Current concepts for rehabilitation and return to sport after knee articular cartilage repair in the athlete

Articular cartilage injury is observed with increasing frequency in both elite and amateur athletes and results from the significant acute and chronic joint stress associated with impact sports. Left untreated, articular cartilage defects can lead to chronic joint degeneration and athletic and functional disability. Treatment of articular cartilage defects in the athletic population presents a therapeutic challenge due to the high mechanical demands of athletic activity. Several articular cartilage repair techniques have been shown to successfully restore articular cartilage surfaces and allow athletes to return to high-impact sports. Postoperative rehabilitation is a critical component of the treatment process for athletic articular cartilage injury and should take into consideration the biology of the cartilage repair technique, cartilage defect characteristics, and each athlete's sport-specific demands to optimize functional outcome. Systematic, stepwise rehabilitation with criteria-based progression is recommended for an individualized rehabilitation of each athlete not only to achieve initial return to sport at the preinjury level but also to continue sports participation and reduce risk for reinjury or joint degeneration under the high mechanical demands of athletic activity.     

Infected common iliac artery aneurysm repaired in an infant with cadaveric vein graft

Aneurysms are rare in children. Causes include congenital, traumatic, inflammatory, and infectious etiologies. When and how to best surgically treat arterial aneurysms in a child remain unclear. We present the case of a 3-month-old child with an aneurysm of the left common iliac artery, which was first detected on abdominal ultrasound and was successfully repaired with a cadaveric vein graft.     

A multicenter,randomized, controlled trial comparing bupivacaine with ropivacaine for labor analgesia

BACKGROUND: A meta-analysis of studies comparing high doses of bupivacaine with ropivacaine for labor pain found a higher incidence of forceps deliveries, motor block, and poorer neonatal outcome with bupivacaine. The purpose of this study was to determine if there is a difference in these outcomes when a low concentration of patient-controlled epidural bupivacaine combined with fentanyl is compared with ropivacaine combined with fentanyl. METHODS: This was a multicenter, randomized, controlled trial, including term, nulliparous women undergoing induction of labor. For the initiation of analgesia, patients were randomized to receive either 15 ml bupivacaine, 0.1%, or 15 ml ropivacaine, 0.1%, each with 5 microg/ml fentanyl. Analgesia was maintained with patient-controlled analgesia with either local anesthetic, 0.08%, with 2 microg/ml fentanyl. The primary outcome was the incidence of operative delivery. We also examined other obstetric, neonatal, and analgesic outcomes. RESULTS: There was no difference in the incidence of operative delivery between the two groups (148 of 276 bupivacaine recipients vs. 135 of 279 ropivacaine recipients; P = 0.25) or any obstetric or neonatal outcome. The incidence of motor block was significantly increased in the bupivacaine group compared with the ropivacaine group at 6 h (47 of 93 vs. 29 of 93, respectively; P = 0.006) and 10 h (29 of 47 vs. 16 of 41, respectively; P = 0.03) after injection. Satisfaction with mobility was higher with ropivacaine than with bupivacaine (mean +/- SD: 76 +/- 23 vs. 72 +/- 23, respectively; P = 0.013). Satisfaction for analgesia at delivery was higher for bupivacaine than for ropivacaine (mean +/- SD: 71 +/- 25 vs. 66 +/- 26, respectively; P = 0.037). CONCLUSIONS: There was no difference in the incidence of operative delivery or neonatal outcome among nulliparous patients who received low concentrations of bupivacaine or ropivacaine for labor analgesia.     

Congenital high airway obstruction syndrome: natural history and management

Background

Congenital high airway obstruction syndrome (CHAOS) is a life-threatening condition with a poorly understood natural history.

Methods

A retrospective review of five patients with CHAOS between 1997 and 2002 was performed.

Results

All fetuses had large echogenic lungs, dilated airways, inverted diaphragms, and massive ascites. One fetus with a laryngeal cyst was terminated at 22 weeks. A twin fetus with findings suggestive of a tracheal web had progressive hydrops, which led to fetal demise. The remaining 3 patients delivered via the ex utero intrapartum treatment (EXIT) procedure survived. The first patient tolerated progressive hydrops for 12 weeks in utero. He had tracheal atresia but underwent laryngotracheoplasty successfully. He is the first long-term CHAOS survivor and is speaking at 5 years of age. The 2 patients with relatively stable lung volumes prenatally have laryngeal atresia with a pinpoint posterior laryngeal fistula. Their postnatal clinical courses were much more benign than the first survivor.

Conclusions

The prenatal natural history and postnatal course of CHAOS depends on whether the airway obstruction is complete. The EXIT procedure offers the potential for salvage of this otherwise lethal condition. Hydrops may be well tolerated prenatally for weeks with potential resolution if airway fistulization is present.     

The natural history of prenatally diagnosed conjoined twins

Background/Purpose: Accurate prenatal diagnosis of complex anatomic connections and associated anomalies has only been possible recently with the use of ultrasonography, echocardiography, and fetal magnetic resonance imaging (MRI). To assess the impact of improved antenatal diagnosis in the management and outcome of conjoined twins, the authors reviewed their experience with 14 cases. Methods: A retrospective review of prenatally diagnosed conjoined twins referred to our institution from 1996 to present was conducted. Results: In 14 sets of conjoined twins, there were 10 thoracoomphalopagus, 2 dicephalus tribrachius dipus, 1 ischiopagus, and 1 ischioomphalopagus. The earliest age at diagnosis was 9 weeks' gestation (range, 9 to 29; mean, 20). Prenatal imaging with ultrasonography, echocardiography, and ultrafast fetal MRI accurately defined the shared anatomy in all cases. Associated anomalies included cardiac malformations (11 of 14), congenital diaphragmatic hernia (4 of 14), abdominal wall defects (2 of 14), and imperforate anus (2 of 14). Three sets of twins underwent therapeutic abortion, 1 set of twins died in utero, and 10 were delivered via cesarean section at a mean gestational age of 34 weeks. There were 5 individual survivors in the series after separation (18%). In one case, in which a twin with a normal heart perfused the cotwin with a rudimentary heart, the ex utero intrapartum treatment procedure (EXIT) was utilized because of concern that the normal twin would suffer immediate cardiac decompensation at birth. This EXIT-to-separation strategy allowed prompt control of the airway and circulation before clamping the umbilical cord and optimized control over a potentially emergent situation, leading to survival of the normal cotwin. In 2 sets of twins in which each twin had a normal heart, tissue expanders were inserted before separation. Conclusions: Advances in prenatal diagnosis allow detailed, accurate evaluations of conjoined twins. Careful prenatal studies may uncover cases in which emergent separation at birth is lifesaving.     

Impact of Prostate-specific Antigen (PSA) Screening Trials and Revised PSA Screening Guidelines on Rates of Prostate Biopsy and Postbiopsy Complications

Background

Prostate biopsy and postbiopsy complications represent important risks of prostate-specific antigen (PSA) screening. Although landmark randomized trials and updated guidelines have challenged routine PSA screening, it is unclear whether these publications have affected rates of biopsy or postbiopsy complications.

Active surveillance is superior to radical nephrectomy and equivalent to partial nephrectomy for preserving renal function in patients with small renal masses: Results from the DISSRM registry

Purpose

We compared renal function outcomes among patients in the surveillance and intervention arms of the DISSRM registry.

Initial results of managing severe bone loss in infected total joint arthroplasty using customized articulating spacers

Twenty-three cases of infected total joint arthroplasty with substantial bone loss were treated with a cement spacer, which was customized intraoperatively to achieve joint stability and to allow motion. All but one of the patients were ambulatory with the spacer in place. Spacer dislocation occurred in 1 hip patient (9%) and in none of the knee patients. Articulating antibiotic-impregnated spacers with intraoperative customization is our preferred treatment of cases of infected total joint arthroplasty even in the presence of bone loss.     

The relationship between preoperative cervical alignment and postoperative spinal cord drift after decompressive laminectomy and arthrodesis for cervical spondylotic myelopathy

BackgroundCervical spondylotic myelopathy represents a debilitating disorder, often resulting in significant neurological impairment over time. Cervical laminectomy has enjoyed a successful track record in the surgical management of these patients. Little is understood regarding the significance of postdecompressive migration of the spinal cord in relation to patient outcome.MethodsPreoperative and postoperative cervical spine MRIs of 28 patients who underwent cervical laminectomy and fusion for the treatment of CSM were reviewed. Radiographic parameters including preoperative cervical alignment, LDI, space available at the level cepahlad/caudad to the decompression, percent spinal cord expansion at the radiographically most compressed level, and spinal cord drift to the midpoint of the spinal cord were measured and subsequently analyzed for statistical correlation. The recovery rate based on the mJOA score was calculated for each patient and analyzed for correlation with spinal cord drift.ResultsThe Cobb angle C2-7, cervical spinal angle, and CCI represented tightly correlated measures of cervical alignment. The preoperative cervical alignment did not statistically correlate with postoperative spinal cord drift. No statistical correlation was revealed between postdecompressive spinal cord drift and recovery rate.ConclusionsPreoperative cervical alignment does not statistically correlate with postoperative spinal cord drift in patients undergoing multisegmental decompressive laminectomy and fusion for CSM. The observation of significant posterior shifting of the spinal cord in the context of straight or kyphotic preoperative alignment suggests that posterior decompression and arthrodesis represent a viable option in the surgical management of patients with CSM with nonlordotic preoperative alignment.     

The reliability of determining “leg dominant pain”

Background contextPatients with back dominant pain generally have a worse prognosis after spine surgery when compared with patients with leg dominant pain. Despite the importance of determining whether patients with lumbar spine pain have back or leg dominant pain as a predictor for success after decompression surgery, there are limited data on the reliability of methods for doing so.PurposeTo assess the test-retest reliability of a patient's ability to describe whether their lumbar spine pain is leg or back dominant using standardized questions.Study design/settingProspective, blinded, test-retest cohort study performed in an academic spinal surgery clinic.Patient sampleConsecutive patients presenting for consultation to one of three spinal surgeons for lumbar spine pain were enrolled.Outcome measuresEight questions to ascertain a patient's dominant location of pain, either back dominant or leg dominant, were identified from the literature and local experts.MethodsThese eight questions were administered in a test-retest format over two weeks. The test-retest reliability of these questions were assessed in a self-administered questionnaire format for one group of patients and by a trained interviewer in a second group.ResultsThe test-retest reliability of each question ranged from substantial (eg, interviewer-administered percent question, weighted kappa=0.77) to slight (eg, self-administered pain diagram, weighted kappa=0.09). The Percent question was the most reliable in both groups (self-administered, interviewer). All questions in the interviewer-administered group were significantly (p<.001) more reliable than the self-administered group. Depending on the question, between 0% and 32% of patients provided a completely opposite response on test-retest. There was variability in prevalence of leg dominant pain, depending on which question was asked and there was no single question that identified all patients with leg dominant pain.ConclusionA patient's ability to identify whether his or her lumbar spine pain is leg or back dominant may be unreliable and depends on which questions are asked, and also how they are asked. The Percent question is the most reliable method to determine the dominant location of pain. However, given the variability of responses and the generally poorer reliability of many specific questions, it is recommended that multiple methods be used to assess a patient's dominant location of pain.