Comparative effectiveness of imaging modalities for preoperative assessment of anorectal malformation in the pediatric population

ObjectiveThe aim of this study was to compare the accuracy of MRI, colostography/fistulography, and X-ray imaging modalities for preoperative diagnosis of anorectal malformations (ARMs) in pediatric patients.MethodsThis retrospective analysis included a total of 84 pediatric patients with ARMs. Preoperative imaging findings were assessed by 2 radiologists and compared to surgical findings.ResultsMRI identified anomalies of the spine in 25 of 84 patients (29.8%), anomalies of the genital system in 7 of 84 patients (8.3%), anomalies of the urinary system in 22 of 84 patients (26.2%), and underdeveloped sphincter muscle complex in 34 of 84 patients (40.5%). In the 44 subjects receiving both MRI and X-ray, MRI was more sensitive in detecting anomalies of spine (18/44 vs. 8/44; P = 0.002), and both correctly identified the distal end of the rectum in 77.3% (34/44) of the cases. In the 24 subjects receiving both MRI and colostography/fistulography, MRI was more accurate in identifying Pena's classification (22/24 vs. 15/24; P = 0.039). Distal end of the rectum was correctly identified in 75.0% (18/24) and 58.3% (14/24) of the cases (P = 0.125).ConclusionsMRI could clearly reveal fistula anatomy and associated anomalies of ARMs and should be routinely used for preoperative evaluation of ARMs.Type of studyStudy of diagnostic test.Level of evidenceLevel II.     

Comparison of radiographs and computed tomography (CT) imaging for preoperative evaluation and planning for shoulder arthroplasty

BackgroundThe purpose of this study was to determine if addition of CT to axillary radiographs (AXR) alters preoperative decision making for shoulder arthroplasty.MethodsPreoperative deidentified images (XR alone and XR with CT) of 50 patients with glenohumeral arthritis were reviewed independently by 3 reviewers in a blinded fashion. Each reviewer graded images for glenoid wear pattern as simple (Walch A1 or B1) or advanced [A2, B2, C]), adequacy of AXR and need for advanced imaging. The reviewers determined a preoperative plan for all patients based on XR alone vs. XR and CT including the arthroplasty type (anatomic or reverse total shoulder) and their plan for treating glenoid wear (eccentric or standard reaming vs. bone graft or augment). Kappa values (κ) were calculated to determine inter-rater agreement and consistency among multiple reviewers. Fisher's exact test was used to assess any difference in preoperative plan once the shoulders were separated into simple and advanced glenoid wear patterns.ResultsThe 3 reviewers agreed that quality of AXRs was significantly inadequate (P < .001) for assessing glenoid wear in advanced glenoid wear patterns compared to simple wear patterns. Following evaluation on AXRs alone, the need for CT imaging was significantly higher in advanced glenoid wear patterns compare to simple ones (81% vs. 31%; P < .001). The addition of CT images did not result in a significant change to the preoperative plan in simple glenoid wear patterns but in advanced glenoid wear, addition of CT can change the preoperative plan with respect to arthroplasty type and/or strategy for addressing glenoid wear.ConclusionAxillary radiographs are often inadequate for preoperative planning in shoulder arthritis with advanced glenoid wear patterns (Walch A2, B2, C types). Addition of CT imaging to radiographs in shoulder arthritis with advanced glenoid wear can affect the preoperative decision with respect to type of shoulder arthroplasty and/or plan for addressing glenoid wear (reaming, bone graft or augmented glenoids).Level of evidenceLevel IV     

Initial experiences with preoperative three-dimensional image reconstruction technology in laparoscopic pyeloplasty for ureteropelvic junction obstruction

BackgroundTo explore the clinical value of three-dimensional image reconstruction technology (3DIT) on preoperative surgical planning and perioperative outcomes in laparoscopic pyeloplasty (LP).MethodsData of 25 patients with ureteropelvic junction obstruction (UPJO) admitted to our hospital from January 2018 to January 2019 was analyzed retrospectively. All patients underwent preoperative enhanced computed tomography (CT) scanning. In the 12 cases in the 3DIT group, preoperative planning involved the use of virtual operation and morphometry based on reconstruction of the CT data into three-dimensional (3D) images. Surgery in the other 13 cases was performed with traditional CT examination. Demographic, surgical outcome, and postoperative parameters were compared between these two groups.ResultsReconstructed 3D images clearly showed the spatial structural relationships between the UPJO and surrounding blood vessels. In all 25 cases surgery was completed with no conversion to open surgery. Preoperative 3DIT analyses resulted in significant improvements to mean operation time (107.76 vs. 141.58 min, P=0.024), mean time of dissociating ureteropelvic junction (UPJ) (11.26 vs. 19.40 min, P=0.020), and mean estimated blood loss volume (23.84 vs. 49.16 mL, P=0.028). There were no statistically significant differences in perioperative complications, postoperative hospital stays or postoperative drainage time.Conclusions3DIT based on enhanced CT scans is of clinical value in the treatment of UPJO, as it can provide accurate anatomical information and reliable guidance for preoperative operation planning, and it facilitates image-guided LP.     

Three-dimensional preoperative planning accurately guides surgeons for intraoperative implant selection in shoulder arthroplasty

BackgroundWith the rapid growth of shoulder arthroplasty (SA) over the past decade, the focus has been on improving outcomes and minimizing complications. As a result, preoperative planning tools have become a trend among orthopedic surgeons for SA to aid in achieving optimal implant selection and ultimately continual improvement of outcomes. Success in achieving these goals is predicated on software precision and reliability. Therefore, the purpose of our study was to assess the accuracy of three dimensional (3D) preoperative planning software in guiding orthopaedic surgeons for implant selection in SA.MethodsThis was a retrospective study of 76 patients who underwent SA all with the same manufacturer's implants by a single fellowship-trained shoulder surgeon. All patients had preoperative CT scans and completed 3D preoperative plans. The final implant selection was decided intraoperatively solely under surgeon's discretion based on review of preoperative plan, intraoperative bone quality, and soft tissue balancing, not restricted by the preoperative plan. Software accuracy was assessed by directly comparing each component size planned to the actual implant selected in the procedure for both humeral and glenoid components. Statistical analyses was performed including paired-sample t tests and rate for perfect matching.ResultsOur results demonstrated glenoid implant size matched perfectly in 75% of cases and 100% within 1 size in anatomic total shoulder arthroplasty (TSA). Humeral head diameter matched perfectly in 31% of cases and 100% within 1 size. Humeral head thickness matched perfectly in 69% of cases and 100% within 1 size. For reverse shoulder arthroplasty, glenoid baseplate diameter matched perfectly in 81% of the cases and 100% within 1 size. Glenosphere diameter matched perfectly in 88% of the cases and 98% within 1 size. Humeral stem size in both groups were more variable than the remaining components.ConclusionOur study demonstrates that 3D preoperative planning was accurate to guide intraoperative implant selection for both anatomic and reverse SA including both glenoid and humeral components within 1 size. This tool may decrease the need for extensive inventory and instrumentation by improving operating room workflow and surgeon efficiency and may ultimately be translate into better postoperative outcomes.Level of evidenceLevel IV; Case Series     

Use of preoperative advanced imaging for reverse total shoulder arthroplasty

BackgroundIn order to avoid implant related complications related to glenosphere malposition, there has been an increased interest in the use of advanced imaging, including computed tomography (CT) and magnetic resonance imaging (MRI) for preoperative planning and patient-specific instrumentation for reverse shoulder arthroplasty (RSA). While recent literature has demonstrated improved component position when this technology is applied, the clinical benefits remain largely hypothetical and unproven. Thus, the goals of the current study were to utilize a national database to describe current trends in the use of preoperative advanced imaging and investigate the relationship between such imaging and postoperative complications compared to matched controls without any preoperative imaging.MethodsPatients undergoing RSA for non-fracture indications were identified within the Mariner dataset within the PearlDiver database from 2010 to 2018Q2. Patients who underwent preoperative advanced imaging (MRI and/or CT) within a year prior to surgery were then identified as study cohorts. A matched cohort undergoing RSA without preoperative advanced imaging was created for comparison purposes. The incidence of imaging over time and rates of loosening/osteolysis, periprosthetic fracture, prosthetic dislocation, and revision shoulder arthroplasty of all groups were compared using a regression analysis.ResultsThe percentage of patients who underwent preoperative CT (141% increase, P < .0001), and either MRI or CT (107% increase, P = .002) increased significantly during the study period, while there was no significant increase in MRI utilization (P = .122). Patients who underwent preoperative CT experienced significantly lower rates of revision shoulder arthroplasty (2.4% vs. 3.3%, OR = 0.72, P = .004) and periprosthetic dislocation (2.8% vs. 3.3%, OR 0.80, P = .039) within 2 years of RSA compared to patients who did not undergo preoperative CT, while preoperative MRI was associated with significantly lower rates of periprosthetic fracture (0.2% vs. 0.4%, OR 0.44, P = .005), revision shoulder arthroplasty (2.1% vs. 2.6%, OR = 0.75, P = .006), and periprosthetic dislocation (2.5% vs. 3.2%, OR 0.78, P = .003) within 2 years of RSA compared to patients without an MRI.ConclusionThere has been a significant increase in the utilization of preoperative CT as compared to MRI for RSA during the time period studied. The utilization of preoperative advanced imaging may be associated with a statistically significant reduction in multiple implant related complications following RSA for non-fracture indications, although these findings are of unclear clinical significance given limitations of the database and low percentage difference in complication rates.Level of Evidence: Level III     

Preoperative hyponatremia is associated with postoperative major morbidity,prolonged length of stay,non-home discharge,and readmission in total shoulder arthroplasty

IntroductionHyponatremia is a known risk factor for postoperative complications, but prior research has not investigated its outcomes in patients undergoing total shoulder arthroplasty (TSA). The purpose of this study was to determine the association between preoperative hyponatremia and postoperative 30-day major morbidity, 30-day reoperation, length of stay (LOS), non-home discharge, and 30-day readmission.MethodsPatients undergoing anatomic or reverse TSA from 2012 to 2016 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. A multiple logistic regression model was estimated for associated outcomes. An alpha level of 0.005 was used after accounting for Bonferroni correction.ResultsPrimary analysis of 12,437 patients showed significant independent association of preoperative hyponatremia with 30-day major morbidity (OR = 2.00; 99% CI: 1.46–2.73), LOS greater than the 75th percentile (OR = 1.63; 99% CI: 1.31–2.03), non-home discharge (OR = 1.73; 99% CI: 1.08–2.79), and 30-day readmission (OR = 1.69; 99% CI: 1.08–2.64), but not with 30-day reoperation (OR = 1.55; 99% CI: 0.75–3.19).ConclusionPreoperative hyponatremia in TSA was significantly associated with increased odds of 30-day postoperative major morbidity, prolonged LOS, non-home discharge, and 30-day readmission compared to preoperative normonatremia. These findings emphasize the importance of pre-admission testing prior to undergoing elective orthopedic procedures. Additional research is needed to stratify hyponatremia by severity and measure the impact of correcting hyponatremia in patients planning on undergoing TSA.Level of EvidenceLevel III; Retrospective Study-Defined     

Aberrations of the intrinsic innervation of the anorectum in fetal rats with anorectal malformations

Background

Fecal accumulation, constipation, soiling, and incontinence are common sequelae after repair of anorectal malformations (ARMs) in children. It is believed that besides the abnormalities of sacral roots, certain inherent abnormalities of the myenteric plexuses may play an important role in the final outcome after definitive repair.

Methods

This study was conducted to investigate the distribution of neuron-specific enolase (NSE), vasoactive intestinal peptide (VIP), and substance P (SP)-100 neurotransmitters in the rectosigmoid and fistulous tract of the ethylenethiourea-treated rat with ARMs.

Results

ARMs were induced by administering 1% ethylenethiourea (125 mg/kg) on gestational day 10, and the litter was harvested on gestational day 21 by cesarean section. Forty-eight controls and 63 with ARMs (46 high-type and 17 low-type) were recovered. Whole-mount preparations of each rectosigmoid and fistulous communication between the rectum and genitourinary tract were stained with fluorescent antibodies against NSE, VIP, and SP-100. The tissues were counterstained with Eriochrome black-T and methyl green dyes to improve the visualization of the myenteric plexuses.

Conclusions

The immunoreactivity of NSE, VIP, and SP-100 was markedly reduced in the rectum and fistulous tract of high-type ARMs and slightly reduced in low-type ARMs compared with controls. Intramural nerves stained by VIP and SP-100 antisera were decreased in both types of ARM, indicating that both inhibitory and excitatory motor neural elements were affected, and this may explain the distal colonic dysmotility seen postoperatively in both high and low ARMs.     

Clinical and radiographic results of eccentric glenoid reaming in anatomical total shoulder arthroplasty using 3D planning and PSI

BackgroundTreatment of deformed type B glenoids with anatomical total shoulder arthroplasty (TSA) can be challenging when using standard imaging and instrumentation. 3D planning and PSI-guided (patient-specific instrumentation) eccentric reaming may substantially aid in both the glenoid correction and implantation of anatomical components in difficult cases. We hypothesized that the implementation of preoperative planning and a PSI-guided anatomical component protocol would result in accurate correction of the glenoid deformity and precise glenoid implant positioning.MethodsTwenty-two consecutive patients with primary glenohumeral osteoarthritis, intact rotator cuff and modified-Walch type B glenoids were treated with anatomical total shoulder arthroplasty. Preoperative 3D planning and PSI were used to guide eccentric reaming and correct glenoid deformity. Postoperative clinical and radiographic outcomes were assessed in all patients with a minimum follow-up of 2 years (mean of 26 months). Postoperative corrections of glenoid version and inclination were measured and the variation between preoperative planning and postoperative implant position was evaluated on CT 3D reconstructions. Similarly, both humeral subluxation in the axial scapular plane and glenoid joint line medialization were compared between preoperative and postoperative computed tomographic imaging.ResultsThe mean age was 57 years (range, 54-68). Significant improvements in pain and functional outcome measurements were seen in all 22 subjects. Mean native glenoid version and inclination were −15° ± 5° and 3° ± 5°, respectively. Postoperatively, version was corrected to −7° ± 6° and inclination to 1° ± 2°. Cortical central peg perforation was noted in 1 case and cement perforation in 3 cases. The mean deviation from the preoperative plan was 3° ± 3° for version and 2° ± 2° for inclination. Humeral head subluxation improved from 68% ± 6% to 37% ± 6% and re-centering on the glenoid implant was achieved in all cases. The mean executed medialization of the glenoid joint line was 6 ± 3 mm and proved accurate to within 1 ± 1 mm of the planned medialization. A strong linear correlation was found between the degree of correction of retroversion and the amount of medialization (R = 0.82; P< .001).Conclusion3D preoperative planning and PSI guided correction of deformed modified-type B glenoids resulted in accurate postoperative correction of the glenoid deformity, correct glenoid component implantation with low deviation from the planned position and excellent short-term functional and radiographic results.Level of Evidence: Level IV; Case Series; Treatment Study.     

Three-dimensional endoanal ultrasound and anorectal manometry in children with anorectal malformations: new discoveries

Background/PurposeFecal incontinence and constipation are common problems in follow-up of anorectal malformations (ARMs). We evaluated the anal sphincters using the 3-dimensional endoanal ultrasonography (3D-EAUS) and the anorectal manometry after ARMs repair.MethodsSeventeen patients, divided into 3 groups according to Wingspread classification, underwent anorectal manometry and 3D-EAUS. Clinical, manometric, and endosonographic scoring systems were used.ResultsThe average anal resting pressure (aARP) was significantly higher in low ARMs than in intermediate and high ARMs. The anal squeeze pressure was not statistically different between the 3 groups. Three-dimensional EAUS visualized internal anal sphincter (IAS) disruptions in 7 of 17 patients and absence of IAS in 6 of 17 children with high ARMs. Scars of the external anal sphincter were localized in low ARMs and generalized in the other groups. In the case of IAS disruption with aARP greater than 20 mm Hg, fecal incontinence and constipation improved with biofeedback and/or laxatives, whereas daily enemas were necessary in absence of IAS with aARP less than 20 mm Hg. Statistical correlation was observed between endosonographic and manometric findings and clinical outcomes.ConclusionsLesions of the anal sphincter are common in ARMs. Three-dimensional EAUS and anorectal manometry ensure a complete assessment of the anal sphincter and could provide useful information to define the most appropriate treatments to improve the quality of life.     

3D preoperative planning for shoulder arthroplasty: an evaluation of different planning software systems

BackgroundOptimal glenoid component positioning in shoulder arthroplasty can sometimes be challenging. 3D preoperative planning and patient-specific instruments can help position the glenoid component more accurately. Multiple medical companies have developed their method of performing preoperative glenoid measurements. The goal of this study was to compare those different measurement techniques for inclination and version measurements.MethodsCT scans of 13 cadaveric shoulders were used for 3D analysis. All CT scans were sent to different companies that agreed to participate in this study. Each company was expected to report on their methods and measure the preoperative glenoid inclination and version. Furthermore, the researchers calculated preoperative inclination and version of these shoulders using 2 different methods. The measurements were statistically analyzed to determine differences between all methods in a pairwise manner.ResultsSix methods were evaluated in a pairwise manner, resulting in 15 pairs being analyzed. 10 pairs differed significantly for inclination (P < .008), and 4 pairs differed significantly for version (P < .008).ConclusionThere are significant differences between measurement techniques concerning preoperative glenoid inclination and version. The knowledge that different companies use different measurement techniques for preoperative 3D planning of shoulder surgery is essential and should be taken into account when using different planning systems.Level of evidenceLevel III; Study of Diagnostic Test     

One-stage versus staged laparoscopic-assisted anorectoplasty for high-and intermediate anorectal malformations: Medium-term outcomes from a propensity score matching analysis

BackgroundThe timing of anorectoplasty for anorectal malformations (ARMs) is controversial and essential for long-term bowel function. The advantages of laparoscopy make primary anoplasty possible for neonates. This study aims to report the medium-term results of the one-stage laparoscopic-assisted anorectoplasty (LAARP) and compare them with the staged LAARP.MethodsThis study included 242 boys who underwent LAARP between June 2013 and December 2018 in our center. Forty-five neonatal patients successfully underwent the one-stage LAARP, and the remaining 197 patients who had already undergone colostomy received staged procedures. The complications and bowel function were compared between the two groups after 1:1 propensity score matching (PSM).ResultsBefore matching, age at assessment and classification were significantly different between the two groups (P < 0.05). After PSM, 42 patients were included in each of the two groups, and the patients were well balanced. The overall occurrence of postoperative complications in the one-stage group was significantly lower than in the staged group (P < 0.05). The median follow-up periods were 55.0 and 54.5 months, respectively. The mean value of BFS was similar in the two groups. After medical management, a second evaluation was conducted to distinguish overflow pseudo-incontinence from patients with no bowel control potential. The functional outcome in the two groups is comparable (P = 0.307).ConclusionsOne-stage LAARP is safe and feasible for neonates with high-and intermediate-type ARMs. Compared with staged LAARP, one-stage LAARP has fewer complications and comparable functional outcomes. The authors recommend these procedures to be performed in dedicated centers with sufficient expertise.Level of evidenceLevel III.     

Magnetic resonance imaging pelvimetry predicts the technical difficulty of rectal surgery

BackgroundThe relationships between the pelvimetry and technical difficulties in performing rectal surgery for mid-low rectal cancer remain unclear.MethodsTwo hundred and twenty-one cases of mid-low rectal cancer patients who underwent sphincter-preserved total mesorectum excision (TME) were analyzed. The data of the pelvimetry and the relative position between trocar site and tumor were measured with magnetic resonance imaging (MRI).ResultsUnivariate analysis showed that the interspinous diameter, the sacrococcygeal distance, and the angle of sacral promontory inclination were significantly associated with the technical difficulty during laparoscopic surgery, but only the interspinous diameter remained an independent risk factor in multivariate analysis. The simulated trocar angle θ was an independent risk factor affecting the operation time during laparoscopic surgery, simulated trocar angle η was significantly related to intraoperative blood loss in both laparoscopic surgery and transanal TME (taTME) surgery groups.ConclusionInterspinous diameter can predict difficulty in laparoscopic surgery and may provide useful information for preoperative planning and consideration of approach.     

Risk Factors for Intraoperative Periprosthetic Femoral Fractures During Primary Total Hip Arthroplasty. An Analysis From the National Joint Registry for England and Wales and the Isle of Man

BackgroundThe aim of this study is to estimate risk factors for intraoperative periprosthetic femoral fractures (IOPFF) and each anatomic subtype (calcar crack, trochanteric fracture, femoral shaft fracture) during primary total hip arthroplasty.MethodsThis retrospective cohort study included 793,823 primary total hip arthroplasties between 2004 and 2016. Multivariable regression modeling was used to estimate relative risk of patient, surgical, and implant factors for any IOPFF and for all anatomic subtypes of IOPFF. Clinically important interactions were assessed using multivariable regression.ResultsPatient factors significantly increasing the risk of fracture were female gender, American Society of Anesthesiologists grade 3 to 5, and preoperative diagnosis including avascular necrosis of the hip, previous trauma, inflammatory disease, pediatric disease, and previous infection. Overall risk of IOPFF associated with age was greatest in patients below 50 years and above 80 years. Risk of any fracture reduced with computer-guided surgery and in non–National Health Service hospitals. Nonposterior approaches increased the risk of shaft and trochanteric fracture only. Cementless implants significantly increased the risk of only calcar cracks and shaft fractures and not trochanteric fractures.ConclusionFracture risk increases in patients younger than 50 and older than 80 years, females, American Society of Anesthesiologists grade 3 to 5, and indications other than primary osteoarthritis. Large cumulative reduction in IOPFF risk may occur with use of cemented implants, posterior approach, and computer-guided surgery.Level of EvidenceLevel 3b (cohort study).     

Management of intravascular thrombus in cases of bilateral Wilms tumor or horseshoe kidney

PurposeTo describe the oncologic and surgical management of bilateral Wilms tumor or Wilms tumor arising in a horseshoe kidney with intravenous tumor thrombus to help pediatric surgeons negotiate this rare and difficult anatomic circumstance.MethodsA single-institution, retrospective medical record review identified 4 cases of bilateral WT and one case of WT arising in a horseshoe kidney with intravenous tumor thrombus between 2009 and 2021. The presentation, imaging, chemotherapy regimen, intraoperative approach, and surgical and oncologic outcomes were reviewed for each of these patients.ResultsAll patients received a total of 12 weeks of neoadjuvant chemotherapy. In two patients, a staged approach to the bilateral tumors was undertaken with the first side being operated on after six weeks of therapy and the other side undergoing surgery after an additional six weeks of therapy. Of five patients, four underwent nephron-sparing surgery of all tumors and one underwent unilateral radical nephroureterectomy with contralateral nephron-sparing surgery. Tumor thrombectomy was performed in four of five cases; one patient demonstrated a complete response of the intravenous tumor thrombus to neoadjuvant chemotherapy and did not require thrombectomy. Three patients received adjuvant flank radiotherapy. Three patients developed medically managed stage II or III chronic kidney disease and no patient required renal replacement therapy or kidney transplant to date.ConclusionNephron-sparing surgery is feasible and safe to perform in selected cases of bilateral Wilms tumor with intravascular thrombus by utilizing three-drug neoadjuvant chemotherapy, staged approaches to each kidney when appropriate, and detailed preoperative and/or intraoperative mapping of renal venous anatomy. Successful nephron-sparing surgery with tumor thrombectomy is dependent on a branched renal venous system or the presence of accessory renal veins.Level of evidenceLevel 4.     

Simultaneous antegrade urography of the upper urinary tract and retrograde cystography combined with computed tomography imaging in the management of ureteral complications after renal transplantation

BackgroundTo investigate the significance of simultaneous urography of the upper and lower urinary tract of transplanted kidneys combined with computed tomography urography (CTU), computed tomography arteriography (CTA), and computed tomography venography imaging in the planning of open surgery performed to treat any ureteral complications of a transplanted kidney.MethodsIn all, 24 patients with ureteral complications after renal transplantation were admitted, 12 of whom had renal graft ostomy during open surgery. Simultaneous antegrade urography of the upper urinary tract and retrograde cystography of the transplanted kidneys were performed on the patients. With the use of computed tomography imaging results, surgical planning was carried out.ResultsAll surgeries were successfully completed according to preoperative planning. Three patients underwent end-to-end anastomosis of the ureter and bladder muscle flap, 8 patients underwent ureterocystostomy, and 1 patient underwent an end-to-end ureteral anastomosis. After the follow-up up to now, all the patients had stable renal function, and no complications such as ureteral stenosis or urine leakage have thus far reoccurred in the transplanted kidneys.ConclusionsWhen open surgery is required to treat any ureteral complications following renal transplantation, preoperative multiangle imaging can be used to better understand the condition of the transplanted urinary tract and thus aid considerably in surgical planning.     

Diagnosis and management of a remnant of the original fistula (ROOF) in males following surgery for anorectal malformations

PurposeA complication of the surgical management of anorectal malformations (ARMs) is a retained remnant of the original fistula (ROOF) formerly called a posterior urethral diverticulum (PUD). A ROOF may have multiple presentations or may be incidentally discovered during the work-up of ARM after previous surgery. We sought to define the entity and the surgical indications for excision of a ROOF when found.MethodsWe performed a retrospective cohort study of all male patients who presented to our center following previous repair for ARM at another institution, who came for evaluation of problems with urinary and/or fecal continence, from 2014 to 2017. Charts were reviewed for symptoms, original type of malformation, preoperative imaging, treatment, and postoperative follow-up.ResultsOf 180 referred male patients, 16 had a ROOF. 14 underwent surgical repair to address this and for other redo indications, and 2 did not require intervention. 13 patients had an additional reason for a redo such as anal mislocation or rectal prolapse. Indications for ROOF excision were urinary symptoms (e.g. UTI, dribbling, passage of mucous via urethra, stone formation), to make a smoother posterior urethra for intermittent catheterization, or for prophylactic reasons. Patients were repaired at an average age of 4.2 years, using a PSARP only approach with excision of the ROOF for all except one patient who needed a laparotomy due to abdominal extension of the ROOF. No patient needed a colostomy. The original ARM repairs of the patients were PSARP (9), laparoscopic assisted (4) and abdominoperineal pullthrough (3). Preoperative evaluation included pelvic MRI, VCUG, and cystoscopy. The ROOF was visualized on 14 of 16 MRIs, 10 of 14 VCUGs, and 14 of 15 cystoscopies. Urinary symptoms associated with a ROOF and ease of catheterization were improved in all repaired cases.ConclusionPatients not doing well from a urinary or bowel standpoint post ARM pull-through need a complete evaluation which should include a check for a ROOF. Both modalities MRI and cystoscopy are needed as a ROOF can be missed on either alone. A VCUG was not reliable in identifying a ROOF.Excision is needed in patients to improve urinary symptoms associated with these lesions and to minimize the small but theoretical oncologic risk present in a ROOF.Level of evidenceLevel III.     

Assessment of 3D automated software to predict postoperative impingement free range of motion after reverse shoulder arthroplasty

BackgroundIn the past few years 3-dimensional (3D) automated software for preoperative planning in shoulder arthroplasty has increased in practice. It has been used to improve accuracy on implant placement, size, and selection, especially on the glenoid side. New additions have been added however, to look at prediction of range of motion (ROM) for after surgery. Therefore, the purpose of this study was to assess the accuracy of the software feature of predicting impingement-free range of motion compared to postoperative functional outcomes.MethodsA shoulder arthroplasty database including 192 patients was reviewed and 55 patients who underwent a primary RSA without evidence of preoperative fracture, trauma, or neurological associated diseases which could impact postoperative rehabilitation were included in the study. Preoperative plans for RSA were created for all patients based on preoperative shoulder CT scan and each patient's preoperative predictive ROM (PROM) suggested by the software was recorded. These PROM were then compared to postoperative final follow-up clinical range of motion for accuracy (CE ROM). Demographic information and Walch classification were recorded.ResultsOur cohort was composed of 30 males and 25 females with an average age of 71.2 years old and mean BMI 30.0 kg/m². The predominant diagnosis was rotator cuff arthropathy (RCA: 32 patients) followed by severe osteoarthritis (SOA: 19 patients). The mean difference between clinical and predicted ROM for active FF was 42° (SD = 46°), passive FF was 61° (SD = 39°), passive ABD was 81° (SD = 33°), active ER was 22° (SD = 22°), and passive ER was 24° (SD = 25°). Our results also showed that the CE ROM was significantly higher than PROM for each clinical measurement (P< .001). We also found weak correlations between the groups for active FF (r = 0.106), active ER (r = 0.246), passive ER (r = 0.209) and no correlation for remaining groups.ConclusionNot all features available in preoperative planning for RSA using 3D automated software can be translated into practice. Our results demonstrated PROM weakly correlated with CE ROM for patients who underwent RSA. Surgeons need to be aware that surgical decisions should not be altered based on this feature. More research needs to be done to validate this new tool incorporating both scapulothoracic motion and clinical correlation with predictive ROM. As we move into the era with 3D preoperative simulation and optimizing outcomes for shoulder arthroplasty these features incorporating clinical outcomes and function will be critical to consider.Level of EvidenceLevel IV, retrospective case series.     

Favorable postoperative outcomes for children with COVID-19 infection undergoing surgical intervention: Experience at a free-standing children's hospital

BackgroundCurrent literature has shown that adult patients with perioperative Coronavirus Disease-2019 (COVID-19) have increased rates of postoperative morbidity and mortality. We hypothesized that children with COVID-19 have favorable postoperative outcomes compared to the reported adult experience.MethodsWe performed a retrospective cohort study for children with a confirmed preoperative COVID-19 diagnosis from April 1st, 2020 to August 15th, 2020 at a free-standing children's hospital. Primary outcomes evaluated were postoperative complications, readmissions, reoperations, and mortality within 30 days of operation. Secondary outcomes included hospital resource utilization, hospital length of stay, and postoperative oxygen support.ResultsA total of 66 children with preoperative confirmed COVID-19 were evaluated with median age of 9.5 years (interquartile range (IQR) 5–14) with 65% male and 70% Hispanic White. Sixty-five percent of patients had no comorbidities, with abdominal pain identified as the most common preoperative symptom (65%). Twenty-three percent of patients presented with no COVID-19 related symptoms. Eighty-two percent of patients had no preoperative chest imaging and 98% of patients did not receive preoperative oxygen support. General pediatric surgeons performed the majority of procedures (68%) with the most common diagnosis appendicitis (47%). Forty-one percent of patients were discharged the same day as surgery with 9% of patients utilizing postoperative intensive care unit resources and only 5% receiving postoperative invasive mechanical ventilation. Postoperative complications (7%), readmission (6%), and reoperation (6%) were infrequent, with no mortality.ConclusionCOVID-19+ children requiring surgery have a favorable postoperative course and short-term outcomes compared to the reported adult experience.Type of studyPrognosis Study.Level of evidenceLevel IV.     

Preoperative functional status predicts outcomes after total shoulder arthroplasty

BackgroundPrevious studies have found an association between functional status and outcomes following hip and knee arthroplasty. The purpose of this study was to evaluate the effect of dependent functional status on outcomes after total shoulder arthroplasty (TSA).MethodsThe American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent primary TSA (anatomic or reverse) for glenohumeral osteoarthritis from January 1, 2011 to December 31, 2016. Patients whose preoperative functional status was dependent were compared with independent patients. Demographic data, length of hospital stay, and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of functional status on postoperative complications and readmission.ResultsA total of 12,982 patients underwent primary TSA (anatomic or reverse) and 3.2% had a dependent functional status. Dependent patients had higher rate of comorbidities, higher mean American Society of Anesthesiologists class, longer hospital stays, and higher complication rates (including pneumonia, urinary tract infection, and blood transfusion). Logistic regression revealed that dependent functional status was an independent predictor for occurrence of any complication (odds ratio 2.0, P < .01) and for readmission (odds ratio 2.6, P < .01).ConclusionPatients with dependent functional status preoperatively are at increased risk for short-term complications and readmission within 30 days following primary TSA.Level of evidence: Level III