Effectiveness of Reconstruction of the Anterior Cruciate Ligament With Quadrupled Hamstrings and Bone-Patellar Tendon-Bone Autografts: An In Vivo Study Comparing Tibial Internal-External Rotation

Background: The 2 most frequently used autografts for anterior cruciate ligament reconstruction are the bone-patellar tendon- bone and the quadrupled hamstrings tendon. Hypothesis: Hamstring tendon graft is superior to patellar tendon graft in restoring tibial rotation during highly demanding activities because of its superiority in strength and linear stiffness and because it is closer morphologically to the anatomy of the natural anterior cruciate ligament. Study Design: Case control study; Level of evidence, 3. Methods: Eleven patients with patellar tendon graft anterior cruciate ligament reconstruction, 11 patients with hamstring tendon graft anterior cruciate ligament reconstruction, and 11 controls were assessed. Kinematic data were collected (50 Hz) with a 6-camera optoelectronic system while the subjects descended stairs and, immediately after, pivoted on their landing leg. The dependent variable examined was the tibial internal-external rotation during pivoting. All patients in both groups were also assessed clinically and with the use of a KT-1000 arthrometer to evaluate anterior tibial translation. Results: The results demonstrated that reconstructions with either graft successfully restored anterior tibial translation. However, both anterior cruciate ligament reconstruction groups had significantly increased tibial rotation when compared with the controls, whereas no differences were found between the 2 reconstructed groups. Conclusion: The 2 most frequently used autografts for anterior cruciate ligament reconstruction cannot restore tibial rotation to normal levels. Clinical Relevance: New surgical techniques are needed that can better approximate the actual anatomy and function of the anterior cruciate ligament

Tibial Rotation is Not Restored after ACL Reconstruction with a Hamstring Graft

Recent research suggests ACL reconstruction does not re- store tibial rotation to normal levels during high demand activities when a bone-patellar tendon-bone graft is used. We asked if an alternative graft, the semitendinosus-gracilis (ST/G) tendon graft, could restore tibial rotation during a high demand activity. Owing to its anatomic similarity with the normal ACL we hypothesized the ST/G graft could re- store excessive tibial rotation to normal healthy levels along with a successful reinstatement of the clinical stability of the knee. We assessed tibial rotation in vivo, using gait analysis. We compared the knees of ACL reconstructed patients with an ST/G graft to their intact contralateral and healthy con- trols during a pivoting task that followed a stair descent. We also evaluated knee stability after ACL reconstruction with standard clinical tests. ACL reconstruction with the ST/G graft and with current techniques did not restore tibial ro- tation to previous physiological levels during an activity with increased rotational loading at the knee, although abnormal anteroposterior (AP) tibial translation was restored

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Effects of partial ionization on magnetic flux emergence in the Sun

We have performed 3D numerical simulations to investigate the effect of partial ionization on the process of magnetic flux emergence. In our study, we have modified the single-fluid MHD equations to include the presence of neutrals and have performed two basic experiments: one that assumes a fully ionized plasma (FI case) and one that assumes a partially ionized plasma (PI case). We find that the PI case brings less dense plasma to and above the solar surface. Furthermore, we find that partial ionization alters the emerging magnetic field structure, leading to a different shape of the polarities in the emerged bipolar regions compared to the FI case. The amount of emerging flux into the solar atmosphere is larger in the PI case, which has the same initial plasma beta as the FI case, but a larger initial magnetic field strength. The expansion of the field above the photosphere occurs relatively earlier in the PI case, and we confirm that the inclusion of partial ionization reduces cooling due to adiabatic expansion. However, it does not appear to work as a heating mechanism for the atmospheric plasma. The performance of these experiments in three dimensions shows that PI does not prevent the formation of unstable magnetic structures, which erupt into the outer solar atmosphere

Arthroscopic Removal of Tenosynovial Giant-Cell Tumors of the Cruciate Ligaments. Presentation of Two Cases.

BACKGROUND: Tenosynovial giant-cell tumor (GCT) arising from cruciate ligaments consists a rather rare entity. Predominantly areas where this tumor appears are the palmar sides of fingers and toes. The involvement of larger joints such as the knee or the ankle is rather rare, but, in the case of synovial joints, the knee joint is particularly affected. Furthermore, rare seems to be the intra-articular localization of the tenosynovial GCT of the tendon sheath. Hereby, we present an arthroscopic approach of treatment with two cases. CASE REPORTS: The first case was a 32-year-old male with a GCT arising from the anterior cruciate ligament (ACL). The second case was a 26-year-old male with a GCT arising from the posterior cruciate ligament (PCL). In the first case, a round-shaped mass with a reddish-brown color was located just anterior to the ACL and impeded the full extension of the knee joint, while, in the second case, a well-circumscribed oval-shaped mass was found with a peduncle attached to the synovium of the PCL. After arthroscopic excision, both patients became asymptomatic, with complete lack of pain and full ROM. CONCLUSIONS: There is a lack of clinical features for the GCT of the knee, and thus, a thorough clinical examination is prudent. Usually, the diagnosis is set after an investigation based on suspicion. This entity can present with symptoms of instability and patients may present signs of mechanical derangement. With the knee joint, meniscal symptoms and locking are often present. The best non-invasive technique to diagnose this tumor has been reported to be the magnetic resonance imaging. Arthroscopic excision has been reported as a safe and effective procedure for treatment

Delayed colorectal cancer care during covid-19 pandemic (decor-19). Global perspective from an international survey

Background The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer (CRC) care during the pandemic. Methods The impact of COVID-19 on preoperative assessment, elective surgery, and postoperative management of CRC patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in CRC care. Respondents were divided into two comparator groups: 1) ‘delay’ group: CRC care affected by the pandemic; 2) ‘no delay’ group: unaltered CRC practice. Results A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the ‘delay’ (745, 70.9%) and ‘no delay’ (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to COVID-19 units, units fully dedicated to COVID-19 care, personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology and prolonged chemoradiation therapy-to-surgery intervals. In the ‘delay’ group, 48.9% of respondents reported a change in the initial surgical plan and 26.3% reported a shift from elective to urgent operations. Recovery of CRC care was associated with the status of the outbreak. Practicing in COVID-free units, no change in operative slots and staff members not relocated to COVID-19 units were statistically associated with unaltered CRC care in the ‘no delay’ group, while the geographical distribution was not. Conclusions Global changes in diagnostic and therapeutic CRC practices were evident. Changes were associated with differences in health-care delivery systems, hospital’s preparedness, resources availability, and local COVID-19 prevalence rather than geographical factors. Strategic planning is required to optimize CRC care

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit