A Novel Distal Biceps Rupture Repair Technique Utilizing a Biocomposite Scaffold.

Distal biceps tendon ruptures are uncommon injuries that have a re-rupture rate of 1.2% - 6%. In severe traumatic injuries or chronic injuries, a distal biceps tendon repair may require augmentation due to insufficient tissue quality. Unsuccessful treatment of these injuries can result in the loss of approximately 40% of supination strength and 30% of elbow flexion strength. There has been a growing interest in biologic augmentation in orthopedic surgery, and its incorporation into distal biceps tendon repairs has increased as well. Established bio-inductive implants and dermal allografts have been shown to be of benefit; however, these biologics have drawbacks such as failure to incorporate at time of implantation, lack of structural strength, and technical difficulty of implantation. The BioBrace® (ConMed, New Haven, CT) is a bio-inductive, biocomposite scaffold that is composed of highly porous type I collagen and bio-resorbable poly (L-Lactide) (PLLA) microfilaments. It can be used in conjunction with distal biceps tendon repair or reconstruction. It has the advantage of providing strength to the augmented repair at time zero of implantation, while also demonstrating the ability to induce new organized tissue growth throughout its resorptive phase. We describe a technique to successfully augment a distal biceps tendon repair using the BioBrace®.

Safety of Cryoneurolysis as a Preoperative Treatment for Total Knee Arthroplasty (TKA).

Cryoneurolysis is a minimally invasive procedure that utilizes extreme cold temperature to achieve thermal neurolysis of peripheral sensory nerves. This study aimed to evaluate the safety of cryoneurolysis as a preoperative treatment for total knee arthroplasty (TKA) and assess the incidence of major and minor wound complications associated with the procedure. A retrospective chart review was conducted on 357 patients who underwent cryoanalgesia within two weeks of their scheduled TKA. The study found that cryoneurolysis as a preoperative treatment for TKA did not demonstrate an increased incidence of major complications, including acute periprosthetic joint infections, skin necrosis, or permanent treatment site nerve damage/neuroma compared to published rates of infection. Complications were minimal, with only three cases of infection and five cases of superficial cellulitis observed; however, none were directly attributable to the cryoneurolysis procedure. These findings are encouraging and suggest that cryoneurolysis is a relatively safe adjunct procedure with a similar risk of major or minor complications when used as a preoperative treatment for TKA.

A Novel Achilles Tendon Repair Technique Utilizing a Bio-Composite Scaffold for a Sub-Acute Tear.

Achilles tendon ruptures are prevalent musculoskeletal injuries accounting for 20% of all large tendon ruptures with a re-rupture rate of 2.1-8.8%. Ineffectual management of these injuries can lead to a significant loss in push-off strength and overall ankle function. The field of orthopedic surgery has shown an increasing interest in biologic augmentation. Encouraged by its success in various other applications, this approach holds promise for potentially enhancing outcomes in Achilles tendon repairs, especially in poor tendon tissue. The BioBrace® (ConMed, New Haven, Connecticut) is a biocomposite scaffold made of highly porous type I collagen and bioresorbable poly (L-Lactide) (PLLA) microfilaments. It can be applied in conjunction with Achilles tendon repair or reconstruction. It provides immediate strength to the augmented repair upon implantation and simultaneously promotes new, organized tissue growth throughout its resorptive phase. Here, we outline a technique to effectively augment an acute Achilles tendon repair utilizing the BioBrace® reinforced bio-inductive implant.

The Use of Plant-Based Polysaccharide (PSP) Agents May Improve Early Outcomes Following Total Knee Arthroplasty-A Proof-of-Concept Study.

Our study sought to investigate the effects of a topical plant-based polysaccharide (PSP) as an adjunctive hemostat to minimize blood loss and improve early clinical outcomes in patients undergoing primary TKA. In this multi-center and randomized proof-of-concept study, 61 patients undergoing TKA were randomly assigned to one of two groups: A) intraoperative utilization of PSP (n=31) or B) no intervention (n=30). The primary outcomes were blood loss and change in hemoglobin, measured preoperatively and 24 hours postoperatively. Other endpoints included postoperative complications, Knee Society Score (KSS), knee range of motion (ROM), and thigh circumference. There was no difference in postoperative change of hemoglobin or calculated blood loss between the PSP and control groups. The PSP group achieved elevated flexion at two weeks (100.1° vs. 86.6°, p<0.05) and better change in KSS from preop to 90 days (29.5 vs. 22.4, p<0.05) than the controls. Some early postoperative outcomes were improved, which suggests a potential benefit of using PSP in primary TKA. However, the clinical significance of these differences warrants further investigation in a larger randomized trial.

Pulmonary Barotrauma in COVID-19 Patients With ARDS on Invasive and Non-Invasive Positive Pressure Ventilation.

BACKGROUND: We experienced a high incidence of pulmonary barotrauma among patients with coronavirus disease-2019 (COVID-19) associated acute respiratory distress syndrome (ARDS) at our institution. In current study, we sought to evaluate the incidence, clinical outcomes, and characteristics of barotrauma among COVID-19 patients receiving invasive and non-invasive positive pressure ventilation. METHODOLOGY: This retrospective cohort study included adult patients diagnosed with COVID-19 pneumonia and requiring oxygen support or positive airway pressure for ARDS who presented to our tertiary-care center from March through November, 2020. RESULTS: A total of 353 patients met our inclusion criteria, of which 232 patients who required heated high-flow nasal cannula, continuous or bilevel positive airway pressure were assigned to non-invasive group. The remaining 121 patients required invasive mechanical ventilation and were assigned to invasive group. Of the total 353 patients, 32 patients (65.6% males) with a mean age of 63 ± 11 years developed barotrauma in the form of subcutaneous emphysema, pneumothorax, or pneumomediastinum. The incidence of barotrauma was 4.74% (11/232) and 17.35% (21/121) in the non-invasive group and invasive group, respectively. The median length of hospital stay was 22 (15.7 -33.0) days with an overall mortality of 62.5% (n = 20). CONCLUSIONS: Patients with COVID-19 ARDS have a high incidence of barotrauma. Pulmonary barotrauma should be considered in patients with COVID-19 pneumonia who exhibit worsening of their respiratory disease as it is likely associated with a high mortality risk. Utilizing lung-protective ventilation strategies may reduce the risk of barotrauma.

The Evolution of Cryoneurolysis for the Treatment of Shoulder, Hip, and Knee Pain: Where Are We Now and Where Will We Go? A Systematic Review.

Cryoneurolysis, otherwise known as cryoanalgesia, is a process of addressing nerve-related pain via disruption of nerve conduction utilizing extreme cold temperatures. Throughout the literature, cryoneurolysis has been described for decades across various specialties. Within the past few years, a growing movement of its application within orthopedics has provided pain relief solutions in both the non-surgical and surgical space. A review of the literature utilizing multiple medical search engines was performed to identify relevant orthopedic articles related to the treatment of joint pain with cryoneurolysis or cryoanalgesia. A review of the cryoneurolysis, indications, efficacy, and treatment gaps within the literature were identified to provide guidance for future research.

Identification of the Sensory Dependent Locations of the Shoulder Joint to Optimize Surgical Approaches and Reduce Postoperative Pain: A Systematic Review.

INTRODUCTION: Treatment of post-surgical pain is predicated by an understanding of pain generators. The purpose of this review is to identify sensory dependent areas of the shoulder and discuss their correlation in treating postoperative pain. MATERIALS AND METHODS: Pubmed, Embase, and Cochrane Database of Systemic Reviews were searched (key terms: "Nociception" or "sensory pain receptors" or "pain map" or "neuroanatomy and shoulder" or "rotator cuff") to identify studies in the current literature (1966-2018) regarding sensory innervation of the shoulder and rotator cuff. The search was limited to the English language, human studies, and publication types to reviews and clinical studies. Articles written in other languages besides English, animal studies, abstracts, and conference notes were excluded. Each search result was investigated for relevant physiological information of the nerve endings and nociceptors as well as pertinent information and figures that illustrated the location of the identified receptors. RESULTS: A total of 12 articles were identified that addressed the sensory innervation of the shoulder. The shoulder capsule has the highest sensory nerve density. The attachment sites between the labrum and the capsule and glenoid rim were also found to be highly sensory dependent, in contrast to the peri-core zone at the capsulolabral junction, which was found to be less concentrated with fascicles and sensory nerve endings. The subacromial bursa is also a highly sensory dependent structure, with a more concentrated neural network on the coracoacromial side compared to other quadrants of the bursa. Cutaneous locations of sensory fibers on the shoulder are best defined by mapping the pressure pain threshold (PPT) of various locations on the shoulder. The most sensory dependent locations of the shoulder were found to be the posterior border of the acromion, the glenohumeral joint, the anterior deltoid, and the upper trapezius. CONCLUSION: This review examined the origin of pain in the shoulder, the location of cutaneous pain receptors, and receptors in each major part of the shoulder. Providing analgesia to these densely innervated areas of the shoulder can potentially reduce pain associated with surgical trauma. In addition, knowledge of the sensory dependent areas of the shoulder may elicit consideration of alternative incision sites and surgical protocols to decrease the insult to nociceptors in these locations. These changes could possibly decrease the narcotic requirement in the postoperative period.

Patient-Reported Outcomes After Arthroscopic Shoulder Surgery With Interscalene Brachial Plexus Nerve Block Using Liposomal Bupivacaine: A Prospective Observational Study.

BACKGROUND: Interscalene brachial plexus nerve blocks (ISBPNBs) are commonly used to mitigate postsurgical pain after shoulder surgery. MATERIALS AND METHODS: We performed a prospective observational study in 57 consecutive adult patients undergoing arthroscopic shoulder surgery with an ultrasound-guided ISBPNB using liposomal bupivacaine (LB; 133mg/10ml) mixed with 0.5% bupivacaine (10ml). All patients received prescriptions for 1000mg of oral acetaminophen and 10 5mg oxycodone tablets upon discharge. RESULTS: Post-discharge telephone surveys revealed that mean (standard deviation [SD]) patient-reported motor and sensory recovery times after surgery were 26.8 (3.2) and 34.0 (3.6) hours, respectively. The average (SD) visual analog scale pain score was 5.1 (3.1) at day two post-surgery. The estimated opioid utilization rate at day seven post-surgery was 21% of the prescribed opioid tablets. CONCLUSIONS: Our real-world observational findings suggest that multimodal postsurgical pain control using single-shot, ultrasound-guided ISBPNB with LB and postsurgical acetaminophen provides favorable pain control and limited need for postsurgical opioid rescue for seven days after shoulder surgery.

Arthroscopic Hip Labral Repair Using Needle Arthroscopic Visualization.

Hip arthroscopy has become increasingly popular in recent years and continues to grow as techniques and understanding of hip arthroscopy evolve. Needle hip arthroscopy is emerging as a technique that can offer potential advantages compared with a traditional arthroscope. These benefits include a higher degree field of view, lower profile design for easier maneuverability, decreased arthroscopic fluid, and potentially decreased postoperative pain and swelling. We herein present and describe a technique of needle hip arthroscopy as a viable option in the treatment of hip pathology.

Improved Network Integrity and Patient Follow-up After In-Office Needle Arthroscopy Compared to Outpatient Advanced Diagnostic Imaging for Intra-articular Pathology.

Purpose: To evaluate network integrity for diagnostic testing and patient follow-up comparing in-office needle arthroscopy and outpatient advanced diagnostic imaging for intra-articular pathology. Methods: A retrospective chart review was performed to identify patients who were indicated for either in-office needle arthroscopy (IONA) or outpatient advanced diagnostic imaging (OADI). Current Procedural Terminology (CPT) codes 29870 and 29805 with place of service modifier 11 were used to identify patients who underwent IONA of the knee and shoulder, respectively, between January 2020 and March 2023. CPT codes 73721-3 and 73221-3 were utilized to identify patients indicated for outpatient advanced magnetic resonance imaging of the knee or shoulder. All patients who were indicated for the procedure and denied by the insurance were identified and recorded. Inclusion criteria consisted of patients older than 18 years with suspected intra-articular pathology who had failed conservative treatment. Exclusion criteria included patients younger than 18 years, non-English speaking, or those who failed to follow up due to death. The location of where the imaging was performed was recorded (within the health system vs an unaffiliated center). Additionally, patient follow-up with the provider after the diagnostic testing was indicated was recorded. Results: Two separate groups of 100 consecutive patients who were indicated for IONA or OADI were identified and retrospectively chart reviewed. Ninety-four percent of the IONA patients underwent the procedure after it was indicated within the physician office. Sixty-eight percent underwent the procedure the day they were indicated for the procedure. All 94 patients were deemed to have a follow-up with a definitive plan of care after the procedure. Eighty-seven percent of the OADI patients completed their ordered testing. Sixty-two percent (54/87) of the patients had the study performed at one of the primary hospital-affiliated imaging centers. Thirty-eight percent of the studies (33/87) were deemed to have leaked from the system. Of the 87 patients who had the imaging performed, 79% (69/87) had a definitive treatment plan rendered with the lead author (S.M.) based on the imaging results. Twenty-one percent (18/87) of the patients who underwent imaging did not follow up with the treating provider or show for a scheduled follow-up appointment. Nineteen percent (13/69) of the patients who had a definite treatment plan rendered did not come into the office for their results but requested and received them over the phone from the provider. The IONA cohort demonstrated statistically significant (P < .001) network integrity in terms of location of service remaining within the system compared to the OADI group. Furthermore, patient follow-up for definitive treatment plans after IONA was also higher (P < .001) than in the OADI group. Conclusions: IONA results in greater network integrity and patient follow-up compared to conventional imaging. Clinical Relevance: In-office needle arthroscopy performed for the diagnosis of intra-articular pathology may offer a valuable clinical diagnostic tool while providing a meaningful avenue for network integrity and patient retention.

No Difference in Pullout Strength Between a Bio-inductive Implant and a Semitendinosus Tendon Graft in a Biomechanical Study of Medial Patellofemoral Ligament Repair Augmentation.

Purpose: To compare the pullout strength of a bio-inductive implant (BI) used to augment a medial patellofemoral ligament (MPFL) repair with the pullout strength of semitendinosus graft in a biomechanical cadaveric model. Methods: Six matched pairs of cadavers (12 knees) were used in the biomechanical testing comparing semitendinosus tendon (Semi-T) versus a BI. The Semi-T was harvested from 1 of the matched pairs. A standard double-bundle technique using 2 sockets in the upper two-thirds of the patella 15 mm apart was performed. After docking of the graft into the patella, the patella was dissected free of soft tissues and potted into a fixture to allow mechanical pull parallel to the transverse axis of the patella. The construct was pulled to failure. Results: There was no statistically significant difference in pullout strength (P = .77) between the BI group (249.3 ± 36.3 N) and Semi-T group (235.0 ± 113.6 N) double-bundle constructs. In the Semi-T group, 50% of the specimens (3 of 6 knees) failed via anchor pullout and a fourth specimen failed at the suture-anchor interface (16.7%), whereas in the BI group, 16.7% of the specimens (1 of 6 knees) failed by anchor pullout. Although the Semi-T group (49.5 ± 14.1 N/mm) showed significantly greater stiffness than the BI group (13.8 ± 0.6 N/mm, P < .01), pullout strength in the Semi-T group was highly variable: 50% of the specimens (3 of 6 knees) with semitendinosus constructs failed at 5 mm of displacement or less via graft or anchor pullout. Maximum load, displacement at failure, stiffness, and load at 5 mm were compared between the augmented and non-augmented control specimens using a 2-tailed non-equal variance Student t test. For all comparisons, P < .05 was considered to indicate a statistically significant difference. Conclusions: In this biomechanical study, augmentation of an MPFL reconstruction using a common double-bundle technique with a BI had the same pullout strength as a semitendinosus graft using the same technique in cadaveric knees. Clinical Relevance: MPFL repair after a patellar dislocation may be inadequate to restore the strength of the native MPFL and prevent recurrent patellar instability. Recurrent instability of the patella can result in progressive injury to the soft tissue and articular cartilage of the patella and femur. It is important to study the techniques used for MPFL repair to continually improve patient outcomes. Further testing of these additional techniques and clinical studies are needed to evaluate the implants used to augment MPFL repairs.

Patients With Low Resilience Scores Have Significantly Worse Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction Than Patients With Normal or High Resilience Scores.

Purpose: To evaluate the relationship between patient resilience and patient-reported outcome measures (PROMS) after primary anterior cruciate ligament (ACL) reconstruction. Methods: Patients who underwent an ACL reconstruction by a single surgeon between January 2012 and June 2020 were identified by an institutional query using Current Procedural Terminology codes. Patients were included if they (1) underwent a primary ACL reconstruction and (2) had a minimum of 2 years' follow-up. Data were retrospectively collected regarding demographics, surgical details, visual analog scale (VAS) scores, and 12-item short form survey (SF-12) scores. Resilience scores were obtained via the Brief Resilience Scale questionnaire. Stratification into low (LR), normal (NR), and high resilience (HR) was based on standard deviation from mean Brief Resilience Scale score to determine differences in PROMS between groups. Results: One-hundred eighty-seven patients were identified by the institutional query. Of the 187 patients, 180 met inclusion criteria. Seven patients underwent revision ACL reconstruction and were excluded from the study. One-hundred three patients (57.2%) completed the postoperative questionnaire and were included. Patients in the NR group and HR group had significantly greater postoperative SF-12 scores (P < .001) and lower postoperative VAS pain scores (P < .001) when compared with those of the LR group. This trend was again shown with breakdown of the SF-12 into physical and mental aspects, each of which were significantly greater in either the NR group or HR group when compared with the LR group (P < .001). Overall, 97.9% and 99.0% of patients had changes in their SF-12 total and VAS pain scores respectively that exceeded the minimal clinically important difference for the cohort. Conclusions: Patients with lower resilience scores have worse PROMs and increased pain than patients with greater resilience at a minimum of 2-year follow-up after ACL reconstruction. Level of Evidence: Level IV, prognostic case series.

Biologic graft augmentation for glenoid bone loss in conversion of failed anatomic to reverse shoulder arthroplasty: a systematic review.

Glenoid bone loss presents a challenging dilemma, particularly in the setting of failed arthroplasty requiring conversion to a reverse total shoulder arthroplasty (rTSA). The aim of our systematic review was to examine the success and failure of biologic glenoid bone grafting to address vault deficiencies in the setting of shoulder arthroplasty conversion to rTSA. Twelve articles were included and a complete PUBMED search. Inclusion criteria included glenoid bone grafting for conversion of failed arthroplasty and a minimum of 12 months follow-up. Exclusion criteria included grafting for primary rTSA, and re-revision for infection or humeral loosening. Failures were defined as failure of the graft to radiographically incorporate, symptomatic base plate loosening, and need for further surgical re-revision. Two hundred patients were identified across the 12 articles. Eighteen percent (36/200) of all cases demonstrated failure to radiographically incorporate. Thirteen percent (25/200) of all grafting cases required re-revision due to symptomatic failure (pain or functional deterioration). Femoral shaft demonstrated the highest failure rate at 88% (7/8). Grafting for glenoid bone loss in the setting of conversion to rTSA has an 82% rate of success across autograft and allograft utilization. Further studies are needed to better define the success of autografting versus allografting in the setting of shoulder arthroplasty conversion to rTSA with glenoid bone loss.

Trends in Anterior Cruciate Ligament Injury and Recovery in Professional Snowboarders: The Extreme Sport of Snowboardcross.

Introduction  An anterior cruciate ligament (ACL) tear is a devastating injury for athletes that is predominantly low energy and non-contact in nature. ACL tears are one of the most well-researched injuries in sports, however, scant research has been done on competitive snowboarders. Boardercross is a relatively new sport introduced to the Winter Olympics in 2006. Initially, it entailed four snowboarders racing head-to-head down a course of obstacles in a race to the finish, with the top two riders advancing to the next rounds. It has since expanded to six racers traveling up to 60 mph and jumps up to 100 feet in length in a head-to-head race to the finish. This extreme sport puts its athletes at risk for serious injury, requiring investigation. Purpose Investigate the prevalence of ACL tears in the extreme sport of boardercross, evaluate sport-specific factors that may put athletes at higher risk, and report return to sport data. Methods An expedited IRB approval was obtained. A survey was distributed to athletes via e-mail to national/regional coaches of countries with competitive boardercross teams. Professional coaches distributed the survey and secondarily distributed it to athletes. Results Sixty-six competitive snowboardcross athletes responded to the email surveys 48.5% of respondents had torn their ACL at least once in their career. Of the female respondents, 55.6% suffered at least one ACL tear, and 43.6% of male respondents suffered at least one ACL tear. 31.2% suffered more than one ACL tear during their career. Of those who tore their ACL, 91.3% (p <0.001) tore their front leg. 100.0% of the respondent athletes returned to sport post-ACL reconstruction. Conclusion Professional boardercross racers are at a higher risk of tearing their ACL than other winter sport athletes, including alpine skiers. A predominance of ACL injuries occurred on the front leg during landing from an aerial maneuver. All respondent athletes returned to the sport after injury, with approximately half returning within six months. Although no statistical significance was achieved, the data provided trends on risk factors related to ACL injuries among snowboardcross athletes.

Cryo-electron microscopy analysis of myosin at work and at rest.

Myosins are a superfamily of ATP-driven actin-dependent molecular motors that are responsible for diverse functions from muscle contraction to cell division. The resolution revolution in cryo-EM has enabled characterisation of the interaction of myosin with its actin track in several states of the myosin motor cycle, for multiple myosin classes, allowing increased insight into the force generation mechanism. A major advancement in our understanding of myosin-2 regulation has come through solving structures of its shutdown state, dysregulation of which is implicated in multiple diseases. This review will discuss what has been accomplished so far with cryoEM, what is still yet to do, but within reach, and how better understanding of myosin structure-function relationships may lead to future therapeutic interventions.

Arthroscopic Rotator Cuff Repair Technique Using a Bio-Composite Scaffold for Tissue Augmentation.

The use of biologics and rotator cuff augmentation have seen significant growth in interest to combat complications of rotator cuff retear after arthroscopic rotator cuff repair. Bio-inductive implants are used to induce new tissue formation; however, they lack structural strength at the time of implantation. Conversely, dermal allografts are used to provide structural strength at implantation, but they do not allow for sufficient tissue incorporation and carry inherent risks of allograft tissue. The BioBrace™ (Biorez, New Haven, CT) is a bio-inductive scaffold composed of highly porous type I collagen and bio-resorbable poly (l-lactide) microfilaments developed to combat the latter drawbacks. The unique bio-composite properties provide the ability to combine the benefits of bio-induction and strength into a single implant. We propose a successful, reproducible technique for the implantation of BioBrace for rotator cuff augmentation.

Knee Medial Collateral Ligament Augmentation With Bioinductive Scaffold: Surgical Technique and Indications.

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee; however, only a minority of cases require surgical intervention. Classically, isolated grade I and II MCL injuries are treated nonoperatively whereas isolated grade III injuries may be treated with surgery. High-grade MCL injuries are frequently associated with concomitant knee ligamentous injuries, particularly the anterior cruciate ligament. Nonetheless, MCL repair or reconstruction is generally reserved for patients with persistent valgus instability after failed nonoperative management. Synthetic and biological implants are increasing in popularity to augment repairs and reconstructions for biomechanical reinforcement and promotion of the native healing response to hasten rehabilitation. The BioBrace (Biorez, New Haven, CT) is a bioinductive scaffold composed of highly porous type I collagen and bioresorbable poly(L-lactide) microfilaments, providing an environment for soft-tissue regeneration and mechanical support. The purpose of this article is to describe the surgical technique and relative indications for the BioBrace in knee MCL ligament repairs and reconstructions.

Patient-Specific E-mailed Discharge Instructions Improve Patient Satisfaction and Patient Understanding After Surgical Arthroscopy.

Purpose: The purpose of this study is to determine whether patient-specific e-mails after surgical arthroscopy improve patient satisfaction and patient understanding of their procedure compared to traditional, preprinted discharge instructions. Methods: Sixty patients who underwent surgical arthroscopy were prospectively, randomized into two separate groups. One cohort received a detailed e-mail of their procedure, discharge instructions, and labeled intraoperative arthroscopic images, while the second cohort received the standard preprinted instructions, while their arthroscopic images were discussed at the time of follow-up. The procedures were performed by a single surgeon. All patients were seen at 1-week follow-up and given a 14-question survey specific to their postoperative course, discharge instructions, and overall satisfaction using a 5-point Likert Scale. Demographic information was collected and data points comparing overall patient satisfaction, ease of understanding instructions, quality of information, and the number of times referenced were analyzed using nonparametric tests between the two cohorts. Results: Patients in the e-mail cohort were significantly more satisfied with their surgery than patients in the printed cohort (medians: 5 versus 4, Wilcoxon chi-square = 9.98; P =.002). Patients in the e-mail cohort indicated that their instructions more greatly enhanced their overall understanding of their surgery (medians: 5 vs 3, Wilcoxon chi-square = 10.84; P = .001) and were more helpful to their recovery (medians: 5 vs 3, Wilcoxon chi-square = 7.37; P = .007). E-mail patients were significantly more likely to recommend similar instructions be sent to a friend undergoing surgery (medians: 5 versus 3, Wilcoxon chi-square = 11.10; P < .001) and share their instructions with others 72% (18/25) versus 34.5% (10/29). There was no significant difference between the e-mail cohort and the print cohort for the number of times patients referred to their instructions (medians: 3 versus 3, Wilcoxon chi-square = 2.41; P =.121). Conclusions: Patient-specific e-mailed discharge instructions improve patient satisfaction and overall understanding of the procedure compared with traditional printed discharge instructions after surgical arthroscopy. Level of Evidence: Level II, prospective randomized trial.

Pulmonary Tumor Embolism and Pulmonary Tumor Thrombotic Microangiopathy Causing Rapidly Progressive Respiratory Failure: A Case Series.

Pulmonary tumor embolism (PTE) and pulmonary tumor thrombotic microangiopathy (PTTM) are rare etiologies for rapidly progressive dyspnea in the setting of undiagnosed metastatic cancer. They occur most frequently in association with adenocarcinomas, with PTE being most frequently associated with hepatocellular carcinoma and PTTM being most commonly reported with gastric adenocarcinoma. Pulmonary tumor embolism and PTTM appear to be a disease spectrum where PTTM represents an advanced form of PTE. Pulmonary tumor embolism and PTTM are mostly identified postmortem during autopsy as the antemortem diagnosis remains a clinical challenge due to the rapidly progressive nature of these rare diseases. We report 2 cases of rapidly progressive respiratory failure leading to death, due to tumoral pulmonary hypertension resulting from PTE and PTTM, diagnosed postmortem. Both of the patients were middle-aged females, nonsmokers, and had a gastrointestinal source of their primary malignancy.