Background: Takotsubo cardiomyopathy (TTC) is increasingly well-recognized as a cause of chest-pain syndromes, especially in aging females. The most common complications of TTC occur in the first 24 hours post onset of symptoms and include shock and/or arrhythmias. Hypothesis: We tested the hypothesis that the severity of early hypotension in TTC reflects the extent of myocardial involvement and dysfunction. Methods: In 80 consecutive TTC patients, correlates of blood pressure on the day of admission were sought via univariate followed by multivariate analysis. Results: Mean systolic blood pressure (SBP) on day 1 was 120 ± 24 (SD) mm Hg. During the first 3 days of admission, 39% of patients had SBP <90 mm Hg, and 9% died and/or required intra-aortic balloon pump insertion. The extent of release of N-terminal pro-brain natriuretic peptide, with its potential correlate of associated vasodilator activity, varied inversely with pulmonary-artery saturation, a measure of cardiac output. However, there was no significant relationship between normetanephrine release and SBP. On multivariate analyses there was no significant relationship between SBP and (1) wall-motion score index (as an index of left-ventricular systolic dysfunction) or (2) T 2 enhancement on cardiac magnetic resonance imaging and peak N-terminal pro-brain natriuretic peptide (as indices of myocardial inflammation). Conclusions: Although severe hypotension and shock occur commonly during acute stages of TTC, these complications are multifactorial in origin, probably representing a combination of impaired inotropic state and vasodilatation. Importantly, initial hypotension does not imply severe left ventricular inflammation or systolic dysfunction.

Background: Literature is sparse on whether severity of hallux valgus affects outcomes of surgery. We thus aimed to evaluate the impact of hallux valgus severity on the clinical outcomes of surgery. Methods: 83 consecutive scarf osteotomies performed by a single surgeon for symptomatic hallux valgus between 2007 and 2011 were divided into 3 groups (mild, moderate, and severe) based on severity of their preoperative hallux valgus using the hallux valgus and intermetatarsal angles. Outcomes were assessed using the visual analog scale (VAS) for pain, 36-Item Short Form Health Survey physical functioning (SFPF) and mental health (SFMH) subscales, and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores. These were assessed preoperatively and at 6 months and 2 years postoperatively. Patient satisfaction was assessed at 6 months and 2 years postoperatively. Eleven (13.2%), 54 (65.1%), and 18 (21.7%) feet were in the mild, moderate, and severe groups, respectively. Results: There was no difference in preoperative VAS, SFPF, SFMH and AOFAS scores between the groups except for AOFAS scores for the second toe, which were poorer with increasing hallux valgus. Postoperatively, there was improvement across all outcome scores. VAS and AOFAS showed excellent scores, and patient satisfaction was high across all 3 groups (88.9%, 89.4%, and 86.7%). The severe group had slightly lower SFPF scores at 6 months (mild, 81.1; moderate, 84.0; severe, 74.3; P = .031) and 2 years postoperatively (mild, 93.4; moderate, 89.7; severe, 76.4; P = .005), and slightly poorer second toe scores for VAS (mild, 0.0; moderate, 0.1; severe, 1.2; P = .017) and AOFAS (mild, 94.7; moderate, 93.5; severe, 83.4; P = .043) at 2 years postoperatively. All other scores including patient satisfaction showed no between-group differences. Complication and revision rates between the groups were similar. Conclusion: Surgery for symptomatic hallux valgus lead to excellent outcomes and high patient satisfaction regardless of severity of deformity. Level of Evidence: Level III, comparative series.

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SUMMARYBezoars are masses formed by the concretion of stomach contents or debris within the gastrointestinal tract. Bezoars are rare and account for only 0.4-4% of all cases of gastrointestinal obstruction and mainly occur in the stomach or small intestine. Intestinal obstruction caused by colonic bezoars is extremely rare. We report a case of a distal sigmoid obstruction caused by a phytobezoar in a 60-year-old man with no obvious precipitating causes. He presented to the emergency department acutely unwell and a subsequent abdominal CT scan showed a mass within the proximal sigmoid colon suspicious for a bezoar. He proceeded to have an urgent laparotomy and the obstructive intraluminal mass in the sigmoid colon was identified and manually broken down. Subsequent histopathological assessment reported amorphous material and plant cellular matter consistent with the diagnosis of a phytobezoar. BACKGROUND

ObjectivesThe role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. There are however, limited studies on the management of the subgroup of significantly symptomatic patients who remain refractory to maximal conservative treatment and are poor candidates for knee replacement surgery.We propose that with careful patient selection, arthroscopic debridement can provide good symptomatic relief with sustained benefits in the degenerative knee.MethodsWe performed a retrospective, single-surgeon study of 180 consecutive knee arthroscopies performed in 169 patients, aged 40 years and above, who had mechanical symptoms affecting their daily lives and underwent arthroscopic debridement after failure of a minimum 2 months of optimized medical and physical therapy. Severity of the knee osteoarthritis on plain radiographs was assessed using the Kellgren-Lawrence classification.Functional and satisfaction scores were assessed using Oxford Knee Score, Koos Knee Survey, Short Form-36, Numeric Pain Rating Scale, and questions adapted from the North American Spine Society Questionnaire.ResultsExcellent functional outcomes and patient satisfaction were reported in the majority of patients over the follow-up timeframe of 2–8 years. The mean pre-operative Kellgren-Lawrence score was 2.02 (SD 0.580). Significant improvements compared to pre-operative scores were seen across all scoring systems tested. 90% of patients reported good to excellent results.ConclusionArthroscopic knee debridement can provide good symptomatic relief and sustained benefits in significantly symptomatic patients with early degenerative knees who have failed conservative management. This is most useful in patients with mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis.