Extracapsular Procedures Research Articles

Complications and postoperative non-steroidal anti-inflammatory use of three extracapsular cruciate ligament repair techniques performed in a general practice clinic environment.

To report complications and postoperative non-steroidal anti-inflammatory use associated with fabellotibial suture, Tightrope and Ligafiba Isotoggle procedures performed on dogs of varying weights within a general practice setting. Clinical records of eligible patients from 2009 to 2018 were retrospectively extracted from five general practice clinics. Data for signalment, patient weight, surgery performed, complications, postoperative use of non-steroidal anti-inflammatory drugs, and timing thereof were extracted and analysed using multinomial logistic regression. Predicted probability tables were generated for complications and non-steroidal anti-inflammatory drug use. The study included 370 surgeries, with 97 fabellotibial suture, 158 Tightrope and 42 Ligafiba Isotoggle procedures in patients less than 15 kg, and 43 fabellotibial suture, 16 Tightrope and 30 Ligafiba Isotoggle procedures in patients at least 15 kg. The proportion of patients that can be expected to have no complications was greatest for older dogs (9 years) weighing less than 15 kg (fabellotibial suture, 91%; Tightrope/Ligafiba Isotoggle, 88%), and the highest major medical and surgical complication risks were expected in young dogs (1year) weighing over 15 kg (fabellotibial suture, 28%; Tightrope/Ligafiba Isotoggle, 59%). The predicted risk of requiring repeated non-steroidal anti-inflammatory drug prescriptions in the 18-month postoperative period for an 15 kg patient was 37% to 39%. Weight and age were significant factors influencing complications and postoperative non-steroidal anti-inflammatory drug use in fabellotibial suture, Tightrope and Ligafiba Isotoggle surgical patients in a general practice setting. Clinicians should consider the possibility of complications and requirement for ongoing non-steroidal anti-inflammatory drug use before performing extracapsular procedures in patients weighing more than 15 kg.

Ponseti Casting vs. Soft Tissue Release for the Initial Treatment of Non-idiopathic Clubfoot.

Purpose: Ponseti casting has universally been accepted as the gold standard for treatment of idiopathic clubfoot. Conversely, primary treatment for non-idiopathic clubfoot has not been established. The purpose of this study is to compare treatment outcomes following primary soft tissue release (STR) and Ponseti casting of non-idiopathic clubfoot.Methods: An IRB-approved retrospective study of patients treated for non-idiopathic clubfoot between 2005 and 2020 was conducted. Patients were included if they began treatment before the age of 2 and had at least 1 year of follow up. Patients were placed into either the STR group or Ponseti group and variables of interest were documented including reoccurrence of deformity, number of surgeries performed, type of surgeries performed, anesthesia time, and surgery time. Data was analyzed using Mann-Whitney U test for continuous variables.Results: A total of 33 children with 57 neuromuscular/syndromic clubfoot were identified of which 9 (15 feet) were treated with STR and 24 (42 feet) were treated with Ponseti casting. Average anesthesia and surgery time were found to be 291 and 179 min, respectively, for the STR group, and 113 and 67 min for the Ponseti group. The difference in operating time was determined to be significant (p = 0.02, p = 0.01). Patients treated with STR were found to have significantly more surgeries performed over the course of treatment than those treated with Ponseti casting (p = 0.001) with an average of 4.2 surgeries in the STR group and 1.5 surgeries in the Ponseti group. Extracapsular procedures were performed in 100% of the STR group and 97.6% of the Ponseti group (p = 0.55). Intracapsular procedures were performed in 100% of the STR group and 50% of the Ponseti group (p = 0.001).Conclusion: The Ponseti method should serve as the primary approach in the initial treatment of non-idiopathic clubfoot as it can reduce the risk of future invasive intracapsular surgery and shorten anesthesia and surgery times when surgical treatment is necessary.Level of Evidence: Level III retrospective case control study.

Zancolli’s procedure: technique and indications

Anatomical variations in the distal insertion of the abductor pollicis longus (APL) muscle onto the 1st metacarpal bone and around the 1st carpometacarpal joint led Eduardo Zancolli to introduce a surgical yet conservative partial APL tenotomy targeting its accessory or supernumerary distal bundles. Following an anatomical and pathophysiological review, we will describe the surgical technique for this minimally invasive extra-capsular procedure. Results and operative indications of this very simple technique are reported as well, which can be performed in Dell stage I or II of trapeziometacarpal osteoarthritis when well-conducted conservative medical treatment has failed to achieve pain relief.

Current Practices for Multimodal Pain Management Using Liposomal Bupivacaine in Extracapsular and Intracapsular Hip Fracture Surgery: Expert Panel Opinion.

Liposomal bupivacaine (LB) has demonstrated efficacy across a range of surgical settings, including shoulder, knee, and hip surgery. However, data are limited on the use of LB as part of a multimodal pain management approach in hip fracture surgery. On April 1, 2017, 4 orthopaedic surgeons and 3 anesthesiologists convened to discuss current practices and develop a consensus statement related to local infiltration analgesia with LB for hip fracture surgical procedures within the context of a multimodal opioid-sparing pain management approach. Separate workshops addressed intracapsular and extracapsular hip fracture surgery. Multimodal strategies before, during, and after hip fracture surgery are paramount to optimizing pain control and minimizing opioid requirements. LB infiltration should occur intraoperatively near the time of closing the incision. For both intracapsular and extracapsular procedures, oral or intravenous acetaminophen, a nonsteroidal anti-inflammatory drug (NSAID) of choice, and tramadol should be given preoperatively. Presurgical fascia iliaca block with bupivacaine HCl may help bridge the period before LB takes effect. After both procedures, patients should receive 1 dose of intravenous acetaminophen, an NSAID, and opioid rescue medication as needed, starting with tramadol. Postoperative NSAIDs may help minimize opioid use. Patient and provider education are integral to managing patient expectations and alleviating concerns about pain and opioid use. Standardized, validated, and appropriately timed pain assessments are also necessary to optimize postsurgical pain management. These consensus recommendations regarding multimodal pain management protocols incorporating local infiltration analgesia with LB for extracapsular and intracapsular hip fracture procedures serve as a basis for additional research. Level V.

Infiltration Techniques for Local Infiltration Analgesia With Liposomal Bupivacaine in Extracapsular and Intracapsular Hip Fracture Surgery: Expert Panel Opinion.

Liposomal bupivacaine (LB) has demonstrated efficacy in improving pain scores and reducing opioid consumption across a variety of surgical settings, including orthopaedic surgery. However, meticulous infiltration techniques combined with a multimodal approach are important to optimizing outcomes. A panel of 4 orthopaedic surgeons and 3 anesthesiologists convened on April 1, 2017, to discuss current practices and develop a consensus statement regarding local infiltration analgesia with LB for extracapsular and intracapsular hip fracture surgery, including LB infiltration techniques. Optimizing surgical outcomes with LB in hip fracture surgery requires an understanding of the neuroanatomy of the surgical site and the pharmacology of the drug. Meticulous infiltration technique is critical to achieve optimal results with LB given its viscosity and reduced diffusion compared with bupivacaine HCl. For extracapsular procedures, a total injection volume of 120 mL is recommended, whereas intracapsular procedures typically require a lower volume (∼80 mL). In both cases, infiltration is best achieved using a 22-gauge needle and applying a tracking and/or fanning technique. To ensure optimal placement, LB should be infiltrated using multiple, small-volume (1- to 5-mL) injections spaced at 1.0-cm intervals. These consensus recommendations regarding LB infiltration techniques can serve as a resource for designing clinical studies to evaluate outcomes using periarticular infiltration of LB in extracapsular and intracapsular hip fracture surgery as part of a multimodal pain management approach. Level V.

Biomechanical evaluation of two extracapsular techniques for cranial cruciate ligament reconstruction in cadaver dogs

Cranial cruciate ligament rupture (CCLR) is one of the most important orthopedic conditions in dogs, leading to joint instability, pain, osteoarthritis and eventually to meniscal injuries. Several surgical techniques have been described to reestablish joint stability following CCLR, including extracapsular procedures. This study compared the biomechanical effects of two extracapsular stabilization techniques (lateral fabello-tibial suture – LFTS, and modified retinacular imbrication technique – MRIT) using nylon leader line following experimental CCLR in cadaver dogs. Twenty canine cadaveric stifles were used. Joint stiffness, cranial and caudal tibial displacement were evaluated in 4 different experimental scenarios: intact stifle, stifle with CCLR, CCLR treated with lateral fabello-tibial suture (LFTS), and CCLR treated with modified retinacular imbrication technique (MRIT). Results: Mean cranial tibial displacement increased progressively from intact to MRIT, LFTS and CCRL stifles. MRIT resulted in less caudal drawer motion than LFTS. Joint stiffness did not differ significantly between LFTS and MRIT treated stifles. Conclusion: LFTS and MRIT increase joint stability but MRIT is more effective; however none of the techniques studied was able to restore original intact stifle stiffness. Clinical implications of the results presented remain to be determined but kinetic gait analysis studies are warranted to determine whether this biomechanical advantage translates into improved hind limb function in dogs.

Sushruta in 600 B.C. introduced extraocular expulsion of lens material

It is generally accepted that Jacques Daviel introduced in the 18th century the extracapsular technique of extraction of the lens while the couching method of cataract operation had already been practiced since ancient times. Present study analyses the first known cataract surgery description in three translations into English from the original Sanskrit Sushruta textbook and all the available literature on the subject. We found evidences that some sort of extraocular expulsion of lens material through a limbal puncture (paracentesis) was described by the Indian surgeon. Nevertheless, this incision cannot be considered as a classic extracapsular procedure because it was not large enough to allow the extraction of the entire lens.

Allograft Nephrectomy: What Is the Best Surgical Technique?

BackgroundThe objective of this study was to evaluate differences in outcomes of allograft nephrectomies performed by extracapsular versus intracapsular techniques. MethodsFrom 1993 to 2010, we performed 89 allograft nephrectomies, including 57 by extracapsular techniques and 32 by intracapsular, chosen according to feasibility at the beginning of the surgery. Fisher exact test and logistic regression were used for statistical analysis. Survival estimates after allograft nephrectomy were calculated according to the Kaplan-Meier method. ResultsAfter a mean graft survival of 49.7 months, the indications for transplant nephrectomy were chronic rejection (39.3%), acute rejection (22.5%), infection/sepsis (19.1%), gross hematuria (6.7%), renal vein thrombosis (6.7%), renal artery thrombosis (3.4%), and graft rupture (2.3%). Mean operative time, blood loss, transfusions, and complications were similar between the extracapsular and intracapsular groups. The only difference in surgical aspects between the 2 groups was the mean hospital stay, which was longer for the extracapsular group (13.8 vs 7.6 days; P = .01), a result that was confirmed by multivariate analysis (odds ratio, 1.05; 95% confidence interval, 1.0–1.1; P = .03). ConclusionsOur experience showed no significant advantages in favor of the intracapsular technique except for a shorter length of hospital stay than after the extracapsular procedure.

Simultaneous bilateral cataract extraction

Purpose To evaluate the visual outcome and safety of simultaneous bilateral cataract extraction. Setting Stobhill Hospital NHS Trust, Glasgow, United Kingdom. Methods This retrospective case review comprised 259 consecutive patients (518 eyes) who had simultaneous bilateral cataract surgery. Surgeries included bilateral extracapsular procedures, uniocular extracapsular procedures performed simultaneously with a different type of intraocular lens surgery in the other eye, and 1 bilateral intracapsular procedure. Outcome measures were postoperative best spectacle-corrected visual acuity (BSCVA), intraoperative and postoperative complication rates, and conjunctival swab culture results. Results Eighty-three percent of patients (75% of eyes) with measured preoperative and postoperative BSCVA achieved an acuity of 6/12 or better. Intraoperative and postoperative complication rates were similar to those in previous reports of unilateral extracapsular surgery and simultaneous bilateral cataract surgery. Endophthalmitis occurred in 1 eye (0.19%). There were no bilateral complications that resulted in visual loss. Cultures were positive from 42% of conjunctival swabs; 81% of positive cultures were coagulase-negative Staphylococcus and 10% were Staphylococcus aureus. Conclusions Simultaneous bilateral cataract surgery did not lead to an increased incidence of serious intraoperative or postoperative complications, and visual acuity results were good.

A strategic approach to phacoemulsification based on nuclear density.

ARS AGO it was common practice to ing them learn intracapsular surgery first, followed by nucleus expression extracapsular procedures, followed then by phacoemulsification. It still remains a fairly common thought that one should learn phacoemulsification by first mastering iris plane phacoemulsification and then proceeding to endocapsular phacoemulsification. It is my opinion that following this pathway causes one to perform the inappropriate procedure in many eyes and that the decision-making process regarding the cataract surgery ought to be to perform the correct operation for that particular patient. Over a period of time one will learn to master various techniques based on their appropriateness and not based on any arbitrary chronological priority. I believe the thought process for cataract removal involves a series of decision points (Fig

Atonic Pupil: An Unusual Complication of Cataract Surgery

Eight cases of atonic pupil, an unusual complication following cataract surgery, are presented. Six of the eyes involved had intracapsular cataract extraction and anterior chamber intraocular lens implantation; one case underwent extracapsular cataract extraction with a posterior chamber intraocular lens implantation; the other had an extracapsular procedure with no implant. The etiology is unknown, but we believe the most likely one is that the sodium hyaluronate used in all these patients caused a temporary reduction of the iris blood supply by mechanical factors or by a vasoconstriction induced by some toxicity of the material that produced a lesion on the iris sphincter.

New Trends in Posterior Chamber IOL Implantation

The advantages that the intercapsular technique for cataract extraction offers over the more traditional extracapsular procedures are discussed. The authors' personal experiences with 800 cases are presented.

Cystoid macular edema in pediatric aphakia.

The presence of cystoid macular edema (CME) after cataract extraction in the pediatric age group could adversely affect rapid visual rehabilitation of the eye by contributing to irreversible amblyopia. Several previous studies, including one by our group, have addressed this problem. Hoyt's observations of CME in ten of 27 eyes undergoing lensectomy-vitrectomy procedures have stirred renewed interest in this topic. The current study includes 12 eyes undergoing lensectomy-vitrectomy procedures, five eyes undergoing manual extracapsular procedures (ECCE) with discission of the posterior capsule, three eyes undergoing ECCE without discission of the posterior capsule, and three eyes undergoing secondary discissions. No CME was found angiographically on postoperative evaluation.

Retinal detachment following intraocular lens implantation.

This report concerns a consecutive series of 154 pseudophakic eyes in which primary scleral buckling procedures were performed for rhegmatogenous retinal detachments. Most cases involved eyes in which extracapsular surgery had been combined with iridocapsular implants or posterior chamber lenses or in which iris-fixation intraocular lenses were placed following intracapsular surgery. The characteristics of the detachments were similar, although there was a trend towards an increased incidence of significant preoperative proliferative vitreoretinopathy in the intracapsular cases. Anatomical success rates were over 90% in all groups. There was a trend for lower visual acuities following successful surgery in the eyes in which intracapsular surgery had been performed than in those following extracapsular procedures.

Cataract Surgery in Patient Who Sneezes-Reply

In Reply.— Drs Gross and Hoffer recommend phacoemulsification cataract extraction for the patient described in the original question. I would agree that an extracapsular extraction is safer for this man, and I would prefer it to an intracapsular procedure. The question as to whether phacoemulsification is safer than a planned extracapsular is somewhat moot. It is true that phacoemulsification can be done through a 3-mm incision, but since we all agree that an intraocular lens is appropriate, the incision would have to be enlarged to 7 mm to insert the lens. Planned extracapsular cataract surgery can be done comfortably through a 10-mm incision. There may be some advantage to an incision 3 mm smaller, but I do not believe this is critical. The essential point is the one with which we all agree—an extracapsular procedure would be safer than intracapsular extraction. As to general anesthesia for this patient, I agree

Pseudophakic retinal detachments.

Primary scleral buckling procedures were performed for rhegmatogenous retinal detachments in a consecutive series of 179 pseudophakic eyes. Most cases involved eyes in which extracapsular surgery had been combined with iridocapsular implants or posterior chamber lenses or in which iris-fixation IOLs were placed following intracapsular surgery. The characteristics of the detachments were similar, regardless of the type of cataract surgery employed, although there was a trend toward an increased incidence of significant preoperative proliferative vitreoretinopathy in the intracapsular cases. Anatomic success rates were greater than 90% in all groups. There was a trend for lower visual acuities following successful surgery in the eyes in which intracapsular surgery had been performed than in those following extracapsular procedures.

Anterior-posterior stiffness and laxity of the knee after major ligament reconstruction.

We recorded anterior-posterior force-versus-displacement curves at 20 and 90 degrees of flexion preoperatively and three years after major ligament reconstruction in patients with documented absence of the anterior cruciate ligament. Patients who had an extracapsular stabilization procedure alone showed no significant changes in laxity or stiffness of the injured knee in either position of flexion. Those who underwent reconstruction of the absent anterior cruciate ligament utilizing the middle or medial one-third of the patellar ligament in addition to the extracapsular procedure showed a significant decrease in anterior laxity and increase in anterior stiffness of the injured knee at 20 degrees of flexion. These changes in stability were not observed at 90 degrees of flexion. Six patients with a cruciate substitution had improved laxity and stiffness values at one year postoperatively which were unchanged at three years. At three-year follow-up the increases in activity scores, decreased feelings of giving-way and pain, and elimination of the pivot shift were comparable in both groups of patients.

Deposits on the surface of intraocular lenses: a pathologic study.

The clinical course of implanted intraocular lenses is frequently complicated by the formation of deposits or "precipitates" on the lens surfaces. These lesions are related to the amount of inflammation in the eye, the use of pilocarpine, and the presence of lens cortex in extracapsular procedures. Corticosteroids cause the lesions to diminish or disappear. Similar lesions seen in the course of lens implantation in laboratory animals are found on histologic examination to be accumulations of inflammatory cells. In the chronic state the cells are macrophages, epithelioid cells, and giant cells, accompanied in the early stages by acute inflammatory leukocytes. The relationships between these cells, inflammation, the presence of the foreign body, and the chemistry of methacrylate are difficult to sort out.

The Evolution of the Anterior Chamber Implant up to, and Including, the Choyce Mark IX

Since 1963, the Choyce Mark VIII lens, a quadrupedal, anterior chamber implant, has proved satisfactory following conventional intracapsular surgery in eyes of normal size, but less successful after primary extracapsular procedures and in small eyes. Reducing some of its dimensions by as much as 30% enables the surgeon to treat a much wider range of cataract problems through a smaller incision. The reduced-size version is known as the Choyce Mark IX anterior chamber implant. The quadrupedal principle has been preserved.

One-day hospitalization for extracapsular cataract surgery without phacoemulsification.

A technique is described for an extracapsular cataract extraction that combines the advantage of freedom of activity associated with phacoemulsification without many of the disadvantages of this procedure. The technique retains one of the advantages of a small wound, the use of the irrigating cystotome, with an advantage of a large wound, ease of delivery of a firm nucleus. An intact posterior capsule is maintained. Although it is similar to the one-day intracapsular method that we described, the present procedure preserves the advantages of a well planned extracapsular extraction for the situations in which intracapsular surgery is not desirable. The technique has been used in 25 cases which have been followed longer than nine months, in which there have been no complications nor secondary opacification of the posterior capsule. The desirable and undesirable features of phacoemulsification, classical extracapsular, our extracapsular and intracapsular procedures have been compared. Comparison with the techniques of lens extraction through a pars plana approach is beyond the scope of this paper.