Candidates For Surgical Repair Research Articles

Arthroscopic Repair of a High-Grade Partial Articular-Sided Subscapularis Tendon Tear Without Bursal-Sided Tendon Overtension

The subscapularis tendon is one of the shoulder’s primary anterior stabilizers along with capsulolabral tissues to prevent anterior dislocation and attaches to the lesser tuberosity. Subscapularis tendon ruptures can cause anterior shoulder pain and weakness of internal rotation. Patients with partial-thickness tears of subscapularis tendons who do not respond to conservative treatment may be candidates for surgical repair. The transtendon repair of a partial articular-sided subscapularis tendon tear, like the transtendon repair of a PASTA (partial articular supraspinatus tendon avulsion), can result in overtension and bunching of the bursal-sided subscapularis tendon. We propose an all-inside arthroscopic transtendon repair technique of a high-grade partial articular-sided subscapularis tendon tear without bursal-sided tendon overtension or bunching.

Dissection of the interventricular septum after compressive blunt chest trauma

We report the case of a 21-year-old woman who was referred after a severe compressive blunt trauma in the context of job injury. Myocardial contusion is a common injury; however, rupture of the ventricular septum after blunt chest trauma is a rare event. Echocardiography revealed a large ventricular septal rupture with two small ventricular septal defects. The patient was a candidate for surgical repair after early conservative management. We discuss about the prevalence and management of this rare traumatic complication.

The "All-Inside" Arthroscopic Broström Procedure With Additional Suture Anchor Augmentation: A Prospective Study of 45 Consecutive Patients.

Lateral ankle sprains are a common injury that typically respond well to nonoperative therapy. When nonoperative therapy fails and patients develop chronic lateral ankle instability, they become candidates for surgical repair. The present study examined 45 consecutive patients (45 ankles) with chronic lateral ankle instability who underwent arthroscopic Broström repair using a double-row suture anchor construct. The 45 patients (27 females and 18 males) were followed up for a mean of 14 (range 12 to 20) months. The mean time to weightbearing with crutches was 3.3 (range 2 to 4) days, and full weightbearing was initiated at a mean of 14.4 (range 12 to 16) days. All patients participated in structured physical therapy, which was started at 21.6 (range 18 to 23) days. Patients were transitioned to regular shoe gear with a stirrup-style ankle brace at 28.7 (range 26 to 31) days. The American Orthopaedic Foot and Ankle Society scale scores improved from an average preoperative score of 48.7 (range 45 to 55) to 95.4 (range 90 to 100) postoperatively. The average visual analog scale decreased from 8 (range 6 to 10) preoperatively to 0.6 (range 0 to 5) postoperatively at the last follow-up visit. The Karlsson-Peterson score postoperatively was 87 of 100. We have shown that patients with this new arthroscopic Broström technique modified with a proximal suture anchor can begin weightbearing earlier than previously reported, without adverse effects in terms of pain, functional outcomes scores, and clinical outcomes.

Outcome of the Use of a Synthetic Mesh in the Repair of Burst Abdomen as Compared with Simple Suture

Aim: To assess the outcome (postoperative morbidity and mortality and/or development of incisional hernia) of patients with burst abdomen (BA) of midline laparotomy without intestinal fistula comparing early closure of the abdominal wall with a running suture alone vs. running suture plus reinforcement with a non-absorbable synthetic mesh. Methods: Retrospective analysis of the medical records of all patients undergoing surgical repair of a BA in three hospitals between 2006 and 2011. Risk factors, postoperative complications and the incidence of incisional hernia (IH) after a minimum of 12-month follow-up period were compared between groups. Results: A total of 109 patients were treated for BA, 18 patients treated by non-standard procedures were excluded from analysis. Of the remaining 91 patients, 56 belong to the mesh group and 35 to the suture group. The overall rate of postoperative complications was high in both groups (79.1%). Mortality rate was higher in the suture group than in the mesh group (31.4% vs. 14.3%; P = 0.06). IH was also more frequent in the suture group (36.4% vs. 17.6%; P = 0.057). Conclusions: Patients with BA and without intestinal fistula could be candidates for surgical repair using a running suture and a non-absorbable polypropylene mesh in the “onlay” position.

Expanding the indications for percutaneous mitral commmissurotomy in rheumatic mitral stenosis: look carefully at the commissures, and proceed cautiously and skilfully

This editorial refers to ‘Feasibility of percutaneous mitral commissurotomy in patients with commissural mitral valve calcification’[†][1], by J. Dreyfus et al ., on page 1617 Percutaneous balloon mitral valve commissurotomy (PMC) was introduced by Inoue in the 1980s, as an alternative to surgical closed commissurotomy.1 PMC is the first example of a transcatheter valve intervention replicating a surgical procedure, and the fact that Inoue is a surgeon underlines the influence of multidisciplinary efforts in the evolution of transcatheter therapies. Today PMC is the first-line therapy for most symptomatic patients with mitral valve stenosis with favourable clinical and anatomical characteristics (with a recommendation class IB by the latest European guidelines.2 The main objective of PMC is to delay surgery, particularly when this would imply the implantation of a valve prosthesis. In patients not amenable to PMC, in Western countries, closed mitral commissurotomy has been replaced by open mitral commissurotomy using cardiopulmonary bypass in selected patients. Subvalvar apparatus management is the main advantage of open commissurotomy leading to greater valve areas as compared with closed commissurotomy and with PMC in patients with papillo-commissural fusion.3 However, most patients with anatomy not amenable for PMC are also suboptimal candidates for surgical repair and mostly undergo valve replacement. Patient selection plays a key role in PMC, as is the case for other transcatheter interventions. More specifically, anatomical and clinical characteristics are predictive of early and long-term success of the percutaneous procedure. Echocardiography plays a central role in the contemporary decision-making process, and several scores have been developed to predict early and long-term outcomes of PMC.4,5 A contemporary focus of the pre-procedural echocardiographic screening for PMC should include a meticulous analysis of the commissures. The commissures are the … [1]: #fn-2

Arthroscopic and Open Posterior Instability Repair in NFL Linemen

Posterior instability of the shoulder accounts for approximately 5%-10% of all cases of shoulder instability. Patients can present with symptoms of recurrent posterior subluxation (fatigue, soreness, and pain with provocative loading) or frank glenohumeral dislocation. Diagnosis is often made based on patient history, physical examination findings, and confirmatory diagnostic testing such as magnetic resonance arthrography. Initial treatment may consist of physical therapy; however, this treatment may not be successful in most instances. Patients who fail nonoperative treatment are candidates for surgical repair using either an arthroscopic or an open surgical technique. The open technique is detailed in this article and serves as the anatomical basis for the arthroscopic approach.

The Minimally Invasive Repair of Pectus Excavatum

Only patients with a severe pectus excavatum deformity should be candidates for surgical repair. Mild and moderate degrees of deformity should be treated with a deep breathing and exercise program and the vacuum bell. The best age for repair is during puberty, but successful repair in adult patients (up to 70 years of age) has been reported. Those scheduled for minimally invasive repair should be measured for bar length and screened for metal allergies. The minimally invasive technique for pectus excavatum repair is done thoracoscopically and requires no rib cartilage or sternal resection. Instead, it relies on bracing the anterior chest wall with a sub-sternal support bar placed in position under the sternum after first correcting the deformity with an introducer specially developed for the procedure. Two bars generally give better correction than one bar. It is essential that the bars be adequately stabilized to prevent bar displacement and recurrence of the deformity. Several techniques have been developed to elevate the sternum during mediastinal tunneling to improve thoracoscopic visibility in very severe and asymmetric deformities. Since 1987 we have evaluated 3836 patients in our chest wall deformities clinic, of whom 1921(50%) have undergone repair. 1738 patients were primary repairs and 1346 of these have had their bars removed two to three years after placement. The biggest challenge in the early years was bar displacement but that has now been reduced to just over 1% by use of a stabilizer on the left side and 0 PDS pericostal sutures on the right side. 88.9% of patients reported an excellent result, 9.6% a good result and 1.5% a poor or failed result. In conclusion: The minimally invasive repair of pectus excavatum is highly successful when carried out by experienced surgeons in a center dedicated to the management of chest wall malformations.

Successful thoracic endovascular aortic repair of an aortoesophageal fistula

We report three cases of aortoesophageal fistula (AEF), in which the patients remained free from catastrophic bleeding after endovascular stent-grafting. The three patients, who were not candidates for surgical repair because of their poor general condition and prognosis, underwent endovascular stent-grafting following the administration of antibiotics and were successfully managed; hemostasis was maintained for several months until their death. Although we did not find any conclusive evidence to support this strategy, our experiences suggest that endovascular stent-grafting of AEF is useful for maintaining hemodynamic stability.

Exercise, Vascular Health, and Abdominal Aortic Aneurysms

Exercise, Vascular Health, and Abdominal Aortic Aneurysms

Hospital Mortality of Late Preterm Infants with Hypoplastic Left Heart Syndrome

Aim: We evaluated the effect of late preterm (born 34-36 weeks) delivery on hospital mortality of infants with hypoplastic left heart syndrome (HLHS).Methods: Retrospective review of records of infants born at or after 34 weeks with no lethal anomalies, cared for in a single tertiary perinatal center between 2002 and 2009. Factors associated with death prior to discharge from the hospital were ascertained using univariate and multivariate analyses. Mode of delivery, place of birth, presence of other cardiac and non-cardiac congenital anomalies, late preterm birth, intrauterine growth restriction, multiple birth, race and gender were the variables retained in the forward multivariate logistic regression model.Results: Of the 243 infants with HLHS, 35 were late preterm and 208 were ≥37 weeks (term). Both groups had similar total duration of hospitalization for survivors and non-survivors. Most of these infants (94% of the late preterm group and 95% of the term group) underwent palliative cardiac surgery. However, hospital mortality following these surgical procedures was significantly higher in the late preterm (42% vs 17%, p= 0.002). Using logistic regression analysis, (OR; 95% CI) late preterm delivery (2.95; 1.35 - 6.45), the presence of other major CHD (3.76; 1.31-10.81) and the presence of non-cardiac congenital anomalies (6.13; 1.43 - 26.22) were independently associated with hospital death.Conclusions: In a population of infants with HLHS who were considered to be candidates for surgical repair, late preterm birth was independently associated with increased risk of hospital death compared to those delivered at more mature gestational ages.

Development of aortic aneurysm/dilatation during the followup of patients with giant cell arteritis: A cross‐sectional screening of fifty‐four prospectively followed patients

Giant cell arteritis (GCA) may involve the aorta. Retrospective studies have demonstrated a higher prevalence of aortic aneurysm among patients with GCA compared with the general population. We investigated the prevalence of aortic aneurysm in a cohort of patients with biopsy-proven GCA using a defined protocol and assessed whether persisting low-grade disease activity is associated with higher risk of developing aortic aneurysm. Fifty-four patients with GCA (14 men and 40 women) were cross-sectionally evaluated after a median followup of 5.4 years (range 4.0-10.5 years). The screening protocol included a chest radiograph, abdominal ultrasonography scan, and computed tomography scan when aortic aneurysm was suspected or changes with respect to the baseline chest radiograph were observed. Clinical and laboratory data, corticosteroid requirements, and relapses were prospectively recorded. Twelve patients (22.2%) had significant aortic structural damage (aneurysm/dilatation), 5 of them candidates for surgical repair. Aortic aneurysm/dilatation was more frequent among men (50%) than women (12.5%; relative risk 3.5, 95% confidence interval 1.53-8.01, P = 0.007). At the time of screening, patients with aneurysm/dilatation had lower serum acute-phase reactants, lower relapse rate, and needed shorter periods to withdraw prednisone than patients without aortic structural damage. There is a substantial risk of developing aortic aneurysm/dilatation among patients with GCA. Our data do not support that aneurysm formation mainly results from persistent detectable disease activity. Additional factors including characteristics of the initial injury or the target tissue may also determine susceptibility to aortic aneurysm/dilatation.

Repair type I aortic dissection in a patient with human immunodeficiency virus infection

A 57-year-old man with human immunodeficiency virus (HIV) infection was evaluated in October 1997 with complaints of weakness of the right lower extremity. A chest computerized axial tomographic scan revealed a type I aortic dissection. He underwent surgical repair including resuspension of the aortic valve and placement of a 32-mm interposition graft between the aortic root and the transverse arch. Postoperatively he required abdominal aorta fenestration and stenting for ischemia of the left lower extremity. Follow-up magnetic resonance imaging 3 1/ 2 years postoperatively showed a normal-sized ascending and transverse aorta and the residual dissection in the descending thoracic and abdominal aorta. The thoracic and abdominal aorta diameters have remained stable. Select patients with type I aortic dissection and HIV infection are candidates for surgical repair.

The role of self-expandable metallic stents for the treatment of airway complications after lung transplantation.

Airway complications continue to be an important source of morbidity and mortality after lung transplantation (LTx). Different approaches have been used for their nonsurgical management. We describe our experience using self-expandable metallic stents (SEMSs) in patients with airway complications post-LTx. We present a retrospective analysis of stent related-data of all the LTx patients who received SEMSs to treat postoperative airway complications. Between January 1992 and December 2001, 36 of 253 patients (14.2%) developed post-LTx airway complications involving 40 of 348 anastomoses (11.5%). A total of 15 SEMSs were placed in 12 patients (mean age 47.3+/-9.6 years) for tracheobronchomalacia, stenosis, and anastomotic dehiscence, including one patient referred from an outside hospital. Mean follow-up was 20.1+/-19.5 months (range 1.2-58 months). Patency and symptom improvement were achieved in 11 of 12 patients. Stenting of the airway led to successful weaning of two patients who were on prolonged mechanical ventilation. Suture dehiscence was effectively managed in two patients who were not candidates for surgical repair. Overall, the complication rate was 0.040 complications per patient per month (total number of complications and total number of months using the stent). Bacterial bronchitis (four patients) and obstructive granulomas (three patients) were the most frequent complications. The survival of LTx patients with airway SEMSs was similar when compared with the survival of all other LTx patients (P=0.74). SEMSs are safe and effective in the management of airway complications in selected patients post-LTx. Weaning from mechanical ventilation and management of anastomotic dehiscence are the unique attributes of this device.

Case selection and technique for surgical repair of aural atresia

The potential for severe distortion of the normal anatomy makes the repair of aural atresia technically difficult and risky. However, there is a good success rate and low rate of complications in selected patients. The ideal candidate for surgical repair has an isolated atresia with a well-developed atresia plate, a well-developed middle ear, ossicles, facial nerve, and mastoid, and no other severe head and neck malformations. More severe malformations may still be repairable in selected cases. Surgery is genrally delayed until approximately age 5 years to allow full development of the tympanic ring. In general, the atresia is suitable for surgical repair when the expected results can average 25 dB or less hearing level, a patent external canal, and adequate closure of the air-bone gap. The Jahrsdoerfer grading scale may be used to determine the prognosis for good hearing results. Severe microtia/anotia, hemifacial microsomia, and retrodisplacement of the mandible often correspond to low scores on the Jahrsdoerfer scale. In cases where severe malformations carry a poor prognosis for surgical repair, boneanchored hearing-assistive devices are an alternative to surgery.

Shoulder Injuries in the Throwing Athlete

The throwing athlete with shoulder pain presents a diagnostic and treatment challenge to the orthopaedic surgeon. Because pitching a baseball requires the arm to accelerate at 7,000 degrees per second, tremendous forces are experienced at the shoulder joint. Electromyographic studies have shown that the larger scapular and trunk muscles are primarily responsible for arm acceleration. The smaller and more fragile rotator cuff muscles play a significant role in decelerating the arm. During the entire throwing mechanism, the rotator cuff and the capsulolabral complex act to stabilize the humeral head on the glenoid fossa. As a result, the labrum, the capsule, and the rotator cuff are frequently the site of shoulder injury in throwers. The diagnosis of injury to these structures is based on the findings from the history, physical examination, and imaging studies. The majority of throwing injuries respond well to a carefully designed rehabilitation program. Athletes who do not improve within 6 months are candidates for surgical repair. The procedure is planned so as to minimize the amount of surgical trauma and thereby to facilitate an early return to sport. Arthroscopy is a valuable first step to confirm the pathologic diagnosis. The arthroscope alone is used to perform subacromial debridement, labral repair, or debridement of undersurface partial-thickness rotator cuff tears. If the athlete has clinical evidence of shoulder instability and arthroscopic evidence of capsular stretch, an open stabilization procedure is performed.