Early Surgical Repair Research Articles

Isolated PCL and ACL Avulsion Fractures of the Knee

Objectives:Isolated combined PCL and ACL avulsion fractures is a rare condition. A 40 year old woman had both PCL and ACL avulsion fracture due to a car accident. These fractures often have a subtle appearance at conventional radiography. Advanced imaging modalities, particularly CT and MRI are helpful to diagnose correctly and define the extent of damage. The aim of the study was point out this rare injury. We diagnosed this patient who had both PCL and ACL avulsion fractures. In the literature only a few case have been reported. We think that these fractures may be missed in the Emergency Department. If a patient is brought to the ED with high-velocity trauma, careful evaluation of bone and soft tissues followed by advanced imaging modalities should be performed.Methods:The PCL avulsion fracture was fixed with a cancellous screw via posterior approach and ACL avulsion fracture was fixed with arthroscopically assisted pull-out sutures 10 days after the traumatic event. The knee was immobilized in 20° flexion. Isometric knee, hip and ankle exercises were started immediately. Six weeks later after the operation active range of motion exercises and partial weight-bearing were allowed. In the third month full weight bearing was allowed and full range of motion was achieved.Results:Both PCL and ACL avulsion fractures healed uneventfully.Conclusion:Although knee injuries are frequent, simultaneous PCL and ACL avulsion fractures are rare . The clinician should have a high index of suspicion for these injuries. Careful physical examination and radiological imaging, especially magnetic resonance imagination is helpful in the diagnosis. Early surgical repair and appropriate rehabilitation are the keys to a good outcome in these injuries.

Penile Fracture: Outcomes of Early Surgical Intervention

To report a series of penile fractures, describing preoperative evaluation, surgical repair, and long-term outcomes.Medical records from Northwestern Memorial Hospital and Oregon Health & Science University from 2002 to 2011 were reviewed. Clinical presentation, preoperative evaluation, time from injury, mechanism and site of injury, and presence of urethral injury were assessed. Outcomes including erectile dysfunction, penile curvature, and voiding symptoms were evaluated using International Prostate Symptom Score and International Index of Erectile Function scores.Twenty-nine patients with 30 separate episodes of penile fractures presenting to the emergency room were identified. Mean patient age was 43 ± 9.6 years. The time from presentation to the initiation of surgery was 5.5 ± 4.4 hours. Mechanism of injury was intercourse in 26 of 30 fractures with the remaining attributed to masturbation or "rolling over." Immediate surgical repair was offered to all patients. Twenty-seven patients underwent surgery. Urethral injury was noted in 5 of the 27. The site of fracture was at the proximal shaft in 11, mid shaft in 12, and distal shaft in 4 patients. The mean follow-up period was 14.3 ± 15.8 weeks. Nine patients reported new mild erectile dysfunction or penile curvature. One patient reported new irritative voiding symptoms.The most common mechanism of penile fracture was from sexual intercourse, and frequent concomitant urethral injuries were observed. The frequency of concomitant urethral injury was higher than in previous studies. Although we observed high incidence of erectile dysfunction or penile curvature with early surgical repair, we retain it as the favored approach.

Preoperative factors as a predictor for early postoperative outcomes after repair of congenital transposition of the great arteries.

Transposition of the great arteries (TGA) requires early surgical repair during the neonatal period. Several preoperative factors have been identified for the postoperative poor outcome after arterial switch operation (ASO). However, the data remain uncertain an association. Therefore, we investigated the preoperative factors which affect the early postoperative outcomes. Between March 2005 and May 2012, a retrospective study was performed which included 126 infants with an ASO for TGA. Preoperative data included the vasoactive inotropic score (VIS) and baseline hemodynamics. Early postoperative outcomes included the duration of mechanical ventilation, the length of stay in the intensive care unit and hospital, and early mortality. Multivariate linear regression and receiver operating characteristics analysis were performed. The duration of mechanical ventilation was significantly correlated with the preoperative mechanical ventilator support and VIS, and CPB time. On multivariate linear regression analysis, a higher preoperative VIS, preoperative B-type natriuretic peptide (BNP) level, and the CPB time were identified as independent risk factors for delayed mechanical ventilation. Preoperative VIS (OR 1.154, 95% CI 1.024-1.300) and the CPB time (OR 1.034, 95% CI 1.009-1.060) were independent parameters predicting early mortality. A preoperative VIS of 12.5 had the best combined sensitivity (83.3%) and specificity (85.3%) and an AUC of 0.852 (95% CI 0.642-1.061) predicted early mortality. Our results suggest that preoperative VIS and BNP can predict the need for prolonged postoperative mechanical ventilation. Moreover, preoperative VIS may be used as a simple and feasible indicator for predicting early mortality.

Roles of adrenomedullin and hypoxia-inducible factor 1 alpha in patients with varicocele.

This study aimed to assess any changes in the plasma concentrations of adrenomedullin (ADM) and hypoxia-inducible factor 1 alpha (HIF 1a) in patients with varicocele (VC). Plasma concentrations of ADM and HIF 1a were measured in brachial vein (BV) and internal spermatic vein (ISV) of 30 fertile VC subjects and 35 untreated infertile VC patients. The results demonstrated that plasma levels of ADM and HIF 1a were significantly higher in ISV than those in BV in the fertile or infertile group respectively. The values of ADM and HIF 1a in BV or ISV of the infertile group were significantly higher than in BV or ISV of the fertile group respectively. Similar changes in values of reactive oxygen metabolites (ROM) were observed. Plasma HIF 1a concentration positively correlated with ROM levels. Plasma ADM concentration positively correlated with ROM values and HIF 1a levels in the two groups. Moreover, remarkable improvement in clinical sperm parameters was observed 3months after surgery for the infertile patients. It is concluded that ADM may participate, along with HIF 1a, in mechanisms that aid spermatogenic cells in adapting to hypoxia. These predictors may have potential in infertility development in VC patients. Furthermore, early surgical repair is extremely important for infertile VC patients with poor semen quality.

PS-297a Catch-up-growth In Term And Preterm Infants After Surgical Closure Of Ventricular Septal Defect In The First Year Of Life: Only Good News?

Failure to thrive is common in children with non-restrictive ventricular septal defect (VSD). Normalisation of growth has been reported after early surgical correction. However the literature is inconsistent about growth velocity after surgery in term and preterm infants. Objective Establishing the pattern of catch-up growth in infants submitted to VSD surgical repair before 1 year of age, for term and preterm infants. Methods 52 infants (41 term, 11 preterm) were studied. Anthropometric data at birth, at time of surgery and 3, 6, 12 and 24 months after surgery, collected retrospectively, were converted to z-scores. Statistic analyses was performed in SPSS® version 21, α=0,05. Results Mean weight and height z scores at the time of surgery were significantly lower for term infants (-2,24 and -1,42, respectively; p Conclusions Early surgical repair of VSD leads to a significant acceleration of growth, mainly in the first 3–6 months after surgery. An increased weight gain velocity has been associated with higher cardiovascular risk later in life. Knowledge of this specific catch-up growth pattern is important and should influence nutritional goals after surgery.

Timing of surgical reconstruction for closed traumatic injury to the supraclavicular brachial plexus

While it is widely accepted that cases of traumatic injury to the brachial plexus benefit from early surgical exploration and repair, with results deteriorating with long delays, policies vary regarding the exact timing of intervention. This is one of a pair of review articles considering the clinical issues, investigations, and surgical factors relating to management of injuries to the supraclavicular brachial plexus, as well as evidence from experimental work and clinical outcomes.In this article Mr Hems outlines when waiting may be advantageous, allowing for further investigation to help clarify the extent of the injury and thus the best surgical options.

Timing of surgical reconstruction for closed traumatic injury to the supraclavicular brachial plexus

While it is widely accepted that cases of traumatic injury to the brachial plexus benefit from early surgical exploration and repair, with results deteriorating with long delays, policies vary regarding the exact timing of intervention. This is one of a pair of review articles considering the clinical issues, investigations, and surgical factors relating to management of injuries to the supraclavicular brachial plexus, as well evidence from experimental work and clinical outcomes.In this article Professor Birch argues for early exploration of the brachial plexus as the optimum both to delineate the pathology and undertake reconstructive surgery.

Çıkan Aortadan Anormal Kaynaklanan Sağ Pulmoner Arter, Aortopulmoner Pencere ve Kesintili Arkus Aorta Birlikteliği: Tek 3D Yama ile Başarılı Cerrahi Düzeltme

Anomalous origin of the right pulmonary artery from the ascending aorta (AORPA) is a rare congenital heart defect and generally associated with other cardiac anomalies. Patients with AORPA have high pulmonary fl ow results in congestive heart failure and unilateral pulmonary hypertension. Thus, it is frequently a fatal malformation in the neonatal or early infancy periods if early surgical repair is not performed. Herein, we report a 1.5 month-old girl who was diagnosed with AORPA associated with aortopulmonary window and interrupted aortic arch and successfully operated using a single pericardial xenograft 3D patch.

Catheter ablation related mitral valve injury: the importance of early recognition and rescue mitral valve repair.

An increasing number of catheter ablations involve the mitral annular region and valve apparatus, increasing the risk of catheter interaction with the mitral valve (MV) complex. We review our experience with catheter ablation-related MV injury resulting in severe mitral regurgitation (MR) to delineate mechanisms of injury and outcomes. We searched the Mayo Clinic MV surgical database over a 19-year period (1993-2012) and the electrophysiologic procedures database over a 23-year period (1990-2013) and identified 9 patients with catheter ablation related MV injury requiring clinical intervention. Indications for ablation included atrial fibrillation (AF) [n = 4], ventricular tachycardia (VT) [n = 3], and left-sided accessory pathways [n = 2]. In all 4 AF patients, a circular mapping catheter entrapped in the MV apparatus was responsible for severe MR. In all 3 VT patients, radiofrequency energy delivery led to direct injury to the MV apparatus. In the 2 patients with accessory pathways, both mechanisms were involved (1 per patient). Six patients required surgical intervention (5 MV repair, 1 catheter removal). One patient developed severe functional MR upon successful endovascular catheter disentanglement that improved spontaneously. Two VT patients with persistent severe postablation MR were managed nonsurgically, 1 of whom died 3 months postprocedure. Circular mapping catheter entrapment and ablation at the mitral annulus are the most common etiologies of MV injury during catheter ablation. Close surveillance of the MV is needed during such procedures and early surgical repair is important for successful salvage if significant injury occurs.

Functional Results Following Surgical Repair of Simultaneous Bilateral Quadriceps Tendon Ruptures

Background: Unilateral quadriceps tendon ruptures are common conditions treated by orthopedic surgeons. There is a paucity of information concerning functional outcomes in bilateral tendon ruptures. The aim of this study is to assess a series of 5 cases with simultaneous quadriceps tendon ruptures that underwent acute surgical repair with the purpose of identifying the functional outcomes as compared with unilateral injuries. We hypothesize that patients with bilateral quadriceps tendon ruptures have worse functional outcomes than patients with unilateral ruptures. Methods: Five cases of bilateral quadriceps tendon ruptures were identified. All patients underwent acute surgical extensor tendon repair employing a 3-patellar hole and a locked, running, nonabsorbable suture technique followed by a 6-week period of immobilization and bracing for 10 to 12 weeks. Mechanism of injury, medical history, social history, operative report, and postoperative exam were recorded with a minimum 1-year follow-up. In addition, each patient completed a subjective International Knee Documentation Committee (IKDC) score at 18 months. Five patients with unilateral injuries and with similar medical history were included as age-matched controls. Results: The mean age for the bilateral group was 54.8 years (range, 44–68 years). Mean postoperative knee flexion was 129 degrees and all patients had active, resisted knee extension. Only 1 patient had a medical comorbidity (diabetes mellitus). The mean IKDC score (mean follow-up, 25.4 months; range, 22–29 months) was 71.9 (range, 34.4 to 91.6), whereas the age-matched control group had a mean IKDC score of 88.3 (P = 0.23). There was no statistical significance between the 2 groups with regard to range of motion (P = 0.24), IKDC score, and return to activity (P = 0.29). Conclusion: Patients with early surgical repair of bilateral, simultaneous extensor mechanism ruptures exhibit adequate recovery and return to a high level of function. Our patients were younger than those reported in the literature and had minimal comorbidities. The IKDC scores reflected good outcomes in the bilateral rupture group, albeit lower than in the unilateral group.

Disrupting the intrinsic growth potential of a suture contributes to midfacial hypoplasia

Children with unoperated cleft palates have nearly normal growth of their faces whereas patients who have had early surgical repair often exhibit midfacial hypoplasia. Surgical repair is responsible for the underlying bone growth arrest but the mechanisms responsible for these surgical sequelae are poorly understood. We simulated the effect of cleft palate repair by raising a mucoperiosteal flap in the murine palate. Three-dimensional micro-CT reconstructions of the palate along with histomorphometric measurements, finite element (FE) modeling, immunohistochemical analyses, and quantitative RT-PCR were employed to follow the skeletal healing process. Inflammatory bone resorption was observed during the first few days after denudation, which destroyed the midpalatal suture complex. FE modeling was used to predict and map the distribution of strains and their associated stresses in the area of denudation and the magnitude and location of hydrostatic and distortional strains corresponded to sites of skeletal tissue destruction. Once re-epithelialization was complete and wound contracture subsided, the midpalatal suture complex reformed. Despite this, growth at the midpalatal suture was reduced, which led to palatal constriction and a narrowing of the dental arch. Thus the simple act of raising a flap, here mimicked by denuding the mucoperiosteum, was sufficient to cause significant destruction to the midpalatal suture complex. Although the bone and cartilage growth plates were re-established, mediolateral skeletal growth was nonetheless compromised and the injured palate never reached its full growth potential. These data strongly suggest that disruption of suture complexes, which have intrinsic growth potential, should be avoided during surgical correction of congenital anomalies.

Symptomatic Pneumocephalus After Trans-sphenoidal Surgery

A 43-year-old woman underwent endoscopic transsphenoidal resection of a 34-mm nonfunctioning pituitary macroadenoma with optic chiasmal compression. Cerebrospinal fluid (CSF) leak was noted and repaired with gelfoam and a duraseal (hydrogel sealant) buttressed with Nasopore. Day 4 postsurgery, she had ongoing postnasal drip, and she rapidly deteriorated with headaches, drowsiness, vomiting, and urinary incontinence. She was receiving adequate hydrocortisone replacement, serum sodium levels were normal, and CSF cultures excluded infection. Brain computed tomography (CT) showed significant pneumocephalus with mass effect (Figure 1). Figure 2 shows air in the prefrontal region (Mount Fuji sign) and cisterns (air bubble sign) on coronal sections. Initial management comprised high-flow oxygen therapy and a lumbar drain with controlled CSF release. Despite treatment, she developed Cushing’s reflex, with systemic hypertension and bradycardia, suggesting intracranial hypertension. Serial imaging demonstrated progressive tension pneumocephalus, and the lumbar drain was clamped. Repeat surgery confirmed a moderate CSF leak (Daniel Kelly system grade 2) (1), which was repaired using a fat graft. Neurological status markedly improved, and there was complete clinical recovery. Symptomatic tension pneumocephalus after transsphenoidal pituitary surgery is a rare but serious complication, necessitating rapid recognition (2, 3). Conservative treatment with high-flow oxygen increases the rate of resorption of pneumocephalus (4). Early surgical repair of the CSF leak should be considered in moderate to severe cases (5). Lumbar drainage in the presence of intraoperative CSF leak and significant pneumocephalus may exacerbate the pneumocephalus by drawing in air from the nasal passages.

Symptomatic Popliteal Vein Aneurysm

Popliteal vein aneurysms (PVAs) can have serious consequences, including pulmonary embolism and death. We report a case of PVA in a previously healthy 58-year-old female with a history of pain in her right popliteal fossa for the past 3 years. Patient had no history of trauma or claudication of the right leg. Following a preoperative venogram to confirm the diagnosis, the PVA was dissected circumferentially through a posterior incision. The aneurysm was resected and repaired with lateral venorrhaphy. Patient had an uneventful recovery. Due to the possibility of severe consequences, if left untreated, early surgical repair is highly recommended whether the patient has symptoms or not.

The management of endoscopic retrograde cholangiopancreatography-related duodenal perforation.

Uneventful duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is an uncommon but occasionally fatal complication. ERCP-related perforations may occur during sphincterotomy and improper manipulation of the equipment and scope. Traditionally, duodenal perforation has been treated with early surgical repair. Recently, nonoperative early endoscopic management techniques including clips or fibrin glue have been reported. In the present paper we review the literature pertaining to the treatment of perforations.

A Case of Spontaneous Bilateral Achilles Tendon Rupture

Tendo-Achilles (TA) rupture is the most commonly ruptured tendon in the lower limb despite being one of the toughest tendons. Typically, it occurs unilaterally in middle-aged individuals who participate in strenuous activity. Spontaneous ruptures without any risk factors predisposing the patient is uncommon and for it to occur bilaterally is very rare. To raise awareness of the potential for TA ruptures to occur bilaterally and thus the importance of assessing the TA contralateral to a seemingly unilateral rupture. This is particularly the case in patients with risk factors, which are reviewed in this report. A summary of the main treatment options is also described. We report a case of spontaneous, bilateral TA rupture in a 40-year-old man with no identifiable risk factors. It occurred following a heavy impact during a sports activity and although painful, was able to mobilize slowly. After a clinical examination confirmed the diagnosis, the patient underwent early bilateral surgical repair and subsequently embarked on a comprehensive rehabilitation program with a good functional outcome at follow-up. His return to premorbid work and social life was uneventful. Bilateral TA ruptures are rare but increased awareness would help avoid a tear or rupture of the contralateral side being missed. All patients presenting clinically with any TA rupture should have risk factors reviewed. Surgical repair must be accompanied by a comprehensive rehabilitation program for adequate recovery and return of function.

Abstract 18089: Functional Mitral Regurgitation in Patients With Ischemic Cardiomyopathy Undergoing Surgical Ventricular Restoration for Anterior Aneurysm: Echocardiographic Findings and Clinical Impact

Objective: to evaluate clinical impact of severe functional mitral regurgitation(MR) in patients with dilatative post-ischemic CMP submitted to Surgical Ventricular Restoration(SVR). Methods: Among 445 consecutive patients operated of SVR for anterior aneurysm at our Institution between July 2001 and December 2011, 337(76%) patients presented with MR<2+(Group A,mean age 65±10yrs) while moderate to severe MR(3-4+) was evident in 108(24%) patients(Group B,mean age 64±9yrs;). LV volumes(p=.019), LV sfericity index(p=.004) and mitral tenting area(p=.005) resulted independent predictor of severe MR at presentation(Figure 1). Results: All patients underwent standard SVR with exclusion of antero-septal akinetic area. CABG was concomitantly performed in 414 patients(93%; mean number of graft=2.7±1.5). All patients in Group B underwent mitral annuloplasty; on the opposite, mitral repair was performed in 18 patients(5%) of GroupA, who presented with annular enlargement > 40mm. Thirty-days mortality was significantly higher in Group B(15%vs6%; p=.006). Seventy-five patients(22%) in Group A and 46 patients(43%) in Group B died at follow-up(p=.001). Kaplan-Meyer 5 and 10 years cumulative survival were significantly higher in group A(p=.008). Despite identical early mitral repair success rate, 15(7%) and 22(35%) patients in group A and B respectively(p=.001) showed long-term recurrence of severe MR. At Cox regression analysis preoperative mitral annulus dimension and postoperative systolic conicity index were the only independent predictors of late MR recurrence. Long-term 5 and 10 years survival(p=.037) as well as 5 and 10 years freedom from HF readmission(p=.001) were significantly affected by MR recurrence at FU. Conclusion: Severe preoperative MR significantly impacts surgical risk of SVR as early and long-term mortality. Furthermore, despite early succesfull surgical repair, severe MR recurrs in nearly a third of the discharged patients.

Early versus late reconstruction of cloacal malformations: The effects on postoperative complications and long-term colorectal outcome

IntroductionPatients with a cloacal malformation generally undergo reconstructive surgery within the first years of life. However, the ideal age for surgery has rarely been mentioned. The aim of this study was to report differences in outcome between early (<6months) and late repair of cloacal malformations. MethodsCharts of patients with a cloacal malformation treated in 5 pediatric surgical centers between 1985 and 2009 were retrospectively studied for associated anomalies, postoperative complications, and colorectal and urological outcome. ResultsForty-two patients were eligible for this study, giving a mean exposure of less than 1 patient yearly per center. Forty-five percent of the patients had a short common channel (>3cm), and 14% had a long common channel. Length of common channel was missing in 41% of the patients. Median age of the cloacal reconstruction was 9months (range 1–121months). Twelve patients (29%) underwent an early surgical repair (within the first 6months of age; median 3months), and 30 (71%) patients underwent a late repair (after 6months of age; median 14months). Eighteen postoperative complications (<30days) had been documented in 15 patients (35%), with significant more perineal wound dehiscences in patients with an early repair (42% vs. 10%, p=0.031). There were no differences in complication rate between patients with short and long common channels. Mean follow-up was 142months (range 15–289). At the last follow-up, 10 patients (24%) had voluntary bowel movements. Fourteen patients (33%) had complaints of soiling, 25 (60%) were constipated, with no differences between the early and late repair groups. Patients in the late repair group as well as the group of patients with a short common channel were more frequently able to void spontaneously. ConclusionsPostoperative complications are common in patients with cloacal malformations. Early repair is associated with more wound dehiscences, however, without affecting long-term functional outcome. All centers had limited annual exposure of less than 1 patient. In these clinical settings, ideal age of cloacal reconstruction seems to be between 6 and 12months. In general, centralized care for these complex malformations may be the crucial factor for reducing postoperative complications and better long-term outcome.

Management of Combined Anterior Cruciate Ligament–Posterolateral Corner Tears

Background: A consensus on the treatment of combined anterior cruciate ligament (ACL) and posterolateral corner (PLC) injuries is still lacking. Purpose: To review the available literature on the management of these combined lesions to investigate the influence that injuries of knee posterolateral structures play in the outcome of an ACL lesion. Study Design: Systematic review; Level of evidence, 4. Methods: A comprehensive search was performed on PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: “posterolateral corner,” “plc,” “posterolateral instability,” “posterolateral injury,” “anterior cruciate ligament,” and “acl.” Results: A total of 6 studies involving 95 patients were included. For those with PLC lesions, 14 patients were treated nonoperatively, 9 underwent an early anatomic repair, while the remaining 72 underwent a reconstruction. In all 95 patients, an ACL reconstruction was performed. Sixty-seven of the 72 patients who underwent a PLC reconstruction were assessed for anteroposterior laxity, with a mean side-to-side difference of 1.5 ± 1.1 mm. Evaluated by the objective International Knee Documentation Committee (IKDC) Knee Form, 88% of the patients who underwent a PLC reconstruction were graded as good/excellent (A/B). The 9 patients who underwent an early surgical repair of the PLC lesion were evaluated by means of the objective IKDC score, with 3 patients (33%) graded as good/excellent (A/B), and by means of a clinical evaluation, with 5 of 9 patients (56%) graded as 1+ for varus laxity. For the 14 patients who were managed nonoperatively for PLC injuries, the only clinical score available was the subjective IKDC score, with a mean value of 80.5 (87.8 for the 6 patients with type A PLC injuries and 75.0 for type B PLC injuries). Conclusion: There is a paucity of literature focused on the management of combined ACL and PLC injuries. Combined ACL and PLC reconstruction seems to be the most effective approach to these combined lesions. However, future work is needed to explore the long-term outcome of the different treatment options.

Precision in cardiology: should all cases of myocardial infarction with ventricular septal rupture require early repair?

Though the incidence of ventricular septal rupture (VSR) after myocardial infarction (MI) has reduced from 3%1 to 0.2%2 due to improvements in cardiac pharmacotherapy and intervention, the mortality rate still...

Prenatal Diagnosis and Successful Outcome in Neonate of Aorto-Left Ventricle Tunnel

Aorto-left ventricular tunnel (ALVT) is an abnormal congenital communication between the ascending aorta and the left ventricle. Prenatal diagnosis is rare and can be misinterpreted as aortic insufficiency on fetal echocardiogram. We present a case of ALVT diagnosed in a fetus who underwent successful early neonatal surgical repair.