Delayed Repair Group Research Articles

Experience of the Early Penile Fracture Repair: A Cross-Sectional Study in A Tertiary Care Center

Background: Penile fracture is a surgical emergency and most often it can be diagnosed clinically. But delayed presentation due to the embarrassing nature of the injury makes surgical outcome worse. Objectives: This study was conducted to compare results of early and delayed surgical interventions of patients presenting with penile fracture. Methodology: A cross-sectional study was conducted at the department of Urology, in Dhaka Medical College of hospital, Bangladesh from 30th July 2018 to 30th January 2020. Twenty- Seven (27) patients with penile fracture were enrolled in this study. They were diagnosed on the basis of history and clinical findings. They were divided into two groups; early presenter (15 patients) who came within 24 hours and delayed presenter (12 patients) who came after 24 hours. Among the early presenters, 13 patients had unilateral corporeal injury and 2 patients had bilateral corporeal injury. On the other hand, in delayed presenters, 11 patients had unilateral corporeal injury and 1 patient had bilateral corporeal injury. Surgical repair was done in all patients. Results: Patient age range was between 15 to 60 years. The commonest presenting complaints were cracking sound 26 out of 27 (96.30%), penile swelling 24 out of 27 (88.88%), pain 22 out of 27(81.48%) and detumusence during sexual intercourse or an erection 17 out of 27(62.96%), urethra bleeding 3 out 27(11.1%). Among different causes, vigorous intercourse where female on top (62.9%) was the commonest followed by bending during erection (18.5%), masturbation (11.1%) And rolling over bed (7.4%). Out of 15 patients in early group, patients presented with urethral injury. The complications in delayed repair group were, plaque formation 3 out of 15 (20%); penile shaft deformity 2(13.3%); erectile dysfunction 1(6.6%) and skin necrosis 2 (13.3%). But in early repair group only one patient developed skin necrosis which was managed conservatively. Conclusion: Fracture of the penis is a surgical emergency. Immediate surgical repair gives excellent results even in the presence of urethral injury. Early diagnosis by history and clinical examination and timely surgical intervention is essential for better outcome with minimal longterm complications. J Dhaka Med Coll. 2022; 31(2) : 210-214

Giant Omphaloceles—Morbidity, Mortality, and Financial Impact of Early Versus Delayed Repair

IntroductionWe compared strategy outcomes and financial impact over the first two years of life (F2YOL) for patients with giant omphaloceles undergoing early repair (ER) (primary or staged) versus delayed repair (DR). MethodsA retrospective review of giant omphaloceles (fascial defect > 5 cm/> 50% liver herniation) at a tertiary children's hospital between 1/1/2010 and 12/31/2019 was performed. Survival, length of stay, age at repair, ventilation days (VD), time to full enteral feeds, readmissions during the F2YOL, incidence of major associated anomalies, and total hospitalization charges during the F2YOL were compared. A subanalysis removing potential confounders and only including patients who underwent fascial closure within the F2YOL was also conducted. ResultsThirty four giant omphaloceles (23DR and 11ER) were identified. The median age (days) at repair was 289 [148, 399] DR versus 10 [5, 21] ER, P < 0.001. Total cohort two-year survival was significantly higher in the DR group (95.7% versus 63.6%, P = 0.03). Including patients with a tracheostomy there was no significant difference in VD during the index hospitalization. Excluding tracheostomy patients, the DR group had significantly fewer VD during the index hospitalization, 15 [0, 15] versus 18 [10, 54], P = 0.02 and over the F2YOL 6.5 [ 0, 21] versus 18 [14, 43], P = 0.03. There were no significant differences in the incidence/type of major associated anomalies, time to full enteral feeds, index length of stay, total hospital days, total admissions, or associated hospital charges. On subanalysis, there was no significant difference in VD or survival at any time. ConclusionsDelayed and early repair strategies for giant omphaloceles have equivalent outcomes in the index hospitalization and over the course of the first two years of life. These findings are useful for family counseling and expectation setting.

Observational management of Grade II or higher blunt traumatic thoracic aortic injury: 15 years of experience at a single suburban institution.

Background:We aimed to investigate the outcomes after delayed management of ≥ Grade II blunt traumatic thoracic aortic injury (BTAI).Methods:Between January 2005 and December 2019, we retrospectively reviewed the medical records of 21 patients with ≥ Grade II thoracic aortic injury resulting from blunt trauma. Twelve patients underwent observation for the injury, whereas nine patients were transferred immediately after the diagnosis. Patients were divided into a nonoperative management group (n = 7) and delayed repair group (n = 5) based on whether they underwent thoracic endovascular aneurysm repair or surgery.Results:The most common dissection type was DeBakey classification IIIa (n = 9). Five patients underwent delayed surgery (including aneurysm repair), with observation periods ranging from 1 day to 36 months. The delayed repair group exhibited higher injury severity scores than the nonoperative management group (n = 7). The nonoperative management group was followed-up with blood pressure management without a change in status for a period ranging from 3 to 96 months.Conclusions:Our findings indicated that conservative management may be appropriate for select patients with Grade II/III BTAI, especially those exhibiting hemodynamic stability with anti-impulse therapy and minimally sized pseudoaneurysms. However, further studies are required to identify the risk factors for injury progression and long-term outcomes.

The proteome of distal nerves: implication in delayed repair and poor functional recovery.

Chronic denervation is one of the key factors that affect nerve regeneration. Chronic axotomy deteriorates the distal nerve stump, causes protein changes, and renders the microenvironment less permissive for regeneration. Some of these factors/proteins have been individually studied. To better delineate the comprehensive protein expression profiles and identify proteins that contribute to or are associated with this detrimental effect, we carried out a proteomic analysis of the distal nerve using an established delayed rat sciatic nerve repair model. Four rats that received immediate repair after sciatic nerve transection served as control, whereas four rats in the experimental group (chronic denervation) had their sciatic nerve repaired after a 12-week delay. All the rats were sacrificed after 16 weeks to harvest the distal nerves for extracting proteins. Twenty-five micrograms of protein from each sample were fractionated in SDS-PAGE gels. NanoLC-MS/MS analysis was applied to the gels. Protein expression levels of nerves on the surgery side were compared to those on the contralateral side. Any protein with a P value of less than 0.05 and a fold change of 4 or higher was deemed differentially expressed. All the differentially expressed proteins in both groups were further stratified according to the biological processes. A PubMed search was also conducted to identify the differentially expressed proteins that have been reported to be either beneficial or detrimental to nerve regeneration. Ingenuity Pathway Analysis (IPA) software was used for pathway analysis. The results showed that 709 differentially expressed proteins were identified in the delayed repair group, with a bigger proportion of immune and inflammatory process-related proteins and a smaller proportion of proteins related to axon regeneration and lipid metabolism in comparison to the control group where 478 differentially expressed proteins were identified. The experimental group also had more beneficial proteins that were downregulated and more detrimental proteins that were upregulated. IPA revealed that protective pathways such as LXR/RXR, acute phase response, RAC, ERK/MAPK, CNTF, IL-6, and FGF signaling were inhibited in the delayed repair group, whereas three detrimental pathways, including the complement system, PTEN, and apoptosis signaling, were activated. An available database of the adult rodent sciatic nerve was used to assign protein changes to specific cell types. The poor regeneration seen in the delayed repair group could be associated with the down-regulation of beneficial proteins and up-regulation of detrimental proteins. The proteins and pathways identified in this study may offer clues for future studies to identify therapeutic targets.

Early versus delayed repair of traumatic rotator cuff tears. Does timing matter on outcomes?

The purpose of this study was to determine if delay (before or after 4months) in repairing a symptomatic traumatic rotator cuff tear affected clinical outcome, re-rupture rates and use of interpositional dermal grafts. This was a case matched (age + tear size) series of patients who underwent an early (≤ 4months) or delayed (> 4months) rotator cuff repair following a traumatic tear. If a direct repair could not be achieved a dermal interposition graft was used. Outcomes were collected at a median time of 30months post-operatively using the Oxford, Constant and EQ5D scores. Twenty patients underwent rotator cuff repair within 4months (1-4) of injury. Twenty age and cuff tear size-matched patients were identified who had undergone a delayed repair (4.1-24months) after injury. We found no significant difference (p > 0.05) in patient reported outcomes scores between the early and delayed repair. [Oxford scores; Early 43(13-48), Delayed 45 (31-48); Constant scores; Early 73 (21-94), Delayed 73.5 (44-87); EQ5D; Early 0.75 (0.25-1), Delayed 0.77 (0.4-1)]. Time to full recovery was significantly longer (14 vs 33.8months) for the delayed repair group (P > 0.05). When cuff tears were subdivided into < 3cm tears or ≥ 3cm tears, no significant difference outcome scores were founds. However, use of dermal interposition graft was 44% in delayed group for tears ≥ 3cm. No grafts were used in early repair group. There was one symptomatic re-tear in our series which was in the early repair group. When compared to the delayed repair group, patients that underwent early repair of traumatic rotator cuff tears had shorter time of recovery, and less need for allograft augmentation for tears 3cm or greater. However, at mid-term follow-up, this study found no difference in patient reported outcomes following early versus delayed repair of traumatic rotator cuff tears. 3.

多発外傷における鈍的胸部大動脈損傷治療のタイミング(Timing of treatment for blunt thoracic aortic injury in cases of multiple trauma)

要旨【目的】多発外傷における鈍的胸部大動脈損傷（BTAI）に対する治療のタイミングについて検討する。【対象】2011年から2018年に自施設で診療したBTAIのうち，AIS≥3または治療手技（手術あるいは血管内治療）を要する体幹部外傷を伴い，かつ侵襲的治療［ステントグラフト内挿術（SG）あるいは開胸手術（OS）］を行った25例を後方視的に検討した。【結果】48時間以内に侵襲的治療を施行した群は17例（68%，生存15例）で，48時間以降に施行した群の8例（32%，生存7例）と比較して入院期間が短く（43［31–55.5］日／64.5［61.5–82.75］日），RBC輸血量が少なかった（2［0–4］単位／8［4–19］単位）。待機期間がとくに長かった3例のうち2例はStanford B型のII型で，経過中に非手術的治療からSGへ変更したものだった。最終的に22例（88%）を救命した。BTAIの損傷形態は，日本外傷学会分類IIIbが1例でOSを施行，IIIaが18例（72%）で17例にSGが選択された。II型（IIaまたはIIb）は6例（24%）で，そのうちStanford A型の2例にはOSが，B型の4例にはSGが選択された。【結語】多発外傷におけるBTAIは48時間以内に侵襲的治療を行えば入院期間を短縮できRBC輸血量を減らすことができた。

Effects of Nogo-A and its receptor on the repair of sciatic nerve injury in rats.

Regeneration of injured peripheral nerves is an extremely complex process. Nogo-A (neurite outgrowth inhibitor-A) inhibits axonal regeneration by interacting with Nogo receptor in the myelin sheath of the central nervous system (CNS). The aim of this study was to investigate the effects of Nogo-A and its receptor on the repair of sciatic nerve injury in rats. Sprague-Dawley rats (n=96) were randomly divided into 4 groups: control group (control), sciatic nerve transection group (model), immediate repair group (immediate repair), and delayed repair group (delayed repair). The rats were euthanized 1 week and 6 weeks after operation. The injured end tissues of the spinal cord and sciatic nerve were obtained. The protein expressions of Nogo-A and Nogo-66 receptor (NgR) were detected by immunohistochemistry. The protein expressions of Nogo-A, NgR, and Ras homolog family member A (RhoA) were detected by western blot. At 1 week after operation, the pathological changes in the immediate repaired group were less, and the protein expressions of Nogo-A, NgR, and RhoA in the spinal cord and sciatic nerve tissues were decreased (P<0.05) compared with the model group. After 6 weeks, the pathological changes in the immediate repair group and the delayed repair group were alleviated and the protein expressions decreased (P<0.05). The situation of the immediate repair group was better than that of the delayed repair group. Our data suggest that the expression of Nogo-A and its receptor increased after sciatic nerve injury, indicating that Nogo-A and its receptor play an inhibitory role in the repair process of sciatic nerve injury in rats.

Pattern of Presentation and Surgical Outcomes of Canalicular Laceration Repair in a Pediatric Population.

To evaluate demographic data, clinical profile, and factors responsible for the success of anatomical and functional outcomes of canalicular laceration repair with the Mini Monoka stent (FCI Ophthalmics) in children younger than 10 years. This was a retrospective cohort observational study involving children younger than 10 years who underwent canalicular tear repair with the Mini Monoka stent with a minimum follow-up of 6 months. A total of 18 patients (9 boys and 9 girls) with a mean age of 5.39 ± 3.05 years were included. Twelve and 6 patients had lower and upper canalicular tear, respectively. Six (33.4%) patients had associated ocular comorbidity. The common mode of trauma was direct injury in 77.8% of the patients. The blouse hook of the mother was noted as the most common object causing canalicular laceration. Early repair (< 48 hours) and delayed repair were done in 7 (38.9%) and 11 (61.1%) patients, respectively. Anatomical and functional success was achieved in 88.9% and 94.4% of patients, respectively. The odds ratio (95% CI) for anatomical and functional success with the time since injury was 0.6 (CI: 0.03 to 11.47) and 0.19 (CI: 0.01 to 5.33), respectively. There was no significant difference between the early and delayed repair groups in terms of the distribution of anatomical (P = 1.000) and functional (P = .389) success. There was no significant difference between the various groups in terms of the distribution of complications (P = .224). Canalicular laceration repair with the Mini Monoka stent in children younger than 10 years has shown good outcomes in terms of anatomical and functional success irrespective of time lag since injury to repair. [J Pediatr Ophthalmol Strabismus. 2021;58(1):42-47.].

Urgent surgical repair is pivotal in the management of major airway injury due to blunt trauma

BackgroundBlunt traumatic airway injury is a life-threatening injury in which urgent management is pivotal and this would come through improving our clinical management and diagnostic tools. Our objective was to emphasize the importance of early referral and urgent surgical repair of major airway injury.ResultsRecords of 42 patients with major airway injury out of 17,520 registered thoracic trauma cases were reviewed over the past 15 years. Twenty-eight cases documented to have major tracheobronchial injuries due to blunt trauma underwent surgical repair either urgent (21 cases) or late (7 cases). The age ranged from 8 to 43 years old with a mean age of 22.3 ± 0.8. The most common presenting symptom was shortness of breath in 22 (78.6%) cases and the most frequent sign was subcutaneous emphysema which was seen in 22 (78.6%) cases. The postoperative morbidity and mortality rates were significantly higher in the delayed repair group (p value < 0.001).ConclusionThe urgent surgical repair is the treatment of choice for major airway injury which is facilitated by early recognition and referral. It is pivotal to avoid respiratory and systemic complications and related mortality.

MP39-11 SURGICAL OUTCOMES OF TRAUMATIC PENILE FRACTURE REPAIR ON LONG-TERM ERECTILE AND URINARY FUNCTIONS: ANALYSIS OF TRAUMA REGISTRY

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy II (MP39)1 Apr 2020MP39-11 SURGICAL OUTCOMES OF TRAUMATIC PENILE FRACTURE REPAIR ON LONG-TERM ERECTILE AND URINARY FUNCTIONS: ANALYSIS OF TRAUMA REGISTRY Caleb Natale*, Niklos Moring, Laith Alzweri, Amit Reddy, Jacob Greenberg, Ayad Yousif, Cooper Benson, Wayne Hellstrom, and Omer Raheem Caleb Natale*Caleb Natale* More articles by this author , Niklos MoringNiklos Moring More articles by this author , Laith AlzweriLaith Alzweri More articles by this author , Amit ReddyAmit Reddy More articles by this author , Jacob GreenbergJacob Greenberg More articles by this author , Ayad YousifAyad Yousif More articles by this author , Cooper BensonCooper Benson More articles by this author , Wayne HellstromWayne Hellstrom More articles by this author , and Omer RaheemOmer Raheem More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000888.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile fracture (PF) is a traumatic injury necessitating timely surgical intervention. This study examines the impact of an early vs delayed surgical intervention for PF on long-term erectile and urinary outcomes. METHODS: Patients who underwent surgical treatment for traumatic PF from March 2010 to October 2019 at our institution were evaluated to characterize demographics, surgical interventions and long-term outcomes. Non-traumatic PF patients were excluded. International Index of Erectile Function (IIEF-5) was utilized for objective post-operative erectile assessments. RESULTS: A total of 23 patients were evaluated with mean follow-up of 11.6 months. Mean age was 38.5 years and mean BMI was 28.6. No history of erectile dysfunction (ED) or Peyronie’s disease prior to trauma. Majority of patients 18/23 (78%) had surgical interventions within 24 hours (early repair), whereas 5/23 (22%) patients received surgical repair beyond 24hrs (delayed repair). In both groups, the preferred approach at the time of PF repair was the degloving incision 18/23 (78%) compared to ventral raphae incision 5/23 (22%). All patients underwent unilateral or bilateral corpora cavernosa repair of PF. Anastomotic urethroplasty for concomitant corpora spongiosum rupture was required in 6/23 patients. Although the most common complication after surgery was ED (62%), erectile function recovery after six months was 15/18 (83%) and 1/5 (20%) in the early vs delayed groups (p<0.05) (Table). 7 patients (3 in early and 4 in delayed groups) developed severe and persistent ED (IIEF-5: 5-7). 8 (17%) patients complained of post-operative penile curvature (6/18, 33% vs 2/5 40%). Deviation was <30° in all cases. One case of subjective penile shortening was reported in each group. In the delayed repair group, there was one each of reoperation for urethral stricture and transient priapism. CONCLUSIONS: Early surgical repair of PF provides satisfactory long-term outcomes with adequate recovery of erectile and urinary functions. Majority of patients preserve erectile and urinary functions without the development of debilitating long-term sequalae. Large multi-institutional prospective follow-up would further elucidate the relationship between time to surgical intervention, aiding the surgical decision making. Source of Funding: NONE © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e580-e581 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Caleb Natale* More articles by this author Niklos Moring More articles by this author Laith Alzweri More articles by this author Amit Reddy More articles by this author Jacob Greenberg More articles by this author Ayad Yousif More articles by this author Cooper Benson More articles by this author Wayne Hellstrom More articles by this author Omer Raheem More articles by this author Expand All Advertisement PDF downloadLoading ...

Delayed (14-30 Days) Percutaneous Repair of Achilles Tendon Ruptures Offers Equally Good Results As Compared With Acute Repair

Background: Minimally invasive repair of acute Achilles tendon ruptures has been performed for several years, resulting in reduced morbidity as compared with open repair. Hypothesis: A minimally invasive technique can be used to manage Achilles tendon ruptures in patients presenting between 14 and 30 days from injury. Study Design: Cohort study; Level of evidence, 3. Methods: We prospectively recruited 21 consecutive patients who presented between 14 and 30 days after the index injury, and we compared them with 21 patients who were matched according to sex, age (±2 years), and level of activity, who presented within 14 days of the index injury. All patients underwent the same minimally invasive procedure under local anesthesia: a core suture repair consisting of a modified Bunnell suture in the proximal stump and a modified Kessler suture in the distal stump. Results: At 12 months after minimally invasive repair, patients with delayed treatment had a median Achilles tendon rupture score of 91 (SD, 2.4; range, 87-96) as compared with 91 (SD, 2.2; range, 86-96) in patients treated acutely, who presented at a median 2.4 days (range 1-6 days) from the injury. There were no significant differences between groups in terms of mean (SD) Achilles tendon resting angle: delayed repair group, −3.9° (2.0); acute repair group, −3.7° (1.9) (P = .69). No patient in either group developed a wound infection. One patient in the acute group experienced an iatrogenic sural nerve injury. Conclusion: Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patient treated <14 after injury.

Outcomes of Early Versus Delayed Transcatheter Closure of Post-Myocardial Infarction Ventricular Septal Defect

BackgroundPost myocardial infarction ventricular septal defect (VSD) is a rare, but devastating complication which carries a poor prognosis if left untreated. Optimal therapy remains unclear and surgical repair is associated with high mortality. ObjectiveThe aim of our study is to compare 30-day survival in patients with early versus late primary transcatheter repair of post myocardial infarction ventricular septal defect. MethodsWe performed a comprehensive search of published data through SCOPUS and identified published reports of primary transcatheter closure of post myocardial infarction VSD. We included case reports and series that reported timing of VSD closure and 30-day survival and excluded those with prior surgical repair. Early repair was defined as transcatheter closure within 14 days of diagnosis of VSD while late repair was defined as transcatheter closure after 14 days of diagnosis of VSD. ResultsA total 27 publications describing 193 patients were identified in the SCOPUS search. We excluded 8 publications with no reported timing of VSD repair or 30-day outcome. Of the 193 patients initially included, a total of 126 patients fulfilled all the criteria and were included in the final analysis. The overall 30-day survival rate was found to be 62.7% (79 patients). In the early repair group, only 36.2% of the patients were still alive at 30 days compared to 85.3% in the delayed repair group, P < .01. No significant difference in age, gender, presence of shock, VSD size, presence of significant residual shunt, location of VSD or infarction was observed. The early repair group was found to have a significantly larger Qp: Qs ratio as well as larger occluder size and lower rate of successful repair. ConclusionCompared to the late repair group, the early transcatheter VSD repair group had a larger pre-procedure Qp:Qs and worse 30-day survival. Further studies are needed to determine the optimal timing of transcatheter repair of a post myocardial infarction VSD.

150 The Impact Of Surgical Treatment Of Penile Fracture On Long-term Erectile and Urinary Functions

Penile fracture (PF) is a relatively uncommon genitourinary traumatic injury that often necessitates timely surgical intervention. The aim of this study is to examine the impact of an early vs delayed surgical interventions for PF on the long-term erectile and urinary outcomes. Patients underwent surgical treatment for traumatic penile fractures (PF) from March 2010 to October 2019 at our institution were evaluated to characterize demographics, surgical interventions and long-term outcomes. Patients with a history of non-traumatic PF including Collagenase intralesional injections were excluded. International Index of Erectile Function (IIEF-5) utilized for objective post-operative erectile assessments. A total of 23 patients evaluated. The mean age was 38.5 years (range 18-52 years) and mean BMI of 28.6. Ethnicity were 11 African American, 6 Caucasian, 4 Hispanic and 2 unknown. Mean follow up was 11.6 months (range 6-18 months). No history of erectile dysfunction (ED) or Peyronie’s disease (PD) prior to trauma. Majority of patients 18/23 (78%) had surgical interventions (PF repair) within 24hrs (range 6-18hrs) (early repair), whereas 5/23 (22%) patients received surgical repair beyond 24hrs (range 3-21 days) (delayed repair). In both groups, the degloving circumcision incision was the preferred approach at time of PF repair 18/23 (78%), compared to ventral raphae incision 5/23 (22%). All patients underwent either unilateral or bilateral corpora cavernosa repair of PF, and 6/23 patients (5 vs 1 patients in early vs delayed group) underwent anastomotic urethroplasty for concomitant corpora spongiosum rupture. Although the most common complication following surgical repair of PF was ED (62%), erectile function recovery after six months were 15/18 (83%) vs 1/5 (20%) in the early vs delayed repair groups respectively (p<0.05) (Table 1). Seven patients (3 in early and 4 in delayed groups) developed severe and persistent ED (IIEF-5: 5-7) at time of last follow-up. Eight (17%) patients complained of penile curvature after surgery (6/18, 33% vs 2/5 40%). Intracavernosal injection test showed deviation <30 degree in all cases. Subjective penile shortening was reported in both groups (1 in each group). In the delayed repair group, only 1 patient required reoperation for urethral stricture disease at site of prior urethroplasty and one patient developed transient priapism.

Outcomes of Pectoralis Major Tears in Active Duty US Military Personnel: A Comparison of Surgical Repairs Performed in the Forward Deployed Setting to Those Performed in the Continental United States.

The purpose of our study is to compare pectoralis major tears in active duty military personal repaired surgically in the forward deployed setting to those performed in the Continental United States. Retrospective comparison of all pectoralis major tendon repairs performed at Madigan Army Medical Center from 2000 to 2007 to a forward deployed series treated by two deployed United States Air Force orthopedic surgeons at one expeditionary medical treatment facility over a 4-month deployment cycle from December 2013 through March 2014. Fourteen patients from the CONUS group and eight patients from deployed group were compared; they had a mean age of 32 years (21-52) all with pectoralis major ruptures that underwent operative fixation. Nineteen of the 22 patients (86%) sustained their injuries during bench press. The average bench press weight was similar with 271.8 lbs in the CONUS group and 273.1 lbs in the deployed group. There were 9 complete tears and 5 partial tears in the CONUS cohort whereas 7 complete tears and 1 partial tear in the deployed cohort, with all tears in both groups occurring at the insertion of the humerus. All 22 patients in both cohorts denied the use of anabolic steroids. The average DASH score at final follow-up was 12.74 in the CONUS group and 36.44 in the deployed group. The CONUS group reported that 7 out of 8 immediate repair patients and 4 out of 6 delayed repair patients returned to functional work level within 6 months with the 2 patients in the delayed repair group taking longer than 9 months to return to work. The deployed members reported return to functional work level at an average of 6.5 months. Both cohorts had early return to weight lifting at 6 and 7 months, respectively. The CONUS group reported a 39% bench press weight reduction and 34% pushup maximum reduction whereas the deployed cohort reported a 20% and 8% reduction respectively. When comparing deployed to CONUS results, we demonstrated that surgical repairs at one permanent US military in-theater tertiary referral medical center were as successful as repairs performed at one CONUS US Army academic tertiary referral medical center. Although in-theater surgical repair was technically feasible and clinically successful, we believe the lengthy convalescence, stringent post-operative restrictions, demanding environment and impact on operational readiness should preclude deployed surgical repairs from becoming standard practice.

Management of chronic distal biceps tendon ruptures: primary repair vs. semitendinosus autograft reconstruction

Delayed presentation of distal biceps tendon ruptures can make primary repair difficult, in which case reconstruction using a tendon graft is an option. The aim of this study was to compare outcomes and complications between delayed distal biceps tendon ruptures managed with repair vs. semitendinosus autograft reconstruction. Nineteen delayed distal biceps tendon rupture cases treated with a tendon reconstruction were compared with 16 delayed primary repair cases (>21 days). The reconstructions were performed using a semitendinosus autograft looped through a transosseous tunnel in the bicipital tuberosity and secured with a Pulvertaft weave to the remnant distal biceps tendon. The patient groups were reviewed and completed functional outcomes testing including range of motion, isometric elbow flexion and supination strength, Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Elbow Evaluation, Single Assessment Numeric Evaluation, and Mayo Elbow Performance Index. Mean patient age (49 ± 9 vs. 46 ± 8 years, P = .65) and follow-up (47 ± 25 vs. 45 ± 27 months, P = .45) were similar between delayed primary repair and reconstruction groups. Range of motion (P = .62), supination strength (P = .26), elbow flexion strength (P = .93), Disabilities of the Arm, Shoulder, and Hand (P = .08), and Single Assessment Numeric Evaluation (P = .22) were not significantly different between groups. The Patient-Rated Elbow Evaluation (P = .02) and Mayo Elbow Performance Index (P = .04), however, were better in the delayed repair group compared with the reconstruction group. Complications were similar between groups (P = .87). Delayed reconstruction of irreparable distal biceps tendon ruptures with semitendinosus autograft produces similar strength, range of motion, and complication rates but slightly worse functional outcome scores compared with delayed primary repair. This suggests that when possible direct repair is preferred, however, if not possible, reconstruction with an autologous tendon graft results in predictably good outcomes.

Midterm Echocardiographic Assessment of Right Ventricular Function After Midline Unifocalization

Patients with an open ventricular septal defect (VSD) after repair of pulmonary atresia (PA), VSD, and major aortopulmonary collaterals (MAPCAs) are the most vulnerable subgroup. We analyzed the impact of concomitant versus delayed VSD closure on survival and intermediate-term right ventricular (RV) function. Between October 1996 and February 2017, 96 patients underwent a pulmonary flow study-aided repair of PA/VSD/MAPCAs. For patients who underwent either concomitant or delayed intracardiac repair, echocardiographic RV systolic function was retrospectively calculated to assess (1) RV fractional area change (RVFAC) and (2) two-dimensional RV longitudinal strain (RVLS) of the free wall of the right ventricle. QLAB cardiac analysis software version 10.3 (Philips Medical Systems, Andover, MA) was used for analysis. A total of 64 patients underwent concomitant VSD closure at the time of unifocalization, and 16 patients underwent delayed VSD closure at a median of 2.3 years (range: 3 days to 7.4 years). At a median follow-up of 8.1 years (range: 0.1 to 19.5 years) for the concomitant repair group versus 7.4 years (range: 0.01 to 15.3 years) for the delayed repair group, no differences in RVFAC and RVLS were observed (RVFAC: 41.0% ± 6.2% versus 41.2% ± 7.6%, p= 0.91; RVLS:-18.7 ± 4.3 versus-18.9 ± 4.0, p= 0.87). Patients (83%) with PA/VSD/MAPCAs underwent complete repair at intermediate-term follow-up with preserved RV function. Delayed VSD closure was accomplished in 50% of the patients initially deemed unsuitable for repair. Delayed VSD closure did not affect survival and did not portend impaired RV systolic function.

A Mouse Model of Delayed Rotator Cuff Repair Results in Persistent Muscle Atrophy and Fatty Infiltration

Background: Rotator cuff (RC) tears are common tendon injuries seen in orthopaedic patients. Successful repair of large and massive RC tears remains a challenge due to our limited understanding of the pathophysiological features of this injury. Clinically relevant small animal models that can be used to study the pathophysiological response to repair are limited by the lack of chronic repair models. Purpose: To develop a highly clinically relevant mouse model of delayed RC repair. Study Design: Controlled laboratory study. Methods: Three-month-old C57BL/6J mice underwent unilateral supraspinatus (SS) and infraspinatus (IS) tendon tear with immediate, 2-week delayed, or 6-week delayed tendon repair. Animals with no repair or sham surgery served as controls. Gait analysis was conducted to measure shoulder function at 2 weeks and 6 weeks after surgery. Animals were sacrificed 6 weeks after the last surgery. Shoulder joint, SS, and IS muscles were harvested and analyzed histologically. Ex vivo mechanical testing of intact and repaired SS and IS tendons was conducted. Reverse-transcriptase polymerase chain reaction was performed on SS and IS muscles to quantify atrophy, fibrosis, and fatty infiltration–related gene expression. Results: Histological and tendon mechanical testing showed that torn tendons could be successfully repaired as late as 6 weeks after transection. However, significant atrophy and fatty infiltration of muscle, with impaired shoulder function, were persistent in the 6-week delayed repair group. Shoulder function correlated with the severity of RC muscle weight loss and fatty infiltration. Conclusion: We successfully developed a clinically relevant mouse model of delayed RC repair. Six-week delayed RC repair resulted in persistent muscle atrophy and fatty infiltration with inferior shoulder function compared with acute repair. Clinical Relevance: Our novel mouse model could serve as a powerful tool to understand the pathophysiological and cellular/molecular mechanisms of RC muscle and tendon degeneration, eventually improving our strategies for treating and repairing RC tears.

When Should We Repair Partial-Thickness Rotator Cuff Tears? Outcome Comparison Between Immediate Surgical Repair Versus Delayed Repair After 6-Month Period of Nonsurgical Treatment

Background: Patients with partial-thickness rotator cuff tears (PTRCTs) can be treated nonoperatively and/or undergo operative treatment, but the ideal time for surgical intervention is unclear. Purpose: To compare the results of immediate arthroscopic rotator cuff repair with repair after 6 months of nonoperative care of PTRCTs involving more than 50% of the tendon thickness. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: The authors prospectively randomized and analyzed 78 consecutive patients diagnosed with either isolated bursal-side or articular-side PTRCTs (supraspinatus only). Group 1 (n = 44) received immediate rotator cuff repair. Group 2 (n = 34) received delayed rotator cuff repair after 6 months of nonoperative treatment. The American Shoulder and Elbow Surgeons (ASES) Score, Constant score, visual analog scale (VAS) for pain, and range of motion at initial visit; months 3, 6, and 12 postoperatively; and the last visit after 24 months were used for the evaluation. Cuff integrity was assessed with magnetic resonance imaging at 12 months postoperatively. Results: There were no significant differences in age, sex (18/26 vs 13/21, male/female), symptom duration, composition of PTRCTs, or clinical outcomes between groups 1 and 2 (P > .05). In group 2, 10 patients voluntarily dropped out from the study due to improvement of symptoms during the 6 months of preoperative nonoperative treatment. The mean follow-up period in groups 1 and 2 was 31.9 ± 1.5 months and 37.0 ± 2.2 months, respectively. At the end of the study, both groups showed significant improvements in terms of functional scores and pain VAS scores compared with the initial period. There were no significant differences between the 2 groups, except for lower pain VAS score and higher ASES Score in group 2 at 6 months postoperatively. At 12 months postoperatively, 1 patient from group 1 and 2 patients from group 2 experienced a retear. Conclusion: Both immediate surgical repair and delayed repair after nonsurgical care for PTRCTs were effective in improving clinical outcomes, and there was a very low incidence of retears in both groups. However, at 6 months postoperatively, superior functional outcomes were observed in the delayed repair group compared with the immediate repair group. A trial period of preoperative nonsurgical care is reasonable, and immediate surgical repair is not crucial for the treatment of PTRCT.

An evaluation of the Effect of Surface Treatment On Amalgam Repair

The purpose of this in vitro study was to evaluate the effect of different surface treatments on shear bond strength of repaired amalgam using two types of amalgam. 120 acrylic blocks (2.7cm diameter by 2.0cm high) were constructed from cold cure resin, each one contained cylindrical hole (7mm diameter by 2mm high) on its circular face that filled with amalgam. The samples were divided into immediate repair group and delayed repair group, which was stored and incubated at 37C0 for one month. After aging the amalgam surface of delayed repair was finished with carbide bur and polished with abrasive rubber cup then divided into three groups according to the surface treatment that include group with out surface treatment, group roughened with diamond bur and the last group was abraded with aluminum oxide (50m) particles size, both immediate and delayed repair were further subdivided according to the type of amalgam used into three subgroups. The repair procedure was done by using a Teflon split mold which containing an opening (3mm diameter by 5mm high) then all the samples were storage and incubated at 37C0 for one week prior to testing.Testing was done by applying shear force at the interface between the initial and repair amalgam with special designed chisel shape rod by using Zwick testing machine at across head speed of 5mm/min.Analysis of the results showed that the shear bond strength in immediate repair were significant higher than of delayed repair and the group roughened with diamond bur is higher than group treated with aluminum oxide and untreated group.The shear bond strength of delayed repair of amalgam is less than that of immediate repair, the surface produced by roughening the samples with a diamond bur will give best strength than the surface treated by aluminum oxide and untreated surface (smooth surface) and the same types of amalgam restorations used in amalgam repair gave better result than different type of amalgam.

Comparison of subacute and delayed free flap reconstruction in the treatment of open lower extremity fractures.

Although early free flap coverage for lower extremity traumatic defects has been recommended by several authors, it is often not practical due to associated patient injuries or logistics. The aim of this study was to evaluate the impact of subacute and delayed surgical timing on flap success. A retrospective analysis of adult patients who underwent a microsurgical free flap operation between 2007 and 2012 following lower extremity trauma was performed. The patients were divided into 2 groups according to the time period between the injury and the free flap operation: a subacute group (flap performed 10 to 29 days after injury) and a delayed repair group (&gt;30 days after injury). The details of patient demographics, the mechanism of injury, timing from operation to discharge, minor and major complications, and flap failure rates were evaluated and compared. The study included 35 patients who underwent 37 free flap operations. A total of 20 patients were operated on 10 to 29 days after the injury (subacute repair group), and 15 patients were operated on more than 30 days after the injury (32-92 days) (delayed repair group). No significant correlation was found between the timing of the reconstruction, flap failure, and complication rates. Both subacute and delayed reconstruction for lower extremity traumatic defects can be performed with favorable results with appropriate wound preparation and precise preoperative planning.