Anatomic Repair Research Articles

Endoscopic Repair of Proximal Hamstring Insertion With Sciatic Nerve Neurolysis

Open surgical repair of proximal hamstring avulsions has been the standard of care for a long time, when surgery is needed. Endoscopic repair is a relatively new surgery, and its popularity increased in the last 10 years. This technique allows the surgeon an anatomic repair and a safe sciatic nerve exploration with small incisions and dissection. As a new technique, it has its limitations, mostly in chronic retracted tears, and long follow-up series are needed to assess long-term outcomes. We present an endoscopic repair of a right proximal hamstring avulsion performed along with a sciatic nerve neurolysis.

Congenitally Corrected Transposition Cardiac Surgery: Society of Thoracic Surgeons Database Analysis

BackgroundCongenitally corrected transposition of the great arteries (ccTGA) has many management strategies, with the emergence of anatomic repair increasing the available surgical options. Contemporary surgical practices have not been described in multicenter analyses. This study describes the distribution of heart surgery in patients with ccTGA and defines contemporary outcomes in a large multicenter cohort. MethodsIndex cardiovascular operations in patients with primary or fundamental diagnosis of ccTGA were identified in The Society of Thoracic Surgeons Congenital Heart Surgery Database from 2010 to 2019. Operations of interest were combined into mutually exclusive groups designating overall ccTGA management strategies. Outcomes were defined with standard Society of Thoracic Surgeons Congenital Heart Surgery Database definitions. Pearson χ2 and Kruskal-Wallis tests were used for statistical comparisons. ResultsOne hundred one centers performed 985 index operations, with anatomic repair the most common approach. Twenty-six centers performed more than 10 operations. Atrial switch plus Rastelli operations had the highest rate of operative mortality (8.4%) and major complications (38.2%). Heart transplant operations had the longest postoperative length of stay among survivors (18 days [interquartile range, 13.5-26]). ConclusionsPatients with ccTGA remain a challenging cohort, with significant diversity in the operations used and a substantial burden of operative mortality and morbidity.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair. Purpose: To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed. Results: A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311). Conclusion: Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

Modeling of mitral chordae\u2019s length in echocardiography as a function of their manual measurement in the operating room

ObjectiveIn mitral insufficiency, trans-esophageal echocardiography (TEE) analysis of the mitral valve is an indispensable and irreplaceable examination to establish precisely the type of surgical repair to be performed and the exact length of neo-chordae to be used for an anatomical repair. The aim of our study is to find a predictive model of the Echographic Measurement (EM) variable according to the Manual Measurement (MM) variable of the mitral valve chordae, when the echocardiography measurement is not feasible.Patients and methodsThis is a retrospective study on 191 patients undergoing mitral valve repair. The sex ratio (M/F) is 2.13 (130 men and 61 women). The collection of data of mitral chordae measurements performed echographically in preoperatively conditions, and then manually in intraoperatively conditions from January 2008 to December 2016 was made from the medical records of patients at the cardiology and cardiac surgery department of the University Hospital Center of Amiens in Picardy.ResultsFor this study 191 patients of mean age of 68 ± 13 years were included. The averages of the MM and EM of the mitral chordae were respectively 23 ± 2.5 mm and 24 ± 2.4 mm. The Pearson correlation coefficient was 0.897 (p-value < 10−4) showing a strong positive correlation between MM and EM. The results of the linear regression allow us to found the following mathematical model: EM = 0.87 × MM + 4.ConclusionsWhen patients have a contraindication to transesophageal echocardiography or when TEE is not feasible, manual measurement is performed during the surgery. By using the values obtained (MM) in the model, it is possible to predict the corresponding echographic measurements. This allows us to achieve the mitral tendinous chordae substitution with a very high precision.Trial registration: Retrospectively registered.

A comparative study of anatomical repair versus meshplasty in para umbilical hernia

Introduction: Para Umbilical hernia is the commonest of all the abdominal hernias. It constitutes about 6% of all abdominal hernias in adults. Mesh onlay repair by open surgery can be applied to all sizes of para umbilical hernias, it has low recurrence rate and the rates of morbidity and recurrence are comparable with international standards. Aim and Objectives: To compare the surgical outcome of anatomical repair versus meshplasty in the treatment of uncomplicated para umbilical hernias in context of post-operative pain, wound infection, hospital stay, post-operative complications, cost of treatment and recurrence rate. Material and Methods: A total of 50 patients attending the general surgery department for para-umbilical hernia with defect of less than 3cms were included in the study. The surgical outcome of anatomical repair versus meshplasty in the treatment of uncomplicated para umbilical hernias with respect to post-operative pain, wound infection, hospital stay, postoperative complications (seroma, hematoma), and cost of treatment and recurrence rate was compared. Results: The mean age of the patients was 44.4±9.67 yrs of age. There was equal distribution of gender with 48% male and 52% female patients with male to female ratio of approximately 1:1. Significant lower mean pain score was seen among the patients who underwent meshplasty. Incidence of SSI, seroma and hematoma was present in 8% among the anatomical repair. Significant higher duration of hospital stay was seen among the patients who underwent anatomical repair (6.24±0.72 days) as compared to meshplasty (5.64±0.7 days). The cost of treatment was higher among the patients of meshplasty, whereas the rate of recurrence was higher among the patients with anatomical repair (12%) as compared to meshplasty. Conclusion: We found significant better outcome in patients who underwent meshplasty as compared to anatomical repair.

Distal insertion rupture of lateral ankle ligament as a predictor of weakened and delayed sports recovery after acute ligament repair: mid-term outcomes of 117 cases

BackgroundFor lateral ankle ligament rupture, surgical repair has been considered for patients requiring return to high-demanding sports. However, there is a lack of systematic research regarding arthroscopic treatment followed by ligament repair for severe acute ankle sprain. The purpose of this study was to analyze the mid-term outcomes of arthroscopy followed by open anatomic lateral ankle ligament repair surgery for acute lateral ankle sprain and the impact of ligament rupture site on the outcomes.MethodsProfessional or amateur athletes with clinically- and radiologically-confirmed grade III acute lateral ankle ligament injuries undergoing ankle arthroscopy followed by open anatomic ligament repair between June 2007 and May 2017 were reviewed. Intra-articular lesions and the location of rupture were first examined under arthroscopy. Simple suture repair was performed for mid- substance ligament rupture (middle group), while suture repair with anchors were used for the ruptures near the ligament attachment site on the fibular (proximal group), talar or the calcaneal side (distal group). Outcomes were evaluated at final follow-up, including visual analog scale (VAS) pain score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Tegner score, time to return to sports, resumption of pre-injury sports level, sprain recurrence and range of motion (ROM).ResultsA total of 117 patients were included for analysis, with a mean follow-up duration of 46.4 ± 16.1 months. There were 48 (41%) cases in the proximal group, 41 (35%) cases in the middle group and 28 (24%) cases in the distal group respectively. At final follow-up, all of the VAS score, AOFAS score and the Tegner score were significantly improved from the pre-operative level (p < 0.001). 12 (10%) patients complained of sprain recurrence during follow-up. 14 (12%) patients reported mild ROM restriction and 7 (6%) patients experienced transient skin numbness. The average time to return to pre-injury sports was 4.34 ± 1.11 months. The smallest proportion (86% ± 13%) of resumption of pre-injury sports level was reported from the distal group, compared with 93% ± 12% for the proximal group and 89% ± 14% for the middle group (p = 0.037). Time to return to sports was significantly longer for the distal group, with an average of 4.59 ± 1.27 months compared to 3.99 ± 1.09 months for the proximal group and 4.58 ± 0.90 months for the middle group (p = 0.009).ConclusionsAnkle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients requiring return to high demanding sports after severe acute ankle sprains. Distal rupture near the talar or calcaneal end was associated with delayed return-to-sport and inferior performance in resuming pre-injury sports level.

Double Switch in Congenitally Corrected Transposition of the Great Arteries With Incomplete Atrioventricular Septal Defect, Ebsteinoid Tricuspid Valve, Ventricular Outflow Tract Obstructions, and Multiple VSDs.

We describe the management of a 2 month-old male (BSA 0.27 m2) with congenitally corrected transposition of the great arteries (CCTGA), left and right ventricular outflow tract obstruction, incomplete atrioventricular (AV) canal defect, Ebsteinoid left AV valve, and multiple VSDs. In short, the patient presented with respiratory failure, metabolic acidosis with worsening AV valve regurgitation, and acute decompensation from pulmonary overcirculation. We performed a complex double switch operation described below. Despite the unique anatomical complexities, the patient's successful course demonstrates the importance of multidisciplinary discourse, preoperative imaging and planning, and intraoperative decision making from patient selection to anatomic repair.

Laparoscopic Resurrection of an Old Technique: A New Approach for Total Urogenital Separation and Rectal Pull-Through in Patients with Long Common Channel Cloacal Malformation.

Background and Aims:Before the significance of urethral length was highlighted in patients with cloacal malformation, total urogenital mobilization using a posterior sagittal approach was recommended for common channel (CC) length <3 cm, those >3 cm it was followed by urogenital separation. However, many urologists are advocating that the urethral length rather than length of the CC should influence the choice of operation. It is also recommended that total urogenital mobilization should be avoided in patients with short urethral length as intraoperative decision to shift to urogenital separation will risk devascularization of the urethra, advocating total urogenital separation (TUS) from the start; the later technique was deemed difficult using open approach. We describe our experience with laparoscopic TUS and rectal pull-through in patients with cloacal malformation.Methods:Six patients were operated for a period of 3 years from December 2017 to July 2021; they underwent laparoscopic TUS and rectal pull-through. Preoperative investigations included cystoscopy, genitogram, and MRI pelvis and abdominal ultrasound. IRB approval has been obtained from research ethical committee at Cairo University.Results:Six female patients born with single perineal opening had colostomy at birth. Age during the second operation ranged from 1 to 4 years. Length of the CC ranged between 2 and 5 cm. Proximal urethral length ranged between 0.5 and 1.5 cm and vaginal depth >3 cm. Average operative time was 4.25 hours. Postoperative period was 1–5 days and uneventful. On the long-term follow-up. No patient developed urethrovaginal fistula and one patient developed vaginal stenosis. All patients had no urinary problems, dry over 4-hour interval, voiding spontaneously, and had normal kidney functions.Conclusions:Laparoscopic urogenital separation, as well as vaginal and rectal pull-through for cloacal malformation, is feasible in cloacal malformation providing anatomical repair.

All-Inside Repair of a Radial Lateral Meniscal Root Tear With an Anterior Cruciate Ligament Injury

Background: Root tears are functionally compromising injuries that require an anatomic repair for functional restoration of native joint mechanics. Posterior root tears of the lateral meniscus are commonly associated with anterior cruciate ligament (ACL) ruptures as lateral root tears contribute to anterolateral rotational instability. Two-tunnel transtibial root repair allows for root repair with superior pullout strength and can be combined with ACL reconstruction to treat this injury pattern. Indications: Two-tunnel transtibial root repair is indicated in active patients with meniscal root tears that have low-grade chondromalacia (grade II or less). It is contraindicated in patients with advanced degenerative changes (grade III-IV), severe mal-alignment, and extrusion related to advanced degenerative changes; those who cannot complete postoperative rehabilitation; and patients with significant medical comorbidities. Technique Description: After repairing a vertical horn tear of the posterior medial meniscus, a vertical tear of the posterior root of the lateral meniscus was observed. Following preparation of the anatomic footprint, 2 transtibial tunnels were drilled and sutures were passed and secured using a surgical button over the anterior tibial cortex. Horizontal repair of the tear was then performed using 2 all-inside devices. Subsequently, an ACL reconstruction was performed. Results: At 11 months postoperative, the patient has continued to progress as expected. She was able to ambulate without pain, had a symmetric and balanced gait, and was able to return to running. Discussion/Conclusion: Lateral meniscal root repairs using 2 transtibial tunnels and concomitant ACL reconstruction have yielded good and reliable clinical outcomes with low failure rates and low rates of revision surgery.

Return to Play After Distal Biceps Tendon Repair.

Purpose of ReviewDistal biceps tendon ruptures (DBTR) are uncommon injuries in 40- to 50-year-old men but occur at a younger age in the athlete population. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow. A complete injury results in limiting function in the upper extremity. The current review evaluates the different options in management and the current literature on return to play in athletes.Recent FindingsThe distal biceps tendon inserts on the posterior aspect of the radial tuberosity as two independent heads. The long head footprint is more proximal and posterior giving it a better lever arm for supination. The short head footprint is more distal and anterior giving it a better lever arm for flexion. Surgical anatomic repair is highly recommended among the athlete population, to restore proper function of the upper extremity. There is scarce literature on return to play among athletes. The most recent studies on high-performance athletes are on National Football League (NFL) players. These studies showed that 84–94% of NFL players returned to play at least one game after distal biceps repair. Compared to matched control groups, there was no difference in the player’s performance after surgery.SummaryAnatomic repair of DBTR results in excellent outcomes, high return to work, and high rate of return to play among athletes. When compared to matched control groups, NFL players have the performance score and play the same number of games after surgery.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12178-022-09742-x.

Anatomic Repair of Deltoid Ligaments in Acute Injury With Suture Anchor Technique.

Acute disruption of the deltoid ligament usually occurs in rotational ankle fracture. If left untreated, its instability may contribute to ankle arthritis. We have designed a suture technique to repair all deltoid ligament layers. It provides anatomic ligament-to-bone repair of the superficial and deep deltoid ligaments and anchor suture reinforcement. This technique may protect the horizontally oriented fibers of the deep deltoid ligaments and allow them to heal with sufficient rest while providing immediate stability of the construct. The superficial ligaments are then repaired with residual anchor sutures. [Orthopedics. 2022;45(3):e168-e173.].

Anatomical intramedullary distal biceps tendon fixation. Our first experience.

BackgroundIntramedullary fixatiovn in distal biceps tendon repair has been proposed to address specific shortcomings of current fixation techniques. Previous studies described a nonanatomical repair.HypothesisThe purpose of the present study is to report the short-term outcomes of an anatomic intramedullary fixation.Study DesignWe evaluated functional and radiographic outcomes up to 6 months of follow-up.MethodsPatients with an acute distal biceps tendon rupture eligible for surgical repair were invited to take part in the study. Eleven patients were included in the final analysis. All patients were evaluated both clinically and radiographically at 2 weeks, 6 weeks, 3 months, and 6 months. Outcomes were recorded using the visual analog scale score for pain, the Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand scores. The radiographic evaluation comprised X-ray and CT evaluation.ResultsThere were no failures of fixation in the patient group examined. Elbow mobility was symmetric for all patients from 6 months onward. Supination strength was similar uninjured side at final follow-up. Mean Disabilities of the Arm, Shoulder, and Hand score and Mayo Elbow Performance Score at final follow-up were 0 and 100, respectively. Computed tomography images showed no signs of button migration, cortical thinning due to button pressure or button breakout. The tendon could be followed to the button in all cases. One case of heterotopic ossification was seen.ConclusionsAnatomical intramedullary fixation of the DBT has excellent functional outcomes at 6 months. The anatomical repair resulted in a restoration of supination strength. This technique allows the anatomical reinsertion of the distal biceps tendon while minimizing the risk of PIN injury. The intraosseous position of the tendon avoids gap formation. No adverse reactions of the button on the bone were seen.

Anatomic Repair of Congenitally Corrected Transposition: Reappraisal of Eligibility Criteria

Several criteria to identify suitable candidates for anatomic repair in congenitally corrected transposition (cc-TGA) have been proposed. The purpose of this study was to critically re-evaluate adequacy of these recommendations in our patient cohort. All cc-TGA patients undergoing anatomic repair between 2010 and 2019 were reviewed. Evaluated eligibility criteria for repair included age ≤ 15 years, LV mass index ≥ 45–50 g/m2, LV mass/volume ratio > 0.9–1.5 and systolic LV to right ventricle pressure ratio > 70–90% among others. Repair failure was defined as postoperative early mortality or LV dysfunction requiring mechanical circulatory support. Twenty-five patients were included (median [interquartile range] age at surgery 1.8 years [0.7;6.6]; median postoperative follow-up 3.2 years [0.7;6.3]). Median preoperative LV ejection fraction was 60% [56;64], indexed LV mass 48.5 g/m2 [43.7;58.1] and LV mass/volume ratio 1.5 [1.1;1.6], respectively. A total of 12 patients (48%) did not meet at least one of the previously recommended criteria, however, all but two patients (92%) experienced favorable early outcome. Of 7 patients (28%) with indexed LV mass < 45 g/m2, 6 were successfully operated. There were two early repair failures (8%) with LV dysfunction: one patient died and one required mechanical circulatory support but recovered well. Surgery was performed successfully in patients with LV mass and volume Z-scores as low as − 2 and − 2.5, respectively. Anatomic correction for cc-TGA can be performed with excellent early outcome and is feasible even in patients with LV mass below previously recommended cut-offs. The use of LV mass and volume Z-scores might help to refine eligibility criteria.

Arthroscopic Anatomical Acromioclavicular Joint Reconstruction using a Button Device and a Semitendinosus Graft.

ObjectiveTo report a new technique for anatomical acromioclavicular (AC) joint reconstruction.MethodsIn order to minimize such complications, the authors describe a new anatomical and biological AC joint repair. This technique aims to provide greater stability by using two anatomically placed clavicular tunnels and a combined construct with a double endobutton cortical fixation for primary stabilization, and to be biologically advantageous by using an autologous semitendinosus (ST) tendon graft. Additionally, the coracoclavicular ligament reconstruction is complemented with an AC joint cerclage and capsular reinforcement, which will protect the biological construction in its initial stage of healing.ResultsThis technique provides adequate primary and secondary biomechanical stability by passing both a semitendinosus autogenous graft and a double endobutton device, through anatomically placed and small diameter clavicle holes, without the need for coracoid drilling. Our technique showed encouraging results regarding pain resolution, range of motion, and function. At final follow‐up we experienced excellent results with average pain score of 1.6, and average ROM of 159° of forward flexion, 160° of abduction, 68° of external rotation, and internal rotation level at T11. Postoperative function also showed great improvements with average ASES of 85 points, an average Constant Score of 87 and a Subjective Shoulder Value of 89 points. This technique also achieved perfectly acceptable radiographic results, with an average coracoclavicular distance increase of 0.8 mm. Regarding complications, our sample showed one case of AC join subluxation, two cases of internal saphenous nerve injury, and two partial graft tears at the suture‐button interface, with none of these requiring surgical revision.ConclusionThis technique is advantageous in treatment of acromioclavicular joint dislocation and can be performed in both the subacute and chronic setting.

Mild inflammation persists in the glenohumeral joint of patients with shoulder instability: Cross-sectional study

ObjectiveApproximately two-thirds of patients with history of shoulder dislocation may develop osteoarthritis (OA) of the glenohumeral joint. However, the biochemical mechanisms underlying the association between dislocation and OA are largely unknown. This study aimed to investigate macrophage markers and inflammatory cytokine expression associated with shoulder instability (SI) in comparison to rotator cuff tears (RCTs). DesignThis study included 30 patients with SI and 30 patients with RCTs. Synovial membrane samples were harvested from the rotator interval during the arthroscopic anatomical repair for both groups. The localization of tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, and cluster of differentiation (CD) 68 in synovial membranes was determined by immunohistochemistry. Transcript-level expressions of the inflammatory cytokines (TNFA and IL1B) and macrophage markers pan-CD68 and -M1 (CD80 and CD86) were quantified. CD80 and CD86 expression in macrophages from the SI group was confirmed using flow cytometry. ResultsTNF-α, IL-1β, and CD68 were expressed in the synovial lining layer of the synovial tissue in both groups. In addition, the mRNA expressions of TNFA, IL1B, CD68, and CD80 were significantly higher in the SI group compared to the RCT group (P ​= ​0.012, 0.014, 0.022, 0.003, respectively). In samples from the SI group, 96.3% of CD68+/CD14+ macrophages were CD86-positive, whereas 2.5% of CD68+/CD14+/CD86+ cells were CD80-positive. ConclusionsPatients with SI had higher mRNA levels of TNFA, IL1B, CD68, and CD80 than those with RCTs. These findings may partially explain the biochemical mechanism underlying the frequent development and progression of osteoarthritis in patients with SI.

Arthroscopic Transtibial Pull-Out Repair for Meniscal Posterior Root Tear: The Slip Knot Technique

A meniscal root tear can increase the tibiofemoral contact pressure to approximate that of total meniscectomy and eventually lead to degenerative change. An anatomic and stable meniscal root repair is essential in restoring the tibiofemoral contact pressure back to that of a normal knee. Suture anchor technique and pull-out suture technique are the 2 main arthroscopic root repair procedures with equivalent success; nonetheless, there remains a lack of an optimal technique with a biomechanical property matching that of the intact root. This article presents a technically simple, fast, and robust pull-out suture construct that incorporates 2 slip-knot locking loops at the meniscus-suture interface. This technique can be used for both medial and lateral posterior root repair, as well as concomitantly with cruciate ligament reconstruction.

The Anatomical Repair Technique to Correct Penile Hypospadias Provides Excellent Long-term Function with Low Complications

<i>Introduction</i> There are various techniques described for repair of penile hypospadias. <i>Objective</i> To present the anatomical repair technique and to discuss the lessons learned from this technique over 18 years. <i>Methods</i> All consecutive patients with penile hypospadias who underwent anatomical repair of urethra, spongiosum, bucks and dartos fascia and foreskin by the 3^rd author, with a minimum of 1 year follow up from January 2003 to March 2020 at the Royal Manchester Children's Hospital, United Kingdom, were included in the study. No formal ethics approval taken as this study was done as a service evaluation. Perioperative and follow up data were recorded prospectively in the departmental database. SIPP 21 was used for statistical analysis. Fisher’s Exact Test used for sub-group analysis. Findings were considered statistically significant at p<0.05. <i>Results</i> 368 patients had surgery at a median age of 18 months. 94.6% had no complications, 4.1% had minor and 1.3% had significant complications. 77.5% had a distal ectopic meatus. The mean length of urethroplasty was 8mm. To widen the urethral plate, a meatoplasty (M) was performed in 34% and urethral plate incision (UPI) in 14%. Catheters were used in 71% for a median duration of 7 days, and 40% had a 6F catheter. Regards to meatal stenosis the only statistically significant causative factor was UPI with 6fr catheter. P value=0.02. <i>Conclusions</i> Anatomical repair provides a completely normal penis with minimal complications. Meatoplasty widens the urethral-plate and reduces the risk for meatal stenosis.

Cardiovascular Complications of Large Hiatal Hernias: Expanding the Indications for Robotic Surgical Anatomic and Physiologic Repair: A Review

Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact, until recently, most patients with HH have been watched and referred for surgery as a last resort. Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a common problem known to impact adjacent organs such as the hearts and lungs. Those referred for surgical repair often complain of dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents. This article reviews the present understanding of GHH, the cardiac complications which result from GHH, and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH. Methods: In a prospective cohort study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH) were identified preoperatively and enrolled prospectively in this study. Preoperative characteristics, medical comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical outcomes database. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly intervals thereafter, all patients received an endoscopy study to ascertain the presence of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or 10% of the stomach above the diaphragm detected by CT, esophagogram or endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5 patients (5/423) for a recurrence rate of 1.1%. Conclusion: This experience has been the basis of two important realizations: 1) all patients with GHH have at least some degrees of clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely resolves after successful surgical repair; and 2) primary care providers and gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the cause of the shortness of breath and gradual increase in dyspnea on exertion and progressive fatigability in these patients. This article reviews the present understanding of GHH, the cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH.

Does BMI Effect Intermediate Outcomes of Open Brostrom-Gould Repair?

Category:Ankle; Midfoot/ForefootIntroduction/Purpose:High BMI is a known risk factor for development of CAI and intraarticular pathology, but few studies have examined BMI's impact of the outcomes of lateral ligament reconstruction. The open Brostrom-Gould reconstruction, an anatomic repair, is the gold standard for repair of the lateral ligamentous complex. We aim to evaluation the impact of BMI on patient reported outcomes after open Brostrom-Gould repair.Methods:A total of 201 patients who underwent open Brostrom-Gould Repair were identified using CPT code. Patients undergoing repair for acute ligamentous injury were excluded. A completed telephonic survey was required for inclusion yielding 92 patients. The telephone survey included: PROMIS Physical Function (PF), Pain Interference (PI), and Depression domains(D) and the Foot and Ankle Ability Measure (FAAM). Medical records were examined for patient characteristics, operative variables, and complications. Patients were grouped by BMI <30 and BMI >30.Results:A total of 28 males (30%) and 61 females (69%) were including in this study. The average time at completion of survey was 4.1 years (standard deviation of 2.8). The median age was 44 with an interquartile range (IQR) of 20, while the median BMI was 31.5 with an IQR of 13.4. Obese patients had significantly worse PROMIS PF (Median 44.5 IQR 7.4 vs median 48 IQR 16.5) and FAAM Activity of Daily Living subscale scores (Median 61.6 IQR 30.0 vs. median 82.7 IQR.36). Patients' FAAM self-reported overall level of function was significantly lower in obese patients (Median 70.0 IQR 20.0 vs median 85 IQR 29). The BMI groups did not vary by other PROMIS domains or FAAM subscales.Conclusion:At intermediate term follow-up, Obese patients report significantly worse physical function after open Bostrom- Gould repair compared to non-obese patients. Surgeons should be aware of this when prognosticating the outcomes of anatomic ankle reconstruction.

Robotic Laparoscopic Transdiaphragmatic Repair of Large Hiatal Hernias

Introduction: Although laparoscopic Nissen fundoplication is the most common procedure for the repair for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty has been reported as a common mechanism of failure after primary repair. Left transthoracic anatomic and physiologic repair (AFR) of HH is associated with lower incidence of leak and reoperation but greater morbidity. Adopting the transthoracic approach to a robotic laparoscopic platform may represent the ideal approach to the repair of HH. This study reviews the results of this technique. Methods: A retrospective review was performed on patients who had robotic AFR (RAFR) of large HH. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and postoperatively. Objectively, symptoms were graded using the Visick Scale. Recurrence was defined as greater than 2 cm or 10% of the stomach above the diaphragm detected by either CT, esophagogram or endoscopy. The preoperative data was compared to the results at 2 years. Results: 396 patients underwent RAPR. The Median GERD-HRQL score was 42 (range 38 - 45) preoperatively and 6 (range 0 - 14) at two years (p Conclusion: RAFR of HH is associated with excellent symptom relief and low recurrence rate. RAFR should be considered when deciding on what operation to perform in patients with large paraesophageal hiatal hernias.