Need For Further Surgery Research Articles

Outcomes of Trabeculectomy With Mitomycin-C in Uveitis Associated With Vogt-Koyanagi-Harada Disease.

To evaluate the outcomes of trabeculectomy with mitomycin-C (MMC) in uveitis associated with Vogt-Koyanagi-Harada disease (VKH). Retrospective cohort study included 27 eyes of 15 patients with uveitic glaucoma associated with VKH disease who underwent trabeculectomy with MMC as a first glaucoma procedure at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia between 1992 and 2011. The main outcome measures were: the intraocular pressure (IOP), the number of antiglaucoma medications, the presence of visually threatening complications, and the need for further surgeries to control the IOP. The mean follow-up was 78.19 months. The IOP decreased significantly from a mean of 40.15±7.0 to 13.12±6.9 mm Hg on the last follow-up (P<0.01) as well as during the whole follow-up period. The number of medications needed to control the IOP also decreased significantly from 3.89±0.6 to 1.04±1.3. The cumulative probabilities of success were 77.8%, 74.1%, 63.0%, and 51.9% at 12, 24, 36, and 48 months postoperatively, respectively. The most common complications were cataract development and progression (53.8%), hypotony (IOP≤5 mm Hg) (33.3%), choroidal effusion (7.4%), and decompressive retinopathy (7.4%). Eight eyes (29.6%) needed a second procedure to control the IOP. Trabeculectomy with MMC offers an acceptable intermediate term success and IOP control in uveitic glaucoma associated with VKH. However, significant number of eyes needed further procedures to control the pressure. Therefore, continuous monitoring of the pressure is important.

Very long-term outcomes after endoprosthetic replacement for malignant tumours of bone.

The aim of this study was to establish what happens to patients in the long term after endoprosthetic replacement for a primary malignant tumour of bone. We conducted a retrospective analysis of a prospectively maintained database to identify all patients who had undergone an endoprosthetic replacement more than 25 years ago and who were still alive. Their outcomes were investigated with reference to their complications and need for further surgery. A total of 230 patients were identified. Their mean age at diagnosis was 20.7 years (five to 62). The most common diagnosis was osteosarcoma (132). The most common site was the distal femur (102). The mean follow-up was 29.4 years (25 to 43). A total of 610 further operations were undertaken, an average of 2.7 further operations per patient. A total of 42 patients (18%) still had the original prosthesis in place. The risk of amputation was 16% at 30 years (31 patients). Those without infection had a mean of 2.1 further operations (one to nine) while those with infection had a mean of 4.6 further operations (two to 11). The risk of infection persisted throughout the life of the prosthesis with a mean of 1% per year becoming infected. Of the 60 patients who developed an infection, 21 (35%) developed this following the primary procedure at a mean of 50 months, but another 19 developed this within a year of another surgical procedure. The risk of infection after any further surgery was 2.7%. The site with the highest risk of infection was the proximal tibia (43.3%). This study highlights the inevitable need for further surgery following first-generation endoprosthetic reconstruction, although in most cases, limb salvage is maintained. Late complications, especially infection, continue for the lifetime of the implant. Cite this article: Bone Joint J 2016;98-B:857-64.

Outcomes of endoscopic suturectomy with postoperative helmet therapy in bilateral coronal craniosynostosis.

OBJECTIVE Historically, bilateral frontoorbital advancement (FOA) has been the keystone for treatment of turribrachycephaly caused by bilateral coronal synostosis. Early endoscopic suturectomy has become a popular technique for treatment of single-suture synostosis, with acceptable results and minimal perioperative morbidity. Boston Children's Hospital has adopted this method of treating early-presenting cases of bilateral coronal synostosis. METHODS A retrospective review of patients with bilateral coronal craniosynostosis who were treated with endoscopic suturectomy between 2005 and 2012 was completed. Patients were operated on between 1 and 4 months of age. Hospital records were reviewed for perioperative morbidity, length of stay, head circumference and cephalic indices, and the need for further surgery. RESULTS Eighteen patients were identified, 8 males and 10 females, with a mean age at surgery of 2.6 months (range 1-4 months). Nine patients had syndromic craniosynostosis. The mean duration of surgery was 73.3 minutes (range 50-93 minutes). The mean blood loss was 40 ml (range 20-100 ml), and 2 patients needed a blood transfusion. The mean duration of hospital stay was 1.2 days (range 1-2 days). There was 1 major complication in the form of a CSF leak. The mean follow-up was 37 months (range 6-102 months). Eleven percent of nonsyndromic patients required a subsequent FOA; 55.6% of syndromic patients underwent FOA. The head circumference percentiles and cephalic indices improved significantly. CONCLUSIONS Early endoscopic suturectomy successfully treats the majority of patients with bilateral coronal synostosis, and affords a short procedure time, a brief hospital stay, and an expedited recovery. Close follow-up is needed to detect patients who will require a secondary FOA due to progressive suture fusion or resynostosis of the released coronal sutures.

Exposure of Prebiopsy Antibiotics Influence Bacteriological Diagnosis and Clinical Outcomes in Patients With Infectious Spondylitis.

The benefit of prebiopsy empirical antibiotics for patients with infectious spondylitis and the effect on clinical outcome are not well known. This study assessed the impact of prebiopsy empirical antibiotics in patients with infectious spondylitis.We retrospectively reviewed 41 adult in-patients with infectious spondylitis who received percutaneous endoscopic debridement and drainage (PEDD) at a tertiary care hospital from August 2002 to August 2012. The average patient age was 55.2 years old and causative bacteria were identified in 32 out of 41 biopsy specimens (78.0%) via the PEDD procedure, which has good diagnostic efficacy comparable to open biopsy.Seventeen patients (41.5%) received prebiopsy empirical antimicrobial therapy, and these patients were less likely to have positive cultures than those who did not receive preoperative antibiotics (64.7% vs 87.5%, P = 0.04). Patients with positive cultures had a better infection control rate (78.1% vs 67.7%) and were less likely to undergo subsequent open surgery. Patients given preoperative antibiotics were more likely to need subsequent open surgery (35.3% vs 16.7%, P = 0.02). From multivariate logistic analysis showed age at diagnosis to be an independent risk factor for the need of further surgery. There were no major complications following the PEDD procedure, except 2 patients had transient paresthesia in the affected lumbar segments.Prebiopsy empirical antibiotic therapy was associated with lower positive culture rate and an increased need for subsequent open surgery. Patients with positive cultures were more likely to have initially adequate treatment, better infection control, and better clinical outcome.

Arthroscopic Lateral Retinacular Release in Adolescents With Medial Patellofemoral Ligament-centered Knee Pain

The medial patellofemoral ligament (MPFL) has been implicated as a common pain generator in adolescents with anterior knee pain. The purpose of this study is to report the clinical outcomes of arthroscopic lateral retinacular release (ALRR) for refractory MPFL-centered pain and to identify risk factors for poor outcomes and surgical failures. A single-surgeon database was queried to identify all patients undergoing ALRR. Inclusion criteria included minimum 12-month follow-up and ALRR performed for MPFL pain rather than for generalized anterior knee pain or patellar instability. All patients had persistent MPFL-centered pain despite participating in a nonsurgical protocol before surgery. Primary outcomes included International Knee Documentation Committee (IKDC) subjective score and need for further surgery, typically tibial tubercle osteotomy (TTO). Eighty-eight knees in 71 patients [66 female, 5 male; average age, 15.7 y (range, 8.4 to 20.2 y)] were included. Average follow-up was 59 months (range, 12 to 138 mo). Average preoperative IKDC score was 41.9 (range, 18.4 to 67.8), whereas average postoperative IKDC score was 77.8 (range, 11.5 to 98.9; P<0.01). Postoperative IKDC scores were worse in patients with a preoperative sulcus angle of <134 degrees than those with sulcus angle of ≥134 degrees (69.9±22.1 vs. 82.0±12.5, P=0.04). Lower preoperative IKDC score correlated negatively with improvement of IKDC score postoperatively (r=-0.40, P<0.05). Seventeen knees (19.3%) subsequently underwent TTO for persistent symptoms. Patients who ultimately required TTO were younger than patients who did not (14.8±1.5 vs. 15.9±2.1; P=0.04) and had lower mean preoperative Blackburne-Peel ratio (0.95±0.25 vs. 1.11±0.24; P=0.02). This study demonstrates that patients with refractory MPFL-centered knee pain had significant improvements in clinical outcomes after undergoing ALRR at mean 5 years' follow-up. Poor outcomes and surgical failures were associated with lower preoperative IKDC score, younger age, lower preoperative Blackburne-Peel ratio, and sulcus angle of <134 degrees. Outcomes were not recorded prospectively, but mean IKDC scores <60 months postoperatively were similar to those collected ≥60 months after surgery (80.4 vs. 78.3, P=0.15). Level IV.

Outcome of Posterior Stabilisations for Metastatic Spinal Lesions

Introduction The objective of this study was to determine whether posterior only stabilization of metastatic spinal lesions provides adequate stability over the life span of the recipient patient. There are no gold standards for surgical stabilization of metastatic spinal lesions however National Institute of Clinical Excellence guidelines (UK) state that anterior reconstruction should be considered in patients with metastatic spinal cord compression who are likely to survive a year. Standard practice in our regional unit has been to stabilize metastatic spinal lesions through a posterior only approach. Our rationale is that posterior stabilization provides sufficient stability while avoiding the additional risks, time, and cost of anterior stabilization. Materials and Method Retrospective review of all cases of posterior only spinal stabilization performed for metastatic disease over a 5 year period. Patient demographics, pathology and metal work construct including number of levels stabilized was recorded. All post-operative imaging was reviewed. Failures and revisions were recorded. Clinical notes were reviewed for surviving patients. Results Of the 94 cases 49 were male, average age at time of surgery was 62. 77 (81.9%). Of the patients who were deceased by the study end date mean time from surgery to death was 504 (15 to 1865) days. 72 (93.5%) of constructs remained stable until death. 5 patients required further surgery. 3 had broken rods requiring revision and 2 required anterior decompression and stabilization for disease progression. None of the 17 alive patients required further surgery and all remained neurologically intact. Conclusion This case series revealed very low rates of posterior construct failure or need for further surgery for disease progression. This indicates that posterior only stabilization is a safe and effective surgical management option for metastatic spinal lesions.

Modified Ponseti method of treatment for correction of neglected clubfoot in older children and adolescents--a preliminary report.

Congenital talipes equinovarus may be the most common congenital orthopedic condition requiring treatment. Nonoperative treatment including different methods is generally accepted as the first step in the deformity correction. Ignacio Ponseti introduced his nonsurgical approach to the treatment of clubfoot in the early 1940s. The method is reportedly successful in treating clubfoot in patients up to 9 years of age. However, whether age at the beginning of treatment affects the rate of effective correction and relapse is unknown. We have applied the Ponseti method successfully with some modifications for 11 patients with a mean age of 11.2 years (range, 6 to 19 years) with neglected and untreated clubbed feet. The mean follow-up was 15 months (12 to 36 months). Correction was achieved with a mean of nine casts (six to 13). Clinically, 17 out of 18 feet (94.4%) were considered to achieve a good result with no need for further surgery. The application of this method of treatment is very simple and also cheap in developing countries with limited financial and social resources for health service. To the best of the authors' knowledge, such a modified method as a correction method for clubfoot in older children and adolescents has not been applied previously for neglected clubfeet in older children in the literature.

Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions.

This systematic review and meta-analysis compares the safety and effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the treatment of flat and sessile colorectal lesions >20 mm preoperatively assessed as noninvasive. We reviewed the literature published between January 2000 and March 2014. Pooled estimates of the proportion of patients with en bloc, R0 resection, complications, recurrence, and need for further treatment were compared in a meta-analysis using fixed and random effects. A total of 11 studies and 4678 patients were included. The en bloc resection rate was 89.9% for ESD vs 34.9% for EMR patients (RR 1.93 p < 0.001). The R0 resection rate was 79.6% for ESD vs 36.2% for EMR patients (RR 2.01 p < 0.001). The rate of perforation was 4.9% for the ESD group and 0.9% for EMR (RR 3.19, p < 0.001), while the rate of bleeding was 1.9% for ESD and 2.9% for EMR (RR 0.68, p = 0.070). Therefore, the overall need for further surgery, including surgery for oncologic reasons and surgery for complications, was 7.8% for ESD and 3.0% for EMR (RR 2.40, p < 0.001). ESD achieves a higher rate of en bloc and R0 resection compared to EMR, at the cost of a higher risk of complications. This, added to an increased need for surgery for oncologic reasons for a plausible tendency to extend indication for endoscopic excision, increases the risk of further surgery after ESD.

Complications of inguinal herniotomy are comparable in term and premature infants

Inguinal hernias are common, and prevalence is highest in premature males. Recognised complications include recurrence, iatrogenic cryptorchidism and testicular atrophy. We reviewed complication rates following inguinal herniotomy (IH), comparing premature (gestation <36weeks) and term infants. A retrospective case note review of infants aged 0-12months undergoing IH between January 2006 and December 2010. Data collected included demographics, side of hernia, incarceration, complications, duration of follow-up and need for further surgery. Comparison was made using unpaired student t test and Fishers exact test. Four hundred and eight patients underwent IH (365 male, 42 female, 1 complete androgen insensitivity); 197 were premature (prem), mean weight 3.81kg (1.02-9.4); 211 were term (gestation ≥36weeks), mean weight 5.85kg (2.4-11.7), p=0.0001 versus prem. Total herniotomies performed=472 (131 Left, 213 Right, 64 bilateral); 89 hernias were incarcerated at presentation (60 prem vs. 29 term, p=0.0001). Bowel resection was required in six patients (5 prem vs. 1 term, p=0.1109), and 14 had simultaneous orchidopexy (12 prem vs. 2 term, p=0.0049). Early post-operative complication rate 2.8% (8 prem vs. 5 term; p=0.4037). Two hundred and forty patients attended follow-up; 58.8% (125 prem, 115 term). This group accounted for 279 IH (264 male, 15 female). Mean follow-up=5months (0.5-36). Complication rates: recurrence 2.7%, metachronous hernia 7.5%, iatrogenic cryptorchidism 3.8% and testicular atrophy 0.7%. No significant difference was found in complication rates between premature and term infants despite significantly more premature infants presenting with incarcerated hernias.

Revision Ankle Syndesmosis Fixation: Functional Outcome after TightRope® Fixation

ABSTRACT Introduction Syndesmotic injuries present a challenge to orthopedic surgeons. Malreduction of the syndesmosis has been reported to cause instability and secondary osteoarthritis and is correlated with poor subjective and objective outcomes. There are very few studies that report the outcome after revision fixation of these injuries. Previous studies have reported varying techniques for revision syndesmosis reconstruction, including screw fixation and tendon transfers. We present the results of the use of the TightRope® suture for revision syndesmosis fixation. This implant has the advantage of maintaining physiological motion whilst allowing for healing of syndesmotic ligaments and prevents the need for further surgery to remove screws in already scarred soft tissues. Materials and methods We retrospectively analyzed 124 patients who required syndesmotic stabilization from January 2000 until December 2009. Eight of these 124 patients required surgical revision of their failed syndesmosis fixation, each of which was stabilized with the TightRope® Suture. All eight patients were followed up and their outcomes assessed. Seven of the eight patients in our study had technically sound initial fixation of the syndesmosis. Four of the eight patients had syndesmotic separation after screw removal 10 weeks after primary fixation. Results In our study, 6 of the 8 patients had good or satisfactory outcomes based on American Orthopedic Foot and Ankle Society (AOFAS) scores. In spite of accurate revision fixation of the syndesmosis, two patients required further surgery. One patient had conversion to an ankle fusion because of persistent syndesmotic widening and ongoing pain after revision surgery. Another patient required syndesmotic arthrodesis as a result of persistent pain. Conclusion TightRope® suture fixation is a good method of syndesmosis stabilization in patients requiring revision surgery. Randomized studies would be required to compare the effectiveness of this method of fixation with screw fixation. How to cite this article Rajagopalan S, Moonot P, Sangar A, Taylor H. Revision Ankle Syndesmosis Fixation: Functional Outcome after TightRope® Fixation. J Foot Ankle Surg (Asia- Pacific) 2016;3(1):23-27.

Outcome of laser therapy in patients with anal fissure

In the past decade, several studies have investigated the effect of laser therapy on haemorrhoids, anal fistulas and tumours but few have explored its use in acute anal fissure. Therefore, the present study aimed to evaluate the efficiency of laser therapy in treating acute anal fissure. This clinical trial was conducted on all the patients referred to Valiasr Hospital, Arak, Iran, with acute anal fissure. Patients who were unresponsive to medical treatment and in whom surgery was indicated were divided into two equal-sized groups. Age, medical treatment duration, healing time, pain relief, relapse and indication for reoperation were recorded in all patients. The mean age of the patients and the mean medical treatment duration were significantly different in the two groups. Although there were no significant differences in the mean healing time and response to pain in the first and third months after surgery and laser therapy, by month 6 the mean response to pain was significantly different in the two groups. Frequency of relapse and need for further surgery were not significantly different between the groups. Laser therapy of acute anal fissure is a simple, non-invasive and painless surgical procedure with a low rate of complications. It can be viewed as an effective treatment for patients with anal fissure. However, this procedure has some limitations.

(18)F-FDG PET/CT to assess response and guide risk-stratified follow-up after chemoradiotherapy for oropharyngeal squamous cell carcinoma.

To evaluate the use of (18)F-FDG PET/CT as the principal investigation to assess tumour response, to determine the need for further surgery and to guide follow-up following radical chemoradiotherapy for stage III/IV oropharyngeal squamous cell carcinoma (OPSCC). A retrospective analysis was undertaken in 146 patients treated at our centre with radical chemoradiotherapy for OPSCC and who had a PET/CT scan to assess response. According to the PET/CT findings, patients were divided into four groups and recommendations: (1) complete metabolic response (enter clinical follow-up); (2) low-level uptake only (follow-up PET/CT scan in 12weeks); (3) residual uptake suspicious for residual disease (further investigation with or without neck dissection); and (4) new diagnosis of distant metastatic disease (palliative treatment options). The initial PET/CT scan was performed at a median of 12.4weeks (range 4.3 - 21.7weeks) following treatment. Overall sensitivity and specificity rates were 92.0% (74.0 - 99.0%) and 85% (77.5 - 90.9%). Of the 146 patients, 90 (62%) had a complete response and had estimated 3-year overall and disease-free survival rates of 91.9% (85.6 - 98.2%) and 85.6% (78.0 - 93.2%), respectively, 17 (12%) had residual low-level uptake only (with two having confirmed residual disease on subsequent PET/CT, both surgically salvaged), 30 (21%) had suspicious residual uptake (12 proceeded to neck dissection; true positive rate at surgery 33%). HPV-positive patients with reassuring PET/CT findings had an estimated 3-year progression-free survival rate of 91.7% (85.2 - 98.2%), compared with 66.2% (41.5 - 90.9%) of HPV-negative patients. A strategy of using PET/CT results alongside clinical examination to help select patients for salvage surgery appears successful. Despite a complete response on the 12-week PET/CT scan, HPV-negative patients have a significant risk of disease relapse in the following 2years and further studies to assess whether surveillance imaging in this group could improve outcomes are warranted.

Efficacy of phosphorus-32 brachytherapy without external-beam radiation for long-term tumor control in patients with craniopharyngioma.

OBJECT Radioactive phosphorus-32 (P32) has been used as brachytherapy for craniopharyngiomas with the hope of providing local control of enlarging tumor cysts. Brachytherapy has commonly been used as an adjunct to the standard treatment of surgery and external-beam radiation (EBR). Historically, multimodal treatment, including EBR, has shown tumor control rates as high as 70% at 10 years after treatment. However, EBR is associated with significant long-term risks, including visual deficits, endocrine dysfunction, and cognitive decline. Theoretically, brachytherapy may provide focused local radiation that controls or shrinks a symptomatic cyst without exposing the patient to the risks of EBR. For this study, the authors reviewed their experiences with craniopharyngioma patients treated with P32 brachytherapy as the primary treatment without EBR. The authors reviewed these patients' records to evaluate whether this strategy effectively controls tumor growth, thus avoiding the need for further surgery or EBR. METHODS The authors performed a retrospective review of pediatric patients treated for craniopharyngioma between 1997 and 2004. This was the time period during which the authors' institution had a relatively high use of P32 for treatment of cystic craniopharyngioma. All patients who had surgery and injection of P32 without EBR were identified. The patient records were analyzed for complications, cyst control, need for further surgery, and need for future EBR. RESULTS Thirty-eight patients were treated for craniopharyngioma during the study period. Nine patients (23.7%) were identified who had surgery (resection or biopsy) with P32 brachytherapy but without initial EBR. These 9 patients represented the study group. For 1 patient (11.1%), there was a complication with the brachytherapy procedure. Five patients (55.5%) required subsequent surgery. Seven patients (77.7%) required subsequent EBR for tumor growth. The mean time between the injection of P32 and subsequent treatment was 1.67 ± 1.50 years (mean ± SD). CONCLUSIONS In this small but focused population, P32 treatment provided limited local control for cyst growth. Brachytherapy alone did not reliably avert the need for subsequent surgery or EBR.

The callus fracture sign: a radiological predictor of progression to hypertrophic non-union in diaphyseal tibial fractures.

We report a radiological sign which predicts progression to hypertrophic non-union for fractures of the tibial diaphysis. Radiographs of 46 tibial fractures were reviewed independently by four orthopaedic trauma surgeons and two musculoskeletal radiologists. Patients were identified from a database of tibial fractures managed with Ilizarov frame fixation. There were 23 fractures that progressed to non-union requiring further surgery. The controls were 23 fractures that had united without need for further surgery at 1-year follow-up. Radiographs selected were the first images taken following frame removal. All radiographs were anonymised and randomized prior to review. Presence of the callus fracture sign was identified in 16 radiographs of the fractures that progressed to non-union, and 7 of the united fracture group. Sensitivity is 69.6 %. Specificity is 91.4 %. Positive and negative predictive values are 88.9 and 75.0 %, respectively. These results compare favourably with computerised tomography for predicting non-union. Intra- and inter-observer reliability was good (κ = 0.68), and moderate (κ = 0.57), respectively. The callus fracture sign is a useful radiological predictor of progression to non-union and may represent insufficient mechanical stability at the fracture site.

Please provide us with a reasonable definition for curative R0 resection in Barrett's esophagus neoplasia; which one should we choose?

A resection is considered to be R0 when the pathological examination confirms that the edges of the resected specimen are free of disease. A resection is curative when the patient is cured by the endoscopic treatment without need for further surgery or chemoradiation therapy. In the colon for example, the definition of the curative R0 resection is quite simple: a strict R0 is defined by an 'en bloc' specimen with normal mucosa on the edges when examined histologically. The treatment is considered to be curative if the resection is R0 with an invasion depth less than 1000 µm in the submucosa, without lymphatic or venous emboli, without budding, and with a differentiated carcinoma. The situation is far more complex in the neoplasia developed on Barrett’s esophagus (BE) since different degrees of neoplasia are possible with different prognosis and treatment strategies. At present, we do not have any consensus on the definition of R0 and curative resections for BE neoplasia (Fig. 1 a). This editorial aims to discuss various definitions of the R0 resection and their clinical impact. We shall also discuss the literature available to choose the best criteria to define resection curativeness. Fig. 1 Schematic representation of the different R0 resections. a Neoplasia representation; b Colon-like R0; c Intestinal metaplasia R0; d LGD or less R0; e HGD or less R0; f Flat components R0. IM, intestinal metaplasia; LGD, low grade dysplasia; ...

Wrist Arthroplasty: A Complicated Matter: Level 4 Evidence

Despite continued advances in implant design for partial and total wrist arthroplasty, these surgeries present a high incidence of complications, many of which require revision surgery with the potential of a complicated post-operative course. We hypothesize that the incidence of complication is higher then the current reported literature. Follow up duration averaged 2.6 years with longest being 12.4 years. A retrospective review of 105 wrist surgeries in 100 patients who underwent surgery with prosthetic replacement of the distal radius, the proximal carpus or both at a single institution (2005-2014) was performed. Patient factors including age, sex, BMI, handedness, underlying disease and previous injury were recorded. Outcomes were focused particularly on post-operative complications and need for revision surgery. Fourty-seven total wrist arthroplasties (TWA), 52 distal radius hemi-arthroplasties (DRH), and 6 proximal carpal hemiarthroplasties (CH) were performed. Majority (61.7%) of TWA were performed for Rheumatoid Arthritis (RA) or other inflammatory arthropathies, whereas degenerative or post-traumatic arthritis represented the underlying condition for majority of both the DRH (76.9%), and CH (66.7%) groups. Overall complication rate was 50.1% (53/105). Post-operative contracture accounted for the largest number of complications needing additional surgery (20%) though the incidence was much higher in DRH than in TWA (42.3 vs. 16.7%). Component failure composed 15% of all complications, with TWA having the highest incidence across the groups with 24%. Superficial infections occurred at 7.1 and 7.6% in TWA and DRH, respectively. One superficial infection resulted in wound dehiscence that was operatively debrided and closed. All other superficial infections resolved with a short course of oral antibiotics. Deep infections occurred in 4.7 and 3.8% of TWA and DRH, respectively. They were associated with a high number of medical co-morbidities and multiple prior surgeries. All deep infections required removal of hardware, antibiotic spacer placement, and a prolonged course of IV antibiotics prior to a definitive operation. •Though total and partial wrist arthroplasty can provide significant pain relief for the arthritic wrist, there remains a significant potential for complications and need for further surgery.•Patients should be counseled on the potential risks and post-operative course.•It should be noted that the likelihood of failure of wrist arthroplasty tends to increase as time from surgery increases.•Certain patients should be screened with great caution, particularly those with multiple medical co-morbidities, and those pre-disposed to wound issues such as those with low BMI, or poor skin quality.

Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH).

Idiopathic normal pressure hydrocephalus (iNPH) is a type of communicating hydrocephalus also known as non-obstructive hydrocephalus. This type of hydrocephalus is caused by impaired cerebrospinal fluid reabsorption without any obstruction in the ventricular system and is associated with normal cerebrospinal fluid pressure. It is characterised clinically by gait disturbance, cognitive dysfunction, and urinary incontinence (known as the Hakim-Adams triad). The exact cause of iNPH is unknown. It may be managed conservatively or treated surgically by inserting a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt. However, a substantial number of patients do not respond well to surgical treatment, complication rates are high and there is often a need for further surgery. Endoscopic third ventriculostomy (ETV) is an alternative surgical intervention. It has been suggested that ETV may lead to better outcomes, including fewer complications. To determine the effectiveness of ETV for treatment of patients with iNPH compared to conservative therapy, or shunting of CSF using VP or VA shunts.To assess the perioperative and postoperative complication rates in patients with iNPH after ETV compared to conservative therapy, VP or VA shunting. We searched for eligible studies using ALOIS: a comprehensive register of dementia studies, The Cochrane Central Register of Controlled Trials (CENTRAL) and several bibliographic databases such as MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost) and LILACS (BIREME).We also searched the Database of Abstracts of Reviews of Effects (DARE) to identify potentially relevant reviews. The search strategy was adapted for other databases, using the most appropriate controlled vocabulary for each. We did not apply any language or time restrictions. The searches were performed in August 2014. We included randomised controlled trials (RCTs) of ETV treatment of iNPH. Patients had to have at least two symptoms of the Hakim-Adams triad. Exclusion criteria were obstructive causes of hydrocephalus, other significant intracranial pathology and other confirmed causes of dementia. The eligible comparators were conservative treatment or shunting using VP and VA shunts. Two review authors independently screened search results, selected eligible studies, assessed risk of bias and extracted data. We contacted trial authors for additional data. Only one study met the inclusion criteria: an RCT comparing effectiveness of ETV and non-programmable VP shunts in 42 patients with iNPH. The study was conducted in Brazil between 2009 and 2012. The overall study risk of bias was high. The primary outcome in the study was the proportion of patients with improved symptoms one year after surgery, determined as a change of at least two points on the Japanese NPH scale. Due to imprecision in the results, it was not possible to determine whether there was any difference between groups in the proportion of patients who improved 3 or 12 months after surgery (3 months: odds ration (OR) 1.12, 95% confidence interval (CI) 0.26 to 4.76, n = 42; 12 months: OR 2.5, 95% CI 0.62 to 10.11, n = 38). We were unable to estimate the effect of treatment on other efficacy outcomes (cognition, balance, function, gait and mobility) because they were inadequately reported. Of the 26 patients in the VP shunting group, 5 developed subdural hematoma postoperatively, while there were no complications among the 16 patients in the ETV group (OR 0.12, 95% CI 0.01 to 2.3, n = 42), but the estimate was too imprecise to determine whether this was likely to reflect a true difference in complication rates. This was also the case for rates of further surgical intervention (OR 1.4, 95% CI 0.31 to 6.24, n = 42). There were no deaths during the trial. We judged the quality of evidence for all outcomes to be very low because of a high risk of selection, attrition and reporting bias and serious imprecision in the results. The only randomised trial of ETV for iNPH compares it to an intervention which is not a standard practice (VP shunting using a non-programmable valve). The evidence from this study is inconclusive and of very low quality. Clinicians should be aware of the limitations of the evidence. There is a need for more robust research on this topic to be able to determine the effectiveness of ETV in patients with iNPH.

Extra-articular Drilling for Adolescents with Osteochondritis Dissecans of the Talus

Objectives:To determine the radiographic outcome and need for further surgery in children with osteochondritis dissecans (OCD) of the talus treated with extra-articular drilling. Children requiring further surgery for pre-operative risk factors of the initial failure were also evaluated.Methods:Fifty-six ankles were identified between August 2006 and August 2012 with talus OCD that underwent extra-articular talar drilling. Demographic data, mechanism of injury, conservative treatment history, surgical details of initial treatment and subsequent treatment, if necessary, was collected. Pre-operatively, radiographs were evaluated for physeal status, signs of osteoarthritis according the Kellgren and Lawrence Scale, location of the lesion, border, and size of the lesion. Each lesion was classified according to the Berndt and Harty classification for radiographs, Hepple classification for MRI, and Ferkel and Sgaglione for CT. Radiographs at each follow-up visit were evaluated by a Healing matrix that assessed serial changes in lesion length, lesion depth, perilesional sclerosis, or density of the lesion. At final follow-up, lesion size, border, Berndt and Harty classification, and signs of osteoarthritis were recorded.Results:At final follow-up, all but one lesion showed radiographic improvement but no lesion reached complete radiographic resolution. The mean Healing matrix score at final follow-up was 59/100. Risk factors for reaching statistical significance for poor healing included closed physes (p = 0.025) and lesions with a distinct border (p = 0.029). Age, size of lesion, and length of follow-up did not correlate with healing. Comparison of pre-operative and final follow-up radiographs showed no significant change in the size or border of the lesion. For the 23% of children who underwent a second surgery, they were found to have a lower Healing matrix score after index surgery compared to those without repeat surgery, p < 0.001). Moreover, patients with closed physes were more likely to have second surgery, 38% vs. 14% (OR 3.7). After a second extra-articular talar drilling surgery, the mean Healing matrix score improved to match the mean of the entire cohort.Conclusion:Extra-articular talar drilling of OCD does not appear to improve radiographic outcomes as compared with other reported techniques of intra-articular drilling. As with other joints, successful radiographic resolution is associated with open physes - highlighting that children have better OCD healing potential. Other modalities of talus OCD treatment should be explored, especially for higher-grade lesions at risk for instability, since the radiographic results of current drilling techniques are disappointing.

PWE-392 Need for further surgery after delormes procedure for rectal prolapse in elderly patients

<h3>Introduction</h3> Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly females. Delormes procedure is often the preferred operative option for high risk elderly patients due to its minimal invasive nature and minimal postoperative morbidity. A recent randomised control trial looking at the different operative procedure for rectal prolapse has quoted rectal prolapse recurrence after Delormes procedure as high as 46% at 5 years. Whether that high recurrence rates correlates with the need of further surgery is not known. We aimed to analyse rectal prolapse recurrence and further surgery rates for patients undergoing Delormes procedure in our institution. <h3>Method</h3> All consecutive adult patients undergoing Delormes procedure between April, 2000 – December, 2014 at the University Hospitals of Leicester NHS Trust were reviewed. This was a retrospective study. Patients were analysed for mode of surgery, 30 day post-operative mortality, post-operative length of hospital stay, clinically detected recurrence and further rectal prolapse surgery. <h3>Results</h3> 109 patients (median age = 79 years, female n = 102, male n = 7) underwent Delormes procedure over the 14 years. Ninety nine (91%) patients had planned surgery and ten (9%) patients had an urgent operation after being admitted via emergency admission route. Median follow up for all the patients was 4 years and 69 patients were alive at the time of analysis. 30 day post-operative mortality was 2.75% and median length of hospital stay after surgery was 4.5 days. 15 (13.7%) patients had a clinically detected rectal prolapse recurrence during the follow up period, 12 (11%) underwent further surgery for their rectal prolapse (redo Delormes n = 4, Altemeier–s procedure n = 5, abdominal rectopexy n = 3) and 3 patients did not undergo further surgery. <h3>Conclusion</h3> Delormes procedure remains safe and an effective procedure to treat rectal prolapse in elderly patients as clinically significant recurrence rates are low. <h3>Disclosure of interest</h3> None Declared.

PTU-012 Endoscopic resection of giant colorectal adenomas greater than 8 cm – lessons from a tertiary referral practice

Introduction Patients with large sessile colorectal polyps can be technically challenging to resect endoscopically and have been subject to colorectal resection in the United Kingdom and in several centres in the Western world. Surgery can be associated with significant morbidity and mortality particularly in the elderly and in patients with rectal lesions. Our aims were to determine the safety and efficacy of endoscopic resection of large colorectal lesions at a tertiary referral unit. Method All patients with colorectal polyps greater than or equal to 8 cm deemed suitable for endoscopic resection were included in the study. Patients underwent magnification colonoscopy after dye spraying with 0.4% indigo carmine under midazolam sedation after oral bowel preparation. Snares were utilised for endoscopic mucosal piecemeal resection (EMR) and the Fuji flush knife for endoscopic submucosal dissection (ESD). The scar was examined with magnification chromoendoscopy post resection to check for residual disease. All patients underwent follow up magnification colonoscopy at 3 and 12 months by the same endoscopist. Results 84 endoscopic resections of lesions greater than or equal to 8 cm were undertaken, with a mean age of 72 years (SD 10.6). The location of lesions included rectum (n = 23); recto-sigmoid (n = 25); sigmoid (n = 26); descending colon (n = 2); ascending colon (n = 4) and caecum (n = 4). The mean size of the polyps was 102 mm. Histology revealed 78 tubulo-villous adenoma, 5 tubular adenomas and 1 adenocarcinomas. All lesions were resected completely with curative intent. There were 3 perforations (3.6%) all of which were closed endoscopically using clips without need for further surgery. One of the patients had evidence of post procedure haemorrhage. The local recurrence rate was 9.5%. The rate of complications and recurrence were significantly higher than that seen in patients with lesions less than 8 cm (n = 180). Conclusion Endoscopic resection of giant colorectal adenomas may be undertaken with low risk of complications thereby avoiding the need for surgical resection. Nonetheless, it is associated with a higher risk of complications, recurrence and admission to hospital when compared with lesions less than 8 cm and therfore should be considered in specialist units. Disclosure of interest None Declared.