Posterolateral Incision Research Articles

Meniscal Repair Techniques for Middle- and Posterior-Third Tears

Technical advancements in meniscal repairs have greatly contributed to the ability to repair a variety of meniscal tears that were once thought untreatable. The gold-standard treatment for arthroscopic meniscal body repair remains an inside-out technique. The advantages of this technique are innate to the low-profile nature of the suture-passing construct, which allows for perpendicular access to tears with the benefit of multiple fixation points, in contrast to often bulkier all-inside repair devices. This technique requires a posteromedial or posterolateral incision for safe suture passing and needle retrieval and necessitates a surgical team experienced in this method of repair. However, the newest generation of all-inside devices has allowed for more facile placement of a variety of suture types. The all-inside repair technique includes both capsular-based and meniscal-based fixation, is not limited by a need for additional experienced surgical personnel to pass and retrieve needles, and does not require additional incisions. Regardless of fixation type, meniscal repair has been shown to improve long-term functional scores when compared with meniscectomy. Additionally, biological adjuncts have been introduced into the repair algorithm to improve healing rates when performing isolated meniscal repairs. Preparing the healing site with abrasion or trephination creates vascular channels that can facilitate repair. Intercondylar-notch marrow venting attempts to replicate the environment created by anterior cruciate ligament drilling for which healing rates are notably higher than those with isolated meniscal repairs. The use of fibrin clots in inside-out meniscal repairs with suturing of the clot to the area of the tear has also shown promising early healing rates on both magnetic resonance imaging and second-look arthroscopy. Finally, biological adjuncts such as platelet-rich plasma and concentrated bone marrow aspirate have shown both early clinical and radiographic improvements in Level IV case series, but further research is needed to more definitively measure their utility in the setting of meniscal repair.

Esophagectomy combined with off-pump coronary artery bypass grafting through left posterolateral incision is safe and feasible for esophageal cancer associated with coronary artery disease.

Controversy still exists as to whether surgical treatment has any impact on the long-term survival of esophageal cancer (EC) patients with coronary artery disease treated with curative esophagectomy combined with off-pump coronary artery bypass grafting (OPCABG). Therefore, the aim of this study was to introduce and assess the effect of esophagectomy combined with OPCABG on both short- and long-term outcomes. From January 2010 to January 2015, 1428 EC or esophagogastric junction cancer patients underwent surgical treatment at Henan Chest Hospital, Zhengzhou, China. The clinical data of 25 patients who underwent EC resection through a left thoracotomy following OPCABG and the perioperative characteristics and follow-up results were analyzed. The majority of the patients were male, and the EC stage was predominantly cT2N0-1M0 II. The most common pathological types were squamous cell carcinoma. The EC surgeries consisted of 15 chest anastomosis procedures and 10 cervical anastomosis procedures with aortocoronary graft implantation (mean: 2.36 grafts per patient). The mean total operative time was 330.8 ± 83.5minutes. The median intensive care unit and hospital lengths of stay were 1.72 and 21.16days, respectively. Resection without macroscopic residual disease (R0) was achieved in all of the patients. The most frequent complications included pulmonary infections (24%), arrhythmias (24%), pleural effusion (12%), and esophageal anastomotic leakage (8%). There were no postoperative deaths or myocardial infarctions within 30 days after the surgery. The overall 1-, 3-, and 5-year survival rates were 88%, 40%, and 24%, respectively, with a median survival time of 43months. In the short-term, radical resection of EC following OPCABG is a safe and feasible treatment with low postoperative mortality rates. In the long-term, simultaneous surgery is acceptable and is associated with favorable overall and disease-free survival.

The ACL of the Ankle Joint: A Cadaveric Evaluation of the Subtalar Intrinsic Ligaments and Optimal Surgical Approach

Category:Ankle; Basic Sciences/Biologics; SportsIntroduction/Purpose:The biomechanics of ankle sprains involves a multiplanar-supination motion and not the strict inversion as is often described. During supination, calcaneal inversion occurs at the anatomic subtalar joint. The intrinsic subtalar ligaments include a series of broad thick ligaments situated in the tarsal canal that separate the anterior and posterior compartments. The subtalar intrinsic ligaments are damaged in an estimated 25% to 80% of all lateral ankle sprains. We hypothesize that the intrinsic subtalar ligaments have a multiplanar role in ankle joint stabilization similar to that of the anterior cruciate ligament at the knee. The purpose of this study is to evaluate the efficacy of four surgical approaches to the subtalar ligaments through cadaveric dissection.Methods:Four fresh-frozen cadaveric ankle specimens were utilized. Ability to access the extrinsic lateral ankle ligament (anterior talofibular), the extrinsic subtalar ligaments (calcaneofibular, lateral talocalcaneal) and the intrinsic subtalar ligaments (interosseous talocalcaneal, cervical) was evaluated. The first cadaveric specimen was dissected as a baseline to identify the extrinsic and intrinsic subtalar ligaments. The three remaining cadaveric specimens were utilized to evaluate the efficacy of three standard surgical approaches (a curvilinear incision made over the distal anterior border of lateral malleolus, a posterolateral longitudinal incision, and an extensile sinus tarsi approach) to access both the extrinsic ankle and subtalar ligaments as well as the intrinsic subtalar ligaments. Ability to access all ligaments as well as identification of neurovascular structures at risk during the dissection was recorded for each approach.Results:The curvilinear incision made over the distal anterior border of the lateral malleolus provided access to the anterior talofibular, calcaneofibular ligaments. Branches of the superficial peroneal nerve were noted to be at direct risk. The posterior longitudinal incision provided access to the calcaneofibular, lateral talocalcaneal ligaments. Branches of the sural nerve were noted to be at direct risk with this approach. An extensile posterolateral incision improved access to the anterior talofibular ligament. An extensile sinus tarsi approach provided the most direct access to the interosseous talocalcaneal and cervical ligaments. Visualization of the calcaneofibular and lateral talocalcaneal was also provided with this incision. The saphenous and superficial nerve branches and the sinus tarsi artery were noted to be at risk.Conclusion:We hypothesize that the intrinsic subtalar ligaments have a multiplanar role in ankle joint stabilization similar to that of the anterior cruciate ligament at the knee. Accurate identification and optimal surgical approach to these structures has not been well described in the orthopaedic foot and ankle literature. This cadaveric study provides evidence that an extensile sinus tarsi approach can provide access to the extrinsic ankle and subtalar ligaments as well as the intrinsic ligaments of the subtalar joint.

A Modified 2-Stage Treatment for AO/OTA 43-C1 Pilon Fractures Accompanied by Distal Fibular and Posterior Lip of the Distal Tibia Fracture

The management of pilon fractures remains challenging owing to the high-energy axial loading mechanism that produces comminution of the articular surface, displacement of tibia metaphysis, and severe soft tissue injury. How to preserve the vitality of soft tissue and achieve anatomic reduction has become a timely issue. We report and evaluate the effect of a modified staging treatment for AO Foundation/Orthopaedic Trauma Association (AO/OTA) 43C1 pilon fracture accompanied by distal fibular and posterior lip of the distal tibia fracture. We performed a modified 2-stage treatment of type C1 pilon fracture with distal fibular and posterior malleolar fractures. In the first stage, the posterolateral incision was used for simultaneous reduction of fibula and posterior malleolus, and the tibia was fixed with an external fixator. In the second stage, the external fixator was removed, and the medial malleolus and tibia were fixed after the edema of soft tissue had subsided. The following data were collected: Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short Form 36 (SF-36) score, Burwell-Charnley fracture reduction score, and postoperative complications. Twenty-seven patients were monitored for an average of 31.70 ± 7.38 months. The Burwell-Charnley fracture reduction scores had anatomic and fair ratings of 92.59%. SF-36 physical component score was 42.94 ± 12.47 and mental component score was 48.73 ± 9.79. Score data from the multiple scales of FAOS included pain, 88.79 ± 8.59; activities of daily living, 91.89 ± 7.50; quality of life, 90.26 ± 10.52; sports, 87.93 ± 11.64; and symptoms, 85.32 ± 8.65. The AOFAS ankle-hindfoot scores were 87.30 ± 13.45. Complications were reported in 5 patients (18.52%). Our study provides a good alternative to the existing protocol for type C1 pilon fractures with distal fibular and posterior lip of the distal tibia fracture and effectively reduces soft tissue complications.

AbsorbableMicroplate Externally SuspendingBronchomalaciain Congenital Heart Disease Infant.

To evaluate the feasibility and efficacy of external suspension with absorbable poly-l-lactic acid material shaping microplates for infants with severe bronchomalaciaand congenital heart disease. From November 2017 to January 2019, 11 continual patients with severe bronchomalaciaand congenital heart disease underwent bronchial membrane external suspension together with cardiovascular surgery. An absorbable plate made with poly-l-lactic acid material was used as the shaping fixation material in all patients. Data included the details of the operation, and clinical results were collected. The mean age was 1.2 ± 1.0years, and the mean weight was 7.7 ± 2.9kg. The patients with cardiac malformations were operated on under low-temperature cardiopulmonary bypass (CPB) through median sternotomy. There were no in-hospital deaths. The CPB time, mechanical ventilation time, and length of intensive care unit stay were 123.9 ± 36.9min, 20.7 ± 19.4h, and 71.6 ± 54.9h, respectively. Two patients underwent surgery through a left posterolateral incision without CPB. One was a double aortic arch repair, and the other was only bronchial membrane external suspension with prior IAA repair. No patients needed ECMO support. The mean follow-up time was 12.1 ± 5.6months, and no patients were lost to follow-up. No cases of late death were noted, and no patients needed reoperation. According to the CT scans, no patients had bronchial restenosis. External bronchial membrane suspension with an absorbable poly-l-lactic acid material shaping plate, which had better histocompatibility, for infants with severe bronchomalaciaand congenital heart disease was a safe and feasible procedure.

Application of preoperative embolization during surgery for the destroyed lung.

The destroyed lung has been a challenge in the clinical practice of thoracic surgery, and severe adhesions and massive bleeding during surgery are the main obstacles faced by surgeons. This study aimed to investigate the efficacy of the preoperative embolization of blood vessels in adhesions during surgery for the destroyed lung. A total of 7 patients underwent preoperative embolization for lung resection of destroyed lungs between June 2016 and February 2019. Preoperative embolization was performed for 45 min to 2 h within 48 h before surgery. The embolized arteries included the intercostal artery, radial artery, subclavian artery and their branches, and the number of embolized arteries ranged from 5 to 13. A posterolateral incision was made in these patients, and endoscope-assisted separation of the adhesions at the top of the chest wall and on the lateral chest wall was performed. The operation time ranged from 3.5 to 8 h, and the blood loss was 1,200-5,000 mL. The postoperative drainage was in the normal range. One patient developed multiple organ failure and bronchopleural fistulas (BPF) one month after surgery, which was resolved after active drainage and argon cauterization; another patient developed BPF 7 months after surgery, which was resolved after placement of a nonreturn valve in the subsegmental bronchi via bronchoscopy. Surgery of the destroyed lung is a great challenge in clinical practice, mainly due to the risk of the blood supply in the adhesions. Preoperative embolization may reduce intraoperative blood loss and surgical difficulty.

From Open to Robotic-assisted Latissimus Dorsi Muscle Flap Harvest.

Background:The latissimus dorsi muscle is the largest muscle in the body. The classic open flap harvest technique of this muscle results in a long posterolateral thoracic vertical oblique incision that can leave an unappealing scar. The minimally invasive robotic approach has the potential to reduce scar length and to overcome technical limitations of endoscopic techniques.Methods:Six robotically assisted latissimus dorsi muscle flaps were harvested by a single surgeon. One was used as reversed turnover pedicled flap based on lumbar perforators for lumbosacral bone coverage, another flap was transposed for a Poland syndrome anterior axillary line reconstruction, and the remaining 4 were dissected as free flaps for upper and lower limb reconstruction. All 6 procedures used a short 5-cm axillary crease incision along the posterior axillary fold and two 8-mm port incisions for robotic access.Results:The first robotic flap harvest was converted to the classic open technique due to malposition of the 2 lower port incisions too close to the latissimus dorsi anterior border. The 5 other flaps were successfully transferred without flap or donor site complications. The average flap dissection time was 110 minutes; latter surgeries took less time than the early surgeries as the surgeon became more familiar with the robotic system and due to the use of a newer system.Conclusion:Robotic-assisted latissimus dorsi muscle flap harvest is a safe, reproducible, and effective tool that offers precise dissection control and that leaves a minimal thoracic scar.

Arthroscopically Assisted Treatment of Complex Ankle Fractures: Intra-articular Findings and 1-Year Follow-Up

Especially after complex ankle fractures, patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. The aim of this study was to evaluate the intra-articular lesions, identify fractures specifically at risk for these, and assess the results after arthroscopically assisted open reduction and internal fixation of complex ankle fractures after 1 year. The primary outcome was the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Secondary outcome parameters were the Olerud and Molander Ankle Score (OMAS), Tegner activity scale, arthroscopic findings, functional assessment, and complications. Thirty-two patients (56% female) were enrolled. Chondral lesions were detected in 91%. Full-thickness lesions treated by microfracturing were observed in 0% of unimalleolar, 43% of bimalleolar, and 40% of trimalleolar fractures. After 1 year, the median (interquartile range) AOFAS was 94 (9) and OMAS was 90 (10) for all patients. When analyzing factors possibly influencing the outcome, age, sex, smoking, grading for surgical procedures according to the American Society of Anesthesiologists, fracture type (uni-, bi-, or trimalleolar), severity of chondral lesions graded according to the International Cartilage Repair Society (grade <4 versus grade 4), and syndesmotic instability had no significant influence on the outcome. The only variable significantly influencing the AOFAS (p = .004) and OMAS (p < .001) was body mass index (BMI; rs = –0.522 and –0.606, respectively), with a higher BMI resulting in inferior outcome scores. Complications were observed in 3 patients, 2 with superficial skin necrosis at the posterolateral incision and 1 nonunion of the medial malleolus. Taken together, these data show that intra-articular injuries were common in ankle fractures. Bi- and trimalleolar fractures were particularly at risk for full-thickness lesions. A higher BMI tended to result in inferior outcome scores. Arthroscopically assisted open reduction and internal fixation led to good to excellent results in all but 1 patient.

Modified two-flaps palatoplasty with lateral mucus relaxing incision in cleft repair: A STROBE-compliant retrospective study.

Study Design:clinical results of A STROBE-compliant retrospective studyObjective:To achieving adequate pharyngeal closure and improve the pharyngeal function by a modified two-flap palatoplasty.Summary of Background:Excessive tension in soft palate is the main factor causing the dysphonia after cleft palate. The tension-free suture of the soft palate is the key to achieving adequate pharyngeal closure. In this paper, a modified two-flap palatoplasty improved the pharyngeal functionMethods:From August 2016 to December 2017, 20 patients with cleft palate were treated with a modified two-flap palatoplasty of the posterolateral symmetrical mucosal relaxation incision. The mucosal relaxation incision was performed on both posterolateral sides of the soft palate.Results:All cases had good healing of mucosal flap and the palate. All patients underwent endoscopic examination at 6 months after operation. The postoperative results were satisfactory, with no complications. Twelve patients had bilateral exudative otitis media before operation, 4 patients returned to normal postoperatively, and 8 patients underwent bilateral tympanic membrane catheterization; 2 patients had abnormal function of bilateral eustachian tube before operation and returned to normal postoperatively; 3 patients had unilateral exudative otitis media before operation, and all of them returned to normal; the acoustic impedance test was normal in 3 children before operation. Most children begin to learn to speak, parents are satisfied with their pronunciation, and 3 children are in speech rehabilitation due to unclear pronunciation.Conclusions:We propose a technique to improve the function of the velopharyngeal closure which effectively reduces the incidence of pharyngeal insufficiency and occurrence of operative correction of pharyngeal closure dysfunction. The modifed two-flap palatoplasty with posterior lateral symmetric mucosal relaxation incision is beneficial for better velopharyngeal closure.

The extended latissimus dorsi–serratus anterior chimeric local free flap for salvage of the complicated posterolateral thoractomy incision

BackgroundComposite chest wall reconstruction, following the assurance of chest wall stability, often requires well-vascularized soft tissue coverage with flaps to insure adequate wound healing. Unfortunately, prior surgical approaches such as the posterolateral thoractomy incision or extensive wound breakdown may impede the availability of local or regional choices. A free flap would then be a reasonable option, but in the unstable patient a new donor site is unreasonable. Instead, the otherwise inadequate muscle remnants often transected by the usual thoracotomy incision can be extended by microvascular grafts to provide the necessary reach to the defect. MethodThe ipsilateral cephalic latissimus dorsi and/or serratus anterior muscle remnants following their transection by a posterolateral thoractomy incision can be simultaneously raised as a chimeric flap pedicled in common by the thoracodorsal vessels. The distance the pedicle must be extended to reach the defect requiring coverage is measured, and a vascular graft from the descending branch of the lateral circumflex femoral vessels of the same length is harvested. The thoracodorsal vessels are divided, the vascular graft inserted and anastomosed end-to-end to the cut ends of the former, and then the flap can be stretched the required distance for insetting. ResultA case example of use of the ipsilateral latissimus dorsi–serratus anterior muscle remnants used after extension with arterial and venous grafts to the thoracodorsal vessels as the recipient site is presented with successful salvage of a life-threatening posteriolateral thoractomy wound dehiscence. ConclusionTransection of muscles from a posterolateral thoracotomy incision does not preclude their use as flaps in extenuating circumstances. Their pedicle can be extended using vascular grafts and microvascular techniques in a sense to create a local free flap to provide another solution to a challenging problem.

Posterior Approaches to the Ankle: An Analysis of 3 Approaches for Access to the Posterior Distal Tibia

Category:Ankle, TraumaIntroduction/Purpose:With the increase in the use of CT scanning and fragment specific fixation for complex ankle fractures, utilisation of multiple surgical approaches has increased. The posterolateral approach has been advocated by many, however in our experience, a large proportion of these fractures are not attainable by this approach. Our aim in this study was to analyse three posterior ankle approaches to find their use and efficacy in accessing the posterior tibia in the fixation of posterior malleolar fractures.Methods:We examined 5 fresh frozen cadaveric lower limbs. Three posterior ankle approaches (posterolateral (PL), posteromedial (PM) and medial posteromedial (MPM) approaches were performed, using a consistent repeatable incision of 7 cm extended proximal from the palpable distal extent of the medial malleolus. In both the PL and PM approaches, the flexor hallucis longus (FHL) was taken medially. In the MPM approach, the access was anterior to tibialis posterior (TP).K-wires were then placed parallel to one another at the 4 extremities of the approach. The ankles were imaged using an image intensifier and the distances measured.Our database of 172 consecutively treated posterior malleolar fractures in our department, was used to analyse the fracture fragment size and compare these fracture patterns to the approaches. The fractures were categorised using the Mason and Molloy classification. Only type 2 and 3 fractures were included, leaving 101 in the study.Results:On radiographic analysis, the type 2B and type 3 fractures incorporate 100% and 83% of the posterior width of the tibia respectively. Considering the PL approach only allows access to 40% of the posterior width of the tibia, another approach is required for these fracture patterns. Only 65% of fractures could be adequately exposed using the PL incision. In comparison, 78% of fractures could be exposed using the PM incision.The MPM incision gave the largest area for access to the posterior tibia, however it did not allow access to the constant posterolateral fragment. Only 35% of patients had posteromedial fractures that could be dealt with using the MPM incision, thus its usage is primarily as a supplementary incision, in conjunction with the PL incision.Conclusion:We conclude that the most commonly used approach (the PL approach) gives the least amount of access to the posterior tibia. In comparison to fracture fragment size, almost half of fractures would not be adequately exposed through the PL approach, and if fixing such fractures the surgeon should be comfortable with multiple approaches.

Giant cavernous hemangioma of the eleventh rib

BackgroundCavernous hemangioma of the rib is extremely rare benign vascular tumor. It is difficult to diagnose in time because both invasive and noninvasive examinations usually fail to distinguish it from other tumors of the rib and other bones.Case presentationWe described an asymptomatic 44-year-old woman with cavernous hemangioma of the rib that was incidentally discovered in the bathing. The tumor was completely resected by minithoracotomy through posterolateral incision. The pathological tissue was diagnosed as a cavernous hemangioma composed of thin-walled blood vessels and red blood cells.ConclusionsWe reported this case of giant cavernous hemangioma of the rib for its extremely rare occurrence. The preoperative diagnosis is a challenge both clinically and radiologically, and difficult to distinguish this tumor from other tumors of the rib or long bones.

Posterior Malleolar Ankle Fractures: An Effort at Improving Outcomes.

Background:There is increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. We report our results of posterior malleolar fracture management based on the classification by Mason and Molloy.Methods:All fractures were classified on the basis of computed tomographic (CT) scans obtained preoperatively. This dictated the treatment algorithm. Type-1 fractures underwent syndesmotic fixation. Type-2A fractures underwent open reduction and internal fixation through a posterolateral incision, type-2B fractures underwent open reduction and internal fixation through either a posteromedial incision or a combination of a posterolateral with a medial-posteromedial incision, and type-3 fractures underwent open reduction and internal fixation through a posteromedial incision.Results:Patient-related outcome measures were obtained in 50 patients with at least 1-year follow-up. According to the Mason and Molloy classification, there were 17 type-1 fractures, 12 type-2A fractures, 10 type-2B fractures, and 11 type-3 fractures. The mean Olerud-Molander Ankle Score was 75.9 points (95% confidence interval [CI], 66.4 to 85.3 points) for patients with type-1 fractures, 75.0 points (95% CI, 61.5 to 88.5 points) for patients with type-2A fractures, 74.0 points (95% CI, 64.2 to 83.8 points) for patients with type-2B fractures, and 70.5 points (95% CI, 59.0 to 81.9 points) for patients with type-3 fractures.Conclusions:We have been able to demonstrate an improvement in the Olerud-Molander Ankle Score for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. Mason classification type-3 fractures have marginally poorer outcomes, which correlates with a more severe injury; however, this did not reach significance.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Transaxillary Surgical Ligation of Patent Ductus Arteriosus in Paediatric Group of Patient

Background: Patent ductus arteriosus is a frequent congenital anomaly with left to right shunt. The aim of this study is to assess 3 years’ experience of transaxillary approach in surgical ligation of patent ductus arteriosus.&#x0D; Methods: In three years from July 2015 to September 2017, 46 patients underwent in surgical ligation of patent ductus arteriosus through transaxillary approach. All patients had undergone elective operation. Intra operative and post-operative data were analyzed and follow up after 1 month and 3 years.&#x0D; Results: There were 18 male (39%) and 28 female (61%). Their age range was from 5 months to 10 years months (mean 39.2±24.7 months) and body weight ranges from 4.5 kg to 32 kg (mean 16.05±6.63 kg).There was no mortality or residual patency. Morbidity includes superficial wound infection and chylothorax. All patient discharge on 3rd-5th postoperative day except those who developed chylothorax was discharged after 8 days.&#x0D; Conclusion: Trans axillary approach for closure of PDA has moved from an alternative incision to a standard posterolateral incision in our experience. It is less traumatic and more cosmetic.&#x0D; Cardiovasc. j. 2019; 11(2): 114-117

Short and midterm results of surgical treatment of interrupted aortic arch

Objective: To analyze the early and midterm results of surgical treatment of interrupted aortic arch (IAA) with double-ventricular procedure. Methods: The data of the 68 cases with the main diagnosis of IAA with biventricular structure from June 2009 to June 2017 at Department of Cardiac Surgery, Guangdong General Hospital was collected, including 46 cases of type A, 22 cases of type B. There was no type C case. Except for 5 cases without patent ductus arteriosus or other intracardiac malformations, the remaining 63 cases were combined with intracardiac deformity. The age of operation was 8 days to 18 years, including 28 cases(41.2%) of newborns, 32 cases(47.1%) within 1 year old, 6 cases(8.8%) from 1 to 15 years old, and 2 cases(2.9%) above 15 years old. Of the 5 patients with no intracardiac malformations, 4 patients were treated with a left-posterior thoracic lateral incision for primary surgical correction with end-to-side anastomosis, and 1 adult patient was treated with a median sternotomy incision to complete the anastomosis with the assist of extracorporeal circulation. Of the 63 patients with intracardiac malformation, 2 underwent reconstruction of the aortic arch via posterolateral left thoracic incision merely; 2 patients underwent staged surgery to correction the IAA and intracardiac malformation; the remaining 59 patients underwent the one-stage procedure of IAA and intracardiac malformation correction with deep hypothermic circulatory arrest and 43 cases of selective cerebral perfusion. A total of 55 cases of end-to-end or end-to-side anastomosis were performed in all aortic arch reconstruction. There were 6 cases of connection the arch to descending aorta with autogenous pulmonary artery conduit, and 1 case with homemade bovine pericardial conduit. And there were 5 cases of anastomosis enlargement with autogenous pulmonary artery patch, and 1 case with left subclavian artery flap patch. There were 1 case performed with D. K.S. operation for the severe hypogenetic aortic valve and ascending aorta, and 1 case with left ventricular double outlet channel operation for the severe subvalvular aortic stenosis. Results: Follow-up to 9 years, 4 deaths (5.9%) related to circulatory system diseases: 3 cases died within 30 days after surgery (1 case was neonatal, 2 cases were 1 to 12 months old); one died 8 months after surgery for low cardiac output syndrome. In the early postoperative period, 11 cases (16.2%) of residual aortic arch obstruction (pressure gradient >30 mmHg) were observed, of which 3 cases were moderate (4.4%); follow-up to 5 years after operation was residual obstruction in 3 cases and moderate in 2 cases. There were 3 cases with aortic valve and subvalvular obstruction (differential pressure >30 mmHg), 3 cases were followed up to 5 years after aortic valve and subvalvular obstruction, and 2 cases were moderate or above. To date, 5 patients have undergone 6 reoperations of the cardiovascular system: 3 cases because of pulmonary artery stenosis, 2 cases because of severe aortic arch stenosis, and 1 case because of aortic subvalvular obstruction. Conclusions: One-stage surgical repair of IAA is safe and clinically effective in the neonatal and infant. But some patients still requires reoperation for re-obstruction from subvalvular or aorta arch. For some patients, the choice of aortic arch reconstruction depends on the specific situation.

“Flip-over flap” in two-stage cleft palate repair

PurposeThis study served to evaluate a two-stage concept in cleft palate repair, including key use of a triangular hinge (“flip-over”) flap, in order to prevent palatal fistulae. It uses data from a prospective registry established in 1991. Materials and methodsThe concept entails Furlow soft palate repair (at 1 year of age) and hard palate closure (at 4 years) by a three-pronged approach [paring of the edges with or without postero-lateral relaxing incisions, peninsula (Veau) flap(s)], plus a triangular hinge flap. The latter is elevated from the oral layer of the already-repaired soft palate, stays based anteriorly, and is flipped over to close the posterior nasal layer defect. The case series is compared with data from the literature. ResultsThe palatal fistula rate for Veau II to IV types (two-stage surgeries) was 4.3%. The overall fistula rate in the cleft population (Veau I–IV) was 2.9%. Meta-analyses describe 4.9 and 8.6% on average. There was no difference between sample A in which the flip-over flaps were used only when modified Veau flaps were indicated (until 2006) and sample B in which it was used regardless of the technique of hard palate closure applied (2006–2018). The fistula rate decreased to zero after 2010, which may reflect also an influence of other factors such as the interpositioning of a collagen membrane and also of improved surgical judgment. ConclusionsUsing a flip-over flap in two-stage cleft palate repair may contribute to prevent fistula formation at the hard/soft palate junction. Level of evidenceIII.

Posterior Malleolar Ankle Fractures

Category: Ankle Introduction/Purpose: There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. In creating a treatment guiding classification and algorithm, we report our results in a system change in management of posterior malleolar fractures in our unit. Methods: All fractures were classified according to Mason and Molloy classification (Foot Ankle Int. 2017 Nov;38(11):1229-1235) based on CT scans obtained pre-operatively. This dictated the treatment algorithm. Type 1 fractures underwent syndesmotic fixation. Type 2A fractures underwent ORIF through a posterolateral incision, and type 2B and 3 fractures underwent ORIF through a posteromedial incision. The patient remained NWB for 6 weeks postoperative. Data was collected prospectively from December 2014 to July 2017. Results: Patient-related outcome measures were obtained in 50 patients with at least 1 year follow up (mean 18 months). The overall OMAS score for all posterior malleolar fractures in this cohort was 74.1 (range 35-100). According to Mason and Molloy classification, the mean OMAS for type 1 was 75.9 (Range 30-100), type 2A 75.0 (range 35-100), type 2B 74.0 (range 55-100) and type 3 70.5 (Range 35-100). Using one way ANOVA test, there was no significant difference (p=.886) between groups or within groups. There was a trend, however, that the lower the Mason and Molloy classification had higher OMAS outcomes. The overall 1-year EQ-5D index for this cohort was 0.88 (SD 0.22). The average visual analogue score for this patient group was 77.5 (SD 26.2). Conclusion: We have been able to demonstrate an improvement in functional scores for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. This is compared to our previous study where traditional posterior malleolar management was undertaken. Our OMAS scores have now improved to what would be expected from unimalleolar fractures, illustrating the importance of understanding the injury mechanism and patterns of injury. Mason and Molloy type 3 fractures have marginally poorer outcomes, which correlates with a more significant injury.

Peroneus brevis tendon transfer with the use of an interference screw in Achilles tendon injuries

Objective: To perform a functional evaluation of peroneus brevis tendon transfer using an interference screw fixation in chronic Achilles tendon injuries. Methods: This was a cross-sectional, retrospective and observational study with medical record reviews and a convenience sample of ten (10) patients who underwent surgery between January 2013 and June 2017. The following clinical aspects were evaluated: sex, age group, race, affected side, injury time, distal stump size, gap between stumps, AOFAS questionnaire (pre- and 3 and 6 months postoperatively), patient satisfaction with treatment and complications. Results: The mean subject age was 38.1 years; subjects were predominantly male (80%), and with respect to laterality, the right side was predominant. The paratendinous posterolateral incision technique was used, with the identification and use of the peroneus brevis associated with bone tunnel fixation onto the Achilles using an interference screw. Surgical planning of the technique followed the same procedure in all cases. Two complications occurred during evolution when considering the early and late postoperative periods. Conclusion: The treatment of Achilles tendon injuries with this technique proved to be a good option for chronic injuries with satisfactory results in terms of maintenance of functionality and patient satisfaction postoperatively. Level of Evidence III; Prognostic Studies; Retrospective Study.

Soft Tissue Structures at Risk With Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck.

Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous guidewire and screw placement poses anatomic risks for posterolateral and posteromedial neurovascular and tendinous structures. The objective of this study was to determine the injury rate to local neurovascular and tendinous structures using this technique in a cadaveric model. In addition, we aimed to determine the number of attempts at passing the guidewires required to achieve acceptable placement of 2 parallel screws. Eleven fresh frozen cadaver limbs were used. Two 2.0-mm guidewires were placed under fluoroscopic guidance, posterior to anterior centered within the talus. The number of attempts required was recorded. A layered dissection was then performed to identify injury to any local anatomic structure. The shortest distance between the closest guidewire and the soft tissue structures was measured. The mean total number of guidewires passed to obtain optimal placement of 2 parallel screws was 2.9 ± 0.7. Direct contact between the guidewire and the sural nerve was seen in 100% of the specimens, with the nerve impaled by the guidewire in 3 of 11 (27.2%) cases. The peroneal tendons were impaled in 1 of 11 (9%) specimens and the Achilles tendon was in contact with the guidewire in 8 of the 11 (72.7%) specimens, and impaled at its most lateral border with the guidewire in 2 specimens (18.2%). The placement of posterior to anterior percutaneous screws for talar neck fixation is technically demanding, and multiple guidewires are needed. Our cadaveric study showed that important tendinous and neurovascular structures were in proximity with the guidewires and that the sural nerve was injured in 100% of the cases. Given the risk of injury to these structures, we recommend a formal posterolateral incision for proper visualization and retraction of the anatomic structures at risk.

Pedicled gastric seromuscular patch for one-stage closure of a bronchopleural fistula: a case report

BackgroundOne-stage closure and fenestration are the available surgical options for bronchopleural fistula (BPF). One-stage closure may be applicable in cases with favorable infection control. Closing the bronchopleural stump is difficult due to thick adhesion caused by inflammation and a high risk of pulmonary artery injury. We report the successful closure of a BPF using a gastric seromuscular patch with an omental pedicle flap.Case presentationA 73-year-old man underwent right lower lobectomy with ND2a-2 lymph node dissection for lung adenocarcinoma. He was admitted to a local hospital for pneumonia. Three days after admission, his thoracic cavity was drained and a BPF was suspected. During the primary operation, the latissimus dorsi muscle and anterior serratus muscle were dissected via posterolateral incision, and we decided to close the fistula using the gastric seromuscular layer and omental pedicle flap. The patient was discharged 20 days after surgery. After 2 years, he has not had cancer recurrence and currently leads an active life.ConclusionsThis method provided immediate airtight closure and luminal opening of the middle bronchus in our patient with a large BPF and appeared superior to using the omentum alone. This procedure is useful for one-stage closure and does not require fenestration in cases with favorable infection control.