Citations

Objective We describe a novel way to calculate estimated blood loss (EBL) using an intraoperative pictographic tool in gynecologic surgery. Methods A pictographic tool to estimate sponge saturation was developed to calculate EBL during surgery. A prospective cohort of women 18 years or older undergoing benign vaginal hysterectomy with planned adnexal surgery at Mayo Clinic were consented for use of the pictographic tool. Demographic, preoperative, intraoperative, and postoperative data were abstracted. Estimated blood loss was compared among surgeons, anesthesia providers, and the pictographic tool and then correlated with change in hemoglobin. Results Eighty-one patients met inclusion with mean age of 45.3 ± 8.7 years. Successful vaginal hysterectomy was achieved in all patients with successful completion of planned adnexectomy in 69 (85.2%). Mean EBL among surgeons, anesthesia providers, and pictographic estimates, respectively, was as follows: 199.4 ± 81.9 mL, 195.5 ± 152.2 mL, and 288.5 ± 186.6 mL, with concordance correlation coefficients for surgeons and anesthesia providers versus pictographic tool of 0.40 (95% confidence interval, 0.29–0.51) and 0.68 (95% confidence interval, 0.57–0.79), respectively. The mean postoperative change in hemoglobin was −1.8 g/dL; there were no postoperative transfusions. Change in hemoglobin was more correlated with blood loss estimates from surgeons ( r = −0.31, P = 0.008) and anesthesia providers ( r = −0.37, P = 0.003) than the pictographic tool ( r = −0.19, P = 0.11). Conclusions Use of a pictographic tool to objectively estimate blood loss demonstrated significant overestimations compared with both anesthesia providers’ and surgeons’ estimates because the pictographic tool was less correlated with postoperative change in hemoglobin than anesthesia provider and surgeon estimates.

Purpose The purpose of this meta‐analysis was to determine overall objective graft failure rate, failure rate by graft type (allograft vs autograft reconstruction), instrumented laxity, and patient outcome scores following revision anterior cruciate ligament (ACL) reconstruction. Outcomes of interest were collected for all studies meeting the study inclusion criteria, but lower‐level studies (level III/IV) were not pooled for quantitative synthesis due to high levels of heterogeneity in these study populations. Methods A comprehensive search strategy was performed to identify studies reporting outcomes of revision ACL reconstruction. The primary outcome reported was graft failure. A meta‐analysis comparing rate of failure by graft type was conducted using a random effects model. Studies also reported patient clinical outcome scores, including International Knee Documentation Committee (IKDC), Lysholm, and knee injury and osteoarthritis outcome scores (KOOS) and graft laxity. Results Eight studies with 3,021 patients (56% male, 44% female) with an average age of 30 ± 4 years and mean follow‐up time of 57 months were included. The overall objective failure rate was 6% (95% confidence interval [CI], 1.8%‐12.3%). Mean instrumented laxity as side‐to‐side difference was 2.5 mm (95% CI, 1.9‐3.1 mm). Mean IKDC subjective score was 76.99 (95% CI, 76.64‐77.34), mean KOOS symptoms score was 76.73 (95% CI, 75.85‐77.61), and mean Lysholm score was 86.18 (95% CI, 79.08‐93.28). The proportion of patients with IKDC grade A or B was 85% (95% CI, 77%‐91%). When the available data for failure rate were analyzed by graft type, autograft reconstruction had a failure rate of 4.1% (95% CI, 2.0%‐6.9%), similar to allograft reconstruction at 3.6% (95% CI, 1.4%‐6.7%). Conclusions In this meta‐analysis, revision ACL reconstruction had failure rates similar to autograft or allograft reconstruction. Overall outcome scores for revision reconstruction have improved but appear modest when compared with primary ACL reconstruction surgery. Level of Evidence Meta‐analysis of Level II studies, Level II.

Glioblastoma (GBM) is a devastating brain tumor with poor prognosis despite advances in surgery, radiation, and chemotherapy. Survival of patients with glioblastoma remains poor, with only 1 in 4 patients alive at 2 years, and a 5-year survival rate of about 5%. Recurrence is nearly universal and, after recurrence, prognosis is poor with very short progression-free survival and overall survival (OS). Various salvage chemotherapy strategies have been applied with limited success. Tumor Treating Fields (TTFields) are a novel treatment modality approved for treatment of either newly diagnosed or recurrent GBM. TTFields therapy involves a medical device and transducer arrays to provide targeted delivery of low intensity, intermediate frequency, alternating electric fields to produce antimitotic effects selective for rapidly dividing tumor cells with limited toxicity. In the phase 3 EF-14 trial, TTFields plus temozolomide provided significantly longer progression-free survival and OS compared with temozolomide alone in patients with newly diagnosed GBM after initial chemoradiotherapy. The addition of TTFields to standard therapy improved median OS from 15.6 to 20.5 months (P=0.04). In the phase 3 EF-11 trial, for recurrent GBM, TTFields provided comparable efficacy as investigator’s choice systemic therapy, with improved patient-reported quality of life and a lower incidence of serious adverse events. Primary toxicity associated with TTFields is skin irritation generally managed with array relocation and topical treatments including antibiotics and steroids. TTFields therapy has demonstrated proven efficacy in management of GBM, including improvement in OS for patients with newly diagnosed GBM, and is under current investigation in other brain and extracranial tumors.

Background: The reported rate of second anterior cruciate ligament (ACL) injuries (20%-30%), including graft failure and contralateral ACL tears, after ACL reconstruction (ACLR) or nonoperative therapy indicates that multiple factors may predispose patients to subsequent ACL injuries. Purpose: To determine the incidence of second ACL injuries in a population-based cohort over a 10-year observation period (2001-2010) and to identify factors that contribute to the risk of second injuries. Study Design: Descriptive epidemiological study. Methods: International Classification of Diseases, 9th Revision (ICD-9) codes relevant to the diagnosis of an ACL tear and the procedure code for ACLR were utilized to search the Rochester Epidemiology Project, a multidisciplinary county database, between the years of 2001 and 2010. The complete medical records for all cases were reviewed to confirm diagnosis and treatment details. A total of 914 unique patients with 1019 acute, isolated ACL tears were identified. These patients were stratified by primary and secondary tears, sex, age, activity level, side of injury, sex × side of injury, and graft type of reconstruction. Results: Second ACL tears were recorded in 141 (13.8%) of the 914 patients diagnosed with an ACL tear in Olmsted County, Minnesota, USA, from 2001 to 2010; 50.4% of these occurred in the contralateral knee. A noncontact mechanism was responsible for 76.4% of all ACL injuries. A second ACL injury was influenced by factors of sex × age group, treatment type × age group, and treatment type × activity level. Nonparametric analysis of graft disruption × graft type demonstrated that a higher prevalence of second ACL tears occurred with allografts compared with hamstring autografts ( P = .0054) and patellar tendon autografts ( P = .0001). Conclusion: The incidence of second ACL tears in this population-based cohort was 13.8%, and half occurred to the ACL of the contralateral knee. Statistically, second ACL injuries differed by sex, occurring in female patients younger than 25 years and male patients aged 26 to 45 years. Allografts continued to be associated with a greater risk of second ACL injuries compared with hamstring and patellar tendon autografts. Nonoperative treatment carried more risk of contralateral tears than ACLR.

Abstract Horizontal cleavage meniscus tears are a common orthopedic injury often treated with partial or total meniscectomy versus repair. This Technical Note presents a technique for all‐inside repair with uniform compression of the superior and inferior leaflets by placement of multiple circumferential compression stitches using an all‐inside self‐retrieving suture passing device. The currently described technique provides several advantages for all‐inside repair of a horizontal cleavage tear: (1) eliminates the need for a posterior incision, (2) minimizes the risk of neurovascular injury, (3) uses standard arthroscopy portals (or small modifications), and (4) requires only a single suture deployment with a self‐retrieving device for each circumferential compression stitch. The resulting circumferential stitch provides uniform compression to the superior and inferior leaflets, promoting meniscal healing. This configuration has been shown to have the highest load to failure of all repair patterns. Technique Video video See video under supplementary data.

Background: First-time lateral patellar dislocation is a common orthopaedic injury. The purposes of this study were to (1) evaluate the incidence of first-time lateral patellar dislocation in a geographically-determined population, (2) report trends over time in the incidence of dislocation, and (3) describe the rate of surgical treatment. Hypothesis: The rate of patellar dislocation is highest among adolescent patients. Study Design: Cohort study. Level of Evidence: Level 3. Methods: The study population included 609 individuals identified through a multidisciplinary geographic cohort county database who were diagnosed with first-episode lateral patellar dislocation between 1990 and 2010. The complete medical records were reviewed to confirm the diagnosis and to evaluate details of injury and treatment. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 US population. Poisson regression analyses were performed to examine incidence trends by age, sex, and calendar period. Results: The overall age- and sex-adjusted annual incidence of patellar dislocation was 23.2 (95% CI, 21.2-24.9) per 100,000 person-years. The annual incidence was similar between male and female patients and highest among adolescents aged 14 to 18 years (147.7/100,000 person-years). The mean age at dislocation was 21.4 ± 9.9 years, and 331 patients (54.4%) were female. During the study period, there was a significant decline in the incidence of patellar dislocation among men aged 19 to 25 years ( P = 0.002) and girls aged 14 to 18 years ( P = 0.025). Eighty patients received surgical treatment during the study period, including 66 patients (10.8%) for recurrent instability and 14 patients (2.3%) for acute osteochondral injury. Conclusion: With an annual incidence of 23.2 per 100,000 person-years, lateral patellar dislocation is a frequently encountered orthopaedic injury. The incidence of dislocation among adolescent patients in this cohort is higher than previously reported. Despite a decrease in the annual incidence of dislocation in adolescent girls, the overall incidence of patellar dislocation remained relatively constant over a 21-year observation period. Clinical Relevance: This study demonstrates that the incidence of patellar dislocation in adolescents is greater than previously reported.

Abstract Lateral meniscus tears are commonly encountered by orthopaedic surgeons. Despite efforts to repair and preserve the meniscus, meniscectomy is occasionally required to treat irreparable tears. The resulting lateral meniscus deficiency leads to increased tibiofemoral contact pressures and ultimately early osteoarthritic changes in the knee. Lateral meniscal allograft transplant (LMAT) has been proposed as a way to restore the lateral meniscus–deficient knee to its native form. Although several techniques for LMAT have been proposed, osseous fixation has demonstrated increased stability, improved outcomes, and improved long‐term survival. This article presents a technique for LMAT using bone plugs and standard arthroscopic portals. Technique Video video See video under supplementary data.

Assessment of tumor-infiltrating lymphocytes (TILs) in histopathologic specimens can provide important prognostic information in diverse solid tumor types, and may also be of value in predicting response to treatments. However, implementation as a routine clinical biomarker has not yet been achieved. As successful use of immune checkpoint inhibitors and other forms of immunotherapy become a clinical reality, the need for widely applicable, accessible, and reliable immunooncology biomarkers is clear. In part 1 of this review we briefly discuss the host immune response to tumors and different approaches to TIL assessment. We propose a standardized methodology to assess TILs in solid tumors on hematoxylin and eosin sections, in both primary and metastatic settings, based on the International Immuno-Oncology Biomarker Working Group guidelines for TIL assessment in invasive breast carcinoma. A review of the literature regarding the value of TIL assessment in different solid tumor types follows in part 2. The method we propose is reproducible, affordable, easily applied, and has demonstrated prognostic and predictive significance in invasive breast carcinoma. This standardized methodology may be used as a reference against which other methods are compared, and should be evaluated for clinical validity and utility. Standardization of TIL assessment will help to improve consistency and reproducibility in this field, enrich both the quality and quantity of comparable evidence, and help to thoroughly evaluate the utility of TILs assessment in this era of immunotherapy.

Assessment of the immune response to tumors is growing in importance as the prognostic implications of this response are increasingly recognized, and as immunotherapies are evaluated and implemented in different tumor types. However, many different approaches can be used to assess and describe the immune response, which limits efforts at implementation as a routine clinical biomarker. In part 1 of this review, we have proposed a standardized methodology to assess tumor-infiltrating lymphocytes (TILs) in solid tumors, based on the International Immuno-Oncology Biomarkers Working Group guidelines for invasive breast carcinoma. In part 2 of this review, we discuss the available evidence for the prognostic and predictive value of TILs in common solid tumors, including carcinomas of the lung, gastrointestinal tract, genitourinary system, gynecologic system, and head and neck, as well as primary brain tumors, mesothelioma and melanoma. The particularities and different emphases in TIL assessment in different tumor types are discussed. The standardized methodology we propose can be adapted to different tumor types and may be used as a standard against which other approaches can be compared. Standardization of TIL assessment will help clinicians, researchers and pathologists to conclusively evaluate the utility of this simple biomarker in the current era of immunotherapy.