Months Of Index Surgery Research Articles

EP39 - Retrospective study of delays in reversal of loop ileostomy – reasons and outcomes during the COVID era

Abstract Aims Formation of loop ileostomy is common after anterior resection to reduce the sequele of an anastomosis leak.1-5 Delays to reversal of ileostomy is associated with complications. Methods Retrospective study between 1 July 2017 – 30 June 2023. Patients were included: >18 years old, loop ileostomy formed as part of anterior resection surgery (benign and malignant). Exclusion criteria: loop ileostomy performed during other colonic resections, patients with inflammatory bowel disease, defunctioning ileostomy for obstructions. Primary outcome measures included complications associated with delayed closure of loop ileostomy and readmissions after reversal surgery. Secondary measures included reasons for delay to surgery, complications prior to reversal surgery, and morbidity and mortality associated with it. Results 135 patients were included. 85.9% of patients experienced delays in reversal surgery. Those without delays in surgery had higher rate of stoma-related complications (p=0.002). Delays were due to a long waitlist (p<0.01) and adjuvant chemotherapy (p=0.598). There was no significant differences in the delays to surgery during COVID pandemic. Delays were associated with higher rate of wound infection (6.04%), post-operative ileus (12.07%), anastomotic leak (1.72%), and Clostridium difficile (C.diff) infection (3.45%). Handsewn end to end anastomosis was associated with a higher proportion of post-operative ileus compared to the stapled side to side anastomosis group. Conclusion Reversal of ileostomy within 6 months of index surgery after adjuvant therapy could potentially reduce post-operative complications, and alleviate the burden on our healthcare system in the long run. A stapled side to side anastomosis should also be considered.

Slalom technique for multilevel degenerative spinal stenosis, surgical outcome and complication rate: Review of our experience.

Lumbar canal stenosis (LCS) is a common spinal disease affecting the elderly. Primarily it is asymptomatic until there is neurogenic claudication. Minimally invasive surgical (MIS) techniques are used to treat patients with lumbar spinal stenosis (LSS), while tubular system with alternative multilevel decompression is specifically used for those with minimal back pain and no mechanical instability on dynamic imaging. The aim of the study is to evaluate surgical outcome of Slalom procedure and complications in Middle East population. One hundred and five patients with lumbar stenosis (61 males and 44 females) underwent the procedure between 2015-2021 who were regularly followed-up using preoperative and postoperative COMI score (the core outcome measure index) at six months after index surgery. Progressive improvement in COMI score from average seven pre-op score to an average of three after six months of index surgery. The postoperative complications were dural tear (6.67%), Postoperative infection (3.81%), mechanical instability (1.9%), postoperative neuritis (8.57%) and death (1.9%).

Retrospective study in a single unit: outcomes of delays in reversal of loop ileostomy

Background: Formation of loop ileostomy is common after anterior resection to reduce the sequalae of an anastomosis leak. Delays to reversal of ileostomy is associated with complications. Methods: Retrospective study between 1 July 2017 to 30 June 2023. Patients were included: >18 years old, loop ileostomy formed as part of anterior resection surgery (benign and malignant). Exclusion criteria: loop ileostomy performed during other colonic resections, patients with inflammatory bowel disease, de-functioning ileostomy for obstructions. Primary outcome measures included complications associated with delayed closure of loop ileostomy and readmissions after reversal surgery. Secondary measures included reasons for delay to surgery, complications prior to reversal surgery, and morbidity and mortality associated with it. Results: 135 patients were included. 85.9% of patients experienced delays in reversal surgery. Those without delays in surgery had higher rate of stoma-related complications (p=0.002). Delays were due to a long waitlist (p<0.01) and adjuvant chemotherapy (p=0.598). There were no significant differences in the delays to surgery during COVID pandemic. Delays were associated with higher rate of wound infection (6.04%), post-operative ileus (12.07%), anastomotic leak (1.72%), and Clostridium difficile (C. diff) infection (3.45%). Handsewn end to end anastomosis was associated with higher proportion of post-operative ileus compared to the stapled side to side anastomosis group. Conclusions: Reversal of ileostomy within 6 months of index surgery after adjuvant therapy could potentially reduce post-operative complications, and alleviate the burden on our healthcare system in the long run. A stapled side to side anastomosis should also be considered.

473. PARACONDUIT HIATUS HERNIA AFTER OESOPHAGECTOMY: INCIDENCE, RISK FACTORS AND MANAGEMENT

Abstract Background Hiatus hernia after oesophagectomy is an uncommon but serious complication of oesophageal cancer surgery. With improving long-term oncologic outcomes, post oesophagectomy hiatus hernia is an increasingly recognised entity in oesophageal cancer survivorship. The aim of this study was to assess the incidence of and risk factors for paraconduit hiatus hernia (PHH), and to describe management approaches in a tertiary referral centre. Methods All patients undergoing oesophagectomy for cancer from 2008 to 2022 were included. Early PHH was defined as occurring within 3 months of index surgery, with all other PHH defined as late PHH. Surveillance computed tomography scans were undertaken among all disease-free patients to 5-years postoperatively. Kaplan Meier and Cox proportional hazards regression models were used to determine independent risk factors for PHH. Results 897 patients were studied. Early PHH occurred in 1.2%, and late PHH in 5.7% of patients. There was no late recurrence after early PHH. PHH was an asymptomatic radiologic finding in 45.5% of early and 84.3% of late cases. Median time to PHH was 15.7 months postoperatively. Nausea, abdominal pain and vomiting were the most common symptoms associated with PHH. Surgical intervention was required in 25.8% of cases, more commonly following early PHH (63.6%) as compared with late PHH (17.6%, P < 0.01). Operative approach (P < 0.001), extended resection of crura or diaphragm (P < 0.001) and male sex (P = 0.037) were associated with increased risk of hiatus hernia. Conclusion Paraconduit hiatus hernia is an uncommon complication after oncologic oesophagectomy. Surgical intervention is often required for patients with PHH presenting in the first three months after surgery, but a majority of patients with asymptomatic late PHH may be managed expectantly.

TLIF is Associated with Lower Rates of Adjacent Segment Disease and Complications Compared to ALIF: A Matched-Cohort Analysis.

Retrospective cohort. To compare the rate of adjacent segment disease (ASD) in patients undergoing anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF) for treatment of degenerative stenosis and spondylolisthesis. ALIF and TLIF are frequently used to treat Lumbar stenosis and spondylolisthesis. While both approaches have distinct advantages, it is unclear whether there are any differences in rates of ASD and postoperative complications. A retrospective cohort study of patients who underwent index 1-3 levels ALIF or TLIF between 2010-2022, using the PearlDiver Mariner Database, an all-claims insurance database (120 million patients). Patients with a history of prior lumbar surgery and those undergoing surgery for cancer, trauma, or infection were excluded. Exact 1:1 matching was performed using demographic factors, medical comorbidities, and surgical factors found to be significantly associated with ASD in a linear regression model. The primary outcome was a new diagnosis of ASD within 36 months of index surgery and secondary outcomes were all-cause medical and surgical complications. Exact 1:1 matching resulted in two equal groups of 106,451 patients undergoing TLIF and ALIF. The TLIF approach was associated with a lower risk of ASD (RR 0.58, 95% CI 0.56-0.59, P < 0.001), and all-cause medical complications (RR 0.94, 95% CI 0.91-0.98, P=0.002). All-cause surgical complications were not significantly different between both groups. After 1:1 exact matching to control for confounding variables, this study suggests that for patients with symptomatic degenerative stenosis and spondylolisthesis, a TLIF procedure (compared to ALIF) is associated with a decreased risk of developing ASD within 36 months of index surgery. Future prospective studies are needed to corroborate these findings. III.

Aspirin Administered for Venous Thromboembolism Prophylaxis May Protect Against Stiffness Following Total Knee Arthroplasty.

Aspirin has become the main agent for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA). This study assessed whether aspirin is associated with less knee stiffness compared to warfarin and other chemoprophylaxis agents. This is a retrospective review of all primary and revision TKAs performed between January 2009 and October 2020 at a high volume institution. Demographics, comorbidity data, and operative variables were extracted from medical records. VTE prophylaxis administered during this time period included aspirin, warfarin, and "others" (factor Xa, unfractionated heparin, low-molecular-weight heparin, fondaparinux, adenosine diphosphate receptor inhibitor, and direct thrombin inhibitor). The primary outcome assessed was manipulation under anesthesia (MUA) performed within 6 months of index surgery. Secondary outcome included major bleeding events. Univariate followed by multivariate regression analyses were performed. A total of 15,903 cases were included in the study, of which 531 (3.3%) patients developed stiffness that required MUA. The rates of MUA were 2.7% (251/9223) for patients receiving aspirin, 4.2% (238/5709) for patients receiving warfarin, and 4.3% (42/971) for all others (P's < .001). Multivariate regression analysis confirmed that aspirin is associated with lower rates of VTE compared to warfarin (adjusted odds ratio 1.423, 95% confidence interval 1.158-1.747, P < .001) and compared to other anticoagulation medications (adjusted odds ratio 1.742, 95% confidence interval 1.122-2.704, P= .013). Major bleeding events were also significantly lower in patients who received aspirin compared to the other 2 groups (P's= .001). Aspirin prophylaxis is associated with lower rates of MUA following TKA compared to warfarin and other VTE chemoprophylactic agents when grouped together.

Are NOACs as safe and efficient as VKA regarding thromboembolic prophylaxis and major bleeding in patients with surgical bioprosthesis and atrial fibrillation within 3 months of surgery?

SummaryA best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: ‘Are NOACs as safe and efficient as vitamin K antagonist regarding thromboembolic prophylaxis and major bleeding in patients with surgical bioprosthesis and atrial fibrillation within 3 months of surgery?’ Altogether more than 324 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The RIVER and ENAVLE trials showed non-inferiority of rivaroxaban (regarding mean time free from composite of death, major cardiovascular events or major bleeding at 12 months) and edoxaban (composite of death, clinical thromboembolic events or asymptomatic intracardiac thrombosis; and major bleeding) when compared with vitamin K antagonist. These studies include a low number of patients within 3 months of index surgery and overall low statistical power regarding this particular subgroup of patients. Data derived from lower evidence studies are compatible with the aforementioned findings. The available evidence suggests that non-vitamin K antagonist anticoagulants are as safe and as efficient as vitamin K antagonist regarding thromboembolic prophylaxis and bleeding event rates in patients with surgical bioprosthesis and atrial fibrillation within 3 months of bioprosthesis implantation. However, this evidence is derived from a limited number of studies with important methodological limitations. Expanding non-vitamin K antagonist anticoagulant recommendation to the early postoperative period warrants more confirmatory research.

Revision Surgery for Instability After Total Hip Arthroplasty: Does Timing Matter?

BackgroundInstability is a common reason for revision surgery after total hip arthroplasty (THA). Recent studies suggest that revisions performed in the early postoperative period are associated with higher complication rates. The purpose of this study is to assess the effect of timing of revision for instability on subsequent complication rates. MethodsThe Medicare Part A claims database was queried from 2010 to 2017 to identify revision THAs for instability. Patients were divided based on time between index and revision surgeries: <1, 1-2, 2-3, 3-6, 6-9, 9-12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics and comorbidities. ResultsOf 445,499 THAs identified, 9298 (2.1%) underwent revision for instability. Revision THA within 3 months had the highest rate of periprosthetic joint infection (PJI): 14.7% at <1 month, 12.7% at 1-2 months, and 10.6% at 2-3 months vs 6.9% at >12 months (P < .001). Adjusting for confounding factors, PJI risk remained elevated at earlier periods: <1 month (adjusted odds ratio [aOR]: 1.84, 95% confidence interval [CI]: 1.51-2.23, P < .001), 1-2 months (aOR: 1.45, 95% CI: 1.16-1.82, P = .001), 2-3 months (aOR: 1.35, 95% CI: 1.02-1.78, P = .036). However, revisions performed within 9 months of index surgery had lower rates of subsequent instability than revisions performed >12 months (aOR: 0.67-0.85, P < .050), which may be due to lower rates of acetabular revision and higher rates of head-liner exchange in this later group. ConclusionWhen dislocation occurs in the early postoperative period, delaying revision surgery beyond 3 months from the index procedure may be warranted to reduce risk of PJI.

What Factors Increase Revision Surgery Risk When Treating Displaced Femoral Neck Fractures With Arthroplasty: A Secondary Analysis of the HEALTH Trial.

HEALTH was a randomized controlled trial comparing total hip arthroplasty with hemiarthroplasty in low-energy displaced femoral neck fracture patients aged ≥50 years with unplanned revision surgery within 24 months of the initial procedure being the primary outcome. No significant short-term differences between treatment arms were observed. The primary objective of this secondary HEALTH trial analysis was to determine if any patient and surgical factors were associated with increased risk of revision surgery within 24 months after hip fracture. We analyzed 9 potential factors chosen a priori that could be associated with revision surgery. The factors included age, body mass index, major comorbidities, independent ambulation, type of surgical approach, length of operation, use of femoral cement, femoral head size, and degree of femoral stem offset. Our statistical analysis was a multivariable Cox regression using reoperation within 24 months of index surgery as the dependent variable. Of the 1441 patients included in this analysis, 8.1% (117/1441) experienced reoperation within 24 months. None of the studied factors were found to be predictors of revision surgery (P > 0.05). Both total and partial hip replacements are successful procedures in low-energy displaced femoral neck fracture patients. We were unable to identify any patient or surgeon-controlled factors that significantly increased the need for revision surgery in our elderly and predominately female patient population. One should not generalize our findings to an active physiologically younger femoral neck fracture population. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Functional and Disability Assessment Among Hispanics With Zone 2 Flexor Tendon Injuries: Comparative Study Between Flexor Digitorum Superficialis Repair and Flexor Digitorum Superficialis Excision.

Introduction:Flexor tendon lacerations in zone II have been reported to be the most complicated of all tendon injuries. Currently, there is no consensus on treatment in surgical management for patients with flexor tendon laceration of flexor digitorum profundus and flexor digitorum superficialis (FDS). The aim of this study was to evaluate whether the repair of FDS tendons provided superior functional outcomes compared with FDS excision in Hispanic patients.Methods:Total active motion, original Strickland criteria, and the disability of arm shoulder and hand questionnaire were provided postoperatively at 3 and 6 months to all consecutive Hispanic patients who underwent zone II flexor tendon repair. The cohort was divided into two groups, those who underwent FDS repair and those underwent FDS excision.Results:Functional and disability outcome analysis showed a notable improvement with FDS repair using total active motion, Strickland criteria, and disability of arm shoulder and hand score at the 3 months postoperative interval. No statistical differences were identified regarding functional and disability outcomes at the 6-month evaluation between both groups.Conclusions:Among Hispanics, the FDS-repaired group had similar functional and disability outcomes at their 6 months postoperative evaluation compared with the FDS-excised group. Increased awareness for tendon rerupture during the initial 3 months of index surgery is recommended for FDS-excised patients.

Methods of Colostomy Construction: No Effect on Parastomal Hernia Rate: Results from Stoma-const-A Randomized Controlled Trial.

The primary objective of this trial was to compare the parastomal hernia rates 1 year after the construction of an end colostomy by 3 surgical techniques: cruciate incision, circular incision in the fascia and using prophylactic mesh. Secondary objectives were evaluation of postoperative complications, readmissions/reoperations, and risk factors for parastomal hernia. Colostomy construction techniques have been explored with the aim to improve function and reduce stoma complications, but parastomal herniation is frequent with an incidence of approximately 50%. A randomized, multicenter trial was performed in 3 hospitals in Sweden and Denmark; all patients scheduled to receive an end colostomy were asked to participate. Parastomal hernia within 12 months was determined by computed tomography of the abdomen in prone position and by clinical assessment. Complications, readmissions, reoperations, and risk factors were also assessed. Two hundred nine patients were randomized to 1 of the 3 arms of the study. Patient demographics were similar in all 3 groups. Assessment of parastomal hernia was possible in 185 patients. The risk ratio (95% confidence interval) for parastomal hernia was 1.25 (0.83; 1.88), and 1.22 (0.81; 1.84) between cruciate versus circular and cruciate versus mesh groups, respectively. There were no statistically significant differences between the groups with regard to parastomal hernia rate. Age and body mass index were found to be associated with development of a parastomal hernia. We found no significant differences in the rates of parastomal hernia within 12 months of index surgery between the 3 surgical techniques of colostomy construction.

Persistent Iliosacral Joint Syndrome following Instrumentation to the Sacropelvis in Patients with Adult Spinal Deformity.

Persistent sacroiliac joint syndrome (PSIJS) may complicate adult spinal deformity surgery (ASDS). This study assesses the relationship between clinical/morphometric parameters and PSIJS following ASDS including pelvic fixation and the therapeutic efficacy of secondary iliosacral fusion (ISF). Perioperative health-related quality of life (HRQOL) outcomes (Oswestry Disability Index, Short Form 12-item health survey, version 2 scores) at 6, 12, and 24 months, and radiographic studies were analyzed retrospectively in a cohort of 71 consecutive patients undergoing ASDS. PSIJS was confirmed in nine individuals (12.7%) by placebo-controlled dual sacroiliac joint (SIJ) blocks. The relationships between global and regional spinopelvic morphometry, PSIJS, and HRQOL outcomes were assessed by logistic regression and receiver operating characteristic curve (ROC) analysis. PSIJS, independently causing significantly reduced improvement in HRQOL scores (p < 0.001) 6 months postoperatively, warranted secondary ISF in nine patients (12.7%) within 12 months of index surgery, without evidence of progressive SIJ arthrosis, pseudarthrosis, or hardware issues. Eight of nine patients undergoing secondary ISF reported≥ 70% pain reduction at 24 months. Logistic regression/ROC analysis revealed a close association between PSIJS and nonharmonious postoperative L4-S1 fractional lordosis (p < 0.0001), pelvic incidence angle > 53 degrees, hip arthrosis, and preexistent advanced SIJ arthrosis (p < 0.01). PSIJS may negatively impact the clinical outcome of ASDS. Recurrent preoperative SIJ syndrome requiring interventional treatment, preexisting hip and SIJ arthrosis, insufficient restoration of L4-S1 fractional lordosis, and high pelvic incidence predispose to PSIJS. PSIJS may potentially be avoided by restoring physiologic lumbosacral geometry and S2 sacral alar-iliac screw fixation during index surgery. Secondary ISF appears to be effective in reducing pain and physical impairment due to PSIJS.

Assessment of drainage techniques for evacuation of chronic subdural hematoma: a consecutive population-based comparative cohort study.

OBJECTIVE Surgery for chronic subdural hematoma (CSDH) is one of the most common neurosurgical procedures. The benefit of postoperative passive subdural drainage compared with no drains has been established, but other drainage techniques are common, and their effectiveness compared with passive subdural drains remains unknown. METHODS In Scandinavian population-based cohorts the authors conducted a consecutive, parallel cohort study to compare different drainage techniques. The techniques used were continuous irrigation and drainage (CID cohort, n = 166), passive subdural drainage (PD cohort, n = 330), and active subgaleal drainage (AD cohort, n = 764). The primary end point was recurrence in need of reoperation within 6 months of index surgery. Secondary end points were complications, perioperative mortality, and overall survival. The analyses were based on direct regional comparison (i.e., surgical strategy). RESULTS Recurrence in need of surgery was observed in 18 patients (10.8%) in the CID cohort, in 66 patients (20.0%) in the PD cohort, and in 85 patients (11.1%) in the AD cohort (p < 0.001). Complications were more common in the CID cohort (14.5%) compared with the PD (7.3%) and AD (8.1%) cohorts (p = 0.019). Perioperative mortality rates were similar between cohorts (p = 0.621). There were some differences in baseline and treatment characteristics possibly interfering with the above-mentioned results. However, after adjusting for differences in baseline and treatment characteristics in a regression model, the drainage techniques were still significantly associated with clinical outcome (p < 0.001 for recurrence, p = 0.017 for complications). CONCLUSIONS Compared with the AD cohort, more recurrences were observed in the PD cohort and more complications in the CID cohort, also after adjustment for differences at baseline. Although the authors cannot exclude unmeasured confounding factors when comparing centers, AD appears superior to the more common PD. Clinical trial registration no.: NCT01930617 (clinicaltrials.gov).

Early complications of acromioclavicular joint reconstruction requiring reoperation.

Prior studies have reported high complication rates with acromioclavicular joint reconstruction (ACJR). However, many of these reports have suffered from small sample sizes and inclusion of older surgical techniques. The purpose of this study was to determine the rates of early complications requiring reoperation in patients treated with ACJR. From 2007 to 2011, patients who were treated with ACJR were identified using the PearlDiver database, a large insurance database in the USA. The following reoperations were then queried from this patient cohort: irrigation and debridement within 30days of index surgery, manipulation under anaesthesia (MUA) of the shoulder joint within 3months of index surgery, and revision ACJR, distal clavicle excision, and removal of hardware within 6months of index surgery. In total, 2106 patients treated with ACJR were identified. The reoperation rates for irrigation and debridement, MUA, revision ACJR, distal clavicle excision, and removal of hardware were 2.6, 1.3, 4.2, 2.8, and 6.2%, respectively. Patients≥35years of age and females more likely to undergo a reoperation after ACJR. Specifically, patients≥35years of age were more likely to undergo MUA and revision ACJR, while patients≥50years of age were more likely to undergo an irrigation and debridement. Females were more likely than males to undergo revision ACJR and distal clavicle excision. Older patients and females were more likely to experience postoperative complications requiring reoperations, including revision ACJR, distal clavicle excision, and irrigation and debridement. By analysing a large cohort of patients across multiple centres and providers, this study provides valuable insight into the recent complication profiles of ACJR, allowing surgeons to appropriately counsel patients on the risks of these procedures. IV.

Long-term outcomes of needle revision of failing deep sclerectomy blebs.

To report on long-term outcomes of mitomycin C (MMC)-augmented needle revision of failing deep sclerectomy (DS) blebs. Retrospective database search of all needle revisions with MMC for DS blebs between 2002 and 2008 was conducted. Sixty-six eyes of 66 patients were included in the study. Subconjunctival MMC 0.01-0.02 mg was injected 15 min before needle revision. Complete success was defined as intraocular pressure ≤ 18 mmHg or 20% decrease from baseline with no glaucoma medications or further surgical procedures. Partial success was based on the same criteria, but with medications. Mean follow-up after index needle revision was 67.8 ± 24.8 months (range 1-10 years). The mean number of needle revisions was 1.6 ± 0.8 (range 1-4). Two or more procedures were done in 31 eyes (47.0%). Mean preoperative intraocular pressure was 23.2 ± 6.9 mmHg. Complete and partial success rates were 64% and 71% at 1 year, 57% and 68% at 3 years, and 40 % and 58 % at 5 years after surgery, respectively. Early needle revision, within 6 months of index surgery, was significantly associated with failure, both on uni- and multivariate tests. Significant complications included delayed hypotony in five eyes (7.6%), delayed bleb leak in two eyes (3.0%), endophthalmitis in one eye (1.5%), and corneal oedema in two eyes (3.0%). Needle revision with subconjunctival MMC may successfully lower the intraocular pressure in eyes with a failing DS bleb in the long term. Complications known to be associated with trabeculectomy and MMC were anticipated and observed in our DS group.

Use of femoral nail with spiral blade in subtrochanteric fractures

The aim of this study was to evaluate the outcome of acute subtrochanteric fractures managed with intramedullary nail and spiral blade fixation of the proximal fragment. Charts of 33 patients (17 males and 16 females) with acute subtrochanteric fractures operated with intramedullary nail and spiral blade at our institution between March 2006 and February 2011 were retrospectively reviewed. The most common (67%) mechanism of injury was ground-level fall, predominantly involving elderly patients. Results were evaluated in terms of union time, implant failure rate, infection rate and functional outcome. Mean duration of surgery was 2.4 hours and average length of hospital stay was 7 days. Mean radiological healing time was 16 weeks. Good healing occurred in 31 (94%) patients within 6 months of surgery. Uneventful healing occurred in 28 (85%) patients and 3 (9%) had delayed healing requiring dynamization in two patients and bone grafting in one. Implant failure occurred in 2 (6%) patients within 2 months of index surgery requiring repeat surgery. One (3%) patient had varus malunion. Intramedullary nailing with spiral blade is a good option for acute subtrochanteric fractures with promising results. We think that this is a superior device compared to conventional methods of fixation for subtrochanteric fractures.

Irrigation and Debridement

Irrigation and Debridement