David S. Strosberg

The Role of Femoroacetabular Impingement in Core Muscle Injury/Athletic Pubalgia: Diagnosis and Management

Chronic groin pain in athletes represents a major diagnostic and therapeutic challenge in sports medicine. Two recognized causes of inguinal pain in the young adult athlete are core muscle injury/athletic pubalgia (CMI/AP) and femoroacetabular impingement (FAI). CMI/AP and FAI were previously considered to be two distinct entities; however, recent studies have suggested both entities to frequently coincide in the athlete with groin pain. This article briefly discusses the role of FAI in CMI/AP and the diagnosis and management of this complex disease.

The Role of Endovascular In Situ Revascularization in the Treatment of Arterial and Graft Infections

Mycotic aneurysms and prosthetic graft infections are traditionally treated with excision of the infected tissue or graft, often requiring anatomical or extraanatomical bypass, carrying significant morbidity and mortality. Currently, the role of endovascular repair without excision in this setting has yet to be defined. We present 2 case scenarios, whereby mycotic pseudoaneurysms were successfully treated with endovascular stent-graft coverage and to present an in-depth review of endovascular in situ revascularization in the treatment of arterial and graft infections. There are data to support the use of stent grafting in mycotic aortic and iliac aneurysms, lower and upper extremity native arterial infections, lower extremity prosthetic bypass infections, and infections of carotid artery aneurysms. It is our belief that this technique may be utilized as primary therapy if there is no significant contamination and certainly serves an essential role in acute rupture or hemorrhage. In situations where there is significant tissue infection, stent grafting should be considered as a bridge if traditional excision is warranted.

Development of a Prehospital Tranexamic Acid Administration Protocol

Abstract Objective: Early administration of tranexamic acid (TXA) has been shown to reduce all-cause mortality and death secondary to trauma. Our objective was to develop a collaborative prehospital TXA administration protocol between a ground EMS and academic medical center. Methods: Physicians, pharmacists, and EMS and fire department personnel developed a prehospital TXA administration protocol between a local fire and EMS center with a Midwest tertiary care health system based on results from the CRASH-2 Trial. The protocol was initiated March 27, 2013 and the first dose of TXA was administered in September 2013. Results: Since September 2013, nineteen trauma patients received TXA. Survival rate was 89% (17/19); 2 patients expired immediately following arrival to the trauma bay. Seven patients did not receive the in-hospital maintenance dose due to the following: 3/7 (43%) due to miscommunication of pre-TXA administration; 2/7 (29%) did not meet inclusion criteria for TXA protocol; 1/7 (14%) due to protocol noncompliance; 1/7 (14%) due to a chaotic situation with an unstable patient. Conclusions: Prehospital TXA protocol based on the CRASH-2 trial is safe and feasible. The first dose of TXA administered under this protocol marks the first ground EMS administration in the USA. Conceivably, this will pose as a model to other trauma centers that receive patients from outlying areas without immediate access to care. Large multi-institutional analyses need to be performed to evaluate survival benefits of prehospital TXA administration protocol.

A Case of Acute Iliocaval Thrombosis in the Setting of a Suprarenal Inferior Vena Cava Saccular Aneurysm.

Inferior vena cava (IVC) aneurysms are a rare finding, whose management and outcomes remain uncertain due to their low incidence and long-term follow-up. As IVC aneurysms remain a poorly understood clinical entity, it is important to expand upon our existing knowledge base as new cases arise. We present a patient with a suprarenal IVC saccular aneurysm and an overview of the current literature regarding IVC aneurysm classification, presentation, and management. Based on the expanding literature, we propose that IVC aneurysms may be simplified into a 2-type classification, which can further guide clinicians on management of the aneurysm.

Retirement: 401k, Roth IRAs, College Funds, and More

In the following discussion, financial retirement preparation issues are addressed so that a surgeon is financially prepared for retirement. We discuss assembling an advisory team, determining the financial target, and obtaining the financial goal considering income benefits and asset accumulation benefits. Short- and long-term investment strategies including Social Security, pension plans, annuities, individual retirement arrangements (IRAs), life insurance, stocks, bonds, and mutual funds are reviewed. Retirement for the surgeon requires careful financial planning to maintain an acceptable quality of life.

Chronic Groin Pain Following Anterior Hernia Surgery

Inguinal herniorrhaphy is one of the most common general surgery operations performed in the United States with nearly 600,000 repairs annually. An anterior approach is the most common method for surgical repair, which may be performed as either a tissue repair or tension-free mesh repair. While recurrence rates are lower with tension-free repairs, long-term neuralgia is a feared complication. Chronic post-herniorrhaphy groin pain is defined as pain lasting >3 months following hernia repair. Studies show an incidence of chronic pain of 11 %. Treatments for chronic groin pain include nonoperative interventions such as pain control with or without narcotic pain medications, and injection-based therapies such as nerve blocks and radiofrequency neurolysis. Additionally, operative intervention has been used for refractory chronic groin pain. Surgical treatments include single nerve resection, triple neurectomy, and mesh removal.

Common carotid artery end-diastolic velocity and acceleration time can predict degree of internal carotid artery stenosis

Objective: Whereas duplex ultrasound parameters for predicting internal carotid artery (ICA) stenosis are well defined, the use of common carotid artery (CCA) Doppler characteristics to predict ICA stenosis when the ICA cannot be insonated directly or accurately because of anatomy, calcification, or tortuosity has not been studied. The objective of this study was to identify CCA Doppler parameters that may predict ICA stenosis. Methods: We reviewed all patients at our institution who underwent carotid duplex ultrasound (CDU) from 2008 to 2015 and also had a comparison computed tomography, magnetic resonance, or catheter angiogram. We excluded patients whose CDU examination did not correlate with the comparison study, those whose arteries were not visualized on the comparison study, and those with complete occlusion of the CCA. We collected CCA peak systolic velocity (PSV), end‐diastolic velocity (EDV), and acceleration time (AT) in addition to CDU and comparison imaging interpretation of degree of stenosis. A multivariate model was used to identify predictors of ICA stenosis. Results: There were 99 CDU examinations with corresponding comparison imaging included. For every increase of 10 cm/s in EDV in the CCA, the odds of a >50% ICA stenosis being present vs a ≤50% ICA stenosis decreased by 37% (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.41‐0.97; P = .03). For every increase of 10 cm/s in EDV in the CCA, the odds of a 70% to 99% ICA stenosis being present vs a ≤50% ICA stenosis decreased by 48% (OR, 0.52; 95% CI, 0.28‐0.94; P = .03). A CCA EDV of 19 cm/s or below was associated with a 64% probability of a 70% to 99% ICA stenosis. For every 50‐millisecond increase in AT in the CCA, the odds of a >50% stenosis being present vs a ≤50% ICA stenosis increased by 56% (OR, 1.56; 95% CI, 1.03‐2.35; P = .04). A CCA AT of 80 milliseconds or above was associated with a 69% probability of a >50% ICA stenosis. There was no correlation between CCA PSV and ICA stenosis. Conclusions: CCA EDV and AT are independent predictors of ICA stenosis and may be used in the setting of patients whose ICA cannot be directly insonated or when standard duplex ultrasound parameters of ICA PSV, EDV, or ICA/CCA ratio conflict.

Clinical and Ultrasound Sequelae of Nonvisualized Calf Veins on Duplex Ultrasound for Suspected Deep Vein Thrombosis

Objectives Calf veins are not visualized in up to 40% of lower extremity venous duplex ultrasounds (DUS). Little is known about the clinical implications of nonvisualized calf veins. We sought to investigate the incidence of nonvisualized calf veins, rate of subsequent venous thromboembolism (VTE), and factors influencing successful visualization on subsequent DUS. Methods We reviewed all patients who had DUS in 2012 at our institution who had nonvisualized calf veins, no deep vein thrombosis (DVT), and available follow-up. Demographics, Wells score, body mass index (BMI), indication for DUS, activity level, reason for nonvisualization, initial and subsequent DUS results, and subsequent occurrence of VTE were collected. Results A total of 8,237 DUS were performed in 2012. Of these, 891 (10.8%) DUS in 717 patients had at least one nonvisualized calf vein. Seven hundred twenty-eight limbs (484 patients) had no DVT and had available follow-up and comprised the study population. The most common reasons for nonvisualization were edema (35.5%) and body habitus (31.8%). Twenty-two (4.5%) patients were subsequently identified to have VTE; 9 limbs had only pulmonary emboli, 12 had only DVT, and 1 had both. Only length of stay in the hospital correlated with the development of VTE. One hundred forty-eight of the 484 patients had subsequent DUS at a median of 2.43 months; 45.3% of subsequent DUS successfully imaged the previously nonvisualized veins. Whole lower extremity swelling, single vein nonvisualization, and single limb nonvisualization at initial DUS were associated with successful visualization on subsequent DUS. Thirteen (8.8%) new DVT were seen on subsequent DUS, six were seen in calf veins that previously were not visualized, and seven were seen in either femoropopliteal veins or calf veins that previously were visualized and did not have thrombus. Conclusions Non-visualized calf veins are common in DUS. Almost half of patients with nonvisualized veins on initial DUS had successful visualization on subsequent DUS. Whole lower extremity swelling, single vein nonvisualization, and single limb nonvisualization at initial DUS were associated with successful visualization on subsequent DUS. In all, 4.1% of patients with nonvisualized veins on initial DUS go on to develop VTE and 8.8% of patients who have subsequent DUS are found to have DVT. When initial DUS is unable to visualize calf veins, selective repeat DUS may be useful to identify either new or initially unseen DVT.

Resection of a large intra-abdominal desmoid tumor requiring abdominal wall reconstruction: A case report and review of literature

Abdominal desmoid tumors (ADTs) are rare, fast-growing, nonmalignant tumors of the soft tissue. ADTs have no known metastatic potential; however, they are locally aggressive and may result in local tissue destruction. The diagnosis of an ADT should be considered in a female patient with a prior history of pregnancy and previous abdominal surgery who presents with a painless intra-abdominal mass. We present the case of a 23 cm intra-ADT excision in a 40-year-old African American female requiring abdominal wall reconstruction with component separation. We also discuss a comprehensive review of the literature including current treatment methods and prognostic outcomes in patients following the resection of ADTs. An individualized multi-modality treatment approach employing both surgical and medical therapy to achieve histologically negative margins appears to be the most effective treatment strategy to reduce the recurrence rate of ADTs. The following core competencies are addressed in this article: Patient care and medical knowledge.