Ipsilateral Reoperation Research Articles

Young age, female gender, Caucasian race, and workers’ compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction

Given the increasing incidence of arthroscopic anterior cruciate ligament reconstruction (ACLR), mid- to long-term rates of reoperations were investigated on the ipsilateral knee following ACLR. New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2003 to 2012 to identify patients with a primary ICD-9 diagnosis for ACL tear and concomitant CPT code for ACLR. Patients were longitudinally followed for at least 2years to determine incidence and nature of subsequent ipsilateral knee procedures. The inclusion criteria were met by 45,231 patients who had undergone ACLR between 2003 and 2012. Mean age was found to be 29.7years (SD 11.6). Subsequent ipsilateral outpatient knee surgery after a mean of 25.7 ± 24.5months was performed in 10.7% of patients. Revision ACLR was performed for nearly one-third of reoperations. Meniscal pathology was addressed in 58% of subsequent procedures. Age 19 or younger, female gender, worker's compensation (WC) insurance, and Caucasian race were identified as independent risk factors for any ipsilateral reoperation. An initial isolated ACLR and initial ACLR performed by a high-volume surgeon were found to be independently associated with lower reoperation rates. Tobacco use was not significant. Survival rates of 93.4%, 89.8% and 86.7% at 2-, 5- and 10years, respectively, were found for any ipsilateral reoperation. A 10.7% ipsilateral reoperation rate at an average of 25.9 (SD 24.5) months after ACLR and an overall ACLR revision rate of 3.1% were demonstrated by the analysis. Meniscal pathology was addressed in the majority of subsequent interventions. Age 19 or younger, female gender, Caucasian race, and WC claim were associated with reoperation. Initial isolated ACLR and procedure performed by high-volume surgeon were associated with reduced reoperation. Level III.

Impact of paravertebral blockade use in geriatric patients undergoing thoracic surgery on postoperative adverse outcomes.

While it is known that thoracic paravertebral blockade (TPVB) could reduce pain undergoing thoracic surgery, it has not been confirmed whether this reduction in pain reduces pulmonary complications in an elderly population. We performed a monocentric retrospective analysis for a prospectively collected patients receiving thoracic surgery with or without intraoperative TPVB between November 7, 2018 and April 1, 2019, at Shanghai Chest Hospital. Whether or not to use TPVB depending on anesthesiologists' preference, the chances of harm and benefit of each patients after discussed with their anesthetist. Chest wall resection, bilateral lung resection, conversion to thoracotomy and ipsilateral reoperation were excluded. A total of 154 patients with lung operations were included in the final analysis, 34 of whom received general anesthesia combined with TPVB (GA-TPVB). The primary outcome was the incidence of postoperative pulmonary complications (PPCs). The secondary outcomes were the incidence of cardiovascular and other complications, required analgesia in post anesthesia care unit (PACU), patient controlled analgesia (PCA) pressing frequency in 24h, chest tube duration, ICU stay and the hospital length of stay (LOS). The incidence of PPCs undergoing thoracic surgery was about 21.4% (33/154). Compared with GA, GA-TPVB could reduce the incidence of PPCs (25% vs. 9%, P=0.042), mostly reduce postoperative atelectasis (19% vs. 3%, P=0.021). TPVB could reduce the rate of required analgesia in PACU, PCA pressing frequency in 24 h and chest tube duration. However, there were no significant differences on the rate of cardiovascular and other complications, ICU stay and LOS between the two groups (P>0.05). Multivariable logistic regression analysis identified preoperative DLCO% ≥92% (OR =0.293, P=0.006), duration of surgery <75 min (OR =0.278, P=0.008) and GA-TPVB (OR =0.270, P=0.048) was associated with fewer PPCs. Our study shows that general anesthesia combined with TPVB may reduce PPCs by reducing postoperative pain in geriatric patients undergoing thoracic surgery compared with general anesthesia alone. Chinese Clinical Trial Registry number, ChiCTR1800019526. Registered on Nov 7, 2018.

EP1.18-08 Pulmonary Lobectomy and Completion Pneumonectomy for Ipsilateral Lung Cancer After Radical Resection

Ipsilateral reoperation such as lobectomy and completion pneumonectomy after radical resection of lung cancer is a high-risk operation. We evaluated outcomes after these operations in our hospital. We retrospectively reviewed the records of 27 patients who underwent ipsilateral lobectomy or completion lobectomy for new primary lung cancer or recurrence after pulmonary lobectomy or bi-lobectomy between 1998 and 2017. 9 patients underwent completion lobectomy, of which 4 were right and 5 were left, and 18 patients underwent lobectomy. Mean operative time was 308.7±27.4 minutes, and mean blood loss was 706.9±254.3mL. Blood loss was significantly higher in completion pneumonectomy patients as compared to lobectomy patients, whereas operative time was not different between the operations. There was no perioperative mortality, but intraoperative complications were seen in 4 cases (14.8%), which were 2 pulmonary artery injury, superior venous cava injury and azygos vein injury. Perioperative morbidity was seen in 8 cases (29.6%), and postoperative bronchopleural fistula occurred in one case. Fourteen patients had Pathological stage IA disease, 6 had IB, and 5 stage II or over. As clinical outcome, 5-year overall survival rate was 71.1%. Pulmonary lobectomy or completion pneumonectomy for ipsilateral lung cancer after radical resection were performed in 27 patients without perioperative mortality. Our results strongly suggests that this strategy is a meaningful option for new or recurrent ipsilateral lung cancer.

Feasibility Investigation of Ipsilateral Reoperations by Thoracoscopy for Major Lung Resection.

Video-assisted thoracoscopic surgery (VATS) has become the preferred approach for minimizing harm from thoracic operations. There is no report, however, which has discussed the feasibility of VATS in ipsilateral reoperation of major lung resection. The present study included patients who had undergone ipsilateral reoperation of major lung resection by VATS from October 2009 to May 2017. Referring clinical data were recruited for analysis. Fourteen patients were recruited in the present study, including nine patients who underwent lobectomy and five who underwent segmentectomy during the second operation. Different hila were found in 6 patients, and pleural adhesions appeared in 10 patients. The average intraoperative blood loss was 203.6 ± 121.7 mL, and the mean operating room time was 2.2 ± 0.5 hours. There were no intraoperative deaths, and only one patient required conversion to thoracotomy. The average drainage time was 5.9 ± 4.6, and the mean hospital stay was 6.7 ± 4.2 days. Though it is technically demanding to safely handle the changed hilum structure caused by the last operation, major lung resection by VATS is feasible for ipsilateral reoperation in appropriate candidates.

Long-term follow-up of pediatric open and laparoscopic inguinal hernia repair

BackgroundPediatric laparoscopic inguinal hernia repair is not widely accepted. Study designChildren 0–14 years who underwent inguinal hernia repair during 2010–2016 at Kaiser Permanente Northern California were classified into five groups: (1) open unilateral repair without contralateral exploration; (2) open unilateral repair with contralateral laparoscopic exploration (“open+explore”); (3) open bilateral repair; (4) laparoscopic unilateral repair; and (5) laparoscopic bilateral repair. Outcomes included ipsilateral reoperation, metachronous contralateral repair, incision time, and complications. ResultsThe study included 1697 children. Follow-up averaged 3.6 years after open (N = 1156) and 2.6 years after laparoscopic (N = 541) surgery. Metachronous contralateral repair was performed in 3.8% (26/683) of patients with open unilateral surgery without contralateral exploration, 0.7% (2/275) of open+explore patients, and 0.9% (3/336) of laparoscopic unilateral patients (p < 0.01). Ipsilateral repair was performed in 0.8% (10/1156) of open repairs and 0.3% (2/541) of laparoscopic repairs. Chart review confirmed 5 postoperative infections in 1156 patients with open surgery (0.43%) and 6 infections in 541 patients with laparoscopic surgery (1.11%) (p = 0.11). ConclusionOur study's laparoscopic and open approaches have similar low ipsilateral reoperation rates, incision times, and complications. The use of laparoscopy to visualize the contralateral side resulted in a significantly lower rate of metachronous contralateral repair. Level of evidenceLevel III.

Combined Anterior Cruciate and Anterolateral Ligament Reconstruction in the Professional Athlete: Clinical Outcomes From the Scientific Anterior Cruciate Ligament Network International Study Group in a Series of 70 Patients With a Minimum Follow-Up of 2 Years

To evaluate clinical outcomes in professional athletes after combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction at a minimum follow-up of 2years. A retrospective analysis of prospectively collected data from the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group database was performed. All professional athletes who underwent primary combined ACL and ALL reconstruction between January 2011 and March 2016 were included. Patient assessment included physical examination, pre- and postoperative subjective and objective International Knee Documentation Committee (IKDC), Tegner activity scale, and Lysholm scores. Seventy-two professional athletes underwent primary ACL and ALL reconstruction; 70 (97%) were available, with a mean follow-up of 3.9years (range, 2-7). The preoperative side-to-side anteroposterior laxity difference was 7.1 ± 1.4mm, and this decreased significantly after surgery to 0.4 ± 0.9mm(P < .0001). Pivot-shift grade evolved from 16 grade I (22.8%) and 54 grade II or III (77.2%) preoperatively, to 66 absent pivot shift (94.3%) and 4 grade I (5.7; P < .001). By 1-year postoperatively, 60 athletes (85.7%) returned to professional sport, with a mean time interval of 7.9months (range, 5-12). Preoperatively, the mean subjective IKDC was 56.1 ± 12.3, the Lysholm score was 48.4 ± 12.5, and the Tegner score was 9.3 ± 1. At final follow-up, the mean subjective IKDC was 90.5 ± 7.6 (P < .0001), the Lysholm score was 94.4 ± 7.5 (P < .0001), and the Tegner score was 8.8 ± 1.5 (P < .004). The objective IKDC evolved from 39 grade C (55.7%) and 31 grade D (44.3%) preoperatively to 65 grade A (92.9%) and 5 grade B (7.1%) (P < .0001). Eleven Patients (15,7%) underwent a subsequent ipsilateral reoperation including 4 (5.7%) revision ACL reconstructions. The risk of graft rupture was significantly higher in female patients (13.6% vs 2.1% in male patients; P= .048). Combined ACL and ALL reconstruction is associated with excellent outcomes in professional athletes with respect to graft rupture rates, return to sport, knee stability, and reoperation rates after injury. Level IV, case series.

What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy?

The number of arthroscopic knee surgeries performed annually has increased over the last decade. It remains unclear what proportion of individuals undergoing knee arthroscopy is at risk for subsequent ipsilateral procedures. Better knowledge of risk factors and the incidence of reoperative ipsilateral arthroscopy are important in setting expectations and counselling patients on treatment options. The aim of this study is to determine the incidence of repeat ipsilateral knee arthroscopy, and the risk factors associated with subsequent surgery over long-term follow-up. The New York Statewide Planning and Research Cooperative Systems outpatient database was reviewed from 2003 to 2016 to identify patients who underwent elective, primary knee arthroscopy for one of the following diagnosis-related categories of procedures: Group 1: cartilage repair and transfer; Group 2: osteochondritis dissecans (OCD) lesions; Group 3: meniscal repair, debridement, chondroplasty, and synovectomy; Group 4: multiple different procedures. Subjects were followed for 10years to determine the odds of subsequent ipsilateral knee arthroscopy. Risk factors including the group of arthroscopic surgery, age group, gender, race, insurance type, surgeon volume, and comorbidities were analysed to identify factors predicting subsequent surgery. A total of 765,144 patients who underwent knee arthroscopy between 2003 and 2016, were identified. The majority (751,873) underwent meniscus-related arthroscopy. The proportion of patients undergoing subsequent ipsilateral knee arthroscopy was 2.1% at 1-year, 5.5% at 5years, and 6.7% at 10years of follow-up. Among patients who underwent subsequent arthroscopic surgery at 1-, 5-, and 10-year follow-up, there was a greater proportion of patients with worker's compensation insurance (p < 0.001), index operations performed by very high volume surgeons (p < 0.001), and cartilage restoration index procedures (p < 0.001), compared with those who never underwent repeat ipsilateral surgery. Understanding the incidence of subsequent knee arthroscopy after index procedure in different age groups and the patterns over 10years of follow-up is important in counselling patients and setting future expectations. The majority of subsequent surgeries occur within the first 5years after index surgery, and subjects tend to have higher odds of ipsilateral reoperation for up to 10years if they have worker's compensation insurance, or if their index surgery was performed by a very high volume surgeon, or was a cartilage restoration procedure. III.

Reoperation Rates After Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction: A Series of 548 Patients From the SANTI Study Group With a Minimum Follow-up of 2 Years

Background: Early clinical results of anterolateral ligament (ALL) reconstruction are promising, but concerns exist due to high rates of complications after other types of lateral extra-articular tenodesis. The rate of surgery after combined anterior cruciate ligament (ACL) and ALL reconstruction is not known. Purpose: To determine the rate of reoperation after combined ACL and ALL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of prospectively collected data from the Scientific ACL Network International (SANTI) Study Group database was performed to include all patients who had undergone combined ACL and ALL reconstruction between January 2012 and June 2014. At the end of the study period, all patients were contacted by telephone, and the operative notes of those who stated that they had undergone reoperation were reviewed to determine the type and rates of the subsequent procedures performed. Descriptive data were analyzed for the entire patient cohort. Results: The study population comprised 548 quadruple hamstring graft (4HT)+ALL reconstructions. The mean age (±SD) was 24.3 ± 7.9 years (range, 11.9-55.7 years), and 70.3% of subjects were male. The mean duration of follow-up was 35.5 ± 8.0 months (range, 24-54 months). Seventy-two patients (13.1%) underwent ipsilateral reoperation. This comprised a total of 77 procedures. Graft revision occurred in 14 knees (2.6%) at a mean of 18.3 months (±7.4 months) after the index procedure. There were 63 reoperations for ipsilateral, non–graft rupture–related indications (meniscus, n = 30; arthrofibrosis, n = 22; removal of hardware, n = 4; deep infection, n = 3; arthroscopic lavage without infection, n = 4). The only specific complications related to the ALL procedure (n = 3) were all related to femoral hardware that required removal. In both univariate and multivariate analyses, only the presence of a medial meniscal lesion at the index procedure was significantly associated with ipsilateral reoperation (odds ratio, 2.58; 95% CI, 1.43-4.76; P = .002). Conclusion: The reoperation rate after combined ACL and ALL reconstruction in this series is broadly comparable to the reoperation rate after isolated ACL reconstruction as reported in previous studies. In addition, the high rates of knee stiffness and reoperation reported in historical series of nonanatomic, lateral extra-articular tenodesis were not observed in the current series.

Validity of Same-Side Reoperation After Total Hip and Knee Arthroplasty Using Administrative Databases

Many arthroplasty outcome studies use administrative data to evaluate complications and mortality. Most databases use International Classification of Diseases, Ninth Revision or Current Procedural Terminology codes, which lack laterality information. This study determined the frequency with which a second operation occurs on the same side after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and identified variables associated with ipsilateral reoperation. In a hospital-based sample of patients undergoing multiple THA or TKA, the side of the index operation was compared with the side of the subsequent operation. Concordance was defined as the percentage of same-side reoperations. Overall concordance was 23% for THA and 22% for TKA, suggesting most reoperations were on the contralateral hip or knee. This study provides estimates of misclassification of reoperation after lower extremity arthroplasty when conducting orthopedic research with administrative data. Studies using these data should be aware of this limitation, and efforts should be made to limit reoperation to revision THA and TKA.

Descending necrotizing mediastinitis: surgical management.

Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. Between April 1994 and April 2000, 13 patients, mean age 39.23+/-18.47 (median 38, range 16-67) years, with DNM were submitted to surgical treatment. Primary odontogenic abscess occurred in six, peritonsillar abscess in five and post-traumatic cervical abscess in two patients. Diagnosis was confirmed by computed tomography (CT) of the neck and chest. All patients underwent surgical drainage of the cervico-mediastinal regions by a bilateral collar incision associated with right thoracotomy in ten cases. Six patients out of 13 required reoperation. Two patients previously submitted only to cervical drainage required thoracotomy; four patients, which have been submitted to cervico-thoracic drainage, underwent contralateral thoracotomy in two cases and ipsilateral reoperation in two cases. Ten patients evolved well and were discharged without major sequelae; three patients died of multiorgan failure related to septic shock. Mortality rate was 23%. Early diagnosis by CT of the neck and chest suggest a rapid indication of surgical approach to DNM. Ample cervicotomy associated with mediastinal drainage via large thoracotomic incision is essential in managing these critically ill patients and can significantly reduce the mortality rate for this condition, often affecting young people, to acceptable values.

Sites of recurrence and long-term results of redo surgery.

The authors determined whether carotid endarterectomy in patients with recurrent stenosis could provide durable stroke prevention with acceptable perioperative risk. Balloon angioplasty and stenting are being advocated for recurrent stenosis because of the presumption that reoperation is unsafe with poor results. The authors retrospectively reviewed their experience with 67 patients undergoing 74 operations for recurrent stenosis in a recent 11-year period. This represented 8.4% of 883 endarterectomies performed during the same period. At original operation, 55% had primary closure and 45% were patched. Reoperation was performed for amaurosis fugax and transient ischemic attack (45%), post-stroke (7%), global ischemia (10%), and asymptomatic severe occlusive disease (35%). Four patients (6%) undergoing simultaneous cardiac procedures were excluded from further analysis. Mean duration between primary and first redo operation was 78 months (range, 1-240 months). The 30-day combined mortality and stroke morbidity was 2.8%, evenly divided with 1.4% stroke and 1.4% mortality rates. Recurrent disease occurred predominantly (69%) in the previous endarterectomy site. Follow-up ranged from 1 to 162 months (mean, 48.2). Seventeen deaths occurred, of which 10 (59%) were cardiac. Two late ipsilateral neurologic events and four late contralateral events occurred. Two patients required third ipsilateral reoperation. Life-table analysis shows the ipsilateral stroke-free rate at 5 years to be 93.6% Recurrent stenosis occurs either proximal to or in the previous endarterectomy site in the majority of patients. Recurrent stenosis can be treated surgically with low morbidity and mortality and durable long-term stroke prevention. The presumption that results of redo carotid surgery are poor is disproved.