Adequate Preoperative Planning Research Articles

The Validity and Reliability of CT Scan Based Tibial Plateau Mapping for Tibial Plateau Fractures

Abstract Background Tibial plateau fractures are intra-articular fractures presume a threat to knee function and represent great challenge to treat. Treatment with open reduction and internal fixation is variable because fractures vary from simple to complex, with little or extensive articular involvement. Hence, recognition of the fracture features will help orthopedic surgeons to understand the injury mechanism better and manage these fractures by planning optimal surgical procedures. Aim of the Work To assess the inter and intra-observer reliability of the new CT scan based tibial plateau classification (the ten segment tibial plateau mapping) and the secondary aim is to clarify its validity in clinical practice assisting the surgeons in choosing their approach and fixation implant during open reduction and internal fixation of such fractures. Our hypothesis is that this more sophisticated classification system may facilitate the choice of surgical approach and implants used and that this classification could be widely accepted among trauma surgeons. Patients and Methods A total of 30 patients with tibial plateau fractures diagnosed by the department of orthopedic surgery at el Demerdash hospital, Ain Shams university were collected in the time period between January 2020 and December 2022. Results in our study, we compared the inter and intra observer reliability of Schatzker, three column, and ten-segment classification using Kappa values. The results showed that schatzker and three column classification systems have higher inter-observer mean kappa values (0.749± 0.07, 0.692± 0.08) (0.639± 0.06, 0.667± 0.08 after 2 weeks‟ time interval) respectively representing good interobserver agreement in relation to the ten-segment classification which showed mean Kappa value 0.409± 0.30 representing moderate interobserver agreement when the cases were observed for the first time. The mean Kappa value decreased (0.081± 0.17) when the cases were observed after 2 weeks‟ time interval representing poor interobserver agreement. As regard to intra-observer reliability, both schatzker and three column classifications have higher mean Kappa values (0.766± 0.22, 0.697± 0.17 respectively) representing good intra-observer agreement in relation to ten segment classification which showed mean Kappa value (0.342± 0.10) representing poor intra-observer agreement. Conclusion tibial plateau fractures represent great challenge for orthopedic surgeons to treat and adequate preoperative planning is mandatory. The use CT scan with 3D reconstruction can help surgeons to describe and classify all fracture patterns thus reaching the optimal plane for fracture fixation. Our study concluded that ten segment classification has moderate to poor reliability compared to the conventional widely used schatzker classification and three column classification. We think that this because ten segment classification still not familiar to orthopedic surgeon. More research is needed on ten segment classification so that it can be applied in the future in clinical practice.

Surgical Treatment of Spinal Intra-Extradural Meningioma: A Clinical Case

Spinal meningiomas are rare, predominantly benign tumors that exhibit slow growth and typically have a non-invasive pattern of development. They originate from arachnoid cells and fibroblasts of the dura mater. Despite their benign nature, some meningiomas can exhibit intra-extradural extension, complicating both diagnosis and treatment. This article presents a clinical case involving a patient with an intra-extradural spinal meningioma. Despite radiological imaging suggesting a neurinoma, the final diagnosis confirmed a meningioma. Case Report: A female patient underwent surgical tumor resection through a posterolateral approach with laminectomy and facetectomy at the C4-C5 vertebral levels. The tumor, extending through the intervertebral foramen, was completely resected along with the affected nerve root. Histological examination verified a Grade II meningioma. Discussion: Despite advancements in neuroimaging and surgical techniques, intraoperative findings can be unpredictable, necessitating an adaptive approach to tumor resection. The article emphasizes the importance of adequate preoperative planning and the use of intraoperative neurophysiological monitoring to reduce the risk of complications and improve treatment outcomes. Conclusions: The primary treatment for spinal meningiomas is surgical. For dorsal and lateral localizations, total resection with the involved dura mater (Simpson Grade I) is optimal. For ventral localizations, tumor resection with coagulation of the dural attachment site (Simpson Grade II) is preferred. Preoperative and intraoperative use of electrophysiological methods is recommended to assess the functional status of neural structures. Intra-extradural localization of meningiomas is rare and presents significant challenges in preoperative diagnosis, requiring specific skills for effective removal.

The Complications of Cataract Surgery in Patients with Pseudoexfoliation

Abstract The senile cataract represents the blurring of the crystalline lens after the age of 65. It occurs due to metabolic changes in the crystalline lens which occur over the years. The only effective way to treat cataract is the surgical one. Pseudoexfoliation is an age related systemic disorder. PEX represents the accumulation fibrillar material in the extracellular matrix of the tissue. The most known ocular manifestation of the PEX are the collection at iris pupillary margin and anterior lens capsule. This accumulation is associated with many intraoperative and postoperative complications in patients scheduled for cataract surgery. The aim of the study was to investigate the prevalence of the surgical complications during phacoemulsfication in patients with PEX. The study included 91 patients scheduled for cataract surgery divided into two groups (PEX group 46, control group 45 patients). Poor intraoperative midryasis, zonular dehiscence, postoperative corneal edema, anterior chamber inflammation, elevated intraocular pressure and tear film instability had particularly higher rate of occurring in PEX group comparing to the control group (p<0.001). The highest mean value of intraocular pressure was observed in PEX group on the first postoperative day 25.6 ± 1.1 mmHg, while the best corrected visual acuity was measured in control group 0.71 ± 1.2 one month after phacoemulsification. Cataract surgery in patients with PEX carries great risk, but with adequate preoperative planning, the awareness of the potential complications, can provide safe and routine phacoemulification in these patients.

REMOVAL OF RETAINED BULLETS FROM THE HIP JOINT IN CIVILIAN GUNSHOT INJURIES

Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and systemic lead poisoning. The literature is sparse on this subject, with mostly sporadic case reports utilizing hip arthroscopy. We report on the largest series of removal of bullets from the hip joints using open surgical.We reviewed prospectively collected data of patients who presented to a single institution with civilian gunshot injuries that breached the hip joint between 01 January 2009 and 31 December 2022.We included all cases where the bullet was retained within the hip joint area. Exclusion criteria: cases where the hip joint was not breached, bullets were not retained around the hip area or cases with isolated acetabulum involvement.One hundred and eighteen (118) patients were identified. One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Of the remaining 117 patients, 70 had retained bullets around the hip joint. In 44 patients we undertook bullet removal using the followingsurgical hip dislocation (n = 18), hip arthrotomy (n = 18), removal at site of fracture fixation/replacement (n = 2), posterior wall osteotomy (n = 1), direct removal without capsulotomy (tractotomy) (n = 5).In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove (n=4), patients’ clinical condition did not allow for further surgery (n= 4) and patient refusal (n=1). No patients underwent hip arthroscopy.With adequate pre-operative imaging and surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy; using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation.

V05-05 3D SURGICAL PLANNING IN PARTIAL NEPHRECTOMY FOR COMPLETELY ENDOPHYTIC TUMORS

You have accessJournal of UrologyCME1 Apr 2023V05-05 3D SURGICAL PLANNING IN PARTIAL NEPHRECTOMY FOR COMPLETELY ENDOPHYTIC TUMORS Patricio Garcia, Jorge Abril, Tomas Carminatti, Angelica Castillo, Sebastian Tirapegui, and Alberto Jurado Patricio GarciaPatricio Garcia More articles by this author , Jorge AbrilJorge Abril More articles by this author , Tomas CarminattiTomas Carminatti More articles by this author , Angelica CastilloAngelica Castillo More articles by this author , Sebastian TirapeguiSebastian Tirapegui More articles by this author , and Alberto JuradoAlberto Jurado More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: When we talk about precision surgery, it is necessary to have adequate preoperative planning. 3D technology allows us to locate renal lesions that are difficult to access, and in this way generate less damage to the uncompromised parenchyma.In recent years it has been seen that the incorporation of 3D models could improve surgical results, the learning curves of novice surgeons and also the understanding of patients.In Urology, the use of surgical planning with 3D models and simulation is mainly used in renal tumors. The objetive is to present a series of cases of completely endophytic renal tumors with 3D models created for surgical planning. METHODS: We present a series of 5 cases with 3D models created for surgical planning. Case #1A 47-year-old female patient with congenital solitary kidney, presents an incidental renal tumor of 2 cm completely endophytic in contact with the renal sinus, it is a R.E.N.A.L Score 9x. It was performed by lumboscopic approachCase #2 A 60-year-old male patient with bilateral renal tumors, has a Left renal exophytic formation and completely endophytic right renal lesion of 2 cm R.E.N.A.L. Score 10p. The exophytic left renal tumor was treated 3 months before. It was performed by a lumboscopic approach.Case #3A 61-year-old female patient with a completely endophytic mesorenal lesion in the left kidney of 2.5cm R.E.N.A.L. Score 12x. In this patient we performed a transperitoneal approach Case #4A 54-year-old male patient with a completely endophytic mesorenal lesion in the left kidney of 3cm R.E.N.A.L. score 12x. It was performed by a lumboscopic approach.Case #5. A 45-year-old male patient with a completely endophytic mesorenal lesion in the left kidney of 2.5 cm. RENAL Score 12x. In this patient we performed a transperitoneal approach RESULTS: In our hospital we did 21 minimally-invasive partial nephrectomy for completely endophytic tumors between 2010 to 2022. In the last year we incorporated the use of 3D technology for surgical planning in these cases.The average days of hospitalization was 2, 9. In the pathology reports, the majority of tumors were Clear-cell RCC and pT1a. Two patients had postoperative complications with Clavien dindo III.Negative margins, warm ischemia time <25 minutes, and postoperative glomerular filtration rate <15% were established as cut-off points with respect to the strict Trifecta criteria to ensure optimal preservation of renal function. We achieved strict trifecta results in 16 patients (76.19%) CONCLUSIONS: In our case series, 3D models seem to be useful for surgical planning and provide us with more tools to perform precision surgeries. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e425 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patricio Garcia More articles by this author Jorge Abril More articles by this author Tomas Carminatti More articles by this author Angelica Castillo More articles by this author Sebastian Tirapegui More articles by this author Alberto Jurado More articles by this author Expand All Advertisement PDF downloadLoading ...

Navigated Transcranial Magnetic Stimulation Motor Mapping and Diffusion Tensor Imaging Tractography for Diencephalic Tumor in Pediatric Patients

Background. In deep-seated brain tumors, adequate preoperative planning is mandatory to assess the best surgical corridor to obtain maximal safe resection. Functional diffusor tensor imaging (DTI) tractography based on navigated transcranial magnetic stimulation (nTMS) motor mapping has proven to be a valid preoperative examination method in adults. The aim of this paper is to present the application of nTMS and functional DTI tractography in a series of pediatric diencephalic tumors. Material and methods. Three patients affected by thalamic (one) and thalamopeduncular tumor (two) were successfully examined with nTMS motor mapping and DTI tractography between October 2020 and October 2021 (F:M 3:0, mean age 12 years ± 0.8). Cortical representation of leg, hand and mouth were determined in the affected hemisphere and the positive stimulation spots were set as seeds point for tractography. Results. Mapping of the motor cortex and tracts reconstruction for leg and hand were successful in all patients, while facial function was properly mapped in one patient only. In all cases, the procedure was well tolerated and no adverse events were recorded. Spatial relationships between tumor and functional tissue guided the surgical planning. Extent of the resection varied from 96.1% to 100% with a postoperative new motor deficit in one patient. Conclusions. nTMS and DTI fiber tracking is a feasible, effective and well-tolerated method to identify motor pathway in deep-seated lesion in pediatric population.

Bilateral Outpatient Total Knee Arthroplasty – Is it Feasible, Safe, and Worth Considering: A Pilot Study

Introduction: Outpatient total knee arthroplasty (TKA) in selected patients has proved to be beneficial to both patients and health-care systems in terms of safety, reoperations, readmission rate, complications, cost-effectiveness, increased patient satisfaction, and improved outcome scores. However, these benefits of outpatient TKA have been limited to unilateral TKA. Hence, we reviewed the results of bilateral outpatient TKA in five patients to educate surgeons about the feasibility, safety, benefit, and area of research for bilateral outpatient TKA and its worth consideration in selected groups of patients to decrease patient morbidity and cost. Materials and Methods: Five bilateral knee arthroplasties done as outpatient surgeries at our center were reviewed for patient satisfaction, readmission, reoperation, emergency visit without readmission, unplanned clinic visits, and complications. All these cases followed proper selection criteria, adequate preoperative planning, and strict adherence to our standard operating protocols. Results: Five patients of bilateral outpatient TKA with a mean age of 48.6 years were included in the study. All patients have excellent outcomes at 1-month follow-up. The mean Knee Society Score was 91. None of the patients required reoperation or revision surgery. All the patients demonstrated a high level of satisfaction, without any complications of instability, infection, ileus, urinary tract infection, or deep vein thrombosis. Conclusion: Bilateral outpatient TKA can be considered a suitable alternative with benefits of reduced hospital stay, and hence decreased morbidity and cost, early mobilization and recovery, economical advantages, minimal pain owing to multimodal analgesia, faster return to normalcy, and less mental stress or disturbances, but in selected patients at specialized center only. The study stresses on the fact of bilateral outpatient TKA should also considered a key area of research in the field of outpatient TKA in addition to other areas of universal selection criteria, ideal risk assessment tool, safety aspect, surgical duration, ambulation, and reasons for not able to discharge.

Incidence and Patterns of Major Complications Following Spinal Instrumentation- A Retrospective Descriptive Study from a Tertiary Care Center in Nepal

Background: With the continuous uprise of spinal instrumentations within the global front, the complications they harbinger may have multispectral effects upon the patients as well as their caretakers. These are of prime significance in the context of low and middle-income nations. There is however drought of studies pertaining to the same in our subcontinent. Materials and methods: A retrospective descriptive study was undertaken to study the incidence and patterns of early and late major complications among 300 patients undergoing spinal instrumentation from the hospital database of the College of Medical Sciences (CMS), in Bharatpur, Chitwan, Nepal. Results: Trauma comprised 63.33% of cases in the study. 40% of the study cohorts were either in the American Spinal Injury Association (ASIA) ‘A’ or ‘B’ neurological status. The incidence of major complications in our study cohort was 20.33%. The posterior-only surgical approach was undertaken in 200 (66.67%). Surgical site infection was the most common type of complication observed (6.67%). Hardware-related complications were observed in 5.67%) of cases. The incidence of re-operation was 2.67%. The mortality rate observed in our study was 2%. Conclusion: Adequate preoperative planning, proper optimization of the patient, and adoption of procedure-specific, risk-adjusted predictive models may be pivotal for nullifying complications adherent to spinal instrumentation.

Scar endometriosis: Looking beyond the diagnosis - A case series

Scar endometriosis usually affects the abdominal wall or the perineum. Virtually all cases are linked with some form of surgical manipulation. Although the clinical diagnosis of scar endometriosis may be straightforward with classical symptomology, imaging with ultrasound and MRI are important for the determination of its extent, which is imperative for adequate preoperative planning. In addition, assessment of perineal scar endometriosis also requires the identification of anal sphincter complex involvement, which can significantly impact the surgical approach. Radiology plays a vital role in its diagnosis in atypical clinical scenarios.Contribution: This series of four cases describes the morphology and highlights the importance of imaging in the surgical management of scar endometriosis; three with abdominal wall involvement and one with the involvement of perineum.

Modified Branch-first Open Repair of Thoracoabdominal Aortic Aneurysm- A Technical Description

The current conventional open TAAA repairs are performed by select centers around the world with good outcomes. However, lesser experienced centers often encounter difficulties in replicating similar results of open TAAA surgeries. The modified branch-first open repair of TAAA has shown to be effective in minimizing visceral and renal complications by providing continuous visceral blood flow throughout the procedure. By debranching the visceral vessels first, we can perform this complex aortic procedure in a more controlled manner as compared to the traditional clamp and sew technique which requires speed, precision and experience. The entire repair can be performed on beating heart by deriving native blood flow via a closed circuit or a modification of the left heart bypass and continuously perfusing the abdominal viscera, thus avoiding cardiopulmonary bypass or deep hypothermic circulatory arrest which helps minimize bleeding and overall morbidity associated with extensive TAA surgeries. Adequate pre-operative planning is imperative to prevent spinal cord complications and intra-operative emergencies.

Cochlear Implantation in Advanced Otosclerosis: Rising to the Challenges of Surgery and Decision making

Introduction: Cochlear implantation as well as stapedotomy followed by use of hearing aid are acceptable modes of surgically rehabilitating patients with far advanced otosclerosis. Surgical challenges of CI include difficulties associated with electrode insertion and facial nerve stimulation. Improvement in speech discrimination scores and overall satisfaction with stapedotomy and hearing aid use are reportedly poor in many patients, yet being a low cost procedure it may be used as initial management in a subset of patients.&#x0D; Case Report: 46 year old patient with diffuse confluent retrofenestral otoscerosis underwent cochlear implantation. He was mapped using behavioral thresholds as despite intracochlear electrode position no neural response was recordable per-operatively as well as in the postoperative period. Perimodiolar electrodes and sodium flouride therapy were used to overcome problems of FNS. 18 months post CI the patient has good audiologic outcomes (CAP 7) without any FNS.&#x0D; Conclusion: High resolution computed tomography, air bone gap and speech discrimination scores are important in formulating treatment plan in patients with far advanced otosclerosis. Early cochlear implantation can be considered in patients with poor speech discrimination scores and extensive cochlear lesions. Facial nerve stimulation can be prevented by adequate pre-operative planning.&#x0D; Bangladesh J Otorhinolaryngol 2022; 28(1): 112-117

Prevalence of intraoperative and postoperative iatrogenic mandibular fractures after lower third molar extraction: A systematic review.

BackgroundThe surgical extraction of the lower third molars is one of the most common procedures in oral surgery, and this surgical operation can cause intra- and postoperative complications such as pain, trismus, bleeding, infection, oedema, inferior alveolar nerve injuries, displacement of teeth to neighbouring spaces and mandibular fractures. The aim of this systematic review is to report the prevalence of mandibular fractures that occur intra- and postoperatively in patients who have undergone surgical removal of the lower third molar. Material and MethodsAn electronic database search for articles published in Cochrane, PubMed (MEDLINE) and Scopus was conducted using the key words “Molar, Third”; “Mandibular Fractures”; “Molar Third, Removal”; “Molar Third, Complications”; “Dental Extractions, Complications”; “Mandibular Fractures, Third molar removal”. The inclusion criteria were articles including at least 10 patients and were published in English in the last 10 years. The exclusion criteria were nonhuman studies and case reports. ResultsPostoperative mandibular fractures after 3MI occur more frequently in male patients between the ages of 40 and 60 and are caused by premature chewing force. The parameters that most frequently characterise mandibular fractures at the mandibular angle are deeply impacted lower third molars, Class II and III, B and C, according to the Pell & Gregory classification system, mesioangular according to the Winter’s classification, and are located on the left mandibular side.. ConclusionsMandibular fractures can be predicted with adequate preoperative planning for each case and identify the related risk factors for this complication. Key words:Molar, Third; Mandibular Fractures; Molar Third, Removal; Molar Third, Complications; Dental Extractions, Complications; Mandibular Fractures, Third molar removal.

Planned percutaneous nephrolithotomy in patients who initially presented with urosepsis: Analysis of outcomes and complications

ABSTRACT Objective To compare the outcomes and complications of planned percutaneous nephrolithotomy (PCNL) in patients with a prior urosepsis episode to those without. Patients and Methods We recorded patients who presented initially with obstructive urosepsis, as identified by systemic inflammatory response syndrome and obstructing kidney stones. We compared the surgical outcomes and complications among those patients who had planned PCNL after control of prior urosepsis with urgent decompression and antibiotics (Group A) to a group who presented for PCNL with no previous history of a septic presentations (Group B). A 1:1 matched-pair analysis was performed using four parameters (age, gender, body mass index, and American Society of Anesthesiologists classification) to eliminate potential allocation bias. Primary outcomes included were stone-free rate (SFR) and complication rate. Secondary outcomes included were operative time, estimated blood loss, and duration of postoperative hospital stay. Results A total of 80 patients underwent PCNL (48 male and 32 females) divided equally between both treatment groups, with a mean (interquartile range) age of 47 (19–75) years. There were no differences in demographic data or stone characteristics between both groups. Both groups had comparable SFRs (92.5% vs 97.5%, P = 0.212) and mean operative time (77 vs 74 min, P = 0.728) (Table 2). Patients in Group A had a significantly higher overall complications rate (35% vs 10%, P = 0.03) . There were no postoperative mortalities and the mean length of hospital stay was significantly longer in Group A patients compared to group B (4.2 vs 1.5 days, P = 0.042). Conclusions : Planned PCNL after decompression for urolithiasis-related sepsis has comparable operative time and SFR but higher complication rates and longer postoperative hospital stay. This is critical in counselling patients prior to definitive treatment of kidney stones after urgent decompression for urosepsis and for adequate preoperative planning and preparation. Abbreviations: ASA: American Society of Anesthesiologists; BMI: body mass index; ICU: intensive care unit; IQR: interquartile range; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; PCN: percutaneous nephrostomy; PCNL: percutaneous nephrolithotomy; SFR: stone-free rate; URS; ureteroscopy; US: ultrasonography

Management of a Multiple Recurrent Solitary Fibrous Tumor of the Orbit

Solitary fibrous tumors (SFT) are rare entities that can arise from almost any tissue. The treatment of choice is always complete surgical resection, which may require major reconstructions. We report a case of a 49 year old man with a recurrent SFT of the orbit and anterior skull base, who underwent eight surgical procedures. A craniofacial resection was successfully performed. The reconstruction was made with an anterolateral thigh flap, and a titanium mesh. Management of these tumors is always challenging. They must be approached by a specialized multidisciplinary team, with adequate preoperative planning

Experience with management of renal cell carcinoma with inferior vena cava/right atrial tumor thrombus

Introduction:We aimed to present our experience in managing renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus.Methods:Records of all patients aged 18 years and older, with a diagnosis of primary renal masses with IVC thrombus, presenting to our institute from January 2012 to August 2020 were retrospectively reviewed. Patients with tumor thrombus limited only to renal vein were excluded from the analysis. Their hospital course and outcomes were recorded and evaluated for predictors of survival.Results:During the study period, we treated 61 patients with a renal mass and concurrent IVC thrombus and 56 of these underwent surgery. 7 of them had level III and 6 had level IV thrombus. A total of six patients received neoadjuvant tyrosine kinase inhibitor (TKI) therapy and all of them showed a decrease in size and level of tumor thrombus and cardiopulmonary bypass was safely avoided. Fourteen patients had distant metastasis and underwent cytoreductive surgery and of these 12 patients received TKI therapy after surgery with a mean survival of 26.8 months. The overall survival at 2 and 5 years of nonmetastatic group was 81.1% and 47.5% respectively and in metastatic group was 35.1% and 0%, respectively. Poor performance status, distant metastasis, higher T stage, higher thrombus levels, and positive surgical margins were all predictors of decreased survival.Conclusions:Complete surgical resection in both nonmetastatic and metastatic RCC with IVC thrombus has long-term survival benefits. Neoadjuvant TKI therapy, with adequate preoperative planning, helps in decreasing the size of the thrombus and in safely avoiding bypass in level III and IV IVC thrombi.

Soft tissue sarcoma of the upper extremity: oncological and functional results after surgery.

This retrospective study evaluates outcomes after treatment of upper-extremity soft tissue sarcoma in 44 patients. We re-resected 19 tumours that had been resected elsewhere without adequate preoperative planning, and we made 25 well-planned primary resections. Four patients in the unplanned group and five in the planned group eventually received amputations. Thirty-three patients were alive at a median follow-up time of 33months (IQR 18 to 57). Tumour size > 7 cm, tumour Grade 3 and the presence of distant organ metastases were the main factors affecting the oncological outcomes. We found no statistical differences between the planning groups. Functional outcomes and quality of life were significantly worse after amputation or major nerve resections. We conclude with this sized sample that the lack of planning in itself did not influence the final results, but there were differences in tumour size, grade and localization between the groups that may play a role.Level of evidence: IV.

Long-term chimney/snorkel endovascular aortic aneurysm repair experience for complex abdominal aortic pathologies within the PERICLES registry

ObjectiveThe early and short-term efficacy of the snorkel/chimney technique for endovascular aortic aneurysm repair (ch-EVAR) have been previously reported. However, long-term ch-EVAR performance, vessel patency, and patient survival remain unknown. Our study evaluated the late outcomes to identify possible predictors of failure within the PERICLES (performance of the chimney technique for the treatment of complex aortic pathologies) registry. MethodsClinical and radiographic data from patients who had undergone ch-EVAR from 2008 to 2014 in the PERICLES registry were updated with an extension of the follow-up. Regression models were used to evaluate the relevant anatomic and operative characteristics as factors influencing the late results. We focused on patients with ≥30 months of follow-up (mean, 46.6 months; range, 30-120 months). ResultsA total of 517 patients from the initial PERICLES registry were included in the present analysis, from which the mean follow-up was updated from 17.1 months to 28.2 months (range, 1-120 months). All-cause mortality at the latest follow-up was 25.5% (n = 132), with an estimated patient survival of 87.6%, 74.4%, and 66.1% at 1, 3, and 5 years, respectively. A subgroup of 244 patients with 387 chimney grafts placed (335 renal arteries, 42 superior mesenteric arteries, 10 celiac arteries) and follow-up for ≥30 months was used to analyze specific anatomic and device predictors of adverse events. In the subgroup, the technical success was 88.9%, and the primary patency was 94%, 92.8%, 92%, and 90.5% at 2.5, 3, 4, and 5 years, respectively. The mean aneurysm sac regression was 7.8 ± 11.4 mm (P < .0001). Chimney graft occlusion had occurred in 24 target vessels (6.2%). Late open conversion was required in 5 patients for endograft infection in 2, persistent type Ia endoleak in 2, and endotension in 1 patient. The absence of an infrarenal neck (odds ratio, 2.86; 95% confidence interval, 1.32-6.19; P = .007) was significantly associated with long-term device-related complications. A sealing zone diameter >30 mm was significantly associated with persistent or late type Ia endoleak (odds ratio, 4.86; 95% confidence interval, 1.42-16.59; P = .012). ConclusionsThe present analysis of the PERICLES registry has provided the missing long-term experience for the ch-EVAR technique, showing favorable results with more than one half of the patients surviving for >5 years and a chimney graft branch vessel patency of 92%. The absence of an infrarenal neck and treatment with a sealing zone diameter >30 mm were the main anatomic long-term limits of the technique, requiring adequate preoperative planning and determination of the appropriate indication.

Effect of operative time on complications following primary total hip arthroplasty: analysis of the NSQIP database.

Long operative times in total hip arthroplasty (THA) have been shown to be associated with increased risk of revision as well as perioperative morbidity. This study assesses the effect of extended operative times on complication rates following primary THA using the most recent national data. The National Surgical Quality Improvement Program (NSQIP) database (2008-2016) was queried for primary THA. Groups were defined by operative time 1 standard deviation (1 SD) above the mean. Univariate, propensity score-matched, and multivariate logistic regression analyses were performed to evaluate outcomes. Data was available for 135,013 THA patients. Among these groups, mean operative time in the extended operative time group was 166 minutes (compared with 82 minutes). Patients undergoing longer operative times were 3.8 years younger, had a 1.5 kg/m2 higher body mass index and had a 0.5 day longer mean length of stay. Propensity matching identified 16,123 pairs for analysis in the 1 SD group. Longer operative time led to 173% increased risk of major medical morbidity, 140% increased likelihood of length of stay greater than 5 days, 59% increased risk of reoperation, 45% increased risk of readmission, and a 30% decreased likelihood of return to home postoperatively. There was no increased risk of death within 30 days. Long operative times were associated with increases in multiple postoperative complications, but not mortality. Surgeons should be advised to take steps to minimise operative time by adequate preoperative planning and optimal team communication.

Complications and Solutions in Propeller Flap Surgery.

Propeller perforator flaps (PPFs) have long been proven as valid reconstructive tools for a wide range of soft tissue defects in different body regions. During the last decade, despite their numerous advantages, many authors have thoroughly analyzed outcomes of these flaps, sometimes discouraging their use mainly because of a high failure rate. Accurate patient selection, adequate preoperative planning, and an appropriate dissection technique seem to potentially improve outcomes. Our study provides a review of the relevant literature related to PPF complications and of our experience, describing reasons for failure, measures for preventing them, and approaches for a prompt evaluation and management of complications.

Effects of surgeon experience and patient characteristics on accuracy of digital pre-operative planning in total hip arthroplasty.

The effect of surgeon experience on accuracy of digital pre-operative planning for total hip arthroplasty (THA) remains unclear. The aims of our study were to compare pre-operative planning accuracy between fellow-trained orthopaedic surgeons and residents and to explore whether surgery indication effects the prediction accuracy. We prospectively reviewed 101 patients who underwent pre-operative digital templating for THA in our center from January 2019 to January 2020 with King Mark device. Extracted data included baseline characteristics and indication for primary arthroplasty. Pre-operative digital templating was performed separately by both a fellow-trained surgeon and a resident. Accuracy of each group was compared with the implanted components. The overall adequate pre-operative planning of the acetabular cup (exact or +/-1 size match) by the fellow-trained group was higher compared with the resident's group (77.2 and 64.3% respectively, p = 0.037), whereas the overall adequate pre-operative planning of the femoral stem (exact or +/-1 size match) was higher in the resident's group compared with the fellow-trained group (83.2 and 61.4% respectively, p < =0.001). The fellow-trained group showed better pre-operative planning of complex cases (developmental dysplasia of the hip and avascular necrosis of femoral head) than the resident's group. The experience of the planner does not significantly affect the accuracy of correctly predicting component sizes. However, in complex cases, fellow-trained surgeons should assist residents in digital pre-operative templating for THA.