Complications of treatment of acromioclavicular and sternoclavicular joint injuries

Although common, AC joint injuries and their treatments are not benign. The injury itself and both nonsurgical and surgical treatments may result in complications yielding persistent pain, deformity, or dysfunction. Sternoclavicular joint injuries are far less common and are typically the result of higher energy trauma. As such, the associated complications may be more serious. Familiarity with the potential complications of these injuries can help the treating physician to develop strategies to minimize their incidence and sequelae.     

Technical considerations in revision anterior cruciate ligament surgery

Revision ACL surgery is a technically demanding enterprise that requires meticulous preoperative planning and tempered postoperative expectations on the patient's part. Despite the complexities of the procedure, it is becoming more common as an increasing number of primary ACL reconstructions are being performed, expanding the pool of patients at risk for failure. Candidates for revision surgery should be selected carefully, focusing on those patients with recurrent instability rather than pain as their primary complaint. A thorough history and physical examination is essential, taking care to identify additional patholaxity that might contribute to a failed ACL reconstruction. To optimize outcomes, surgeons must take care to avoid common pitfalls in index and revision procedures. Femoral and tibial tunnels should be positioned anatomically, and staged bone grafting procedures should be considered if revision graft fixation may be compromised by tunnel defects. The type of graft must be carefully selected, appropriately tensioned, and securely fixed. Surgeons should have a number of techniques and instruments at their disposal for performing each of these steps, as the highly variable presentation of failed ACL reconstructions demands a versatile approach. Ultimately, with cautious rehabilitation, these techniques will allow for restoration of knee stability and, in many cases, an improvement in activity level.     

Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment.

A retrospective review was performed of 106 patients to determine the effect of knee pain as the initial complaint of slipped capital femoral epiphysis (SCFE). Sixteen (15%) patients had a primary complaint of distal thigh or knee pain or both at initial presentation to our institution or to a referring physician. Ninety (85%) patients described primarily hip, groin, or proximal thigh discomfort. Of the 106 patients with SCFE, 65 patients received no operative treatment before being evaluated at our institution and were the subject of the remainder of the study. Of these, 15 (23%) patients had distal thigh or knee pain or both as their chief complaint (group I), and 50 (77%) patients had hip, groin, or proximal thigh pain (group II). There was no difference between the groups with respect to age, gender, or slip stability. Group I patients were more likely to receive a misdiagnosis (p < 0.05) and undergo unnecessary or uninformative radiographs (p < 0.05). Additionally, patients in group I were found to have slips of greater radiographic severity (p < 0.05). Although not statistically significant, there was a trend for group I patients to experience a longer delay to diagnosis and to require a proximal femoral osteotomy as treatment for their slips. We conclude that isolated distal thigh or knee pain or both is a common presentation of SCFE. Furthermore, this symptom complex, when compared with the more classic presentation of SCFE, leads to higher rates of unnecessary radiographs, misdiagnoses, and severe slips, potentially increasing long-term morbidity.     

Cross-cultural comparison of patients undergoing ACL reconstruction in the United States and Norway

Data from large prospectively collected anterior cruciate ligament (ACL) cohorts are being utilized to address clinical questions regarding ACL injury demographics and outcomes of ACL reconstruction. These data are affected by patient and injury factors as well as surgical factors associated with the site of data collection. The aim of this article is to compare primary ACL reconstruction data from patient cohorts in the United States and Norway, demonstrating the similarities and differences between two large cohorts. Primary ACL reconstruction data from the Multicenter Orthopaedic Outcomes Network (MOON) in the United States and the Norwegian National Knee Ligament Registry (NKLR) were compared to identify similarities and differences in patient demographics, activity at injury, preoperative Knee injury and Osteoarthritis Outcome Score (KOOS), time to reconstruction, intraarticular pathology, and graft choice. Seven hundred and thirteen patients from the MOON cohort were compared with 4,928 patients from the NKLR. A higher percentage of males (NKLR 57%, MOON 52%; P < 0.01) and increased patient age (NKLR 27 years, MOON 23 years; P < 0.001) were noted in the NKLR population. The most common sports associated with injury in the MOON cohort were basketball (20%), soccer (17%), and American football (14%); while soccer (42%), handball (26%), and downhill skiing (10%) were most common in the NKLR. Median time to reconstruction was 2.4 (Interquartile range [IQR] 1.2–7.2) months in the MOON cohort and 7.9 (IQR 4.2–17.8) months in the NKLR cohort (P < 0.001). Both meniscal tears (MOON 65%, NKLR 48%; P < 0.001) and articular cartilage defects (MOON 46%, NKLR 26%; P < 0.001) were more common in the MOON cohort. Hamstring autografts (MOON 44%, NKLR 63%) and patellar tendon autografts (MOON 42%, NKLR 37%) were commonly utilized in both cohorts. Allografts were much more frequently utilized in the MOON cohort (MOON 13%, NKLR 0.04%; P < 0.001). Significant diversity in patient, injury, and surgical factors exist among large prospective cohorts collected in different locations. Surgeons should investigate and consider the characteristics of these cohorts when applying knowledge gleaned from these groups to their own patient populations.     

Pediatric anesthesia training to early career stage: Opportunities for firm foundations

Attaining professional contentment can be challenging for many. Academic success, psychosocial support, and the confidence to provide excellent clinical care at the workplace are key pillars that can help build a sense of meaning in a career. The role of mentorship in facilitating these key pillars at different stages of pediatric anesthesia training and new independent practice is instrumental. For mentees aspiring for a career in pediatric anesthesia, there are several points of focus. Mentees should seek out mentors early in training, build on these relationships, and explore opportunities for peer mentorship as they advance in their career. For mentors, introducing mentees to the clinical and academic aspects of pediatric anesthesia and setting the foundation for the mentee to advance in their career can be both gratifying and stimulating. In this article, we explore the development and progression of a mentor‐mentee relationship through training to the early career stage and its role in developing a meaningful career in pediatric anesthesia.     

Complications associated with paediatric airway management during the COVID-19 pandemic: an international,multicentre, observational study

Respiratory adverse events in adults with COVID-19 undergoing general anaesthesia can be life-threatening. However, there remains a knowledge gap about respiratory adverse events in children with COVID-19. We created an international observational registry to collect airway management outcomes in children with COVID-19 who were having a general anaesthetic. We hypothesised that children with confirmed or suspected COVID-19 would experience more hypoxaemia and complications than those without. Between 3 April 2020 and 1 November 2020, 78 international centres participated. In phase 1, centres collected outcomes on all children (age ≤ 18 y) having a general anaesthetic for 2 consecutive weeks. In phase 2, centres recorded outcomes for children with test-confirmed or suspected COVID-19 (based on symptoms) having a general anaesthetic. We did not study children whose tracheas were already intubated. The primary outcome was the incidence of hypoxaemia during airway management. Secondary outcomes included: incidence of other complications; and first-pass success rate for tracheal intubation. In total, 7896 children were analysed (7567 COVID-19 negative and 329 confirmed or presumed COVID-19 positive). The incidence of hypoxaemia during airway management was greater in children who were COVID-19 positive (24 out of 329 (7%) vs. 214 out of 7567 (3%); OR 2.70 (95%CI 1.70–4.10)). Children who had symptoms of COVID-19 had a higher incidence of hypoxaemia compared with those who were asymptomatic (9 out of 51 (19%) vs. 14 out of 258 (5%), respectively; OR 3.7 (95%CI 1.5–9.1)). Children with confirmed or presumed COVID-19 have an increased risk of hypoxaemia during airway management in conjunction with general anaesthesia.