Acute Postoperative Period Research Articles

Application and validation of ukrainian-language modification of the ferrans and powers quality of life questionnaire for patients with heart rhythm distirancies in Ukraine

Introduction. Atrial flutter (AFl) and atrial fibrillation (AF) are ones of the most common arrhythmias, they constitute a significant proportion of cardiovascular events. Radiofrequency ablation (RFA) is the most common strategy of rhythm control in these patients, affects many endpoints, including quality of life. Existing validated questionnaires are not specific, need a lot of time as for patient during filling in, as for doctor during interpretation. In English resources Ferrans and Powers questionnaire has shown high sensitivity and specificity for patients with heart rhythm disturbances, which further uses in different patients’ cohorts. The aim of our work was to evaluate acceptability, reliability, legitimacy and sensitivity of the Ukrainian-language modification of the Ferrans and Powers questionnaire for patients with AFl and AF before and after RFA. Materials and methods. The original Ferrans and Powers questionnaire, which consists of 15 questions, was translated and adapted from English into Ukrainian. The survey was conducted among patients before the RFA procedure, in the acute postoperative period (3–5 days), 3 months and 12 months after the procedure. According to the results, the sum of points was calculated and classes were allocated: class 1 (significant decrease in quality of life) – 15–44 points, class 2 (moderate decrease in quality of life) – 45–74 points and class 3 (slight decrease, or high quality of life) – 75–90 points. Acceptability, reliability, legitimacy and sensitivity of the survey scale were assessed. Results. The study included 118 patients with a mean age of 58.98 ± 9.6, 49 women (41.5 %). The scale of the Ukrainian-language modification of the Ferrans and Powers questionnaire had a high internal sequence (logic), the average correlation between the points of the scale was 0.51; Cronbach’s alpha coefficient is 0.9. All the recommended criteria for constructing such scales were agreed, 15 points were combined into a single scale, in which 32 % of discrepancies with the original points were observed. By acceptability, the highest and lowest extremes of quality of life were below the recommended maximum of 20 %. Reliability was confirmed by compliance with the recommended criteria of internal density and reproducibility in repeated measurements. A high intrinsic density was demonstrated, confirming the design-related validity of the questionnaire. The sensitivity of the proposed scale was reflected in the increase in the quality of life of patients after all types of RFA procedures. The study proved the high acceptability, reliability, validity and sensitivity of the quality of life questionnaire of patients with cardiac arrhythmia in patients with paroxysmal, persistent and persistent forms of AFl and/or AF, as well as their observation in the stages after RFA. Conclusions. The Ukrainian-language modification of the Ferrans and Powers questionnaire has high levels of acceptability, reliability, legitimacy and sensitivity for patients with AFl and AF, which is a useful practical tool for the treatment and control of these patients.

Abstract 12333: Intravenous Sotalol for Adenosine Refractory Supraventricular Tachycardia

Introduction: For re-entrant supraventricular tachycardia (SVT) that is refractory to adenosine, options of intravenous (IV) anti-arrhythmics for acute conversion are limited. IV sotalol has become more readily available, but experience in children with adenosine refractory SVT is limited. Hypothesis: IV sotalol is safe and effective for acute termination of adenosine refractory re-entrant SVT. Methods: A retrospective study of all pediatric patients receiving IV sotalol for SVT from 2016-2021, that had previously failed to convert with adenosine administration was performed. SVT consisting of orthodromic reciprocating tachycardia were included, all other supraventricular arrhythmias were excluded. Patient demographics, presence of congenital heart disease (CHD), arrhythmia type, efficacy of IV sotalol use and adverse effects were evaluated. For patients that failed to convert after the administration of adenosine a 1 mg/kg IV bolus of sotalol was given over 1 hour. Complete efficacy was defined as SVT terminating with IV sotalol bolus, partial efficacy was defined as adenosine converting SVT during or after the sotalol bolus, when adenosine had previously failed to convert SVT. Results: A total of 20 separate SVT events were treated with IV sotalol in 19 patients (53% male). Wolff-Parkinson-White syndrome was present in 5/19 patients (26%), and 9/19 patients (47%) had associated CHD. Patients had a median age of 0.24 yrs (IQR 0.03-6.86 yrs), median weight 4.30 kg (IQR 3.61 - 25.55 kg). Ventricular function prior to IV sotalol use was mildly or moderately depressed in 5/19 (26%) patients. Of the 20 events 5 (25%) were during the acute post-operative period. A single IV sotalol bolus was effective in converting adenosine refractory SVT in 19/20 (95%) events, with 16/20 (80%) having complete efficacy and 3/20 (15%) with partial efficacy. Median time to conversion was 0.5 hours (IQR 0.3-0.98 hours). No patient experienced an adverse effect during IV sotalol bolus. Conclusions: IV sotalol is a safe and effective antiarrhythmic option for acute conversion of adenosine refractory SVT.

Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial.

Introduction & aim: Temporary (60-day) percutaneous peripheral nerve stimulation (PNS) has demonstrated effectiveness for the treatment of chronic post-amputation pain, and this pilot study aims to evaluate the feasibility of temporary percutaneous PNS for the treatment of acute post-amputation pain. Patients & methods: Sixteen veterans undergoing lower extremity amputation received PNS and standard medical therapy or standard medical therapy alone. Results: The PNS group reported greater reductions in average phantom limb pain, residual limb pain and daily opioid consumption, and there were fewer participants taking opioids through 3 months post-amputation. Conclusion: This pilot study suggests that PNS is feasible in the acute postoperative period following lower limb amputation and may provide a non-pharmacologic analgesic therapy that lowers pain scores and reduces opioid consumption, and thus warrants further investigation.

Role of postoperative imaging in neuro-oncology

Postoperative imaging in primary and secondary brain tumors is becoming challenging due to advancements in molecular genetic classification of brain tumors influencing advancing treatment options. In this review, we summarize the standard-of-care practice, commonly encountered clinical and postoperative imaging issues. The timeline for follow-up imaging in low-grade, high-grade, and secondary tumors is discussed, particularly in reference to tumor and treatment-related effects. Standardized imaging protocols are essential for postoperative evaluation, which should always be read in the context of previous imaging. Where possible, advanced magnetic resonance imaging techniques, including multiparametric diffusion, perfusion, and spectroscopy imaging, should be used to differentiate between recurrent tumor and treatment-related changes. Surgical complications are often seen in the immediate and acute postoperative period and chemoradiotherapy-related complications following several weeks to months. The main aim of postoperative imaging is to evaluate expected and unexpected findings for appropriate management. Background information of tumor molecular genetics, histological grade, patient clinical status, and treatment given is essential for interpreting postoperative imaging.

Postoperative Delirium: A Literature Review of Management in Intensive Care Unit

Perioperative delirium is a wide-ranging problem that directly affects primary clinical results. The anesthesiologist must understand how to define and diagnose delirium, identify patients at high risk of delirium, identify predisposing factors to adjust the care plan appropriately, and manage delirium in the acute postoperative period. Delirium is an organ dysfunction in critically ill patients, independently associated with improved morbidity. Research on delirium in hospitalized patients (including critically ill patients) has increased exponentially in the last decade. This study emphasizes the need for a mechanistic explanation of delirium to help advance the research that ultimately leads to its prevention and treatment. In this study, multinational and multidisciplinary clinicians, and researchers from the fields of critical care medicine, psychiatry, anesthesiology, neurology, and pharmacy sought to collaborate in the management of delirium in the intensive care unit (ICU).

Incidence, Diagnosis and Treatment of Broad Ligament Fibroids in Women Undergoing Minimally Invasive (MIS) Myomectomy: A Chart Review

<h3>Study Objective</h3> The incidence of broad ligament fibroids is reported to be approximately 1% in the literature, however based on our surgical population, we propose that the incidence is much higher. Broad ligament fibroids are commonly misdiagnosed on preoperative MRI imaging. We aim to determine preoperative imaging characteristics that suggest a diagnosis of broad ligament fibroid. We aim to determine the true incidence of broad ligament fibroids in women undergoing MIS myomectomy at a single institution. <h3>Design</h3> Retrospective chart review was performed to identify preoperative imaging, operative reports, and postoperative data in the acute postoperative period (10 weeks following surgery). <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> Patients were identified for inclusion via review of the surgical schedule during the study period (January 2018 – December 2020). Women ≥18 years-old undergoing MIS myomectomy were eligible for inclusion. 227 patients were identified for inclusion and chart review. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A total of 27 (11.9%) patients were identified to have a broad ligament fibroid at the time of surgery. One additional patient was identified in whom the fibroid had significant adhesions to the broad ligament but did not arise from the broad ligament itself. No patients had preoperative imaging correctly identifying the location of the fibroid as within the broad ligament. Complications included pelvic sidewall hematoma (1), thermal colon injury (1), postoperative hypotension (1), incisional hernia (1), readmission for hemoperitoneum (1), reoperation for hemoperitoneum (1), incisional cellulitis (1), and unexpected salpingo-oophorectomy secondary to adhesions (1). <h3>Conclusion</h3> The 11.9% incidence reported here is significantly higher than previously reported. Correct preoperative diagnosis is exceedingly rare, making accurate surgical counseling difficult. A goal of gynecologic imaging should be to identify common characteristics of broad ligament fibroids on MRI imaging because such patients can have increased rates of complications after MIS myomectomy. Accurate imaging and preoperative diagnosis are critical for proper surgical counseling, planning and intraoperative management.

Perioperative Intravenous Lidocaine Infusion on Postoperative Recovery in Patients Undergoing Arthroscopic Rotator Cuff Repair Under General Anesthesia: A Randomized Controlled Trial.

Arthroscopic rotator cuff repair (ARCR) is known to cause severe postoperative pain that may interfere with recovery. Intravenous (IV) lidocaine has analgesic, anti-inflammatory, and antihyperalgesic effects, and is being used in various types of surgeries. However, the effect of IV lidocaine in ARCR is not well-known. Ninety patients undergoing ARCR were randomly allocated to receive IV lidocaine (1.5 mg/kg bolus of 1% lidocaine after anesthesia induction followed by a continuous infusion of 2 mg/kg/h up to 1 h after surgery) or an equal volume of saline. In both groups, an IV patient-controlled analgesia (PCA) device was used that contained fentanyl 10 µg/mL, infused at 1 mL/h with a 1 mL bolus dose. The primary outcome was fentanyl requirements given via IV PCA during the first 24 hours after surgery. Perioperative pain scores and functional recovery were assessed as secondary outcomes. The amount of fentanyl administered via IV PCA up to 24 hours after surgery was significantly lower in the lidocaine group compared with the control group (329 [256.2 to 428.3] vs. 394.5 [287.0 to 473.0], P=0.037). The number of PCA bolus attempts were lower in the lidocaine group without statistical significance. There were no differences in postoperative pain scores or functional shoulder scores between the 2 groups. IV lidocaine appears to be helpful in reducing opioid requirements during the acute postoperative period in patients undergoing ARCR. IV lidocaine may be a viable option as a component of multimodal analgesia in ARCR when regional analgesia is not possible.

Commentary: Management of Refractory Pain After Total Joint Replacement

Chronic refractory pain after total joint replacement is debilitating and a source of dissatisfaction for patients. The management of pain following total joint replacement varies during the acute postoperative period compared to the 3 months postoperative at which point the pain is considered chronic pain. Acute postoperative pain relief programs have seen promising results with multimodal pain control through the use of combinations of opioids, acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids and ketamine. The addition of regional blocks to the multimodal regimen has improved acute postoperative pain control following total joint replacements. On the other hand, chronic pain can be successfully managed with options including genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). While there is still minimal data on chronic pain relief regimens, meta-analyses and case reports have demonstrated the effectiveness and promising outcomes. This paper aims to evaluate the current medications and treatment options for managing refractory pain following TJA.

OS14.4.A The Neuroplastic Potential of the Human Brain before and After Glioma Surgery: Towards “Interventional Neurorehabilitation

Abstract INTRODUCTION The human brain is a highly neuroplastic ‘complex’ network: it self-organises without a hard blueprint, adapts to evolving circumstances, and can withstand insults. However, similar to other naturally occurring networks, brain networks can only endure a finite amount of damage before cognitive processes are affected. In this study, we first sought to establish the brain networks governing domain-general cognition (DGC) in healthy individuals across the lifespan. We then sought to map, track, and potentially rehabilitate networks governing DGC through connectomics and non-invasive brain stimulation (NIBS) when damaged by low-grade gliomas (LGG) and surgical oncology. METHODS Using MRI and cognitive data from n=629 individuals (aged 18–88, Female= 51%), we assessed the structural, functional, and topological relevance of the spatially-distributed multiple-demand (MD) system for DGC. Next, in n=17 patients undergoing glioma surgery, we longitudinally acquired connectomic and cognitive data at multiple time points: pre-surgery and post-surgery Day 1, Month 3, Month 12. In an independent cohort of n=34 patients, we sought to establish the safety profile for “interventional neurorehabilitation”: connectome-driven NIBS in the acute post-operative period to accelerate cognitive recovery. RESULTS In healthy individuals, the MD system across multiple scales of biological organisation was positively associated with higher-order cognition (Catell’s fluid intelligence). In our patients, pre-operative LGG infiltration into the structural MD system was negatively associated with the number of long-term cognitive deficits, suggesting a functional reorganisation. Mixed-effects modelling demonstrated the resilience of the functional MD system to infiltration and resection, while the early post-operative period was critical for effective neurorehabilitation. Graph analyses revealed increased perioperative modularity can distinguish patients with long-term cognitive improvements at one-year follow-up. Finally, NIBS within two weeks post-craniotomy had a 90% (n=31/34) recruitment rate into the trial. There were no seizures or serious complications due to NIBS in this patient population. Transient headaches and tingling were reported in a minority of patients. CONCLUSION For the first time, we elucidate long-term cognitive and network trajectories following LGG surgery while establishing a positive safety-profile for NIBS in the acute post-operative period. We argue that “mesoscale” brain mapping serves as a robust biomarker for intervention-related plasticity for future clinical trials. While we performed these experiments in the context of neurosurgery, connectomics and NIBS could be adopted across diverse neuro-oncological care pathways (i.e. chemotherapy/radiation).

Managing Perioperative Pain After Anterior Cruciate Ligament (ACL) Reconstruction: Perspectives from a Sports Medicine Surgeon.

Anterior cruciate ligament reconstructions (ACLR) are a relatively common procedure in orthopedic sports medicine with an estimated 130,000 arthroscopic operations performed annually. Most procedures are carried out on an outpatient basis, and though success rates of ACLR are as high as 95%, pain remains the most common postoperative complication delaying patient discharge, and thereby increasing the costs associated with patient care. Despite the success and relative frequency of ACLR surgery, optimal and widely accepted strategies and regimens for controlling perioperative pain are not well established. In recent years, the paradigm of pain control has shifted from exclusively utilizing opiates and opioid medications in the acute postoperative period to employing other agents and techniques including nerve blocks, intra-articular and periarticular injections of local anesthetic agents, NSAIDs, and less commonly, ketamine, tranexamic acid (TXA), sedatives, gabapentin, and corticosteroids. More often, these agents are now used in combination and in synergy with one another as part of a multimodal approach to pain management in ACLR, with the goal of reducing postoperative pain, opioid consumption, and the incidence of delayed hospital discharge. The purpose of this review is to consolidate current literature on various agents involved in the management of postoperative pain following ACLR, including the role of classically used opiate and opioid medications, as well as to describe other drugs currently utilized in practice either individually or in conjunction with other agents as part of a multimodal regimen in pain management in ACLR.

Postoperative Delirium: A Literature Review of Management in Intensive Care Unit

Perioperative delirium is a wide-ranging problem that directly affects primary clinical results. The anesthesiologist must understand how to define and diagnose delirium, identify patients at high risk of delirium, identify predisposing factors to adjust the care plan appropriately, and manage delirium in the acute postoperative period. Delirium is an organ dysfunction in critically ill patients, independently associated with improved morbidity. Research on delirium in hospitalized patients (including critically ill patients) has increased exponentially in the last decade. This study emphasizes the need for a mechanistic explanation of delirium to help advance the research that ultimately leads to its prevention and treatment. In this study, multinational and multidisciplinary clinicians, and researchers from the fields of critical care medicine, psychiatry, anesthesiology, neurology, and pharmacy sought to collaborate in the management of delirium in the intensive care unit (ICU).

The most effective local infiltration analgesic (LIA) in reducing overall opioid use and nausea in the acute postoperative period of shoulder arthroplasty patients; a prospective, double-blind, randomized observational study

IntroductionEffective pain management in the immediate postoperative period is a crucial first step in the treatment of shoulder arthroplasty patients. Previous studies suggested that local infiltrative analgesia (LIA), specifically with Liposomal Bupivacaine (LB), is equivalent to interscalene nerve block (ISNB) for postoperative pain management. This prospective, randomized, double-blinded study seeks to measure the difference in efficacy between the 3 widely-used LIA cocktail formulations: Bupivacaine, LB, and Ropivacaine. MethodsBetween 2018 and 2019, 179 consecutive patients underwent reverse total shoulder arthroplasty for end-stage shoulder arthropathy. Patients were enrolled and randomized in a prospective, double-blind clinical trial to receive one of 3 LIA injections before skin incision and after skin closure: 0.25% Bupivacaine ±Epinephrine, 1.3% LB, or 0.5% Ropivacaine cocktail with Ketorolac. There were 67 patients excluded due to preoperative comorbidities or consent refusal. The eligible 112 patients were monitored for 24 hours after surgery. Mean age was 67.9 years (range: 40-90 years). The primary outcome measure was the mean preoperative Visual Analog Scale (VAS) pain score, mean postoperative VAS score during the 24-hour postoperative period, and change in mean VAS score. The secondary outcome measure was total Morphine Milligram Equivalents (MMEs) used, antiemetic use, and laxative use during the same period. Pre-hoc power analysis found a total sample size of 219 (73 per group) was estimated to detect a significant difference at 80% power and 0.05 Type I error rate. ResultsUse of Bupivacaine, LB, and Ropivacaine resulted in 1.2±2.9, 0.6±3.2, and 0.1±2.8 change in VAS scores, respectively (P=.32). Total postoperative MMEs used were 124.1±115.1, 116±84.5, and 105±96.7 milligrams, respectively (P=.71). There were no statistically significant differences amongst the 3 cocktails for postoperative pain relief or rate of antiemetic/laxatives used.There was a nonsignificant trend toward superior analgesic effect of Ropivacaine compared to Bupivacaine. Ad-hoc power analysis found that the estimated sample sizes required to detect a difference between the Ropivacaine and Bupivacaine treatment for change in VAS score and total MMEs use, were 321 and 1593 patients, respectively. Because of the non-clinically significant differences, continued patient enrollment was terminated. The cost of Bupivacaine was comparable to Ropivacaine ($13.43 and $21.95, respectively), whereas LB cost ($434.96) was 20-30 times higher. ConclusionThere were no differences in clinical efficacy amongst Bupivacaine, LB, and Ropivacaine cocktails for perioperative pain management in shoulder arthroplasty. LB was not clinically advantageous compared to the other two medications and did not justify the increase in cost. Level of EvidenceLevel I; Randomized, Controlled Trial

28. Does loss of spondylolisthesis reduction impact clinical and radiographic outcomes after minimally invasive transforaminal lumbar interbody fusion?

<h3>BACKGROUND CONTEXT</h3> Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is the workhorse minimally invasive treatment for patients with degenerative lumbar stenosis and spondylolisthesis refractory to nonoperative care. While the basic tenets of surgical treatment do not differ between minimally invasive and open techniques, surgeons performing MI-TLIF are more likely to attempt reduction of spondylolisthesis in order to optimize restoration of canal dimensions due to a greater reliance on indirect decompression, which has been shown to be effective. While intraoperative reduction is often successful, postoperative loss of reduction and slip recurrence can be seen. <h3>PURPOSE</h3> To determine the rate and clinical impact of slip recurrence after MI-TLIF with expandable cage technology. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> Patients undergoing MI-TLIF for degenerative spondylolisthesis using an articulating, expandable cage <h3>OUTCOME MEASURES</h3> Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) for back/leg pain, Short Form-12 (SF-12) and PROMIS Physical Function (PF) <h3>METHODS</h3> Patients undergoing MI-TLIF for degenerative spondylolisthesis using articulating, expandable cages from 2017-2019 were retrospectively studied. Lateral radiographs were reviewed and evaluated for the presence or absence of spondylolisthesis preoperatively, intraoperatively, and at follow-up times including 2 weeks, 6 weeks, 12 weeks, 6 months and 1-year postoperatively. Spondylolisthesis was measured from the posterior inferior corner of the cephalad vertebra to the posterior superior corner of the caudal vertebral, with any measurement >1mm classified as spondylolisthesis, and Meyerding grade was noted. Intraoperative reduction was measured and loss of reduction was defined as >1mm increase in spondylolisthesis comparing follow-up imaging to intraoperative films. PROMs were recorded at the preoperative and follow-up time points. Fusion was assessed 1-year postoperatively via CT. <h3>RESULTS</h3> A total of 63 patients and 70 levels were included, with mean age 59.8 years (SD,13.8). Nineteen levels (27.1%) had complete reduction intraoperatively, 40 (57.1%) had partial reduction and 11 (15.7%) had no reduction. Of the 30 levels with loss of reduction (50.8%), 20 (66.7%) occurred by 2 weeks postoperatively and 28 (93.3%) occurred by 12 weeks postoperatively. At 6 months, there were significant differences between those who had loss of reduction and those who did not in VAS back pain (3.0 vs 0.9, p=0.017) and SF-12 PCS (41.5 vs 50.0, p=0.035), but no differences were found between the groups for any instruments at any other time points. The overall fusion rate was 89.5% (34/38) at 1 year postoperatively. There was no significant difference in fusion rate between the loss of reduction (16/18) and no loss of reduction (18/20) groups. Patients with loss of reduction had no difference in reoperation rate (1/28) compared to those without loss of reduction (2/24). <h3>CONCLUSIONS</h3> While a majority of patients demonstrated reduction intraoperatively, 51% had loss of reduction, most commonly in the acute postoperative period. There were few differences in PROMs between patients who had loss of reduction and those who did not, suggesting that radiographic loss of reduction after MI-TLIF in the setting of degenerative spondylolisthesis may not be clinically meaningful. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

RADI-08. Elucidating the Electrophysiology of Intraoperative Radiotherapy – Experience from Two Cases

Brain metastases require multimodality treatment, often combining surgical resection, radiation therapy, and individualized systemic pharmacotherapy based on oncogenic drivers. Intraoperative radiation therapy (IORT) is an emerging treatment option where radiation is delivered directly to the resection cavity at the time of surgery. We present two patients who underwent electrocorticography (ECoG) during IORT, providing information regarding electrophysiologic safety and tolerability of the technique.In the first case, a 65-year-old woman underwent resection of a hemorrhagic right occipital metastasis from non-small cell lung cancer. IORT was administered over sixteen minutes for a surface dose of 30 Gy.In the second case, a 73-year-old man with underwent resection of a right posterior frontal metastasis from non-small cell lung cancer. IORT was delivered over eleven minutes for a surface dose of 30 Gy.In both cases, a 1x6 contact array of subdural electrodes was placed adjacent to the planned field of radiation. Electrocortigraphy (HFF 70 Hz, TC 0.3 sec, sensitivity 150uV/mm) was obtained from the array two minutes prior to initiation of therapy, during therapy, and two minutes after completion of therapy in both cases. We found that IORT did not induce electrophysiological change in the tissue surrounding it in both cases with no epileptiform or ictal discharges during 20 minutes of ECoG recording around the time radiation therapy, nor did the patients have episodes suggestive of epileptic seizures in the acute post-operative period. One of the patients (case 1) experienced a single epileptic seizure 4 months after IORT, but this was temporally related to a new intraparenchymal hemorrhage and unlikely due to radiation therapy. These two cases illustrate the relative safety of IORT with respect to induction of immediate epileptiform changes within the brain parenchyma.

Early aseptic reoperation after shoulder arthroplasty increases risk of subsequent prosthetic joint infection.

BackgroundDespite the success of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), the clinical course of some patients necessitates operative intervention in the acute postoperative period. In this study, we evaluate the risk of subsequent prosthetic joint infection (PJI) in patients who undergo an aseptic reoperation within 90 days of primary shoulder arthroplasty.MethodA retrospective review of patients with primary TSA and RSA was performed using a commercially available national database (PearlDiver Inc., Fort Wayne, IN, USA). Queries were performed with use of International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Technology codes. Patients were divided into cohorts based on undergoing aseptic reoperation, reoperation for PJI, or no reoperations within 90 days of index procedure. Primary outcome was subsequent PJI within 1 year of index procedure. Observed PJI rates were compared using chi-square analysis. Risk factors for PJI were compared using logistic regression.ResultsFrom 2010 to 2018, a total of 96,648 patients underwent primary shoulder arthroplasty: 46,810 underwent TSA and 49,838 underwent RSA. The rate of aseptic reoperation within 90 days was 0.72% and 1.5% in the TSA and RSA cohorts, respectively. At 1 year postoperatively, patients who underwent an aseptic reoperation within 90 days had an elevated risk of subsequent PJI compared with the overall rate of PJI in the TSA (3.54% vs. 0.75%; P < .001) and RSA (3.08% vs. 0.73%; P < .001) cohorts. On multivariate logistic regression analysis, aseptic reoperation within 90 days was identified as a significant risk factor for subsequent PJI in the TSA cohort (odds ratio, 14.19; P < .001) and RSA cohort (odds ratio, 8.38; P < .001). The most common indication for aseptic reoperation was postoperative prosthetic joint instability in both the TSA (31%) and RSA (49%) cohorts.ConclusionAseptic reoperation within 90 days of primary TSA or primary RSA was associated with a notably increased risk of subsequent PJI.

Partial Flap Loss in Gender Affirming Phalloplasty.

Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

Pain Catastrophizing Throughout the Perioperative Period in Adolescents With Idiopathic Scoliosis.

Objectives:Pain catastrophizing in children and adolescents has been associated to unfavorable postsurgical outcomes. However, pain catastrophizing is rarely measured throughout the perioperative period. Using a prospective longitudinal approach, the present study aimed to identify how pain catastrophizing changes over the perioperative period in pediatric surgical patients with adolescent idiopathic scoliosis.Materials and Methods:Adolescent patients undergoing spinal fusion surgery completed the Pain Catastrophizing Scale for Children and additional questionnaires to assess pain intensity, state and trait anxiety, and kinesiophobia before surgery, and 1, 2, 5 days, 6 weeks, and 6 months after surgery.Results:Patients who had higher levels of pain catastrophizing before surgery were more likely to be anxious, avoid activity that may cause pain, report higher pain intensity before surgery and anticipate more pain after surgery. Low pain catastrophizers increased into a moderate level of pain catastrophizing before decreasing after discharge from the hospital. Meanwhile, moderate and high pain catastrophizers both decreased into lower and moderate levels of catastrophizing, respectively, after discharge from the hospital.Discussion:These findings demonstrate that pain catastrophizing in adolescents changes over the perioperative period. Observing changes in pain catastrophizing throughout the perioperative period may help in recognizing when patients are most vulnerable during this time. Decreasing pain catastrophizing before surgery or in the acute postoperative period through therapies that target pain catastrophizing may help reduce the patient’s likelihood of experiencing unfavorable postoperative outcomes.

Early Use of Blood Flow Restriction Training with Low-Intensity Exercises following Anterior Cruciate Ligament Reconstruction Improves Quadriceps Strength and Post-Operative Pain: A Randomized Controlled Trial

Objectives:Blood flow restriction therapy (BFRT) has been proposed as a method to enhance rehabilitation following anterior cruciate ligament reconstruction (ACLR). However, a paucity of data exists to support the use of BFRT in clinical practice. The purpose of this study is to determine if early application of BFRT, used with low-weight therapy exercises, increases quadriceps strength, and functional outcomes following ACLR compared to a traditional rehabilitation protocol without BFRT.Methods:Twenty-six patients undergoing ACLR were randomized to receive either: (1) a traditional rehabilitation program (n=14), or (2) a modified program using BFRT with low-weight (20-50% of 1-repetition maximum) exercises (n=12). Two patients crossed over from the control to BFRT groups. An as treated analysis was performed for biweekly measurements in the acute postoperative period of range of motion (ROM), thigh circumference, and terminal knee extension (TKE) strength. Circumference and TKE strength were analyzed as a percentage of the contralateral side. VAS and IKDC scores were assessed preoperatively and during the first 12 weeks postoperatively.Results:Compared to the control group, the BFRT patients demonstrated significantly greater TKE strength at week 8 (68.3% vs. 82.7%, p = 0.022), week 10 (69.0% vs. 82.8%, p = 0.044), and week 12 (64.4% vs. 84.2%, p = 0.002) , as well as greater overall change in TKE strength from week 3 to 12 (8.3% vs 24.4%, p = 0.044). The BFRT group reported significantly lower VAS values at week 6 (2.5 vs. 0.6, p = 0.041), though scores were similar at week 12 (0.9 vs. 1.0, p = 0.912).There was no significant difference for knee ROM, thigh circumference, or IKDC scores at any time point.Conclusions:In comparison to a traditional rehabilitation protocol following ACLR, BFRT used in conjunction with low-weight exercises during the acute postoperative period was associated with significantly lower VAS scores at week 6, as well as greater quadriceps strength at 8, 10, and 12 weeks. These results suggest that BFRT may accelerate rehabilitation after ACLR, though future studies are needed to assess long-term outcomes.

Does loss of spondylolisthesis reduction impact clinical and radiographic outcomes after minimally invasive transforaminal lumbar interbody fusion?

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a common operative approach to address degenerative lumbar stenosis and spondylolisthesis which has failed nonoperative care. Compared to open TLIF, MI-TLIF relies to a greater extent on indirect decompression resulting in a heightened awareness of spondylolisthesis reduction among MI surgeons. To what extent intraoperative reduction is achieved as well as the rate and clinical impact of loss or reduction and slip recurrence remain unknown. To determine the rate and clinical impact of slip recurrence after MI-TLIF with expandable cage technology STUDY DESIGN/SETTING: Retrospective Cohort Study PATIENT SAMPLE: Patients undergoing MI-TLIF for degenerative spondylolisthesis using an articulating, expandable cage OUTCOME MEASURES: Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) for back/leg pain, Short Form-12 (SF-12), and PROMIS Physical Function (PF) METHODS: Patients undergoing MI-TLIF for degenerative spondylolisthesis using articulating, expandable cages from 2017 to 2019 were retrospectively studied. Lateral radiographs were reviewed and evaluated for the presence or absence of spondylolisthesis preoperatively, intraoperatively, and at follow-up times including 2 weeks, 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Spondylolisthesis was measured from the posterior inferior corner of the cephalad vertebra to the posterior superior corner of the caudal vertebra, with any measurement >1 mm classified as spondylolisthesis, and Meyerding grade was noted. Intraoperative reduction was measured, and loss of reduction was defined as >1 mm increase in spondylolisthesis comparing follow-up imaging to intraoperative films. PROMs were recorded at the preoperative and follow-up time points. Fusion was assessed at 1 year postoperatively via CT. A total of 63 patients and 70 levels were included, with mean age 59.8 years (SD,13.8). 19 levels (27.1%) had complete reduction intraoperatively, 40 (57.1%) had partial reduction, and 11 (15.7%) had no reduction. Of the 30 levels with loss of reduction (50.8%), 20 (66.7%) occurred by 2 weeks postoperatively and 28 (93.3%) occurred by 12 weeks postoperatively. At 6 months, there were significant differences between those who had loss of reduction and those who did not in VAS back pain (3.0 vs. 0.9, p=.017) and SF-12 PCS (41.5 vs. 50.0, p=.035), but no differences were found between the groups for any instruments at any other time points. The overall fusion rate was 82.1% (32/39) at 1 year postoperatively. There was no significant difference in fusion rate between the loss of reduction (16/20) and no loss of reduction (20/23) groups. Patients with loss of reduction had no difference in reoperation rate (1/28) compared to those without loss of reduction (2/24). While a majority of patients demonstrated reduction intraoperatively, 51% had loss of reduction, most commonly in the acute postoperative period. There were few differences in PROMs between patients who had loss of reduction and those who did not, suggesting that radiographic loss of reduction after MI-TLIF in the setting of degenerative spondylolisthesis may not be clinically meaningful.

Direct Clipping of Paraclinoid Aneurysm in Conjunction with Extradural Anterior Clinoidectomy: Technical Nuance and Functional Outcome.

Objective Because of their anatomical features, treatment for paraclinoid aneurysms has remained to be challenging. Thus, the aim of this report is to prove the validity of our surgical method for unruptured paraclinoid aneurysms, together with surgical videos. Study Design Between August 2017 and November 2019, we were able to perform surgical clipping for 11 patients with unruptured paraclinoid aneurysm using a completely unified method. This study investigated the effect of surgery on multiple measures, including visual impairment, brain contusion, temporalis muscle atrophy, and multiple neurocognitive functions. Results Of the 67 unruptured aneurysms treated at our hospital, 17 were identified to be paraclinoid aneurysm, and 11 of them were treated by direct clipping using anterior clinoidectomy. Three were ophthalmic artery aneurysms, three were superior hypophyseal artery aneurysms, and five were anterior carotid wall aneurysms without branch projection. Only one patient had asymptomatic mild enlargement of the Marriott blind spots postoperatively. No brain contusion and temporalis muscle atrophy were observed in any cases. Only the Trail Making test (TMT) showed a significant worsening in the acute postoperative period: mean pre- and postoperative TMT scores were 59.1 ± 29.1 and 72.7 ± 37.3 for Part A ( p = 0.018) and 80.5 ± 35.5 and 93.8 ± 39.9 for Part B ( p = 0.030), respectively. However, it improved in the chronic phase. Conclusion We can conclude that our surgical method is safe and can be considered an acceptable treatment. Although surgical stress can cause temporary executive dysfunction shortly after surgery, this decline is temporary.