Preoperative Physical Examination Research Articles

Accuracy of pre-operative tumor size assessment compared to final pathology and frequency of adjuvant treatment in patients with FIGO 2018 stage IB2 cervical cancer

ObjectiveThe primary aim of our study was to compare tumor size assessment by pre-operative evaluation (physical examination and/or imaging) with tumor size on final pathology. As a secondary outcome, we...

Early combined arthroscopic and open management of combined ACL and PCL tibial spine avulsion in a knee dislocation: A case report

A 35-year-old man presented with right knee pain following a tree stump landing on his leg two days prior. Evaluation revealed a knee dislocation injury (KD III M) with displaced avulsion fractures of the anterior cruciate ligament and posterior cruciate ligament, with the fragments flipped 180 degrees. Additional injuries identified through preoperative imaging (computer tomography, magnetic resonance imaging) and physical examination included bony medial patellofemoral ligament tear, bony posterolateral corner injury, complete medial collateral ligament tear, and medial/lateral meniscus root bony avulsions. The injury was treated utilizing a single-staged arthroscopic and open ligament repair and reconstruction. Bicruciate avulsion fractures in the setting of a knee dislocation injury is a challenging surgical problem in which arthroscopic management of bicruciate tibial spine injuries can be utilized successfully.

Surgical correction of radially deviated Wassel type III thumb polydactyly: a prospective case series.

We report our experience with correction of radially deviated Wassel type III thumb polydactyly. After comprehensive assessments from preoperative radiographs, physical examinations and intraoperative reports, we corrected the metacarpophalangeal joint in 34 cases of radially deviated Wassel type III thumb polydactyly. Opening-wedge osteotomies combining bone graft and soft tissue reconstruction were used in 28 cases and soft tissue reconstruction only in six cases. Absorbable sutures were used instead of traditional Kirschner (K)-wires to fix the bone grafts. Patients were followed up for 12-78 months (mean 47 months). According to the Tada scoring system, 25 patients achieved good results, seven fair results and two poor results. Our modified technique for correcting radially deviated Wassel type III thumb polydactyly yielded satisfactory results. Continued follow-up and further studies will contribute to a better understanding of the long-term efficacy and potential refinements of this technique.Level of evidence: IV.

Anesthesia in Caesarean Section Patients with Hyperthyroid

Thyrotoxicosis is defined as a state of excess thyroid hormone and is not synonymous with hyperthyroidism, which is the result of excessive thyroid function. The prevalence of hyperthyroidism ranges from 0.2% to 1.3% in iodine-sufficient regions of the world. The combination of increasing FT4 and suppressing TSH is one way to enforce the hyperthyroidism diagnosis. The case of a 22-year-old woman with a diagnosis of G6P3A2H3 premature contractions has been reported , who came to the surgical room at Dr. HOSPITAL. Suhatman MARS to perform a caesarean section. Based on the pre-operative physical examination carried out, it was found that the patient's physical status was ASA II. In this patient, regional anesthesia will be planned. The patient has a history of hyperthyroidism since ± 10 years ago and regularly takes Thyrozol once a day during pregnancy and controls it with a specialist in Internal Medicine. Theoretically, this shows that the suspected condition of the patient is hyperthyroidism and if continued it could lead to Graves' disease, toxic nodular goiter, subclinical hyperthyroidism, or other conditions that lead to hyperthyroidism so surgery must be carried out taking this situation into account.

Thoracal meningioma and neurological status recovery 6 months postoperative: A case report

Introduction: Meningioma is the most common intradural tumor of the spinal cord in adults. Spinal meningioma arises from slow-growing arachnoid cap cells, which are generally located intradural extramedullary and grow laterally into the subarachnoid space to stretch the surrounding arachnoid. Local pain is usually the first major symptom. However, the majority of cases are diagnosed after the onset of neurological deficits or impaired walking. Case Presentation: Woman, 46 years old, with back pain radiating to both legs in the last 2 years before surgery. At 16 months before surgery, she had paralysis of both legs with bowel and bladder incontinence. Preoperative physical examination shows no muscle contraction on both lower extremities, with hypoesthesia in the Thoracal 2 dermatome. MRI examination shows intradural extramedullary mass at the level of the 2nd thoracal that compresses the entire spinal canal. Laminectomy surgery on thoracal 2 and tumor resection in toto were performed. Surgical resection showed a tumor mass of 2x1,2x1cm with a thick, spongy, brownish-yellow consistency. Histopathological examination shows psammomatous type meningioma, WHO Grade 1. The patient was discharged postoperatively with palpable muscle contractions on both legs, accompanied by no sensory abnormalities. Evaluation 1 month postoperatively, the patient was able to voluntarily move the lower extremities accompanied by the return of ability to micturate and defecate. Examination at 6 months postoperatively, the patient was able to walk without assistance and no other neurological deficit was found. Conclusion: Tumor resection remains as treatment of choice for spinal meningioma regardless of neurological deficit onset and histological type of tumor.

Electrodiagnostic severity does not predict short- to midterm outcomes of cubital tunnel release surgery

This study aimed to explore the prognostic value of electrodiagnostic studies (EDS) to clarify their utility in clinical practice prior to cubital tunnel release surgery and to identify patient factors associated with patient-reported functional improvement after surgery. Our hypothesis was that patients with severe preoperative findings on EDS will tend to experience less functional improvement after surgery given the extent of ulnar nerve compressive injury. Patients with cubital tunnel syndrome and preoperative electrodiagnostic data treated from 2012 to 2022 with cubital tunnel release were assessed regarding demographic information, preoperative physical examination findings, EDS findings, postoperative complications, and patient-reported outcomes. Short- to midterm quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) scores were collected for all patients for further evaluation of preoperative EDS data. Patients were grouped into those who had met the minimal clinically important difference (MCID) in delta qDASH at short- to midterm follow-up and those who did not. EDS data included sensory nerve onset latency, peak latency, amplitude, conduction velocity, as well as motor nerve latency, velocity, and amplitude. Electromyographic (EMG) studies were also reviewed, which included data pertaining to fibrillations, presence of abnormal fasciculation, positive sharp waves, variation in insertional activity, motor unit activity, duration of activity, and presence of increasing polymorphisms. Of the 257 patients included, 160 (62.0%) were found to meet the MCID for short- to midterm qDASH scores. There were no significant differences between patients who did or did not meet the MCID regarding baseline demographics, comorbidities, preoperative examination findings, and operative technique. Patients who met MCID tended to have lower complication (3.80% vs. 7.20%, P=.248) and revision (0.60% vs. 4.10%, P=.069) rates, but these findings were not statistically significant. The cubital tunnel severity as determined by the EDS was similar between cohorts (14.1% vs. 14.3%, P=.498). Analysis of EMG testing showed there were no significant differences in preoperative, short- to midterm qDASH, or delta short- to midterm qDASH scores for patients with or without abnormal EMG findings. Multivariate regression suggested that only age (P=.003) was associated with larger delta qDASH scores. Patient-reported preoperative disease severity may predict the expected postoperative change in ulnar nerve functional improvement, and EDS may not have prognostic value for patients undergoing cubital tunnel decompression. Therefore, physicians may suggest surgical treatment without positive EDS findings and still expect postoperative improvement in functional outcomes.

Dynamic Computed Tomography of the Distal Radioulnar Joint Versus Magnetic Resonance Imaging in Detecting Foveal Tears of the Triangular Fibrocartilage Complex.

Diagnosis of foveal triangular fibrocartilage complex (TFCC) tears remains difficult. The purpose of this study was to evaluate whether dynamic computed tomography (CT) of the distal radioulnar joint (DRUJ) has a higher sensitivity in detecting foveal tears of the TFCC when compared with magnetic resonance imaging (MRI). A database query identified all patients above the age of 18 years with suspected foveal TFCC injuries who underwent bilateral dynamic CT imaging of the DRUJ, static 3T MRI, and subsequent wrist arthroscopy. All patients had evidence of foveal tenderness on clinical examination. The imaging results were validated with wrist arthroscopy. Twelve patients with a mean age of 31 years (range, 18-53 years) were identified. Eight patients were diagnosed with a complete foveal detachment of the TFCC on wrist arthroscopy. Of the 8 patients with a foveal tear on DRUJ arthroscopy, only 3 had a preoperative physical examination suggestive of DRUJ instability. Magnetic resonance imaging identified foveal injuries in 4 of these 8 patients (sensitivity, 50%), and 3 of these were identified as only partial tears. Dynamic CT identified instability of DRUJ in 6 of 8 patients (sensitivity, 75%). Seven of 8 patients had imaging findings suggestive of a foveal tear when including either MRI or CT imaging (sensitivity, 88%). Of the 4 patients with an intact foveal attachment on arthroscopy, 3 (specificity, 75%) had a stable DRUJ on CT and all 4 (specificity, 100%) had an intact foveal attachment on MRI. Sixty-two percent of patients with foveal tears on arthroscopy have a stable DRUJ on clinical examination. When combining MRI and dynamic CT imaging of the DRUJ, the sensitivity of detecting a foveal TFCC tear approaches 88% compared with a gold standard of wrist arthroscopy.

Abnormal lesion that can be confused with medial meniscal tears, medial meniscocapsular band: a rare presentation

This case report describes a medial meniscocapsular band, a structure extending from the medial capsule of the knee joint to the corpus of the medial meniscus, observed during arthroscopy in a 48-year-old woman. Preoperative physical examination findings were compatible with medial meniscal pathology only; magnetic resonance imaging showed an abnormal medial meniscus and was interpreted in favor of a tear. Arthroscopic examination showed an abnormal band inside the knee. This anatomical lesion is quite rare and similar lesions have been reported in the literature, but the extension of the band in our case is different from the extension in the cases seen in the literature. We believe that the identification of abnormal meniscal types or intra-articular bands is necessary to provide greater accuracy in MR imaging reporting.

Routine history and physical examinations prior to cataract surgery are not beneficial

ObjectifDéterminer l'innocuité d'une politique éliminant la prise des antécédents préopératoires et la réalisation d'un examen physique avant une chirurgie de la cataracte. NatureÉtude rétrospective de population. MéthodesÉtant donné que les antécédents préopératoires et l'examen physique n’étaient plus nécessaires en Alberta après le 1er avril 2017, on a réalisé une étude rétrospective des données issues des demandes de remboursement auprès du régime provincial d'assurance maladie afin de déterminer s'il était sécuritaire d’éliminer ces 2 exigences. Les données provenant d'Albertains qui ont subi une chirurgie de la cataracte et qui ont fait l'objet d'un examen médical préopératoire entre avril 2014 et mars 2017 ont été comparées à celles de patients qui ont subi une chirurgie de la cataracte entre avril 2017 et mai 2020 sans avoir subi d'examen médical préalable. La survenue d'effets médicaux indésirables (soit une visite au service des urgences, une admission à l'hôpital ou le décès dans les 30 jours suivant la chirurgie de la cataracte) tenait lieu de paramètre principal. RésultatsUn total de 236 046 chirurgies de la cataracte ont été réalisées pendant la période à l’étude. La probabilité d'une visite au service des urgences en période postopératoire était plus grande (rapport de cotes [RC] = 1,04; intervalle de confiance [IC] à 95 % : 1,01–1,08) dans le groupe examen préopératoire (n = 112 806 yeux), soit 4,8 % des patients, comparativement à 4,7 % des patients du groupe sans examen préopératoire (n = 123 240 yeux; p = 0,03). De même, les admissions à l'hôpital étaient plus susceptibles de se produire dans le groupe examen préopératoire (RC = 1,26; IC à 95 % : 1,18–1,34) et ont touché 1,8 % de ces patients, comparativement à 1,5 % des patients du groupe sans examen préopératoire (p < 0,0001). Le taux de décès s'est élevé à 0,09 % dans les 2 groupes (p = 0,992). ConclusionsLe taux de visites au service des urgences et d'admissions à l'hôpital dans les 30 jours suivant la chirurgie de la cataracte étaient pour ainsi dire identiques, ce qui donne à penser que les examens préopératoires, qui étaient jusqu'alors réalisés pour réduire le taux de morbi-mortalité postopératoire, offrent peu d'avantages pour les patients.

Use of custom glenoid components for reverse total shoulder arthroplasty.

Our purpose was to evaluate a custom reverse total shoulder arthroplasty glenoid baseplate for severe glenoid deficiency, emphasizing the challenges with this approach, including short-term clinical and radiographic outcomes and complications. This was a single-institution, retrospective series of 29 patients between January 2017 and December 2022 for whom a custom glenoid component was created for extensive glenoid bone loss. Patients were evaluated preoperatively and at intervals for up to 5 years. All received preoperative physical examinations, plain radiographs, and computed tomography (CT). Intra- and postoperative complications are reported. Of 29 patients, delays resulted in only undergoing surgery, and in three of those, the implant did not match the glenoid. For those three, the time from CT scan to implantation averaged 7.6 months (range, 6.1-10.7 months), compared with 5.5 months (range, 2-8.6 months) for those whose implants fit. In patients with at least 2-year follow-up (n=9), no failures occurred. Significant improvements were observed in all patient-reported outcome measures in those nine patients (American Shoulder and Elbow Score, P<0.01; Simple Shoulder Test, P=0.02; Single Assessment Numeric Evaluation, P<0.01; Western Ontario Osteoarthritis of the Shoulder Index, P<0.01). Range of motion improved for forward flexion and abduction (P=0.03 for both) and internal rotation up the back (P=0.02). Pain and satisfaction also improved (P<0.01 for both). Prolonged time (>6 months) from CT scan to device implantation resulted in bone loss that rendered the implants unusable. Satisfactory short-term radiographic and clinical follow-up can be achieved with a well-fitting device. Level of evidence: III.

Variability of somatosensory evoked potential and motor evoked potential change criteria in thoracic spinal decompression surgery based on preoperative motor status

Background contextCombined somatosensory- and motor-evoked potential (SSEP and MEP) changes for predicting prognosis in thoracic spinal surgery have been variably reported. PurposeWe aimed to explore the validity of combined SSEP and MEP for predicting postoperative motor deficits (PMDs) in thoracic spinal decompression surgery (TSDS) and identify a relatively optimal neurophysiological predictor of PMDs in patients based on preoperative motor status. Study settingRetrospective study. Patient sampleA total of 475 patients were analyzed. Outcome MeasuresA reduction in muscle strength by more than or equal to one manual muscle testing (MMT) grade postoperatively compared with the preoperative MMT grade was identified as PMDs. Postoperative motor deficits were detected by comparing the preoperative and postoperative physical examination findings in short- and long-term follow-up visits. MethodsAll patients were divided into two subgroups according to preoperative motor status. The following data were collected: (1) demographic data; (2) IONM (intraoperative neuromonitoring) data; and (3) postoperative motor outcomes. Binary logistic regression analysis was performed to assess the efficacy of IONM change to predict PMDs. A receiver operating characteristic curve (ROC) was used to establish optimal IONM warning criteria. ResultsNinety-eight patients had severe preoperative motor deficits (Group S), and 377 patients did not (Group N). MEP and SSEP change was effective for predicting PMDs in the short term (p<.01) and long term (p<.01) for TSDS patients. In Group N, the cutoff values for predicting PMDs in the short term were a decrease of 65% in SSEP amplitude and 89.5% in MEP amplitude of the baseline value. Furthermore, the cutoff values for predicting PMDs in the short term were durations of change of 24.5 minutes for SSEP and 32.5 minutes for MEP. In Group S, however, the cutoff values for predicting PMDs in the short term were a decrease of 36.5% in SSEP amplitude and 59.5% in MEP amplitude of the baseline value. Moreover, the critical values for predicting short-term PMDs were durations of change of 16.5 minutes for SSEP and 17.5 minutes for MEP. ConclusionsThe optimal IONM changes for prediction vary depending on preoperative motor status. Combined SSEP and MEP are excellent for predicting PMDs in TSDS.

Factors Associated With Humeral Avulsion of Glenohumeral Ligament Lesions in Patients With Anterior Shoulder Instability: An Analysis of the MOON Shoulder Instability Cohort.

Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability. To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions. Cross-sectional study; Level of evidence, 3. Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student t test, Kruskal-Wallis H test, Fisher exact test, and chi-square test were used to compare groups. A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; P = .03) or an anterior labral tear (87.2% vs 66.7%; P = .01) on preoperative MRI and demonstrated increased external rotation when their affected arm was positioned at 90° of abduction (85° vs 90°; P = .03). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization surgery (odds ratio, 74.6 [95% CI, 25.2-221.1]; P < .001). Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions.

Effects of COVID-19 vaccination on cervical lymph nodes in patients with thyroid cancer.

Cervical lymph node enlargement caused by coronavirus disease 2019 (COVID-19) vaccination has been reported, but little is known on whether the vaccination would influence preoperative cervical lymph node evaluation and its risk of lymph node metastasis in thyroid cancer. We retrospectively analyzed data of patients who underwent thyroid cancer surgery in Tangdu Hospital, China, from 1 March 2021 to 30 June 2021. A total of 182 patients were included in the cohort study. All patients with suspected malignant tumors underwent ultrasound (US)-guided fine needle aspiration (FNA) of thyroid lesions before surgery to confirm the diagnosis. Cervical lymph nodes were evaluated by preoperative physical examination and imaging. Wilcoxon rank-sum test and Fisher's exact test were used to evaluate the effect of vaccination on cervical lymph nodes in patients with thyroid cancer. Statistical significance was defined at P<0.05. The patients were divided into two groups according to whether they had been vaccinated or not. Our results showed that there were no significant differences between the two groups in the brand of the vaccine, operation method, and the extent of surgery. Moreover, there was no significant difference in the evaluation of US characteristics of cervical lymph nodes between the two groups regardless of having the vaccination or not. Interestingly, US evaluation found that the experimental group's proportion of cervical lymph node enlargement increased significantly within 14 days after vaccination, which was statistically significant. This study found that vaccination against COVID-19 did not increase the number of cervical lymph node metastases, but inaccurate assessment of cervical lymph nodes in thyroid cancer patients within 14 days of vaccination (due to temporary lymph node enlargement) may lead to more extensive surgery.

A Combined Surgical Approach for Recurrent Patellar Dislocation in Adolescents With Patella Alta and Increased Tibial Tuberosity-Trochlear Groove Distance: Improved Clinical Outcomes but Decreased Posterior Tibial Slopes in Skeletally Immature Patients at Minimum 4-Year Follow-Up

Purpose(1) To report the clinical and radiological outcomes of a surgical technique combining anatomic medial patellofemoral ligament (MPFL) reconstruction and tibia tuberosity transfer in adolescents with patella alta and elevated tibial tuberosity-trochlear groove (TT-TG) distance, in the treatment of recurrent patellar dislocation (RPD); (2) To investigate the potential risks of growth arrest or developmental deformities associated with this combined technique. MethodsMedical records of patients underwent the combined surgery were reviewed from 2015 to 2019. This study included adolescents aged between 14 and 18 years with a Caton-Deschamps index (CDI) greater than 1.30 and TT-TG distance greater than 20mm, with a minimum follow-up of 4 years. Radiological examinations including lateral views and full-length posteroanterior standing radiographs were investigated to assess patella height by CDI, posterior tibia slope (PTS) angle, side-to-side difference (SSD) in bone length, and lower extremity alignment by hip-knee-ankle (HKA) angle; CT-scans and MRI profiles were investigated to evaluate TT-TG distance and staging of growth plate closure. Other evaluations included preoperative and postoperative physical examination, Kujala score, and Tegner activity score. The patients were stratified into 3 subgroups according to a MRI-based staging system of the growth plate closure, and each outcomes were analyzed. A cohort-specific minimal clinically important difference (MCID) estimation was performed using standard error of measurement. ResultsThe average age at the time of surgery was 16.1 years (range, 14.1-17.8). The average follow-up was 5.6 years (range, 4.0-7.6). No recurrent dislocation occurred, no clinically significant deformity or axis deviation was encountered. Postoperative patellar height by CDI was 1.00±0.11 (range, 0.81-1.15). No significant differences were found in pre- and postoperative HKA angle and SSD in femur/tibia length among all subgroups. A significantly decreased PTS angle was found in patients with open growth plates, from 10.2±1.7° preoperatively to 8.1±1.0° postoperatively (P=.015). The Kujala score and Tegner score both significantly improved, from 65.5±13.9 preoperatively to 90.4±7.2 postoperatively in Kujala score (P <0.001), and from 4.0±1.1 preoperatively to 4.7±1.3 postoperatively in Tegner score (P <0.001). Of the whole cohort, 63.1%, 100%, 47.1% and 94.1% patients achieved the MCID for PTS angle, CDI, Tegner score, and Kujala score respectively. ConclusionThis combined technique is safe and effective in treating RPD in skeletally mature adolescents with concurrent patella alta (CDI > 1.30) and TT-TG distance > 20mm, permitting patients to have improved knee function and low complication rates. Nonetheless, patients with open growth plates demonstrated a decrease in PTS, which might predispose the knee to recurvatum and osteoarthritis in the long-term. Study DesignRetrospective therapeutic case series; level of evidence, Ⅳ.

Influence of Electrodiagnostic Studies on Surgery for Carpal Tunnel Syndrome: A Retrospective Analysis of Data from a Single Urban Institution.

Background: This study aimed to clarify the influence of preoperative electrodiagnostic (EDX) utilisation and its severity on surgically treated patients with carpal tunnel syndrome (CTS). Methods: This retrospective study analysed the data of patients who underwent CTS surgery at our facility from 2012 to 2022. Data regarding age, sex, affected side, diabetes mellitus, rheumatoid arthritis, haemodialysis and insurance type were collected, along with the following clinical information: utilisation of EDX, steroid injection, number of items of preoperative physical examination and history taking, intervals between symptom onset and the initial visit and between the initial visit and surgery, type of surgical procedure and surgery categorisation (primary or revision). EDX data (EDX severity, interval between EDX and surgery and concomitant nerve lesions) were also investigated. Univariate and multivariate analyses were conducted to assess the influence of EDX utilisation and severity on clinical parameters. Results: Of the 343 hands enrolled in our study, 304 (89%) underwent preoperative EDX assessment. EDX severity was classified as normal, mild, moderate or severe in 6 (2%), 18 (6%), 102 (34%) and 178 hands (58%), respectively. After the univariate and multivariable analyses, more items of preoperative physical examination and history taking were associated with non-EDX utilisation, whereas younger age, female sex and steroid injection were associated with milder EDX. Conclusions: Increased number of items of preoperative physical examination and history taking or steroid injection were independently associated with non-EDX utilisation or milder EDX, respectively, suggesting that when thorough clinical evaluation is conducted, hand surgeons may be less likely to request for EDX before surgery. Moreover, their treatment recommendation may be influenced by EDX severity. Level of Evidence: Level III (Diagnostic).

Clinical Validation of an Adult-acquired Buried Penis Classification System Based on Standardized Evaluation of the Penis, Abdomen, and Scrotum

To clinically validate a previously developed adult-acquired buried penis (AABP) classification system that is based on a standardized preoperative physical examination that subtypes patients by their penile skin/escutcheon complex (P), abdominal pannus (A), and scrotal skin (S). The Trauma and Urologic Reconstruction Network of Surgeons (TURNS) database was used to create an AABP cohort. Patients were retrospectively classified using the previously described PAS classification system. The frequency of subtypes, surgical methods utilized for AABP repair, and correlations between PAS classification and surgery subtypes were analyzed. The final cohort consisted of 101 patients from 10 institutions. Interrater reliability between two reviewers was excellent (κ = 0.95). The most common subtypes were P2c (contributory escutcheon+insufficient penile skin; 27%) and P2a (contributory escutcheon+sufficient penile skin; 21%) for penile subtypes, A0 (no pannus; 41%) and A1 (noncontributory pannus; 39%) for abdominal subtypes, and S0 (normal scrotal skin with preserved scrotal sulcus; 71%) for scrotal subtypes. AABP repair procedures included escutcheonectomy (n = 59, 55%), scrotoplasty (n = 51, 48%), split-thickness skin grafting (n = 50, 47%), penile skin excision (n = 47, 44%) and panniculectomy (n = 7, 7%). P, A, and S subtypes were strongly associated with specific AABP surgical techniques. The PAS classification schema adequately describes AABP heterogeneity, is reproducible amongobservers, and correlates well with AABP surgery types. Future work will focus on how PAS subtypes affect both surgical and patient-centered outcomes.

Risk factors for pelvic organ prolapse recurrence following colpocleisis: A meta-analysis.

Studies aimed to assess risk factors for pelvic organ prolapse (POP) recurrence following colpocleisis with nonconclusive results. To investigate risk factors for POP recurrence following colpocleisis. MEDLINE, PUBMED, Embase, Web of Science, and Cochrane databases were systematically searched. Experimental and non-experimental studies investigating POP recurrence following colpocleisis. We assessed the association between preoperative and postoperative physical examination findings, demographics and medical history, and the risk of recurrence following colpocleisis. A total of 954 studies were identified, of which five studies comprising 2978 patients were eligible for analysis. Both preoperative and postoperative genital hiatus length were significantly longer in the recurrence group (mean difference [MD] 0.48, 95% confidence interval [CI] 0.01-0.94, P = 0.04, I2 = 0% and MD 1.15, 95% CI 0.50-1.81, P = 0.005, I2 = 0%; respectively). Preoperative total vaginal length (TVL) did not differ between groups (MD 0.05, 95% CI -0.40 to 0.50, P = 0.83, I2 = 6%), postoperative TVL was found significantly longer in the recurrence group (MD 0.07, 95% CI -0.03 to 1.38, P = 0.04, I2 = 68%). Both preoperative and postoperative perineal body did not differ between groups. Women with a previous POP surgery were more likely to experience recurrence following colpocleisis (relative risk 2.09, 95% CI 1.18-3.69, P = 0.01, I2 = 0%). Patient's age and previous hysterectomy did not affect recurrence rates. Wider preoperative and postoperative genital hiatus as well as longer post-operative TVL and previous POP surgery were associated with a higher risk for recurrence following colpocleisis, highlighting the importance of appropriate patient selection and surgical technique in minimizing this risk.

Paper 53: A Predictive Model for Mobile vs. Immobile Osteochondritis Dissecans Lesions of the Knee

Objectives: Osteochondritis dissecans (OCD) of the knee is a focal idiopathic alteration of subchondral bone and/or its precursor with risk for instability and disruption of adjacent cartilage that may result in premature osteoarthritis. Treatment options vary depending on multiple patient and lesion characteristics, including lesion mobility. Recent multicenter studies helped develop the ROCK (Research on Osteochondritis Dissecans of the Knee) Arthroscopy Classification of OCD lesions of the knee. To advance the clinical utility of the classification system, this current investigation aimed to develop a simple, clinical outcomes-based model that could be used to differentiate lesion mobility. We hypothesized that a multivariable model including patient demographics and physical examination findings at clinical presentation would predict the arthroscopically confirmed mobility status of the OCD lesion with high sensitivity and specificity. Methods: Patient data for the predictive modeling came from a multi-center national prospective cohort of patients with osteochondritis dissecans of the knee. Inclusion criteria included patients &lt; 19 years of age, operatively treated OCD of the medial or lateral femoral condyle, and appropriate preoperative and intra-operative data. Demographic, preoperative physical examination, and radiographic data were considered independent predictors in the model. Multivariable logistic regression analysis using stepwise model selection was used to determine factors associated with the likelihood of a mobile versus an immobile lesion. Receiver operating characteristic (ROC) curve analyses were used to dichotomize relevant variables for a final predictive model. The authors reviewed the relevant variables for clinical utility. A 75% partition of the data was used for model training, and 25% was held out for model validation testing. Quantitative model fit statistics were computed using the hold-out data, including sensitivity, specificity, and the area under the ROC curve (AUC), along with the corresponding 95% confidence interval (CI). Results: 479 patients in the prospective cohort who were less than 19 years of age and had surgical treatment of a knee OCD lesion were reviewed. 407 patients had usable preoperative and intra- operative data, including 235 immobile and 172 mobile lesions. Mean chronologic age of the 407 patients was 13.7 (2.2 SD) years with 62% male. Mean height was 63.6 (5.3 SD) inches and 129.5 (40.4 SD) lbs. Mean BMI was 22 (5.1 SD). 21% of the total cohort presented with an effusion on physical examination and 20% presented with reduced range of motion either in flexion or extension compared with their contralateral knee. Patient demographics (age, sex, age, height, weight, BMI) and physical examination findings of relative loss of motion (ROM) compared to unaffected knee and presence of effusion on examination were primary variables of interest. 88 patients were excluded because of missing partial data for modeling. 319 patients had complete data for modeling (training data 75%; n=239; validation data 25%; n=80). Using the training dataset, the multivariable analysis found that chronologic age ≥ 14 years, effusion on physical examination (p=0.004), and any loss of ROM on physical examination (p=0.004) increased the likelihood of mobile lesion controlling for male sex (p=0.42) and weight &gt;120lbs (p=0.23). In the 25% holdout sample (n=80), this model yielded a sensitivity of 83%, a specificity of 75%, and an AUC of 0.86 (95% CI, 0.78-0.94). The final predictive model was created from dichotomized relevant variables (Figure 1). Conclusions: This predictive model for knee OCD lesions indicates a patient presenting with chronologic age ≥ 14 years, evidence of a knee effusion on physical examination, and reduced ROM relative to the contralateral knee is between 90% and 95% likely to have a mobile lesion compared to an immobile lesion using the ROCK Arthroscopy Classification. The ability to predict the mobility of knee OCD lesions before surgical intervention can facilitate improved surgical planning and more relevant communication with families regarding the procedures that will be required. Specifically, this can aid in distinguishing between less invasive interventions such as drilling versus more invasive procedures such as OCD fixation and salvage.

Diagnosis of Posterior and Combined-Type Shoulder Instability: A 10-Year Cross-sectional Study From a Single Military Base

Background: Large variations exist in the reported frequency and etiology of posterior and combined shoulder instability in the active-duty military population. Purpose: To compare imaging and clinical examination findings as well as reoperation rates between active-duty military patients who underwent surgery for anterior, posterior, and combined-type shoulder instability. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was conducted on patients treated surgically for shoulder instability from a single military base from January 2010 to December 2019. Each case was characterized as isolated anterior, isolated posterior, or combined, according to arthroscopic findings. Information was collected on patient characteristics, history of trauma, time to surgery, associated pathological findings, and survivorship at a minimum 2-year follow-up. Results: Overall, 416 patients (n = 394 men; n = 22 women), with a mean age of 29.1 years, underwent primary shoulder stabilization surgery during the study period. There were 158 patients (38%) with isolated anterior instability, 139 (33%) with isolated posterior instability, and 119 (29%) with combined instability. A history of trauma was more prevalent with isolated anterior instability (129 [81.7%]) than with either isolated posterior (95 [68.4%]) or combined instability (73 [61.3%]) ( P = .047 and P = .001, respectively). Patients with anterior instability were significantly more likely to be diagnosed on the preoperative physical examination when compared with patients with posterior instability (93% vs 79.1%; P &lt; .001) or combined instability (93% vs 75.6%; P &lt; .001) and were also more likely to have a discrete labral tear detected on a preoperative magnetic resonance arthrogram than patients with posterior instability (82.9% vs 63.3%; P &lt; .001). There was no significant difference in the rate of medical discharge or recurrent instability requiring reoperation between groups. Conclusion: The study findings indicated that young, active-duty military patients are at increased risk for isolated posterior and combined-type shoulder instability, with posterior and combined instability collectively accounting for over 60% of instability cases in this cohort. Orthopaedic surgeons should be aware of instability when evaluating and treating young, active-duty military patients with shoulder pain, even in the absence of diagnostic physical examinations or imaging findings.

Surgical treatment ofsnapping proximal hamstring tendon syndrome: the resolution ofsnapping andexcellent patient satisfaction.

Snapping proximal hamstring is an uncommon phenomenon, with few case reports documenting surgical treatment. The purpose of this study is to report snapping resolution, minimum 2-year post-operative patient-reported outcome (PRO), satisfaction scores and complications from patients who underwent surgical release of the conjoint tendon from the sacrotuberous ligament with reattachment to the ischial tuberosity. Prospectively collected data from two institutional databases were retrospectively reviewed for patients who underwent hamstring repair for partial- or full-thickness tears. Patients were included if they demonstrated 'snapping proximal hamstrings' on preoperative physical examination, including ultrasound confirmation, and repair subsequently performed. Patients were excluded if they had reconstruction of the proximal hamstring tendon or claimed worker's compensation. With a total of 20 patients (15 females and 5 males), successful resolution of snapping was reported in 100% of the cohort. For patients with pre- and post-surgical lower-extremity functional scores (LEFS), post-surgical LEFS were significantly higher than pre-surgical LEFS (pre-surgical: 17.0 ± 4.0, post-surgical: 73.6 ± 3.3, P < 0.001). Average post-operative PROs were as follows: International Hip Outcome Tool-12, 92.3 ± 8.3; modified Harris Hip Score, 93.2 ± 7.8; Non-arthritic Hip Score, 92.5 ± 6.8; Hip Outcome Score-Sports Specific Subscale, 94.4 ± 6.7; LEFS, 73.9 ± 3.4; and median visual analog scale of 0 with an interquartile range of 0-1. Patient satisfaction was 'very satisfied' in 19 (95%) patients and 'satisfied' in 1 (5%) patient. At a minimum 2-year follow-up, patients who underwent surgical treatment for chronic snapping of the proximal hamstrings demonstrated complete resolution of painful posterior snapping, reported high PROs and satisfaction, and had no reported post-operative complications.