Need For Surgical Revision Research Articles

Retrospective Analysis of the Akin Osteotomy

Hallux abductovalgus is one of the most common deformities addressed by foot and ankle surgeons. Surgically, it can be approached using a wide variety of procedures. After performing the first metatarsal osteotomy, the final step is often to realign the great toe in a rectus position. This is performed with an osteotomy of the proximal phalanx. The Akin osteotomy is a medially based closing wedge osteotomy of the proximal phalanx. When executing the osteotomy, the goal is not only to correct abduction, but also to keep the lateral cortex intact, which allows it to act as an additional point of fixation. However, the lateral cortex can be iatrogenically compromised during surgery or in the postoperative period. We investigated the frequency of disruption of the lateral cortex, osteotomy displacement, healing time, and the need for surgical revision associated with the Akin procedure. A total of 132 patients who had undergone Akin osteotomy were included in the present retrospective study. Intraoperative fluoroscopy showed the lateral cortex was compromised in 47 (35.6%) patients and remained intact for 85 (64.4%) patients. Of the 47 (35.6%) patients with lateral cortex disruption intraoperatively, 9 (19.1%) experienced displacement during the postoperative period, of whom, 3 (6.38%) required surgical revision. Although intact during surgery, the other 6 (4.55%) patients sustained lateral cortex fractures postoperatively, 2 (33.3%) of whom required surgical revision. A statistically significant difference was found between the integrity of the lateral cortical hinge and the healing time of the osteotomy. All the osteotomies with displacement postoperatively were noted to have lateral cortex failure, either during surgery or during the follow-up period.

Lessons learned from the management of adults who have undergone augmentation for spina bifida and bladder exstrophy: Incidence and management of the non-lethal complications of bladder augmentation.

The present review provides clinical insights and makes recommendations regarding patient management garnered by the long-term follow up of patients undergoing enteric bladder augmentation for the management of congenital anomalies. A prospectively maintained database on 385 patients that have experienced an enteric bladder augmentation, using either the ileum or colon, was reviewed. Evaluations included methods used to prevent bladder calculi formation and recurrence, the incidence and etiology of renal calculi development, the incidence and treatment of vitamin B12 deficiency, and the complications and need for surgical revisions for continent catheterizable stomas. A significantly increased risk for continent catheterizable stomal complications occurred after Monti-Yang tube formation, 70% (21/30 patients), compared with appendicovesicostomy, 41% (27/66 patients), P = 0.008. Both procedures had significantly more complications than continent catheterizable stomas using tapered ileum with a reinforced ileal-cecal valve, 21% (13/63 patients), P < 0.0001 and P < 0.013, respectively. Approximately 50% of the patient population developed a body mass index ≥30 during adulthood. The onset of obesity resulted in significantly more complications developing in patients with a Monti-Yang tube (87%; 13/15 patients) or appendicovesicostomy (55%; 18/33 patients) compared with a tapered ileum with a reinforced ileal-cecal valve (27%, 8/30 patients), P < 0.00015 and P < 0.025, respectively, with a median follow-up interval of 16 years, range 10-25 years. Long-term follow-up evaluations on patients undergoing an enteric bladder augmentation are necessary to prevent the long-term sequela of this procedure. The key to improving patient prognosis is the nutritional management of the patient as they mature, especially if a continent abdominal stoma is going to be carried out.

The effect of surgical access for mitral valve surgery on incidence of atrial fibrillation and atrioventricular block

Atrial fibrillation and conduction disorders are very common and severe postoperative complications in heart surgery.Retrograde analysis of patients (n=103) who had undergone mitral valve surgery or concomitant mitral and tricuspid valve surgery was performed (from January 2006 to December 2016). Patients from each group were divided into two groups: a subgroup with surgery access through the right atrium and interatrial septum (transseptal access) and a subgroup with surgery access through the left atrium (left atrial access). The following data were recorded for all patients: age, sex, extracorporeal circulation time, aortic clamping time, blood loss after surgery, count of blood transfusions administered, the need for surgical revision because of higher blood loss and postoperative atrial and atrioventricular conduction defect (atrial fibrillation and atrioventricular block with pacemaker implantation).A statistically significant difference in extracorporeal circulation time (p<0.05) and aortic clamping time (p<0.01) was recorded between transseptal access and left atrial and right atrial access separately, if combined surgery of both atrioventricular valves was performed. No other statistically significant differences were recorded between the groups.In general, the choice of surgical access for mitral valve on incidence of postoperative atrial and atrioventricular conduction disorders showed no effect. Both access through the right atrium and interatrial septum and access through the left atrium have a similar incidence of postoperative atrial fibrillation and atrioventricular block.

Extended Experience with High Submuscular Placement of Urological Prosthetic Balloons and Reservoirs: Refined Technique for Optimal Outcomes

IntroductionSince 2012, we have routinely placed urological prosthetic balloons and reservoirs in a high submuscular location between the transversalis fascia and rectus abdominis muscle during inflatable penile prosthesis and artificial urinary sphincter surgery. We review our experience of more than 600 high submuscular cases, describe refinements in our technique through time and compare outcomes to prior consecutive space of Retzius prosthetic cases. MethodsWe retrospectively reviewed patients who underwent inflatable penile prosthesis and/or artificial urinary sphincter placement between January 2009 and April 2016. Complications and need for surgical revision were recorded and compared between the 2 placement locations. ResultsDuring the study period 872 prosthetic cases were performed, including 619 high submuscular cases from 2012 to 2016 (inflatable penile prosthesis in 344, artificial urinary sphincter in 275). Of 399 first-time high submuscular implants 54 (14%) required revision, of which 8 (2%) were attributable to the urological balloon or reservoir due to “pain/bother” (4) or herniation (4). Of the 161 space of Retzius urological balloons and reservoirs placed from 2009 to 2011 a similar rate of herniation (3 cases, 1.9%) was noted, although higher rates of deep pelvic complications (3, 1.9%) were noted compared to high submuscular cases (2, 0.5%; p=0.14). Since implementing our refined high submuscular technique, no deep pelvic complications have occurred. ConclusionsExperience with high submuscular placement of urological balloons and reservoirs confirms that it is safe and well tolerated. With refinements in technique the complication rates are similar in frequency to those with space of Retzius but appear to be minor in nature with negligible risk of visceral or vascular injury.

Repeated lumbar or ventricular punctures in newborns with intraventricular haemorrhage.

Although in recent years the percentage of preterm infants who suffer intraventricular haemorrhage (IVH) has reduced, posthaemorrhagic hydrocephalus (PHH) remains a serious problem with a high rate of cerebral palsy and no evidence-based treatment. Survivors often have to undergo ventriculoperitoneal shunt (VPS) surgery, which makes the child permanently dependent on a valve and catheter system. This carries a significant risk of infection and the need for surgical revision of the shunt. Repeated removal of cerebrospinal fluid (CSF) by either lumbar puncture, ventricular puncture, or from a ventricular reservoir in preterm babies with IVH has been suggested as a treatment to reduce the risk of PHH development. To determine the effect of repeated cerebrospinal fluid (CSF) removal (by lumbar/ventricular puncture or removal from a ventricular reservoir) compared to conservative management, where removal is limited to when there are signs of raised intracranial pressure (ICP), on reduction in the risk of permanent shunt dependence, neurodevelopmental disability, and death in neonates with or at risk of developing posthaemorrhagic hydrocephalus (PHH). We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE via PubMed (1966 to 24 March 2016), Embase (1980 to 24 March 2016), and CINAHL (1982 to 24 March 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. RCTs and quasi-RCTs that compared serial removal of CSF (via lumbar puncture, ventricular puncture, or from a ventricular reservoir) with conservative management (removing CSF only when there were symptoms of raised ICP). Trials also had to report on at least one of the specified outcomes of death, disability, or shunt insertion. We extracted details of the participant selection, participant allocation and the interventions. We assessed the following outcomes: VPS, death, death or shunt, disability, multiple disability, death or disability, and CSF infection. We assessed the quality of the evidence using the GRADE approach. Four trials (five articles) met the inclusion criteria of this review; three were RCTs and one was a quasi-RCT; and included a total of 280 participants treated in neonatal intensive care units in the UK. The trials were published between 1980 and 1990. The studies were sufficiently similar regarding the research question they asked and the interventions that we could combine the trials to assess the effect of the intervention.Meta-analysis showed that the intervention produced no significant difference when compared to conservative management for the outcomes of: placement of hydrocephalus shunt (typical risk ratio (RR) 0.96, 95% confidence interval (CI) 0.73 to 1.26; 3 trials, 233 infants; I² statistic = 0%; moderate quality evidence), death (RR 0.88, 95% CI 0.53 to 1.44; 4 trials, 280 infants; I² statistic = 0%; low quality evidence), major disability in survivors (RR 0.98, 95% CI 0.81 to 1.18; 2 trials, 141 infants; I² statistic = 11%; high quality evidence), multiple disability in survivors (RR 0.9, 95% CI 0.66 to 1.24; 2 trials, 141 infants; I² statistic = 0%; high quality evidence), death or disability (RR 0.99, 95% CI 0.86 to 1.14; 2 trials, 180 infants; I² statistic = 0%; high quality evidence), death or shunt (RR 0.91, 95% CI 0.75 to 1.11; 3 trials, 233 infants; I² statistic = 0%; moderate quality evidence), and infection of CSF presurgery (RR 1.73, 95% CI 0.53 to 5.67; 2 trials, 195 infants; low quality evidence).We assessed the quality of the evidence as high for the outcomes of major disability, multiple disability, and disability or death. We rated the evidence for the outcomes of shunt insertion, and death or shunt insertion as of moderate quality as one included trial used an alternation method of randomisation. For the outcomes of death and infection of CSF presurgery, the quality of the evidence was low as one trial used an alternation method, the number of participants was too low to assess the objectives with sufficient precision, and there was inconsistency regarding the findings in the included trials regarding the outcome of infection of CSF presurgery. There was no evidence that repeated removal of CSF via lumbar puncture, ventricular puncture or from a ventricular reservoir produces any benefit over conservative management in neonates with or at risk for developing PHH in terms of reduction of disability, death, or need for placement of a permanent shunt.

Improvement of Perioperative Outcomes in Major Gynecological and Gynecologic-Oncological Surgery with Hemostatic Gelatin-Thrombin Matrix.

To assess the impact of the use of intraoperative hemostatic gelatin-thrombin matrix (HM) (Floseal®, Baxter Healthcare) on transfusion rates and short-term perioperative outcomes in gynecological surgery. In this retrospective, single-center study, we evaluated data of 215 patients (83 cases and 132 controls) undergoing extensive gynecological surgery (e.g. oncological procedures) with and without intraoperative HM application. Cases and controls did not differ according to age, preoperative hemoglobin (Hb) concentration, and Hb or C-reactive protein (CRP) levels at discharge. Patients receiving HM had significantly reduced operative (168 vs. 199 min, p=0.02) and hospitalization (9 vs. 14 days, p<0.001) times. The mean postoperative Hb drop (3.33 vs. 4.51 g/dl, p<0.001), and the mean postoperative increase in CRP (94.9 vs. 149.1 mg/l, p<0.001) were significantly less pronounced within the HM group. Despite more prevalent coagulopathy (48 vs. 31%, p=0.02), e.g. due to anticoagulant use (15.7 vs. 3%, p<0.001), patients treated using HM needed less frequent transfusions of packed red blood cells [odds ratio (OR)= 0.13, 95% confidence interval (CI)=0.07-0.24) and fresh frozen plasma (OR=0.51, 95% CI=0.24-1.05). In comparison to controls, the need for surgical revisions (OR 0.1, CI 95% 0.02-0.42) and intensive-care unit admissions (OR 0.15, 95% CI=0.08-0.30) was lower in patients treated with HM. To our knowledge, our study is the largest case-control study focusing on Floseal® use in gynecology. The use of HM was associated with significantly better short-term perioperative outcomes. Due to its local action, HM seems to be particularly useful in patients in which anticoagulant medication cannot be paused.

Postmastectomy Breast Reconstruction Combined With Contralateral Breast Augmentation for Taiwanese Women With Small Breasts.

Although autogenous tissue-based breast reconstruction has been widely used in the past decade, implant-based breast reconstruction is more often used in Taiwan because Asian women are generally slender with small breasts. For patients with very small breasts, it is hard to achieve the goal of reconstructing a similar breast to the contralateral one, even with the smallest size implant available commercially. Therefore, these patients need not only breast reconstruction but also contralateral breast augmentation. Here we report the surgical outcomes and cosmetic results of breast reconstruction using cohesive gel implants combined with simultaneous contralateral breast augmentation. A retrospective chart review was conducted to identify all patients with AA-sized to B-sized breast cups undergoing expander-implant reconstruction combined with contralateral breast augmentation between 2002 and 2015. Thirty patients were included. For each patient, patient profile (age, body mass index, and initial breast size), type and stage of breast cancer, surgical information (including implant sizes and the type of reconstruction and augmentation), and postoperative subjective pain scales were recorded. Outcomes were analyzed by identifying complications, the need for surgical revision, the presence of local or distant metastases, and patient satisfaction ratings. At a mean 2.3-year follow-up (range, 4 months to 12 years), problems occurred in 7 of the 30 patients, with 9 complications in 8 reconstructed breasts and in 1 augmented breast. Complications were mostly capsule contracture. Aesthetic satisfaction was rated as "excellent" or "good" by most of the patients, and only 1 commented "poor" on both overall and reconstructed results because of postoperative radiotherapy-associated skin necrosis. The total mean subjective pain scale was 1.9/10; a higher mean pain scale of 3.08 was noted in those patients undergoing augmentation with no extra incision. This is the first report of implant-based breast reconstruction with simultaneous contralateral augmentation in Taiwan, showing its efficacy, safety, and good cosmetic outcomes with relatively low complication and revision rates.

Reconstruction Outcomes Following Lateral Skull Base Resection.

Compare reconstruction outcomes for various lateral skull base closure techniques. Retrospective medical records review. University-based tertiary referral center. Patients who underwent resections of tumors involving the lateral skull base requiring reconstruction beyond primary closure. Reconstructive techniques, from rotational flaps to free tissue transfer. Outcome data including wound complications, cerebrospinal fluid (CSF) leakage, and need for surgical revision were tabulated. Eighty-six patients underwent lateral skull base tumor resection and reconstruction. Procedures were primarily lateral temporal bone resections but also included subtotal temporal bone, total temporal bone, and infratemporal fossa resections. Cutaneous malignancy was the most common resection indication (83%) and the temporalis rotational flap was the most commonly employed reconstructive option (30%). When free tissue transfer techniques were used, the radial forearm, anterolateral thigh, and latissimus dorsi were the most frequent donor sites. Patients with T2 disease were more likely to undergo temporalis flaps, whereas patients with T4 disease were more likely to undergo free flap reconstruction. Major complications were uncommon (∼8%), the most frequent being stroke (∼3%). The postoperative wound complication rate was approximately 45%. The majority involved minor dehiscences and were managed conservatively. Patients with T4 disease were more likely to have wound complications (p < 0.05). Radial forearm free flaps were less likely to have wound complications when compared with other reconstruction techniques (p < 0.05). Many factors go into planning lateral skull base reconstruction. Free flaps were more often used for T4 disease. Radial forearm free flaps tended to have lower wound complication rates when compared with other techniques.

Stratégie thérapeutique des méga-uretères primitifs avant 1 an de vie, étude rétrospective de 20 ans

What is the proper way to manage complicated primary mega-ureter in infants under the age of one. This has already been discussed in the literature but the controversy remains. Evaluate the long-term results of the management of mega-ureter based support under the age of one. Single-center retrospective study from 1990 to 2010. All children under one year found were evaluated including clinical examination, ultrasound, scintigraphy and cystography. They were divided into two groups: group 1: children operated on before the age of one year, group 2 non-operated or operated children after the age of one year. We analyzed the long-term evolution of these children on the following criteria: reflux, pyelonephritis, changes in dilation, renal function, need for surgical revision or secondary surgery, and impact on bladder function. In total, 54 patients were included in group 1 and 56 patients in group 2. In a median follow-up of 12years. A total of 101boys and 9girls (sex-ratio 11.22). There were 57 left MUP (52%), 22 right (20%) and 31 bilateral (28%). A total of 71% of antenatal diagnosis. No difference on the emergence of complications: 25 (group 1) versus 31 (group 2) OR=0.69; 95% (0.307; 1.574); P=0.44. No difference between secondary surgery and revision surgery: group 1=12, group 2=22, OR=0.45; 95% CI (0.17, 1.09); P=0.06. No difference for daytime incontinence: OR=1.04; 95% CI (0.14; 7.64); P=0.67. Seventy-six children (69%) were finally made, 12 children operated twice (10.9%) and 34 children (31%) never made. The main challenge of the MUP of management is the preservation of renal function. Sixty-nine percent of our children received surgery due to impaired renal function lower than 30% of urethral dilatation greater than 10mm associated with reflux or recurrent pyelonephritis. Clinical monitoring, regular ultrasound and isotopic testing are necessary and should be extended to adulthood. 5.

Incidence and risk factors for early renal dysfunction after liver transplantation.

To determine renal dysfunction post liver transplantation, its incidence and risk factors in patients from a Belgian University Hospital. Orthotopic liver transplantations performed from January 2006 until September 2012 were retrospectively reviewed (n = 187). Patients with no renal replacement therapy (RRT) before transplantation were classified into four groups according to their highest creatinine plasma level during the first postoperative week. The first group had a peak creatinine level below 12 mg/L, the second group between 12 and 20 mg/L, the third group between 20 and 35 mg/L, and the fourth above 35 mg/L. In addition, patients who needed RRT during the first week after transplantation were also classified into the fourth group. Perioperative parameters were recorded as risk factors, namely age, sex, body mass index (BMI), length of preoperative hospital stay, prior bacterial infection within one month, preoperative ascites, preoperative treatment with β-blocker, angiotensin-converting enzyme inhibitor or non steroidal anti-inflammatory drugs, preoperative creatinine and bilirubin levels, donor status (cardiac death or brain death), postoperative lactate level, need for intraoperative vasopressive drugs, surgical revision, mechanical ventilation for more than 24 h, postoperative bilirubin and transaminase peak levels, postoperative hemoglobin level, amount of perioperative blood transfusions and type of immunosuppression. Univariate and multivariate analysis were performed using logistic ordinal regression method. Post hoc analysis of the hemostatic agent used was also done. There were 78 patients in group 1 (41.7%), 46 in group 2 (24.6%), 38 in group 3 (20.3%) and 25 in group 4 (13.4%). Twenty patients required RRT: 13 (7%) during the first week after transplantation. Using univariate analysis, the severity of renal dysfunction was correlated with presence of ascites and prior bacterial infection, preoperative bilirubin, urea and creatinine level, need for surgical revision, use of vasopressor, postoperative mechanical ventilation, postoperative bilirubin and urea, aspartate aminotransferase (ASAT), and hemoglobin levels and the need for transfusion. The multivariate analysis showed that BMI (OR = 1.1, P = 0.004), preoperative creatinine level (OR = 11.1, P < 0.0001), use of vasopressor (OR = 3.31, P = 0.0002), maximal postoperative bilirubin level (OR = 1.44, P = 0.044) and minimal postoperative hemoglobin level (OR = 0.059, P = 0.0005) were independent predictors of early post-liver transplantation renal dysfunction. Neither donor status nor ASAT levels had significant impact on early postoperative renal dysfunction in multivariate analysis. Absence of renal dysfunction (group 1) was also predicted by the intraoperative hemostatic agent used, independently of the extent of bleeding and of the preoperative creatinine level. More than half of receivers experienced some degree of early renal dysfunction after liver transplantation. Main predictors were preoperative renal dysfunction, postoperative anemia and vasopressor requirement.

Validation of a noninvasive test routinely used in otology for the diagnosis of cerebrospinal fluid shunt malfunction in patients with normal pressure hydrocephalus.

Ventriculoperitoneal shunting is the first-line treatment for normal pressure hydrocephalus. Noninvasive auditory tests based on recorded otoacoustic emissions were assessed, as currently used for universal neonatal hearing screenings, for the diagnosis of cerebrospinal fluid shunt malfunction. The test was designed based on previous works, which demonstrated that an intracranial pressure change induces a proportional, characteristic, otoacoustic-emission phase shift. Forty-four patients with normal pressure hydrocephalus (23 idiopathic and 21 secondary cases) were included in this prospective observational study. The male:female sex ratio was 1.44, the age range was 21-87 years (mean age 64.3 years), and the range of the follow-up period was 1-3 years (mean 20 months). Patients were implanted with a Sophy SU8 adjustable-pressure valve as the ventriculoperitoneal shunt. The phase shifts of otoacoustic emissions in response to body tilt were measured preoperatively, immediately postoperatively, and at 3-6 months, 7-15 months, 16-24 months, and more than 24 months postoperatively. Three groups were enrolled: Group 1, 19 patients who required no valve opening-pressure adjustment; Group 2, 18 patients who required valve opening-pressure adjustments; and Group 3, 7 patients who required valve replacement. In Group 1, phase shift, which was positive before surgery, became steadily negative after surgery and during the follow-up. In Group 2, phase shift, which was positive before surgery, became negative immediately after surgery and increasingly negative after a decrease in the valve-opening pressure. In Group 3, phase shift was positive in 6 cases and slightly negative in 1 case before revision, but after revision phase shift became significantly negative in all cases. Otoacoustic emissions noninvasively reflect cerebrospinal fluid shunt function and are impacted by valve-opening pressure adjustments. Otoacoustic emissions consistently diagnosed shunt malfunction and predicted the need for surgical revision. The authors' diagnostic test, which can be repeated without risk or discomfort by an unskilled operator, may address the crucial need of detecting valve dysfunction in patients with poor clinical outcome after shunt surgery.

The Use of an Aspirating/Resecting Device to Reduce Stoma Closure Following Endoscopic Third Ventriculostomy for Aqueductal Stenosis.

Endoscopic third ventriculostomy (ETV) is commonly used to treat obstructive hydrocephalus. Closure of the stoma can be associated with symptom recurrence and need for further surgical intervention. To describe the use of a side-cutting aspiration device for treatment of aqueductal stenosis in patients undergoing ETV. A retrospective review of 30 consecutive adults with aqueductal stenosis treated with ETV using an adjunct side-cutting aspiration device between 2011 and 2013 was performed. Patients included in the study ranged from 35 to 64 years of age. ETV success was determined by the absence of stoma closure (aqueductal and cisternal flow assessed by high-resolution, gradient-echo magnetic resonance imaging), post-ETV symptom recurrence, and need for subsequent surgical intervention. Patients treated by using a side-cutting aspirator had no observed stoma closure (0%) and a 10% (n = 3) rate of post-ETV symptom recurrence. Three patients (10%) demonstrated a need for surgical revision following initial ETV with the side-cutting aspirator. Adult patients with obstructive hydrocephalus secondary to aqueductal stenosis exhibited a low rate of stoma closure with the use of a side-cutting aspiration device, and a rate of complications comparable to the known literature. Likewise, patients treated with a side-cutting aspirator may have lower symptom recurrence post-ETV and require fewer revisions in comparison with the known literature. As such, a side-cutting aspirator may be considered as a useful adjunct to traditional ETV for the treatment of obstructive hydrocephalus secondary to aqueductal stenosis.

Validation of the Charlson comorbidity index in patients undergoing revision total hip arthroplasty.

The Charlson comorbidity index (CCI) was developed to quantify the influence of comorbidities on survival. The age-related CCI respects patients' age as an additional risk factor. There are several studies available based on administrative data regarding functional outcome, implant survival, resource use and length of hospital stay in patients undergoing primary total hip arthroplasty (THA). To date, there is a lack of knowledge regarding the correlation of the CCI and the age-related CCI in case of revision total hip arthroplasty (RTHA). Our objective was to validate the influence of the CCI and age-related CCI in patients undergoing RTHA regarding complication rate, resource use implant survival and mortality rate. Between October 2007 and November 2012, 142 consecutive patients undergoing RTHA were included in this retrospective study. Routine clinical data were collected and analysed as anonymized aggregated data. In accordance to CCI and age-related CCI the rate of complications (internal medical and surgical complications), the length of hospital stay and the need for ICU treatment and the mortality rate was evaluated. Kaplan-Meier survivorship was used to determine implant survival. Twenty-one patients (15%) had a low risk CCI, 59 patients (41%) a moderate risk CCI and 62 patients (44%) a high risk CCI. The mean follow-up was 27 months (range 24-70 months). In total, we recorded 57 complications (40%), of which 45 were surgical (79%) and 12 were internal medical complications (21%). Twenty-four patients (17%) had to undergo revision surgery. CCI and age-related CCI had no influence regarding implant survival. We recorded a significant influence of the age-related CCI in regard to the necessity of postoperative intensive care unit stay and the length of total hospital stay. Further we recorded a significant influence of the CCI and the age-related CCI regarding postoperative complications and internal complications, postoperative dislocation and the need for surgical revision. In summary, we conclude that the CCI and the age-related CCI are strong predictors regarding complication rate in patients undergoing RTHA. In a short- to mid-term follow-up, no influence on implant survival is detectable.

Benefit-risk profile of non-vitamin K antagonist oral anticoagulants in the management of venous thromboembolism.

The prevention and treatment of venous thromboembolism (VTE) remains a clinical challenge, primarily owing to drawbacks associated with the use of heparins and vitamin K antagonists (VKAs). These and other factors, including a growing elderly population, mean that VTE presents a continuing burden to patients and physicians. Anticoagulant therapy is a fundamental approach for VTE management. Non-VKA oral anticoagulants, including the factor Xa inhibitors apixaban, edoxaban and rivaroxaban, and the thrombin inhibitor dabigatran, have been studied in phase III trials across a spectrum of thromboembolic disorders. These agents offer simplified care, with similar or improved efficacy and safety outcomes compared with heparins and vitamin K antagonists. There are several factors a physician must consider when prescribing an anticoagulant. An important consideration with all anticoagulant use is bleeding risk, especially in high-risk groups such as the elderly or those with renal impairment or cancer. In orthopaedic patients, other risks include a need for surgical revision or blood transfusion, or wound complications. Therefore, the clinical benefits of an anticoagulant should ideally be balanced with any risks associated with the therapy. Quantitative benefit-risk assessments are lacking, and owing to differences in trial design the non-VKA oral anticoagulants cannot be compared directly. Based on trial and "real-life" data, this review will summarise the clinical data for the non-VKA oral anticoagulants in the prevention and treatment of VTE, focusing on the balance between the benefits and risks of anticoagulation with these drugs, and their potential impact on VTE management.

An observational case series of HIV-positive patients treated with open reduction internal fixation for a closed lower extremity fracture.

The purpose of this study was to investigate the influence of immune deficiency status of HIV-positive patients on postoperative complication such as surgical site infection and nonunions. Retrospective observational cohort study: Level III. Level I trauma center. Consecutive adult HIV-positive patients with closed fractures who underwent operative treatment between January 1, 2001 and December 31, 2012. postoperative complication including infection and fracture nonunion. A total of 42 HIV-positive patients with closed fractures who underwent surgical fracture fixation were identified during the 12-year study time window. Of these, 18 patients were excluded due to incomplete medical records (n = 16) or open fractures (n = 2). The remaining 24 patients with closed fracture treated surgically (19 males and 5 females; mean age 45.1 ± 10.5 years; age range 20-67 years) were included in the study. Within a 6-month period from the time of injury, 16 patients had a CD4+ cell count >200 and five patients had a CD4+ cell count <200 (CD4+ cell count was not available in three patients). Twenty-two patients (91.6 %) were on antiretroviral therapy at the time of injury. Only one patient, with associated end-stage renal failure and diabetes mellitus, developed a postoperative infection (4.2 %). All patients achieved fracture union within 180 days postoperatively, without the need for surgical revisions. Our study suggests that HIV infection does not seem to correlate with a higher risk for the development of postoperative complication related to surgical site infection and fracture nonunions after operative fixation of closed fractures.

Surgical tracheotomy performed with and without dual antiplatelet therapy.

Some patients who need dual antiplatelet therapy sometimes require tracheotomy. Aim of this study was to compare the rate of complications during and after surgical tracheotomy between patients requiring dual antiplatelet therapy and those without dual antiplatelet therapy. We retrospectively included 79 patients (62% men, mean age 64 ± 14 years) in the period 2007–2011. The following complications were analyzed: need for surgical revision within 24 hours after tracheotomy, need for bronchoscopy within 24 hour after tracheotomy, need for blood transfusion within 24 hours after tracheotomy, death attributed to tracheotomy and any complication attributed to tracheotomy. We compared patients where tracheotomy was performed while receiving dual antiplatelet therapy (n=27, 34%) to patients where tracheotomy was performed without dual antiplatelet therapy (n=52, 66%). Nonsignificant differences between the two groups were observed general characteristics. There were no statistically significant differences in complications after tracheotomy (surgical revision after tracheotomy p=0.63, bronchoscopy after tracheotomy p=0.74, blood transfusion after tracheotomy p=0.59, death attributed to tracheotomy p=1.00 and any complication attributed to tracheotomy p=1.00). The study shows that tracheotomy is safe in cardiac patients on dual antiplatelet therapy.

What happens to the bone flap? Long-term outcome after reimplantation of cryoconserved bone flaps in a consecutive series of 92 patients.

Reimplantation of cryoconserved autologous bone flaps is a standard procedure after decompressive craniotomies. Aseptic necrosis and resorption are the most frequent complications of this procedure. At present there is no consensus regarding the definition of the relevant extent and indication for surgical revision. The objective of this retrospective analysis was to identify the incidence of bone flap resorption and the optimal duration of follow-up. Between February 2009 and March 2012, 100 cryoconserved autologous bone flaps were reimplanted at the Department of Neurosurgery, Inselspital Bern. Three patients were not available for follow-up, and five patients died before follow-up. All patients underwent follow-up at 6 weeks and a second follow-up more than 12 months postoperatively. A clinical and CT-based score was developed for judgment of relevance and decision making for surgical revision. Mean follow-up period was 21.6 months postoperatively (range: 12 to 47 months); 48.9 % (45/92) of patients showed no signs of bone flap resorption, 20.7 % (19/92) showed minor resorption with no need for surgical revision, and 30.4 % (28/92) showed major resorption (in 4 % of these the bone flap was unstable or collapsed). Aseptic necrosis and resorption of reimplanted autologous bone flaps occurred more frequently in our series of patients than in most reports in the literature. Most cases were identified between 6 and 12 months postoperatively. Clinical observation or CT scans of patients with autologous bone flaps are recommended for at least 12 months. Patient-specific implants may be preferable to autologous bone flaps.

CORR Insights ®: Intramedullary nailing of femoral diaphyseal metastases: is it necessary to protect the femoral neck?

M ore than 1.5 million patients are diagnosed with cancer annually in the US, and more than half a million die each year from metastases [2]. Bone metastases to the femur are common; in fact, the femur is the most common site of osseous metastatic disease resulting in orthopaedic intervention. As such, most general orthopaedic surgeons are likely to encounter this problem. The goal in stabilizing these lesions is to allow the patient to regain mobility and maintain a high quality of life. Experience has shown fixation with intramedullary devices is superior to using plates and screws [3], although this may not apply for periprosthetic femoral bone metastases, where plate fixation may be the treatment of choice. When choosing an intramedullary implant, the conventional wisdom has been to use locked cephalomedullary nails. Locking the nails makes sense because of the inherent instability of the femur when a metastatic lesion is present. The rationale for cephalomedullary nails instead of conventional nails is to prevent femoral neck fractures if a lesion were to develop in this region during the remaining lifespan of the patient, but this theory is supported only by anecdotal evidence. The use of a cephalomedullary nail adds a degree of difficulty to the surgical procedure due to technical aspects of implanting screws in the femoral neck. The additional steps take more surgical time, and entail the use of more fluoroscopy with resultant radiation exposure to the patient, surgeon and staff. Additionally, current high-quality imaging has greatly improved the detection of occult bone lesions, and occult femoral neck lesions seem unlikely to be missed with careful imaging. The use of bisphosphonates for patients with skeletal metastases also has substantially reduced the number of skeletal events requiring surgical intervention [4]. In addition, there is no evidence available to suggest that even if a metastatic bone lesion developed in the femoral neck, that a cephalomedullary nail would be sufficient to prevent a pathologic fracture or the need for surgical revision. Finally, patients with metastatic disease in general have a limited lifespan, with the majority dying in the This CORR Insights is a commentary on the article ‘‘Intramedullary Nailing of Femoral Diaphyseal Metastases: Is it Necessary to Protect the Femoral Neck?’’ by Moon and colleagues available at: DOI: 10.1007/ s11999-014-4064-1. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999014-4064-1. M. T. Scarborough MD (&) Department of Orthopaedics and Rehabilitation, University of Florida, PO Box 112727, Gainesville, FL 32611, USA e-mail: scarbmt@ortho.ufl.edu CORR Insights Published online: 24 December 2014 The Association of Bone and Joint Surgeons1 2014

The role of interventional radiology in complications after paediatric liver transplantation.

Liver transplantation has become an established treatment in both adults and children for end-stage liver disease, acute hepatic failure andcertain livertumours. There is a significant rate of complications after all forms of liver transplantation. The interventional radiologist plays a critical role in the diagnosis and treatment of these complications. The use of image-guided, minimally invasive procedures reduces the need for surgical revision or retransplantation, and improves graft and patient survival rate. This article reviews some of the most common vascular and non-vascular complications after paediatric liver transplantation, and the interventional radiology techniques used to diagnose and treat them.

Free Flap Reconstruction Experience and Outcomes in a Low‐Volume Setting over 20 Years

Objectives: (1) Recognize the potential efficacy of free flap reconstruction performed at a low volume program. (2) Understand how reconstructive microvascular outcomes and success change over 20 years. Methods: A retrospective chart review was performed at a tertiary care academic program on all free tissue flaps from the primary reconstructive surgeon over 20 years (1993-2013). A total of 135 procedures were obtained from operative notes, billing codes, and chart databases. Outcome variables included overall procedure success, need for surgical revision, and complications. Patients stayed in general surgical intensive care and hospital floor units. Results: Free tissue flaps were successful in 91% of all cases. In the past 13 years, 70 flaps were performed with 3 failures (96% success rate). Take-back rate was 14% of total cases with a flap recovery rate of 50%. Postoperative failure occurred after 72 hours in 70% of cases. Nearly 60% of patients experienced a complication of any type or severity. Twenty percent of successful flaps had a complication, with half due to partial dehiscence. Systemic complications affected 20% of all cases. The average hospital stay for noncomplicated patients was 13 days. There was 1 postoperative mortality. Fibula and radial forearm were the most common flaps, at 44% and 26%, respectively. Conclusions: Free flap reconstruction of the head and neck can be performed with acceptable outcomes even in low volume settings.