Current Surgical Techniques Research Articles

TCT-364 Percutaneous deep vein aRterialization for the treatment Of late stage critical liMb ISchEmia, The PROMISE Trial: Early Feasibility Interim Results

Within Critical Limb Ischemia (CLI) there is a broad spectrum of severity, from milder degrees of vascular insufficiency to “no option” situations where occlusive lesions are so complex that current available surgical and endovascular techniques are not sufficient and amputation is considered

The Postoperative Meniscus: Anatomical, Operative, and Imaging Considerations.

Meniscal surgery is commonplace. Patients who have had prior surgery may return for additional imaging for continued or new pain, limited range of motion, or interval injury. Accurate interpretation of postoperative imaging requires a clear understanding of the normal meniscal anatomy and biomechanics. Surgical goals and current surgical techniques impact the imaging appearance. These techniques are reviewed in the context of the various meniscal tear patterns. Multiple imaging modalities may be used in patient assessment with magnetic resonance (MR) imaging providing key information regarding the integrity of the meniscal repair. Imagers need to be aware of the key findings for a normal versus pathologic appearance to the postoperative meniscus as well as other potential MR findings that may account for patient presentation.

Classifications of Mastoid and Middle Ear Surgery: A Scoping Review.

The aim of this scoping review was to evaluate existing classifications of surgical procedures of the middle ear and mastoid and find a suitable classification that could serve as an international standard. Scoping review with a systematic literature search using reference tracking and a syntax including all surgical procedures in mastoid and middle ear surgery and their synonyms. Studies were selected based on inclusion and exclusion criteria. Eleven reported classifications were included; six of which focused on middle ear surgery, two on mastoid surgery, and three on both. However, none of the classifications included all current surgical procedures of mastoid and middle ear surgery. Many classifications have been proposed for innumerable surgical techniques in middle ear and mastoid surgery. Some are outdated, some are incomplete, most are not widely accepted, and only few correspond with all current surgical techniques.

Laparoscopic liver resection: a review of current indications and surgical techniques.

Laparoscopic liver resection (LLR) has been the most impressive development in the field of liver surgery in recent two decades. Technical innovations and experience accumulation have made LLR a safe and effective procedure with faster postoperative recovery. Despite the fast spreading of the procedure, details regarding the indications, oncological outcomes and technical essentials were still disputable. To address these issues, two international consensus conferences were hold to update the knowledge in this field. The statements of the both conferences were not conclusive and more high-quality researches are required. In this article, we reviewed the development and the current state of LLR. Indications, outcomes, surgical techniques and devices used in LLR were also discussed.

The Evolution of Man and Machine—a Review of Current Surgical Techniques and Cutting Technologies After Upper Extremity Amputation

This review focuses on the cutting edge of surgery and technologies following upper extremity loss. A range of technologies will be reviewed with the common theme of bionics. Traditional surgical amputation techniques are antiquated, especially with commercially advanced prosthetic technologies available following Targeted Muscle Reinnervation (TMR) surgery for the upper extremity. TMR should be standard of care not only for its benefits for advanced prosthetic control but also for its improvement in neuroma pain and prevention of neuroma formation. Current investigations of different technologies hold a bionic solution to arm restoration. Many technologies currently exist in different phases of clinical research while others are immediately available and should be standard of care following upper extremity amputation. It is important that the healthcare community has understanding of the developing and available technology in the area of bionics and its application to upper extremity prosthetics.

Posterior laxity increases over time after PCL reconstruction.

Restoration of posterior tibial translation (PTT) after reconstruction of the posterior cruciate ligament (PCL) is deemed necessary to restore physiological knee kinematics. However, current surgical techniques have failed to show a complete reduction of posterior laxity. It was hypothesized that early postoperative PTT increases over time. The study comprised of 46 patients (10 female, 36 male; 30 ± 9years), who underwent PCL reconstruction in a single-surgeon series. Patients were evaluated by bilateral stress radiographs in a prospective manner preoperatively; at 3, 6, 12 and 24months; and at a final follow-up (FFU) of at least 5years. Covariants included age, gender, BMI, tibial slope (TS) and the number of operated ligaments. Two blinded observers reviewed all radiographs, evaluating the TS and the posterior tibial translation. All patients were evaluated at a mean final follow-up of 102 (range 65-187) months. Mean side-to-side difference of the PTT significantly improved from preoperative to 3-month postoperative values (10.9 ± 3.1 vs. 3.6 ± 3.8mm; P < 0.0001). The PTT increased to 4.6 ± 3.7mm at 6months, to 4.8 ± 3.3mm at 12months, to 4.8 ± 3.2mm at 24months, to 5.4 ± 3.4mm at FFU. Consequently, there was a significant increase of PTT between 3-month and final follow-up (3.6 ± 3.8 vs. 5.4 ± 3.4mm; P = 0.02). Flattening of the TS resulted in a significantly higher PTT compared to subjects with a high TS at 24months and FFU. There was no significant influence by BMI, age, gender and the number of operated ligaments. Early results after PCL reconstruction seem promising as posterior tibial translation is significantly improved. However, there is a significant increase in PTT from early postoperative values to the final follow-up of at least 5years. This is particularly notable in patients with flattening of the TS. As a consequence, surgeons and patients need to be aware that initial posterior stability should not be equated with the final outcome. Cohort study, Level III.

Radial head resection and hemi-interposition arthroplasty in patients with multiple hereditary exostoses: description of a new surgical technique.

Multiple hereditary exostoses (MHE) are a rare disorder characterized by the growth of bony protrusions. Elbow involvement is found in a considerable number of patients and varies from the presence of a simple osteochondroma to severe forearm deformities and radial head dislocation. Patients encounter a variety of symptoms, for example, pain, functional impairment, and cosmetic concerns. Several types of surgical procedures, therefore, can be offered, ranging from excision of symptomatic osteochondromas to challenging reconstructions. In this paper, we will discuss the essential basics of visualizing, planning, and treatment options of forearm deformities in MHE. In more detail, we will describe our current surgical technique as a salvage procedure for Masada type II forearm deformities in patients with MHE.

Magnetic resonance morphometry of the adult normal lumbar intervertebral space

This study aims to: (a) quantify and evaluate normal relationships between neighboring spinal units using MR imaging indices, (b) propose an easy-to-apply-and-reproduce method of estimating the correct amount of distraction when surgically restoring a collapsed intervertebral disc, based on individualized measurements. This is a retrospective cross-sectional MR imaging study of 119 adult subjects, aged 18-54, asymptomatic for low back pain. Each of the examinees should demonstrate two or more consecutive intervertebral discs classified as Pfirrmann grade I or II to be included. We measured and studied the relationships of disc height index, Dabbs index, Farfan index, disc convexity index and mean and posterior disc height per spinal level using multiple regression analysis. All measurements were tested for intra- and interobserver agreement by two raters. DHI, Dabbs, Farfan, and mean disc height had a statistically significant correlation with the spinal level and age. Our results were highly reproducible, with excellent inter- and intraobserver agreement and reliability between two raters (ICC = 0.992 and 0.994, respectively). Furthermore, we expressed each intervertebral space as a percentage of its adjacent space, introducing the coefficient α factor for every intervertebral space. Our results suggest that a normal values' database to refer during preoperative planning of correction of a degenerated intervertebral disc is feasible. Our study offers new anatomical and radiological insight in terms of spinal measurements and their potential correlation with current surgical techniques. A new approach for calculating disc space as an expression of its adjacent disc has been introduced with various potential applications.

Current surgical strategies and techniques of aortic valve diseases in children.

While the long-term outcome of surgical aortic valvotomy (SAV) appears to be better than that of balloon aortic valvuloplasty (BAV) as the primary procedure of aortic valve stenosis, the surgical strategies and techniques of treating aortic valve disease in children in other situations remain controversial. Valve repair should be first considered while replacement is still unavoidable in some cases, and new repair techniques developed by innovative surgeons are gradually becoming adopted. Some complex repair procedures such as cusp extension, leaflet replacement/reconstruction have provided satisfactory outcomes. The Ozaki technique replaces aortic valve leaflets with glutaraldehyde-treated autologous pericardium instead of replacing the valve entirely. Special instruments have been developed to make the Ozaki technique more reproducible and standardized. Neonates and infants undergoing aortic valve replacement (AVR) are a high-risk group, where repair should be the primary consideration rather than replacement. Several systematic reviews reveal that all currently available aortic valve substitutes such as pulmonary autograft, mechanical prosthesis, homograft and bioprosthesis are associated with suboptimal results in children, but pulmonary autograft appeared to be superior with high freedom from reintervention and better hemodynamic performance. The strategy for treatment of aortic valve disease should be specifically analyzed based on the brief of being beneficial for children.

Modern Osteochondral Allograft Transplantation: The “Gold Standard” for Femoral Condyle Cartilage Repair?

Objectives:Cartilage repair for femoral condyle lesions comprise the majority of the biological procedures performed in the knee joint. Treatment options have evolved but there is still uncertainty regarding longer-term clinical outcomes with current surgical techniques. The objective of this study was to evaluate outcome of osteochondral allograft (OCA) transplantation utilizing dowel type grafts for the treatment of isolated femoral condyle cartilage lesions.Methods:This study comprised 187 patients (200 knees) who underwent OCA transplantation for isolated cartilage lesions on the femoral condyle between 1999 and 2014. Mean patient age was 31.1 ± 11.6 years, 62.6% were male, and the medial femoral condyle was affected in 69% of the knees. For all cases, dowel technique was used with commercially available surgical instruments utilizing the minimum amount of bone necessary for fixation (modern technique). A single graft was used in 145 knees (72.5%), two grafts were used in 55 knees (27.5%). Average allograft area was 6.3 cm2 (range, 2.3 to 13 cm2) and graft thickness was 6.5 ± 1.4 mm (cartilage and bone combined). All patients had a minimum follow-up of 2 years. Evaluation included International Knee Documentation Committee (IKDC) scores; Knee injury and Osteoarthritis Outcome Score (KOOS), and patient satisfaction. The frequency and type of further surgery was assessed. OCA failure was defined as a further surgery that involved removal of the allograft. An additional subgroup analysis on location comparing medial to lateral femoral condyle grafts was performedResults:The average follow-up was 6.7 years (range, 1.9 to 16.5 years). IKDC scores improved from preoperatively to latest follow-up for pain (5.5 to 2.7), function (3.4 to 7.3) and total scores (43.7 to 76.2) (all p<0.001). KOOS pain and activities of daily living scores improved from 66.5 to 85.3 and 74.5 to 91.1, respectively (p<0.001). At latest follow-up, outcome scores did not differ by location on the femoral condyle (Table 1). The majority of patients (89%) reported satisfaction with the results of the OCA transplantation. Further surgery was required in 52 knees (26%), of which 16 knees (8% of entire cohort) were defined as OCA failures (4 OCA revisions, 1 arthrosurface, 6 unicompartmental knee arthroplasties, and 5 total knee arthroplasties). The median time to failure was 4.9 years (range, 0.3 to 16.1 years). Survivorship of the OCA was 95.6% at 5 years and 91.2% at 10 years (Figure 1).Conclusion:OCA transplantation utilizing a modern technique is a valuable procedure for the treatment of femoral condyle cartilage lesions, resulting in significant improvement in clinical scores, high patient satisfaction, and low reoperation and clinical failure rates. These results are similar or better than any other cartilage repair procedure for isolated femoral condyle lesions.Table 1.Outcomes among 184 knees with grafts in situ at latest follow-upMeasureAll knees N=184Medial N=125Lateral N=59p-value*IKDC Pain2.7 ± 2.42.6 ± 2.43.1 ± 2.50.176 Function7.3 ± 2.27.4 ± 2.27.2 ± 2.20.364 Total76.2 ± 18.776.9 ± 19.274.8 ± 17.50.312KOOS Symptoms82.5 ± 15.584.0 ± 14.579.7 ± 17.20.251 Pain85.3 ± 16.386.9 ± 15.682.5 ± 17.30.103 Activities of daily living91.1 ± 14.791.8 ± 14.089.8 ± 16.00.535 Sports / recreation70.2 ± 26.473.6 ± 24.064.9 ± 29.40.199 Quality of life62.1 ± 24.364.5 ± 24.957.7 ± 22.60.113Satisfaction Extremely satisfied67.7%70.5%61.5%0.260 Satisfied21.3%19.6%25.0% Somewhat satisfied5.5%4.5%7.7% Somewhat dissatisfied3.0%1.8%5.8% Dissatisfied2.4%3.6%0.0%Results are shown a mean ± standard deviation or percentage.IKDC, International Knee Documentation Committee; KOOS, Knee injury and Osteoarthritis Outcome Score*P-value for comparison of medial vs lateralFigure 1.Kaplan-Meyer survivorship with revision of the allograft or conversion to arthroplasty as the endpoint

Quantitative Anatomic Analysis of the Medial Ulnar Collateral Ligament Complex of the Elbow.

Background:A more detailed assessment of the anatomy of the entire medial ulnar collateral ligament complex (MUCLC) is desired as the rate of medial elbow reconstruction surgery continues to rise.Purpose:To quantify the anatomy of the MUCLC, including the anterior bundle (AB), posterior bundle (PB), and transverse ligament (TL).Study Design:Descriptive laboratory study.Methods:Ten unpaired, fresh-frozen cadaveric elbows underwent 3-dimensional (3D) digitization and computed tomography with 3D reconstruction. Ligament footprint areas and geometries, distances to key bony landmarks, and isometry were determined. A surgeon digitized the visual center of each footprint, and this location was compared with the geometric centroid calculated from the outline of the digitized footprint.Results:The mean surface area of the AB was 324.2 mm2, with an origin footprint of 32.3 mm2 and an elongated insertional footprint of 187.6 mm2 (length, 29.7 mm). The mean area of the PB was 116.6 mm2 (origin, 25.9 mm2; insertion, 15.8 mm2), and the mean surface area of the TL was 134.5 mm2 (origin, 21.2 mm2; insertion, 16.7 mm2). The geometric centroids of all footprints could be predicted within 0.8 to 1.3 mm, with the exception of the AB insertion centroid, which was 7.6 mm distal to the perceived center at the apex of the sublime tubercle. While the PB remained relatively isometric from 0° to 90° of flexion (P = .606), the AB lengthened by 2.2 mm (P < .001).Conclusion:Contrary to several historical reports, the insertional footprint of the AB was larger, elongated, and tapered. The TL demonstrated a previously unrecognized expansive soft tissue insertion directly onto the AB, and additional analysis of the biomechanical contribution of this structure is needed.Clinical Relevance:These findings may serve as a foundation for future study of the MUCLC and help refine current surgical reconstruction techniques.

Access to the Ischium: A Simple Extension of the Posterior Approach in Revision Hip Arthroplasty

AbstractReconstruction of acetabular defects in revision total hip arthroplasty (THA) requires excellent exposure. Most extensile approaches to the acetabulum were described in the trauma literature and are not beneficial for revision THA. This article describes a modification of the standard posterior surgical approach to improve visualization of the ischium as required for acetabular defect reconstruction, insertion of standard and custom triflange cages as well as posterior column plating. The current surgical technique utilizes an intermuscular plane between the gemellus inferior muscle and the obturator externus muscle. This intermuscular plane leads the surgeon directly to the ischium and facilitates easy extension toward the insertion of the hamstring muscles without compromising the insertion of the external rotator muscles along the ischium. This article describes a novel surgical approach to the posterior column and ischium under special consideration of the sciatic nerve, superior gluteal vessels, and medial femoral circumflex artery. This simple extension of the standard posterior approach optimizes exposure of the posterior column during revision THA using a posterior approach.

Engineering Stem and Stromal Cell Therapies for Musculoskeletal Tissue Repair.

Stem cells and tissue-derived stromal cells stimulate the repair of degenerated and injured tissues, motivating a growing number of cell-based interventions in the musculoskeletal field. Recent investigations have indicated that these cells are critical for their trophic and immunomodulatory role in controlling endogenous cells. This Review presents recent clinical advances where stem cells and stromal cells have been used to stimulate musculoskeletal tissue repair, including delivery strategies to improve cell viability and retention. Emerging bioengineering strategies are highlighted, particularly toward the development of biomaterials for capturing aspects of the native tissue environment, altering the healing niche, and recruiting endogenous cells.

Current concepts in cleft care: A multicenter analysis

The current surgical techniques used in cleft repair are well established, but different centers use different approaches. To determine the best treatment for patients, a multi-center comparative study is required. In this study, we surveyed all craniofacial departments registered with the German Society of Maxillofacial Surgery to determine which cleft repair techniques are currently in use. Our findings revealed much variation in cleft repair between different centers. Although most centers did use a two-stage approach, the operative techniques and timing of lip and palate closure were different in every center. This shows that a retrospective comparative analysis of patient outcome between the participating centers is not possible and illustrates the need for prospective comparative studies to establish the optimal technique for reconstructive cleft surgery.

Repair Techniques for Mitral Valve Insufficiency in Children.

Congenital mitral valve (MV) dysplasia is a relatively rare and highly complex cardiac disease. We sought to provide a comprehensive analysis of the current surgical techniques for treating mitral valve insufficiency and the results of mitral valve repair at our institution. Between 1972 and 2017, 104 consecutive patients underwent surgical repair of congenital MV dysplasia-insufficiency at our institution. Among these, 59 patients presented with MV insufficiency (or prevalent MV insufficiency) and were part of the study. There was 1 early (1.7%) and 1 late death (1.7%). Survival at 5, 10 and 20 years was 98%, 98% and 94%, respectively. Eight patients (14%) required MV replacement for residual significant MV insufficiency. Freedom from re-intervention for MV dysfunction at 5, 10 and 20 years were 89%, 84% and 79%, respectively. Surgical techniques for treating mitral valve insufficiency must be tailored for each patient with the main goal of achieving a proper valve function, rather than a "normal" anatomy. The mechanism underlying valve dysfunction in congenital mitral valve insufficiency is multifactorial and requires the application of a variety of surgical techniques in each case.

Management of Severely Atrophic Maxilla in Ectrodactyly Ectodermal Dysplasia-cleft Syndrome.

Background:Ectrodactyly ectodermal dysplasia-cleft syndrome is a rare genetic syndrome with an incidence of 1/90,000 live births, characterized by cleft lip and palate, severely hypoplastic maxilla, and hypodontia. Patients diagnosed with ectrodactyly ectodermal dysplasia-cleft syndrome suffer from a severely hypoplastic maxilla that is highly difficult to treat using traditional orthognathic methods. In this study, we propose using distraction osteogenesis to achieve a major advancement while maintaining good stability and minimal relapse. To our knowledge, this is the first description of patients with this syndrome treated using distraction osteogenesis.Methods:Five patients diagnosed with ectrodactyly ectodermal dysplasia-cleft syndrome were included in the study. All patients had been operated on according to the well-established protocol of cleft lip and palate reconstruction before maxillary distraction osteogenesis. Hard and soft-tissue changes were evaluated by cone beam computed tomography and lateral cephalograms before distraction osteogenesis (T1), at the postdistraction point (T2) and after 1 year of follow-up (T3).Results:Examination revealed marked maxillary advancement in all our patients with a significant mean difference in hard tissue parameters (condylion to A point = 18 mm; nasion-sella line to A point = 15.2 degrees) and a notable improvement in facial convexity (20.9 degrees). One year follow-up measurements demonstrated mild relapse rates of 6% in the horizontal plane.Conclusions:We conclude that despite the challenging anatomic and physiological features of ectrodactyly ectodermal dysplasia-cleft patients, by enhancing current surgical techniques, there is promising potential for improved patient outcomes, achieving normognathic facial appearance with implant supported rehabilitation.

PREOPERATIVE MAGNETIC RESONANCE IMAGING DIAGNOSTIC FEATURES OF UTERINE LEIOMYOSARCOMAS: A SYSTEMATIC REVIEW.

There are no current established pathognomonic diagnostic features for uterine leiomyosarcomas in the pre- or perioperative setting. Recent inadvertent upstaging of this rare malignancy during laparoscopic morcellation of a presumed fibroid has prompted widespread debate among clinicians regarding the safety of current surgical techniques for management of fibroids. This study aims to conduct a systematic review investigating significant diagnostic features in magnetic resonance imaging (MRI) of uterine leiomyosarcomas. A comprehensive database search was conducted guided by PRISMA recommendations for peer-reviewed publications to November 2017. Parameters available in MRI were compared for reliability and accuracy of diagnosis of leiomyosarcomas. A decision tree algorithm classifier model was constructed to investigate whether T1 and T2 MRI signal intensities are useful indicators. Nine eligible studies were identified for analysis. There appears to be a significant relationship between histopathological type and T1 and T2 intensity signals (p < .05). A decision tree model analyzing T1 and T2 signal intensity readings supports this trend, with a diagnostic specificity of 77.78 percent for uterine leiomyosarcomas. The apparent diffusion coefficient (ADC) values were not observed to have a significant relationship with tumor pathology (p = .18). Various studies have investigated pre- and perioperative techniques in differentiating uterine leiomyosarcoma from benign fibroids. Given the rarity of the malignancy and lack of pathognomonic diagnostic parameters, there is difficulty in establishing definitive criteria. A decision tree model is proposed to aid diagnosis based on MRI signal intensities.

Augmentation of Patellar Tendon Repair With Autologous Semitendinosus Graft—Porto Technique

Patellar tendon ruptures can lead to significant functional deficiency of the extensor mechanism of the knee. These injuries, because of their inherent nature and associated complications, may require a complex treatment and remains a challenge for orthopaedic surgeons. Current surgical techniques present significant complications, including patellar fracture, damage to patellar articular cartilage, and abnormal patella height. This note describes a surgical technique to provide an additional reinforcement to the patellar tendon repair with a semitendinous autograft, without the necessity to perform any transosseous tunnels at the patella bone. First, the patellar tendon is repaired with an end-to-end technique and the semitendinous tendon is harvested. A transosseous tunnel at the tibial tubercle is drilled and 2 rents are made, both medial and lateral to the retinaculum at the level of the intermedial segment of the patella close to the patellar margin. The graft is passed through the tunnel and rents in a U-shaped form. The graft is sutured along the length of the patellar tendon on both margins in tension at 30° of knee flexion. Fluoroscopy imaging is performed to assess the patella height. This technique provides a significant augmentation of patellar tendon, avoiding the potential patella bone tunnel complications.

Gestione dei difetti acetabolari: l’uso di osso omologo

Bone grafts are implanted materials that support or promote bone healing through an osteogenic, osteoconductive and/or osteoinductive mechanism to the local site. Acetabular bone deficiencies encountered during acetabular hip arthroplasty revision vary from cavitary or segmental defects to complete discontinuity. Several techniques exist to manage these defects. In this review we present the current surgical techniques for reconstructing the acetabular socket which includes a cementless acetabular component with morselised bone, structural allograft, reinforcement rings and bone cages. Segmental acetabular defects involving both columns with more than 50% of the graft supporting the cup suggest the application of ilioischial devices. The aim is to bridge areas of bone loss, providing immediate mechanical fixation. Acetabular reconstruction with the use of the antiprotrusion cage and allografts has to be considered as a reliable procedure to manage severe periprosthetic deficiencies with highly successful long-term outcomes in revision arthroplasty.

Patch Augmentation and Patch Extension for Complex Rotator Cuff Tears

The successful management of large to massive rotator cuff tears is challenging. Multiple factors to include poor tendon quality with fatty degeneration lead to high retear rates despite improved arthroscopic and open repair techniques. Patch augmentation and patch interposition with various grafts have been studied in an effort to both reinforce and bridge massive rotator cuff repairs, and provide an optimal biologic and mechanical environment at the tendon-bone interface. The purpose of this review is to present the current indications, surgical techniques, and outcomes of patch augmentation and patch interposition (extension) for large and massive rotator cuff tears.