Interposition Graft Research Articles

Treatment of along defect fracture of the right lower leg using medullary nailing, cage interposition and autologous spongiosa graft (MaCIS) in aUkrainian soldier

This article presents the MaCIS method for treatment of long defect fractures of long bones using the example of aUkrainian soldier. This method includes locking medullary nailing of the affected long bone by an individually tailored cage interposed through the defect and filling of the cage with autologous spongiosa. In comparison to bone segment transport this method results in immediate full load-bearing capability of the affected extremity with substantially higher patient comfort.

Our Surgical Results in Popliteal and Infrapopliteal Artery Injuries: 21 Cases without Amputation.

Popliteal and infrapopliteal artery injuries have significant morbidity and mortality rates, especially in terms of amputation. In our study, we aimed to evaluate patients who operated due to popliteal and infrapopliteal vascular injuries in our clinic. Patients and Methods. Between 2016 and 2023; 21 patients who were operated in our clinic due to popliteal and infrapopliteal artery injuries were retrospectively evaluated. 2 of the patients were female (9.5%) and 19 were male (90.5%). Age ranges were 21-78. The causes of injury were gunshot wounds in 9 patients (42.86%), blunt trauma in 7 patients (33.33%), and sharp object injuries in 5 patients (23.80%). Reversed saphenous vein interposition in 7 patients (33.33%), primary repair in 6 patients (28.57%), 6 mm polytetrafluoroethylene graft (PTFE) interposition in 3 patients (14.28%), end-to-end anastomosis in 2 patients (9.52%), saphenous-PTFE composite graft interposition in 2 patients (9.52%), and embolectomy in 1 patient (4.76%) were performed. Arterial ligation was not performed. Simultaneous orthopedic intervention was performed in 8 patients. Fasciotomy was performed in 3 patients. Venous repair was performed in 5 patients with venous injuries. Vein ligation was not performed. Mortality was observed postoperatively in 1 patient. No patient developed amputation. Foot drop developed with nerve damage in 2 patients. Mortality and morbidity rates may increase in popliteal and infrapopliteal artery injuries in cases of hemodynamic disorder, simultaneous bone fracture, multivessel injury, and nerve transection. These rates can be reduced by appropriate surgical repair and ensuring hemodynamic stability.

The Medial Antebrachial Cutaneous Nerve Is a Low-Morbidity Alternative to the Standard Sural Nerve Autograft.

Nerve interposition grafting is an important technique in nerve reconstructive surgery that is used when a primary repair is not feasible without significant tension. This study sought to evaluate the long-term morbidity of the medial antebrachial cutaneous (MABC) nerve as an alternative donor nerve in comparison with sural nerve harvest. A single surgeon and institution retrospective chart review was performed to identify all patients who underwent nerve autografting using the sural and MABC as donor nerves between January 1, 2000 and December 31, 2019. Surveys assessed overall patient satisfaction with surgery, as well as donor and recipient site morbidity, satisfaction, pain, numbness, and cold sensitivity. Of the 73 patients contacted, 54 agreed to participate, and 43 of 73 (58.9%) ultimately completed the survey: 28 MABC (65.1%) and 15 sural (34.9%). There were no significant differences between the sural and MABC groups in overall satisfaction with surgery, donor and recipient site satisfaction, pain, cold sensitivity, and effect on quality of life. Even though 66.7% of sural donor sites and 75% of MABC donor sites had residual numbness, the effect this had on quality of life was very low (2 and 3, respectively). The MABC is a safe alternative to the traditional sural nerve autograft. A small subset of patients undergoing nerve autograft harvest will experience long-term morbidity in the form of pain. Conversely, the more common presence of numbness is not reported as bothersome.

In situ interposition bypass for complex intracranial aneurysms: A single-center experience and efficacy analysis.

The purpose of this study was to investigate the application and efficacy analysis of in situ interposition bypass in complex intracranial aneurysms. This study retrospectively analyzed the clinical data of 21 patients with complex intracranial aneurysms treated with in situ interposition bypass grafting in the Department of Neurosurgery at Tianjin Huanhu Hospital from June 2015 to December 2022. The aneurysms were located in the middle cerebral artery in 16 cases, the anterior cerebral artery in 3 cases, the posterior cerebral artery in 1 case, and the posterior inferior cerebellar artery in 1 case. The interposition graft vessels were taken from the radial artery in 15 cases, the superficial temporal artery in 5 cases, and the occipital artery in 1 case. All patients underwent end-to-end anastomosis with in situ interposition bypass after aneurysm resection, including 13 cases of "I-shaped" type, 5 cases of "V-shaped" type, and 3 cases of "Y-shaped" type. Postoperative digital subtraction angiography (DSA) or computed tomography angiography (CTA) reviews were performed for all the patients, and modified Rankin Scale (mRS) score was used to assess patient prognosis. Three patients developed postoperative basal ganglia infarction and two of them recovered well. One case developed transient incomplete aphasia and one case developed mild hemiparesis, which recovered well after 3months. The remaining 16 patients did not develop new neurological deficits. Postoperative DSA or CTA showed that the anastomosis of the bypass graft and the graft vessels were patent, and all aneurysms were completely eliminated. Regular postoperative follow-up ranged from 3 to 89months, and no aneurysm recurred. The percentage of patients with mRS ≤ 2 at the final follow-up was 90.5%. Based on the experience of surgical treatment in our center, in situ interposition bypass technique is a safe and effective option for the treatment of some complex intracranial aneurysms.

Vascular Pancreatic Surgery with Interposition Grafts: Mortality Depends on Timing with Respect to Previous Pancreatic Resections

Vascular Pancreatic Surgery with Interposition Grafts: Mortality Depends on Timing with Respect to Previous Pancreatic Resections

Popliteal artery aneurysmal dilatation by intimomedial mucoid degeneration causing emergency limb ischemia: a case report and literature review

ntimomedial mucoid degeneration (IMMD) is an extremely rare vascular condition characterized by mucin accumulation in the intima and media, resulting in arterial wall elastic tissue degradation and aneurysm formation. We report the case of a 34-year-old woman who presented to the emergency department with a 1-month history of left lower limb pain. On local physical examination, both lower limbs were warm with palpable regular pulses in the entire lower limbs and normally capillary refill. No palpable masses were felt. Computed tomography angiography (CTA) of the lower limbs revealed an aneurysm with a thrombosed sac in the left popliteal artery behind the knee joint. Thoracic and abdominal CTA revealed normal findings. The patient underwent posterior exploration of the left popliteal artery, which revealed a large aneurysm requiring excision, and an interposition vein graft end-to-end anastomosis was performed. Histopathological examination of the aneurysm disclosed the presence of fibrosis, scattered chronic inflammatory cells, and a hyalinized fibrin thrombus associated with marked fragmentation and distortion of the elastic tissue. Extensive mucoid deposition in the intima and media of the artery was also detected. The postoperative recovery was uneventful, and the patient was discharged home with regular follow-up during the last year in our outpatient clinic. IMMD can affect smaller vessels such the brachial, coronary, temporal arteries, and dorsalis pedis. The main histological hallmarks of IMMD include intimal and medial thickening caused by the formation of mucin pools, which leads to elastin fibers fragmentation and aggregation. The prognosis of IMMD-related aneurysms is determined by the extent of the disease and the time it is discovered. IMMD-related aneurysms should be included in the differential diagnosis of isolated popliteal artery aneurysms. Open surgical repair is the gold standard of treatment for IMMD-related aneurysms.

Septal perforation

Aim: This study isolates septal perforations due to nasal surgery for clinical analysis and their effect on bilateral mucosal flap repair. Methods: This is a retrospective review of a single surgeon’s 20-year experience with endonasal perforation repair utilizing bilateral mucosal advancement flaps supported with an autologous tissue interposition graft. Patients with a minimum of 4-month postoperative follow-up were included in the study. Comparative analyses of repair failure rates and perforation size of failures between surgical and non-surgical etiologies were performed. Results: Three hundred ninety-two patients met the criteria for inclusion in the study. The incidence of perforation and prior septal surgery was 40.6%. Overall repair closure in patients with a minimum of 4 months follow-up was 94.8%. Failures were noted in 5.7% of surgical and 4.7% of non-surgical perforation etiologies (P = 0.816). Mean differences in perforation length and height in failed repairs between non-surgical and surgical etiologies (19.4 vs. 13.7 and 15.5 vs. 9.3 mm, respectively) were significant (P = 0.048 length, P = 0.006 height). Conclusion: Post-surgical nasal septal perforations can be repaired with a low rate of failure. However, this study found that the size of perforations in failed repairs was significantly smaller in patients with a history of septal surgery, suggesting that prior septal surgery increases the technical difficulty of a bilateral flap perforation repair.

Complications of ankle arthroscopy: frequency, prevention, and treatment.

The complication rate of ankle arthroscopy (AA) ranges from 3.5% to 14%. To avoid such complications, it is essential to have a thorough understanding of the anatomy of the ankle, to perform the procedure very carefully and with appropriate instrumentation, and to use a non-invasive distraction technique. The most frequent complications are neurological (cutaneous nerve injuries), which are usually caused by direct injury during arthroscopic portals or by a distracting pin when using an invasive distraction technique. They usually resolve spontaneously within a few months. The iatrogenic formation of a pseudoaneurysm is a severe but extremely rare complication (an incidence of 0.008%). There are several treatments for pseudoaneurysms: external compression; direct thrombin injection, surgical intervention (resection of the damaged segment of the artery and reconstruction with a reversed long saphenous vein interposition graft), and endovascular embolisation. Other rare complications include wound infections (localised superficial infection), problems at the portal incisions (prolonged portal drainage, residual pain in the portal, portal scar dehiscence, cyst at the portal site), type I complex regional pain syndrome, instrument breakage, painful scars and nodules, and a number of other rarer complications. In conclusion, when performing AA, it is important to remember the potential complications and try to avoid them. When they do occur, it is essential to diagnose and treat them appropriately.

Less invasive bonnet bypass with subcutaneous tunneling method for common carotid artery occlusion - A technical note.

Common carotid artery occlusion (CCAO) sometimes requires vascular reconstruction. Ipsilateral superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is unsuitable due to insufficient blood flow to the external carotid artery. The bonnet bypass, one treatment option for CCAO, requires a long coronal incision and bone groove to prevent malposition and collapse of an interposition graft. However, this long incision might lead to skin complications and reduced collateral blood flow. A 60-year-old man who experienced recurrent ischemic stroke presented with the right internal carotid artery occlusion and left CCAO. The left STA was unavailable; however, both branches of his right STA were well-developed. Minimizing skin invasion was a priority because the patient had diabetes mellitus. We performed a right STA parietal branch - right MCA anastomosis, followed by a right STA frontal branch - left radial artery graft (RAG) - left MCA bonnet bypass using small intermittent skin incisions. We drilled a bone groove extending across the entire length of the interposition graft through the small intermittent skin incisions. Furthermore, we applied a right STA-RAG end-to-side anastomosis instead of an endto-end anastomosis to preserve collateral skin anastomosis. Postoperatively, the bypass remained patent, and the patient was discharged without complications. The bonnet bypass is a potential treatment for CCAO, but the procedure is invasive. Our modified bonnet bypass method enables less invasive management, preventing collapse and malposition of the interposition graft and minimizing skin complications.

Hypoglossal Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-Analysis.

Background: Hypoglossal-facial nerve (12-7) anastomosis can restore symmetry and voluntary movement on the face in patients with facial nerve paralysis. Traditional 12-7 transfer includes direct end-to-end nerve anastomosis, sacrificing the entire hypoglossal nerve. Contemporary, end-to-side anastomosis, or split anastomosis techniques limit tongue morbidity by preserving some hypoglossal nerve. Direct outcome comparisons between these techniques are limited. Objective: To compare reported outcomes of facial movement, tongue, speech, and swallow outcomes among the different types of hypoglossal-facial nerve anastomosis schemes. Evidence Review: For this systematic review and meta-analysis, a comprehensive strategy was designed to search PubMed, Scopus, and the Cochrane Database from inception to January 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, reporting guideline yielding 383 results. Any participant who underwent 12-7 transfer using any of the three techniques, with or without an interposition graft, and had documented preoperative and postoperative evaluation of facial nerve function with a validated instrument such as House-Brackmann (HB), was considered for inclusion. Secondary outcomes of synkinesis, tongue atrophy, and speech or swallowing dysfunction were also compared. Forty-nine studies met inclusion criteria, representing data from 961 total patients who underwent 12-7 transfer. Results: The proportion of good HB outcomes (HB I-III) did not differ by anastomosis type: End-to-side and end-to-end anastomosis (73% vs. 59%, p = 0.07), split and end-to-end anastomosis (62% vs. 59%, p = 0.88), and end-to-side anastomosis and split anastomosis (73% vs. 62%, p = 0.46). There was no difference in reported synkinesis rates between the anastomosis types. However, end-to-side anastomosis (z = 6.55, p < 0.01) and split anastomosis (z = 3.58, p < 0.01) developed less tongue atrophy than end-to-end anastomosis. End-to-side anastomosis had less speech/swallowing dysfunction than end-to-end anastomosis (z = 3.21, p < 0.01). Conclusion: End-to-side and split anastomoses result in similar HB facial nerve outcomes as the traditional end-to-end 12-7 anastomosis. End-to-side anastomosis has decreased complications of tongue atrophy and speech/swallow dysfunction compared to end-to-end anastomosis. In addition, split anastomosis has decreased rates of tongue atrophy compared to end-to-end anastomosis.

Facial Reanimation After Intratemporal Facial Nerve Schwannoma Resection: A Systematic Review.

Objective: To systematically analyze the outcomes of reanimation techniques that have been described for patients undergoing non-fascicle sparing resection of intratemporal facial schwannomas. Methods: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines of the PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials databases. Results: Eight hundred forty studies were screened with 22 meeting inclusion criteria comprising 266 patients. Most facial nerve reanimations (81.2%) were performed using an interposition nerve graft. The remaining patients underwent hypoglossal-facial nerve transposition (13.9%), primary anastomosis (3.4%), and free muscle transfer (0.1%). Of the reported interposition grafts, the two most utilized were the great auricular (113/199) and sural (86/199) nerves. Interposition nerve grafts resulted in significantly better outcomes in facial nerve function postoperatively than hypoglossal-facial transposition (3.48 vs. 3.92; p < 0.01). There was no difference between interposition grafts. Conclusion: This study systematically reports that interposition nerve grafts, after resection of intratemporal facial schwannoma, result in superior outcomes than hypoglossal-facial nerve transposition in these patients.

Angiographic and Clinical Outcomes of Various Techniques of Intracranial-to-Intracranial Bypass for Complex Cases with a Review of Pertinent Literature and Illustrated Cases

We sought to determine the utility of intracranial-to-intracranial bypass (IIB) surgery and the available bypass options for complex cases. A total of 18 IIB cases were included. Each case was classified as IIB with or without an interposition graft. The clinical and angiographic status were evaluated pre- and postoperatively and at the last follow-up. Angiographic images were analyzed and reconstructed schematically. Postoperative angiography was used to measure the bypass patency and the presence of postoperative cerebral infarction. The recipient artery occlusion time for each bypass was measured. Of the 18 patients, 14 had presented with a complex intracranial aneurysm (IA), 1 with vertebrobasilar dolichoectasia, and 3 with intracranial arterial steno-occlusive disease. Ten patients had an incidentally discovered IA. Seven patients had presented with neurological deficits due to ischemia or aneurysmal mass effects. Of the 18 cases, 10 were IIBs with an interposition graft, including 4 cases of superficial temporal artery and 6 of radial artery graft bypass, and 8 were IIBs with a noninterposition graft, including 3 cases of in situ bypass, 1 case of reanastomosis, and 4 cases of reimplantation. The pre- and postoperative modified Rankin scale score did not change or improve, and all the bypasses were patent. No patient had died during the mean follow-up period of 50.0 months. The mean occlusion time of the recipient artery was 59.5 minutes. A total of 8 patients experienced postoperative cerebral infarction but all had almost recovered at discharge. With proper selection of the IIB type, IIB can be a suitable treatment option for some patients with complex IAs and intracranial arterial steno-occlusive disease when extracranial-to-intracranial bypass is not feasible.

The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery And Orthopedic Injuries

The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a level 1 trauma center from 2014 to 2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing the operative order were analyzed. Twenty-nine patients were treated for popliteal artery injuries. Twelve of these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and open reduction internal fixation (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend toward lower blood pressure on arrival (P=0.068). There was no significant difference in emergency department to operating room (OR) time, OR time, ISS, mangled extremity severity score, estimated blood loss, or blood transfusion for the sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs. 100%, P=0.19). Of the remaining limbs available for follow-up, limb salvage at 4.25years is 100%. In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.

Interposition Grafting Using Fascia Lata Autograft for Failed Rotator Cuff Repairs

Massive rotator cuff tears are a huge challenge for orthopaedic surgeons, as the patients may be in need of multiple operations, even including reverse total shoulder arthroplasty. The various repair methods for the rotator cuff, such as partial rotator cuff repair, patch-augmented rotator cuff repair, bridging rotator cuff reconstruction with graft interposition, tendon transfer, and superior capsular reconstruction, have always been the focus of research. During surgical intervention for failed rotator cuff repairs, complexity of tears, poor tissue quality, retained hardware, and adhesions are the problems routinely encountered. In this Technical Note, we describe the technique of interposition grafting using fascia lata autograft to reconstruct the rotator cuff after failed primary repair.

Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series.

Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach. Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023. Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved. The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.

Outcomes of Selective Arthrodesis Based on Joints Affected in 33 Feet With Müller-Weiss Disease

No consensus exists regarding operative treatment of Müller-Weiss disease (MWD). Its only classification is based solely on Méary's angle and serves neither as guide to management nor prognosis. We report on 33 feet that underwent surgery following failed conservative management. Treatment was directed towards joint(s) involved, as determined by clinical examination, plain radiography and SPECT-CT. Thus, surgery consisted of isolated talonavicular in 6 feet, triple in 8, subtalar and talonavicular in 7, talonaviculocuneiform in 4, talonaviculocuneiform with interpositional tricortical iliac crest graft in 6 and pantalar arthrodesis in 2. PROMIS scores for pain interference and depression decreased significantly (p < .001) with significant accompanying increase in physical function (p = .003). Union occurred in 31 of 33 feet (94%) with complete resolution of pain at an average follow-up of 84 months. Of the 2 nonunions, 1 had fracture through the lateral navicular, and the other marked sclerosis and avascularity of the lateral navicular. We describe our pathways for selecting arthrodesis based on the joints affected. Isolated talonavicular arthrodesis was performed in early stages of MWD, which begins at the talonavicular articulation. When disease extended to both sides of the navicular, we performed talonaviculocuneiform arthrodesis. When considering isolated talonavicular, double medial or triple arthrodesis, there should be adequate cancellous bone stock remaining in the lateral part of the navicular, as determined on medial oblique radiographs and CT scan. In case of inadequate bone stock or fracture through the lateral navicular, talonaviculocuneiform arthrodesis with interpositional iliac crest bone graft is recommended.

Comparing Outcomes of Acute Versus Gradual Surgical Correction in Brachymetatarsia

Brachymetatarsia consists of a shortened metatarsal resulting in a shorter toe. Pain with shoe wear and cosmetic concerns are the main reasons for surgical intervention. Surgical techniques to increase metatarsal length include acute lengthening with interpositional bone grafting or gradual lengthening with callus distraction. We performed a retrospective cohort study for 1 surgeon's patients at 1 institution over 10 years. Twenty-nine feet in 22 patients met inclusion criteria for acute correction; 16 feet in 11 patients were included for gradual correction. Mean ages were 26.3 ± 12.1 and 27 ± 10.8 in the acute and gradual groups, respectively (p = .79). Most patients were female: 95.4% of acute cases and 90.1% of gradual cases. Most involved lengthening the fourth metatarsal: 86.7% and 100% of acute and gradual groups, respectively (p = .54). Correction obtained amounted to 14.4 ± 2.97 mm (range, 10-22 mm) in acute cases and 14.8 ± 2.39 mm (range, 10-20 mm) in gradual cases (p = .81). The mean percent increase in metatarsal length was 21.1 ± 14% for acute and 22.6 ± 12.4% for gradual (p = .72). Mean consolidation was 8.9 ± 2.51 weeks for acute and 21.4 ± 10.8 weeks for gradual (p = <.001). Nonunions were most common in the gradual group (37.5%) with need for more revisional surgery (43.5%) compared with the acute group; both were statistically significant. We conclude that acute brachymetatarsia correction can obtain correction similar to the gradual technique with fewer postoperative complications and less osseous consolidation time.

The "Standing Peanut" Scaphoid View: A Semi-supinated Radiographic View for Intraoperative Evaluation of Screw Placement in Scaphoid Waist Fractures.

Scaphoid waist fractures are the most common fracture of the scaphoid. Operative management is indicated with unstable fractures and often for nondisplaced waist fractures to decrease time to union and return to work/sport. Screw placement within the central axis of the scaphoid is paramount and correlates with outcomes. Assessment of intrascaphoid screw placement is classically done via intraoperative fluoroscopy. An additional fluoroscopic view is presented to assist in confirming implant positioning. Along with the standard anterioposterior, lateral, pronated oblique, and "scaphoid" view we obtain a "standing peanut" view for assessment of central screw placement. This view also allows for further evaluation of center/center positioning and better assessment of fixation crossing the fracture into the proximal pole. The "standing peanut" view is best obtained in a sequential manner beginning with the forearm in neutral rotation. First, the forearm is then supinated 30 degrees; next, the wrist is placed at 45 degrees of ulnar deviation. Then finally, 10 degrees of wrist extension. We utilize this additional intraoperative view in conjunction with the standard fluoroscopic views for assessing and ensuring center-center implant positioning, particularly within the proximal pole. When ensuring center-center positioning, we prefer this view as an adjunct view to the standard fluoroscopic views intraoperatively. It provides a beneficial view of the proximal pole delineating the number of screw threads that have obtained proximal pole purchase. We have found it particularly useful in the setting of scaphoid waist fracture nonunion with the classic 'humpback' deformity after correction with volar interposition grafting. Standard radiographic views may be misinterpreted regarding implant positioning if there remains any residual flexion. The view requires little in the way of training to obtain once appreciated and exposes the patient to minimal additional radiation.

Comparison of Open and Endovascular Aneurysm Repair in Native Arteriovenous Fistulas

Arteriovenous accesses develop aneurysms (FA) during their active use, resulting in pain, erosion, bleeding, and difficulty in cannulation. This study aims to evaluate the outcomes of open and endovascular management of single FA in arteriovenous fistulas (AVF). A retrospective review of all upper extremity primary AVFs over 12years was undertaken at a single center. Patients undergoing elective open and endovascular repair of a single FA were identified. Thirty-day outcomes, cannulation failure, line placement, re-intervention, and functional dialysis (continuous hemodialysis) for 3 consecutive months were examined. Three hundred and seventy nine patients presented with a single FA that met the requirements for intervention: 126 (33%) underwent endovascular repair, and the remainder 253 (67%) underwent open repair. Preoperative fistulogram identified anatomically significant issues in 91% of the cases, and these were treated by balloon angioplasty: 10% within the fistula tract, 44% within the outflow tract, and 47% in the central veins. In open repair, 57% underwent plication, 35% underwent resection and re-anastomosis, and the remainder (8%) underwent interposition grafting. In endovascular repair, successful placement of a stent was achieved in all cases with 1±2 (mean±standard deviation [SD]) covered stents (diameter: 6 -8 mm) placed, achieving successful exclusion of the FA. The combination of early thrombosis and cannulation failures led to the greater need for a tunneled central line in endovascular repair (6.5% vs. 2.4%; endovascular versus open repair; P=0.04). As a result, the mean time for establishing renewed access in the index AVF was significantly higher in endovascular repair (2±3 vs. 2±2weeks, mean±SD; endovascular open repair versus open repair; P=0.001). In follow-up, there were more secondary interventions per year in the endovascular compared to open repair groups (3.1 vs. 1.4 secondary interventions per year; endovascular versus open repair; P=0.04). Median functional dialysis durations were superior in the open repair (48±6%, mean + standard error) compared to the endovascular repair at 5years. (26±7%; P=0.03). Open repair results in a more rapid return to access use, lower need for a tunneled central line, lower secondary re-intervention rates, and superior functional dialysis durations compared to endovascular repair. Open FA repair should be considered for symptomatic single FA repairs before endovascular FA repair.

Comparison of Arterial and Venous Interposition Grafting for Arterial Defects in a Rat Model.

Interposition microvascular grafting may be required to bridge arterial defects during digital replantation or revascularization and has traditionally been performed utilizing a venous autograft. Arterial interposition grafting has been shown to be superior in maintaining patency in large vessel surgery; there are case reports of its use in microsurgery. Six fellowship-trained hand and microsurgeons performed arterial and venous interposition grafts on the femoral arteries of 40 Wistar rats. After sectioning one femoral artery a segment of the contralateral femoral artery or vein was obtained. The time was recorded per graft and patency tested 10 minutes following grafting by an independent assessor. Each surgeon also completed a questionnaire detailing regular microsurgical volume, technical ease, and conceptual preference for either graft. Time for arterial interposition (median time 51.7 minutes) was longer than venous grafting (median time 45.9 minutes, p = 0.075). Arterial grafts were more likely to be patent or questionably patent (odds ratio [OR] = 6.77, p = 0.031). All surgeons found arterial interposition grafting technically easier and preferred it conceptually. Improvements were noted in patency rates (OR = 11.29, p = 0.018) and avoidance of anastomotic leak (OR = 0.19, p = 0.029) when surgeons performed moderate levels or greater of microsurgery within their regular practice. Greater immediate patency was noted with arterial interposition grafting in a rodent model when compared to venous grafting, although procedural time was greater. All surgeons found arterial grafting technically easier. Arterial microvascular grafting may be useful in the setting of digital replantation or revascularization with an arterial defect.