Preoperative Physical Examination Research Articles

Risk factors for allogenic transfusion after posterior correction surgery for adolescent idiopathic scoliosis

Objective To investigate the incidence and risk factors for allogenic transfusion after posterior correction surgery for adolescent idiopathic scoliosis (AIS). Methods We retrospectively analyzed 936 patients (147 male and 789 female) undergoing posterior correction surgery for AIS. The patients, aged (14.4±1.7) (11-18) years, were divided into two groups: postoperative blood transfusion group (n=188) and postoperative non-transfusion group(n=748). The preoperative blood assay and physical examination were performed, and information about the surgery and treatment was collected. Potential risk factors for postoperative allogenic transfusion were evaluated by univariate and multivariate regression analysis. Results Postoperative allogenic transfusion was performed in 188 (20.1%) patients undergoing posterior correction surgery for AIS. Univariate analysis showed that Hb levels, Cobb angle and BMI before operation, estimated blood loss during operation, operation time, tranexamic acid (TXA), number of fused levels, postoperative drainage volume, ASA score, and gender had significant effects on postoperative allogenic transfusion. Logistic regression analysis identified male [odds ratio (OR)=2.258, 95%CI 1.266-4.028], the number of fused levels>12(OR=1.587, 95%CI 1.070-2.353), preoperative hemoglobin lower than 128 g/L(OR=1.956, 95%CI 1.356-2.820), postoperative drainage volume>515 ml(OR=2.025, 95%CI 1.409-2.911), are influencing factors for postoperative allogenic transfusion, the use of TXA (OR=0.497, 95%Cl 0.266-0.930) is the protective fator for it. Conclusions The allogenic transfusion rate after posterior correction surgery for AIS was 20.1% in this study. Male, the numbers of fused levels>12, postoperative drainage volume>515 ml, preoperative Hb<128 g/L are risk factors for postoperative allogenic transfusion, the use of TXA is the only protective fctor for postoperative allogenic transfusion. Key words: Idiopathic scoliosis; Adolescent; Posterior correction surgery; Bloodtransfusion; Risk factors

Defunding preoperative histories and physical exams: putting the cart before the evidence?

ObjectiveSeveral Canadian health authorities have defunded preoperative cataract history and physical examinations performed by general practitioners. While these authorities suggest that such decisions are evidence-based, we are unaware of reviews addressing this topic, nor have health authorities been forthcoming with evidence used in their decision-making processes. The objective of this study is to perform a comprehensive review of the literature regarding the value of preoperative histories and physical examinations in cataract surgery. DesignSystematic review. MethodsThe following databases were searched: PubMed, MEDLINE, Cochrane Library, Google Scholar, Web of Science, EMBASE, CINAHL, and BIOSIS Previews. Only higher-level forms of evidence were assessed, including randomized controlled trials, cohort, and case-control studies. Two reviewers independently assessed titles and abstracts for concordance with inclusion criteria. Disagreements between authors were resolved by discussion. ResultsWe identified 3 articles that met our inclusion criteria: two prospective and one retrospective cohort studies. These articles suggest traditional preoperative histories and physical examinations could be replaced by a health questionnaire (Jastrzebski et al. and Reeves et al.) or eliminated altogether (Alboim et al.). DiscussionScientific literature presently contains 3 studies suggesting that preoperative histories and physical examinations could be modified or eliminated. However, methodological weaknesses and data analysis derived from these studies suggests defunding preoperative medical examination may be premature. ConclusionsWhile finding efficiencies in medical care is admirable, physicians should be cautious in accepting recommendations that reduce checks ensuring perioperative safety. Further studies of better methodological quality should be completed to clarify the present evidence.

High Rate of Return to High-Intensity Interval Training After Arthroscopic Management of Femoroacetabular Impingement Syndrome

Background: Since the inception of CrossFit in 2000, the popularity of high-intensity interval training (HIIT) in the United States has risen dramatically. While HIIT is a highly efficient exercise for weight loss and improved conditioning, some literature reports injuries in up to 34% of HIIT participants. We sought to evaluate the functional and sports-specific results of hip arthroscopic surgery in recreational HIIT participants. Purpose: To evaluate patients’ ability to return to HIIT after hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS). Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients with FAIS who had identified themselves as participating in HIIT and had undergone hip arthroscopic surgery for the treatment of FAIS by a single fellowship-trained surgeon between 2012 and 2015 were reviewed. Demographic data; preoperative physical examination findings; preoperative imaging results; preoperative patient-reported outcome (PRO) scores including the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain; and postoperative examination and PRO scores at a minimum 2 years after surgery, including a HIIT-specific questionnaire, were assessed for all patients. Results: Thirty-two patients (13 male, 19 female) with a mean age of 34.7 ± 6.9 years (range, 21-49 years) were identified with a minimum 24-month follow-up. Among these, 22 participated in CrossFit, 4 in Shred415, 3 in Orangetheory, and 3 in self-directed cross-training including plyometrics. Preoperatively, 14 patients had discontinued HIIT because of activity-related hip complaints, 17 patients had scaled back involvement in HIIT, and 1 patient maintained her baseline routine. Postoperatively, 28 of 32 patients (88%) returned to HIIT at a mean of 9.8 ± 5.7 months after surgery (range, 3-24 months); 96% returned to HIIT at the same level as or better than before the injury. Fear of reinjury was the most common reason for cessation (3/4). Preinjury and postoperative involvement in HIIT were comparable (5.3 vs 5.1 h/wk, respectively; P = .8). All patients had significant improvements in the HOS-ADL score (69.7 ± 17.3 to 94.2 ± 8.4; P < .001), HOS-SSS score (49.2 ± 21.2 to 83.3 ± 21.4; P < .001), mHHS score (59.9 ± 14.2 to 85.4 ± 11.6; P < .001), and VAS for pain score (7.5 ± 1.8 to 1.1 ± 1.3; P < .001) from preoperatively to postoperatively. Conclusion: Arthroscopic treatment of FAIS in recreational HIIT participants resulted in significant improvements in hip function and predictably high rates of patient satisfaction. Postoperatively, 88% of patients returned to HIIT, 44% noted improvement from preinjury HIIT performance, and the mean weekly participation was comparable with before the injury.

Open Reduction and Internal Fixation for the Treatment of Symptomatic Osteochondritis Dissecans of the Femoral Head in Patients With Sequelae of Legg-Calvé-Perthes Disease.

Osteochondritis dissecans (OCD) is estimated to occur in 2% to 7% of patients with Legg-Calvé-Perthes disease (LCPD). Unstable osteochondral fragments secondary to LCPD may produce mechanical symptoms requiring surgical intervention. Reattachment of the fragment with open reduction and internal fixation (ORIF) may provide good clinical outcomes. The purpose of this study is to report short-term clinical and radiographic results of ORIF for the treatment of symptomatic osteochondral lesions resulting from LCPD. Clinical data including patient demographics and patient-reported outcome scores were collected prospectively. All patients underwent preoperative radiographs and magnetic resonance imaging confirming an unstable OCD fragment as well as postoperative radiographs at regular intervals. Indications for ORIF of the OCD fragment were hip pain and mechanical symptoms with radiographic evidence of LCPD and a magnetic resonance imaging demonstrating an OCD fragment of the femoral head. Osteochondral fragment instability was confirmed intraoperatively. Preoperative and postoperative physical examination findings were documented. All patients failed a course of nonsurgical treatment (activity modification, anti-inflammatories, and physical therapy). From a total of 64 consecutive patients treated with hip preservation surgery for LCPD, 7 patients with symptomatic OCD secondary to LCPD were treated with surgical hip dislocation and ORIF of the femoral head osteochondral fragment. OCD size lesion ranged from 200 to 625 mm. All patients reported marked clinical improvement, with resolution of both pain and mechanical symptoms. Radiographs at final follow-up demonstrated complete osteochondral fragment healing without implant failure. Mean follow-up was 4.6 years (range, 1.1 to 7.4 y). There was a significant postoperative improvement in measured internal rotation in flexion (5.0±5.0 to 16.4±9.8; P=0.02). Modified Harris Hip Score markedly improved from baseline to final follow-up (47.8 to 82.7; [INCREMENT]34.9; minimal clinically important difference, 11; P=0.002), with all patients meeting minimal clinically important difference for modified Harris Hip Score. There were no complications and no progression of osteoarthritis in all patients at final follow-up. We have demonstrated both predictable radiographic healing and marked clinical improvement following ORIF of symptomatic post-Perthes OCD lesions. We advocate ORIF for symptomatic osteochondral lesions as a first-line surgical treatment for these patients due to the advantages of native osteochondral tissue preservation, predictable healing, and marked clinical improvement. Level IV-case series.

Airway Management for the Oral Surgery Patient.

This article discusses anesthesia assessment concepts related to airway evaluation and airway maintenance for safe and reliable selection of either open system (entrainment of room air) or closed system (no entrainment of room air) airway devices, which can be used during office-based oral surgical procedures, depending on the needs of a patient. Dental facial and oral structures are integral to an anesthetist's preoperative patient evaluation prior to surgery. The preoperative medical history and physical examination as well as the nature of the oral surgical procedure affect the selection of a proper and safe airway device.

High Rate of Return to Swimming After Hip Arthroscopy for Femoroacetabular Impingement

To evaluate patients' ability to return to swimming after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) with capsular closure. Consecutive FAIS patients who had undergone hip arthroscopy for the treatment of FAIS by a single fellowship-trained surgeon were reviewed. The inclusion criteria included patients with a diagnosis of FAIS who self-reported being swimming athletes with a minimum clinical follow-up duration of 2years. For all patients, we assessed demographic data; preoperative physical examination findings, imaging findings, and patient-reported outcome (PRO) scores including the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and visual analog scale for pain; and postoperative examination findings and PROs at a minimum of 2years after surgery, including a swimming-specific questionnaire. The study included 26 patients (62% female patients; average age, 31.3 ± 7.2years; average body mass index, 24.2 ± 2.7 kg/m2). Preoperatively, 24 patients (92%) were unable to swim at their preinjury level, and swimming was either decreased or discontinued entirely at an average of 6.0 ± 4.0months before surgery. All 26 patients (100%) returned to swimming at an average of 3.4 ± 1.7months after surgery, including 14 (54%) who returned at a higher level of performance than their preoperative state, 10 (38%) who returned to the same level, and 2 (7%) who returned at a lower level. The ability to return at a higher level of performance was not associated with age (P= .81), sex (P= .62), or body mass index (P= .16). At an average of 31.2 ± 4.95months' follow-up, postoperative PRO scores improved significantly from preoperative values (Hip Outcome Score-Activities of Daily Living subscale from 68.5 ± 19.9 to 93.9 ± 5.7, P < .0001; Hip Outcome Score-Sports-Specific subscale from 44.0 ± 21.0 to 85.2 ± 16, P < .0001; and modified Harris Hip Score from 59.5 ± 12.1 to 94 ± 8.6, P < .0001). The average patient satisfaction level was 93% ± 9%. Recreational and amateur swimmers return to swimming 100% of the time after hip arthroscopy for FAIS, with just over half returning at a higher level, and most of these patients return within 4months after surgery. This information is critical in counseling patients on their expectations with respect to returning to swimming after hip arthroscopy for FAIS. Level IV, case series.

High Rate of Return to Yoga for Athletes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Background:Femoroacetabular impingement syndrome (FAIS) is most commonly diagnosed in patients who perform activities that require repetitive hip flexion and rotational loading. Yoga is an activity growing in popularity that involves these motions. The purpose of this study was to evaluate patients’ ability to return to yoga after hip arthroscopy for FAIS.Hypothesis:There would be a high rate of return to yoga after hip arthroscopy.Study Design:Retrospective analysis.Level of Evidence:Level 4.Methods:Consecutive patients with FAIS who had identified themselves as participating in yoga and had undergone hip arthroscopy for the treatment of FAIS between 2012 and 2015 were reviewed. Demographic data were collected and assessed for all patients, as well as preoperative physical examination, imaging, and patient-reported outcome (PRO) scores, including the modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, and visual analog scale (VAS) for pain. Postoperatively, examination and PRO data were collected at a minimum 1 year after surgery, including a yoga-specific questionnaire.Results:A total of 42 patients (90% female; mean age, 35 ± 9 years; mean body mass index, 23.1 ± 3.2 kg/m2) were included. Thirty patients (71%) had to discontinue their yoga routine preoperatively because of hip-related symptoms at a mean 9.5 ± 8.2 months before surgery. After surgery, 39 patients (93%) were able to return to yoga at a mean 5.3 ± 2.2 months after surgery. Two of the 3 patients who did not return to yoga noted loss of interest as their reason for stopping, while 1 patient was unable to return because of persistent hip pain. Nineteen patients (45%) returned to a higher level of yoga practice, 17 patients (40%) returned to the same level, and 3 patients (7%) returned to a lower level. There was no difference in the number of hours spent practicing yoga per week pre- and postoperatively (2.7 ± 1.9 vs 2.5 ± 1.3 hours; P = 0.44). All patients demonstrated significant improvement in all PROs as well as pain scores after surgery (HOS-ADL, 67.4 ± 18.3 to 93.1 ± 6.9 [P < 0.001]; HOS-SS, 45.6 ± 24.7 to 81.5 ± 18.8 [P < 0.001]; mHHS, 62.3 ± 11.3 to 86.8 ± 12.3 [P < 0.0001]; VAS pain, 6.3 ± 2.2 to 0.90 ± 1.1 [P < 0.001]).Conclusion:Patients participating in yoga return to yoga 93% of the time and at a mean 5.3 ± 2.2 months after hip arthroscopy for FAIS.Clinical Relevance:Information regarding surgical outcomes is critical in counseling patients, particularly female athletes, on their expectations with respect to returning to yoga after hip arthroscopy for FAIS.

Endoscopic Repair of Partial-Thickness Undersurface Tears of the Abductor Tendon: Clinical Outcomes With Minimum 2-Year Follow-up

To report the minimum 2-year outcomes of transtendinous repair of partial-thickness undersurface tears of the abductor tendon using patient-reported outcomes (PROs), visual analog scale (VAS) scores, and patient satisfaction scores. All patients who underwent endoscopic transtendinous gluteus medius repair between October 2009 and May 2013 at 1 institution were prospectively evaluated. The exclusion criteria consisted of less than 2years' follow-up, previous hip surgery, inflammatory arthritis, open surgery, full-thickness abductor tear, and Workers' Compensation patients. All patients underwent a documented preoperative physical examination with strength testing (scale of 0-5) and observation of their gait. Patient satisfaction and PRO scores were recorded preoperatively; at 3months postoperatively; and at 1, 2, 5, and 10years after surgery. The PRO scores collected were the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living Subscale, Hip Outcome Score-Sports-Specific Subscale, Non-arthritis Hip Score, and VAS score. Preoperative strength and gait were compared with latest follow-up. There were 25 patients who fit our criteria. Significant improvement in PRO scores were shown for the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living Subscale, Hip Outcome Score-Sports-Specific Subscale, Non-arthritis Hip Score, and VASscore from 54.9 to 76.2, from 50.2 to 80.6, from 30.1 to 67.3, from 51.9 to 82.4, and from 7.1 to 2.7, respectively (P<.001). Before surgery, 11 patients had objective weakness; 7 of these patients moved up at least 1 strength grade byfinal follow-up. Preoperatively, 14 patients had a Trendelenburg gait; 12 of them had a normal gait at latest follow-up (P < .001). The average patient satisfaction rating was 7.5. There were no revision surgical procedures, and no complications were noted. Partial-thickness undersurface tears of the abductor can be treated successfully with endoscopic transtendinous repair preserving the intact attachment of the superficial fibers of the gluteus medius. We recommend this treatment for partial undersurface tears recalcitrant to nonoperative treatment because patients showed clinical benefit at greater than 2years' follow-up that exceeded substantial clinical benefit and the minimal clinically important difference. Level IV, case series.

What Determines the Success of Closed-Wedge High Tibial Osteotomy: Severity of Malalignment, Obesity, Follow-up Period, or Age?

Objectives:High tibial osteotomy (HTO) is a well-established procedure for the treatment of medial knee osteoarthritis originating from malalignment of the lower extremity. The current study was designed to evaluate the clinical and radiographic results of closed-wedge HTO for the treatment of medial knee osteoarthritis and to reveal factors affecting the outcome.Methods:A retrospective study was conducted with 138 patients who were operated on for medial knee osteoarthritis between 2000 and 2007 using closed-wedge HTO. Preoperative and follow-up physical examination findings, body mass index (BMI) values, and Hospital for Special Surgery (HSS) and Lysholm knee scores were reviewed. Radiographic evaluation included measurement of the mechanical axis preoperatively and the most recent follow-up orthoroentgenograms. The follow-up knee scores were evaluated according to preoperative mechanical axis, obesity, age, follow-up period, and gender of the patient. The mechanical axis measurement was assessed based on obesity, age, and follow-up period.Results:The mean preoperative and latest follow-up mechanical axis was 4.92o±4.24o varus and 3.43o±3.74o valgus, respectively (p=0.0001). Improvement in the Lysholm (p=0.0001) and HSS (p=0.0001) knee scores was significant. The preoperative mechanical axis, obesity, follow-up period, and gender had no negative effect on the follow-up knee scores, whereas a preoperative age over 50 years had a negative effect on the follow-up knee score. Obesity and the length of the postoperative follow-up period did not have a negative effect on the postoperative mechanical axis, whereas a preoperative age over 50 had a negative effect on the postoperative mechanical axis.Conclusion:The results of this study suggest that medial knee osteoarthritis may be treated successfully with closed-wedge HTO. The analysis indicated that factors such as obesity, the degree of preoperative deformity, and gender do not adversely affect the success of treatment. However, a preoperative age over 50 adversely affected the outcome.

Anatomic findings associated with epispadias in boys: Implications for surgical management and urinary continence

Pre-operative physical examination of male epispadias allows for classification of epispadias level as glanular (GE), penile (PE) or penopubic (PPE), and for delineation of anatomic anomalies. The incidence of associated extragenital abnormalities, such as vesicoureteral reflux (VUR), bladder neck (BN) abnormality and abnormal pubic diastasis (PD), and their impact on urinary continence has not yet been systematically studied. The goal of this study was to evaluate whether the more proximal level of epispadias correlated with associated extragenital anatomic anomalies seen on initial imaging or endoscopic evaluation, and whether these pre-operative findings contributed to subsequent surgical management and impacted on achieving urinary continence. It was hypothesized that the more severe forms of epispadias may be associated with a higher frequency of associated anomalies. The study was an IRB-approved, retrospective case study of all male patients treated initially for isolated epispadias at the current institution between 1994 and 2011. Data collection was achieved by chart and radiology review evaluating PD, BN appearance, presence of VUR, surgical treatment, and urinary continence. A total of 26 patients were identified and divided into three groups based on appearance at physical examination: four glanular (GE), eight penile (PE), and 14 penopubic (PPE); 17 patients had an abnormal BN. Reflux was noted in nine of 20 patients who had a voiding cystourethrogram (VCUG), two of which had an episode of pyelonephritis. Of the 22 patients past the age of toilet training, 17 were continent (64% (9/14) penopubic, 63% (5/8) penile, and 75% (3/4) glanular). Anatomic classification for male epispadias did not provide sufficient information regarding extragenital findings. This study provided new information regarding PD, BN appearance, presence of reflux, and ultimate urinary continence. Pubic diastasis and BN abnormalities were more frequently seen in more severe forms of epispadias, whereas VUR seemed more prevalent in less severe forms. A template for pre-operative evaluation was outlined. Limitations of the study were its retrospective design and relatively small cohort of patients, which reflected the rarity of the condition. Based on the information generated, additional anatomic information was generated regarding boys with epispadias. This information will help guide the evaluation and the management of these patients in the future.

Management of Subscapularis Tendon Tears

Subscapularis tendon pathologies present challenges to the shoulder surgeon at every stage of management: in understanding normal and pathoanatomy, in establishing the correct diagnosis, in making treatment decisions, and in executing an arthroscopic surgical repair. In this article, we summarize the principles and key points of knowledge for successful management of tears of the subscapularis tendon and associated structures. Anatomical and biomechanical studies continue to broaden our understanding of the critical role of the upper subscapularis tendon, where tears are most common yet difficult to screen for with preoperative imaging studies and physical examination. Arthroscopic techniques have become invaluable tools for the surgeon in diagnosis and repair of subscapularis tendon and associated tears, and these are discussed in detail. With proper surgical technique and postoperative management, isolated or combined repair of the subscapularis tendon routinely results in improved patient outcomes, with low reported complication rates.

Surgical and Clinical Decision Making in Isolated Long Thoracic Nerve Palsy.

Isolated long thoracic nerve palsy results in scapular winging and destabilization. In this study, we review the surgical management of isolated long thoracic nerve palsy and suggest a surgical technique and treatment algorithm to simplify management. In total, 19 patients who required surgery for an isolated long thoracic nerve palsy were reviewed retrospectively. Preoperative demographics, electromyography (EMG), and physical examinations were reviewed. Intraoperative nerve stimulation, surgical decision making, and postoperative outcomes were reviewed. In total, 19 patients with an average age of 32 were included in the study. All patients had an isolated long thoracic nerve palsy caused by either an injury (58%), Parsonage-Turner syndrome (32%), or shoulder surgery (10%); 18 patients (95%) underwent preoperative EMG; 10 with evidence of denervation (56%); and 13 patients had motor unit potentials in the serratus anterior (72%). The preoperative EMG did not correlate with intraoperative nerve stimulation in 13 patients (72%) and did correlate in 5 patients (28%); 3 patients had a nerve transfer (3 thoracodorsal to long thoracic at lateral chest, 1 pec to long thoracic at supraclavicular incision). In the 3 patients who had a nerve transfer, there was return of full forward flexion of the shoulder at an average of 2.5 months. A treatment algorithm based on intraoperative nerve stimulation will help guide surgeons in their clinical decision making in patients with isolated long thoracic nerve palsy. Intraoperative nerve stimulation is the gold standard in the management of isolated long thoracic nerve palsy.

Preoperative physical examination and imaging of femoroacetabular impingement prior to hip arthroscopy-a systematic review.

The purpose of this systematic review is to report current preoperative assessment for femoroacetabular impingement (FAI) including physical examination and imaging modalities prior to hip arthroscopy, and report current imaging measures used in the diagnosis of FAI. The electronic databases MEDLINE, EMBASE and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, non-operative treatment, preoperative assessment including physical examination and imaging prior to hip arthroscopy were abstracted. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies criteria. Sixty-eight studies of fair quality evidence that involved a total of 5125 patients (5400 hips) were included. In total, 56% of all patients were male and mean age was 36 years (SD ± 10.0). Within physical examination, FADIR impingement testing was reported in 57% of patients. All included studies reported plain radiographic imaging as a component of preoperative assessment with anterior–posterior pelvis view being the most commonly reported view, followed by the cross-table lateral and Dunn views. Magnetic resonance imaging was obtained for 52% of included patients and computed tomography for 26% of patients. The most commonly reported measure within imaging for the diagnosis of cam type impingement was alpha angle (66%), whereas for pincer type impingement, the cross-over sign (48%) was most reported. Preoperative assessment is underreported in the FAI literature. Improved reporting is warranted to develop a more consistent and validated diagnostic algorithm for FAI to enhance patient selection. Level of evidence: Level IV, Systematic Review of Level I–IV Studies.

688 - Blunt scrotal trauma in adults: A multi-institution experience evaluating the American Association for the Surgery of Trauma organ injury grading scale about 107 cases

The authors evaluated the usefulness of the American Association for the Surgery of Trauma (AAST) testis injury scale based on preoperative scrotal ultrasonography (US) and physical examination compared to peroperative findings. A retrospective review was performed on 107 patients (mean age=29,2±5.8 years) with a testis blunt trauma treated between January 2005 and August 2015. All patients underwent surgical scrotal exploration. Preoperative US was performed in all cases. Testis trauma was classified according to the AAST organ injury scale, preoperatively based on physical examination and scrotal US and then compared to peroperative definitif grading scale. Of the included patients, 14 were found to have abnormal testis contours on US, 25 had a rupture of the tunica albuginea, with a sensitivity of 70,8% and a specificity of 71,2%. Orchidectomy was performed in 12 cases, partial orchidectomy in 32 and tunica albuginea repair in 35 patients. Through this series, US was not a specific and sensitive exam to really precise the severity grade of testis trauma. Pre- and preoperative findings were significantly different. Thus, we continue to support history and clinical findings and we encourage surgical exploration when testis lesion is suspected.

Difficult tracheal intubation and post-extubation airway stenosis in an 11-month-old patient with unrecognized subglottic stenosis: a case report

BackgroundSubglottic stenosis can lead to life-threatening difficult tracheal intubation during general anesthesia. We report a case of difficult tracheal intubation in an 11-month-old female who had unrecognized subglottic stenosis.Case presentationThe patient was scheduled for elective correction of a right accessory auricle. She was suspected of having first and second branchial arch syndrome. Preoperative physical examination was normal. Anesthesia was induced uneventfully using sevoflurane. It was not possible to pass size 4.0, 3.5, or 3.0 cuffed endotracheal tubes due to an advanced subglottic lesion. Subsequent successful intubation was achieved using a 3.0 uncuffed tube. Stridor was audible after extubation, and the patient required several days’ treatment with dexamethasone to address respiratory distress.ConclusionsWe encountered unrecognized subglottic stenosis that led to difficult tracheal intubation and post-extubation airway stenosis.

Preoperative Testing and Planning for Safer Surgery

Consensus statements and regulatory guidelines endorse the process of identifying patients at increased risk for surgical morbidity and mortality. This is termed prognostic testing, and it identifies patients who are deemed to be too sick to benefit from the anticipated gain of surgery. However, much more valuable than prognostic testing is predictive, or directive, testing. A predictive test pinpoints the patient’s problem that will benefit from a specific available intervention. This review covers what is risk?, changing paradigms of surgical success, building a case for moderation, so, does anyone disagree?, timing, frailty and age (and the eyeball test), is the heart the only organ that counts?, changing paradigms, the enhanced importance of functional capacity, resting electrocardiogram, exercise stress testing, ventricular function testing, stair climbing: putting it all together, pulmonary function tests, obstructive airway disease, perioperative nutrition, how can we make surgery safer?, enhanced recovery after surgery, putting it all together, extended enhanced recovery after surgery, tight glucose control, smoking cessation, and timing of collaboration with anesthesia. Figures show routine preoperative tests for elective surgery (adapted from the National Institute for Health and Care Excellence clinical guideline 3, preoperative assessment strategies and recommended risk-reducing therapy relative to American Society of Anesthesiologists (ASA) classification performed by the surgeon and age, ASA Class I and II patients may be safely be evaluated by an anesthesiologist on the day of their scheduled surgery for a full preoperative history and physical examination, flow volume loop. Tables list ASA physical status classification, effect of abnormal screening results on physician behavior, and minimum preoperative test requirements at the Mayo Clinic (in 1997). This review contains 4 highly rendered figures, 3 tables, and 111 references

Hip instability treated with arthroscopic capsular plication

Atraumatic microinstability of the hip is felt to be a cause of intra-articular pathology, particularly tears of the anterior labrum. The purpose of this study is to evaluate a consecutive series of patients with atraumatic hip microinstability that resulted in anterior labral and cartilage pathology, treated with hip arthroscopy and capsular plication without any associated bony procedures. Thirty-two patients underwent hip arthroscopy and suture capsular plication for the treatment of hip instability without concomitant bony resections of the acetabulum or proximal femur between November 2009 and November 2012 and were followed for a minimum of 12months. Patients were clinically evaluated preoperatively and again at 3, 6, 12, 24, and 36months postoperatively with the modified Harris hip score (mHHS) and iHOT score in some patients (as this was introduced late in the study). Comparison was made evaluating centre-edge angle, Tönnis angle, physical examination findings, and demographics on outcome. There was significant improvement in the mean mHHS from 67 (SD=8.7) to 97 (SD=4.7) and iHOT score from 41 (SD=18.3) to 85 (SD=10.1) at final follow-up. When comparing patients with mild hip dysplasia to patients without hip dysplasia, there was no significant difference in clinical outcome at any point in follow-up. There was no significant association between patient age, duration of preoperative symptoms, previous ipsilateral hip arthroscopy, nature of onset of symptoms, centre-edge angle, Tönnis angle, or preoperative physical examination findings with clinical outcome at final follow-up. Isolated arthroscopic suture capsular plication performed for the treatment of hip instability resulted in improved patient pain and function at a minimum of 1-year follow-up.

The effects of dynamic airway photographs on preoperative airway planning among a panel of anesthetists

Study objectiveTo determine whether having preoperative airway photographs will change the preanesthetic airway plan. DesignQuestionnaire. SettingAmerican academic medical center (Brigham and Women's Hospital, Boston MA). SubjectsTwenty-five test subjects (American Society of Anesthesiologists 1-4) were enrolled to have their preoperative airway photographs taken as well as to have a customary preoperative history and physical examination. In addition, 15 anesthetists were enrolled to review the subjects' preoperative history, physical examination, and preoperative airway photographs. MeasurementsAll 15 anesthetists were asked to fill out a survey for airway management for each test subject. Main resultsAll 15 anesthetists completed the survey. Across all providers, plans were changed a median of 24% (95% confidence interval [CI], 12.7-38.6). Among attending anesthesiologists, airway management plans were changed 30% of the time (95% CI, 12.4-40.0), whereas among nonattending level providers, plans changed 24% of the time (95% CI, 12.0-38.8). χ2 Tests found no difference between the percent change of airway plans between attending and nonattending level providers (P=.306). ConclusionsOur findings suggest that the addition of dynamic airway photographs to preoperative airway reports affects airway management plans among a variety of anesthesia care providers. In general, dynamic airway photographs can aid preoperative airway management planning.

Adenotonsillectomy outcomes regarding bone age and osteocalcin in treatment of obstructive sleep apnea syndrome in children.

To investigate the effect of adenotonsillectomy (AT) on bone development, quality of life and polysomnography evaluation in children with obstructive sleep apnea syndrome (OSA). Preoperative and postoperative (6 months) physical examination, PSG, bone age (BA) and osteocalcin (OC) evaluation were performed on the selected OSA children (n=92) and the healthy children (n=87). The OSA children were also scored based on the OSA 18-item questionnaire. A two-year follow-up was conducted to evaluate BA and OC changes. After AT, 81 (88.04%) OSA children recovered completely, eight (8.70%) achieved remarkable improvements, and three (3.26%) achieved moderate improvements. In the OSA children, postoperative OSA 18-item score and the scores of the five domains were significantly higher than preoperative ones. Compared with the preoperative, body mass index (BMI), weight for age Z-sores, height for age Z-sores, weight for height Z-sores and BMI Z-score in the OSA group 6 months after the operation were significantly increased, but no significant difference was detected between the OSA and the control group. The changes of BA and chronological age in the OSA group were significantly different from those in the control group. Two years after AT, BA between the two groups was no longer significantly different. Preoperative serum OC in the OSA group was lower than that in the control group, but increased to normal levels 6 months after AT. Correlation analysis showed serum OC levels were negatively correlated with apnea hyponea index, obstructive apnea index, arousal index, and lowest oxygen saturation. After AT, bone growth and development in children with OSA recovered gradually, and the serum OC levels decreased to the normal level. Therefore, preventive measures and positive treatments should be applied to minimize the negative effects of OSA in children.

Predicting postoperative gait in cerebral palsy

In this work, postoperative lower limb kinematics are predicted with respect to preoperative kinematics, physical examination and surgery data. Data of 115 children with cerebral palsy that have undergone single-event multilevel surgery were considered. Preoperative data dimension was reduced utilizing principal component analysis. Then, multiple linear regressions with 80% confidence intervals were performed between postoperative kinematics and bilateral preoperative kinematics, 36 physical examination variables and combinations of 9 different surgical procedures. The mean prediction errors on test vary from 4° (pelvic obliquity and hip adduction) to 10° (hip rotation and foot progression), depending on the kinematic angle. The unilateral mean sizes of the confidence intervals vary from 5° to 15°. Frontal plane angles are predicted with the lowest errors, however the same performance is achieved when considering the postoperative average signals. Sagittal plane angles are better predicted than transverse plane angles, with statistical differences with respect to the average postoperative kinematics for both plane’s angles except for ankle dorsiflexion. The mean prediction errors are smaller than the variability of gait parameters in cerebral palsy. The performance of the system is independent of the preoperative state severity of the patient. Even if the system is not yet accurate enough to define a surgery plan, it shows an unbiased estimation of the most likely outcome, which can be useful for both the clinician and the patient. More patients’ data are necessary for improving the precision of the model in order to predict the kinematic outcome of a large number of possible surgeries and gait patterns.