Revision ACL Reconstruction in Adolescent Patients.

BACKGROUND: High failure rates have been documented after anterior cruciate ligament reconstruction (ACLR) in pediatric patients, and revision surgery is indicated due to high activity levels of children and adolescents. PURPOSE: To define trends in revision ACLR in patients who underwent initial ACLR at younger than 18 years. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: An electronic medical record was used to retrospectively identify revision ACLR procedures performed by 2 surgeons between the years 2010 and 2016 in patients younger than 18 years at initial reconstruction. Descriptive information, intraoperative findings, surgical techniques, and rehabilitation data were recorded from initial and revision surgeries. Descriptive statistics were used. RESULTS: A total of 32 patients (17 girls, 15 boys) met the inclusion criteria, with a mean age of 15.8 years at initial reconstruction. For initial reconstructions, 15 patients underwent transphyseal procedures, 3 patients underwent adult-type procedures using an anatomic reconstruction technique that did not take into account the physis, and 2 patients underwent partial intraepiphyseal procedures. Graft types included hamstring autograft (n = 17), allograft (n = 5), hybrid (n = 4), and bone-patellar tendon-bone autograft (BTB; n = 3). Average primary reconstruction graft diameter was 8.0 mm (girls, 7.72 mm; boys, 8.36 mm; P = .045). After initial reconstruction, 10 patients had postoperative protocol noncompliance, and 8 patients reported delayed recovery. Mean time to retear was 565 days (range, 25-1539 days). At revision, BTB autograft was used in 50% (n = 16), followed by hamstring autograph (31.3%; n = 10) and allograft (12.5%; n = 4); mean graft diameter was 9.05 mm. Chondral surgery was more common during revision (25% for revision vs 0% for index; P = .031). There were 4 patients who required staged reconstruction with bone grafting. At mean final follow-up of 29.5 months (SD, 22.2 months), there were 3 graft failures (9.4%) and 5 contralateral ACL ruptures (15.6%). CONCLUSION: Most patients with ACL graft failure were adequately treated with a single revision. Conversion from a soft tissue graft to a BTB autograft was the most common procedure. Infrequently, patients required staged reconstructions. Providers should have a high index of suspicion for associated intra-articular injuries resulting from graft failure in adolescent patients.

Mental health, preoperative disability, and postoperative outcomes in patients undergoing shoulder arthroplasty.

BACKGROUND: Mental health conditions are associated with poor outcomes in patients with chronic disease as well as various orthopedic conditions. The purpose of this study was to describe the relationship between mental health, preoperative disability, and postoperative outcomes in patients undergoing shoulder arthroplasty. METHODS: Data, including mental health diagnoses, were prospectively collected from patients undergoing total shoulder arthroplasty or reverse total shoulder arthroplasty from 2009 to 2015 at a single academic institution. Shoulder range of motion, visual analog scale, 12-Item Short Form Health Survey, and American Shoulder and Elbow Surgeons scores were collected preoperatively and at 1 and 2 years postoperatively. Data were analyzed using multivariate mixed-effect regression analysis. RESULTS: The study included 280 patients, 105 (37.5%) of whom had a mental health diagnosis of depression, anxiety, schizophrenia, or bipolar disorder. Both groups of patients had similar shoulder range of motion, pain, and function before shoulder arthroplasty. Hospital length of stay, discharge destination, and readmissions were similar for both groups. There were similar improvements in pain, function, and range of motion after shoulder arthroplasty in patients with and without diagnosed mental health conditions. CONCLUSIONS: Overall, the presence of a psychiatric diagnosis was not predictive of outcomes. Although psychiatric conditions are often considered surgical comorbidities, mental health diagnoses should not be a barrier to performing clinically indicated shoulder arthroplasty, because both groups of patients appear to benefit from pain relief and improved shoulder function.

The effect of patient gender on outcomes after reverse total shoulder arthroplasty.

BACKGROUND: Gender differences may exist for patients undergoing shoulder arthroplasty. Limited data suggest that women may have worse preoperative disability and outcomes. Our objective was to determine whether gender influences preoperative disability and patient-reported outcomes after reverse total shoulder arthroplasty. METHODS: Data were prospectively collected for patients who underwent reverse total shoulder arthroplasty for rotator cuff arthropathy or osteoarthritis with a rotator cuff tear at a single institution between 2009 and 2015. Range of motion, visual analog scale, 12-Item Short Form Health Survey (SF-12), and American Shoulder and Elbow Surgeons (ASES) scores were collected at the preoperative, 1-year, and 2-year postoperative time points. Data were analyzed using multivariate mixed-effect regression analysis. RESULTS: There were 117 patients included. Men and women had similar demographics, preoperative range of motion, pain, and function. Length of stay was similar (men, 2.32 days; women, 2.58 days; P = .18). Controlling for patient variables, men achieved higher ASES function (P = .009) and SF-12 Physical Component Summary (P = .008) scores compared with women. There was no difference between men and women in ASES pain and SF-12 Mental Component Summary scores, visual analog scale score, or range of motion. CONCLUSION: Improvements in pain and range of motion were similar in men and women; however, men achieved higher ASES function and SF-12 Physical Component Summary scores. Women may be more functionally impaired on the basis of differences in activities of daily living. These results may be used to guide discussion about expected benefits after reverse shoulder arthroplasty.

Suprascarpal fat pad thickness may predict venous drainage patterns in abdominal wall flaps.

BACKGROUND: Abdominal wall flaps are routinely used in reconstructive procedures. In some patients inadequate venous drainage from the deep vein may cause fat necrosis or flap failure. Occasionally the superficial inferior epigastric vessels (SIEV) are of sufficient size to allow for microvascular revascularization. This study looked at the ratio of the sub- and suprascarpal fat layers, the number of deep system perforators, and SIEV diameter to determine any correlation of the fat topography and SIEV. METHODS: 50 abdominal/pelvic CT angiograms (100 hemiabdomens) were examined in women aged 34-70 years for number of perforators, SIEV diameter, and fat pad thickness above and below Scarpa's fascia. Data was analyzed using multivariate model. RESULTS: The average suprascarpal and subscarpal layers were 18.6 ± 11.5 mm and 6.2 ± 7.2 mm thick, respectively. The average SIEV diameter was 2.06 ± 0.81 mm and the average number of perforators was 2.09 ± 1.03 per hemiabdomen. Hemiabdomens with suprascarpal thickness>23 mm had greater SIEV diameter [2.69 mm vs. 1.8 mm (P < 0.0001)] The fat layer thickness did not correlate with the number of perforators. Neither subscarpal fat thickness nor suprascarpal-to-subscarpal fat layer thickness correlated significantly with SIEV caliber or number of perforators in multivariate model. CONCLUSIONS: Suprascarpal fat pad thicker than 23 mm had larger SIEVs irrespective of the number of deep system perforators. This may indicate a cohort of patients at risk of venous congestion from poor venous drainage if only the deep system is revascularized. We recommend harvesting the SIEV in patients with suprascarpal fat pad >23 mm to aid in superficial drainage.

Excision of Elephantiasis Nostras Verrucosa Lesions in a Patient With Hereditary Lymphedema: Case Report and Review of the Literature.

Elephantiasis nostras verrucosa (ENV) is a rare cutaneous sequela of chronic lymphedema. Treatment of ENV remains poorly elucidated but has historically involved conservative management aimed at relieving the underlying lymphedema, with a few cases managed by surgical intervention. We report a case of a 27-year-old male with primary lymphedema complicated by large painful ENV lesions on his left foot that we excised surgically with good functional and cosmetic results as validated by the patient. To our knowledge, this is the first report of a case of ENV with a pedunculated morphology and the presence of a deep invasive stalk.

Recurrent breast cancer in the subpectoral space after implant reconstruction.

Breast reconstruction after mastectomy is most commonly performed with a prosthetic implant placed beneath the pectoralis major. Recurrence may rarely be identified in the subpectoral space where the implant was placed. We report a case of recurrent breast cancer after implant-based reconstruction with isolated subpectoral recurrence discovered 5 years later during secondary revision of her reconstructed breast.

A chemical glycoproteomics platform reveals O-GlcNAcylation of mitochondrial voltage-dependent anion channel 2.

Protein modification by O-linked ß-N-acetylglucosamine (O-GlcNAc) is a critical cell signaling modality, but identifying signal-specific O-GlcNAcylation events remains a significant experimental challenge. Here, we describe a method for visualizing and analyzing organelle- and stimulus-specific O-GlcNAcylated proteins and use it to identify the mitochondrial voltage-dependent anion channel 2 (VDAC2) as an O-GlcNAc substrate. VDAC2(-/-) cells resist the mitochondrial dysfunction and apoptosis caused by global O-GlcNAc perturbation, demonstrating a functional connection between O-GlcNAc signaling and mitochondrial physiology through VDAC2. More broadly, our method will enable the discovery of signal-specific O-GlcNAcylation events in a wide array of experimental contexts.

Mapping yeast N-glycosites with isotopically recoded glycans.

Asparagine-linked glycosylation is a common post-translational modification of proteins; in addition to participating in key macromolecular interactions, N-glycans contribute to protein folding, trafficking, and stability. Despite their importance, few N-glycosites have been experimentally mapped in the Saccharomyces cerevisiae proteome. Factors including glycan heterogeneity, low abundance, and low occupancy can complicate site mapping. Here, we report a novel mass spectrometry-based strategy for detection of N-glycosites in the yeast proteome. Our method imparts N-glycopeptide mass envelopes with a pattern that is computationally distinguishable from background ions. Isotopic recoding is achieved via metabolic incorporation of a defined mixture of N-acetylglucosamine isotopologs into N-glycans. Peptides bearing the recoded envelopes are specifically targeted for fragmentation, facilitating high confidence site mapping. This strategy requires no chemical modification of the N-glycans or stringent sample enrichment. Further, enzymatically simplified N-glycans are preserved on peptides. Using this approach, we identify 133 N-glycosites spanning 58 proteins, nearly doubling the number of experimentally observed N-glycosites in the yeast proteome.

Isotopic signature transfer and mass pattern prediction (IsoStamp): an enabling technique for chemically-directed proteomics.

Directed proteomics applies mass spectrometry analysis to a subset of information-rich proteins. Here we describe a method for targeting select proteins by chemical modification with a tag that imparts a distinct isotopic signature detectable in a full-scan mass spectrum. Termed isotopic signature transfer and mass pattern prediction (IsoStamp), the technique exploits the perturbing effects of a dibrominated chemical tag on a peptide's mass envelope, which can be detected with high sensitivity and fidelity using a computational method. Applying IsoStamp, we were able to detect femtomole quantities of a single tagged protein from total mammalian cell lysates at signal-to-noise ratios as low as 2.5:1. To identify a tagged-peptide's sequence, we performed an inclusion list-driven shotgun proteomics experiment where peptides bearing a recoded mass envelope were targeted for fragmentation, allowing for direct site mapping. Using this approach, femtomole quantities of several targeted peptides were identified in total mammalian cell lysate, while traditional data-dependent methods were unable to identify as many peptides. Additionally, the isotopic signature imparted by the dibromide tag was detectable on a 12-kDa protein, suggesting applications in identifying large peptide fragments, such as those containing multiple or large posttranslational modifications (e.g., glycosylation). IsoStamp has the potential to enhance any proteomics platform that employs chemical labeling for targeted protein identification, including isotope coded affinity tagging, isobaric tagging for relative and absolute quantitation, and chemical tagging strategies for posttranslational modification.