Introduction: Infective endocarditis is well known to produce neurologiccomplications from septic emboli, which mandates a multidisciplinaryapproach including neurosurgery and cardiac surgery. However, the literatureis not conclusive as to the optimal interval between neurosurgery and cardiacsurgery.Case Report: The first case is a 60-year-old woman with significant pastmedical history presenting with native valve methicillin-resistantstaphylococcus aureus (MRSA) endocarditis causing cerebral vascular infarcts.The second case is a 45-year-old man with no significant past medical historypresenting with infective endocarditis of the aortic and mitral valve.Discussion: After neurosurgical intervention cardiac surgery was performed27 and 17 days later for each case, respectively. All operations were successfulwith few complications. Guidelines suggest waiting at least one week untilvalvular surgery, but other reports suggest earlier surgery produces preferableoutcomes. In the cases presented, both patients experienced no furthersignificant events to date after receiving cardiac surgery>3 weeks after theinitial ischemic stroke event.Conclusion: Neurological deficits mandate a collaborative approach betweenneurosurgery and cardiac surgery. The significance of the time betweenneurosurgical intervention and cardiac surgery remains controversial, butwaiting at least one week shows positive results.

Introduction: Varicocele is one of the most common causes of infertility. In this study, we evaluated and compared the operative time, sperm analysis results, and complications of three different methods of open and laparoscopic varicocelectomies.Materials and Methods: From among all bilateral varicocelectomies in our center, we randomly selected 30 of each following cases: laparoscopic varicocelectomy, open subinguinal varicocelectomy under general anesthesia, and open subinguinal varicocelectomy under local anesthesia. We compared the operative time, sperm analysis results, and complications between these three groups.Results: The mean operative times were 30.0±5.5 minutes for laparoscopies, 27.0±3.5 minutes for open varicocelectomies under general anesthesia, and 38.0±1.8 minutes for open varicocelectomies under local anesthesia (P=.02). Intra-operative complications occurred only in the laparoscopic group, and postoperative complications were seen in 23.3%, 20.0%, and 4.2% of the patients with laparoscopy, open surgery under general anesthesia, and open surgery under local anesthesia, respectively. Semen analysis did not show any significant changes after varicocelectomy except for a slight improvement of sperm morphology in patients who underwent open varicocelectomy under local anesthesia.Conclusion: Subinguinal varicocelectomy under local anesthesia is better than laparoscopic method in terms of recurrence, hydrocele formation, and operative time. Subinguinal method under general anesthesia has intermediate efficacy regarding less complications than laparoscopic method and shorter operative time than the two other methods.

Background: There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to the perception that this exposure will improve their professional “ marketability” in a subspecialty they perceive as having higher compensation. Methods: Using Medicare data, we investigated the most common surgeries from these fields and determined which have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement (payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weighted and weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than that of hand surgery. Results: Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest payment and wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius open reduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignments with correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgery has a higher mean payment/min ($10. 46± 3. 22 vs. $7. 52± 2. 89), charge/min ($51. 02± 17. 11 vs. $41. 96± 11. 32), and reimbursement (21± 4. 7% vs. 18± 5. 1%) compared with shoulder/elbow surgery (all, P<0. 01). Non-weighted mean wRVUs/min were similar (0. 12± 0. 03 vs. 0. 13± 0. 03, P = 0. 12). When weighted by procedure frequency, hand surgery had greater wRVUs/min (0. 15± 0. 036 vs. 0. 13± 0. 032), payments/min ($14. 17± 4. 50 vs. $6. 97± 2. 26), charges/min ($75. 68± 30. 47 vs. $42. 61± 7. 83), and reimbursement (20± 5. 0% vs. 17± 6. 0%) (all, P<0. 01). Conclusion: According to Medicare compensation, and when weighted by procedure frequency, hand procedures are associated with greater overall mean wRVUs/min, payments/min, charges/min, and reimbursement compared with shoulder and elbow procedures. Hand-surgery fellowship applicants should be aware that subspecialty compensation is complex in nature but should seek shoulder/elbow elective experience to acquire an additional surgical skill-set as opposed to primarily monetary reason.

Background: Fractures are the most serious injury suffered by athletes, resulting in the greatest time recuperating from Such injuries. Objectives: To describe the difference in outcome for non-operative versus operative management of site-specific soccer-related fractures. Methods: All fractures sustained during soccer from 2007 to 2008 within the Lothian population were prospectively recorded. Patients were followed up in August 2010, via telephone, to determine return rates and times to soccer. High incidence fractures with significant rates of surgery (Tibial Diaphysis, Ankle, Scaphoid, Clavicle, Metacarpus Distal Radius) were identified and classified according to the AO system. Outcomes of similar fracture classifications with contrasting management were compared. Results: Of 367 fractures identified during the study period, 20% were managed operatively. The rates of surgery for the six fractures cohorts were Tibial Diaphyseal 67%, Ankle 51%, Scaphoid 25%, Clavicle 20%, Metacarpal 11% and Distal Radial 10%. Operatively managed fractures of the Distal Radius (14 weeks vs. 9 weeks: P < 0. 031), Ankle (42 weeks vs. 22 weeks: P < 0. 004) and Metacarpus (18 weeks vs. 5 weeks: P < 0. 001) took longer to return to soccer than non-operatively managed fractures, while operatively managed fractures of the Tibial Diaphysis took shorter to return (35 weeks vs. 45 weeks: P = 0. 673). Operatively managed fractures of the Ankle (57% vs. 22%: P < 0. 029), Tibial Diaphysis (89% vs. 50%: P = 0. 683), Scaphoid (80% vs. 60%: P = 0. 613), Clavicle (50% vs. 31%: P = 0. 584), Distal Radius (50% vs. 18%: P = 0. 234) and Metacarpus (67% vs. 40%: P = 0. 537) had higher rates of persisting symptoms at follow-up than non-operatively managed fractures. Conclusions: The role of operative management in the treatment of soccer-related fractures is specific to the location and nature of the fracture. The effect of operative management on return times to sport is fracture specific, though invariably this is associated with higher rates of persisting symptoms. The decision regarding the choice of non-operative versus operative management requires clinical judgment on an individual basis, based on the fracture location and configuration.

Background: Allogeneic blood transfusion in patients undergoing total joint arthroplasty (TJA) has been shown to negatively affect patient outcomes. This study aimed to examine if there is a correlation between operative time and the need for allogeneic blood transfusions during TJA. Methods: We performed a retrospective review of 866 patients who underwent primary TJA during a one-year period at our institution. Logistic regression was performed to identify the association between operative time and need for allogeneic blood transfusion, controlling for other patient and surgical factors. Multiple linear regression analysis was also performed to see how the same factors affected CBL. Results: Of the 866 cases, 13%(115) were simultaneous bilateral. 52%(449) of patients received preoperative autologous blood donation. The average operative time for unilateral and bilateral patients was 74. 1± (33. 9) and 132. 6± (36. 0) minutes, respectively. Average CBL for unilateral patients was 2120mL± (1208) and 4051mL± (1311) for bilateral cases. The average number of allogeneic transfusions was also higher within the bilateral group (0. 49 vs 1. 15 units). Multivariate analysis indicated that duration of surgery (odds ratio [OR]: 1. 35 per 15 minutes) and bilateral TJA (OR: 2. 97) increase the risk of allogeneic blood transfusion, while patients having total knee arthroplasty are less likely to receive allogeneic blood transfusion (OR: 0. 50). CBL also increased significantly with surgical duration (211. 5 mL per 15 minutes). Conclusion: A subgroup analysis confirmed that there was a correlation between operative time and need for allogeneic transfusion following unilateral TJA. Expeditious surgery can minimize blood loss and subsequent need for blood transfusion and its associated adverse consequences.