Nonoperative Procedures Research Articles

A Review of the Success and Recurrence Rate of Hemorrhoids Following Rubber Band Ligation in Blackpool and the Fylde Coast Area of England

Introduction: Despite the existence of various operative and non-operative procedures to treat hemorrhoids, no standard treatment procedure for the disease exists to date. Rubber band ligation is a simple outpatient and easy to perform procedure to treat hemorrhoids, which can be done at the doctor’s office with no need for anesthesia and exceptionally minimal risk of complications. In this study, we report the efficacy of this technique among hemorrhoids patients in the in Blackpool and the Fylde Coast area of England. Materials & Methods: A retrospective case study involving ninety-eight symptomatic grade I, II and III hemorrhoids’ patients were conducted at Blackpool teaching hospital (NHS foundation trust), UK over a 3-year period. Electronic patients’ data were retrieved and analyzed for efficacy of the rubber band ligation procedure and recurrence of hemorrhoids, one year after the procedure. Results: Of the ninety-eight patients analyzed, 66 (67.3%) were males, and 32 (32.7%) were females. They had a mean (± SD) age of 53.6±15.0 years. Most of the patients, 87 (88.8%), presented with the primary symptom of rectal bleeding. Only 8 (8.2%) of the patients reported recurrence of hemorrhoids 6 months after the procedure, while 11 (11.2%) reported recurrence at 12 months after the procedure. Conclusion: In summary, it was an effective technique with only 11.2% recurrence rate 12 months after the procedure. Given its convenience and ease of performance, we believe it could be a useful technique for our setting. However, further studies, preferably prospective studies on larger number of patients and for longer duration will be required to establish its wider application. Our study reveals a significantly lower rate of recurrence in comparison to previously carried out studies and further emphasized that is safe and highly effective procedure We also noted a decreased rate of complications with only one patient requiring a readmission following the procedure, this in contrast to previous studies.

FTP8.13 Validation of a definition of Major Abdominal Surgery (MAS)

Abstract Aims To validate a previously derived definition for major abdominal surgery that has potential for widespread adoption and use in patient-driven outcome studies. Methods We codified our narrative definition for MAS using CCSD and OPCS-4 schedules. Data was extracted from electronic health records over a 5-year period to validate this definition by comparing relevant proxy measurements between MAS and non-MAS groups. Unsupervised machine learning, using the Partitioning Around Medoids algorithm, was used to cross-validate the definition by clustering all procedure codes into MAS and non-MAS groups based on these proxy measures. Results 337 CCSD codes and 214 OPCS-4 codes were reviewed. Of these, 84 CCSD and 45 OPCS-4 codes were considered to be MAS, while 195 CCSD and 111 OPCS-4 codes were considered to be non-MAS. The remaining codes were excluded as they involved non-operative procedures. We extracted data on 16,353 procedures, covering 214 CCSD procedure codes over a 5 year period. There was statistically significant difference between MAS and non-MAS operations, when comparing patient age, procedure duration, length of hospital stay, percentage of ICU admissions (p<0.001 for all values). Unsupervised machine learning allocated 127 CCSD codes, that contained data on more than 10 patients, into 2 distinct clusters with percentage agreement being 87.4% and Cohen’s kappa of 0.736 between narrative definition and machine learning analysis. Conclusions We have arrived at a validated definition of major abdominal surgery, which can now be confirmed using a larger data set. We propose that this will prove useful in the development of comparative patient-driven outcome data.

Higher volume surgeons have lower 1-year postoperative cost after total shoulder arthroplasty

BackgroundThe relationship between total shoulder arthroplasty (TSA) volume and overall postoperative cost is unclear. The purpose of this study is to assess the impact of surgeon volume on total 1-year postoperative costs. MethodsAn observational cohort study was performed utilizing Marketscan databases. Patients undergoing inpatient TSAs between January 1st, 2017 and December 31st, 2019 were included. Patients with ICD-10 Diagnosis codes of trauma, fracture, or shoulder cancer were excluded. Surgeon volume was calculated as the maximum annual volume between 2017 and 2018. The primary outcome was total 1-year postoperative costs, including revision and nonoperative costs. Secondary outcomes were rates of revision and nonoperative procedures. ResultsThe analyzed study population consisted of 2216 patients from 1255 surgeons. Patients operated on by high-volume surgeons were more likely to be older, live in the Northeast and/or metropolitan area, and to have a reverse TSA performed. Total 1-year postoperative costs were lower for high-volume surgeons with an inverse relationship with surgeon volume (high: $1925 medium: $1715, low: $1193, P < .001). Physical therapy rates (high: 76.7%, medium: 82.0%, low: 86.6%, P < .001) and costs (high: $1223, medium: $1655, low: $1870, P < .001) were lowest for high-volume surgeons. ConclusionHigh-volume surgeons were associated with lower 1-year postoperative costs with revisions and physical therapy (PT) as the main driver of these costs. These improved outcomes may reflect surgeon skill and experience. Further research is necessary to establish standardized guidelines for postoperative PT regimen.

Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis

BackgroundIntraoperative hypotension (IOH) is well-described in the academic setting but not in community practice. IOH is associated with risk of postoperative morbidity and mortality. This is the first report of IOH in the community setting using the IOH measure definition from the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System program. Objectives: To describe the incidence of IOH in the community setting; assess variation in IOH by patient-, procedure-, and facility-level characteristics; and describe variation in risk-adjusted IOH across clinicians.MethodsDesignCross-sectional descriptive analysis of retrospective data from anesthesia records in 2020 and 2021.SettingForty-five facilities affiliated with two large anesthesia providers in the USA.ParticipantsPatients aged 18 years or older having non-emergent, non-cardiac surgery under general, neuraxial, or regional anesthesia. Cases were excluded based on criteria for the IOH measure: baseline mean arterial pressure (MAP) below 65 mmHg prior to anesthesia induction; American Society of Anesthesiologists (ASA) physical status classification of I, V, or VI; monitored anesthesia care only; deliberate induced hypotension; obstetric non-operative procedures; liver or lung transplant; cataract surgery; non-invasive gastrointestinal cases.Main outcomesIOH, using four definitions. Primary definition: binary assessment of whether the case had MAP < 65 mmHg for 15 min or more. Secondary definitions: total number of minutes of MAP < 65 mmHg, total area under MAP of 65 mmHg, time-weighted average MAP < 65 mmHg.ResultsAmong 127,095 non-emergent, non-cardiac cases in community anesthesia settings, 29% had MAP < 65 mmHg for at least 15 min cumulatively, with an overall mean of 12.4 min < 65 mmHg. IOH was slightly more common in patients who were younger, female, and ASA II (versus III or IV); in procedures that were longer and had higher anesthesia base units; and in ambulatory surgery centers. Incidence of IOH varied widely across individual clinicians in both unadjusted and risk-adjusted analyses.ConclusionIntraoperative hypotension is common in community anesthesia practice, including among patients and settings typically considered “low risk.” Variation in incidence across clinicians remains after risk-adjustment, suggesting that IOH is a modifiable risk worth pursuing in quality improvement initiatives.

Evaluation of Upper Extremity Function after Operative and Non-Operative Management of Proximal Humeral Fracture Patients at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia

Introduction: Proximal humeral fractures are one of the most common long bone fractures due to osteoporosis. The need for operative action can provide greater benefits than non-operative measures. However, the difference between the need for operative and non-operative measures in proximal fractures is still controversial. This study aimed to determine differences in DASH (disability of the arm, shoulder, and hand) scores as a function of assessing upper extremity patients with proximal humeral fractures after operative and non-operative management at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia.&#x0D; Methods: Cross-sectional analytic observational study, in which 37 research subjects participated in this study. Univariate and bivariate analyses were carried out using SPSS software on the patient's sociodemographic data as well as the clinical data of the study subjects.&#x0D; Results: There was no statistically significant difference in upper extremity function (DASH score) between operative and non-operative procedures in patients with proximal humeral fractures, p&gt; 0.05.&#x0D; Conclusion: There was no difference in upper extremity function as assessed by the DASH score in operative and non-operative procedures in patients with proximal humeral fractures at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia.

Thoracic trauma in national hospital Abuja, Nigeria: The epidemiology, injury severity and initial management options

Trauma is the leading cause of death in individuals between the ages of 1 and 44 years and it is the third commonest cause of death regardless of age. Thoracic trauma is a relatively common cause of preventable death among trauma patients. The spectrum of injuries after blunt chest trauma presents a challenging problem to the emergency physician. This study is intended to discuss the epidemiology, severity and initial management strategies in chest trauma patients, in a low income country. A cross sectional retrospective study among chest trauma patients seen in the emergency room of National Hospital Trauma Centre, Abuja, Nigeria, from January 2015 to December 2017. Relevant patients' information was retrieved from the trauma registry kept in the trauma centre. Data processing and analysis was done using statistical package for social sciences (SPSS) version 24. Test of significance was done where applicable using chi square and student t test, using p value less than 0.05 as significant. Results are presented in tables and figures. A total of 637 patients, male to female ratio of 3.6 and mean age of 34.18 ± 11.34 were enrolled into the study. The most common mechanisms of injury were MVC (54.6%) and assault (23.5%). Blunt injuries were 3.5 times more frequent than the penetrating injuries. The RTS of 12 (76.3%) and the ISS of 1-15 category (52.3%) were the most common scores. Up to 98% of patients were managed non-operatively. Recovery rate was high (89%) with relatively low mortality rate of 4.2%. Majority of thoracic trauma can be managed effectively by employing simple, non-operative procedures such as needle decompression and chest tube insertion. Efforts should be made to include these procedures in the skill set of every medical officer working in the emergency room, particularly in low and middle income countries where there is paucity of emergency physicians.

Comparison of Upper Limb Function after Management of Intraarticular Distal Radius Metaphyseal Fracture between Operative and Non-Operative Procedure with Clinical Assessment of the QuickDASH Score

Introduction: Distal radius fracture is the most common fracture in an orthopedic emergency involving the upper limb. Management of patients with distal radius metaphyseal fractures greatly affects the function of the upper limb during recovery. Then the right choice of type of procedure will affect the function of the upper limb. This study aimed to compare the function of the upper limb in intraarticular distal radius metaphyseal fracture between operative and non-operative procedures with the clinical assessment of the QuickDASH score at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia.&#x0D; Methods: This study was an analytic observational study with a retrospective cohort approach. A total of 55 research subjects consisting of 38 subjects belonging to the operative group and 17 subjects belonging to the non-operative group, participated in this study. Data analysis was carried out using univariate and bivariate to find out the differences between operative and non-operative procedures related to post-fracture upper limb performance.&#x0D; Results: Operative procedure are proven to improve upper limb performance better than non-operative procedure based on the QuickDASH score. Operative procedures provide improved upper limb performance 2.65 times better than non-operative procedure.&#x0D; Conclusion: Operative procedure that are better in maintaining upper limb performance after intraarticular radius distal metaphyseal fractures based on the QuickDASH score compared to non-operative procedure at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia.

Digital Ischemia after Ultrasound-Guided Alcohol Injection for Morton’s Syndrome: Case Report and Review of the Literature

The therapeutic algorithm for symptomatic Morton's syndrome is not standardized as several managements have been proposed. Ultrasound-guided alcohol injection (USGAI) is one of the non-operative procedures described. This report presents the case of digital ischemia that occurred after alcoholization for the treatment of Morton's syndrome. This complication is described for the first time in the scientific literature, and it should not only be added to the list of sequalae of USGAI, but more importantly, it should also be explained to the patient when this alternative treatment to traditional surgery is proposed.

Costs of Nonoperative Procedures for Knee Osteoarthritis in the Year Prior to Primary Total Knee Arthroplasty.

The convergence of national priorities to reduce health-care costs and deliver high-value care warrants the need to examine health-care utilization. The objective of this study was to describe the costs associated with nonoperative procedures in the 1-year period leading up to primary total knee arthroplasty (TKA). An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with late-stage knee osteoarthritis (OA) who underwent unilateral, isolated primary TKA from January 1, 2018, to December 31, 2019, were included. The main outcome was the cost of knee OA-related payments for identified nonoperative procedures in the 1-year period before surgery. Nonoperative procedures examined were (1) physical therapy (PT); (2) bracing; (3) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS); (4) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen; and (5) knee-specific imaging. The study population included 24,492 TKA patients with a mean age of 60.4 ± 8.0 years. The average total cost of nonoperative procedures per patient was $1,355 ± $2,087. The most common nonoperative treatment prescribed was IA-CS (54.3%). The nonoperative procedure with the highest cost per patient was IA-HA ($1,019 ± $913 per patient). The total cost of nonoperative procedures was higher among female compared with male patients ($1,440 ± $2,159 versus $1,254 ± $1,992 per patient; p < 0.01). The highest costs were found for patients in the Northeast ($1,740 ± $2,437 per patient). A total of 14,346 (58.6%) and 7,831 (32.0%) of the patients had >1 and ≥3 nonoperative treatments, respectively. There is substantial variation in the type and the cost of nonoperative treatment for patients with late-stage OA. Future studies should investigate the effectiveness of nonoperative treatments at different stages of the disease. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Complications of alcohol injections for Morton’s neuroma

Introduction Morton’s neuroma (MN) is a neuropathic metatarsalgia that causes pain in the plantar aspect of the forefoot generally between the third and fourth metatarsal heads. Treatment can be nonoperative or surgical. Among nonoperative procedures, alcohol injections are still commonly used as considered simple, relatively safe and well-tolerated treatment. However, they present transient and minor complications. Methods Two hundred patients with a diagnosis of MN underwent ultrasound-guided injections with a 47.5% alcohol solution between 2013 and 2020. We reviewed the current literature to highlight the known complications of this treatment, comparing them to the complications developed by our patients. Results Three patients out of 200 patients, developed necrosis of skin and subcutaneous tissue not described in previous studies about MN. Conclusions Our study focuses attention on the complications subsequent to the alcohol injection therapy for MN. Patients and surgeons should be aware that in a small number of cases this therapy can be burdened by necrotic complications of the skin.

Drivers of Unequal Healthcare Costs in the Nonoperative Treatment of Late-Stage Knee Osteoarthritis Prior to Primary Total Knee Arthroplasty

BackgroundIn the United States, patients with late-stage knee osteoarthritis (OA) often undergo several nonoperative treatments and related procedures prior to total knee arthroplasty. The costs of these treatments and procedures are substantial, and the variation in healthcare costs among different groups of patients may exist. The purpose of this study is to examine these costs and determine the drivers of costs in patients with the highest healthcare expenditure. MethodsAn observational cohort study was conducted using the IBM Watson Health MarketScan databases from January 1, 2017 to December 31, 2019. The primary outcome was the cost of payments for nonoperative procedures which included (i) physical therapy (PT), (ii) bracing, (iii) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS), (iv) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen, and (v) knee-specific imaging. ResultsAmong the 24,492 patients included in the study, the total payments per patient for nonoperative care were $3,735 ± 3,049 in the highest payment quartile (Q4) and $137 ± 70 in the lowest payment quartile (Q1). Per-patient-per-month costs generally increased across quartiles for procedures. Comparing Q4 to Q1, the largest changes in prevalence were found in IA-HA (348×), bracing (10×), and PT (7×). Patients who were prescribed IA-HA and PT had a 28.3-times and 4.8-times greater likelihood, respectively, to be a higher-paying patient. ConclusionUnequal healthcare costs in the nonoperative treatment of late-stage knee OA are driven by differences in prevalent management strategies. Overall healthcare expenditure may be reduced if only guideline-concordant treatments are used.

Application of synthetic and natural polymers in surgical mesh for pelvic floor reconstruction

Pelvic floor dysfunction (PFD) is a common gynecological problem that affects millions of women. Current treatment strategies are to restore the normal anatomical structure by non-operative procedures (such as pelvic floor myoelectric stimulation) or surgery (such as vaginal mesh implantation). Although vaginal meshes can provide effective, long-term and minimally invasive treatment for patients, certain life-altering complications may occur. Physical characteristics (such as porosity, mesh weight and mechanical properties), manufacturing process and material type are parameters that can greatly influence cell attachment, tissue proliferation and regeneration. The best clinical effectiveness of surgical meshes could be obtained by optimizing these parameters. Material type has a particularly important influence on the mechanical strength, biodegradation rate and biocompatibility of the implants. Therefore, material type selection is crucial for the development of an ideal pelvic floor repair mesh for use in pelvic floor reconstruction. The materials that are suitable for use in vaginal meshes have been broadly classified into three groups, which are synthetic polymers, natural polymers and polymer blends. This review mainly focuses on the application and biological characteristics of synthetic polymers, natural polymers and polymer blends in pelvic floor tissue engineering.

A REVIEW OF JALUKAVACHARANA (LEECH THERAPY) IN THE MANAGEMENT OF THROMBOSED HAEMORRHOIDS - CASE REPORTS

Haemorrhoids are dilated veins within the anal canal in the subepithelial region formed by radicles of superior, middle and inferior rectal veins. It is a common ano-rectal disease. Thrombosed hemorrhoid is a painful swelling in the anal tissues caused by a clot in one or more small veins in the anal canal. According to modern science, there are many operative and non-operative procedures for the management of haemorrhoids. Most of the operative pro- cedures are not patient friendly, cause high economic burden and associated with complications like pain, bleeding and recurrence. Acharya Vagbhata defines Arsas (haemorrhoids) as an abnormal growth which obstructs the anal canal and troubles continuously like an enemy. Shalyatantra deals with Sastra karma (surgical procedures), Anusas- tra karma (parasurgical procedures) and conservative management in the different types of diseases. Jaluka is con- sidered as best among Anusastra. Acharya Vagbhata indicates Jalukavacharana in haemorrhoids when they are hard and swollen. The present article deals with Jalukavacharana in two patients having thrombosed haemorrhoids attended in outpatient department of VPSV Ayurveda College Kottakkal. Application of Jaluka (leech) provided improvement in features like pain, edema, tenderness and discoloration of mass. Keywords: Thrombosed haemorrhoids, Arsha, Raktamokshana, Jalukavacharana.

Impact of COVID-19 pandemic on orthopaedic surgeons in terms of anxiety, sleep outcomes and change in management practices: A cross-sectional study from India.

The aim of this study was to assess the effects of the COVID-19 pandemic on anxiety, sleep outcomes and change in clinical management practices among orthopaedic surgeons following a nation-wide lockdown. We conducted an online cross-sectional study using piloted structured questionnaires with self-reported responses from Indian orthopaedic surgeons. Study participants were identified through social networking sites: Facebook and WhatsApp. The extent of anxiety and sleep quality was assessed by the standardised seven-item Generalised Anxiety Disorder (GAD-7) scale, single-item sleep quality scale, questions on unavailability of personal protective equipment, training module on COVID-19 and change in orthopaedic patient management. One hundred male orthopaedic surgeons responded to the survey with majority (79%) in 30-44 years age group. Severe anxiety scores were observed in 8%; moderate, mild and minimal anxiety was observed in 12%, 27% and 53% surgeons respectively. Changes in management practice due to the pandemic was admitted by 65% respondents. We also observed an association between higher anxiety among surgeons and primary or secondary level of healthcare facility: (p = 0.04). Sleep disturbance was significantly associated with change in management practice to non-operative procedures (p = 0.03). Anxiety among orthopaedic surgeons during the COVID-19 pandemic is related to factors like younger age group, working in a primary or secondary healthcare facility. Early recognition of anxiety is essential to prevent serious psychological sequelae.

Platelet-Rich Plasma, Mesenchymal Stem Cell, and Non-metallic Suture-Based Fixation Technique in a Patellar Fracture Nonunion: A Technical Note and Systematic Review.

BackgroudWe performed a systematic review on the management of patellar fracture nonunion and report a novel suture-based non-metallic fixation technique associated with platelet-rich plasma and mesenchymal stem cell injections in the management of this injury.MethodsA systematic search was performed up to August 2020 in PubMed and Scopus electronic databases of scholarly articles evaluating different surgical techniques used for nonunion of patellar fractures, with no restrictions on language or year of publication. Furthermore, we describe our novel non-metallic suture fixation technique and a patient in whom this technique was applied.ResultsA total of 9 articles were included in the systematic review. Tension band wiring was the most commonly used procedure (62.7%). Nonoperative procedures (8.1%) resulted in nonunion in all patients. The most common complication after open reduction and internal fixation was infection (7.8%). Our patient at the latest follow-up reported full functional recovery and full extension and flexion of the affected knee with no pain and subjectively normal strength.ConclusionsThe management of patella nonunions is still a challenge. The technique reported here can be used in patellar fracture nonunion, as well as in primary patellar fractures.

Benign Pediatric Jaw Lesions at Massachusetts General Hospital Over 13 Years

To the best of our knowledge, no study has reported pediatric jaw lesions according to the latest World Health Organization (WHO) classification of head and neck tumors. We reviewed the spectrum of benign pediatric jaw lesions treated at the Massachusetts General Hospital during a 13-year period according to the 2017 WHO classification. We implemented a retrospective cohort study of patients younger than 18years old with benign bony lesions. The primary predictor variable was the histopathologic diagnosis, grouped into odontogenic tumors (OTs), non-OTs, and odontogenic cysts. The primary outcome variables were the incidence of recurrence and the interval to recurrence. Other outcome variables included symptoms, radiographic findings, and treatment modalities. Descriptive statistics were computed. Kaplan-Meier analyses and Cox regressions were performed. The sample included 131 patients (58 males and 73 females; mean age, 12.6±3.7years) with 14 pathologic diagnoses. These were grouped as follows: non-OTs (n=67), OTs (n=36), and odontogenic cysts (n = 28). Odontogenic cysts were predominantly radiolucent, unilocular, and well-circumscribed cysts compared with the OTs and non-OTs (P<.05). Enucleation was the most commonly performed surgical procedure (72.5%). Adjuvant nonoperative procedures included cryotherapy for 10 patients, interferon therapy for 9 patients, and chemotherapy with denosumab for 3 patients to treat aggressive tumors. The overall incidence of recurrence was 0.77/100 person-years. The Cox hazard ratio of non-OTs/OTs was 3.1 (P=.13) and cysts/OTs was 4.3 (P=.075). Neither the incidence of recurrence nor the interval to recurrence among the 3 groups showed significant differences. A high incidence of recurrence was noted for aggressive central giant cell tumors (39.1%) and odontogenic keratocysts (40%) during a median follow-up of 3years. Although pediatric jaw lesions are uncommon, symptoms such as swelling could indicate potential pathologic findings and require panoramic examination. Management of pediatric jaw lesions should consider the biologic behavior of the lesion, maxillofacial development, and growth. Enucleation combined with pharmacologic therapy is a promising strategy for the management of aggressive central giant cell tumors in children.

Budd-chiari syndrome – outcomes of surgical portal decompression and liver transplantation

Introduction: Budd-Chiari syndrome (BCS) is characterised by hepatic venous outflow obstruction. We present the management outcomes of BCS patients. Methods: The records of 55 patients who presented with BCS between 2011 and 2017 to were retrospectively reviewed. Management plan was based on severity of symptoms, underlying liver function, level of outflow obstruction and patency of retrohepatic cava. Patients were accordingly managed by non-operative procedures, decompressive shunt surgery and liver transplantation. Results: The median age at presentation was 24.8 years(1-43 years). Seven patients had underlying haematological disorder.There were 35 male and 20 female patients. One patient presented with acute BCS. Nonsurgical Interventional procedures were done in 11 patients with Cavoplasty alone in 8, Hepatic venoplasty with RHV stenting in 2 and TIPS in 1 patient. Twenty nine patients underwent surgery for BCS. Surgical procedures performed were Liver transplantation in 15 patients (Living donor-13;Deceased donor-2),Portal decompression in 12 patients(Porto-caval shunt-5,Meso-caval shunt-7),Retro-caval cyst excision in 1 and Denver shunt in 1 patient. Morbidity in patients with transplantation included bile leak in 3, chyle leak in 2, MHV thrombosis in 1 patient and mortality rate was 0.6% (1/15). Median hospital stay was 24 days(11 - 182 days). Mean follow-up was 16 months. In patients with portal decompression, morbidity included chyle leak in 2 and shunt thrombosis in 1 patient and 1 death with mean follow-up of 10.3 months. Conclusion: Budd Chiari syndrome is a challenging clinical problem affecting young patients. Management should be tailored to the anatomy of the obstruction and underlying liver function.

Review of Current Concepts Femoral of Head Osteonecrosis

Background: The avascular necrosis (AVN) or osteonecrosis of the femur head (ONFH), an illness with several etiological factors, impacts young populace and otherwise handled prompt, causes the collapse of femur head eventually requiring hip arthroplasty. Objective: the present article aims to provide an overview of epidemiology, pathophysiology of osteonecrosis along with diagnosis methods and non-surgical in early stages and surgical treatment methods. Methodology: Comprehensive search of the literature was conducted in the following databases; PubMed, and SciVerse Scopus for studies published before November 2017. The PubMed database was searched using an algorithm comprising relevant MeSH terms including “Osteoporosis”, “femoral head osteonecrosis” AND “management” “diagnosis”. Conclusion: Osteonecrosis is a destructive pathology that eventually results in bone death through loss of blood to the bone, it involves almost every bone including the femoral head while early start of osteoarthritis could ultimately demand hip arthroplasty when non-operative procedures and joint-sparing treatments fail. Nevertheless, recent technological advances in surgical treatment methods have improved outcomes and should help patients recover from this functionally debilitating joint disease.

Abstract P41. The Evolving Role of Microsurgery in Living-Donor Liver Transplantation

Purpose: Hepatic arterial (HA) reconstruction is challenging in living-donor-liver-transplantation (LDLT) as the artery diameter is small and has limited length at its origin. Hepatic artery thrombosis is a significant cause of graft loss and historically the most cited complication of LDLT (incidence 1–26%). The introduction of microsurgical techniques in HA reconstruction has improved graft survival and outcomes. The purpose was to analyze our experience transitioning to microsurgical techniques over the last 6-years. Methods: A retrospective review was conducted for patients who underwent a LDLT either at CHOP or University of Pennsylvania, from 3/2010 through 6/2016. The primary outcome was HA thrombosis diagnosed by ultrasound, CT angiogram, or direct visualization. Other outcomes were collected in combination and analyzed using STATA. Results: Seventy-one LDLT were performed 3/2010 to 6/2016, 23 (32%) were completed with microsurgical techniques and 48 (68%) without. The microsurgical cohort was significantly younger (average 28.2 years vs. 47.0 years; p=0.0199) with shorter follow-up time (average 456 days vs. 1100 days; p<0.001). The non-microsurgical cohort had 3 (6.25%) complete graft failures, 3 (6.25%) HA thrombosis, 2 (4.2%) HA pseudoaneurysms, 4 (8.3%) requiring non-operative procedures, and 3 (6.25%) mortalities, compared to zero in the microsurgical cohort. There were statistically significant differences between groups in biliary complications (21/43.8% vs. 1/4.3%; p=0.001), endoscopic retrograde cholangiopancreatography with stent (15/31.25% vs. 0/0%; p=0.002), and complications/return to the OR (10/20.8% vs. 3/13%; p=0.025). Conclusion: Based on our institution’s short and long-term outcomes, microsurgical techniques have significantly improved post-surgical outcomes and reduced the morbidity and mortality in our LDLT population.

Are Orthopaedic Residents Competent at Performing Basic Nonoperative Procedures in an Unsupervised Setting? A "Pop Quiz" of Casting, Knee Arthrocentesis, and Pressure Checks for Compartment Syndrome.

Many patient care procedures are routinely performed by orthopaedic residents while not directly supervised by attending physicians. However, resident competence to perform these procedures is often presumed and not confirmed by objective measures. The purpose of this study was to formally evaluate 3 basic pediatric orthopaedic procedures commonly performed without attending supervision. All orthopaedic residents (n=20) were asked to complete 3 procedures (placement and removal of a short arm cast, aspiration of a knee joint, and compartment pressure checks of a leg) under direct attending supervision. Attending faculty developed a checklist for each procedure, listing the appropriate steps required and criteria with which to assess the final results. Scores were calculated, including means and SDs. Change in score by postgraduate year level was determined by simple linear regression. The mean score for short arm cast application and removal was 6.2 of a total possible score of 8, with an average 1.1 increase in score per year of training (P<0.001). Uneven cast padding and lack of full thumb motion were the most common reasons for losing points. Knee joint aspiration had an average score of 6.2 of 7, with an average increase in score of 0.3 per year of training (P=0.046). Lack of equipment preparation and not donning gloves in a sterile manner were the most common reasons for losing points. Measure of leg compartment pressures had an average score of 9.7 of 12, with an average increase in score of 0.5 per increase in year of training (P=0.087). Injecting an inappropriate amount of fluid and not recording measurements were the most common reasons for losing points. The ability of a resident to appropriately perform certain procedures without direct supervision improves with advancing level of training. The most junior residents might not appropriately be placing short arm casts, aspirating knee joints, or checking compartment pressures of the leg. Level II—Diagnostic.