Failure Of Nonoperative Management Research Articles

Not All Proximal Humerus Fractures Do Well Without Surgery: Anterior Translation Predicts the Need for Surgery.

To evaluate the effect of translation on a large series of low energy proximal humerus fractures initially treated nonoperatively. Retrospective multicenter analysis. 5 level-one trauma centers. 210 Patients (152F;58M) average age 64 with 112 left and 98 right sided low energy proximal humerus fractures (OTA/AO 11-A-C). All patients were initially treated nonoperatively and were followed for an average 231 days. Radiographic translation in the sagittal and coronal planes was measured. Patients with anterior translation were compared to those with posterior or no translation. Patients with ≥80% anterior humeral translation were compared to those with < 80% anterior translation, including those with no or posterior translation. The primary outcome was failure of nonoperative treatment resulting in surgery and the secondary outcome was symptomatic malunion. Nine patients (4%) had surgery, 8 for nonunion and 1 for malunion. All 9 patients (100%) had anterior translation. Anterior translation as compared with posterior or no sagittal plane translation was associated with failure of nonoperative management requiring surgery (p = 0.012). Additionally, of those with anterior translation, having ≥80% anterior translation as compared with < 80% was also associated with surgery (p = 0.001). Finally, 26 patients were diagnosed with symptomatic malunion, of whom translation was anterior in 24 and posterior in 2 (p = 0.0001). In a multicenter series of proximal humerus fractures anterior translation of >80% was associated with failure of nonoperative care resulting in non-union, symptomatic malunion, and potential surgery.

Comparison between level 1 and level 2 trauma centers for the management of splenic blunt trauma

IntroductionThe management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management. MethodsA retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy. Results181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04–0.49 CI 95%, P < .01). ConclusionBoth level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs.

There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis.

Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP). Retrospective analysis of the Nationwide Readmissions Database (2017). All frail geriatric (65 years or older) patients with ABP were included. Patients were grouped by treatment at index admission: CCY vs NOM with endoscopic retrograde cholangiopancreatography. Propensity score matching was performed in a 1:2 ratio. Primary outcomes were 6-month readmissions, mortality, and length of stay. Secondary outcomes were 6-month failure of NOM defined as readmission for recurrent ABP, unplanned pancreas-related procedures, or unplanned CCY. Subanalysis was performed to compare outcomes of unplanned CCY vs early CCY. A total of 29,130 frail geriatric patients with ABP were identified and 7,941 were matched (CCY 5,294; NOM 2,647). Patients in the CCY group had lower 6-month rates of readmission for pancreas-related complications, unplanned readmissions for pancreas-related procedures, overall readmissions, and mortality, as well as fewer hospitalized days (p < 0.05). NOM failed in 12% of patients and 7% of NOM patients were readmitted within 6 months to undergo CCY, of which 56% were unplanned. Patients who underwent unplanned CCY had higher complication rates and hospital costs, longer hospital lengths of stay, and increased mortality compared with early CCY (p < 0.05). For frail geriatric patients with ABP, early CCY was associated with lower 6-month rates of complications, readmissions, mortality, and fewer hospitalized days. NOM was unsuccessful in nearly 1 of 7 within 6 months; of these, one-third required unplanned CCY. Early CCY should be prioritized for frail geriatric ABP patients when feasible.

Variation in the management of adhesive small bowel obstruction in the Netherlands: a prospective cross-sectional study.

ASBO is a frequent abdominal surgical emergency and a leading cause of morbidity and mortality in emergency surgery. The aim of this study is to provide insight into the current management of adhesive small bowel obstruction (ASBO) and associated outcomes. A nationwide prospective cross-sectional cohort study was conducted. All patients with clinical signs of ASBO admitted to participating Dutch hospitals were included during a 6 months inclusion period between April 2019 and December 2020. Ninety-day clinical outcomes were described and compared for nonoperative management (NOM) and laparoscopic and open surgery. In 34 participating hospitals, 510 patients were included, of whom 382 (74.9%) had a definitive diagnosis of ASBO. Initial management consisted of emergency surgery in 71 (18.6%) patients and NOM in 311 (81.4%) patients, 119 (31.1%) of whom required delayed surgery after failure of NOM. Surgical interventions started laparoscopically in 51.1%, of which 36.1% were converted to laparotomy. Intentional laparoscopy resulted in shorter hospital stays compared with open surgery (median 8.0 vs. 11.0 days; P <0.001) and comparable hospital mortality (5.2 vs. 4.3%; P =1.000). Oral water-soluble contrast use was associated with a decreased length of stay ( P =0.0001). Hospital stay for surgical patients was shorter in patients who were operated on within 72h of admission ( P <0.001). This nationwide cross-sectional study demonstrates shorter hospital stay in ASBO patients who received water-soluble contrast, were operated within 72h of admission or were operated with minimally invasive techniques. Results may support the standardization of ASBO treatment.

Risk Factors for Early Failure of Non-operative Management of Degenerative Rotator Cuff Tears

Risk Factors for Early Failure of Non-operative Management of Degenerative Rotator Cuff Tears

Patients Aged >50 Years With Anterior Shoulder Instability Have a Decreased Risk of Recurrent Dislocation After Operative Treatment Compared With Non-Operative Treatment

To compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first-time anterior shoulder dislocation after the age of 50 years. An established geographic medical record system was used to identify patients who experienced a first-time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi-square tests and survivorship curves were generated using Kaplan-Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment. 179 patients were included with a mean follow-up of 11 years. 14% (n= 26) underwent early surgery within 3 months and 86% (n= 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full-thickness rotator cuff tears (82% vs 55%; P= .01), labral tears (24% vs 8.0%; P= .01), and humeral head fracture (23% vs 8.5%; P= .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate-severe pain (19% vs 17%; P= .78) and frozen shoulder (8 vs 9%, respectively; P= .87) at final follow-up. Although nerve palsy (19% vs 8%; P= .08) and progression to osteoarthritis (20% vs 14%; P= .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P= .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent (n= 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01). Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow-up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery. Level III, retrospective cohort study.

Initial Displacement of Humeral Shaft Fractures is Associated with Failure of Nonoperative Management.

To determine if the initial radiographic displacement of humeral shaft fractures is associated with failure of nonoperative management. Retrospective cohort study. Urban level 1 trauma centerPatients/Participants: 106 patients with humeral shaft fractures (OTA/AO 12) initially managed nonoperatively. Functional bracing. Failure of nonoperative management, defined as conversion to surgery, malunion, delayed union/nonunion. Nonoperative management failed in 33 (31%) of 106 included patients with 27 (25%) patients requiring surgery. On multivariate analysis, female gender (odds ratio (OR): 3.50, 95% confidence interval (CI): 1.09 to 11.21), American Society of Anesthesiologist classification >1 (OR: 7.16, CI: 1.95 to 26.29), initial fracture medial/lateral (ML) translation (OR: 1.09, CI: 1.01 to 1.17, per unit change), and initial fracture anterior-posterior (AP) angulation (OR: 1.09, CI: 1.02 to 1.15, per unit change) were independently associated with failure of nonoperative management. Initial fracture displacement values that maximized the sensitivity (SN) and specificity (SP) for failure included an AP angulation >11° (SN 75%, SP 64%) and ML translation >12 mm (SN 55%, SP 75%). The failure rate in patients with none, one, or both of these fracture parameters was 3.1% (1/32), 35.6% (20/56), and 66.6% (12/18), respectively. Nearly one-third of patients experienced failure of initial nonoperative management. Failure was found to be associated with greater initial fracture AP angulation and ML translation. Fracture displacement cutoff values were established that may be used by surgeons to counsel patients with these injuries. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

CLINICAL STUDY ON CONSERVATIVE MANAGEMENT OF BLUNT SPLENIC INJURY

Background: Spleen is the most common intra-abdominal organ to be injured in blunt abdominal trauma and currently most cases are treated nonoperatively. Aim of this study was to evaluate the efcacy of Non-Operative Management (NOM) of blunt splenic injury and to point out the predictors of failure of NOM. Methods: Over a 12 month period (June 2021- May 2022), 16 hemodynamically stable patients with blunt splenic injury admitted in Department of General Surgery in Silchar Medical College and Hospital were evaluated prospectively. Association of various factors were analysed using SPSS statistical software version 22 to nd out efcacy of NOM as well as to point out predictors of NOM. Results: NOM was successful in 81.3% of patients and 18.8% were converted to operative management (NOM failure). Statistical analysis showed that Systolic BP and Haemoglobin at the time of admission, Number of blood transfused, Injury Severity Score (ISS), USG nding of grade of hemoperitoneum, American Association for Surgery of Trauma (AAST) grade of splenic injury, Duration of hospital stay were signicantly associated with the outcome of NOM success (P value &lt; 0.05). Age, Sex, Mode of injury, Pulse rate at the time of admission had no signicant relation with the outcome. AASTgrade IV splenic injury or higher, Massive hemoperitoneum, ISS &gt; 25, Haemoglobin &lt;8 gm%, Requirement of 4 or more units of blood and New-onset hemodynamic instability were independent predictors of failure of conservative management. Conclusion: Conservative management of blunt splenic injury is safe and effective as long as patients are selected based on strict inclusion/exclusion criteria

Concurrent SARS-COV-19 and acute appendicitis: Management and outcomes across United States children's hospitals.

Nonoperative management of acute appendicitis is a safe and effective alternative to appendectomy, though rates of treatment failure and disease recurrence are significant. The purpose of this study was to determine whether COVID-19-positive children with acute appendicitis were more likely to undergo nonoperative management when compared to COVID-19-negative peers and to compare clinical outcomes and healthcare use for these groups. A retrospective cohort study of children <18 years with acute appendicitis across 45 US Children's Hospitals during the first 12 months of the COVID-19 pandemic was performed. Operative management was defined as appendectomy or percutaneous drain placement, whereas nonoperative management was defined as admission with antibiotics alone. Multivariable hierarchical logistic regression using an exact matched cohort was used to determine the association between COVID-19 positivity and nonoperative management. The secondary outcomes included intensive care unit admission, mechanical ventilation, length of stay, nonoperative management failure rates, and hospital variation in nonoperative management. Of 17,481 children in the cohort, 581 (3.3%) were positive for COVID-19. The odds of nonoperative management was significantly higher in the COVID-19-positive group (adjusted odds ratio [95% confidence interval]: 13.4 [10.7-16.8], P < .001). Patients positive for COVID-19 had increased odds of intensive care unit admission (adjusted odds ratio [95% confidence interval]: 3.78 [2.01-7.12], P < .001) and longer length of stay (median 2 days vs 1 day, P < .001). Hospital rates of nonoperative management ranged from 0% to 100% for COVID-19-positive patients and 0% to 42% for COVID-19-negative patients. Children with concurrent acute appendicitis and COVID-19 positivity are significantly more likely to undergo nonoperative management. Both groups experience infrequent nonoperative management failure rates and rare intensive care unit admissions. Marked hospital variability in nonoperative management practices was demonstrated.

Treating acute diverticulitis in pre- and post-solid-organ transplant patients: a single-institution cohort study.

Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent. Transplant recipients form a subcategory among the immunosuppressed with unique challenges. The aim of this work is to report 30-day postoperative complications after colectomy for acute diverticulitis and success rates of nonoperative management in pre- and post-transplant patients. This is a retrospective cohort study at a single-institution tertiary referral centre. Patients with a history of acute diverticulitis were extracted from a database of 6152 recipients of solid-organ abdominal transplant between 2000 and 2015 and stratified by the index episode of diverticulitis: before or after solid-organ transplant surgery. Outcomes included 30-day postoperative complications and failure of nonoperative management. Acute diverticulitis occurred in 93 patients, 69 (74%) posttransplant. Postcolectomy complications were higher posttransplant than pretransplant (43% vs. 13%, p= 0.04). Posttransplant status was not an independent risk factor for complications (odds ratio 3.59, 95% CI 0.79-16.31) when adjusting for sex and surgical acuity. Immediate urgent colectomy (29% vs. 31%, p= 0.84) and failure of nonoperative management (7% vs. 9%, p= 0.82) were similar. Complications occurred equally in those requiring urgent colectomy after nonoperative management and those undergoing immediate urgent colectomy. Urgent colectomy rates are similar in solid-organ abdominal transplant recipients pre- and posttransplant. Posttransplant complication rates appear to be increased but transplant status as an independent factor is not significantly associated with an increased risk in this study cohort. These findings should be considered when counselling patients on the relative risks and benefits of surgical intervention for diverticulitis before versus after solid-organ transplantation.

The L3 Flexion Angle Predicts Failure of Non-Operative Management in Patients with Tandem Spondylolithesis.

Retrospective cohort study. Determine impact of standard/novel spinopelvic parameters on global sagittal imbalance, health-related quality of life (HRQoL) scores, and clinical outcomes in patients with multi-level, tandem degenerative spondylolisthesis (TDS). Single institution analysis; 49 patients with TDS. Demographics, PROMIS and ODI scores collected. Radiographic measurements-sagittal vertical axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, sagittal L3 flexion angle (L3FA) and L3 sagittal distance (L3SD). Stepwise linear multivariate regression performed using full length cassettes to identify demographic and radiographic factors predictive of aberrant SVA (≥5cm). Receiver operative curve (ROC) analysis used to identify cutoffs for lumbar radiographic values independently predictive of SVA ≥5cm. Univariate comparisons of patient demographics, (HRQoL) scores and surgical indication were performed around this cutoff using two-way Student's t-tests and Fisher's exact test for continuous and categorical variables, respectively. Patients with increased L3FA had worse ODI (P = .006) and increased rate of failing non-operative management (P = .02). L3FA (OR 1.4, 95% CI) independently predicted of SVA ≥5cm (sensitivity and specifity of 93% and 92%). Patients with SVA ≥5cm had lower LL (48.7 ± 19.5 vs 63.3 ± 6.9mm, P < .021), higher L3SD (49.3 ± 12.9 vs 28.8 ± 9.2, P < .001) and L3FA (11.6 ± 7.9 vs -3.2 ± 6.1, P < .001) compared to patients with SVA ≤5cm. Increased flexion of L3, which is easily measured by the novel lumbar parameter L3FA, predicts global sagittal imbalance in TDS patients. Increased L3FA is associated with worse performance on ODI, and failure of non-operative management in patients with TDS.

Paper 24: Osteochondritis Dissecans of the Capitellum of the Elbow: A Comparison of Non-Operative and Surgical Outcomes at Long-Term Follow-up

Objectives: Osteochondritis dissecans (OCD) of the humeral capitellum is an often painful condition that typically affects the adolescent athlete. There is little consensus on treatment and a scarcity of long-term outcomes data. The purpose of this study was to (1) report the long-term outcomes associated with both operative and non-operative management of capitellar OCD, (2) identify factors associated with failure of non-operative management, and (3) determine whether delay in surgery affects final outcomes. Methods: All patients diagnosed with OCD of the capitellum from 1995-2020 within a defined geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. Surgical treatment was considered delayed if it occurred more than 6 months after symptom onset. Results: A total of 50 elbows with a mean follow-up of 9.4 years were included. Of these, 7 (14%) were treated non-operatively and never underwent surgery during follow-up, while 43 (86%) underwent surgical intervention: 27 had early surgery and 16 underwent delayed surgery after ≥ 6 months of non-operative treatment. When compared to non-operative management, surgical management resulted in superior MEPI scores (90 vs 83, p=0.05), decreased persistence of mechanical symptoms (9% vs 50%, p&lt;0.01), and better elbow flexion (141° vs 131°, p=0.01) at long-term follow up. Older patients had a trend toward increased failure of non-operative management (p=0.06). The presence of an intra-articular loose body strongly predicted failure of non-operative management (p=0.01; OR 13). Plain radiography and MRI had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes following early versus delayed surgical management were not demonstrated. Conclusions: Patients with capitellar OCD initially treated nonoperatively failed nonoperative management 70% of the time. Elbows that did not undergo surgery had slightly increased symptoms and decreased functional outcomes compared to those treated surgically. In this cohort, the greatest predictors for failure of non-operative treatment were older age and presence of a loose body; however, an initial trial of non-operative treatment did not adversely impact the success of future surgery at long term follow-up. [Table: see text][Table: see text][Table: see text][Table: see text]

Osteochondritis Dissecans of the Capitellum of the Elbow: Improved Outcomes in Surgically Treated Versus Nonoperatively Treated Patients at Long-Term Follow-up

To (1) report the long-term outcomes associated with both operative and nonoperative management of capitellar osteochondritis dissecans (OCD), (2) identify factors associated with failure of nonoperative management, and (3) determine whether delay in surgery affects final outcomes. All patients who received a diagnosis of capitellar OCD from 1995-2020 within a geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. The cohort was divided into 3 groups: (1) nonoperative management, (2) early surgery, and (3) delayed surgery. Delayed surgery (surgery ≥6 months after symptom onset) was considered failure of nonoperative management. Fifty elbows with a mean follow-up period of 10.5 years (median, 10.3 years; range, 1-25 years) were studied. Of these, 7 (14%) were definitively treated nonoperatively, 16 (32%) underwent delayed surgery after at least 6 months of failed nonoperative treatment, and 27 (54%) underwent early surgical intervention. When compared with nonoperative management, surgical management resulted in superior Mayo Elbow Performance Index pain scores (40.1 vs 33, P= .04), fewer mechanical symptoms (9% vs 50%, P < .01), and better elbow flexion (141° vs 131°, P= .01) at long-term follow-up. Older patients trended toward increased failure of nonoperative management (P= .06). The presence of an intra-articular loose body predicted failure of nonoperative management (P= .01; odds ratio, 13). Plain radiography and magnetic resonance imaging had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes after early versus delayed surgical management were not observed. Nonoperative management of capitellar OCD failed 70% of the time. Elbows that did not undergo surgery had slightly more symptoms and decreased functional outcomes compared with those treated surgically. The greatest predictors of failure of nonoperative treatment were older age and presence of a loose body; however, an initial trial of nonoperative treatment did not adversely impact the success of future surgery. Level III, retrospective cohort study.

Patient Satisfaction and Pain Relief After Deep Peroneal Nerve Neurectomy for Midfoot Arthritis: A Preliminary Short Report.

The deep peroneal nerve (DPN) plays a role in afferent nociceptive dorsal midfoot joint pain perception. DPN neurectomy for treatment of symptomatic dorsal midfoot osteoarthritis allows early mobilization and weightbearing. The purpose of our study was to evaluate the patient satisfaction and pain relief after DPN neurectomy for treatment of chronic dorsal midfoot pain due to osteoarthritis. In this retrospective, IRB-approved, questionnaire-based study, we evaluated 48 patients (55 feet) with an average follow-up of 35.1 (range, 16-51) months who underwent DPN neurectomy at our institution between September 2017 and February 2021. There were 38 women and 10 men, 41 unilateral (22 right, 19 left) and 7 bilateral procedures, with an average age of 67.8 (range, 35-88) years at the time of surgery. A questionnaire that included questions regarding postsurgical dorsal midfoot pain relief, surgical result satisfaction, and current functional limitations was administered via telephone. Demographic information, patient responses, and complications were recorded. Of the 48 patients, 80.8% were satisfied with the result of the surgery in relieving their dorsal midfoot pain, 84.6% would repeat the surgery under the same circumstances, 83.8% would recommend the surgery to a friend, 10.4% reported they wish they had undergone arthrodesis, 91.7% reported pain relief in the first 6 months, and 55.6% reported current activity limitations. Six feet (10.9%) underwent a second procedure with an average postoperative time of 20.5 (range, 1-36) months. Complications included 1 hematoma and deep wound infection, 1 DPN neuroma and superficial peroneal nerve entrapment, and 4 patients with inadequate pain relief. In this cohort, DPN neurectomy appeared to be a reasonable surgical alternative to arthrodesis for the management of chronic dorsal midfoot pain due to midfoot osteoarthritis after failed nonoperative management. Level IV, retrospective case series.

Risk Factors for Failure of Nonoperative Management in Children With Ileocolic Intussusception.

Zouari, Mohamed MD; Ben Ameur, Hana MD; Ben Saad, Nesrine MD; Rhaiem, Wiem MD; Ben Ayed, Maha MD; Mhiri, Riadh MD Author Information

Predictors of Nonoperative Management Failure and Recurrence in Adults with Acute Appendicitis: A Single-Center Retrospective Study

Predictors of Nonoperative Management Failure and Recurrence in Adults with Acute Appendicitis: A Single-Center Retrospective Study

Long-Term Patient-Reported Outcomes After Arthroscopic Debridement of Grade 3 or 4 Capitellar Osteochondritis Dissecans Lesions

Background: Arthroscopic debridement for osteochondritis dissecans (OCD) lesions of the capitellum is a relatively common and straightforward surgical option for failure of nonoperative management. However, the long-term outcomes of this procedure remain unknown. Hypothesis: Arthroscopic debridement of capitellar OCD would provide satisfactory long-term improvement in patient-reported outcomes. Study Design: Case series; Level of evidence, 4. Methods: Patients aged ≤18 years who underwent arthroscopic debridement procedures for OCD lesions (International Cartilage Repair Society grades 3 and 4) were identified. Procedures included loose body removal when needed and direct debridement of the lesion; marrow stimulation with drilling or microfracture was added at the discretion of each surgeon. The cohort consisted of 53 elbows. Patient evaluation included visual analog scale for pain; motion; subjective satisfaction; Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; reoperation; and rate of return to sports. Results: At a mean 11 years of follow-up (range, 5-23 years), the median visual analog scale score for pain was 0, and 96% of patients reported being improved as compared with how they were before surgery. The mean ± SD QuickDASH score was 4 ± 9 points (range, 0-52 points), and 80% of patients returned to their sports of interest. The arc of motion significantly improved from 115°± 28° preoperatively to 130°± 17° at latest follow-up (P = .026). Seven elbows (13%) required revision surgery for OCD lesions, resulting in high rates of overall survivorship free of revision surgery: 90% (95% CI, 80%-96%) at 5 years and 88% (95% CI, 76%-94%) at 10 years. At final follow-up, 7 all-cause reoperations were performed without revision surgery on the OCD lesion. Conclusion: Arthroscopic debridement of grade 3 or 4 OCD lesions of the capitellum produced satisfactory patient-reported outcomes in a majority of elbows, although a subset of patients experienced residual symptoms. The inherent selection bias of our cohort should be considered when applying these results to the overall population with OCD lesions, as we do not recommend this procedure for all patients.

To Reduce the Incidence of Postoperative Intraabdominal Abscess, the Application of Nonoperative Management Should be Circumspect Considering Patient Factors and the Nature of Acute Appendicitis

Purpose: Surgery and nonoperative management (NOM) are the treatment modalities for acute appendicitis (AA). There is little evidence to indicate which treatment method should be performed according to the patient's condition or disease severity, surgical extension, and timing after an appendectomy. This study aimed to evaluate postoperative intra-abdominal abscess (PIAA) associated with these factors.Methods: The medical records of 839 patients who underwent appendectomy after a diagnosis of AA between 2019 and 2020 at Gangneung Asan Medical Centre were reviewed retrospectively. The factors associated with PIAA were evaluated.Results: Postoperative complications occurred in 92 patients. Following appendectomy, 16 (1.9%), 83 (9.9%), and three (0.4%) patients developed PIAA, surgical site infection, and incisional hernia, respectively. The American Society of Anesthesiologists class, complicated appendicitis on preoperative abdominal computed tomography, failure of NOM, and extensive surgery above appendectomy were associated with the development of PIAA. However, a laparoscopic approach, irrigation, indwelling drain, ultrasonic dissection, and use of sterile bags were not associated with the development of PIAA.Conclusion: NOM for some patients with complicated AA is an attractive treatment modality. However, to reduce the incidence of PIAA, the application of NOM should be circumspect considering patient factors and the nature of acute appendicitis. Furthermore, appendectomy should be performed as early as possible for patients not indicated for NOM.

Medial Patellofemoral Ligament Reconstruction: A Surgical Technique to Dynamically Control Graft Tension

The medial patellofemoral ligament is an important patellar stabilizer and, when damaged, can lead to recurrent instability, cartilage injury, and debilitating pain among other conditions. In patients with continued patellar instability after failed nonoperative management, medial patellofemoral ligament reconstruction often is recommended. A key step of the procedure is appropriate graft tensioning. Previously described techniques can help guide the surgeon, but few allow for adjustable tensioning after dynamic examination of patellar tracking to avoid over tensioning. This technique offers the ability to dynamically control graft tension with 2 independent graft limbs while also using knotless onlay type fixation, therefore decreasing the risk of over- or undertensioning and the complications that come with it.

Thromboprophylaxis Timing After Blunt Solid Organ Injury: A Systematic Review and Meta-analysis

IntroductionTrauma patients with blunt abdominal solid organ injuries are at high risk for venous thromboembolism (VTE), but the optimal time to safely administer chemical thromboprophylaxis is controversial, especially for patients who are managed nonoperatively due to increased risk of hemorrhage. We sought to compare failure of nonoperative management (NOM) and VTE events based on timing of chemical thromboprophylaxis initiation. MethodsA systematic review was conducted in PubMed and Embase databases. Studies were included if they evaluated timing of initiation of chemical thromboprophylaxis in trauma patients who underwent NOM of blunt solid organ injuries. Outcomes included failure of NOM and incidence of VTE. A random-effects meta-analysis was performed comparing patients who received late (>48 h) versus early thromboprophylaxis initiation. ResultsTwelve retrospective cohort studies, comprising 21,909 patients, were included. Three studies, including 6375 patients, provided data on adjusted outcomes. Pooled adjusted analysis demonstrated no difference in failure of NOM in patients receiving late versus early thromboprophylaxis (odds ratio [OR] 0.92, 95% confidence interval [CI]:0.4-2.14). When including all unadjusted studies, even those at high risk of bias, there remained no difference in failure of NOM (OR 1.16, 95% CI:0.72-1.86). In the adjusted analysis for VTE events, which had 6259 patients between two studies, patients receiving late chemical thromboprophylaxis had a higher risk of VTE compared with those who received early thromboprophylaxis (OR 1.89, 95% CI:1.15-3.12). ConclusionsBased on current observational evidence, initiation of prophylaxis before 48 h is associated with lower VTE rates without higher risk of failure of NOM.