Late Surgery Group Research Articles

Erratum: Anterior Cruciate Ligament Surgery Performed Less Than 3 Weeks after Injury Is Not Inferior to Delayed Surgery.

Performing anterior cruciate ligament (ACL) surgery in the immediate period after injury is controversial. However, there may be instances where the opportunity cost of delayed surgery for the patient may be unacceptable. Concomitant meniscus injuries may also prevent the patient from regaining range of motion in the preoperative period. Every week that surgery is delayed may increase pain and impair mobility for this group of patients. We investigate the functional and clinical outcomes in patients with ACL surgery in the immediate 3-week period following ACL injury. A cohort study was performed to compare the outcome of early ACL (less than 3 weeks after injury) and late ACL surgery (more than 3 weeks after surgery). A total of 58 patients were followed up at fixed time points over a 2-year period. Clinical measurements (range of motion and knee laxity scores) and functional outcome scores (International Knee Documentation Committee, Lysholm's Knee and Tegner's scores) were used to document outcomes over time. The mean time to surgery from the time of injury in the early ACL surgery group was 2 weeks (standard deviation [SD] = 0.45) and the 20 weeks (SD = 9.64) in the late ACL surgery group. The absence or presence of meniscal injuries had no significant effect on the improvement over time for both groups of patients (p > 0.05). Patients in the early ACL group had faster rates of improvement for clinical measurements and functional outcome scores but had started out initially with poorer outcomes at baseline. However, both groups had comparable outcomes (p > 0.05) at the 1- and 2-year mark postsurgery. Patients in both groups had no adverse outcomes. ACL Surgery within 3 weeks of injury (2 weeks SD = 0.45) is safe and has comparable outcomes compared to patients with delayed surgery (20 weeks SD = 9.64).

Factors impacting time to surgery and the effect on in-hospital mortality

ObjectivesEarly surgery improves outcomes after burn injuries but is often not available in limited resource settings (LRS), where a more conservative approach is widespread. This study aimed to analyze factors associated with delay in surgical treatment, and the impact on in-hospital mortality. MethodsAll patients with burns treated with surgery between 2016 and 2019 at the Pietermaritzburg Burn Service, in South Africa, were included in this retrospective study. Early surgery was defined as patients who underwent surgery within 7 days from injury. The population was analyzed descriptively and differences between groups were tested using t-test, and χ2 test or Fisher’s exact test, as appropriate. Multivariable logistic regression was used to analyze the effect of delay in surgical treatment on in-hospital mortality, after adjustment for confounders. ResultsDuring the study period, 620 patients with burns underwent surgery. Of them, 16% had early surgery. The early surgery group had a median age and TBSA of 11 years (3–35) and 12.0% (5–22) compared to 7 years (2–32) and 6.0% (3–13) in the late surgery group (p=0.45, p<0.001). In logistic regression, female sex [aOR: 3.30 (95% CI: 1.47–7.41)], TBSA% [aOR: 1.09 (95% CI: 1.05–1.12)], and FTB [aOR: 3.21 (95% CI: 1.43–7.18)] were associated with in-hospital mortality, whereas having early surgery was not [aOR: 1.74 (95% CI: 0.76–3.98)]. ConclusionThis study found that early surgery was not associated with in-hospital mortality. Independent predictors of in-hospital mortality were female sex, presence of full thickness burn, and larger burn size. Future studies should investigate if burn care capacity in LRS may influence the association between early excision and outcome.

Excisional penetrating keratoplasty for fungal interface keratitis after endothelial keratoplasty: surgical timing and visual outcome.

In this paper, we describe two cases of fungal interface infectious keratitis (IIK) developed after endothelial keratoplasty (EK) who underwent delayed therapeutic penetrating keratoplasty (TPK) with a poor visual outcome. Furthermore, we conducted a review of the literature and analyzed the visual outcomes of TPK in relation to the time from IIK diagnosis. We searched the literature for fungal IIK cases occurred after EK and treated by TPK. We identified 17 cases of fungal IIK, mostly caused by Candida spp. (88%). Infection was diagnosed at a median time of 21 (range 1-90days) days after EK. The median lag time between infection diagnosis and TPK was 30 (range 7-393) days. The median distance corrected visual acuity (DCVA) measured 4-12months after surgery was 20/40 (range 20/200-20/20). When TPK was performed within one month from diagnosis, the final median DCVA was 20/30 (range 20/100-20/20), with 83% of patients achieving ≥ 20/40 vision. When TPK was carried out later, the final median DCVA was 20/50 (range 20/200-20/22) with 44% of patients achieving ≥ 20/40 vision. One patient in the early surgery and four patients in the late surgery group showed postoperative DCVA ≤ 20/100 despite clear grafts. TPK with removal of the sequestered infection is advocated as a safe and effective measure to treat a post-EK infection. Early surgery allows a reduced exposure time to infection and therefore may result in better visual outcomes and lower risk of complications caused by prolonged inflammation.

Valve surgery for infective endocarditis complicated by stroke: surgical timing and perioperative neurological complications.

Ischaemic and hemorrhagic strokes are dreaded complications of infective endocarditis (IE). The timing of valve surgery for IE patients with stroke remains uncertain. The aim was to study perioperative neurological complications in relation to surgical timing. The study cohort consisted of patients diagnosed with acute IE from January 2010 to December 2016. Early surgery was defined as valve surgery within 14days of IE diagnosis, and late surgery as after 14 days. Neurological complications that occurred within 14days post-surgery were considered perioperative and classified as new ischaemic stroke or hemorrhagic stroke, expansion of an existing intracranial hemorrhage and new-onset seizures. Perioperative neurological complications were compared by surgical timing and other variables, including pre-surgical imaging. Overall, 183 patients underwent valve surgery: 92 had early surgery at a median of 8days (interquartile range 6-11); 91 had late surgery at a median of 28days (interquartile range 19-50). Twenty patients (10.9%) had 24 complications: 11 ischaemic, six intraparenchymal hemorrhages, three subarachnoid hemorrhages (SAHs) and four new-onset seizures. Rates of neurological complications were similar for early and late surgery groups (10.9% vs. 11%). Enterococcal IE was more common amongst patients with perioperative neurological complications (35% vs. 12.3%, P<0.01). An acute infarct was present on pre-surgical magnetic resonance imaging of 134 patients (74%) and was not associated with perioperative neurological complications. Thirty-five patients (19.3%) had intracranial hemorrhage on pre-surgical imaging. SAH on pre-surgical imaging was associated with developing SAH perioperatively (66.7% vs. 13.5%, P<0.01). Early valve surgery for patients with IE complicated by stroke was not associated with perioperative neurological complications.

Anterior Cruciate Ligament Surgery Performed Less Than 3 Weeks After Injury Is Not Inferior to Delayed Surgery.

Performing anterior cruciate ligament (ACL) surgery in the immediate period after injury is controversial. However, there may be instances where the opportunity cost of delayed surgery for the patient may be unacceptable. Concomitant meniscus injuries may also prevent the patient from regaining range of motion in the preoperative period. Every week that surgery is delayed may increase pain and impair mobility for this group of patients. We investigate the functional and clinical outcomes in patients with ACL surgery in the immediate 3-week period following ACL injury. A cohort study was performed to compare the outcome of early ACL (less than 3 weeks after injury) and late ACL surgery (more than 3 weeks after surgery). A total of 58 patients were followed up at fixed time points over a 2-year period. Clinical measurements (range of motion and knee laxity scores) and functional outcome scores (International Knee Documentation Committee, Lysholm's Knee and Tegner's scores) were used to document outcomes over time. The mean time to surgery from the time of injury in the early ACL surgery group was 2 weeks (standard deviation [SD] = 0.45) and the 20 weeks (SD = 9.64) in the late ACL surgery group. The absence or presence of meniscal injuries had no significant effect on the improvement over time for both groups of patients (p > 0.05). Patients in the early ACL group had faster rates of improvement for clinical measurements and functional outcome scores but had started out initially with poorer outcomes at baseline. However, both groups had comparable outcomes (p > 0.05) at the 1- and 2-year mark postsurgery. Patients in both groups had no adverse outcomes. ACL Surgery within 3 weeks of injury (2 weeks SD = 0.45) is safe and has comparable outcomes compared to patients with delayed surgery (20 weeks SD = 9.64).

Operative timing and outcomes in the elderly patients with hip fracture

Objective To analyze the impacts of operative timing on the operative outcomes in elderly patients with hip fracture. Methods A cohort of 814 elderly patients with hip fracture were analyzed retrospectively who had been treated at Department of Orthopaedics, The 7th Medical Center, General Hospital of Chinese People's Liberation Army from January 2012 to December 2015. They were 272 males and 542 females, aged from 60 to 99 years (average, 79.9 years). They were divided into 2 categories according to their systemic status by the American Association of Anesthesiologists (ASA) classification. There were 403 cases of ASA class Ⅰ and Ⅱ in the good status category and 411 cases of ASA class Ⅲ and Ⅳ in the poor status category. Each category was further divided into one early operation group and one late operation group depending on whether the patients were operated on within 48 hours after admission. The 2 groups were compared in terms of hospital stay, incidence of complications, 30-day and 1-year mortalities, and 1-year activities of daily living(ADL) scores. Results In the good status patients there were no significant differences between the 2 groups in the preoperative general data, showing compatibility (P>0.05). The early operation group showed significantly lower 30-day mortality [0% (0/94)] and 1-year mortality [5.3% (5/94)], significantly shorter hospital stay (9.6 d ± 5.2 d) and significantly higher 1-year ADL scores [75 (70, 85)] than the late operation group [4.2% (13/309) and 14.2% (44/309), 12.3 d ± 5.9 d, and 70 (60, 80), respectively] (all P 0.05). In the poor status patients there were no significant differences between the 2 groups in the preoperative general data, showing compatibility (P>0.05). The incidence of complications in the early operation group [42.2% (35/83)] was significantly higher than in the late operation group [30.5% (100/328)] (P 0.05). Conclusion For the elderly patients with hip fracture, operation can be carried out as soon as possible if they are in good physical condition, and early operation is not necessary if they are in poor systemic condition because operation should be carried out at an appropriate time after evaluation of their physical condition allows. Key words: Hip fractures; Timing of surgery; Mortality

Timing of conversion surgery in stage IV gastric cancer

Background: Conversion surgery is performed when unresectable gastric cancer is changed to be resectable by chemotherapy. There are the unresectable factors of tumor invasion of adjacent structure (T4b), peritoneal metastasis (P1), hepatic metastasis (H1), distant metastasis (M1), positive peritoneal cytology (CY1). This study was aimed to define the optimal time for operation in conversion therapy by comparing the difference of survival rate between the early conversion surgery group and the late conversion surgery group in the patients with stage IV gastric cancer which was equally down-staged by initial palliative chemotherapy and fulfill the criteria for surgical resection.

Early surgical intervention among patients with acute central cord syndrome is not associated with higher mortality and morbidity

Conflicting reports exist regarding mortality and morbidity of early surgical decompression in the setting of acute central cord syndrome (ACS) in multisystem trauma despite evidence of improved neurological outcomes. Consequently, optimal decompression timing in ACS in multisystem trauma patients remains controversial. This study aims to determine the association between early surgery for acute traumatic central cord and all-cause mortality among multisystem trauma patients in the National Trauma Data Bank (NTDB) using propensity score matching. We used the NTDB (years 2011-2014) to perform a retrospective cohort study, which included patients >18 years, with ACS (identified using ICD-9 coding). Collected patient data included demographics, surgery timing (≤24 hours, >24 hours), injury mechanism, Charlson comorbidity index (CCI), injury severity score (ISS), serious adverse events (SAE). Logistic regression and propensity matching were used to investigate the relationship between surgery timing and subsequent inpatient mortality. We identified 2,379 traumatic ACS patients. This group was 79.3% male with an average age of 56.3±15.2. They had an average ISS of 19.5±9.0 and mortality rate of 3.0% (n=72). A total of 731 (30.7%) patients underwent surgery for ACS within 24 hours. Univariate analysis did not show a significantly higher mortality rate in the early versus late surgery groups (3.8% vs. 2.7%, P=0.127). In unadjusted models, early surgery was not predictive of death or SAE + death in full (P=0.129, P=0.140) or matched samples (P=0.137, P=0.280). In models adjusted for age, ISS, and CCI, early surgery was predictive of death and SAE + death using the full sample (P=0.013, P=0.027), but not when using the propensity matched sample (P=0.107, P=0.255). Early surgical intervention does not appear to be associated with increased mortality among ACS patients unlike previously suggested. We theorize that survival noted within the NTDB is confounded by factors including existing comorbidities and multisystem trauma, rather than surgical timing. Delaying definitive surgical care may predispose patients to worsened greater neurological morbidity.

Microsurgery for Brachial Plexus Injury Before Versus After 6 Months of Age: Results of the Multicenter Treatment and Outcomes of Brachial Plexus Injury (TOBI) Study.

Infants with more severe brachial plexus birth injury (BPBI) benefit from primary nerve surgery to improve function. The timing of the surgery, however, is controversial. The Treatment and Outcomes of Brachial Plexus Injury (TOBI) study is a multicenter prospective study with the primary aim of determining the optimal timing of this surgical intervention. This study compared outcomes evaluated 18 to 36 months after "early" microsurgery (at <6 months of age) with the outcomes of "late" microsurgery (at >6 months of age). Of 216 patients who had undergone microsurgery, 118 were eligible for inclusion because they had had a nerve graft and/or transfer followed by at least 1 physical examination during the 18 to 36-month interval after the microsurgery but before any secondary surgery. Patients were grouped according to whether the surgery had been performed before or after 6 months of age. Postoperative outcomes were measured using the total Active Movement Scale (AMS) score as well as the change in the AMS score. To address hand reinnervation, we calculated a hand function subscore from the AMS hand items and repeated the analysis only for the subjects with a Narakas grade of 3 or 4. Our hypothesis was that microsurgery done before 6 months of age would lead to better clinical outcomes than microsurgery performed after 6 months of age. Eighty subjects (68%) had early surgery (at a mean age of 4.2 months), and 38 (32%) had late surgery (at a mean age of 10.7 months and a maximum age of 22.0 months). Infants who underwent early surgery presented earlier in life, had more severe injuries at baseline, and had a significantly lower postoperative AMS scores in the unadjusted analysis. However, when we controlled for the severity of the injury, the difference in the AMS scores between the early and late surgery groups was not significant. Similarly, when we restricted our multivariable analysis to patients with a Narakas grade-3 or 4 injury, there was no significant difference in the postoperative AMS hand subscore between the early and late groups. This study suggests that surgery earlier in infancy (at a mean age of 4.2 months) does not lead to better postoperative outcomes of BPBI nerve surgery than when the surgery is performed later in infancy (mean age of 10.7 months). Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Impact of Surgical Timing and Approaches to Health Care Utilization in Patients Undergoing Surgery for Acute Traumatic Cervical Spinal Cord Injury.

ObjectiveAcute traumatic cervical spinal cord injury (AcSCI) causes significant morbidity and has an impact on health care utilization. The aim of our study was to analyze health care utilization in patients undergoing surgical decompression and fusion for AcSCI based on timing and type of surgical approaches. Patient and methodsData were extracted using ICD9/10 and CPT codes from MarketScan (IBM Corp. Armonk, New York [v. 2000-2015]). We defined the comparative groups based on the timing of surgery (early <24 hours and late >24 hours) and surgical approaches: anterior, posterior and circumferential. Outcomes of interest were: length of hospital stay, discharge disposition and health care utilization in the index hospitalization, within 30 days after discharge and 12 months following injury.ResultsOf 1604 patients, 80.9% had early procedures and 55.7% of these had anterior-only procedures. Overall, the median age was 46 years in the early surgery group and 47 years in the late surgery group. Patients in the early surgical group incurred higher outpatient services and there was no difference in cumulative median payments (index + 12 months) across the cohorts (early: $127,379, late: $121,049). The incidence of repeat surgery at the index level did not differ based on the timing of surgery (early 5% vs. late 7%). Complications were higher in the circumferential surgery cohort irrespective of the timing of surgery. Overall, combined median payment (index hospitalization + 12 months) was significantly higher for early circumferential cohorts compared to the anterior or posterior-only cohort ($195,990 and $109,977 vs. $121,236 respectively).ConclusionLate (>24 hours) surgeries were associated with a higher likelihood to be discharged home, lower utilization of outpatient services, higher hospital readmissions and no differences in payments (index and cumulative) compared to early surgeries. Circumferential approaches were associated with higher complication rates, lesser likelihood to be discharged home, higher utilization of outpatient services compared to anterior-only approaches.

Gender differences and temporal trends over two decades in acromegaly: a single center study in 112 patients.

To evaluate the impact of gender and year at surgery on clinical presentation and postoperative outcomes in acromegaly. Retrospective review of patients operated between 1994 and 2016 to compare presentation and outcomes in groups defined by gender and year of surgery. Kaplan-Meier survival analyses with a composite endpoint (recurrence, reoperation, and radiation) were used for gender comparison and Youden indices for biochemical remission rates changes during study period. Primary indications for evaluation were phenotype, neurological symptoms, incidentaloma, hypogonadism, and galactorrhea. At surgery, men (N = 54) were younger (43.6 ± 12.7 years) than women (N = 58, 48.7 ± 12.3, P = 0.04). Male:female ratios before and after age 50 were 1.4 and 0.6 respectively. Men had higher mean IGF-1 levels (874 ± 328 vs 716 ± 296, P < 0.01) and smaller tumors (1.8 ± 1.3 cm vs 2.3 ± 1.5, P = 0.04). Postoperative remission rates were comparable (51% men, 56% women) and inversely associated with cavernous sinus invasion and GH levels. Women had longer mean follow-up (5.2 ± 3.4 years vs 3.6 ± 3.6 men, P = 0.02) and longer endpoint-free survival (P < 0.01). At last follow-up, 89.6% women and 70% men had normal IGF-1 levels (P = 0.03). Postoperative remission rates were higher in patients operated after February 15, 2011 (67.35 vs 43.5% previously, P = 0.01). In late vs early surgery group, physical changes as main indication for screening decreased (54 vs 30%, P < 0.01), while incidentaloma and hypogonadism increased. Median GH levels were lower in late vs early surgery group (P = 0.03). We demonstrate gender-specific characteristics and an evolving spectrum of clinical presentation with implications for earlier diagnosis and personalized management of acromegaly.

Extended time interval between diagnosis and surgery does not improve the outcome in patients operated for resection or ablation of breast cancer liver metastases

BackgroundBreast cancer liver metastases (BCLM) is considered a systemic disease with poorly defined selection criteria for surgery and little evidence for the appropriate timing of surgery. MethodsPostoperative outcomes of patients operated for BCLM were retrospectively reviewed and compared based on the timing of surgery, with the early surgery (ES) group treated ≤12 months after BCLM diagnosis, and late surgery (LS) group operated >12 months after diagnosis. ResultsSeventy-two patients with BCLM underwent liver surgery, including 37 and 35 in the ES and LS groups, respectively. Demographic and preoperative characteristics were similar between the groups, except that multifocal liver disease was more frequent in the LS group (p = 0.008). The LS group had a morbidity rate of 38%, compared to 11% in the ES group (p = 0.015). No postoperative deaths occurred. In the whole cohort, median progression-free (PFS) and overall survival (OS) were 19 and 50 months, respectively, and 1-, 3- and 5-year PFS and OS were 63%, 41%, 24% and 93%, 66%, 43%, respectively, with no significant difference observed between the ES and LS groups. Multivariate analysis revealed that breast cancer progesterone receptor negativity (HR = 3.34, p = 0.03) and a size of LM > 40 mm (HR = 3.11, p = 0.01) were significant negative prognostic factors for PFS. Only a size of LM > 40 mm (HR = 2.79, p = 0.008) was significantly associated with shorter OS. ConclusionA prolonged preoperative observational period does not improve long-term outcomes after liver surgery in patients with resectable BCLM, suggesting that early management can safely be proposed to those patients, with good oncological outcomes.

Early Versus Late Surgical Decompression for Central Cord Syndrome: A Propensity Score-Matched Analysis

Abstract INTRODUCTION The optimal timing of surgical decompression for central cord syndrome (CCS) remains unclear. We sought to perform a head-to-head comparison of the neurological and functional outcomes of early (&lt;24 h) vs late (≥24 h) surgical decompression in patients with CCS. METHODS Patients who underwent surgery for CCS (AIS grade C or D; LEMS UEMS ≥ 5) were identified from 3 prospective, multi-center SCI datasets (NACTN SCI Registry; STASCIS; NASCIS III). Propensity scores were calculated as the probability of undergoing early (&lt;24 h) versus late (≥24 h) surgery using the logit method with age, injury mechanism, data source, and initial ASIA motor score, AIS grade, and neurological level as covariates. Propensity score matching (nearest neighbor) was performed in a 1:1 ratio. The primary outcome was ASIA motor score at 1 yr. Secondary outcomes included Functional Independence Measure (FIM) motor score at 1 yr. Outcomes were compared between study groups by t-test. Effect sizes for each outcome measure were summarized by mean differences (MDs). RESULTS A total of 300 patients were eligible. Propensity score matching produced a final cohort of 186 patients (N = 93 early surgery; N = 93 late surgery). Patient demographic, injury, and treatment characteristics at baseline were balanced between matched early and late surgery groups. ASIA motor score at 1 yr was significantly higher in the early surgery (mean: 91.8) compared to late surgery (mean: 87.1) group (MD 4.64, 95% CI 0.19 to 9.09, P = .04). Similarly, patients who underwent early (mean: 84.2) as opposed to late (mean: 77.2) surgery achieved better functional status at 1 yr, as measured by the FIM motor score (MD 7.04, 95% CI 0.59 to 13.49, P = .03). CONCLUSION In patients with CCS, we found early surgery, within 24 h of injury, to result in improved neurological and functional outcomes at 1 yr, as compared to late surgery, after adjusting for key potential confounders by a propensity score matching technique.

Early Versus Late Surgical Decompression for Acute Spinal Cord Injury: An Individual Patient Data Meta-Analysis of 1548 Patients

Abstract INTRODUCTION We sought to leverage the statistical power derived from pooling 4 high-quality prospective datasets to compare sensorimotor recovery with early (&lt; 24 hr) vs late (≥ 24 hr) surgical decompression for acute traumatic spinal cord injury (SCI). METHODS Patients with acute SCI who underwent surgical decompression were identified from 4 prospective, multi-center SCI datasets (NACTN, STASCIS, Sygen, and NASCIS III). Patients were dichotomized into early (&lt; 24 hr) and late (≥ 24 hr) surgery groups. The primary end point was change in ASIA motor score (AMS) at 1-yr. Secondary outcomes included AIS grade and change in ASIA light touch and pin prick scores at 1-yr. One-stage meta-analyses for each outcome were performed by hierarchical mixed-effects regression using a stratified intercept to account for clustering of patients within studies. Fixed-effect covariates were specified for baseline score, age, injury mechanism, AIS grade, neurological level, and steroids. The treatment (early vs late surgery) was specified as a random-effect. RESULTS A total of 1548 patients were eligible. The early surgery group experienced greater improvement than the late surgery group at 1-yr for AMS (MD 4.0, 95% CI 1.7-6.2, P = .001), light touch score (MD 4.6, 95% CI 1.9-7.2, P = .001), and pin prick score (MD 4.2, 95% CI 1.5-6.9, P = .003). Further, on ‘shift analysis’, the early surgery group achieved a more favorable distribution of AIS grades at 1-yr compared to the late surgery group (cOR 1.46, 95% CI 1.14-1.87, P = .003). The effect of early surgery was strongest for cervical SCI (P = .003); however, we observed a trend toward improved recovery with early versus late surgery for thoracic SCI as well (MD 5.2, 95% CI -0.8-11.2, P = .088). CONCLUSION In an individual patient data meta-analysis adjusting for potential confounders, we found early surgery, within 24 hr of injury, to be associated with superior sensorimotor recovery at 1-yr following acute SCI, as compared to late surgery.

S7A-19 SESSION 7A: SAGITTAL SYNOSTOSIS LONG-TERM NEUROCOGNITIVE OUTCOMES IN SAGITTAL SYNOSTOSIS: THE IMPACT OF REOPERATION

Introduction: Optimal age at surgery in nonsyndromic sagittal craniosynostosis (NSC) continues to be debated. This study examined the impact of reoperation on neurocognitive outcome in children with NSC using comprehensive neurocognitive testing. Methods: Forty-seven school-age children (age 5–16 years) with NSC who underwent whole-vault cranioplasty were included in this analysis. Twenty-four participants underwent early surgery (operated at age 6 months or younger; mean age at surgery 4.8 months), and 23 participants underwent later surgery (operated at age greater than 6 months; mean age at surgery 14.3 months). Participants were administered a battery of standardized neuropsychological testing (Wechsler Abbreviated Scale of Intelligence, Wechsler Fundamentals, Beery-Buktenica Visual Motor Integration) to measure neurocognitive outcomes. Results: Thirteen out of the 47 participants underwent a reoperation (27.7%); 11 out of the 13 reoperations were minor revisions while 2 reoperations were cranioplasties. Of the two participants who underwent major revisions, one was in the early surgery and the other was in the late surgery group. Reoperation rate was not statistically greater in those patients who had early surgery when compared to late surgery. Later surgery patients did not perform statistically better than early first surgery patients, even when the early surgery patients underwent reoperation, on any outcome measure of neurocognitive function, including IQ, academic achievement, visuomotor integration, executive function, and behavior (p>0.05 for all). Comparing reoperated early surgery patients with non-reoperated late surgery patients, reoperated early surgery patients scored significantly higher on word reading, reading comprehension, spelling, numerical operations, and visuomotor integration (p<0.05), and had fewer indicators of suspected learning disabilities compared to non-reoperated late surgery patients. Conclusion: Reoperation rate after whole vault cranioplasty was observed to be 27.7%, with few cases of repeat cranioplasty (4.3% of all patients). Operated and reoperated early surgery patients performed better in IQ, academic achievement, and visuomotor integration compared with non-reoperated late surgery patients. This provides evidence that whole-vault cranioplasty before 6 months of age is associated with better neurocognitive outcome compared to after 6 months of age, even when early surgery requires a reoperation.

Timing of Cholecystectomy after Emergent Endoscopic Retrograde Cholangiopancreatography for Cholangitis

Debate remains regarding the timing of laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. We hypothesized that patients undergoing early laparoscopic cholecystectomy would have fewer operative complications and a lower conversion rate. This study is a retrospective review of an ERCP database from 2012 to 2016 of adults with a diagnosis of cholangitis secondary to choledocholithiasis who underwent ERCP followed by a laparoscopic cholecystectomy. Patient demographics, ERCP details, timing of operation (<72 hours vs >72 hours after ERCP), complications, and mortality were recorded. Analysis included chi-square, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. In the 127 patients (65 per cent male; median age, 67 years; 48 (38%) early surgery), there were no differences in demographics, BMI, vital signs, or laboratory values. Patients in the late surgery group were more likely to have a Charlson Comorbidity Index > 3 (P = 0.002), require pre-operative endoscopic sphincterotomy (P < 0.002), need pre-operative insertion of a ductal stent (P < 0.03), and had more postoperative complications (P = 0.04). Patients in the late laparoscopic cholecystectomy group had more comorbidities and suffered more complications.

Long-term impact of pediatric endoscopic endonasal skull base surgery on midface growth.

Cranial base development plays a large role in anterior and vertical maxillary growth through 7 years of age, and the effect of early endonasal cranial base surgery on midface growth is unknown. The authors present their experience with pediatric endoscopic endonasal surgery (EES) and long-term midface growth. This is a retrospective review of cases where EES was performed from 2000 to 2016. Patients who underwent their first EES of the skull base before age 7 (prior to cranial suture fusion) and had a complete set of pre- and postoperative imaging studies (CT or MRI) with at least 1 year of follow-up were included. A radiologist performed measurements (sella-nasion [S-N] distance and angles between the sella, nasion, and the most concave points of the anterior maxilla [A point] or anterior mandibular synthesis [B point], the SNA, SNB, and ANB angles), which were compared to age- and sex-matched Bolton standards. A Z-score test was used; significance was set at p < 0.05. The early surgery group had 11 patients, with an average follow-up of 5 years; the late surgery group had 33 patients. Most tumors were benign; 1 patient with a panclival arteriovenous malformation was a significant outlier for all measurements. Comparing the measurements obtained in the early surgery group to Bolton standard norms, the authors found no significant difference in postoperative SNA (p = 0.10), SNB (p = 0.14), or ANB (0.67) angles. The S-N distance was reduced both pre- and postoperatively (SD 1.5, p = 0.01 and p = 0.009). Sex had no significant effect. Compared to patients who had surgery after the age of 7 years, the early surgery group demonstrated no significant difference in pre- to postoperative changes with regard to S-N distance (p = 0.87), SNA angle (p = 0.89), or ANB angle (p = 0.14). Lesion type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group. Though our cohort of patients with skull base lesions demonstrated some abnormal measurements in the maxillary-mandibular relationship before their operation, their postoperative cephalometrics fell within the normal range and showed no significant difference from those of patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.

Correlation of Meniscal Tear with Timing of Anterior Cruciate Ligament Reconstruction in Patients without Initially Concurrent Meniscal Tear.

The incidence of meniscal tear was reported to increase with the delay of anterior cruciate ligament reconstruction (ACLR). The tear may occur concurrently with the ACL injury or after the ACL injury. Few studies had focused on the patients whose meniscus is intact during ACL injury. We determined the correlation between timing of surgery and incidence of meniscal tears in ACL-deficient knees with initially intact meniscus. We retrospectively reviewed 387 patients who had undergone primary ACLR. Time of initial ACL injury, magnetic resonance imaging (MRI) examination, and surgery was recorded. The MRI was reviewed by experienced radiologic and orthopaedic doctors. Intraoperative arthroscopic images were also obtained and reviewed. The type of tear noted during surgery was classified according to the modification of International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine classification of meniscal tears. Patients were divided into early (surgery within 12 months from injury) and late surgery group (surgery at more than 12 months from injury). There were 216 patients with intact medial meniscus and 257 patients with intact lateral meniscus on the postinjury MRI study. The incidence of medial meniscus tear (MMT) was significantly higher than lateral meniscus tear (LMT) during the ACLR (33.8 vs. 19.8%, p < 0.001). The incidence of MMT is higher in late group than in early group (53.7 vs. 29.1%, p = 0.004, odds ratio= 2.815). The incidence of LMT is mildly higher in late group but without statistics significance (23.8 vs. 18.6%, p = 0.364). In both MMT and LMT, the most common injury pattern observed was a longitudinal tear. The incidence of each type is not different between early and late group. For patients without concurrent meniscal injuries with the ACL tear, the incidence of MMT significantly increased if ACLR was performed more than 12 months after injury. The medial meniscus was more prone to injury than the lateral meniscus in chronic ACL-deficient knee. ACLR should be performed earlier to reduce the risk of meniscal tears for patients without initially concurrent meniscal tear.

Outcome of delayed surgery in developmental hip dysplasia in a tertiary care setting

Background: The delay in the detection of developmental dysplasia of the hip (DDH) can lead to incomplete hip stabilization and poor outcomes. This might also infer that the delay in DDH surgery can also be associated with unfavorable consequences. The purpose of this study was to compare the outcome of delayed versus early surgery on DDH patients with respect to clinical and radiological factors. Methods: This is a retrospective cohort study in which the charts of patients who underwent DDH surgery and whose age was less than 5 years at the date of referral to the orthopedic clinic, between 2008 and 2011 were reviewed. Results: This study included 62 patients, 34 of which presented with unilateral joint involvement and 28 affected bilaterally. Half of the patients underwent early surgeries ( Post-operatively the range of motion was significantly limited in the late surgery group (P=0.001). Limping gait was also significantly associated with late surgery (P=0.005). Radiological abnormalities of all the X-Ray findings didn’t reveal any statistically significant difference between early and delayed surgery except for the reduction in acetabular angle in the right hip post-op (P=0.04). Conclusion: Delayed DDH surgery can lead to a worse clinical outcome, physical disability and possible radiological effects on the patients. Poor outcome was significantly associated with the timing of the surgery. It is therefore recommended to perform DDH surgeries as early as possible to decrease the morbidity and prevent adverse clinical and radiological outcomes.

Transportation mode and timing of spinal cord decompression and stabilization in patients with traumatic spinal cord injury in Iran.

Cross-sectional retrospective study. To describe the transportation mode to hospital and timing of spinal cord decompression and stabilization (D&S), length of hospital stay, frequency of pressure injuries, and sepsis during hospitalization. Brain and Spinal Injury Research Center, Tehran, Iran. Eight hundred and thirty patients with traumatic spinal cord injury (TSCI) were enrolled. Mode of transportation and length of time to reach the first hospital, length of hospital stay (LOS), and the time span between hospital arrival and decompression and stabilization (D&S) were recorded. Fifty-nine percent of the enrolled individuals were transported to the first hospital by ambulance, while 41% were transferred by vehicles without medical equipment and personnel. Median length of time to reach the first hospital was 1 h for both ambulance and non-equipped car groups, with no statistically significant difference (p = 0.1). Median LOS, frequencies of pressure injuries, and sepsis based on the injury levels were not significantly different between two transportation modalities. One hundred and seventy-seven individuals had early surgery, and 254 had late surgery. Median LOS was 13 days in the early surgery group and 20 days in the late surgery group (p = 0.002). Frequencies of pressure injuries and sepsis were not significantly different between the late and early surgery groups for various injury levels. About 59% of our patients had been transported to a hospital by non-medical personnel. Those with late surgery had significantly longer LOS. Improving TSCI patients' transportation method and early surgical interventions, if possible, may be considered.