Number Of Previous Surgeries Research Articles

Outcome of Descemet stripping automated endothelial keratoplasty in eyes with an Ahmed glaucoma valve.

The purpose was to investigate the survival of Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with an Ahmed glaucoma valve (AGV). The study had a retrospective case-series of patients with an AGV in the anterior chamber undergoing a DSAEK. Included in the analysis were graft size, number of previous operations, post-operative glaucoma medications, post-operative intraocular pressure (IOP) control, graft size and donor factors (age, endothelial cell density, and post-mortem time). A generalised linear model with binary logistic regression was used to test for an effect on graft survival at 1year and 1.5years. Fourteen eyes from 13 patients were included. The survival rate of the first DSAEK at 6, 12, 18, 24 and 30-months was 85%, 71%, 50%, 36% and 30%, respectively. The mean duration to graft failure was 12.9 ± 6.2months. Five of the seven failed first grafts went on to have a repeat DSAEK. The mean follow-up in this subgroup was 30.7 ± 18.4months. The survival rate of second DSAEK at 6, 12, 18 and 24 months was 100% (5/5), 100% (5/5), 75% (3/4) and 67% (2/3). Only one second DSAEK failed in the duration of the study and went on to receive a third DSAEK which failed at 18-months. The mean IOP within the first year was significantly lower for grafts that survived at 1 and 1.5years (17.4mmHg, 16.9mmHg) than for grafts that failed (19.4mmHg, 19.4mmHg) (p = 0.04, p = 0.009). DSAEK is a viable alternative to PK to restore visual function in eyes with an AGV sited in the anterior chamber. IOP is an important risk factor for graft failure.

Prognostic Factors Affecting the Results of Modified Thompson Quadricepsplasty for the Treatment of Extension Contracture of the Knee.

Knee extension contracture is a disabling complication after fractures around the knee. In this study we aimed to study factors influencing the outcomes of quadricepsplasty for the treatment of traumatic knee extension contracture. We hypothesized that there is no factor influencing the final range of knee motion. In this retrospective study, we included 64 patients who underwent modified Thompson quadricepsplasty between 2008 to 2011 with a mean follow-up time of 36 months. The mean change in flexion was 66 degrees. Using Judet criteria, results were excellent in 41 patients (64%), good in 15 (23%), fair in 4 (6%) and poor in 4 (6%). Preoperative arc of flexion, duration of extension contracture, number of previous surgeries on the limb, and BMI of the patients were independently influencing the final flexion. Modified Thompson quadricepsplasty is associated with high number of excellent and good results especially when it is performed earlier in more severe contractures. Preoperative arc of flexion, interval between trauma surgery and quadricepsplasty, the number of prior surgeries, and BMI influence the outcomes of quadricepsplasty.

Correlation Between Primary Hypospadias Repair and Subsequent Urethral Strictures in a Series of 408 Adult Patients

BackgroundThe correlation between primary hypospadias repair and subsequent urethral strictures in adults has never been addressed. Objective: To evaluate the correlation between the site of primary hypospadias repair and the site of subsequent strictures and to investigate the predictive factors of failure after urethroplasty. Design, setting, and participantsAn observational, retrospective, descriptive study of adult patients with urethral strictures following hypospadias surgery was carried out in a single centre. InterventionMeatotomy, meatoplasty, end-to-end anastomosis, urethroplasty, perineostomy, urethrotomy, and fistula closure. Outcome measurements and statistical analysisWe performed correlations between the site of primary hypospadias and the site of subsequent strictures, treatment failure, and patient lack of motivation for definitive treatment. Cross-tables, Kaplan-Meier curves, and logistic or Cox regression were used. Results and limitationsA total of 408 patients, with median follow-up of 96 mo, were included. Concordance between the site of primary hypospadias repair and the site of subsequent strictures was observed. Multivariable analysis revealed that the number of previous operations needed for initial hypospadias repair was not associated with the risk of treatment failure (hazard ratio [HR] 0.96; 95% confidence Interval [CI] 0.88–1.04; p=0.3) or a lack of patient motivation (odds ratio 0.99, 95% CI 0.90–1.10; p=0.9). Length of stenosis (HR 1.38, 95% CI 1.11–1.71; p=0.004) and lichen sclerosus (HR 1.73, 95% CI 1.03–3.25; p=0.035) were associated with a higher risk of treatment failure. Our study is not representative of the entire population of patients with hypospadias repair. ConclusionsThe stricture site is usually consistent with the site of hypospadias. Stricture length, but not the number of previous operations needed for primary hypospadias repair, was associated with the risk of failure. Patient summaryThe number of operations needed for hypospadias repair was not associated with failure of subsequent urethroplasty.

Laparoscopic Management of Ureteral Endometriosis and Hydronephrosis Associated With Endometriosis

Study ObjectiveTo evaluate if laparoscopic treatment of ureteral endometriosis is feasible, safe, and effective and to determine if ureteral dilatation and/or the number of incisions increases complications. DesignAn institutional review board–approved retrospective cohort study of consecutive patients who underwent surgery for deep infiltrating endometriosis involving the ureter with hydronephrosis (Canadian Task Force classification III). SettingA university hospital. PatientsOf 658 patients who had surgery for deep infiltrating endometriosis between November 2004 and December 2013, 198 of the 658 patients had ureteral endometriosis and required ureterolysis, and 28 of the 198 patients were identified with ureteral dilatation and hydronephrosis associated with endometriosis. InterventionsOf these 28 cases, 15 ureterolyses, 12 reanastomoses, and 1 reimplantation were performed. Measurements and Main ResultsMedical, operative, and pathological data on the evolution of pain, urinary complaints, fertility, complications, and recurrences were collected from clinical records. Additionally, telephone interviews were performed for the follow-up of long-term outcomes. All 28 patients had concomitant surgical procedures because of endometriosis elsewhere in the pelvis or abdomen; 12 (42.9%) underwent surgery of the bowel, whereas 5 (17.9%) had bladder surgery. The evolution of pain after surgery showed a positive response (mean dysmenorrhea evaluation measured by the Numeric Pain Rating Scale from 0–10 preoperatively at the short-term follow-up and the long-term follow-up: 7.25–1.73 and 0.25, respectively). Three complications were noted in the group of 28 patients with ureterohydronephrosis; 1 required surgical reintervention. Logistic regression analyses found vaginal incision (odds ratio = 2.08; 95% CI 0.92–4.73), bladder incision (odds ratio = 8.77; 95% CI 3.25–23.63), number of incisions (odds ratio = 2.12; 95% CI 1.29–3.47), and number of previous surgeries (odds ratio = 1.26; 95% CI 0.93–1.71) as independent risk factors for complications in the group of 198 patients. Three patients underwent reoperation in the group of 28 patients: 1 for ureterovaginal fistula, 1 for persistent ureter dilatation and hydronephrosis, and 1 for persistent pain. ConclusionLaparoscopically assisted ureterolyses, ureteral reanastomoses, and ureteral reimplantation are feasible, safe, and effective treatments for ureteral endometriosis. Complete laparoscopic excision is possible with minimal complications, which seem to be associated with the number of incisions. Ureteral endometriosis should be suspected in all cases of deep infiltrating endometriosis.

Osteochondral Allograft Transplantation of the Knee: Analysis of Failures at 5 Years

Background: Osteochondral allograft transplantation (OAT) is being performed with increasing frequency, and the need for reoperations is not uncommon. Purpose: To quantify survival for OAT and report findings at reoperations. Study Design: Case series; Level of evidence, 4. Methods: A review of prospectively collected data of 224 consecutive patients who underwent OAT by a single surgeon with a minimum follow-up of 2 years was conducted. The reoperation rate, timing of reoperation, procedure performed, and findings at surgery were reviewed. Failure was defined by revision OAT, conversion to knee arthroplasty, or gross appearance of graft failure at second-look arthroscopic surgery. Results: A total of 180 patients (mean [±SD] age, 32.7 ± 10.4 years; 52% male) who underwent OAT with a mean follow-up of 5.0 ± 2.7 years met the inclusion criteria (80% follow-up). Of these, 172 patients (96%) underwent a mean of 2.5 ± 1.7 prior surgical procedures on the ipsilateral knee before OAT. Forty-eight percent of OAT procedures were isolated, while 52% were performed with concomitant procedures including meniscus allograft transplantation (MAT) in 65 (36%). Sixty-six patients (37%) underwent a reoperation at a mean of 2.5 ± 2.5 years, with 32% (21/66) undergoing additional reoperations (range, 1-3). Arthroscopic debridement was performed in 91% of patients with initial reoperations, with 83% showing evidence of an intact graft; of these, 9 ultimately progressed to failure at a mean of 4.1 ± 1.9 years. A total of 24 patients (13%) were considered failures at a mean of 3.6 ± 2.6 years after the index OAT procedure because of revision OAT (n = 7), conversion to arthroplasty (n= 12), or appearance of a poorly incorporated allograft at arthroscopic surgery (n = 5). The number of previous surgical procedures was independently predictive of reoperations and failure; body mass index was independently predictive of failure. Excluding the failed patients, statistically and clinically significant improvements were found in the Lysholm score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Short Form–12 physical component summary at final follow-up (P < .001 for all), with inferior outcomes (albeit overall improved) in patients who underwent a reoperation. Conclusion: In this series, there was a 37% reoperation rate and an 87% allograft survival rate at a mean of 5 years after OAT. The number of previous ipsilateral knee surgical procedures was predictive of reoperations and failure. Of the patients who underwent arthroscopic debridement with an intact graft at the time of arthroscopic surgery, 82% experienced significantly improved outcomes, while 18% ultimately progressed to failure. This information can be used to counsel patients on the implications of a reoperation after OAT.

Combined intramedullary and extramedullary fixation with autogenous bone grafting for the treatment of forearm nonunions with severe bone loss

Introduction Nonunions of diaphyseal forearm fractures are uncommon. They are usually associated with either a complex injury or a complication such as infection. As a result, the majorities of nonunions are atrophic and result in a defined bone defect. Bridge plates and bone grafts were used for the treatment of such cases; however, the presence of poor bone quality especially with disuse can decrease the screw purchase and stability of fixation. Combined intramedullary and extramedullary fixation may add to the stability of fixation and improve the rates of success. Aim The aim of this work was to assess the results of treatment of forearm nonunions with severe bone loss using combined intramedullary and extramedullary fixation with autologous iliac crest bone grafting. Patients and methods This study included six patients with forearm nonunions with severe bone loss treated by combined intramedullary and extramedullary fixation with autologous iliac crest bone grafting. The study included three males and three females. Their age ranged from 14 to 47 years (mean: 36.1±12.4 years). The duration of nonunion ranged from 6 to 180 ms (mean: 78±71.5 ms). A total of four (66.7%) cases had been infected previously. The number of previous surgical procedures ranged from 1 to 8 (mean: 3.5±2.5). The forearm was transformed into a single bone in three (50%) cases. Results All nonunions healed satisfactorily. The final pain scale ranged from 0 to 2 points (mean: 1.3±0.8 points). There was a slight limitation in activities of daily living in all points. The hand grip was normal in one patient, slightly weak in four patients, and moderately weak in one patient. Conclusion Combined intramedullary and extramedullary fixation with autogenous bone grafting is a reliable method of treatment of difficult forearm nonunions with significant bone loss.

A Standardized Regimen for the Treatment of Acute Postoperative Infections and Acute Hematogenous Infections Associated With Hip and Knee Arthroplasties

BackgroundPapers concerning the treatment of periprosthetic infections and acute hematogenous infections often concern inhomogeneous treatment concepts or low numbers of patients; this results in inconsistent rates of treatment success. MethodsThirty-nine patients with early periprosthetic infections and 28 patients with acute hematogenous infections were treated with a homogeneous concept and followed with a mean period of 41.8 (24-132) months in order to investigate the success rate and influencing factors. All patients were treated with open surgical debridement, a revision of all removable components and irrigation with an antiseptic solution (octinedine). All patients received a systemic vancomycin/rifampicin antibiotic therapy until the microorganism causing the infection could be identified; a specific antibiotic therapy then followed until the end of the sixth week. ResultsThis unified treatment regimen resulted in an overall success rate of 71.6%, an 82.1% success for early infections and 57.1% for acute hematogenous infections. Variables that influenced the recurrence of an infection were the timespan between revision and first appearance of symptoms (<2 days), the number of previous operations, the American Society of Anesthesiologists classification, and nicotine abuse. ConclusionIt appears that, in cases of early postoperative infection, a reproducibly high rate of success in retaining an implant can be achieved with this specific therapy regime if surgical intervention can be carried out within 2 days of first symptoms.

When the Infection Hits the Wound: Matched Case-Control Study in a Neurosurgical Patient Collective Including Systematic Literature Review and Risk Factors Analysis

To avoid surgical site infections (SSIs) by identifying patients at high risk for infectious complications, a better understanding of relevant risk factors is required. This manuscript describes a matched case-control study of patients undergoing cranial neurosurgery with postoperative surgical site infections and a systematic literature review. From January 2012 to March 2015, 70 patients (2.47%) with SSIs (out of 2819 patients) and 185 controls were identified. Statistical analyses were performed using univariate and multivariate models to identify risk factors associated with SSIs. The time of the onset of SSIs ranged from 8 to 854 days after surgery (median: 42 days). American Society of Anesthesiologists score (P= 0.003), surgical drain (P<0.001), number of previous operations (P <0.001), and implantation of foreign material (P <0.001) were significant risk factors for SSIs in multivariate analysis. In a systematic literature review, the authors identified 20 independent risk factors. This article provides information to ease the prospective assessment of patients at risk of SSI based on preoperative and postoperative risk factors. Lowering the incidence of SSIs will improve the patient outcomes and the overall quality of the healthcare delivered. To our knowledge, this is the first systemic literature review of SSIs in cranial neurosurgery and analysis of own cases in a wide spectrum.

Development of a Tool to Predict Outcome of Autologous Chondrocyte Implantation

ObjectiveThe study had 2 objectives: first, to evaluate the success of autologous chondrocyte implantation (ACI) in terms of incidence of surgical re-intervention, including arthroplasty, and investigate predictors of successful treatment outcome. The second objective was to derive a tool predicting a patient’s arthroplasty risk following ACI.DesignIn this Level II, prognostic study, 170 ACI-treated patients (110 males [aged 36.8 ± 9.4 years]; 60 females [aged 38.1 ± 10.2 years]) completed a questionnaire about further surgery on their knee treated with ACI 10.9 ± 3.5 years previously. Factors commonly assessed preoperatively (age, gender, defect location and number, previous surgery at this site, and the preoperative Lysholm score) were used as independent factors in regression analyses.ResultsAt final follow-up (maximum of 19 years post-ACI), 40 patients (23.5%) had undergone surgical re-intervention following ACI. Twenty-six patients (15.3%) underwent arthroplasty, more commonly females (25%) than males (10%; P = 0.001). Cox regression analyses identified 4 factors associated with re-intervention: age at ACI, multiple operations before ACI, patellar defects, and lower pretreatment Lysholm scores (Nagelkerke’s R2 = 0.20). Six predictive items associated with risk of arthroplasty following ACI (Nagelkerke’s R2 = 0.34) were used to develop the Oswestry Risk of Knee Arthroplasty index with internal cross-validation.ConclusionIn a single-center study, we have identified 6 factors (age, gender, location and number of defects, number of previous operations, and Lysholm score before ACI) that appear to influence the likelihood of ACI patients progressing to arthroplasty. We have used this information to propose a formula or “tool” that could aid treatment decisions and improve patient selection for ACI.

A Staging System for Revision Rhinoplasty: A Review.

Rhinoplasty is known to be one of the more technically challenging cosmetic procedures, with a revision rate of 5% to 15%. Reasons for revisions may range from minor deformities that can be treated in the office to major cosmetic and functional defects that require multiple surgical procedures to correct. The literature lacks a uniform scale that systematically evaluates the patient presenting for revision rhinoplasty. The TNM staging system for classifying malignant tumors was developed to aid the physician in planning treatment, providing some information about prognosis, assisting in evaluating the results of treatment, and facilitating the exchange of information. Although the patient presenting for a revision rhinoplasty does not have a potentially lethal disease, a classification system for such patients resembling that used for malignant tumors may provide similar benefits. As in TNM staging, we describe 3 major components that determine the overall difficulty of surgery for revision rhinoplasty. In our PGS system, "P" represents "problem," consisting of the specific anatomic anomaly with which the patient presents. The second component in our system is "G" for "graft," based on the number of grafts required. The third component of this system is "S," for "number of previous surgical procedures." In addition, we have included a category "E," for "patient expectations," which is added after the stage of the patient's condition has been determined through the PGS classification. Rather than being measured in terms of survival, as with the TNM system for malignant tumors, the prognosis in revision rhinoplasty is measured in terms of what can be achieved with surgery as opposed to what cannot. This preoperative staging system may help the patient understand the complexity of the repair required and help manage expectations. The PGS system will facilitate exchange of information between surgeons who perform revision rhinoplasty. A standardized evaluation system will allow meaningful comparisons of surgical techniques and evaluations of outcomes of rhinoplasty procedures.

PTH-058 Retrospective Analysis of Crohn’s Disease Risks for Further Surgery

<h3>Introduction</h3> Surgery plays an important role in the treatment of Crohn’s disease. Only a few large surgical series have been published in the literature. We describe our own experience and factors that determine risk of reoperation over a ten-year period. <h3>Methods</h3> All Crohn’s disease surgeries at St George’s Hospital from 1 st January 2004 to 31 st December 2013 were identified. A random sample of just over 200 patients was selected; not including patients less than 16 years of age at time of surgery or those who had surgery for perianal disease. Information was collected for weight, height, gender, smoking status as well as their medical and surgical management. Patients whose records were incomplete were contacted by telephone for further information. <h3>Results</h3> There were a total of 154 patients selected who had completed histories. This accounted to just over 10,000 months of follow-up. Surgeries were for bowel resections, strictureplasties or fistula repairs. 80 were male and 74 were female. Mean age of diagnosis was 23 years and 10 months. Mean time from diagnosis to first ever surgery was 5 years and 5 months. Mean time to further surgery was 31 months. 69% were non-smokers, defined as never having smoked more than 100 cigarettes in their lifetime. At the time of surgery 18% had a low BMI, 60.1% had a normal BMI and 21.9% had a high BMI. 72.72% were receiving treatment with the immunomodulators: azathioprine, 6 mercaptopurine or methotrexate. 7.14% were receiving biologic therapy at the time of surgery. 46.7% had albumin levels &lt;35 at time of surgery and mean CRP was 27.15. Cox regression analysis was used to assess for risk for further surgery and covariates of: age of diagnosis, number of previous surgeries, time from diagnosis to first ever surgery for Crohn’s disease, treatment with immunomodulators, albumin at time of surgery, change in albumin at 1 year follow up, sex, BMI and smoking status. Significant risk for further surgery was found in those that had ever smoked and low BMI (hazard ratio 4.775 and 2.147 respectively). Importantly previous surgery, albumin and age of diagnosis were not a risk factor for recurrent surgery (hazard ratios 1.016, 0.962 and 1.198 respectively). <h3>Conclusion</h3> We review over 10,000 months of follow-up in a selection of Crohn’s disease patients. We have identified significant risks for further surgery of smoking and low BMI (probably a reflection of more severe disease). It continues to be important to address these risk factors as well as continue to try and identify other cofactors and markers that can be useful in predicting course of disease. <h3>Disclosure of Interest</h3> None Declared

Iatrogenic Radial Nerve Palsy After Humeral Shaft Nonunion Repair

To determine the rate of iatrogenic radial nerve palsy (RNP) after surgical repair of established humeral shaft nonunion (HSNU). Retrospective chart review. Level I trauma center. Fifty-four patients with HSNU, 10 (18.5%) of whom developed an iatrogenic RNP after nonunion repair. HSNU repair with compression plate stabilization with or without autogenous bone graft. Postoperative iatrogenic RNP. Ten (18.5%) patients developed iatrogenic radial nerve palsies: 8 experienced complete resolution (mean, 2.5 months) and 2 experienced partial resolution. There were no statistically significant differences between patients who developed nerve palsy and those who did not in regard to age, gender, tobacco use, diabetic status, previous RNP, initial management (operative vs. nonoperative), surgical approach, presence of infected nonunion, number of previous surgeries, or operative time (P > 0.05). The occurrence of iatrogenic RNP for patients undergoing surgical repair of an HSNU was 18.5%. According to historical data, this rate is nearly 3 times higher than for those undergoing open reduction and internal fixation of either acute humeral shaft fractures or HSNUs. Therapeutic Level IV. See Instructions for Authors for a complete description of Levels of Evidence.

One-year interim comparison of canaloplasty in primary open-angle glaucoma following failed filtering surgery with primary canaloplasty

Background/aimsThis study was to explore the 1-year interim efficacy and safety of canaloplasty for primary open-angle glaucoma (POAG) with failed glaucoma filtration surgery (GFS) but an intact Schlemm's canal (SC).MethodsThis...

Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue.

The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open aortic arch surgery performed during the last decade. Data of 1232 consecutive patients who underwent aortic arch repair with reimplantation of at least one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute aortic dissections and arch surgeries not involving the supra-aortic arteries were not included. Arch repair involving all 3 arch arteries (total), 2 arch arteries (subtotal) or 1 arch artery (partial) was performed in 956 (77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques, including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5 and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively. The surgical risk in elective aortic arch surgery has remained high during the last decade despite the advance in surgical techniques. However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably among the centres. The incompleteness of data gathered retrospectively was not effective enough to determine advantages of particular cannulation, perfusion, protection or surgical techniques; and therefore, we strongly recommend further prospective multicentre studies, preferably registries, in which all relevant data have to be clearly defined and collected.

Surgical Treatment of Anal Stenosis with Diamond Flap Anoplasty Performed in a Calibrated Fashion.

Regarding anoplasty for anal stenosis, it is not clear to what extent the final anal caliber should be targeted. The aim of this study was to investigate the results of diamond-flap anoplasty performed in a calibrated manner for the treatment of severe anal stenosis due to a previous hemorrhoidectomy. Prospectively prepared standard forms were evaluated retrospectively. Anoplasty with unilateral or bilateral diamond flaps was performed for moderate or severe anal stenosis, targeting a final anal caliber of 25 to 26 mm. The demographic characteristics, causes of anal stenosis, number of previous surgeries, anal stenosis staging (Milsom and Mazier), anal calibers (millimeter), the Cleveland Clinic Incontinence Score, and the modified obstructed defecation syndrome Longo score were recorded on pre-prepared standard forms, as well as postoperative complications and the time of return to work. From January 2011 to July 2013, 18 patients (12 males, 67%) with a median age of 39 years (range, 27-70) were treated. All of the patients had a history of previous hemorrhoidectomy. The number of previous corrective interventions was 2.1 ± 1.8 (range, 0-4), and 2 patients had a history of failed anoplasty. Five patients (28%) had moderate anal stenosis and 13 (72%) had severe anal stenosis. Preoperative, intraoperative, and 12-month postoperative anal calibration values were 9 ± 3 mm (range, 5-15), 25 ± 0.75 mm (range, 24-26), and 25 ± 1 mm (range, 23-27) (p < 0.0001, for immediate postoperative and 12-month postoperative anal calibers compared with the intraoperative). Preoperative and 12-month postoperative Cleveland Clinic Incontinence Scores were 0.83 ± 1.15 (range, 0-4) and 0.39 ± 0.70 (range, 0-2) (p = 1.0). The clinical success rate was 88.9%. No severe postoperative complications were observed. This study was limited because it was a single-armed, retrospective analysis of prospectively designed data. Diamond-flap anoplasty performed in a standardized and calibrated manner is a highly successful method for the treatment of anal stenosis caused by previous hemorrhoidectomy.

Recurrent Anterior Shoulder Instability With Combined Bone Loss

Background: Recurrent anterior glenohumeral dislocation in the setting of an engaging Hill-Sachs lesion is high. The Latarjet procedure has been well described for restoring glenohumeral stability in patients with >25% glenoid bone loss. However, the treatment for patients with combined humeral head and mild (<25%) glenoid bone loss remains unclear. Purpose/Hypothesis: This study reports on the outcomes of the modified Latarjet for patients with combined humeral and glenoid defects and compares the results for patients with ≤25% glenoid bone loss versus patients with >25% glenoid bone loss. The hypothesis was that the 2 groups would have equivalent subjective outcomes and recurrence rates. Study Design: Cohort Study; Level of evidence, 3. Methods: Modified Latarjet was performed in 40 patients with recurrent anterior shoulder instability, engaging Hill-Sachs by examination confirmed with arthroscopy, and ≤25% anterior glenoid bone loss (group A). A second group of 12 patients were identified to have >25% glenoid bone loss with an engaging Hill-Sachs lesion (group B). The mean follow-up time was 3.5 years. All patients were assessed for their risk of recurrence using the Instability Severity Index score and Beighton score and had preoperative 3-dimensional imaging to assess humeral and glenoid bone loss. Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), recurrence rate, radiographs, range of motion, and dynamometer strength were used to assess outcomes. A multivariate analysis was performed. Results: Glenoid bone loss averaged 15% in group A compared with 34% in group B. Both groups had comparable WOSI scores (356 vs 475; P = .311). In multivariate analysis, the number of previous surgeries and Beighton score were directly correlated with WOSI score in Latarjet patients. The SANE score was better in group A (86 vs 77; P = .02). Group B experienced more loss of external rotation (9.2° vs 15.8°; P = .0001) and weaker thumbs-down abduction and external rotation strength (P < .032). Subscapularis, abduction, and external rotation strength averaged at least 75% of the contralateral shoulder in both groups. Graft resorption was similar in both groups (32% vs 33%; P < .999). The overall recurrent instability rate for the study, defined as any subsequent subluxations or dislocation, was 15%; recurrent instability rates (15% vs 17%; P > .999) were similar for both groups. The complication rate was 25% for both groups. Conclusion: The modified Latarjet procedure provides satisfactory outcomes for patients with combined bone loss, which is known to have high recurrence rates with traditional arthroscopic stabilization. Previous surgical stabilization procedures and the Beighton score adversely affect outcome after modified Latarjet. Furthermore, the number of previous surgeries and Beighton score can be used to predict WOSI score in Latarjet patients. Further study is needed to determine if these results hold true in the long term.

Operations of adults with congenital heart disease – Single center experience with 10 years results

During the last 10 years, 844 operations of 805 adults with congenital heart disease (CHD) were performed in Hospital Na Homolce in Prague, Czech Republic. The median age was 37 (interquartile range 25–49, full range 16–81) years. Operations of complex and rare CHD represented 47%. Forty-four percent of patients (354) underwent previous cardiac surgery in childhood or adulthood. Three and more operations were performed in 14% (113 patients). Combined surgical procedures were performed in 70% of operations.Thirty-day mortality was 1.36%, hospital mortality 1.7% and 5-year survival probability 97%. The risk factors for early and late mortality were NYHA class III and IV symptoms (p<0.0001; OR 30.8), history of heart failure (p=0.001; OR 6.7), cyanosis (p<0.0001; OR 60.5), number of previous operations (p=0.00033), presence of mechanical prosthetic valves (p=0.0032; OR 3.7) and univentricular circulation (p=0.0276; OR 5.4). The difference was not significant for arrhythmias (p=0.078), pulmonary hypertension (p=0.072), age at operation (p=0.372) and gender (p=0.48).Centralization of adult CHD care in a high volume center carries very good surgical results with low early and late mortality. It is important to perform the operations in time and to eliminate all residual lesions by combined surgical procedure. The presence of pediatric cardiac surgeon is necessary for the operations of complex CHD.

Influence of previous surgery on patient-rated outcome after surgery for degenerative disorders of the lumbar spine.

Few studies have used multivariate models to quantify the effect of multiple previous spine surgeries on patient-oriented outcome after spine surgery. This study sought to quantify the effect of prior spine surgery on 12-month postoperative outcomes in patients undergoing surgery for different degenerative disorders of the lumbar spine. The study included 4940 patients with lumbar degenerative disease documented in the Spine Tango Registry of EUROSPINE, the Spine Society of Europe, from 2004 to 2015. Preoperatively and 12months postoperatively, patients completed the multidimensional Core Outcome Measures Index (COMI; 0-10 scale). Patients' medical history and surgical details were recorded using the Spine Tango Surgery 2006 and 2011 forms. Multiple linear regression models were used to investigate the relationship between the number of previous surgeries and the 12-month postoperative COMI score, controlling for the baseline COMI score and other potential confounders. In the adjusted model including all cases, the 12-month COMI score showed a 0.37-point worse value [95% confidence intervals (95% CI) 0.29-0.45; p<0.001] for each additional prior spine surgery. In the subgroup of patients with lumbar disc herniation, the corresponding effect was 0.52 points (95% CI 0.27-0.77; p<0.001) and in lumbar degenerative spondylolisthesis, 0.40 points (95% CI 0.17-0.64; p=0.001). We were able to demonstrate a clear "dose-response" effect for previous surgery: the greater the number of prior spine surgeries, the systematically worse the outcome at 12months' follow-up. The results of this study can be used when considering or consenting a patient for further surgery, to better inform the patient of the likely outcome and to set realistic expectations.

The short-term outcome of redo-mitral valve surgery: emergency versus elective

Objectives The aim of this study was to investigate the overall outcome of adult patients undergoing redo-mitral valve replacement as emergency cases against elective cases. Background Patients with mechanical prosthetic heart valves are at risk of reoperation. The reported risk of mortality may be as low as 5.4-11% for elective reoperation, but as high as 38-61.5% for emergency procedures. Patients and methods Forty patients who had undergone previous mitral valve replacement were admitted for redo-mitral valve replacement during the period between May 2011 and May 2013 at the National Heart Institute. They were divided into two groups: group A: 20 patients were admitted from the ER as emergency cases; group B: 20 patients were admitted from outpatient clinics as elective cases. A mechanical valve was inserted with horizontal mattress pledgeted nonabsorbable sutures. Sutures were placed from left atrium to left ventricle. Tricuspid valve incompetence, if present, was corrected by tricuspid valve repair (De-Vega suture). Results The hospital mortality was 20%. There was no effect regarding age, sex, cardiac rhythm, number of previous operations, type of the previous prosthesis, and interval from last implantation. Taking into consideration that mortality was higher in the emergency group, the New York Heart Association (NYHA) functional class, left ventricular end systolic diameter, left ventricular end diastolic diameter, redo-cardiac surgery sternotomy, and adhesiolysis carry a significant risk of catastrophic bleeding, especially with the rush accompanying hemodynamic instability. Infective cardiac tamponade, permanent pacemaker, residual infective endocarditis, the need for dialysis, and cerebrovascular accidents were not statistically significant. Conclusion When significant valve dysfunction is first noted, reoperation should be undertaken to minimize the operative risk to avoid mortality and postoperative morbidities.

Long-term results after surgical treatment of paravalvular leak in the aortic and mitral position

ObjectivesThe aim of this study was to determine immediate results and long-term outcomes after surgical management of paravalvular leak (PVL). MethodsBetween 1995 and 2012, a total of 190 patients underwent primary surgical repair (n = 142) or valve replacement (n = 48) for a PVL at our institution. The PVL was mild in 6 (3%) patients, moderate in 85 (45%), moderate to severe in 84 (44%), and severe in 15 (8%). Among these, 120 (63%) had PVL in the mitral position, 63 (33%) had PVL in the aortic position, and 7 (4%) had PVL in both valves. Mean follow-up was 5.3 ± 4.6 years. ResultsMean age at surgery was 63 ± 12 years (64% men). Operative mortality occurred in 13 (7%) patients (10 [8%] in mitral; 2 [3%] in aortic; and 1 [14%] in double valve procedures). Survival at 1, 5, and 10 years was 85% ± 3%, 73% ± 4%, and 56% ± 5%, respectively. The cumulative incidence of PVL recurrence was 3% ± 1%, 14% ± 3%, and 32% ± 6%, at 1, 5, and 10 years, respectively. The number of previous surgeries was a predictor of survival and PVL recurrence. Freedom from New York Heart Association class ≥III was 96% ± 2%, 82% ± 4%, and 58% ± 6%, at 1, 5, and 10 years, respectively. The freedom from rehospitalization for heart failure was 92% ± 2%, 83% ± 4%, and 67% ± 6%, at 1, 5, and 10 years. ConclusionsSurgical treatment of PVL resulted in acceptable outcomes. Nevertheless, the continued risk of PVL recurrence is higher in patients who have had multiple previous surgeries. More studies are needed to compare these results with the transcatheter PVL reduction technique.