Report of the 2018 Arthroscopy Association of North America Traveling Fellowship—Friendship and Mentorship

Thank you AANA for allowing us to participate in one of the most educational and transformative pieces of our careers to date. It was a great honor to be selected to participate in the 2018 Advanced Arthroscopy Training Fellowship. We journeyed to New York City, New Orleans, and Columbus, Ohio. This was a life-changing experience full of remarkable Friendship and Mentorship.     

Anatomic study of the insertions of the levator aponeurosis and Müller's muscle in Oriental eyelids.

To clarify the detailed anatomy of the insertions of the levator aponeurosis and Müller's muscle, 10 upper eyelids of 5 fixed Japanese cadavers were examined. The eyelids were dissected in a manner that the authors devised to disclose the delicate pretarsal structures in close proximity. After removing the orbital roof and fat, they divided the levator aponeurosis at the origin and dissected along its posterior aspect up to the upper tarsal area. The dissected eyelids were evaluated grossly and histologically with a special staining technique. Gross and histological examinations revealed that the dense collagenous levator aponeurosis was transformed distally into fine elastic fibers, which inserted into the pretarsal orbicularis layer. They also found a distinct fascia covering the anterior aspect of the tarsus that continued proximally to Müller's muscle. Conclusively, the levator aponeurosis has no direct collagenous insertion into the tarsus, but is connected mainly to the pretarsal tissue via fine elastic fibers. A fibrous tissue covering the anterior aspect of the tarsus is not the levator aponeurosis, but an extension of Müller's muscle.     

Distraction arthroplasty of the ankle--how far can you stretch the indications?

Ankle joint distraction has been shown to be a viable alternative to ankle arthrodesis or ankle replacement. The à la carte approach to ankle joint preservation (resection of blocking osteophytes, release of muscle/joint contractures, and realignment osseous ankle procedures) presented in this article as important for a successful outcome as is the hinged ankle joint distraction technique itself. The authors reviewed 32 patients who underwent this ankle joint distraction technique and found 78% of patients had maintained their ankle range of motion and have no pain to occasional moderate pain that can be managed generally with nonsteroidal anti-inflammatory drugs alone. Only one has required an ankle fusion, and only one has been converted to an ankle joint replacement. The longevity of these results and the higher percent of good or excellent results when compared with other studies suggest that combining adjunctive procedures and articulation with ankle distraction improves the results of this procedure.     

Prediction of progressive disease in Zollinger-Ellison syndrome—Comparison of available preoperative tests

Availability of alternative methods of treatment of the Zollinger-Ellison syndrome (ZES) has necessitated a reevaluation of that disease. To evaluate ability of preoperative tests to predict postoperative clinical course, serum samples (frozen since collection) obtained fasting and after calcium stimulation in 18 patients with documented ZES with at least 5 years of postoperative follow-up were reassayed, fractionated into molecular components by gel filtration through a 200 × 1-cm Sephadex G-50 superfine column, and quantitated by assay with an antibody with equimolar recognition of the major C-terminal peptides. Total gastrin immunoreactivity (IRG), response of serum gastrin to calcium stimulation (SIRG), or the combination of these two factors are the most frequent criteria for estimating postoperative course and magnitude of disease. These measurements were compared to the percentage of G-17 (G-17/IRG) by the methods of R. S. Galen and S. R. Gambino (Beyond Normality: The Predictive Value and Efficiency of Medical Diagnoses, New York: Wiley, 1975, pp. 10–14, 50–51) (Sensitivity, Specificity, Predictive value of positive and negative tests, Efficiency). Percentage G-17 > 20% of IRG is the most sensitive (100%) and specific (91%) method of evaluating extent of disease preoperatively in patients with ZES.     

Quality of Life After Surgical Treatment of Early Barrett’s Cancer: A Prospective Comparison of the Ivor-Lewis Resection Versus the Modified Merendino Resection

Introduction

The Merendino (MER) procedure has been evaluated as an alternative to transthoracic esophageal resection (TER) for early stage Barrett’s carcinoma. Apart from reducing morbidity and mortality, improvements concerning postoperative health-related quality of life (HRQL) have been postulated. The aim of our study was to compare HRQL between these procedures.

Materials and methods

Between July 2000 and July 2007, 117 patients with early Barrett’s carcinoma underwent surgery. Patients with tumor recurrence were excluded from the study. HRQL was assessed 1 and 2 years after surgery using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (EORTC-QLQ-C30) and the QLQ-OES18 module. Patients recently diagnosed with early Barrett’s carcinoma served as controls. Symptoms that showed a difference of more than ten between the control and the study groups were considered clinically relevant and were tested for significant differences between the study groups using the Mann–Whitney U test (p < 0.05).

Results

The response rates for the questionnaires ranged between 70 and 93 %. In the MER group, more items reflected a clinical relevant impairment of HRQL than in the TER group. Significant complaints in the MER group included nausea/vomiting, appetite loss, local pain, difficulties with social eating, and choking. Moreover, we found a significant restriction concerning global health and emotional and social functioning in this group 1 year after surgery. 2 years postoperatively, hardly any differences between the operative techniques could be detected. The only symptom in favor of the MER procedure was a better dysphagia score postoperatively.

Conclusion

Our study suggests that MER procedure is not superior to subtotal esophagectomy with regard to HRQL.     

Surgical Revascularization—An Innovative Approach to the Treatment of Talar Osteonecrosis Dissecans Stages II and III

Talar osteonecrosis dissecans is caused by osseous malperfusion, leading to destruction of the talar bone. The current reference standard for advanced stages lacking arthrosis is core decompression, followed by autologous cancellous bone grafting. However, talar revascularization has not been observed in a subset of patients after this procedure. Microsurgical vascularized bone grafting can improve outcomes by the induction of angiogenesis. We present the 1-year follow-up data from 3 patients with talar osteonecrosis dissecans, who had undergone free vascularized medial femoral condyle autotransplantation. The patients were evaluated preoperatively and 3, 6, and 12 months postoperatively. The active range of motion, pain (visual analog scale [VAS]), and American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and lower extremity functional scale were used. Osteonecrosis dissecans stage II was seen in patient 1 (aged 27 years) and stage III in patients 2 (aged 18 years) and 3 (aged 41 years). Preoperative pain of the ankle was recorded as VAS score of 3 by patients 1 and 2 and VAS score of 6 by patient 3. At 12 months postoperatively, patients 1 and 2 recorded a VAS score of 2 and patient 3, a VAS score of 0. All patients showed improvement in the lower extremity functional scale and American Orthopaedic Foot and Ankle Society scale scores. After 6 and 12 months, magnetic resonance imaging showed a well-vascularized femoral condyle incorporated into the talus in all the patients. Autotransplantation of vascularized bone grafts from the medial femoral condyle is a promising technique for surgical revascularization of talar osteonecrosis dissecans stage II and III.     

Comparison of RIFLE and AKIN Criteria in the Evaluation of the Frequency of Acute Kidney Injury in Post–Liver Transplantation Patients

BackgroundAcute renal dysfunction is presented quite often after orthotopic liver transplantation (LT), with a reported incidence of 12–64%. The “RIFLE” criteria were introduced in 2004 for the definition of acute kidney injury (AKI) in critically ill patients, and a revised definition was proposed in 2007 by the Acute Kidney Injury Network (AKIN), introducing the AKIN criteria. The aim of this study was to record the incidence of AKI in patients after LT by both classifications and to evaluate their prognostic value on mortality.MethodsWe retrospectively evaluated the records of patients with LT over 2 years (2011–2012) and recorded the incidence of AKI as defined by the RIFLE and AKIN criteria. Preoperative and admission severity of disease scores, duration of mechanical ventilation, intensive care unit length of stay, and 30- and 180-day survivals were also recorded.ResultsSeventy-one patients were included, with an average age of 51.78 ± 10.3 years. The incidence of AKI according to the RIFLE criteria was 39.43% (Risk, 12.7%; Injury, 12.7%; Failure, 14.1%), whereas according to the AKIN criteria it was 52.1% (stage I, 22.5%; stage II, 7%; stage II 22.55%). AKI, regardless of the classification used, was related to the Model for End-Stage Liver Disease score, the volume of transfusions, the duration of mechanical ventilation, and survival. The presence of AKI was related to higher mortality, which rose proportionally with the severity of AKI as defined by the stages of either the RIFLE or the AKIN criteria.ConclusionsAKI classifications according to the RIFLE and AKIN criteria are useful tools in the recognition and classification of the severity of renal dysfunction in patients after LT, because they are associated with higher mortality, which rises proportionally with the severity of renal disease.     

Vats Versus Axillary Minithoracotomy in the Management of the Second Episode of Spontaneous Pneumothorax: Cost–Benefit Analysis

Background

Video-assisted thoracic surgery (VATS) was considered the gold standard approach in recurrent spontaneous pneumothorax, with unanimous consensus of opinions. The cost-effectiveness analysis in the surgical treatment of recurrence of primary spontaneous pneumothorax (PSP) was carried out comparing VATS with muscle-sparing axillary minithoracotomy (MSAM).

Methods

Between July 2006 and October 2012 we treated 56 patients with a second episode of PSP by VATS or open approach. Time of intervention, prolonged air leaks, duration of pleural drainage, length of hospitalization, and long-term morbidity were evaluated, establishing the relationship between costs and quality-adjusted life for each technique.

Results

The assessment of pain and threshold of tenderness was more favorable in VATS in respect to MSAM during the 5 years of follow-up (p = 0.004 and <0.001 at 1st year; p = 0.006 and <0.002 at 5th year). The minimally invasive method was less expensive than axillary minithoracotomy (2443.44 € vs. 3170.80 €). The quality-adjusted life expectancy of VATS was better than that of MSAM (57.00 vs. 49.2 at 60 months) as well as the quality-adjusted life year (0.03 at 1st year and 0.13 at 5th year). Incremental cost per life year gained of VATS versus MSAM was between 24,245.33 € (1st year) and 5776.31 € (5th year), making it advantageous at 3rd, 4th, and 5th years.

Conclusions

VATS compared to MSAM in the treatment of a second episode of PSP ensured undoubted clinical advantages associated with significant cost savings.

     

Evolution of the Use of Noninvasive Mechanical Ventilation in Chronic Obstructive Pulmonary Disease in a Spanish Region, 1997–2010

IntroductionNoninvasive mechanical ventilation (NIV) appeared in the 1980s as an alternative to invasive mechanical ventilation (IMV) in patients with acute respiratory failure. We evaluated the introduction of NIV and the results in patients with acute exacerbation of chronic obstructive pulmonary disease in the Region of Murcia (Spain).Subjects and methodsA retrospective observational study based on the minimum basic hospital discharge data of all patients hospitalised for this pathology in all public hospitals in the region between 1997 and 2010. We performed a time trend analysis on hospital attendance, the use of each ventilatory intervention and hospital mortality through JoinPoint regression.ResultsWe identified 30 027 hospital discharges. JoinPoint analysis: downward trend in attendance (annual percentage change [APC]=?3.4, 95% CI: ?4.8 to ?2.0, P<.05) and in the group without ventilatory intervention (APC=?4.2%, ?5.6 to ?2.8, P<.05); upward trend in the use of NIV (APC=16.4, 12.0–20.9, P<.05), and downward trend that was not statistically significant in IMV (APC=?4.5%, ?10.3 to 1.7). We observed an upward trend without statistical significance in overall mortality (APC=0.5, ?1.3 to 2.4) and in the group without intervention (APC=0.1, ?1.6 to 1.9); downward trend with statistical significance in the NIV group (APC=?7.1, ?11.7 to ?2.2, P<.05) and not statistically significant in the IMV group (APC=?0.8, ?6, 1–4.8). The mean stay did not change substantially.ConclusionsThe introduction of NIV has reduced the group of patients not receiving assisted ventilation. No improvement in results was found in terms of mortality or length of stay.     

Does Anatomic Versus Nonanatomic Resection Affect Recurrence and Survival in Patients Undergoing Surgery for Colorectal Liver Metastasis?

Anatomic resection of colorectal liver metastases may offer a survival advantage because (1) it removes the hepatic functional unit as a whole and (2) nonanatomic resection has been reported to have a higher incidence of positive margins. A retrospective review was performed of patients undergoing hepatic resection for colorectal liver metastases. 183 patients met inclusion criteria of undergoing either anatomic or nonanatomic resection with the aim of removing all gross disease. Mean age was 61 years (range 31–90 years), 57% were male. 89 patients (49%) underwent nonanatomic resection, the remaining 94 (51%) had anatomic resection. Average duration of inflow occlusion was 10 min. Average length of stay was 7.4 days. There were three deaths, yielding a 1.6% 30-day mortality rate. There was no difference in the incidence of positive margins between types of resection. Recurrence was 27%, 55%, and 59% at 1, 3, and 5 years respectively. Overall survival was 89%, 67%, and 55% at 1, 3, and 5 years, respectively. Type of resection was not associated with significant differences in recurrence or survival even when adjusted for differences in preoperative risk. We conclude that hepatic resection for colorectal metastases can be performed safely and offers select patients with stage IV disease prolonged survival. Resection type should be based on the number and location of tumors, rather than on segmental anatomy. An emphasis on the preservation of hepatic parenchyma may be of increasing importance in the setting of chemotherapy-associated steatohepatitis, and the growing number of patients undergoing repeated metastasectomy.