Single-Institution Experience With Component Separation for Ventral Hernia Repair: A Retrospective Review.

PURPOSE: In this study, we reviewed our institution's experience using component separation for repair of ventral hernias. METHODS: This was a retrospective review of all component separations for ventral hernia between July 2009 and December 2015. Recorded data included body mass index (BMI), preoperative albumin, smoking history, comorbidities, additional procedures, length of surgery, hospitalization, recurrence, and postoperative complications. RESULTS: One hundred ninety-six component separations were performed in the study period. The average patient age was 56 years, and 65.3% of patients were female. The average BMI was 32.6 kg/m; preoperative albumin was 3.59; 18.4% were current smokers; 28.1% were diabetic; and 14.3% had heart disease. Postoperative complications developed in 16.8% of patients. Recurrence developed in 8.7% of patients. Patients who developed a postoperative complication had a higher BMI (P = 0.025) and lower albumin (P = 0.047) compared with patients who did not develop complications. Current smokers were more likely to develop complications (P = 0.008). More than one third of patients had additional procedures at the time of the ventral hernia repair. The addition of a plastic surgery procedure was not associated with an increased risk of developing a complication (P = 0.25). Patients who developed complications had a significantly longer hospital course (P < 0.001) but no difference in total operative time (P = 0.975). Increased number of comorbidities did not statistically correlate with an increased complication rate (P = 0.65) or length of hospital stay (P = 0.43). CONCLUSIONS: We identified risk factors that increase the likelihood of postoperative complications and length of hospital stay. In addition, this study suggests that more comorbidities and additional procedures at the time of the hernia repair may not have as large of impact on complication risk as previously thought.

Mass or molar? Recommendations for reporting concentrations of therapeutic drugs.

A working party (WP) from the Australasian Association of Clinical Biochemists, Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, Royal College of Pathologists of Australasia and Royal Australasian College of Physicians recommends the following: *mass units should be used for reporting therapeutic drug concentrations in Australia and New Zealand; and the litre (L) should be used as the denominator when expressing concentration. Examples of these units are mg/L and µg/L Exceptions to these principles include: *drugs for which there is current uniformity of reporting and supporting information using molar units, notably lithium (mmol/L) and methotrexate (µmol/L); *drugs that are also present as endogenous substances, where the units used routinely should continue to be used. This applies to many substances, including minerals (eg, iron; µmol/L), vitamins (eg, vitamin D; nmol/L) and hormones (eg, thyroxine; pmol/L). *drugs for which the denominator is not a 198 of fluid and there is international uniformity of reporting (eg, thiopurine metabolites; per 109 red blood cells). These recommendations relate to drugs that are used therapeutically, whether measured for therapeutic drug monitoring purposes or for assessment of overdose. Other substances, such as drugs of misuse, heavy metals or environmental toxins, were not considered by the WP and are thus not covered by this document. These recommendations should also be applied to other supporting documentation such as published guidelines, journal articles and websites. The implementation of these recommendations in New Zealand is subject to local confirmation.

The inhibin B response to the testicular toxicant 1, 3 dinitrobenzene in male rats.

BACKGROUND: This study was conducted as part of an ILSI-HESI International Life Sciences Institute-Health & Environmental Sciences Institute consortium effort to assess the utility of circulating Inhibin B as an early biomarker of Sertoli cell-specific testicular toxicity in rats. 1, 3-Dinitrobenzene (1,3-DNB) was selected as a testicular toxicant in this study as it is known to target Sertoli cells. METHODS: 1,3-DNB (2 and 6 mg/kg/day) or control (corn oil) was administered orally to male rats for two or five consecutive days. Blood was collected from rats treated for 2 days on days 1 and 2 and from rats treated for 5 days on days 1, 3, and 5. The resulting serum was evaluated for Inhibin B and follicle stimulating hormone. At the end of the treatment periods, the testes were removed, weighed, and examined histopathologically. RESULTS: Daily administration of 1,3-DNB resulted in decreased testis weight only on day 5 and only at the high dose (6 mg/kg/day). There was a time-dependent increase in incidence and severity of testicular findings characterized by degeneration of the germinal epithelium with loss of pachytene spermatocytes and vacuolization of the Sertoli cells in the seminiferous tubules at the high dose. Inhibin B levels in 1,3-DNB-treated animals were decreased with treatment only on day 5 at the high dose; there were no associated changes in follicle stimulating hormone. CONCLUSIONS: Changes in serum Inhibin B levels were detected only in association with moderate or severe testicular toxicity as evidenced by histopathology and is therefore considered to be of limited value as a biomarker for Sertoli cell toxicity.

Reimagining the Path of an Unmatched Orthopaedic Residency Application: A Survey of Program Directors.

Background: Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods: The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results: Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions: Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence: Level IV.

Open Fractures in National Football League Athletes: Analyzing Performance and Return to Sport.

INTRODUCTION: Open fractures are potentially devastating injuries for the professional athlete. We sought to compare return to sports (RTS) and performance in National Football League (NFL) athletes sustaining open versus closed fractures. METHODS: NFL athletes with surgically treated open and closed fractures of the forearm, tibial shaft, and ankle from 2009-2018 were identified through publicly available reports and records. Data including demographics, RTS, career duration, and the approximate value performance metric before and after injury were collected. Statistical analyses were performed comparing open to closed injuries. Continuous variables were compared using Mann-Whitney U or two sample t- tests while categorical variables were compared using Fisher's exact test. RESULTS: Ninety-five athletes met inclusion criteria (10 open and 85 closed fractures). Overall, 90% (n = 9) returned to sport after an open injury and 83.5% (n = 71) returned after closed injury with a median time missed of 48.9 (range 35.1 - 117.4) weeks and 43.0 (range 2.4 - 108.0) weeks, respectively. Athletes undergoing forearm surgery were able to return sooner, at around 20.8 weeks, and ankle fractures conferred the lowest return rate at 80% (n = 48). There were no significant differences in career duration and post-injury performance between open or closed fracture cohorts. CONCLUSIONS: Although open fractures are relatively uncommon injuries seen in NFL athletes, our study suggests RTS for these players is high. Athletes undergoing surgical treatment for open fractures had similar RTS rates, performance metrics, and career durations compared to those with comparable closed fractures. This information can provide guidance for providers counseling elite athletes on postoperative expectations.

Online Patient Education Resources for Anterior Cruciate Ligament Reconstruction: An Assessment of the Accuracy and Reliability of Information on the Internet Over the Past Decade.

PURPOSE: The purpose of this study is to evaluate the quality of patient education materials accessible through popular online search engines regarding anterior cruciate ligament (ACL) injuries and anterior cruciate ligament reconstruction (ACLR).  Methods: Two search terms ("ACL surgery" and "ACL reconstruction") were entered into three search engines (Google, Yahoo, and Bing). The quality of information was scored using a novel scoring system developed and overseen by sports medicine orthopedic clinical research fellows and fellowship-trained orthopedic surgeons. Website quality, credibility, and readability were further assessed by the DISCERN score, Journal of the American Medical Association (JAMA) benchmark criteria, and Flesch-Kincaid Reading Grade Level (FKRGL), respectively. The Health On the Net Code of Conduct (HONcode) certification was also utilized to assess the transparency of health information for each website. RESULTS: We evaluated 39 websites. The average score for all websites was 11.2±5.6 out of 28 total points. Six out of the 39 websites (41%) were HONcode certified. The websites that contained HONcode certification had a higher average JAMA benchmark score (3.5±0.7) and DISCERN score (44.6±14.7) when compared to the websites without the certification, 2.2±1.2 and 37.6 ± 15.9 for JAMA and DISCERN, respectively. The mean JAMA benchmark score was 2.7±1.2 (67.5%) for all websites out of a possible four points. The average FKRGL for all 39 websites was 10.0±2.0 (range: 5.4-13). CONCLUSION: The quality of patient education materials accessible on the internet regarding ACL injuries and ACLR can be misleading and directly impact the patient's decision-making process essential to the patient-physician relationship over the past decade. CLINICAL RELEVANCE: The internet can be a helpful online resource, however, surgeon clarification and consultation with qualified healthcare professionals are strongly recommended prior to clinical decision-making regarding potential treatment options.

The effect of using activity workstations on heart rate variability during complex cognitive tasks.

ObjectivesThe purpose of the current study was to examine the effects of using an activity workstation on the physiological stress response as measured by heart rate variability while completing cognitively demanding tasks. Participants: Eleven college students (6 females; age: 19.4 ± 0.9 years) participated in the study. Methods: The participants completed three psychologically stressful cognitive tasks while seated at a traditional desk and while using an activity workstation. Heart rate variability was recorded and analyzed with power spectrum density and time-domain analysis. Results: Using activity workstations while completing stressful cognitive tasks did not negatively affect task performance. There was; however, a reduction in low frequency heart rate variability but no change in cardiac sympathovagal balance. Conclusion: The results indicate that using activity workstations while completing difficult tasks reduces sympathetic reactivity to stress in college students. This suggests that using activity workstations could provide a coping mechanism for stress.

Open Peroneal Tendon Stabilization With Fibular Groove Deepening.

Peroneal tendon subluxation often occurs because of sudden dorsiflexion of the ankle, leading to a traumatic rupture of the superior peroneal retinaculum. Currently, there are several surgical techniques to deepen the fibular groove, but there is no universally accepted gold standard. This technique article describes a fibular groove deepening with preservation of the fibrocartilage in conjunction with repair of the superior peroneal retinaculum. Addressing the main pathologies that may be leading to subluxation of the peroneal tendons, we offer an approach that avoids many of the common pitfalls from previously proposed techniques while preserving the natural fibrocartilage within the malleolar groove and repairing the retinaculum.

Anchorless Acromioclavicular and Coracoclavicular Ligament Repair Using a Graft-Passing Instrument to Pass Suture Under the Coracoid.

Acromioclavicular joint separation is a common shoulder injury. Grade I and II separation may be treated nonoperatively, whereas higher grades tend to require surgical intervention. Various repair techniques have been described in the literature, with no consensus on the gold standard. This Technical Note describes our use of a graft-passing instrument to pass suture under the coracoid during an anatomic reconstruction of both the acromioclavicular and coracoclavicular ligaments. Although this approach is technically challenging, it avoids coracoid drilling and requires smaller-diameter clavicle and acromion drilling. Furthermore, using suture instead of graft material increases the cost-effectiveness of the procedure.

Rehabilitation After Anterior Cruciate Ligament Injury: Review of Current Literature and Recommendations.

PURPOSE OF REVIEW: Anterior cruciate ligament reconstruction (ACLR) is a common surgical procedure with an estimated 120,000 cases performed in the USA each year. Physical therapy plays a critical role in the successful recovery of both surgically and non-surgically managed patients. Interestingly, ACL rehabilitation protocols vary greatly with little consensus among practitioners. Nonetheless, there has been agreement over the last decade to shift from conservative, standardized length protocols to more accelerated, individualized protocols that vary in length and modalities based on patient-specific findings and preferences. This review summarizes the most recent trends, opinions, and modalities in ACL rehabilitation research, with a specific focus on novel methods to treat the specific psychosocial needs of ACL deficient patients. RECENT FINDINGS: We found that new protocols emphasize early weight bearing, open kinetic chain (OKC) exercises, and other alternative modalities such as neuromuscular electrical stimulation and blood flow restriction. We also found a recent trend toward the use of clinical milestones to determine when a patient is ready for the next phase of a "step-up" rehabilitation program. One particularly nascent topic of research is the inclusion of methods to treat the psychosocial impacts of ACL injury, recovery, and the anxiety around return to sport. Rehabilitation strategy has become increasingly patient-dependent, and the new modalities being utilized are accelerating patient recovery. Return to sport is a particularly important factor for many ACLR patients, and recovery has an important psychological component that has only recently been addressed in the literature, with positive preliminary findings.

Evaluation of Osteochondral Allograft Transplant Using In-Office Needle Arthroscopy.

In-office needle arthroscopy (IONA) has been available in various iterations for decades. Studies have described it as comparable if not superior to magnetic resonance imaging for identifying intra-articular pathology with associated cost savings per patient. A new IONA system has been brought to market with a modernized user interface and disposable handpieces offering the opportunity to address intra-articular pathology. This article outlines the use of this IONA system for the postoperative evaluation of an osteochondral allograft transplant.

Surgical repair of acute on chronic seven-year pectoralis major rupture near the distal myotendinous junction: A case report.

The surgical fixation of an acute on chronic pectoralis major rupture with inciting injury 7 years prior has never been reported in the literature. Thus, we report the first case of an acute on chronic pectoralis major rupture repair in an active male patient who underwent successful surgical intervention and review the pathophysiology and treatment of pectoralis major tears.

Four-Strand Hamstring Diamond Braid Technique for Anterior Cruciate Ligament Reconstruction.

Several factors affect the success of an anterior cruciate ligament reconstruction, including graft origin, type, and morphology. Hamstring and bone-patellar tendon-bone autografts are the most widely used, and there are many different techniques of graft preparation with each. In this Technical Note and accompanying video, a 4-strand hamstring autograft technique is described that uses a simple diamond-type braid to produce a more ovoid morphology with increased cross-sectional area. Increased graft diameters have been associated with higher success rates and more positive long-term outcomes. Therefore, this braiding construct may provide additional tensile strength with increased resistance to failure than grafts that are otherwise undersized using conventional techniques.

Combined Coracoclavicular and Acromioclavicular Joint Reconstruction with Allograft Using a Cerclage Tensioning System.

Acromioclavicular joint separations are common shoulder injuries, yet standard treatment practices vary. Popular surgical techniques include reconstruction using allografts or neighboring ligaments as well as repair using screws and sutures. This Technical Note and accompanying video describe both an acromioclavicular and coracoclavicular joint reconstruction using an allograft to replace native acromioclavicular ligament along with an AC joint reduction using a Suture Cerclage System to precisely control reduction and restore anatomic alignment.

Distal Clavicle Excision for Acromioclavicular Joint Osteoarthritis Using a Fluoroscopic Kirschner Wire Guide.

Pathology of the acromioclavicular joint is common and often resistant to conservative treatment, requiring distal clavicle excision for definitive relief. First described as an open technique by Mumford and Gurd in 1941, distal clavicle excision has evolved greatly, with arthroscopic techniques currently predominating. No significant difference has been found in patient satisfaction or rate of complication between the techniques in a recent meta-analysis. Indeed, open excisions are still performed at a high rate, owing to the difficulty in technique and visualization with arthroscopic methods. One major critique of arthroscopic distal clavicle excision is difficulty safeguarding against under- and overexcision of the distal clavicle due to the lack of depth perception and visual reference points of the arthroscopic perspective. This Technical Note and accompanying video describe an indirect subacromial arthroscopic distal clavicle excision using a fluoroscopic Kirschner wire guide placed at the proximal border prior to resection to serve as a visual and mechanical reference to overexcision.

Mini-Open Subpectoral Biceps Tenodesis Using a Suture Anchor with Bone-Bridge Backup.

Pathology of the long head of the biceps tendon is a known cause of anterior shoulder pain. Current surgical management options include tenotomy and tenodesis. Tenodesis can be performed arthroscopically or as an open procedure. Arthroscopic tenodesis typically uses a suprapectoral attachment, which may fail to address tendon pathology in the bicipital groove. Open tenodesis carries iatrogenic risk to neurovascular structures and a fracture risk while drilling, as well as the morbidity of an open procedure. This technique paper describes a mini-open subpectoral approach using a suture anchor and bone bridge backup for dual fixation. Use of a suture anchor instead of an interference screw reduces drill hole diameter reducing the risk of iatrogenic humeral fracture. Dual fixation provides a robust repair which may be of use for athletic patients desiring an accelerated recovery.

Arthroscopic Osteochondral Autograft Transfer System Procedure of the Lateral Femoral Condyle with Donor-Site Backfill Using Osteochondral Allograft Plug.

The osteochondral autograft transfer system (OATS) procedure is at the forefront of cartilage restoration surgeries of the knee, offering superior return to sport rates and long-term functionality. This technique reports an arthroscopic OATS procedure of the lateral femoral condyle with donor-site backfill using an osteochondral allograft plug. Potential complications from unfilled donor site sockets are eliminated through donor site backfill with an allograft plug.

Single-Portal, Single-Anchor Repair of a Superior Third Subscapularis Tear Using a Self-Punching Knotless Soft Suture Anchor.

Numerous techniques exist for arthroscopic subscapularis repair with varying degrees of complexity based on tear morphology, all of which have established satisfactory outcomes in function and patient satisfaction. Arthroscopic subscapularis repair can require several working portals and suture anchors, increasing both technical complexity and operative time. This Technical Note describes an arthroscopic repair of a superior one-third subscapularis tear using a self-punching knotless soft suture anchor through a single anterior working portal. Thus, we offer a unique approach to arthroscopic repair of superior one-third subscapularis tears that is time-saving, reproducible, and highly efficient while minimizing iatrogenic damage and postoperative complications.

Arthroscopic Single Portal, Single Anchor Knotless Subscapularis Repair with Concomitant Tenodesis of the Long Head of the Biceps Tendon.

Anterior shoulder pathology involving the subscapularis is often associated with the biceps tendon because both anatomic structures intersect the lesser tuberosity. Standard procedures for such pathology often involve simultaneous subscapularis repairs and biceps tenodesis. Single anterior portal subscapularis repairs have been emerging in the past 5 years because of cost-effectiveness and efficiency. Biceps tenodesis is a common procedure performed both open and arthroscopically. This technique takes advantage of the close relation between the long head of the biceps tendon and subscapularis tendon to restore the functional length-tension relation and preserve function through fixation using a single portal and a single knotless suture anchor.

Mini-Open Achilles Repair With a Flat Braided Suture in a Low-Profile Configuration.

Achilles repair has evolved over the past 30 years, from large open procedures with high complication rates to shorter, less-invasive procedures with better outcomes. Percutaneous repair has comparable failure rates with open repairs, fewer complications, and faster recovery. However, percutaneous Achilles repairs risk sural nerve injury. A mini-open repair fuses the gap between percutaneous and open procedures, and this approach has the potential to mitigate nerve injury while maintaining the increased efficiency in procedure time and patient recovery. The purpose of this Technical Note and accompanying video is to outline the repair of the Achilles tendon using a mini open repair using a low-profile flat braided suture.