There is a lack of consensus in the literature for the management of lateral epicondylitis, which is reflected by individual variation in clinical treatment among the experts. Future prospective randomized control studies are needed to establish evidence-based practice standards for this common diagnosis.
Introduction: Pre-operative urinary tract infection (UTI) may be associated with a high rate of complications following surgeries. Few studies have investigated the clinical impact of a pre-operative UTI on post-operative outcomes following surgeries for hip-fracture in geriatric patients. Methods: The 2015e2016 ACS-NSQIP database was queried for patients undergoing hip fracture surgery using CPT-Codes for Total Hip Arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). Only patients 65 years of age undergoing surgery due to a traumatic hip fracture were included in the study. Results: Out of 31,621 patients undergoing surgical treatment for a hip fracture, 410 (1.3%) had UTI at the time of the surgery. Following adjusted logistic regression analysis, UTI present at the time of surgery was associated with a longer length of stay>5 days (OR 5.46 [95% CI 2.27e13.1]; p ¼ 0.008), any complication (OR 1.33 [95% CI 1.49e1.63]; p ¼ 0.007), infectious complications (OR 1.71 [95% CI 1.19 e2.47]; p ¼ 0.004), non-infectious complications (OR 1.28 [95% CI 1.04e1.58]; p ¼ 0.021), 30-day unplanned re-operations (OR 1.96 [95% CI 1.25e3.06]; p ¼ 0.003) and 30-day readmissions (OR 2.04 [95% CI 1.57e2.66]; p < 0.001). With regards to infectious complications, presence of a UTI at time of surgery was a significant independent predictor of sepsis (OR 2.44 [95% CI 1.24e4.80]; p ¼ 0.010) and septic shock (OR 4.05 [95% CI 2.03e8.08]; p < 0.001). Conclusions: Patients undergoing hip-fracture surgery with a concurrent UTI at the time of surgery have more adverse 30-day outcomes as compared to hip fracture patients who do not present with a UTI. Despite adjustment for a delay in the time to surgery, the impact of UTI on post-operative outcomes remained significant. While it is difficult to eradicate a UTI in a non-elective population, the findings stress the need for clinical optimization and potential need for early recognition/management of UTI in patients who sustain a hip fracture to minimize the risk of adverse outcomes.
Background Distal radius fractures (DRF) are commonly treated with open reduction and internal fixation (ORIF). Few studies address perioperative and postoperative pain control for this procedure. Questions/Purpose We attempt to demonstrate efficacy of pain management modalities during the perioperative and acute postoperative period after ORIF. Specifically, does the type of perioperative anesthesia used during fixation of DRF affect pain control postoperatively? Does the quantity of narcotic pain medication prescribed or type of pain medication given postoperatively affect pain management? Methods We retrospectively reviewed 294 adult (≥18 years old) patients who underwent outpatient ORIF of acute DRF between December 2012 and December 2014. All procedures were performed with a standard volar plating technique through a flexor carpi radialis approach. Patient demographics, fracture laterality, severity of fracture, type of operative anesthesia, and details regarding postoperative oral pain medications were recorded. We reviewed the number and timing of patient phone calls regarding postoperative pain and refills of pain prescriptions. Results Two-hundred ninety-four patients (average age 48.7 years) were included. One-hundred twenty-two injuries were right-sided (41.5%), 168 were left-sided (57.1%), and four were bilateral (1.4%). One-hundred fifty-one patients (51.4%) received regional anesthesia prior to surgery. Average number of narcotics tablets prescribed was 58. There were 66 patients who called the orthopaedic patient hotline regarding pain-control issues at a median of 7.0 days postoperatively. One-hundred twenty-nine (43.9%) patients required refills of narcotic pain medication postoperatively. There was no significant difference in the number of calls or refills given with regard to the type of anesthesia used or postoperative pain regimen prescribed. Conclusions More than one-fifth of patients who underwent ORIF experienced pain severe enough to call our institution's orthopaedic hotline to ask for help at a median of 7 days after fixation. Clinical Relevance Our study demonstrates poor pain control regardless of intraoperative anesthesia or utilization of varying postoperative pain regimens.
MRI findings of SEH and disc herniation have been well described in the literature. To our knowledge, this is the third report of intraoperatively confirmed disc herniation with MRI findings suggestive of SEH These discordant MRI and intraoperative findings illustrate that an SEH and a disc herniation may not always be distinguishable on MRI and may require surgical confirmation.
<div>Abstract<p>Psychological stressors have been implicated in the progression of various tumor types. We investigated a role for stress in tumor immune cell chemotaxis in the B16F10 mouse model of malignant melanoma. We exposed female mice to 6-hour periods of restraint stress (RST) for 7 days, then implanted B16F10 malignant melanoma tumor cells and continued the RST paradigm for 14 additional days. We determined serum corticosterone and liver catecholamine concentrations in these mice. To evaluate the tumor microenvironment, we performed IHC and examined cytokine expression profiles using ELISA-based analysis of tumor homogenates. We found that tumors in mice subjected to RST grew significantly slower, had reduced tumor C-C motif ligand 2 (CCL2), and contained fewer F4/80-positive macrophages than tumors from unstressed mice. We observed a concomitant increase in norepinephrine among the RST mice. An <i>in vitro</i> assay confirmed that norepinephrine downregulates CCL2 production in both mouse and human macrophages, and that pretreatment with the pan-β-adrenergic receptor inhibitor nadolol rescues this activity. Furthermore, RST had no effect on tumor growth in transgenic CCL2-deficient mice. This study suggests that stress reduces malignant melanoma by reducing recruitment of tumor-promoting macrophages by CCL2.</p></div>
Background:Achilles tendon ruptures commonly occur in physically active individuals and drastically alter the ability to perform recreational activities1,2. Many patients want to continue participating in recreational activities, which can be facilitated by operatively treating the injury in a timely fashion, maximizing their functional recovery. The Percutaneous Achilles Repair System (PARS) Jig (Arthrex) can be utilized in patients with acute mid-substance Achilles tendon ruptures3,4.Description:Begin by positioning the patient prone with a thigh tourniquet on the operative side. Mark a 3-cm transverse incision 1 cm distal to the proximal Achilles stump and make the incision, taking care to protect the sural nerve laterally. Next, create a transverse paratenon incision and bluntly dissect it from the Achilles circumferentially. After gaining access to the proximal Achilles stump, clamp it with an Allis clamp and insert the PARS Jig between the Achilles tendon and paratenon, sliding it proximally to the myotendinous junction. To secure the jig to the proximal Achilles tendon, insert a guide pin into the jig position-1 hole. To pass sutures through the Achilles tendon, insert pins with their respective sutures into positions 2 through 5 and insert the FiberTape suture (Arthrex) in position 1. Remove the jig from the transverse incision, pulling the suture ends out of the incision. Once they are out, reorient the sutures on the medial and lateral sides to match their positions when initially placed. On both sides, wrap the blue suture around the 2 striped green-and-white sutures twice, and pull the blue suture through the looped green-and-white suture on the ipsilateral side. After doing that, fold the blue suture on itself to create a shuttling suture with the green-and-white suture. Next, pull on the medial non-looped green-and-white suture until it has been pulled out medially, and repeat that with the lateral non-looped green-and-white suture until it has been pulled out laterally, to create a locking stitch. Group the medial sutures together and the lateral sutures together, and utilize a free needle to further incorporate both bundles of sutures into the Achilles tendon. Next, create bilateral mini-incisions 1.5 cm proximal to the calcaneal tuberosity. Insert a rigid cannulated suture-passing device into each mini-incision, pass it through the distal Achilles tendon, load the ipsilateral suture bundle into the Nitinol wire, and pull the suture-passing device out the distal mini-incision to approximate the Achilles. To prepare the calcaneus, drill calcaneal tunnels toward the midline bilaterally, taking care to avoid convergence of the tunnels. Place a suture-passing needle in the tunnels to assist with placing the anchors. Next, tension the sutures, cycling them 5 to 10 times to remove any slack in the system. With the ankle in 15° of plantar flexion, anchor the sutures with cortical bioabsorbable interference screws, following the angle that the suture-passing needles are in. After confirming function of the...
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