Semi-quantitative arthroscopic scoring system is related to clinical outcomes in patients after medial meniscus posterior root repair.

BACKGROUND: Different methods are available to assess the healing status of repaired root for medial meniscus posterior root tears (MMPRT) using second-look arthroscopy. However, few studies are comparing them or validating their usefulness. Therefore, it was hypothesized that the semi-quantitative arthroscopic score might correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. METHODS: Data of 61 patients who underwent MMPRT pullout repair and second-look arthroscopy were retrospectively evaluated. The semi-quantitative arthroscopic scoring system was divided into three evaluation criteria: scores from 0 to 10 points include the width of the bridging tissue, stability of the repaired root, and synovial coverage. The qualitative evaluation was classified into 4 status; complete healing, lax healing, scar tissue healing, and failed healing according to the stability and mobility of the repaired root. Multivariate linear regression analyses were used to identify predictors of 1-year postoperative clinical outcomes, including Knee Injury and Osteoarthritis Outcome, Lysholm, or International Knee Documentation Committee scores. Spearman's correlation analysis was used to analyze the correlation between second-look arthroscopic score/qualitative evaluation and 1-year postoperative clinical outcomes. In addition, the optimal cutoff point of semi-quantitative arthroscopic score was determined by receiver operating characteristic (ROC) curve. The Mann-Whitney U test was used to compare clinical outcomes between patients with semi-quantitative arthroscopic scores ≥8 and scores <8. RESULTS: All clinical scores significantly improved at 1 year postoperatively. A good correlation was observed between the semi-quantitative score and clinical scores, but none between qualitative evaluation and clinical scores. The optimal cutoff point of semi-quantitative second-look arthroscopic score was 8 points. Significantly, better clinical outcomes were observed in patients with semi-quantitative scores ≥8 points. CONCLUSIONS: All 1-year postoperative clinical scores were significantly improved. The semi-quantitative arthroscopic scores correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. LEVEL OF EVIDENCE: IV case series study.

Second-look arthroscopic cartilage status is related to intermediate-term outcomes after medial opening-wedge high tibial osteotomy.

AIMS: To determine the relationship between articular cartilage status and clinical outcomes after medial opening-wedge high tibial osteotomy (MOHTO) for medial compartmental knee osteoarthritis at intermediate follow-up. METHODS: We reviewed 155 patients (155 knees) who underwent MOHTO from January 2008 to December 2016 followed by second-look arthroscopy with a mean 5.3-year follow-up (2.0 to 11.7). Arthroscopic findings were assessed according to the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system. Patients were divided into two groups based on the presence of normal or nearly normal quality cartilage in the medial femoral condyle: good (second-look arthroscopic) status (ICRS grade I or II; n = 70), and poor (second-look arthroscopic) status (ICRS grade III or IV; n = 85) groups at the time of second-look arthroscopy. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 36-Item Short Form survey. RESULTS: Significant improvements in all clinical outcome categories were found between the preoperative and second-look arthroscopic assessments in both groups (p < 0.001). At the latest follow-up, the mean IKDC and WOMAC scores in the good status group further improved compared with those at the time of second-look arthroscopic surgery (p < 0.001), which was not shown in the poor status group. The mean IKDC (good status, 72.8 (SD 12.5); poor status, 64.7 (SD 12.1); p = 0.002) and mean WOMAC scores (good status, 15.7 (SD 10.8); poor status, 21.8 (SD 13.6); p = 0.004) significantly differed between both groups at the latest follow-up. Moreover, significant correlations were observed between ICRS CRA grades and IKDC scores (negative correlation; p < 0.001) and WOMAC scores (positive correlation; p < 0.001) at the latest follow-up. Good cartilage status was found more frequently in knees with the desired range of 2° to 6° valgus correction than in those with corrections outside this range (p = 0.019). CONCLUSION: Second-look arthroscopic cartilage status correlated with clinical outcomes after MOHTO at intermediate-term follow-up, despite the relatively small clinical differences between groups. Cite this article: Bone Joint J 2021;103-B(11):1686-1694.

Medial Meniscus Posterior Root Repair Using a Modified Mason-Allen Suture Can Prevent the Progression of Cartilage Degeneration on the Loading Surface of the Medial Compartment: A Second-Look Arthroscopic Evaluation.

The treatment of medial meniscus posterior root tears (MMPRTs) has evolved to include a variety of repair strategies. This study investigated the location of the articular cartilage degeneration during second-look arthroscopy after transtibial pullout repair with a modified Mason-Allen suture using FasT-Fix (F-MMA) in 22 patients with MMPRTs. Second-look arthroscopy was performed approximately 1 year postoperatively to eval-uate the healing status of the medial meniscus (MM). Articular cartilage degeneration was assessed using the International Cartilage Repair Society grade at primary surgery and again at second-look arthroscopy. Articular surfaces of the medial/lateral femoral condyles, the medial/lateral tibial plateaus, the patella and the trochlea were divided into several subcompartments (MF 1-9, LF 1-9, MT 1-5, LT 1-5, P 1-9, T 1-3). Clinical evaluations used the Japanese Knee Injury and Osteoarthritis Outcome, Lysholm, and International Knee Documentation Committee scores. Second-look arthroscopic findings showed complete healing of the MM posterior root in all patients. Significant differences between pullout repair and second-look arthroscopy were observed for MF 2 and 4, LF 7, and P 7. All clinical outcomes were improved. Our results indicate that this technique improves clinical outcomes postoperatively and may prevent the progression of cartilage degenera-tion on the loading surface of the medial knee compartment.

Does second-look endoscopy reduce the bleeding after gastric endoscopic submucosal dissection for patients receiving antithrombotic therapy?

BACKGROUND: In patients with average risk of bleeding, second-look endoscopy does not reportedly reduce bleeding after gastric endoscopic submucosal dissection. However, effectiveness of second-look endoscopy for patients with a high risk of bleeding, such as those who are taking antithrombotic agents, is unclear. Hence, this study aims to clarify the effectiveness of second-look endoscopy for patients with antithrombotic therapy. METHODS: We studied 142 consecutive patients with 173 gastric epithelial neoplasms who were routinely taking antithrombotic agents and were treated by endoscopic submucosal dissection at Tonan Hospital between November 2013 and December 2019. They were classified into two groups: those with second-look endoscopy (SLE group, 69 patients with 85 lesions) and those without second-look endoscopy (non-SLE group, 73 patients with 88 lesions). The incidence of post-endoscopic submucosal dissection bleeding was compared between the SLE and non-SLE groups. RESULTS: There were no statistical differences in the rate of patients undergoing single antiplatelet therapy, single anticoagulant therapy, and multiple therapy between the SLE and non-SLE groups (SLE group vs. non-SLE group; 32 [46.4%], 16 [23.2%], and 21 [30.4%] patients vs. 37 [50.7%], 20 [27.4%], and 16 [21.9%] patients, respectively; p = 0.50). Post-endoscopic submucosal dissection bleeding incidence was 21.7% (15/69) and 21.9% (16/73) in the SLE and non-SLE groups, respectively, and did not significantly differ between the two groups (p = 0.98). CONCLUSIONS: For patients taking antithrombotic agents, the incidence of post-endoscopic submucosal dissection bleeding was not reduced by second-look endoscopy.

Application of a novel transcanal keyhole technique in endoscopic cholesteatoma surgery.

BACKGROUND: It is difficult to deal with epitympanic cholesteatoma in otologic surgery. The keyhole technique can realize minimally invasive surgery and reconstruct the middle ear canal. OBJECTIVE: To explore the clinical application of keyhole technique in primary and second-look surgery in middle ear cholesteatoma. MATERIALS AND METHODS: 34 cases were analyzed retrospectively in terms of residual and recurrence rate, safety (adverse events) and hearing performance at long-term follow-up. The application of the technique in primary or second stage operation was evaluated and the operation was performed by transanal endoscopy or combined approach. RESULTS: The cholesteatoma revealed by CT before operation was limited to the attic in 23 patients, of which 16 had the same imaging range as that of the keyhole technique. The preoperative imaging findings of 11 showed that the attic cholesteatoma may have extended into the mastoid, of which only 6 cases were confirmed by keyhole technique. An endoscopic second-look surgery using the keyhole technique was performed for these patients, 2 were confirmed to have residual lesions in the attic. CONCLUSIONS: The keyhole technique under otoendoscopy can be used flexibly and conveniently in the second-look surgery to make up for the shortage of diffusion-weighted magnetic resonance imaging.

Bone marrow aspirate concentration provided better results in cartilage regeneration to microfracture in knee of osteoarthritic patients.

PURPOSE: To determine whether microfracture with bone marrow aspirate concentrate (BMAC) improves functional outcome and cartilage regeneration better than microfracture alone in patients undergoing high tibial osteotomy (HTO) for medial unicompartmental osteoarthritis (OA). METHODS: Among 436 patients treated with HTO for medial unicompartmental OA with varus deformity between 2010 and 2016, clinical outcomes were retrospectively compared between the microfracture alone group (group I, 43 cases) and microfracture with BMAC augmentation group (group II, 48 cases). Of these, 64 patients underwent a second-look arthroscopic assessment. Clinical outcomes were compared based on the Knee Society Score (KSS), International Knee Documentation Committee (IKDC) subjective score, and Western Ontario and McMaster Universities Arthritis Index (WOMAC). Cartilage regeneration was assessed according to Koshino's staging system and the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system. RESULTS: At the last follow-up, there were no significant intergroup differences in terms of KSS for pain and function (p > 0.05). Moreover, WOMAC scores were similar between the two groups (p > 0.05). Regarding second-look arthroscopy findings, according to Koshino's staging system, there was no significant intergroup difference in terms of defect coverage (p = 0.187). However, group II showed a significantly better mean CRA score than group I (p = 0.035). CONCLUSION: There were no significant differences in clinical outcomes and cartilage regeneration between the groups. However, the CRA score was significantly higher with BMAC augmentation and microfracture than microfracture alone. Therefore, BMAC augmentation had a synergistic effect for a better cartilage regeneration, although studies with a longer follow-up might help to confirm whether microfracture with BMAC augmentation would ensure better clinical outcomes than microfracture alone for the treatment of knee OA.

Patient-reported evaluation on giving way is important for return to preinjury activity level after Anterior Cruciate Ligament reconstruction.

PURPOSE: The present study evaluated the rate of returning to the preinjury level of competitive sports after ACLR and influential factors. METHODS: After excluding composite ligament injury cases, 96 patients with a Tegner activity score of ≥ 6 who were managed between April 2015 and March 2016 and had been followed for ≥ 2 years were included in the present study. The patients were evaluated for instability, and the following data were collected: second-look arthroscopy findings, muscle strength, and International Knee Documentation Committee (IKDC) subjective score (follow-up rate: 88.1%). RESULTS: The rate of returning to the preinjury level of competitive sports was 62/96 (64.6%). Only the total IKDC subjective score (odds ratio, 1.052; 95% confidence interval 1.004-1.102; p = 0.035) and the subjectively evaluated item about giving way (odds ratio, 1.762; 95% confidence interval 1.066-2.911; p = 0.027) were independently associated with the returning to the preinjury level of competitive sports after ACLR in the logistic regression analysis. CONCLUSION: The rate of returning to the preinjury level of competitive sports after ACLR was 64.6%, even if a good knee stability and healing status of the sutured meniscus were acquired after ACLR. The IKDC subjective score, especially the item about giving way, was significantly associated with the returning to the preinjury level of competitive sports. The factors assessed by patient-reported evaluations concerning giving way that may be related to functional performance, including brain activity, are important to consider to improve the rate of returning to the preinjury level of competitive sports. LEVEL OF EVIDENCE: III.

High-Risk Reoperative Sternotomy-How We Do It, How We Teach It.

With the increasing number of congenital heart disease patients living into adulthood and requiring reoperations, learning a safe and efficient reoperative sternotomy is essential. This article provides insight into the successful reoperative sternotomy, including preoperative evaluation, assessing risk for cardiac injury and preparations to take depending on the level of risk, safeguards taken before and during the sternotomy, and pearls and pitfalls in managing untoward events.

Second-look surgery plus hyperthermic intraperitoneal chemotherapy versus surveillance in patients at high risk of developing colorectal peritoneal metastases (PROPHYLOCHIP-PRODIGE 15): a randomised, phase 3 study.

BACKGROUND: Diagnosis and treatment of colorectal peritoneal metastases at an early stage, before the onset of signs, could improve patient survival. We aimed to compare the survival benefit of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC), with surveillance, in patients at high risk of developing colorectal peritoneal metastases. METHODS: We did an open-label, randomised, phase 3 study in 23 hospitals in France. Eligible patients were aged 18-70 years and had a primary colorectal cancer with synchronous and localised colorectal peritoneal metastases removed during tumour resection, resected ovarian metastases, or a perforated tumour. Patients were randomly assigned (1:1) to surveillance or second-look surgery plus oxaliplatin-HIPEC (oxaliplatin 460 mg/m2, or oxaliplatin 300 mg/m2 plus irinotecan 200 mg/m2, plus intravenous fluorouracil 400 mg/m2), or mitomycin-HIPEC (mitomycin 35 mg/m2) alone in case of neuropathy, after 6 months of adjuvant systemic chemotherapy with no signs of disease recurrence. Randomisation was done via a web-based system, with stratification by treatment centre, nodal status, and risk factors for colorectal peritoneal metastases. Second-look surgery consisted of a complete exploration of the abdominal cavity via xyphopubic incision, and resection of all peritoneal implants if resectable. Surveillance after resection of colorectal cancer was done according to the French Guidelines. The primary outcome was 3-year disease-free survival, defined as the time from randomisation to peritoneal or distant disease recurrence, or death from any cause, whichever occurred first, analysed by intention to treat. Surgical complications were assessed in the second-look surgery group only. This study was registered at ClinicalTrials.gov, NCT01226394. FINDINGS: Between June 11, 2010, and March 31, 2015, 150 patients were recruited and randomly assigned to a treatment group (75 per group). After a median follow-up of 50·8 months (IQR 47·0-54·8), 3-year disease-free survival was 53% (95% CI 41-64) in the surveillance group versus 44% (33-56) in the second-look surgery group (hazard ratio 0·97, 95% CI 0·61-1·56). No treatment-related deaths were reported. 29 (41%) of 71 patients in the second-look surgery group had grade 3-4 complications. The most common grade 3-4 complications were intra-abdominal adverse events (haemorrhage, digestive leakage) in 12 (23%) of 71 patients and haematological adverse events in 13 (18%) of 71 patients. INTERPRETATION: Systematic second-look surgery plus oxaliplatin-HIPEC did not improve disease-free survival compared with standard surveillance. Currently, essential surveillance of patients at high risk of developing colorectal peritoneal metastases appears to be adequate and effective in terms of survival outcomes. FUNDING: French National Cancer Institute.

Significados en torno a la experiencia de someterse a una segunda intervención quirúrgica para bajar de peso / MEANING ABOUT THE EXPERIENCE OF SUBMITTING A SECOND SURGICAL INTERVENTION TO LOSE WEIGHT

Diversos motivos inciden en que los pacientes se sometan a cirugía bariátrica para hacer frente a la obesidad. Pese a ser el procedimiento más eficaz contra el exceso de peso, existe una alta tasa de pacientes que después de la cirugía, recuperan un porcentaje importante del peso perdido. Esta re-ganancia de peso genera consecuencias médicas, físicas y psicológico-emocionales; y en muchos casos lleva a que los pacientes vuelvan a someterse a intervenciones quirúrgicas con el objetivo de reactivar la pérdida de peso. No obstante, las re-operaciones no suelen tener la misma eficacia en términos de la pérdida de peso y su mantención. Esta investigación se centra en los significados psicológicos de la experiencia de someterse a más de una intervención quirúrgica para perder peso, con el objetivo de comprender lo que implica este proceso para los pacientes, así como también las repercusiones que trae consigo someterse a más de una intervención de este tipo. La metodología que se utilizó fue cualitativa con un enfoque desde la Teoría Fundamentada y con un alcance descriptivo para comprender lo que deben vivir estos pacientes. Para llevar a cabo esta investigación, se realizaron entrevistas semi-estructuradas a cuatro mujeres y un hombre, quienes previamente se habían sometido a una intervención quirúrgica para perder peso, y luego de unos años y de haber recuperado el peso perdido se sometieron a una cirugía bariátrica. La elección de la segunda intervención se asoció a la creencia que la recuperación de peso se debió principalmente a la técnica de la primera intervención, evaluación que cambia hacia una percepción de bajo control en la alimentación, tras la re-ganancia de peso post-segunda intervención. Se observa niveles importantes de frustración tras esta segunda re-ganancia.

There are several reasons why patients choose to undergo bariatric surgery to cope with obesity. Despite being the most effective procedure against excess weight, there is a high rate of patients who, after surgery, recover a significant percentage of the weight lost. This regain of weight generates medical, physical and psychological-emotional consequences; and in many cases it leads to patients re-undergo surgery with the aim of reactivating weight loss. However, re-operations are usually not as effective in terms of weight loss and weight maintenance. This research focuses on the psychological meanings of a patient's experience of more than one surgical intervention to lose weight, with the aim of understanding what this process implies for patients, as well as the repercussions of obtaining more than one intervention of this type. The specified methodology was qualitative with an approach from the Grounded Theory and with a descriptive scope to understand what these patients must live. To carry out this research, semi-structured interviews were conducted with four women and one man, who had previously undergone surgery to lose weight, and after a few years and having recovered the lost weight, underwent surgery. bariatric The choice of the second intervention was associated with the belief that weight recovery was mainly due to the technique of the first intervention, an evaluation that changes towards a perception of low control in the diet, after the post-weight gain second intervention. Significant levels of frustration are seen after this second regain

Utility of Second-Look Endoscopy with Debridement After Pediatric Functional Endoscopic Sinus Surgery in Patients with Cystic Fibrosis.

OBJECTIVES: To determine the utility of Second-look endoscopy with debridement (SLED) after functional endoscopic sinus surgery (ESS) in pediatric cystic fibrosis (CF) patients. To compare outcomes in pediatric CF patients undergoing sinus surgery for chronic sinusitis with or without SLED. To describe findings present at the time of SLED. METHODS: Retrospective chart review of 61 ESS procedures performed at a tertiary care pediatric center from 2013 to 2016. Data collected included demographics, SLED findings, and 6-month pre-/postoperative disease specific outcomes including incidence of sinonasal and pulmonary exacerbations and revisions. RESULTS: Sixty-one cases were reviewed. SLED was performed in 38 cases on average 22.4 days postoperatively. Average preoperative Lund-Mackay score was 14.9 and 14.8 among patients undergoing ESS with and without SLED, respectively. Pre-/postoperative intranasal steroid use and extent of surgery performed was similar among all patients. At the time of SLED, rates of synechiae, polyps and maxillary antrostomy obstruction were 26.3%, 23.7%, and 7.9%, respectively. The incidence and number of days to onset of postoperative sinonasal exacerbations requiring antibiotic therapy within 6 months of ESS were 1.0 (SD 1.0) and 85 days (SD 45.7); and 1.3 (SD 1.0) and 80.4 days (SD 40.5) for patients undergoing ESS with and without SLED, respectively (P value .33). The number of days to first pulmonary exacerbation was 113.9 (SD 45.5) and 47.4 (SD 34.1) among SLED and non-SLED patients, respectively (P value .01). No significant difference was observed in revision rates and time to revision ESS (30% and overall average 1.4 years, respectively). CONCLUSION: The utility of SLED among pediatric CF patients remains unclear. While debridement did not have a significant impact on sinonasal exacerbations or revision rates, pulmonary exacerbations for patients undergoing SLED were delayed. Further studies are needed to clarify the impact of SLED.

Arterial Embolization and Second-Look in Spindle Cell Oncocytoma of the Pituitary Gland: Case Report and Review of Literature.

BACKGROUND: Spindle cell oncocytomas are extremely rare neoplasms of the sellar, parasellar, and suprasellar regions that can frequently mimic pituitary adenomas. Fewer than 50 cases have been ever reported in the literature, and there is no consensus on best treatments to be provided. CASE DESCRIPTION: We hereby present a challenging case of sellar and suprasellar spindle cell oncocytoma in a patient of 64 years. The patient, who presented with hydrocephalus, hypopituitarism, and visual deficit, underwent urgent transsphenoidal (TNS) resection of the mass, which was aborted for massive life-threatening bleeding. The patient received ventriculoperitoneal shunt with relief of symptoms. An endovascular embolization of tumor feeders from the distal portion of the right internal maxillary artery, in particular the sphenopalatine artery, was then performed and a second-look TNS surgery was feasible. The patient was discharged in optimal clinical condition, recovered both endocrinologic and visual deficits, and is now in follow-up. CONCLUSIONS: We found that the oncocytoma was radiologically and clinically comparable with a pituitary adenoma, except for higher representation of vasculature. According to our recent experience and review of the literature, we believe that surgery (transsphenoidal or transcranial approach) is the recommended treatment in those who are symptomatic and preoperative embolization might be a suitable option to reduce intraoperative bleeding and increase radicality.

Second-look endoscopy-guided therapy under sedation prevents early rebleeding after variceal ligation for acute variceal bleeding.

OBJECTIVES: To investigate whether second-look endoscopy (SLE)-guided therapy could be used to prevent post-endoscopic variceal ligation (EVL) early bleeding. METHODS: Consecutive cirrhotic patients with large esophageal varices (EV) receiving successful EVL for acute variceal bleeding (AVB) or secondary prophylaxis were enrolled. The patients were randomized into a SLE group and a non-SLE group (NSLE) 10 days after EVL. Additional endoscopic interventions as well as proton pump inhibitors and octreotide administration were applied based on the SLE findings. The post-EVL early rebleeding and mortality rates were compared between the two groups. RESULTS: A total of 252 patients were included in the final analysis. Post-EVL early rebleeding (13.5% vs 4.8%, P = 0.016) and bleeding-caused mortality (4.8% vs 0%, P = 0.013) were more frequently observed in the NSLE group than in the SLE group. However, post-EVL early rebleeding and mortality rates were reduced by SLE in patients receiving EVL for AVB only but not in those receiving secondary prophylaxis. Patients with Child-Pugh classification B to C at randomization (hazard ratio [HR] 8.77, P = 0.034), AVB at index EVL (HR 3.62, P = 0.003), discontinuation of non-selective ß-blocker after randomization (HR 4.68, P = 0.001) and non-SLE (HR 2.63, P = 0.046) were more likely to have post-EVL early rebleeding. No serious adverse events occurred during SLE. CONCLUSION: SLE-guided therapy reduces post-EVL early rebleeding and mortality rates in cirrhotic patients with large EV receiving EVL for AVB.

Use of an Intrauterine Foley Probe for Ultrasound-Assisted Hysteroscopic Resection of Complete Uterine Septum.

STUDY OBJECTIVE: To demonstrate our technique for hysteroscopic resection of the complete uterine septum. DESIGN: Step-by-step description and demonstration of the procedure using pictures and video (educational video). The video was approved by our hospital's Ethical Committee. SETTING: Uterine malformations represent a rare, yet usually asymptomatic condition that can be associated with poor obstetric outcomes. The European Society for Gynaecological Endoscopy(ESGE)/European Society of Human Reproduction and Embryology (ESHRE)classification is widely accepted for the description of female genital tract anomalies. Treatment of the uterine septum should be considered if fertility is desired, with hysteroscopic resection the gold standard procedure. INTERVENTION: A patient with a U2bC2V1 malformation according to the ESGE/ESHRE classification was treated with hysteroscopy. The procedure was performed in the operating room under general anesthesia using a 9-mm hysteroscope with a bipolar cutting loop. Surgery began with resection of the vaginal septum with monopolar electrosurgery until the cervix was visualized. A Foley probe was placed in 1 uterine hemicavity, and then hysteroscopy on the other hemicavity was performed. Transrectal ultrasound guidance was used to identify the limits of the septum and thereby enhance the safety of the procedure. Resection of the septum started in the upper part until the Foley probe was seen, then continued downward until internal cervical orifice was reached. In the hysteroscopic follow-up after 3 months, we visualized a small residual septum that was resected to fully restore the uterine cavity and improve the patient's obstetric outcomes. The procedure was completed without complications, and a second-look hysteroscopy showed a normal uterine cavity. CONCLUSION: The combination of real-time ultrasound guidance and placement of an intrauterine balloon through the cervix may increase safety during the procedure by providing clear visualization of the uterine cavity and septum border during resection.

A Unique Intracardiac Shunt: Identifying Complex Anatomy in Reoperative Adult Congenital Heart Disease.

Adult patients with repaired congenital heart disease are presenting with previously unseen types of residual lesions and consequences of prior repair. Patients with d-transposition of the great arteries repaired with atrial switch operations are returning with dysrhythmias and atrioventricular valve disease requiring intervention. We present the challenging case of a young adult with a residual shunt identified on preoperative three-dimensional transthoracic echocardiography, the precise anatomy of which was only characterized intraoperatively.

Second-look arthroscopic findings after medial open-wedge high tibial osteotomy combined with all-inside repair of medial meniscus posterior root tears.

PURPOSE: To examine the results of medial open-wedge high tibial osteotomy (MOWHTO) combined with all-inside repair focusing on medial meniscus posterior root tears (MMPRT) by second-look arthroscopy and determine the clinical relevance of the findings. METHODS: From June 2015 to June 2017, 27 consecutive patients underwent MOWHTO and meniscal treatment for MMPRT using all-inside repair. All were available for second-look arthroscopy evaluation at the time of plate removal. Cartilage regeneration in the medial condyles and healing status of the MMPRT were assessed at the time of second-look arthroscopy. Clinical outcomes were evaluated by the Hospital for Special Surgery (HSS) scores and the Lysholm score scale. The potential factors affecting the healing of MMPRT, including age, body mass index (BMI), weight-bearing line rate (WBLR) and femorotibial angle (FTA) were discussed. RESULTS: There were 11 (41%) cases with complete healing (group A) and 16 (59%) cases with lax healing (group B). A complete cartilage coverage of chondral lesions was observed at second-look arthroscopy. Improvements of HSS in both groups were 41.25 ± 6.18 and 38.82 ± 5.43, while improvements in Lysholm score seen in both groups were 30.40 ± 4.84 and 32.65 ± 4.11. There was no significant difference in the postoperative clinical results between the two groups. In group A, the age (months), BMI, WBLR, and FTA are 54.61 ± 2.53, 23.58 ± 2.39, 66.10 ± 2.86% and 169.00 ± 2.62°, respectively, while in group B, they are 55.16 ± 4.92, 29.58 ± 3.91, 57.51 ± 5.49% and 175.21 ± 2.87°, respectively. A significant difference has been identified between two groups except for age. CONCLUSION: As seen in this retrospective study, a higher healing rate of MMPRT using all-inside repair and regeneration of degenerated articular cartilage in the medial condyles after MOWHTO can be expected. Healing of the MMPRT was not related to a better clinical outcome. Moreover, it can be inferred that BMI, WBLR and FTA may affect the healing status of MMPRT.

The role of the anterolateral ligament in knee's biomechanics: a case-control retrospective study.

PURPOSE: The aim of this study was to assess the functional and clinical results of patients who underwent ACL reconstruction surgery and were divided into subpopulations related to ACL-associated lesions and focused on ALL-associated lesion. METHODS: Our retrospective analysis included 62 patients who underwent standard ACL reconstruction surgery in our hospital from 2014 to 2016. The mean follow-up period was 21 months (range 11-35). We divided the sample into two subpopulations due to the presence or absence of ALL tear at the preoperative MRI. In 42 patients out of 62 (68%), ALL lesion was evident. We evaluated in both subpopulations the ACL failure rate, the functional outcomes rated with IKDC, KOOS, Lysholm scores and the clinical assessment of anteroposterior and rotatory instability with the Lachman test and pivot-shift test. RESULTS: The overall re-injury rate in our cohort of patients was 4.8% with a smaller but not a significant difference between the two groups. A statistically significant difference was observed for the three functional scores, favoring the isolated ACL-lesion group (p < 0.05). Similarly, a better Lachman score was observed in the isolated ACL-lesion group, without statistical significance (p = 0.77); overall, the rate of positive test was lower in the isolated ACL-lesion group. We observed a significant difference of residual rotatory instability (positive pivot-shift test) in the two subpopulations (p = 0.036), and 9% of patients in the ACL + ALL lesion group showed residual jerk or subluxation. CONCLUSION: The additional ALL reconstruction/repair surgery should always be considered in patients with evident ALL tear at the preoperative MRI.

Transtibial fixation for medial meniscus posterior root tear reduces posterior extrusion and physiological translation of the medial meniscus in middle-aged and elderly patients.

PURPOSE: To investigate changes in meniscal extrusion during knee flexion before and after pullout fixation for medial meniscus posterior root tear (MMPRT) and determine whether these changes correlate with articular cartilage degeneration and short-term clinical outcomes. METHODS: Twenty-two patients (mean age 58.4 ± 8.2 years) diagnosed with type II MMPRT underwent open magnetic resonance imaging preoperatively, 3 months after transtibial fixation and at 12 months after surgery, when second-look arthroscopy was also performed. The medial meniscus medial extrusion (MMME) and the medial meniscus posterior extrusion (MMPE) were measured at knee 10° and 90° flexion at which medial meniscus (MM) posterior translation was also calculated. Articular cartilage degeneration was assessed using International Cartilage Research Society grade at primary surgery and second-look arthroscopy. Clinical evaluations included Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee subjective knee evaluation form, Lysholm score, Tegner activity level scale, and pain visual analogue scale. RESULTS: MMPE at 10° knee flexion was higher 12 months postoperatively than preoperatively (4.8 ± 1.5 vs. 3.5 ± 1.2, p = 0.01). MMPE at 90° knee flexion and MM posterior translation were smaller 12 months postoperatively than preoperatively (3.5 ± 1.1 vs. 4.6 ± 1.3, 7.2 ± 1.7 vs. 8.9 ± 2.0, p < 0.01). Articular cartilage degeneration of medial femoral condyle correlated with MMME in knee extension (r = 0.5, p = 0.04). All clinical scores significantly improved 12 months postoperatively. However, correlations of all clinical scores against decreased MMPE and increased MMME were not detected. CONCLUSIONS: MMPRT transtibial fixation suppressed the progression of MMPE and cartilage degeneration and progressed MMME minimally in knee flexion position at 1 year. However, in the knee extension position, MMME progressed and correlated with cartilage degeneration of medial femoral condyle. MMPRT transtibial fixation contributes to the dynamic stability of the MM in the knee flexion position. LEVEL OF EVIDENCE: IV.

Outcomes of adhesion barriers in gynecologic surgeries: A retrospective study at a medical center.

During second-look surgery or hospitalization, intra-abdominal surgeries may cause severe postoperative complications, such as pelvic adhesion, postoperative ileus, and severe pain. However, only few studies have analyzed the outcomes of antiadhesive barriers in second-look surgery. This retrospective study aims to identify the outcomes of different antiadhesive barriers by analyzing surgical images. The study included patients who received an adhesion barrier during second-look surgery between January 2011 and November 2017. Four brands of adhesive barriers were used: Interceed, Seprafilm, Adept, and SurgiWrap. Adhesion scores were calculated for four quadrants of the uterus and surrounding structures before and after the use of antiadhesive barriers. The differences between the data of 2 observers and surgery times were also determined. A total of 18 patients were enrolled in the study. The adhesion scores were not significantly different before and after the placement of antiadhesive barriers. The difference in the adhesion scores between the two observers was also not significant, except in the Seprafilm group (P = .029). Furthermore, no significant change in the adhesion scores was observed between the first and second surgeries. Therefore, using adhesion barriers may not decrease the adhesion scores in the current setting.