Publications by authors named "L M Wessel"

155 Publications

Comparison of Revision Risk Based on Timing of Knee Arthroscopy Prior to Total Knee Arthroplasty.

J Bone Joint Surg Am 2021 Apr;103(8):660-667

Department of Orthopaedic Surgery, Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis, Missouri.

Background: Knee arthroscopy may be performed prior to total knee arthroplasty (TKA) in patients with symptomatic degenerative knee changes that do not yet warrant TKA. The purpose of this study was to determine whether the time interval between knee arthroscopy and subsequent primary TKA is associated with increased rates of revision and certain complications following TKA.

Methods: Data from 2006 to 2017 were collected from a national insurance database. Patients who underwent knee arthroscopy within 1 year prior to primary TKA were identified and stratified into the following cohorts based on stratum-specific likelihood ratio (SSLR) analysis: 0 to 15, 16 to 35, 36 to 43, and 44 to 52 weeks from the time of knee arthroscopy to TKA. Univariate and multivariable analyses were conducted to determine the association between these specific time intervals and rates of revision surgery, periprosthetic joint infection (PJI), aseptic loosening, and manipulation under anesthesia.

Results: In total, 130,128 patients were included in this study; 6,105 (4.7%) of those patients underwent knee arthroscopy within 1 year prior to TKA and 124,023 (95.3%) underwent TKA without any prior knee surgery, including arthroscopy (the control group). Relative to the control group, the likelihood of undergoing revision surgery was significantly greater in patients who underwent knee arthroscopy ≤15 weeks (odds ratio [OR]: 1.79; 95% confidence interval [CI]: 1.43 to 2.22; p < 0.001) or 16 to 35 weeks (OR: 1.20; 95% CI: 1.01 to 1.42; p = 0.035) prior to TKA. Patients were at significantly increased risk for PJI if knee arthroscopy was done ≤35 weeks prior to TKA, and all 4 time groups that underwent knee arthroscopy within 1 year before TKA were at increased risk for manipulation under anesthesia.

Conclusions: We found a time-dependent relationship between the timing of knee arthroscopy and complications following TKA, with the prevalence of revision surgery and PJI increasing as knee arthroscopy was performed closer to the time of TKA. This study suggests that an interval of at least 36 weeks should be maintained between the 2 procedures to minimize risks of PJI and revision surgery.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.00218DOI Listing
April 2021

Establishment of a Pediatric Surgical Unit at a University Hospital in Eastern Africa.

Children (Basel) 2021 Mar 22;8(3). Epub 2021 Mar 22.

Department of Surgery and Child Health, Jimma University Hospital, Federal Ministry of Health, Jimma 47, Ethiopia.

Introduction: Ethiopia is a rapidly developing country in Eastern Africa. In total, 43.2% of the population are younger than 15. In contrast, until a few years ago, pediatric surgery was only available in Addis Ababa. Now, Ethiopia is making great efforts to improve the care of children who require surgery. JimmaChild was established to set up a pediatric surgery in Jimma.

Material And Methods: JimmaChild developed from a scientific collaboration between Jimma University (JU) and Ludwig-Maximilians-University. The project was developed and realized by Ethiopian and German colleagues. A curriculum was written for this purpose. The pediatric surgical training of the fellows was carried out on-site by German pediatric surgeons.

Results: A new pediatric surgery was established at JU with its own operating room, ward, and staff. After two and a half years, two fellows completed their final examinations as pediatric surgeons. Among others, 850 elective surgeries were performed, 82% assisted by the German colleagues. The German colleagues rated the preparation for the trip, the on-site support, and the professional progress of the fellows mostly as good to very good. Reported problems in the program flow were also recognized and solved in part.

Conclusions: The best possible integration of the project into existing structures was achieved by close cooperation of Ethiopian and German colleagues during the project development. Problems were identified and addressed early on by external monitoring. As the project responsibility was mainly with the Ethiopian colleagues, a department was created that now exists independently of external funding and trains its own fellows.
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http://dx.doi.org/10.3390/children8030244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005109PMC
March 2021

Bowel Lengthening Procedures in Children with Short Bowel Syndrome: A Systematic Review.

Eur J Pediatr Surg 2021 Mar 4. Epub 2021 Mar 4.

Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands.

Introduction:  The aims of the study are to systematically assess and critically appraise the evidence concerning two surgical techniques to lengthen the bowel in children with short bowel syndrome (SBS), namely, the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP), and to identify patient characteristics associated with a favorable outcome.

Materials And Methods:  MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception till December 2019. No language restriction was used.

Results:  In all, 2,390 articles were found, of which 40 were included, discussing 782 patients. The median age of the patients at the primary bowel lengthening procedure was 16 months (range: 1-84 months). Meta-analysis could not be performed due to the incomparability of the groups, due to heterogeneous definitions and outcome reporting. After STEP, 46% of patients weaned off parenteral nutrition (PN) versus 52% after LILT. Mortality was 7% for STEP and 26% for LILT. Patient characteristics predictive for success (weaning or survival) were discussed in nine studies showing differing results. Quality of reporting was considered poor to fair.

Conclusion:  LILT and STEP are both valuable treatment strategies used in the management of pediatric SBS. However, currently it is not possible to advise surgeons on accurate patient selection and to predict the result of either intervention. Homogenous, prospective, outcome reporting is necessary, for which an international network is needed.
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http://dx.doi.org/10.1055/s-0041-1725187DOI Listing
March 2021

Computed tomography based measurements to evaluate lung density and lung growth after congenital diaphragmatic hernia.

Sci Rep 2021 Mar 3;11(1):5035. Epub 2021 Mar 3.

Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Emphysema-like-change of lung is one aspect of lung morbidity in children after congenital diaphragmatic hernia (CDH). This study aims to evaluate if the extent of reduced lung density can be quantified through pediatric chest CT examinations, if side differences are present and if emphysema-like tissue is more prominent after CDH than in controls. Thirty-seven chest CT scans of CDH patients (mean age 4.5 ± 4.0 years) were analyzed semi-automatically and compared to an age-matched control group. Emphysema-like-change was defined as areas of lung density lower than - 950 HU in percentage (low attenuating volume, LAV). A p-value lower than 0.05 was regarded as statistically significant. Hypoattenuating lung tissue was more frequently present in the ipsilateral lung than the contralateral side (LAV 12.6% vs. 5.7%; p < 0.0001). While neither ipsilateral nor contralateral lung volume differed between CDH and control (p > 0.05), LAV in ipsilateral (p = 0.0002), but not in contralateral lung (p = 0.54), was higher in CDH than control. It is feasible to quantify emphysema-like-change in pediatric patients after CDH. In the ipsilateral lung, low-density areas are much more frequently present both in comparison to contralateral and to controls. Especially the ratio of LAV ipsilateral/contralateral seems promising as a quantitative parameter in the follow-up after CDH.
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http://dx.doi.org/10.1038/s41598-021-84623-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930262PMC
March 2021

Case Report: 7-Year-Old Boy with Incarcerated Internal Hernia Leading to Extensive Intestinal Necrosis Due to a Large Congenital Mesenteric Defect.

Klin Padiatr 2021 Jan 19. Epub 2021 Jan 19.

Kinderchirurgie, Klinikum Mannheim gGmbH Universitätsklinikum Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Germany.

We present a case of a 7-year-old boy with acute abdominal symptoms initially misdiagnosed as constipation. Delayed imaging diagnostics revealed an ileus with contorted small intestine, so laparotomy was indicated. An acute bowel obstruction was found based on an incarcerated internal hernia. Small and large bowel segments were incarcerated into a large mesenteric defect leading to extended intestinal necrosis. About 30 cm of necrotic small bowel and 15 cm of large intestine were resected, two primary anastomoses were performed. The mesenteric defect was closed with two running sutures. The boy's clinical outcome was very good. Two aspects are discussed: the initial clinical misdiagnosis of acute bowel obstruction in a child leading to a delay of diagnostics and therapy on the one hand and the origin of mesenteric defects on the other. In children with abdominal pain, ultrasound must be performed as soon as possible and pediatric surgeons have to be involved early. There should be an awareness of the fact, that mesenteric defects and other congenital malformations can occur more often than we suspect it. In the case of an internal hernia, a misjudgement of the clinical condition may be very harmful for the patient and can lead to a short bowel syndrome or even death.
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http://dx.doi.org/10.1055/a-1306-1213DOI Listing
January 2021

Prior Knee Arthroscopy Increases the Failure Rate of Subsequent Unicompartmental Knee Arthroplasty.

J Arthroplasty 2020 Nov 6. Epub 2020 Nov 6.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY.

Background: In selected patients, knee arthroscopy is performed prior to unicompartmental knee arthroplasty (UKA) to treat symptomatic mechanical pathology, delay arthroplasty, and assess the knee compartments. The purpose of this study was to determine if knee arthroscopy prior to UKA is associated with increased rates of UKA failure or conversion to total knee arthroplasty (TKA).

Methods: Data was collected from the Humana insurance database from 2007-2017. Patients who underwent knee arthroscopy within two years prior to UKA were identified and matched with controls based on age, gender, Charlson Comorbidity Index, smoking status, and obesity. Rates of conversion to TKA and failure for various causes were compared between cohorts.

Results: Prior to propensity matching, 8353 UKA patients met inclusion criteria. Of these, 1079 patients (12.9%) underwent knee arthroscopy within two years of UKA and were matched to 1079 patients (controls) who did not undergo knee arthroscopy in the two years preceding UKA. No differences in demographics/comorbidities existed among cohorts. Compared to controls, the knee arthroscopy cohort was more likely to experience failure for aseptic loosening (2.4% vs 1.1%; OR 2.166; P = .044) and significantly more likely to require conversion to TKA (10.4% vs 4.9%; OR 2.113; P < .001) within two years of UKA.

Conclusion: Knee arthroscopy within two years of UKA is associated with an increased rate of UKA conversion to TKA and a higher rate of UKA failure from aseptic loosening. Although clinicians should be mindful of this association when performing knee arthroscopy in patients who may be indicated for future UKA, further research is needed to better characterize these findings.
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http://dx.doi.org/10.1016/j.arth.2020.10.060DOI Listing
November 2020

Standardized Perioperative Patient Education Decreases Opioid Use after Hand Surgery: A Randomized Controlled Trial.

Plast Reconstr Surg 2021 Feb;147(2):409-418

From the University of Chicago, Department or Orthopaedic Surgery and Rehabilitation Medicine; Departments of Orthopedic Surgery and Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery; and Weill Cornell Medicine.

Background: Despite the growing hand surgery literature on postoperative opioid use, there is little research focused on patient-centered interventions. The purpose of this randomized controlled trial was to create a standardized patient education program regarding postoperative pain management after hand surgery and to determine whether that education program would decrease postoperative opioid use.

Methods: Patients scheduled to undergo ambulatory hand surgery were recruited and randomized to standardized pain management education or standard of care. All patients received a webinar with instructions for study participation, whereas the education group received an additional 10 minutes of education on postoperative pain management. All patients completed a postoperative daily log documenting opioid consumption. The total number of opioid pills consumed was compared between groups. The authors constructed a linear regression model to determine risk factors for postoperative opioid use after surgery.

Results: A total of 267 patients were enrolled in the study. One hundred ninety-one patients completed the study (standardized education, n = 93; control group, n = 97). Patients in the standardized education group were more likely to take no opioid medication (42 percent versus 25 percent; p = 0.01) and took significantly fewer opioid pills (median, two) than those in the control group (median, five) (p < 0.001). Standardized education predicted decreased postoperative opioid pill consumption, whereas higher number of pills prescribed and a history of psychiatric illness were risk factors for increasing opioid use.

Conclusion: Perioperative patient education and limitation of postoperative opioid prescription sizes reduced postoperative opioid use following ambulatory hand surgery.

Clinical Question/level Of Evidence: Therapeutic, II.
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http://dx.doi.org/10.1097/PRS.0000000000007574DOI Listing
February 2021

Shoulder and elbow pathology in the female athlete: sex-specific considerations.

J Shoulder Elbow Surg 2021 May 18;30(5):977-985. Epub 2020 Nov 18.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA. Electronic address:

Unique biologic and biomechanical aspects of the female body make women more prone to certain orthopedic injuries. Sex differences are well understood with regard to certain orthopedic pathologies such as anterior cruciate ligament injury, hallux valgus, carpal tunnel, and carpometacarpal joint arthritis; however, sex differences are less commonly discussed with regard to shoulder and elbow pathology. The purpose of this review is to elucidate sex differences specific to sports-related shoulder and elbow injuries in the female athlete population.
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http://dx.doi.org/10.1016/j.jse.2020.10.020DOI Listing
May 2021

Troubles escalate at Ecuador's young research university.

Science 2020 10 22;370(6515):393. Epub 2020 Oct 22.

Lindzi Wessel is a journalist in the San Francisco Bay Area. Rodrigo Pérez Ortega is a science journalist in Mexico City.

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http://dx.doi.org/10.1126/science.370.6515.393DOI Listing
October 2020

Pre-operative Two-Point Discrimination Predicts Response to Carpal Tunnel Release.

HSS J 2020 Oct 5;16(3):206-211. Epub 2019 Jul 5.

Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: Limited evidence informs whether pre-operative values of two-point discrimination (2PD) in patients with carpal tunnel syndrome predict response to surgery.

Questions/purposes: The primary aim of this study was to determine the predictive value of pre-operative 2PD scores on outcomes following carpal tunnel release (CTR). In particular, we sought to evaluate whether a clinically relevant 2PD threshold exists that can predict symptomatic response after surgery.

Methods: Patients who underwent CTR between 2014 and 2018 were retrospectively reviewed. Static 2PD scores in each digit, as well as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Levine-Katz scores, were collected from pre- and post-operative records. Pearson correlation coefficients assessed the relationship between pre-operative 2PD, early post-operative 2PD, and patient-reported outcome scores. Poor 2PD was defined as 2PD greater than 10 mm.

Results: Eighty-nine hands in 73 patients with a mean follow-up of 1.8 years were analyzed. Mean pre- and post-operative 2PD was 7.2 mm and 6.4 mm, respectively, in the most affected digit when measurable. Twenty patients had poor 2PD scores pre-operatively and 14 post-operatively. There was a positive correlation between pre- and early post-operative 2PD scores but no correlation between pre-operative 2PD score and final post-operative functional scores. Only 30% of patients with poor pre-operative 2PD scores demonstrated improvement, compared with 69% of patients with measurable 2PD.

Conclusion: We found that greater pre-operative 2PD scores predicted greater early post-operative 2PD scores but did not lead to worse functional outcome scores post-operatively. Patients with poor pre-operative 2PD scores were likely to demonstrate improvement in functional outcomes scores, while having less reliable improvement in 2PD after CTR. Patients with poor 2PD should be counseled that improvement of tactile perception is less predictable.
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http://dx.doi.org/10.1007/s11420-019-09694-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534881PMC
October 2020

The German health care Innovation Fund - An incentive for innovations to promote the integration of health care.

J Health Organ Manag 2020 Oct;34(8):915-923

Department of Information Systems, School of Business and Economics, Freie Universität Berlin, Berlin, Germany.

Purpose: Many health systems face challenges such as rising costs and lacking quality, both of which can be addressed by improving the integration of different health care sectors and professions. The purpose of this viewpoint is to present the German health care Innovation Fund (IF) initiated by the Federal Government to support the development and diffusion of integrated health care.

Design/methodology/approach: This article describes the design and rationale of the IF in detail and provides first insights into its limitations, acceptance and implementation by relevant stakeholders.

Findings: In its first period, the IF offered € 1.2 billion as start-up funding for model implementation and evaluation over a period of four years (2016-2019). This period was recently extended to a second round until 2024, offering € 200 million a year as from 2020. The IF is triggering the support of relevant insurers for the development of new integrated care models. In addition, strict evaluation requirements have led to a large number of health service research projects which assess structural and process improvements and thus enable evidence-based policy decisions.

Originality/value: This article is the first of its kind to present the German IF to the international readership. The IF is a political initiative through which to foster innovations and promote integrated health care.
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http://dx.doi.org/10.1108/JHOM-05-2020-0180DOI Listing
October 2020

Case report: Infant with a Fast-growing Soft Tissue Tumor on the Thumb, Revealing a PLAG1-positive Connatal Lipoblastoma.

Klin Padiatr 2020 Nov 16;232(6):285-288. Epub 2020 Sep 16.

Kinderchirurgie, Klinikum Mannheim gGmbH Universitätsklinikum Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Germany.

At the age of 4 months, an infant was presented to us with a nodular subcutaneous tumor on the right thumb measuring 2cm, already seen prenatally via ultrasound. An MRI in sedation performed at the age of 4.5 months had no diagnostic specificity. By a biopsy at the age of 5 months malignancy could be excluded. Finally at the age of 16 months the tumor which had meanwhile grown to a monstrous size (5 cm of diameter) could be entirely removed by microsurgical technique maintaining the integrity of all intrinsic structures. The diagnosis of myxoid lipoblastoma was confirmed. According to literature, Lipoblastomas often present as connatal rapid growing soft tissue tumors and are benign. Total removal is essential for avoiding a local recurrence.
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http://dx.doi.org/10.1055/a-1159-7532DOI Listing
November 2020

Relationship between volume and outcome for gastroschisis: a systematic review protocol.

Syst Rev 2020 09 2;9(1):203. Epub 2020 Sep 2.

Institute for Research in Operative Medicine, Faculty of Health, School of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany.

Background: Gastroschisis is a congenital anomaly that needs surgical management for repositioning intestines into the abdominal cavity and for abdominal closure. Higher hospital or surgeon volume has previously been found to be associated with better clinical outcomes for different especially high-risk, low volume procedures. Therefore, we aim to examine the relationship between hospital or surgeon volume and outcomes for gastroschisis.

Methods: We will perform a systematic literature search from inception onwards in Medline, Embase, CENTRAL, CINAHL, and Biosis Previews without applying any limitations. In addition, we will search trial registries and relevant conference proceedings. We will include (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and clinical outcomes. The primary outcomes will be survival and mortality. Secondary outcomes will be different measures of morbidity (e.g., severe gastrointestinal complications, gastrointestinal dysfunctions, and sepsis), quality of life, and length of stay. We will systematically assess risk of bias of included studies using RoB 2 for individually or cluster-randomized trials and ROBINS-I for cohort studies, and extract data on the study design, patient characteristics, case-mix adjustments, statistical methods, hospital and surgeon volume, and outcomes into standardized tables. Title and abstract screening, full text screening, critical appraisal, and data extraction of results will be conducted by two reviewers independently. Other data will be extracted by one reviewer and checked for accuracy by a second one. Any disagreements will be resolved by discussion. We will not pool results statistically as we expect included studies to be clinically and methodologically very diverse. We will conduct a systematic synthesis without meta-analysis and use GRADE for assessing the certainty of the evidence.

Discussion: Given the lack of a comprehensive summary of findings on the relationship between hospital or surgeon volume and outcomes for gastroschisis, this systematic review will put things right. Results can be used to inform decision makers or clinicians and to adapt medical care.

Systematic Review Registration: Open Science Framework (DOI: https://doi.org/10.17605/OSF.IO/EX34M ; https://doi.org/10.17605/OSF.IO/HGPZ2 ).
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http://dx.doi.org/10.1186/s13643-020-01462-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7469094PMC
September 2020

At the US Epicenter of the COVID-19 Pandemic, an Orthopedic Residency Program Reorganizes.

HSS J 2020 Jun 30:1-8. Epub 2020 Jun 30.

Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

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http://dx.doi.org/10.1007/s11420-020-09765-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325474PMC
June 2020

[COVID-19 pandemic: management of pediatric surgical patients].

Monatsschr Kinderheilkd 2020 Jul 14:1-5. Epub 2020 Jul 14.

Kinderchirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Deutschland.

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http://dx.doi.org/10.1007/s00112-020-00989-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359426PMC
July 2020

For science in Latin America, 'a fascinating challenge'.

Science 2020 08;369(6505):753-754

Rodrigo Pérez Ortega is a science journalist in Washington, D.C. Lindzi Wessel is a journalist in the San Francisco Bay Area.

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http://dx.doi.org/10.1126/science.369.6505.753DOI Listing
August 2020

Letter to the Editor concerning Schmedding et al.: Decentralised surgery of abdominal wall defects in Germany (Pediatr Surg Int (2020) 36:569-578).

Pediatr Surg Int 2020 09 21;36(9):1117-1119. Epub 2020 Jul 21.

Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus University Rotterdam, Rotterdam, The Netherlands.

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http://dx.doi.org/10.1007/s00383-020-04717-wDOI Listing
September 2020

ERNICA Consensus Conference on the Management of Patients with Long-Gap Esophageal Atresia: Perioperative, Surgical, and Long-Term Management.

Eur J Pediatr Surg 2020 Jul 15. Epub 2020 Jul 15.

Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.

Introduction:  Evidence supporting best practice for long-gap esophageal atresia is limited. The European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) organized a consensus conference on the management of patients with long-gap esophageal atresia based on expert opinion referring to the latest literature aiming to provide clear and uniform statements in this respect.

Materials And Methods:  Twenty-four ERNICA representatives from nine European countries participated. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing items on perioperative, surgical, and long-term management, and literature review. The 2-day conference was held in Berlin in November 2019. Anonymous voting was conducted via an internet-based system using a 1 to 9 scale. Consensus was defined as ≥75% of those voting scoring 6 to 9.

Results:  Ninety-seven items were generated. Complete consensus (100%) was achieved on 56 items (58%), e.g., avoidance of a cervical esophagostomy, promotion of sham feeding, details of delayed anastomosis, thoracoscopic pouch mobilization and placement of traction sutures as novel technique, replacement techniques, and follow-up. Consensus ≥75% was achieved on 90 items (93%), e.g., definition of long gap, routine pyloroplasty in gastric transposition, and avoidance of preoperative bougienage to enable delayed anastomosis. Nineteen items (20%), e.g., methods of gap measurement were discussed controversially (range 1-9).

Conclusion:  This is the first consensus conference on the perioperative, surgical, and long-term management of patients with long-gap esophageal atresia. Substantial statements regarding esophageal reconstruction or replacement and follow-up were formulated which may contribute to improve patient care.
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http://dx.doi.org/10.1055/s-0040-1713932DOI Listing
July 2020

Impact of Patient-Reported Allergies on Early Postoperative Opioid Use and Outcomes Following Ambulatory Hand Surgery.

Hand (N Y) 2020 Jun 7:1558944720928483. Epub 2020 Jun 7.

Hospital for Special Surgery, New York, NY, USA.

Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition ( < .001) and pain ( < .001) and lower PROMIS mental health scores ( = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, = .016; week 2, = .001; total, = .005). The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.
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http://dx.doi.org/10.1177/1558944720928483DOI Listing
June 2020

Relationship between volume and outcome for surgery on congenital diaphragmatic hernia: A systematic review.

J Pediatr Surg 2020 Dec 1;55(12):2555-2565. Epub 2020 Apr 1.

Institute for Research in Operative Medicine, Faculty of Health, School of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany.

Background: Congenital diaphragmatic hernia (CDH) is a rare and life-threatening anomaly that needs surgical therapy after clinical stabilization of the neonate. Given an existing volume-outcome relationship for other high-risk, low volume procedures, we aimed at examining the relationship between hospital or surgeon volume and outcomes for surgery on CDH.

Methods: We conducted a systematic search in multiple databases in September 2019 and searched for additional literature. We assessed risk of bias of included studies using ROBINS-I and synthesized results in a structured narrative way using GRADE.

Results: We included 5 cohort studies on hospital volume. Results for in-hospital mortality, one-year mortality and length of stay are inconclusive. The certainty of the evidence was very low for all outcomes, due to risk of bias, inconsistency and imprecision. We did not identify any study on surgeon volume.

Conclusion: Due to the very low certainty of the evidence it is uncertain whether higher hospital volume is associated with favorable outcomes for neonates undergoing surgery for CDH. There is no evidence on the relationship between surgeon volume and outcomes. Future studies should use more rigorous methodology and analyze additional outcomes to allow for more meaningful inferences.

Level Of Evidence: III SYSTEMATIC REVIEW REGISTRATION: PROSPERO (CRD42018090231).
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http://dx.doi.org/10.1016/j.jpedsurg.2020.03.025DOI Listing
December 2020

Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation.

J Wrist Surg 2020 Apr 20;9(2):141-149. Epub 2020 Jan 20.

Department of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York.

 Nonunion after open reduction and internal fixation (ORIF) of scaphoid fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not clearly defined.  The purpose of this study is to determine fracture characteristics and surgical factors which may influence progression to nonunion after scaphoid fracture ORIF.  We performed a retrospective case-control study of scaphoid fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical fixation within 6 months from date of injury and postoperative CT with minimum clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in this study. Nonunion cases were matched by age, sex, and fracture location to patients who progressed to fracture union in the 1:2 ratio.  This series of 48 patients matched 16 nonunion cases with 32 cases that progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85% (41/48). Multivariate regression demonstrated that shorter length of time from injury to initial ORIF and smaller percent of proximal fracture fragment volume were significantly associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively). Receiver operating curve analysis revealed that fracture volume below 38% and time from injury to surgery greater than 31 days were associated with nonunion.  Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid.  This is a Level III, therapeutic study.
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http://dx.doi.org/10.1055/s-0039-3402769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7112999PMC
April 2020

#MeToo moves south.

Science 2020 Feb;367(6480):842-845

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http://dx.doi.org/10.1126/science.367.6480.842DOI Listing
February 2020

Digestive enzyme expression in the large intestine of children with short bowel syndrome in a late stage of adaptation.

FASEB J 2020 03 19;34(3):3983-3995. Epub 2020 Jan 19.

Department of Paediatrics, Justus-Liebig-University Giessen, Giessen, Germany.

Background And Aims: Intestinal adaptation in short bowel syndrome (SBS) includes morphologic processes and functional mechanisms. This study investigated whether digestive enzyme expression in the duodenum and colon is upregulated in SBS patients.

Method: Sucrase-isomaltase (SI), lactase-phlorizin hydrolase (LPH), and neutral Aminopeptidase N (ApN) were analyzed in duodenal and colonic biopsies from nine SBS patients in a late stage of adaptation as well as healthy and disease controls by immunoelectron microscopy (IEM), Western blots, and enzyme activities. Furthermore, proliferation rates and intestinal microbiota were analyzed in the mucosal specimen.

Results: We found significantly increased amounts of SI, LPH, and ApN in colonocytes in most SBS patients with large variation and strongest effect for SI and ApN. Digestive enzyme expression was only partially elevated in duodenal enterocytes due to a low proliferation level measured by Ki-67 staining. Microbiome analysis revealed high amounts of Lactobacillus resp. low amounts of Proteobacteria in SBS patients with preservation of colon and ileocecal valve. Colonic expression was associated with a better clinical course in single cases.

Conclusion: In SBS patients disaccharidases and peptidases can be upregulated in the colon. Stimulation of this colonic intestinalization process by drugs, nutrients, and pre- or probiotics might offer better therapeutic approaches.
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http://dx.doi.org/10.1096/fj.201901758RRDOI Listing
March 2020

Elbow contracture following operative fixation of fractures about the elbow.

JSES Open Access 2019 Dec 14;3(4):261-265. Epub 2019 Nov 14.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Background: The rates of elbow contracture and contracture release after surgically treated elbow trauma are poorly defined. The purpose of this study was to define the incidence of elbow contracture diagnosis and release after surgical treatment for elbow trauma.

Methods: The Humana insurance database was queried using the PearlDiver Patient Records Database between 2007 and 2017. Subjects were identified using International Classification of Diseases (ICD) codes in combination with Current Procedural Terminology codes and were included if they had a minimum of 1-year follow-up. Qualifying operative elbow trauma patients were queried for development of postoperative elbow contracture. Patient demographic characteristics, risk factors for elbow stiffness, and use of postoperative anticoagulation were recorded. Fracture severity was classified based on ICD-9 and ICD-10 codes. Logistic multivariate analysis was performed to determine independent risk factors for postoperative elbow contracture.

Results: The study population included 10,672 patients who were surgically treated for elbow trauma. In total, 902 patients (8.4%) were diagnosed with a contracture following fracture. Of patients with a diagnosis of elbow contracture, 65 patients (7.2%) underwent contracture release. On average, time to contracture diagnosis was 3.6 months (SD 7 months) and time to contracture release was 8.4 months (SD 3.6 months). The use of postoperative anticoagulation, burn or head injury at the time of fracture, male sex, obesity, opioid use, and moderate or severe fracture severity were significantly associated with progression to elbow contracture.

Conclusion: The development of elbow contracture after surgical treatment of elbow trauma has a relatively high incidence of 8.4%.
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http://dx.doi.org/10.1016/j.jses.2019.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928310PMC
December 2019

Polydactyly a review and update of a common congenital hand difference.

Curr Opin Pediatr 2020 02;32(1):120-124

Department of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York, USA.

Purpose Of Review: The purpose of this review is to describe various forms of hand polydactyly and their different treatment approaches. Hand polydactyly is commonly classified as ulnar (small finger) or radial (thumb). Polydactyly can be sporadic, genetic, and/or associated with syndromic conditions.

Recent Findings: Both ulnar and radial polydactyly can be surgically treated to optimize hand aesthetics and function. Timing of surgery is based on multiple factors, most notably including safety of anesthesia and socialization of the affected child. The pediatrician should be aware of potential associated conditions, such as chondroectodermal dysplasia or Ellis-van Creveld syndrome for ulnar polydactyly.

Summary: Polydactyly is a common congenital hand difference and can be broadly be classified by radial or ulnar involvement. Polydactyly warrants hand surgical referral, as surgical treatment is often indicated. Pediatricians should be aware of treatment options, as well as of commonly associated anomalies and syndromes.
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http://dx.doi.org/10.1097/MOP.0000000000000871DOI Listing
February 2020

ERNICA Consensus Conference on the Management of Patients with Esophageal Atresia and Tracheoesophageal Fistula: Follow-up and Framework.

Eur J Pediatr Surg 2020 Dec 27;30(6):475-482. Epub 2019 Nov 27.

Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.

Introduction:  Improvements in care of patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) have shifted the focus from mortality to morbidity and quality-of-life. Long-term follow-up is essential, but evidence is limited and standardized protocols are scarce. Nineteen representatives of the European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) from nine European countries conducted a consensus conference on the surgical management of EA/TEF.

Materials And Methods:  The conference was prepared by item generation (including items of surgical relevance from the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)-The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines on follow-up after EA repair), item prioritization, formulation of a final list containing the domains Follow-up and Framework, and literature review. Anonymous voting was conducted via an internet-based system. Consensus was defined as ≥75% of those voting with scores of 6 to 9.

Results:  Twenty-five items were generated in the domain Follow-up of which 17 (68%) matched with corresponding ESPGHAN-NASPGHAN statements. Complete consensus (100%) was achieved on seven items (28%), such as the necessity of an interdisciplinary follow-up program. Consensus ≥75% was achieved on 18 items (72%), such as potential indications for fundoplication. There was an 82% concordance with the ESPGHAN-NASPGHAN recommendations. Four items were generated in the domain Framework, and complete consensus was achieved on all these items.

Conclusion:  Participants of the first ERNICA conference reached significant consensus on the follow-up of patients with EA/TEF who undergo primary anastomosis. Fundamental statements regarding centralization, multidisciplinary approach, and involvement of patient organizations were formulated. These consensus statements will provide the cornerstone for uniform treatment protocols and resultant optimized patient care.
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http://dx.doi.org/10.1055/s-0039-3400284DOI Listing
December 2020

Experience with Fully Covered Self-Expandable Metal Stents for Esophageal Leakage in Children.

Klin Padiatr 2020 Jan 16;232(1):13-19. Epub 2019 Oct 16.

Pediatric Surgery, University Medical Center Mannheim, Mannheim, Germany.

Background: There is a lack of experience with fully covered self-expandable metal stents (SEMSs) for the treatment of esophageal leakage particularly in infants and neonates.

Methods: Eight patients (5M, 3F) with a median age of 17 months (range, 1-135 months) who underwent treatment with SEMSs for an anastomotic leakage or perforation of the esophagus were recruited to this retrospective study. Four children were born premature. In six patients the stents were placed primarily as an emergency procedure.

Results: Median duration of individual stent placement was 42 days (range, 13-72 days). Six out of eight patients (75%) were treated with one stent only. In three preterm infants who had their stents inserted within the first month relative weight gain was 17% compared with 2% in five patients who were treated later in life (p=0.0986). In four cases (50%) distal migration of the stent was observed. Seven out of eight patients (88%) had their leakage resolved after stent therapy.

Conclusions: Insertion of fully covered SEMSs is an alternative tool for the treatment of esophageal leakage in children and preterm infants, and successful with only one single application in selected cases. It can be used either following previous therapy or as part of an emergency procedure. Because of the absence of manufactured, age-related devices SEMSs that are originally designed for other organs can be applied.
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http://dx.doi.org/10.1055/a-1014-3179DOI Listing
January 2020

Determining optimal needle size for decompression of tension pneumothorax in children - a CT-based study.

Scand J Trauma Resusc Emerg Med 2019 Oct 11;27(1):90. Epub 2019 Oct 11.

Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Background: For neonates and children requiring decompression of tension pneumothorax, specific recommendations for the choice of needle type and size are missing. The aim of this retrospective study was to determine optimal length and diameter of needles for decompression of tension pneumothorax in paediatric patients.

Methods: Utilizing computed tomography, we determined optimal length and diameter of needles to enable successful decompression and at the same time minimize risk of injury to intrathoracic structures and the intercostal vessels and nerve. Preexisting computed tomography scans of the chest were reviewed in children aged 0, 5 and 10 years. Chest wall thickness and width of the intercostal space were measured at the 4th intercostal space at the anterior axillary line (AAL) on both sides of the thorax. In each age group, three needles different in bore and length were evaluated regarding sufficient length for decompression and risk of injury to intrathoracic organs and the intercostal vessels and nerve.

Results: 197 CT-scans were reviewed, of which 58 were excluded, resulting in a study population of 139 children and 278 measurements. Width of the intercostal space was small at 4th ICS AAL (0 years: 0.44 ± 0.13 cm; 5 years: 0.78 ± 0.22 cm; 10 years: 1.12 ± 0.36 cm). The ratio of decompression failure to risk of injury at 4th ICS AAL was most favourable for a 22G/2.5 cm catheter in infants (Decompression failure: right: 2%, left: 4%, Risk of injury: right: 14%, left: 24%), a 22G/2.5 cm or a 20G/3.2 cm catheter in 5-year-old children (20G/3.2 cm: Decompression failure: right: 2.1%, left: 0%, Risk of injury: right: 2.1%, left: 17%) and a 18G/4.5 cm needle in 10-year-old children (Decompression failure: right: 9.5%, left: 9.5%, Risk of injury: right: 7.1%, left: 11.9%).

Conclusions: In children aged 0, 5 and 10 years presenting with a tension pneumothorax, we recommend 22G/2.5 cm, 20G/3.2 cm and 18G/4.5 cm needles, respectively, for acute decompression.
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http://dx.doi.org/10.1186/s13049-019-0671-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788035PMC
October 2019