Revision Arthroscopic Posterior Shoulder Capsulolabral Repair in Contact Athletes: Risk Factors and Outcomes.

PURPOSE: To determine risk factors and outcomes of revision arthroscopic posterior capsulolabral repair in contact athletes. METHODS: Contact athletes with unidirectional posterior instability who underwent arthroscopic posterior capsulolabral repair from 2000 to 2014 with minimum 4-year follow-up were reviewed. Revision rate was determined and those who required revision surgery were compared with those who did not. Age, gender, labral and/or capsular injury, level of sport, and return to sport were compared. Pre- and postoperative American Shoulder and Elbow Surgeons, pain, function, stability, range of motion, strength, and satisfaction were also compared. Magnetic resonance imaging measurements of glenoid bone width, glenoid version, labral width, labral version, and cartilage version were also compared. RESULTS: A total of 149 contact athletes' shoulders met inclusion criteria. Eight shoulders required revision surgery (5.4%) at 13.0-year follow-up with 2.6 years between primary surgery and revision. Preoperative stability was significantly worse in those that required revision (0.008). Postoperative American Shoulder and Elbow Surgeons score was significantly worse in the revision group (75.1 vs 87.8, P = .03). The only significant risk factor for requiring revision surgery was decreased glenoid bone width (26.4 mm vs 29.1 mm, P = .005). Cartilage version, labral version, and bone version were not significantly different, nor was labral width. Sex, labral injury, capsule injury, both capsule and labrum injury, and level of sport were not risk factors. Both return to sport at the same level (revision = 16.7% vs nonrevision = 72.1%, P < .001) and overall return to sport (revision = 50.0% vs nonrevision=93.7%, P < .001) were significantly worse in the revision group. CONCLUSIONS: Contact athletes underwent revision arthroscopic posterior capsulolabral repair at an incidence of 5.4% at minimum 4-year and average 13.0-year follow-up. The only significant risk factors for requiring revision surgery was smaller glenoid bone width and higher preoperative instability. Return to play after their subsequent surgery was significantly worse. LEVEL OF EVIDENCE: Level III, comparative study.

Pulmonary Hypertension and the Risk of 30-Day Postoperative Pulmonary Complications after Gastrointestinal Surgical or Endoscopic Procedures: A Retrospective Propensity Score-Weighted Cohort Analysis.

Background: Pulmonary hypertension (PH) patients are at higher risk of postoperative complications. We analyzed the association of PH with 30-day postoperative pulmonary complications (PPCs). Methods: A single-center propensity score overlap weighting (OW) retrospective cohort study was conducted on 164 patients with a mean pulmonary artery pressure (mPAP) of >20 mmHg within 24 months of undergoing elective inpatient abdominal surgery or endoscopic procedures under general anesthesia and a control cohort (N = 1981). The primary outcome was PPCs, and the secondary outcomes were PPC sub-composites, namely respiratory failure (RF), pneumonia (PNA), aspiration pneumonia/pneumonitis (ASP), pulmonary embolism (PE), length of stay (LOS), and 30-day mortality. Results: PPCs were higher in the PH cohort (29.9% vs. 11.2%, p < 0.001). When sub-composites were analyzed, higher rates of RF (19.3% vs. 6.6%, p < 0.001) and PNA (11.2% vs. 5.7%, p = 0.01) were observed. After OW, PH was still associated with greater PPCs (RR 1.66, 95% CI (1.05-2.71), p = 0.036) and increased LOS (median 8.0 days vs. 4.9 days) but not 30-day mortality. Sub-cohort analysis showed no difference in PPCs between pre- and post-capillary PH patients. Conclusions: After covariate balancing, PH was associated with a higher risk for PPCs and prolonged LOS. This elevated PPC risk should be considered during preoperative risk assessment.

Severe Pulmonary Hypertension Meets Intraperitoneal Surgery: No Place to Inflate?

Severe pulmonary hypertension (PH) is associated with poor operative outcomes; however, guidance for perioperative management of this population is lacking. Mechanical ventilation has known deleterious effects on right ventricular preload and cardiac output. Meanwhile, pneumoperitoneum results in further cardiopulmonary insults. We report the successful case management of a patient with severe PH scheduled for elective cholecystectomy. While patients undergoing this surgery typically benefit from the less invasive, laparoscopic approach, the risk-benefit ratio may tilt towards risk in the setting of severe PH. A multidisciplinary approach to optimize outcome included the decision to perform an open rather than laparoscopic procedure, which resulted in a favorable outcome.

Risk Factors and Outcomes of Revision Arthroscopic Posterior Shoulder Capsulolabral Repair.

BACKGROUND: Risk factors and outcomes of revision arthroscopic posterior capsulolabral repair of the shoulder are currently not well defined. HYPOTHESIS: Athletes who require revision arthroscopic posterior unidirectional capsulolabral repair will have poorer outcomes and return to play when compared with those undergoing primary procedures, with risk factors including younger age, injury size, bone loss, and anchor number. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 297 shoulders that underwent arthroscopic posterior capsulolabral repair at minimum 2-year follow-up were reviewed. In addition to surgical data, the American Shoulder and Elbow Surgeons scoring system with subjective stability, range of motion, strength, and pain scores as well as return to sport were compared pre- and postoperatively between those who did and did not require revision surgery. Magnetic resonance arthrogram measurements of glenoid labral, chondral, and bone version and labral and bone width were also compared. RESULTS: Nineteen shoulders required revision surgery (6.4%) at 8.9-year follow-up. Significant risk factors included female sex ( P = .001), dominant shoulder ( P = .005), and concomitant rotator cuff injury ( P = .029). Patients with ≤3 anchors were more likely to require revision (odds ratio = 3.48). Smaller glenoid bone width was a risk factor for requiring future revision surgery ( P < .001), but glenoid labral, chondral, and bone version and labral width were not risk factors. All patients had significant improvements in American Shoulder and Elbow Surgeons, pain, range of motion, and strength scores after the original surgery; however, those who required revision surgery had less improvement ( P < .05). Stability improved significantly for nonrevisions ( P < .001) but did not for revisions ( P = .662). In the nonrevision group, 64.3% returned to sport at the same level, which was significantly higher than the 15.4% of the revision group ( P = .004). Overall, 78.6% of the nonrevision group and 61.6% of the revision group returned to sport at some level ( P = .280). CONCLUSION: Athletes underwent revision arthroscopic posterior capsulolabral repair at an incidence of 6.4%. Revision patients had significantly poorer outcome scores and return to play when compared with those who did not undergo revision surgery with risk factors being dominant shoulder surgery, female sex, concomitant rotator cuff injury, the use of 3 or fewer anchors, and smaller glenoid bone width. These data are essential for patient selection, optimal treatment techniques, and patient education as posterior shoulder instability failure requiring revision has not previously been evaluated.

Spatiotemporal differences in the c-fos pathway between C57BL/6J and DBA/2J mice following flurothyl-induced seizures: A dissociation of hippocampal Fos from seizure activity.

Significant differences in seizure characteristics between inbred mouse strains highlight the importance of genetic predisposition to epilepsy. Here, we examined the genetic differences between the seizure-resistant C57BL/6J (B6) mouse strain and the seizure-susceptible DBA/2J (D2) strain in the phospho-Erk and Fos pathways to examine seizure-induced neuronal activity to uncover potential mechanistic correlates to these disparate seizure responsivities. Expression of neural activity markers was examined following 1, 5, or 8 seizures, or after 8 seizures, a 28 day rest period, and a final flurothyl rechallenge. Two brain regions, the hippocampus and ventromedial nucleus of the hypothalamus (VMH), had significantly different Fos expression profiles following seizures. Fos expression was highly robust in B6 hippocampus following one seizure and remained elevated following multiple seizures. Conversely, there was an absence of Fos (and phospho-Erk) expression in D2 hippocampus following one generalized seizure that increased with multiple seizures. This lack of Fos expression occurred despite intracranial electroencephalographic recordings indicating that the D2 hippocampus propagated ictal discharge during the first flurothyl seizure suggesting a dissociation of seizure discharge from Fos and phospho-Erk expression. Global transcriptional analysis confirmed a dysregulation of the c-fos pathway in D2 mice following 1 seizure. Moreover, global analysis of RNA expression differences between B6 and D2 hippocampus revealed a unique pattern of transcripts that were co-regulated with Fos in D2 hippocampus following 1 seizure. These expression differences could, in part, account for D2's seizure susceptibility phenotype. Following 8 seizures, a 28 day rest period, and a final flurothyl rechallenge, ∼85% of B6 mice develop a more complex seizure phenotype consisting of a clonic-forebrain seizure that uninterruptedly progresses into a brainstem seizure. This seizure phenotype in B6 mice is highly correlated with bilateral Fos expression in the VMH and was not observed in D2 mice, which always express clonic-forebrain seizures upon flurothyl retest. Overall, these results illustrate specific differences in protein and RNA expression in different inbred strains following seizures that precede the reorganizational events that affect seizure susceptibility and changes in seizure semiology over time.