Diagnostic Accuracy of an Algorithm for Discriminating Presumed Solid and Gaseous Microembolic Signals During Transcranial Doppler Examinations

OBJECTIVE

The aim of the work described here was to assess the diagnostic accuracy of a new algorithm (SGA-a) for time-domain analysis of transcranial Doppler audio signals to discriminate presumed solid and gaseous microembolic signals and artifacts (SGAs).

METHODS

SGA-a was validated by human experts in an artifact cohort of 20 patients subjected to a 1-h transcranial Doppler exam before cardiac surgery (cohort 1). Emboli were validated in a cohort of 10 patients after aortic valve replacement in a 4-h monitoring period (cohort 2). The SGA misclassification rate was estimated by testing SGA-a on artifact-free test files of solid and gaseous emboli.

RESULTS

In cohort 1 (n = 24,429), artifacts were classified with an accuracy of 94.5%. In cohort 2 (n = 12,328), the accuracy in discriminating solid/gaseous emboli from artifacts was 85.6%. The 95% limits of agreement for, respectively, the numbers of presumed solids and gaseous emboli, artifacts and microembolic signals of undetermined origin were [-10, 10], [-14, 7] and [-9, 16], and the intra-class correction coefficients were 0.99, 0.99 and 0.99, respectively. The rate of misclassification of solid test files was 2%, and the rate of misclassification of gaseous test files was 12%.

CONCLUSION

SGA-a can detect presumed solid and gaseous microembolic signals and differentiate them from artifacts. SGA-a could be of value when both solid and gaseous emboli may jeopardize brain function such as seen during cardiac valve and/or aortic arch replacement procedures.

Graft failure and revision rate after ACL repair with dynamic intraligamentary stabilization. One-year results of a prospective case series of 155 patients

PURPOSE

The aim of this study was to assess graft failure, revision rate, and functional outcomes after treatment of acute ACL rupture with dynamic intraligamentary stabilization (DIS) Ligamys device one year post surgery. Additionally, differences in functional outcome between patients with and without anteroposterior laxity were assessed. It was hypothesized that the failure rate of DIS was non-inferior to that of previously reported ACL reconstruction (10%).

METHODS

In this prospectively designed multicenter study, including patients with an acute ACL rupture, DIS was performed within 21 days after rupture. Primary outcome was failure of the graft at 1 year post surgery, defined as 1) re-rupture of the graft, 2) revision of DIS, or 3) a > 3 mm side-to-side difference in anterior tibial translation compared to the non-operated knee (∆ATT), measured by the KT1000 device. Additional analysis was performed using a 5 mm threshold. The subjective International Knee Documentation Committee Score (IKDC) and Numerical Rating Scales (NRS) for pain and confidence were used to evaluate functional outcome.

RESULTS

A total of 155 patients were included with a mean age at surgery of 27.8 years (SD 9.4). The mean interval from rupture to DIS was 16.4 days (SD 5.2). At a median follow-up of 13 months (IQR 12-18) the failure rate of the graft was 30.2% (95%CI:22.0-39.4); 11 patients (7%) required secondary reconstructive surgery and of the 105 patients who attended ATT measurement, 24 patients (23%) had an ∆ATT > 3 mm. Secondary analysis, based on a 5 mm threshold, revealed a failure rate of 22.4% (95%CI: 15.2; 31.1). A total of 39 patients (25%) reported at least one complication, comprising mainly arthrofibrosis, traumatic re-rupture and pain. In these patients, removal of the monoblock was performed in 21 cases (13.5%). At follow-up no significant differences in functional outcomes between patients with ∆ATT > 3 mm and stable ATT were observed.

CONCLUSION

This prospective multicenter study found a high failure rate at one year follow-up of 30% (7% revision surgery and 23% > 3 mm side-to-side difference in anterior tibial translation) in patients treated by primary repair of the ACL with DIS, and did therefore not demonstrate non-inferiority to ACL reconstruction. For patients who did not require secondary reconstructive surgery, this study found good functional outcomes, also in case of persistent anteroposterior knee laxity (∆ATT > 3 mm).

LEVEL OF EVIDENCE

Level IV.

Validation of the Super Simple Hip score combined with the University of California, Los Angeles activity scale for younger patients

INTRODUCTION

Patient-reported outcome measures (PROMs) are used increasingly, but for young patients with hip complaints, traditional scoring systems have a ceiling effect that limits their usability. We developed and validated the Super Simple Hip (SUSHI) score, a PROM specifically targeted at younger patients with hip complaints. Although the SUSHI measured hip problems adequately, the responsiveness of its activity rating component was considered inadequate. Consequently, we replaced the activity rating component by the University of California, Los Angeles (UCLA) activity scale. The aim of this study was to validate the resulting new 10-item SUSHI-UCLA score.

METHODS

A prospective multicentre observational cohort study was performed. Patients between 18 and 59 years, who visited the Orthopaedic Department with hip complaints, completed the SUSHI-UCLA and hip osteoarthritis outcome score (HOOS) twice before their 1st appointment, and once 16 months after.

RESULTS

142 patients were included (mean age 49 years; SD 8.8). The SUSHI-UCLA score correlated well with the HOOS, both before and after treatment (Spearman's rho = 0.739 and 0.847, respectively, both p < 0.001). The responsiveness of both the SUSHI-UCLA score and the UCLA activity scale was high (standardised response mean = 2.51 and 1.35 respectively). The reproducibility was good (interclass correlation coefficient for agreement = 0.962). The minimal important change was 21.2. No significant floor or ceiling effect was observed.

CONCLUSION

The SUSHI-UCLA score is an adequate PROM to measure hip complaints in younger patients and includes a validated activity rating.

The European Robotic Spinal Instrumentation (EUROSPIN) study: protocol for a multicentre prospective observational study of pedicle screw revision surgery after robot-guided, navigated and freehand thoracolumbar spinal fusion

INTRODUCTION

Robotic guidance (RG) and computer-assisted navigation (NV) have seen increased adoption in instrumented spine surgery over the last decade. Although there exists some evidence that these techniques increase radiological pedicle screw accuracy compared with conventional freehand (FH) surgery, this may not directly translate to any tangible clinical benefits, especially considering the relatively high inherent costs. As a non-randomised, expertise-based study, the European Robotic Spinal Instrumentation Study aims to create prospective multicentre evidence on the potential comparative clinical benefits of RG, NV and FH in a real-world setting.

METHODS AND ANALYSIS

Patients are allocated in a non-randomised, non-blinded fashion to the RG, NV or FH arms. Adult patients that are to undergo thoracolumbar pedicle screw instrumentation for degenerative pathologies, infections, vertebral tumours or fractures are considered for inclusion. Deformity correction and surgery at more than five levels represent exclusion criteria. Follow-up takes place at 6 weeks, as well as 12 and 24 months. The primary endpoint is defined as the time to revision surgery for a malpositioned or loosened pedicle screw within the first postoperative year. Secondary endpoints include patient-reported back and leg pain, as well as Oswestry Disability Index and EuroQOL 5-dimension questionnaires. Use of analgesic medication and work status are recorded. The primary analysis, conducted on the 12-month data, is carried out according to the intention-to-treat principle. The primary endpoint is analysed using crude and adjusted Cox proportional hazards models. Patient-reported outcomes are analysed using baseline-adjusted linear mixed models. The study is monitored according to a prespecified monitoring plan.

ETHICS AND DISSEMINATION

The study protocol is approved by the appropriate national and local authorities. Written informed consent is obtained from all participants. The final results will be published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov registry NCT03398915; Pre-results, recruiting stage.

Risk factors for postoperative pain in the first three weeks after arthroscopic or open shoulder surgery

INTRODUCTION

Shoulder surgery is a painful procedure. Adequate postoperative pain control increases patient satisfaction. The objectives of this study were to investigate postoperative pain development in shoulder surgery and to assess risk factors for high postoperative pain.

HYPOTHESIS

Patients who undergo rotator cuff repair are more painful than patients who undergo different kinds of shoulder surgery.

MATERIAL AND METHODS

Four hundred and sixty five patients who underwent shoulder surgery were included in this retrospective cohort study. A linear mixed model analysis was used to compare NRS (Numeric Rating Scale) for pain between different kinds of shoulder surgery in the first three weeks postoperatively. To assess risk factors for high postoperative pain odds ratios were calculated.

RESULTS

Pain development in the first 3 weeks differed between procedures with rotator cuff repair being the most painful procedure. Risk factors for high postoperative pain were female sex and subacromial decompression with distal clavicle resection.

DISCUSSION

Patients who undergo rotator cuff repair are indeed more painful than patients who undergo different kinds of shoulder surgery. With identifying these differences in pain development and the risk factors for high postoperative pain after shoulder surgery, we can optimize postoperative pain treatment. However, further research is needed to support these results.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

The influence of food order on postprandial glucose levels in children with type 1 diabetes

OBJECTIVE

To evaluate the effect of the order of intake of carbohydrates, protein, and fat on postprandial glucose levels in children with type 1 diabetes (T1D). Our hypothesis was that postprandial glucose levels would be lower when fat and protein are consumed prior to carbohydrates, compared to a meal where all macronutrients are combined.

METHODS

A randomized, open-label, within-subject crossover study was conducted. Twenty patients aged 7 to 17 years diagnosed with T1D for >1 year consumed 2 isocaloric meals (with similar composition) in random order. In 1 meal, the protein and fat part was consumed 15 minutes prior to the carbohydrates (test meal). In the other meal, all macronutrients were consumed together (standard meal). Capillary blood glucose measurements and continuous glucose monitoring system were used to assess multiple glucose levels during a 3-hour postprandial period.

RESULTS

Overall, mean glucose levels were 1 mmol/L lower following the test meal compared to the standard meal (9.30 ± 3.20 vs 10.24 ± 3.35 mmol/L; P < .001). No significant difference in peak glucose was found. Glucose excursions were 1.5 and 1 mmol/L lower at 30 and 120 minutes following the test meal. A reduction in the total time period in which glucose levels exceeded 10 and 12 mmol/L of 28.7 (P = .001) and 22.3 minutes (P = .004), respectively, after the test meal was found.

CONCLUSIONS

This study shows that consumption of protein and fat prior to carbohydrates results in lower postprandial glucose levels and reduced glycemic variability in children with T1D.

Safety and effectiveness of selective carotid angioplasty prior to cardiac surgery: a single-centre matched case-control study

OBJECTIVES

Reducing the rate of postoperative stroke after cardiac surgery remains challenging, especially in patients with occlusive cerebrovascular disease. Angioplasty in all patients with high-grade carotid artery stenosis has not been shown to be effective in reducing the post-surgical stroke rate. In this study, we present the initial results of a different approach using selective carotid angioplasty only in patients with poor intracranial collaterals.

METHODS

We conducted a single-centre study to assess the safety of this procedure. The postangioplasty complication rate of the study group was compared to that of patients who were scheduled for symptomatic carotid artery angioplasty. To determine the effectiveness of this procedure, the post-cardiac surgery complication rate of the study group was compared with that of the matched case controls.

RESULTS

Twenty-two patients were treated with selective carotid angioplasty without developing persistent major neurological complications. All patients except 1 patient subsequently underwent surgery without developing persistent major neurological disabilities. Two patients died of cardiogenic shock within 30 days.

CONCLUSIONS

Selective carotid angioplasty prior to cardiac surgery in patients with a presumed high risk of stroke was relatively safe and effective in this study group. Although this strategy does not prevent stroke in these high-risk patients, data suggest that this approach shifts the postoperative type of stroke from a severe haemodynamic stroke towards a minor embolic stroke with favourable neurological outcomes. Larger studies are needed to determine whether this strategy can effectively eliminate the occurrence of haemodynamic stroke after cardiac surgery.

Impact of the Haga Braincare Strategy on the burden of haemodynamic and embolic strokes related to cardiac surgery

OBJECTIVES

This study prospectively evaluates the impact of the Haga Braincare Strategy (HBS) on the occurrence of haemodynamic and embolic stroke in a cohort of patients who underwent coronay artery bypass grafting (CABG), valve replacement of a combination of both types of surgery between 2012 and 2015 at the Haga Teaching Hospitals.

METHODS

The HBS is a dual strategy based on a preoperative vascular work-up of the cerebral circulation by transcranial Doppler and a perioperative monitoring of the cerebral circulation by cerebral oximetry. Duplex of the carotid arteries and/or computed tomography angiography prior to surgery was performed in high-risk patients. Patients with severe carotid artery stenosis were scheduled for carotid angioplasty prior to surgery or waived from surgery.

RESULTS

A total of 1065 patients were included. Poor cerebral haemodynamics were identified by transcranial Doppler in 2.1% of patients (n = 22). Based on the HBS, 3 patients were waived from surgery, 4 received preoperative carotid angioplasty followed by cardiac surgery and the remaining patients were operated while being monitored with bilateral cerebral oximetry sensors. In all, 2.2% of the study group experienced a stroke (n = 23), of which none were classified as haemodynamic. Most of the remaining presumed embolic strokes showed a minor to moderate stroke severity.

CONCLUSIONS

In this single-centre prospective follow-up study, surveillance of cerebral perfusion by the HBS eliminated the occurrence of haemodynamic stroke while most of the residual strokes had a good to favourable prognosis.

Short-Term Clinical Outcome of Hemiarthroplasty Versus Arthrodesis for End-Stage Hallux Rigidus

Few data are available to compare the outcomes of first metatarsophalangeal joint (MTPJ) hemiarthroplasty and arthrodesis. We included 46 patients who had undergone BioPro(®) first MTPJ hemiarthroplasty and 132 who had undergone arthrodesis, with a minimum follow-up duration of 12 months. The primary outcome was patient satisfaction, which was determined using binominal questions. The Foot and Ankle Outcome Score, Foot Function Index, and Numerical Rating Scale for pain and limitations questionnaires were also used. The secondary outcome was treatment failure. No differences were found in the satisfaction rate (p = .54) after a median period of 38.4 (range 12 to 96) months and 39.8 (range 12 to 96) months in the hemiarthroplasty and arthrodesis patients, respectively. Furthermore, no differences were found in the failure rates (p = .93) or the interval to failure (p = .32).The results of the present study showed no significant differences in the short-term clinical outcomes and failure rates for BioPro(®) first MTPJ hemiarthroplasty and arthrodesis. Prospective comparative studies are required to determine whether BioPro(®) first MTPJ hemiarthroplasty is a good alternative for first MTPJ arthrodesis in the long term.

Can combining femoral and acetabular morphology parameters improve the characterization of femoroacetabular impingement?

BACKGROUND

Femoroacetabular impingement (FAI) presupposes a dynamic interaction of the proximal femur and acetabulum producing clinical symptoms and chondrolabral damage. Currently, FAI classification is based on alpha angle and center-edge angle measurements in a single plane. However, acetabular and femoral version and neck-shaft angle also influence FAI. Furthermore, each of these parameters has a reciprocal interaction with the others; for example, a shallow acetabulum delays impingement of the femoral head with the acetabular rim.

QUESTIONS/PURPOSES

We introduce the new parameter "omega zone," which combines five parameters into one: the alpha and center-edge angles, acetabular and femoral version, and neck-shaft angle. We sought to determine whether the omega zone could differentiate patients with FAI from (1) normal control subjects (alpha < 55°), but also from (2) control subjects with elevated alpha angles (≥ 55°).

METHODS

We evaluated CT data of 20 hips of male patients with symptomatic cam-type FAI and of 35 male hips extracted from 110 anonymized CT scans for vascular diagnosis. We excluded hips with osteoarthritis, developmental dysplasia, or coxa profunda (center-edge angle 20°-45° on AP pelvic view or corresponding coronal CT views). With dedicated software, femoral and pelvic orientation was standardized; we tested the omega zone in four hip positions in three distinct groups: patients with cam-type FAI (alpha > 60°) and control subjects with normal (< 55°) and high alpha angles (≥ 55°).

RESULTS

The omega zone was smaller in patients with cam-type FAI than normal control subjects (alpha angle < 55°) at 60° and 90° of flexion (mean, 12%; 95% confidence interval [CI], 7-17; p = 0.008; Cohen's d = 9%; 95% CI, 4-13; p = 0.003). Furthermore, the omega zone was smaller in all positions in patients with cam-type FAI than control subjects with high alpha angles (0° p = 0.017, 30° p = 0.004, 60° p = 0.004, 90° p = 0.007). In contrast, the omega zone did not differ between control subjects with normal or high alpha angles. In all hips, the omega zone decreased with flexion, corresponding to a decrease in remaining impingement-free motion with flexion.

CONCLUSIONS

The omega zone visualizes and quantifies the interaction of the proximal femur and acetabulum. The omega zone differed between patients with cam-type FAI and control subjects with high alpha angles (≥ 55°), who could not be distinguished based on alpha angle alone. For hip-preserving surgery, it can help surgeons decide whether to address the femur, the acetabulum, or both.

[Shoulder surgery using only regional anaesthesia]

Effective intra-operative anaesthesia and peri-operative analgesia are important aspects of patient care in orthopaedic surgery. The interscalene regional anaesthetic block technique, performed with the patient lying in a lateral decubitus position, is new for arthroscopic shoulder surgery conducted in the Netherlands. The combination of the interscalene block (without general anaesthesia) and the lateral decubitus position results in better peri-operative conditions for the patient. Better analgesia, increased patient satisfaction and fewer complications in comparison to general anaesthesia have been reported for these types of surgery.