Concordia Hospital

Case presentation A 33-year-old male presented with a three-year history of hematochezia, tenesmus, and anal prolapse.The condition progressed with worsening anal bleeding, requiring blood transfusion.He sought medical attention, and a colonoscopy revealed an arteriovenous malformation 2 cm above the pectinate line.Despite treatment, the symptoms persisted, and the bleeding worsened.He was referred to a specialized center with a provisional diagnosis of hemorrhoidal disease.A proctological examination under sedation was performed, revealing a bleeding, pedunculated lesion measuring 6 cm, located above the pectinate line.Local excision of the lesion was performed.Histopathological analysis showed intramucosal adenocarcinoma associated with a villous adenoma with high-grade dysplasia, with clear surgical margins.Discussion Primary adenocarcinoma of the anus is a rare disease accounting for only 5%-10% of anal canal malignancies.The presentation of this disease is generally late, with a mean age of diagnosis at 59 years, possibly due to the associated non-specific symptoms.Anal adenocarcinomas can be subdivided into two types: (1) colorectal from the mucosa above the dentate line and (2) extramucosal from anorectal fistulas or anal glands.Given the challenges with classification and the low number of cases overall, most of the literature is limited to case reports or outcome-driven observational studies.This case highlights the challenges of early diagnosis of anal malignancies and the importance of immediate evaluation of the anorectal region when recto-anal symptoms, such as bleeding or mucus in the stool, are reported through digital rectal examination, sometimes neglected in medicine.The lesion presented a clinical picture similar to symptoms of hemorrhoidal disease, such as bleeding and anal prolapse.Anal tumors can also be identified in routine or diagnostic colonoscopy, even in asymptomatic patients.Conclusion Due to delayed diagnosis, anal adenocarcinomas often have a poor prognosis.Understanding the patient's symptoms and performing a physical examination, such as a digital rectal exam, supports early diagnosis and targeted treatment.This approach contributes to better patient outcomes and helps reduce the morbidity and mortality associated with the disease.

Fresh-frozen specimen availability and cost may be a barrier for initiation of biomechanical studies where soft tissue is used in a construct with other medical devices. The impact of soft tissue preservation method on the outcomes of biomechanical studies in the specific case of graft-suture constructs is relatively unexplored. This study aimed to observe peak loads and failure modes in biomechanical testing of fresh-frozen (FF) versus formalin embalmed (FE) quadriceps tendon (QT) graft-suture constructs for soft tissue fixation in ACLR and assess suitability of FE QT graft constructs for load-to-fail testing. Twenty QT grafts were harvested from human cadaver specimens. Ten grafts came from fresh-frozen donors and 10 from embalmed donors. All grafts were prepared with the modified Prusik knot using a braided composite suture and subjected to tensile loading. Comparisons between the biomechanical properties of the graft-suture constructs were made with unpaired t tests with α = 0.05. FE and FF constructs displayed similar peak loads and failure modes. FF constructs had greater elongation after pre-tensioning than FE (7.3 vs. 5.5mm, p = 0.02) and greater elongation after cyclic loading than FE constructs (17.5 vs. 10.5mm, p = 0.01). Hysteresis was greater for FF constructs at the 50th, 100th, 150th, and 200th cycle (p = 0.02, p = 0.07, p < 0.001, p = 0.004, respectively). FE constructs were stiffer than fresh-frozen (103 vs. 84N/mm, p < 0.001). FE constructs were significantly stiffer but displayed similar peak load and failure mode to FF which was reflective of the strength of the suture material. FE grafts can offer an alternative to FF grafts in graft-suture constructs for biomechanical studies where load at failure and knot security and strength is of main interest.

To define patient acceptable symptom state (PASS) cut-off values for the EQ-5D-5L and Oxford hip (OHS) and knee (OKS) scores 6 and 12months after total hip (THR) or knee (TKR) replacement. To compare PASS cut-off values for the EQ-5D-5L scored using: (1) the Canadian value set, (2) the crosswalk value set, and (3) the equal weighted Level Sum Score (LSS). We mailed questionnaires to consecutive patients following surgeon referral for primary THR or TKR and at 6 and 12months post-surgery. Patient reported outcome measures (PROMs) were the EQ-5D-5L, the OHS, and OKS. We assessed PASS cut-off values for PROMs using percentile and ROC methods, with the Youden Index. Five hundred forty-two surgical patients (mean age, 64years, 57% female, 49% THR) completed baseline and 12-month questionnaires. 89% of THR and 81% of TKR patients rated PASS as acceptable at 12months. PASS cut-off values for THR for the EQ-5D-5L (Canadian) were 0.85 (percentile) and 0.84 (Youden) at 12months. Cut-off values were similar for the LSS (0.85 and 0.85) and lower for the crosswalk value set (0.74 and 0.73), respectively. EQ-5D-5L cut-off values for TKR were Canadian, 0.77 (Percentile) and 0.78 (Youden), LSS, 0.75 and 0.80, and crosswalk, 0.67 and 0.74, respectively. Cut-off values 6 and 12months post-surgery ranged from 38 to 39 for the OHS, and 28 to 36 for the OKS (range 0 worst to 48 best). PASS cut-off values for the EQ-5D-5L and Oxford scores varied, not only between methods and timing of assessment, but also by different EQ-5D-5L value sets, which vary between countries. Because of this variation, PASS cut-off values are not necessarily generalizable to other populations of TJR patients. We advise caution in interpreting PROMs when using EQ-5D-5L PASS cut-off values developed in different countries. A standardization of methods is needed before published cut-off values can be used with confidence in other populations.

Patients with a greater risk of recurrent instability and inferior clinical outcomes following a primary Latarjet procedure can be preoperatively identified on the basis of clinical, radiographic, and demographic criteria. The purpose of this study was to identify risk factors influencing the rates of recurrent anterior glenohumeral instability and clinical failure following a primary Latarjet procedure. All patients who underwent a primary Latarjet procedure were prospectively enrolled and evaluated. The Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) outcome scores were collected at a minimum 5-year follow-up along with evidence of recurrent instability. Recurrent instability (recurrent subluxation or dislocation) was considered as a failure. Clinical failure was defined as a postoperative WOSI score of ≥630 points (≤70% normal) or a SANE score of ≤70 points. From 2004 to 2014, 344 patients (358 shoulders) with a mean age of 30.6 years (range, 16 to 68 years) were enrolled and had a mean follow-up time of 75 months (range, 61 to 89 months). The median postoperative WOSI score was 265 points (range, 0 to 1,100 points), and the median SANE score was 88 points (range, 50 to 100 points). Recurrence occurred in 17 shoulders (4.7%), 5 with dislocation and 12 with subluxation; and 28 (8.2%) of 341 shoulders without recurrent instability were clinical failures following a Latarjet procedure. The risk factors for recurrence included atraumatic dislocation (odds ratio [OR], 4.6; p < 0.01) and bilateral instability (OR, 4.0; p = 0.01), whereas the risk factors for clinical failure (WOSI score of ≥630 points or SANE score of ≤70 points) were female sex (OR, 2.8; p < 0.01) and bilateral instability (OR, 4.6; p = 0.01). Outcomes at a mean of >6 years following a primary Latarjet procedure for anterior shoulder instability were very good, with an overall recurrence rate of 4.7%. An additional 8.2% of cases were defined as clinical failures. Patients with an atraumatic mechanism of primary dislocation, bilateral instability, and female sex were identified to be at a greater risk of recurrence or clinical failure. Although additional work is necessary, patients with capsuloligamentous laxity, relatively atraumatic instability history, bilateral instability, and female sex may be preoperatively identified as having a higher risk of treatment failure after a primary Latarjet procedure. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

ObjectivesWe assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety.DesignPreimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts.SettingRegional, provincial health authority.ParticipantsPatients awaiting total joint replacement of the hip or knee.InterventionsThe WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood.Primary and secondary outcome measuresPrimary outcomes related to ‘accessibility’: waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression.ResultsVariability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee).ConclusionsThe WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality.

To assess (1) patient expectations before total hip (THR) and knee (TKR) replacement; (2) which expectations are met and unmet 6 and 12months post-surgery; (3) the role of unmet expectations in satisfaction. Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR. Patients listed their own expectations and also completed the Hospital for Special Surgery (HSS) Expectation Survey. We used content analysis to group expectations into themes. At 6 and 12months post-surgery, patients were given a copy of their own list of individual expectations and reassessed each one as met or unmet. We also assessed fulfilled HSS expectations and satisfaction with surgery. The sample of 556 patients (49% THR, 57% female) had a mean age of 64years (SD10). The five most frequent expectation themes were pain relief, mobility, walking, physical activities, and daily activities. Of these, physical activities had the lowest percentage met 12months post-surgery. 95% (THR) and 87% (TKR) were satisfied/very satisfied with their surgery 12months post-surgery. Very satisfied patients had a significantly greater percentage of met expectations (96% THR; 92% TKR) than dissatisfied patients (42% THR; 12% TKR). Although most expectations listed by patients were included in the HSS surveys, some were not, particularly for TKR. From 6 to 12months, there was a significant increase in patient satisfaction for self-care, daily activities, and met expectations for THR and pain relief, self-care, daily activities, and recreational activities for TKR. Expectations should be explicitly addressed before surgery, including a discussion of realistic expectations, particularly for physical activities.