Postoperative Clinic Visit Research Articles

Perioperative MVT-5873, a fully human monoclonal antibody against a CA 19-9 epitope, for operable CA 19-9 producing pancreatic cancers, cholangiocarcinomas, and metastatic colorectal cancers.

TPS4655 Background: Operable hepatopancreatobiliary (HPB) cancers continue to pose significant challenges. Radical resections are rarely curative, and chemotherapy is able to reduce tumor recurrence for only a fraction of patients. Despite the obvious advantages of extirpation of the identifiable tumor(s), the inflammatory milieu that accompanies surgery and the obligate time off cytotoxic agents allows for activation of remote quiescent disseminated tumor cells, leading to metastatic recurrence. We are conducting a study to determine the safety and efficacy of immediate peri-operative MVT-5873, a cytotoxic monoclonal antibody targeting Carbohydrate Antigen 19-9 (CA 19-9), in patients undergoing resections pancreatic cancer, cholangiocarcinoma or metastatic colorectal cancer to the liver. MVT-5873 is a human IgG1 antibody isolated from a patient following immunization with a sLea-KLH vaccine. MVT-5873 has demonstrated cell surface binding in sLea positive human tumor lines and has been shown to be potent in complement-dependent cytotoxicity assays and antibody-dependent cell mediated cytotoxicity assays. In patients with CA 19-9-producing cancers, MVT-5873 treatment has been shown to decrease serum CA 19-9 levels and prevent tumor progression. This trial may open the door for investigation of additional and/or synergistic agents in the immediate peri-operative period and usher in a new paradigm in the management of surgically treated cancers. Methods: This is a prospective, Phase II trial designed to determine the efficacy (increase in 1-yr DFS) and safety of peri-operative MVT-5873 for subjects with operable pancreatic, liver and bile duct cancers with elevated CA 19-9 levels. Patients may receive any standard neoadjuvant regimen prior to enrollment at the NIH Clinical Center in Bethesda, Maryland. Eligible patients will receive a pre-operative dose of MVT-5873 three days prior to the planned operation to remove all demonstrable disease. Following the operation, patients will receive a total of four doses of MVT-5873; the first two doses on postoperative days four and ten. The third dose will be administered on the normally scheduled postoperative clinic visit, followed by a final dose one month after discharge from the hospital and prior to the start of adjuvant treatment. Clinical trial information: NCT03801915 .

Robotic-assisted and laparoscopic hernia repair: real-world evidence from the Americas Hernia Society Quality Collaborative (AHSQC).

Ventral hernia repair (VHR) is a commonly performed procedure and is especially prevalent in patients who have undergone previous open abdominal surgery: up to 28% of patients who have undergone laparotomy will develop a ventral hernia. There is increasing interest in robotic-assisted VHR (RVHR) as a minimally invasive approach to VHR not requiring myofascial release and in RVHR outcomes relative to outcomes associated with laparoscopic VHR (LVHR). We hypothesized real-world evidence from the Americas Hernia Society Quality Collaborative (AHSQC) database will indicate comparable clinical outcomes from RVHR and LVHR approaches not employing myofascial release. Retrospective, comparative analysis of prospectively collected data describing laparoscopic and robotic-assisted elective ventral hernia repair procedures reported in the multi-institutional AHSQC database. A one-to-one propensity score matching algorithm identified comparable groups of patients to adjust for potential selection bias that could result from surgeon choice of repair approach. Matched data describe preoperative characteristics and perioperative outcomes in 615 patients in each group. The following significant differences were observed among the 11 outcomes that were pre-specified. Operative time tended to be longer for the RVHR group compared to the LVHR group (p < 0.001). Length of stay differed between the two groups; while both groups had a median length of stay of 0, stay lengths tended to be longer in the LVHR group (p < 0.001). Rates of conversion to laparotomy were fewer for the RVHR group: < 1% and 2%, respectively (p = 0.007). Through 30days, there were fewer RVHR patient-clinic visits (p = 0.038). Both RVHR and LVHR perioperative results compare favorably with each other in most measures. Differences favored RVHR in terms of shorter LOS, fewer conversions to laparotomy, and fewer postoperative clinic visits; differences favored LVHR in terms of shorter operative times.

Changes in Wide-band Tympanometry Absorbance Following Cochlear Implantation.

Determine if changes in middle ear absorbance measured with wide-band tympanometry (WBT) occur following hearing-preservation cochlear implantation (CI). Such measures may provide insight into the mechanisms of acoustic hearing loss postimplantation. Clinical capsule report. Tertiary academic referral center. WBT absorbance was measured bilaterally during pre- and postoperative clinical office visits in five unilaterally-implanted cochlear implant recipients. Pre- and postoperative WBT measures were compared within each subject in the implanted and contralateral, unimplanted ears. In general, WBT absorbance measurements show a broad spectral pattern including two or three distinct peaks measured over a frequency range of 226 to 8000 Hz. Grand average and linear mixed model comparisons between the pre- and postoperative WBT patterns show significantly reduced (p < 0.05) low-frequency absorbance in the implanted ears in the frequency region over 0.6 to 1.1 kHz, but not in the unimplanted ears. The maximum effect occurred at 1 kHz with absorbance decreasing from ∼0.8 to ∼0.5 after implantation. The limited data are consistent with expected relationships between WBT absorbance and air- and bone-conduction thresholds, assuming an increased air-bone gap reflects conductive hearing loss. Cochlear implantation can result in reduction of low-frequency acoustic absorbance as measured by WBT. WBT may be a useful and sensitive tool for monitoring the mechanical status of the middle and inner ears following cochlear implantation.

Improvement in Outpatient Follow-up With a Postdischarge Phone Call Intervention

Attending clinic appointments after injury is crucial for orthopaedic trauma patients to evaluate healing and to update recommendations. However, attendance at these appointments is inconsistent. The purpose of this study was to assess the effect of a personalized phone call placed 3 to 5 days after hospital discharge on attendance at the first postdischarge outpatient clinic visit. This prospective study was done at an urban level 1 trauma center. One hundred fifty-nine patients were exposed to a reminder phone call, with 33% of patients being reached for a conversation and 28% receiving a voicemail reminder. Phone calls were made by a trained trauma recovery coach, and the main outcome measure was attendance at the first postdischarge clinic visit. Eighty-six patients (54%) attended their scheduled appointments. Appointment adherence was more common among the group reached for a conversation (70% versus 51% for voicemail cohort and 34% for no contact group). Patients exposed to the Trauma Recovery Services (TRS) during their hospital stay attended appointments more often (91% versus 61%, P = 0.026). Age, sex, mechanism of injury, and distance from the hospital were not associated with specific follow-up appointment adherence. Insured status was associated with higher attendance rates (71% versus 46%, P = 0.0036). Other economic factors such as employment were also indicative of attendance (64% versus 48%, P = 0.05). Current tobacco use was associated with poor appointment attendance (30%) versus 56% for nonsmokers (P = 0.001). Patients reached by telephone after discharge had better rates of subsequent clinic attendance. Economic factors and substance use appear vital to postoperative clinic visit compliance. Patients with met psychosocial needs, as identified by individuals with satisfactory emotional support, and exposure to TRS had the highest rates of postdischarge appointment attendance.

Follow-Up Adherence Is Associated with Outcomes After Endoscopic Sinus Surgery.

Clinical follow-up after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) allows for assessment of the sinonasal cavity, debridement, and tailoring of medical therapies. Frequency and timing of postoperative clinical visits is debated, but the impact of adherence on disease-specific outcomes is not well understood. In this longitudinal study, we assessed the association between follow-up adherence and quality of life (QOL) outcomes in the 12 months after ESS. A retrospective review of patients undergoing ambulatory ESS for CRS between 11/2016 and 1/2018 was performed. We assessed sociodemographic characteristics, radiographic severity, and QOL utilizing the 22-item sinonasal outcome test (SNOT-22). Patients were categorized as "non-adherent," "moderately-adherent," and "fully-adherent" to a 1-, 3- and 5-week postoperative visit schedule. A total of 166 patients met the inclusion criteria. Of these, 55 (33.1%) were fully-adherent, 105 (63.2%) were moderately-adherent, and 6 (3.6%) were non-adherent within the 6 weeks following ESS. In the immediate postoperative period, fully-adherent patients demonstrated worse QOL (SNOT-22: 31.2 ± 23.1 vs 27.5 ± 17.6, P = .047). This cohort also had greater psychological dysfunction at baseline and 12-months (P < .05) after ESS. Extra-nasal symptom scores increased at a lower rate in the fully-adherent cohort (0.12 vs 1.29 points per 6 months, P = .038), as did ear/facial symptoms (1.17 vs 3.05 points per 6 months, P = .044). Despite worse symptom severity in the immediate postoperative period, patients who are more adherent to the follow-up schedule demonstrated slower return of symptoms in the extra-rhinological and ear-facial domains. These findings suggest that clinical adherence and management may impact the long-term evolution of ESS outcomes.

Extramedullary Guide Alignment Is not Affected by Obesity in Primary Total Knee Arthroplasty.

Coronal alignment of the tibial implant correlates with survivorship of total knee arthroplasty (TKA), especially in obese patients. The purpose of this study was to determine if obesity affects coronal plane alignment of the tibial component when utilizing standard extramedullary tibial guide instrumentation during primary TKA. A retrospective review from June 2017 to February 2018 identified 142 patients (162 primary TKAs). There were 88 patients (100 knees) with body mass index (BMI) < 35 kg/m2 and 54 patients (62 knees) with BMI ≥ 35.0 kg/m2. The cohorts did not differ in age (p = 0.37), gender (p = 0.61), or Charlson's comorbidity index (p = 0.54). Four independent reviewers measured the angle between the base of the tibial component and the mechanical axis of the tibia on the anteroposterior view of long-leg film at first postoperative clinic visit. Outliers were defined as patients with greater than 5 degrees of varus or valgus alignment (n = 0). Reoperations and complications were recorded to 90 days postoperatively. There was no significant difference in mean tibial coronal alignment between the two groups (control alignment 90.8 ± 1.2 degree versus obese alignment 90.8 ± 1.2 degree, p = 0.91). There was no difference in varus versus valgus alignment (p = 0.19). There was no difference in the number of outliers (two in each group, p = 0.73). There was no difference in rate of reoperation (p = 1.0) or complication (p = 0.51). Obesity did not affect coronal plane alignment of the tibial component when using an extramedullary guide during primary TKA in our population.

Patient-Centered Satisfaction After Secondary Correction of the Cleft Lip and Nasal Defect

To evaluate patient-reported aesthetic and psychosocial outcomes of secondary cleft lip and nose revision procedures. Single-center cohort study. Tertiary care pediatric hospital. Patients who underwent secondary revision procedures for cleft lip and nasal defect (N = 42). Patients were administered a survey during a routine postoperative clinic visit. Outcome measures were planned prior to data collection and included improvement in appearance seen in lip and nose, satisfaction with revision procedure, changes in self-confidence, likelihood to participate in social activities, and effect on teasing by peers. Patients agreed that an improvement was seen in the appearance of their lip (1.93) and nose (1.98) following surgery. Overall, patients felt satisfied with the results of their revision procedure (1.76). An improvement in confidence and decrease in feelings of self-consciousness was reported. Patients were teased less by their peers and more likely to participate in social activities. Secondary revision procedures of the cleft lip and nasal defect provide a patient-reported improvement in appearance and a positive psychosocial impact on patient's lives.

Laparoscopic right hepatectomy for polycystic liver disease

Presenter: Amy Li MD | Stanford University Background: Polycystic liver disease is characterized by 20 or more liver cysts, often with progressive growth. Patients are typically asymptomatic but may develop symptoms of hepatomegaly with compression of surrounding structures, including pain, early satiety, nausea and vomiting as well as dyspnea. Symptoms have a range of impact on quality of life, but can be quite debilitating. Surgery is reserved for those with medically refractory disease and high symptom severity. Surgical options range from cyst fenestration to partial hepatectomy to total hepatectomy with liver transplantation. Methods: This is the case of a 48-year-old otherwise healthy female who presented with multiple episodes of right upper quadrant pain, as well as associated nausea and vomiting. Other symptoms included weight loss secondary to pain and dyspnea upon exertion. CT imaging demonstrated innumerable liver cysts, with a right-lobe predominance. Based on the patient’s symptomatology, right hepatectomy was offered to reduce volume. Results: The patient underwent laparoscopic right hepatectomy with fenestration of left sided liver cysts. A 12 mm port was placed in the supraumbilical position and three 5 mm trocars to the left of the midline, right midclavicular line and right anterior axillary line. There was limited intraabdominal domain due to massive hepatomegaly. Fenestration of the left sided liver cysts was performed first in order to increase working room. Additional fenestration was performed on the right lobe to gain additional working space. The cystic structures were divided to gain exposure to the right pedicle. The right hepatectomy was performed with a Glissonian approach along Cantlie’s line. Due to the diffuse distribution of numerous liver cysts, the typical anatomical planes and vascular anatomy were distorted. Because of this, hepatic vessels may be encountered at any time during division of liver cysts and parenchyma. Therefore, the surgeon must be prepared to control vessels during the dissection. After the right lobe was divided and entirely mobilized, the specimen was further decompressed with fenestration. The specimen was brought up to the skin and morcellated in order to extract through the 12 mm umbilical port site. The patient tolerated the procedure well and was discharged home on postoperative day 2. At her postoperative clinic visit, she reported that she was tolerating a regular diet without nausea or vomiting, and no longer experienced pain with performing her activities of daily living. The postoperative CT demonstrated approximately 60% reduction in volume, from approximately 3,000cc preoperatively to 1200cc postoperatively. Conclusion: While minimally invasive methods have been gaining traction in the treatment of polycystic liver disease, challenges remain including limited intraabdominal domain as well as distortion of the vascular anatomy. In such cases, anatomy cannot be reliable in guiding dissection. Despite these difficulties, we have demonstrated that laparoscopic hepatectomy can be performed safely for polycystic liver disease with good post-operative outcomes.

Free Flap Selection and Outcomes of Soft Tissue Reconstruction Following Resection of Intra-oral Malignancy.

Introduction: Surgery to resect intra-oral malignancy is a well-established mode of primary treatment. The tissue requirement in this area is for a thin, pliable flap with minimal bulk and this has historically been provided by free tissue transfer with a radial forearm free flap (RFFF). More recently, a role for the anterolateral thigh free flap (ALTFF) has been described, although in populations with a westernized diet, body habitus may preclude use of an ALTFF due to flap thickness, relative to a radial forearm free flap.Methods: An analysis of data was performed retrospectively for 90 consecutive patients with intra-oral malignancy, requiring immediate soft tissue reconstruction by the senior author, at Addenbrooke's Hospital between July 2008 and April 2016. Cases requiring bony reconstruction were excluded. Data on patient age, sex, indication for surgery, tumor location and defect type, complications, success rates, and length of stay were recorded.Results: The majority of patients received an ALTFF (n = 56) with 38% receiving a RFFF (n = 34). Surgical resection took place in the floor of the mouth most frequently. These were closed with ALTFF and RFFF in 41 and 28 occasions, respectively. A success rate of 97% was observed in the RFFF group; 1 flap developed partial necrosis and required complete revision. In the ALTFF group, there was a 100% flap success rate. ALTFF usage resulted in a reduction in the number of intraoperative (p = 0.021) in addition a reduction in the number of days in ITU (p = 0.01) and post-operative clinic visits (p = 0.025).Conclusion: We present a series that used predominately the ALTFF to reconstruct intra-oral defects following resection of squamous cell carcinoma in a Western population. The results demonstrate that this treatment can produce at least as comparable results as to the use of a RFFF repair in this population, whilst avoiding the donor site morbidity and aesthetic compromise of a RFFF.

Are In-Person Post-operative Clinic Visits Necessary to Detect Complications Among Bariatric Surgery Patients?

Patients undergoing bariatric surgery are expected to have frequent post-surgical follow-up. With the increased utilization of telemedicine across different surgical specialties, we are considering replacing the in-person post-surgery visits with telemedicine video visits in our bariatric practice. However, the safety and efficacy of conducting these visits through telemedicine is still unknown. Due to the concern of missing complications by eliminating in-person assessments, we reviewed 30-day complications, their severity, and the context of their detection experienced by bariatric surgical patients at our institution. Our results suggest that the majority of complications are detected when patients seek medical care rather than during clinic visits. Therefore, telemedicine is likely safe for 30-day follow-up in bariatric patients. Further studies are needed to assess its effect on patient compliance and outcomes.

Surgical management of symptomatic Tarlov cysts: cyst fenestration and nerve root imbrication-a single institutional experience.

Tarlov cyst disease is a collection of cerebrospinal fluid between the endoneurium and perineurium of spinal, usually sacral, nerve roots. These cysts can become symptomatic in 20% of patients, causing lower back pain, radiculopathy, bladder and bowel dysfunction necessitating medical or surgical intervention. Different surgical and non-surgical modalities have been described for the treatment of symptomatic Tarlov cysts. However, there has been no published study that examined types of surgical techniques side by side. Our study presents a preliminary experience in the surgical management of symptomatic Tarlov cysts using two surgical techniques: cyst fenestration and nerve root imbrication. Retrospective chart review and analysis was done for all patients who underwent surgical intervention for symptomatic Tarlov cyst(s) in the period 2007-2013. Operative reports, preoperative and postoperative clinic visit reports were reviewed. The surgical techniques of cyst fenestration and nerve root imbrication were each described in terms of intraoperative parameters, hospital course and outcome. Modified MacNab criteria were used for evaluation of the final clinical outcome. Thirty-six surgical patients were identified. Three had repeat surgery (total of 39 operations). The median age was 51 years (range, 26-84 years). Eighty-six percent were females. The presenting symptoms were low back pain (94%), sensory radiculopathy (69%), bladder and bowel dysfunction (61%), sexual dysfunction (17%) and motor dysfunction (8%). Cyst fenestration was performed in 12 patients (31%) and nerve root imbrication was done in 27 (69%). All patients in the fenestration group but only 67% in the imbrication group had fibrin glue injection into the cyst or around the reconstructed nerve root. The overall surgery-related complication rate was 28%. The complication rate was 5/12 (42%) in the fenestration group and 6/27 (22%) in the imbrication group. At the time of the last clinic visit, improved clinical outcome was noted in 9/11 (82%) and 20/25 (80%) in the fenestration and the imbrication group, respectively. Cyst fenestration and nerve root imbrication are both surgical techniques to treat symptomatic Tarlov cyst(s), and both can result in clinical improvement.

Telephone Follow-Up for Emergency General Surgery Procedures: Safety and Implication for Health Resource Use

It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk core emergency general surgery (cEGS) procedures is safe. We measured the efficacy of telephone follow-up to determine if it could safely reduce the need for routine postoperative clinic visits in this population. Low-risk nonelective laparoscopic appendectomy, laparoscopic cholecystectomy, umbilical hernia, and inguinal hernia repair patients received telephone follow-up for symptoms concerning for surgical complication within 10 days of discharge. Clinic appointments were made if critical thresholds were reached. Outcomes of interest included rates of completed telephone screens, clinic visits avoided, and missed complications at 30 days postoperatively. Of 402 patients screened, 62 (15.4%) were scheduled for a clinic visit due to threshold responses and 27 (6.7%) were scheduled per patient request, while 275 (68.4%) patients screened negative and did not attend a clinic visit. One hundred sixty-three (59.3%) of the negative screen cohort were contacted after 30 days. Nine (5.5%) patients in this cohort were diagnosed with low-grade complications; no high-grade (Clavien-Dindo ≥ 3) complications were missed by telephone screening. Twenty surgery-related complications were identified in the full patient population; early telephone screening successfully identified the single high-grade complication. Post-discharge telephone follow-up in cEGS patients reduced the need for clinic follow-up visits by 68%. Missed complications were infrequent and low grade; telephone screening identified the single high-grade complication. Telephone follow-up for low-risk EGS patients is safe and increases efficiency of postoperative resource use.

1725 Dual-Opioid Post-Operative Prescription Model in Gynecologic Surgery – A Pilot Study

Study Objective Determine if providing two opioid prescriptions postoperatively is an effective strategy to decrease total number of opioids obtained. Design Retrospective descriptive study. Setting Tertiary care academic institution. Patients or Participants Thirty-nine patients undergoing gynecologic surgery. Interventions Two oral narcotic prescriptions were provided post-operatively. Patients were instructed to initially fill the first prescription with 10 pills. If the patient continued to have opioid requirement for pain control, she was instructed to fill the second prescription with an additional 20 pills. Opioids obtained within 6 weeks post-operatively were confirmed utilizing the Arizona Board of Pharmacy Controlled Substance Monitoring Program. Measurements and Main Results Thirty-nine patients underwent gynecologic surgery via laparoscopy or robotics (N=26), laparotomy (N=3), or vaginal routes (N=10). In the post-operative period, 24 patients (61.5%) filled only 10 pills and 15 patients (38.4%) filled the additional 20 pills (CI 44.62%-76.64% p-value 0.15). Patients filling only one prescription versus two prescriptions were not affected by age (49.6 years vs. 43.2 years, p-value 0.193), BMI (26.9 kg/m2 vs. 29.3 kg/m2 p-value 0.157), history of chronic pain (25% vs. 46.7%, p-value 0.163), smoking history (never smokers 66.7% vs. 66.7%, p-value 0.713), or post-operative IV narcotic use (morphine milligram equivalents) prior to discharge (23.3 mg vs. 31.2 mg p-value 0.187). There were no pain related post-operative clinic visits. Conclusion Providing dual narcotic prescriptions after gynecologic surgery can decrease the number of opioids obtained by patients postoperatively. Patient characteristics cannot be used to predict who fills the second prescription. This strategy was not associated with pain related post-operative visits.

Postoperative Complications Following Ankle Fractures in the Geriatric Population: A Case Series

Category:Ankle, TraumaIntroduction/Purpose:Ankle fractures are among the most common orthopedic injuries. While open reduction and internal fixation (ORIF) is the standard treatment for displaced ankle fractures in younger patients, there is controversy regarding the optimal management of these injuries among geriatric patients due to the high prevalence of comorbidities. Closed manipulation leads to poor long-term functional outcomes, with high rates of malunion and non-union in all populations as well as higher mortality in patients over 65 years of age. However, surgical management in the elderly carries rates of complications as high as 20-40%. The purpose of this study was to investigate risk factors for healing complications following ORIF of ankle fractures in patients greater than 75 years of age.Methods:All patients 75 years of age and older undergoing open reduction and internal fixation of ankle fractures at a single institution from 2008 to 2018 were identified. Patients with polytrauma and/or pilon fractures were excluded. Patient medical records were reviewed to obtain information regarding details about the injury, surgery, and follow-up as well as patient demographics and comorbidities. Radiographs from post-operative clinic visits were examined by a foot and ankle certified orthopedic fellow for each patient and the time for complete union was recorded as well as any delayed union or malunion. Fisher’s exact tests were used to compare post-operative complications (wound infection, wound dehiscence, sepsis, deep vein thrombosis, revision surgery, and malunion/nonunion) among those with and without specific comorbidities.Results:Patients with other comorbidities had a statistically significant increased risk of revision surgery (p<0.0001). Additionally, those who used illicit drugs had statistically significant increased risk of sepsis (0.0213). Revision surgeries included syndesmotic screw removal, a standard procedure which does not necessarily imply presence of complication.Conclusion:Elderly patients are susceptible to various postoperative complications. Substance abuse is associated with revision surgery, while the presence of other comorbidities collectively is associated with sepsis. To optimize postoperative management, surgeons should be aware of patient comorbidities and exceptionally attentive at follow-up examinations for these patients.

Traction Time, Force and Postoperative Nerve Block Significantly Influence the Development and Duration of Neuropathy Following Hip Arthroscopy

To (1) evaluate the individual and combined effects of traction time and traction force on postoperative neuropathy following hip arthroscopy, (2) determine if perioperative fascia iliaca block has an effect on the risk of this neuropathy, and (3) identify if the these items had a significant association with the presence, location, and/or duration of postoperative numbness. Between February 2015 and December 2016, a consecutive cohort of hip arthroscopy patients was prospectively enrolled. Traction time, force, and postoperative nerve block administration were recorded. The location and duration of numbness were assessed at postoperative clinic visits. Numbness location was classified into regions: 1, groin; 2, lateral thigh; 3, medial thigh; 4, dorsal foot; and 5,preoperative thigh or radiculopathic numbness. A total of 156 primary hip arthroscopy patients were analyzed, 99 (63%) women and 57 (37%) men. Mean traction time was 46.5 ± 20.3minutes. Seventy-four patients (47%) reported numbness with an average duration of 157.5 ± 116.2days. Postoperative fascia iliaca nerve block was a significant predictor of medial thigh numbness (odds ratio, 3.36; 95% confidence interval, 1.46-7.76; P= .04). Neither traction time nor force were associated with generalized numbness (P= .85 and P= .40, respectively). However, among those who experienced numbness, traction time and force were greater in patients with combined groin and lateral thigh numbness compared with those with isolated lateral thigh or medial thigh numbness (P= .001 and P= .005, respectively). Postoperative neuropathy is a well-documented complication following hip arthroscopy. Concomitant pudendal and lateral femoral cutaneous nerve palsy may be related to increased traction force and time, even in the setting of low intraoperative traction time (<1hour). Isolated medial thigh numbness is significantly associated with postoperative fascia iliaca blockade. IV, case series.

Early post-operative opioid consumption: A comparison between medial unicompartmental, patellofemoral, and total knee arthroplasty

BackgroundWhile there is emerging literature describing the use of narcotics for post-operative pain control following TKA, little data is available regarding narcotic use in partial knee replacements. The aim of this study is to compare the early post-operative narcotic requirements after medial compartmental arthroplasty (UKA) and patellofemoral arthroplasty (PFA) with that of TKA. MethodsIn this retrospective chart review, we identified 37 patients who underwent PFA and 71 patients who underwent UKA. We identified a cohort of TKA patients who were matched to the unicompartmental group based on sex and age (n = 108). The primary outcome measure was self-reported use of opioids for pain management at the first post-operative clinic visit. Opioid use between groups was compared using Chi-square analysis. ResultsThe PFA group was younger (p < 0.001) and consisted of more females (p < 0.001) than the UKA group. The UKA cohort had more non-smoking patients (p = 0.044) compared to the PFA cohort. Self-reported opioid use at the first post-operative visit differed between the three groups of patients (p < 0.001). A greater proportion of both PFA (38% vs. 11%; p < 0.001) and TKA (41% vs. 11%; p = 0.01) patients reported opioid use when compared to UKA patients. No differences in opioid use existed between TKA and PFA groups (p = 0.61). ConclusionThe prevalence of PFA patients who report opioid use at the first post-operative visit is similar to that for patients following TKA, suggesting that pain management protocols for this specific subset of partial knee arthroplasty patients should be structured similar to TKA patients and separate from UKA patients.

High Satisfaction in Adolescent Idiopathic Scoliosis Patients on Enhanced Discharge Pathway.

Recently, there have been several reports of using an enhanced discharge pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). No previous studies have prospectively examined patient satisfaction of patients with AIS using an enhanced discharge pathway. The purpose of this study was to evaluate patient satisfaction with an enhanced discharge pathway for PSF and whether patients felt that their length of stay was appropriate. Patients with AIS undergoing PSF were prospectively enrolled. At their first postoperative clinic visit, patients were administered a survey regarding their experience. Of the 46 patients enrolled (mean age, 14 y), 1 was discharged on postoperative day (POD) 2, 33 were discharged on POD 3, 9 were discharged on POD 4, and 3 were discharged on POD 5. Eighty (37/46) of patients felt that they were discharged at an appropriate time, whereas 20% (9/46) felt they were discharged too early. Patients who felt they were discharged at an appropriate time (mean, 3.2 d) had a trend toward shorter stays than those who felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction (P=0.723). Patients who felt they were discharged early had a significantly higher mean FACES pain scores than those who felt they were discharged about right both as inpatients (mean, 4.8 vs. 3.4; P=0.0319) and at their first postoperative clinic visit (5.4 vs. 2.9; P=0.004). Eighty percent of patients with AIS who underwent PSF felt that the time of discharge was appropriate with an enhanced discharge pathway. There was no correlation between patient satisfaction and length of stay. Level II.

The utility of post-operative hip radiographs in patients treated with hip hemiarthroplasty for femoral neck fractures

BackgroundPatients treated with hip hemiarthroplasty for low energy femoral neck fractures routinely undergo hip radiographs at each postoperative clinic visit regardless of history and physical findings. No studies to date have evaluated the effectiveness of this accepted practice. The goal of this study was to identify the postoperative utility of both history and physical (H/P) and hip radiographs in the treatment course of patients treated with hip hemiarthroplasty for low energy femoral neck fractures. MethodsA retrospective chart review was performed on consecutive patients treated with hip hemiarthroplasty for low energy femoral neck fractures. An abnormal H/P and hip radiographs as well as a change in treatment course were recorded at each clinic or emergency department visit. ResultsFive hundred and eighty-three patients met inclusion criteria, consisting of 1177 clinic and 50 emergency department (ED) visits. An abnormal radiograph in the presence of a normal H/P did not lead to a change in treatment course. An abnormal H/P alone changed treatment course in 28 (3%) clinic visits and 18 (36%) ED visits. An abnormal H/P and the presence of an abnormal hip radiograph changed the treatment course in 23 (2%) clinic visits and 18 (36%) ED visits. In only one case − 0.3% of abnormal radiographs or 0.08% of 1177 clinic visits - did an abnormal hip radiograph change treatment course in the setting of an abnormal H/P within 6 months from surgery. The average cost of a series of hip and pelvis radiographs was $242. ConclusionsAbnormal radiographs do not change treatment course in the presence of a normal H/P. Hip radiographs obtained in clinic within 6 months of surgery rarely lead to a change in treatment course and thereby are a source of excess cost and radiation exposure to the patient.

Commentaries on health services research

Commentaries on health services research

Catheter burden following urogynecologic surgery

Data on the experience that women who undergo urogynecologic surgery have with postoperative catheterization are severely limited. As the importance of our patients' perioperative experience becomes more valued, assessment of the burden of postoperative catheterization, which has not yet been performed, is increasingly needed. The aim of this study was to compare catheter burden in women who self-selected use of an indwelling Foley catheter vs clean intermittent self-catheterization for voiding dysfunction after reconstructive pelvic surgery. This is a nested study within a nonblinded randomized controlled trial of 2 different voiding trial protocols that was conducted from March to October 2017. Women who underwent pelvic organ prolapse and/or stress urinary incontinence surgery who were English speaking and ≥18 years old with a preoperative postvoid residual <100 mL were included. Participants who did not pass their voiding trial were discharged with an indwelling Foley catheter or self-catheterization per participant preference. Our primary outcome was catheter burden at 1 week after surgery assessed by the Short-Term Catheter Burden Questionnaire, which is a validated 6-item survey comprised of 2 subscales: difficulty of use and embarrassment. Scores range from 3-15 withhigher scores indicating greater difficulty and/or embarrassment, and the sum of the 2 subscale scores measures total catheter burden with a higher score indicating greater burden. Secondary outcomes included the rate of urinary tract infection, the number of postoperative clinic visits, and the number of postoperative phone calls. Of 150 participants, 77 women (51%) did not pass their voiding trial; of those, 47 women (61%) were discharged home with an indwelling catheter and 30 women (39%) with self-catheterization. Baseline demographics were similar, except that women who chose an indwelling Foley catheter were older (62±11 vs 55±11 years; P<.01). There were no significant differences between indwelling Foley catheter and self-catheterization in total catheter burden score (18±5 vs 18±6; P=.77), difficulty of use subscale score (8±3 vs 9±3; P=.20), or embarrassment subscale score (10±4 vs 9±4; P=.12). For secondary outcomes, there were no significant differences in rate of urinary tract infection (23% indwelling vs 30% self-catheterization; P=.60). Consistent with study protocol, women who were discharged with an indwelling Foley catheter did have more postoperative clinic visits (2±1 vs 1±1 visits; P<.01), and those women who were discharged with self-catheterization had more postoperative phone calls (2±3 vs 5±3 phone calls; P<.01). Otherwise there was no significant difference in nonvoiding-related clinic visits (1±1 visits for indwelling and self-catheterization; P=.15) or postoperative phone calls (1±2 indwelling vs 2±3 self-catheterization calls; P=.31). In women who used either an indwelling Foley catheter or clean intermittent self-catheterization for management of postoperative voiding dysfunction after pelvic reconstructive surgery, there were no differences in difficulty of use, embarrassment, or overall catheter burden. There were also no differences in nonvoiding-related postoperative phone calls or clinic visits, with similar rates of urinary tract infection between the 2 groups.