency of isolated radial or ulnar artery repairs. There was also no significant difference in the prevalence of cold sensitivity in patients who underwent vessel ligation compared to those who underwent repair (and subsequently remained patent). These results support the conclusion of there being no clear benefit to attempting repair of a single vessel, although further studies are needed given the often incomplete reporting of clinical outcomes in this patient population. Additionally, though a cost-benefit analysis was not included in this review, exploring this aspect of the decision making process could be valuable.Level of Evidence: IV.