Previous Surgical Incision Research Articles

A Novel Case of Cervical Lipoma Arising From Surgical Incision.

Lipoma is a benign mesenchymal tumor primarily found in subcutaneous fat. Post-traumatic lipoma (PTL) sporadically associates with blunt of penetrating trauma, but the exact mechanism remains not fully understood. This article unveils a rare case of a 32-year-old male presenting with a cervical lipoma at a previous surgical incision, an unprecedented occurrence. The patient incidentally detected the mass and underwent complete excision, with pathology confirming the diagnosis. The etiology of PTL remains speculative, with proposed mechanisms postulating inflammatory chemokines inducing preadipocyte differentiation and acute trauma causing septal rupture, allowing lipoma formation. Notably, the prior use of blade in our patient's surgical procedure aligns with this hypothesis. The varied nature of trauma encompasses acute, blunt, and penetrating injuries. This case represents the second instance attributed to penetrating trauma and the first occurrence at a surgical incision site.

Complex management of larger strangulated incisional hernia in a post-multiple abdominal surgery in a morbidly obese patient-a case report and surgical review

Strangulated incisional hernia following a post-hernia repair is a serious and potentially rare life challenging condition that can occur after surgical intervention. Incisional hernias accounts for 15-20% of all abdominal hernias which occur at the site of a previous surgical incision where the integrity of the fascia has not been fully restored. We are presenting a case report of a 49 years lady who came with complaints of abdominal swelling and pain abdomen following multiple abdominal surgeries diagnosed with strangulated incisional hernia following post hernia repair. It was managed by emergency surgical intervention that is removal of previously kept mesh and resection of gangrenous segment of bowel with end ileostomy after keeping overall patient’s condition.

Incisional lumbar hernias: Current role of laparoscopic approach with intraperitoneal onlay mesh procedure

Abstract PURPOSE: Lumbar incisional hernias are a defect of the posterolateral region on the abdominal wall that originated from previous surgical incisions in the area. A surgical approach is challenging due to low incidence and the lack of enough publications on the topic, which generates controversies among surgeons. The purpose of this paper is to show our laparoscopic approach experience using the intraperitoneal onlay mesh (IPOM) and IPOM Plus procedures for the treatment of lumbar incisional hernias. MATERIALS AND METHODS: This was a retrospective descriptive study, including 10 patients with lumbar/posterolateral incisional hernias, diagnosed by computerized tomography scan and surgically treated with the IPOM laparoscopic technique in one case and IPOM Plus in nine cases from 2014 to 2021. Demographic data and baseline characteristics of enrolled patients were assessed, as well as perioperative data, surgical time, length of hospital stay, and recurrence during an average 38.6-month follow-up. RESULTS: In the series assessed, the defect size ranged between 24 and 72 cm2, with mean longitudinal and transversal diameters of 7.9 and 5.8 cm, respectively. The surgery lasted 120–180 min. There were no cases of conversion or intraoperative visceral lesions. Nine patients were discharged on an average of 37.8 ± 8.9 h after admission, and one patient stayed for 64 h due to extra analgesic demand. Postoperative morbidity was a case of hematoma. There was one case of recurrence. CONCLUSION: The results of our experience have shown the benefits of the laparoscopic approach with the IPOM Plus method for the treatment of lumbar incisional hernias, including short hospital stays and low incidence of postoperative complications. Accordingly, this mainstream technique, which has shown good outcomes both in the short and the long term, appears to be a simple and safe procedure.

Strangulated Incisional Hernia Post Appendectomy: A Rare Case Report

Background: Incisional hernia is a condition in which internal organs, such as the intestines, protrude through a previous surgical incision or suture. This occurs due to the failure of the abdominal wall to close properly. The closure of the abdominal wall is influenced by patient-related factors and technical factors during surgery. Incisional hernia following appendectomy is a rare condition, with an incidence rate of less than 0.12%. With this case report, the author aims to contribute to the literature on strangulated incisional hernia post-appendectomy.
 Case presentation: A 42-year-old male presented to the emergency department with complaints of right lower abdominal pain for the past three days. The patient reported a lump that had been intermittently present for the past nine years but became persistent three days ago. The patient had a history of appendectomy nine years ago. Vital signs were relatively stable, and physical examination revealed a bluish mass measuring 10x8x4 cm in the abdomen. Radiological abdominal assessment revealed a high-level obstructive ileus. Subsequently, the patient underwent a laparotomy, and a right hemicolectomy was performed, removing a segment measuring 50 cm from the ileocecal junction to the ascending colon.
 Conclusion: Incisional hernia following appendectomy is a rare complication, but it can occur due to various risk factors, such as surgical site infection, improper choice of suture material, and inappropriate wound closure technique. The management of this condition can involve the use of tension-free synthetic mesh in either laparotomy or laparoscopy.

Masquelet Technique: Visualization of Cement Spacer Utilizing Methylene Blue

Masquelet Technique: Visualization of Cement Spacer Utilizing Methylene Blue

Spontaneous Rupture of an Unscarred Non-Laboring Gravid Uterus at Term: A Case Report

Background: Rupture of the pregnant uterus is life-threatening for the mother and fetus. Most ruptures occur in women who have had a previous transmyometrial surgical incision, typically for cesarean delivery. Rupture of the unscarred uterus is rare, but the incidence is increasing. It is associated with higher major maternal and neonatal morbidity than cases of rupture of the scarred uterus. Case presentation: Here we presented a case of 36 years old gravida 4 para3 presented at gestational age of 38 weeks with vomiting of ingested matter mixed with blood and abdominal pain of 12 hours and, initially diagnosed to have Placenta previa, severe anemia secondary to acute blood loss secondary to upper gastrointestinal bleeding, Intrauterine fetal death. Finally diagnosed to have uterine rupture and total abdominal hysterectomy done. Conclusion: A high index of suspicion is needed in pregnant patients presenting with sudden onset of abdominal pain so as not to miss uterine rupture and its complications.

Uterine Rupture at a Site Distant From Old Scar: An Unusual Presentation

Uterine rupture is a rare life threatening emergency with severe obstetric consequences. Most ruptures occur in a scarred uterus at the site of previous transmyometrial surgical incision. However, rupture on site distant from previous scar is a very rare entity. It is associated with major maternal and neonatal morbidity than rupture at a scarred area. Index case describes a scenario where uterine rupture occurred at the fundal region, far away from previous caesarean scar site leading to fetal demise. Till now, only a very few cases with uterine rupture away from the site of previous caesarean scar have been reported.
 Keywords: uterine rupture, unscarred uterus, acute abdomen, hemoperitoneum

Ultrasound-guided Spinal Needle Localization for Resection of Abdominal Wall Endometrioma

A 47-year-old patient with 2 previous cesarean sections presented with 2 years of right lower quadrant spasm-inducing pain. The pain began with menses and lasted for 15 days each month. Magnetic resonance imaging revealed a 3.3 × 1.9 × 6.0-cm lesion in the medial aspect of the right rectus abdominis muscle, consistent with abdominal wall endometrioma (Fig. 1A). No fascial involvement was identified. At the time of surgery, intraoperative ultrasound was used to map the endometrioma (Fig. 1B). Under ultrasound guidance, the endometrioma borders were marked using 3.5-cm 20 gauge needles through the anterior abdominal wall (Fig. 2). During robotic-assisted excision of the endometrioma, the needles were intermittently advanced and withdrawn from the peritoneal cavity by the bedside assistant to delineate the limits of necessary dissection (Fig. 3). This technique contributed to efficient and complete excision. Postoperatively, the patient reported complete resolution of right lower quadrant pain. Final pathologic evaluation confirmed extensive endometriosis. Abdominal wall endometriosis (AWE) is most often found in previous abdominal surgical incisions. In women undergoing surgical excision of endometriosis, AWE was noted in 1.34% [1Khan Z Zanfagnin V El-Nashar SA Famuyide AO Daftary GS Hopkins MR. Risk factors, clinical presentation, and outcomes for abdominal wall endometriosis.J Minim Invasive Gynecol. 2017; 24: 478-484Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar]. The most common procedure before AWE is cesarean section with a higher risk reported with Pfannenstiel incision vs vertical midline incision [1Khan Z Zanfagnin V El-Nashar SA Famuyide AO Daftary GS Hopkins MR. Risk factors, clinical presentation, and outcomes for abdominal wall endometriosis.J Minim Invasive Gynecol. 2017; 24: 478-484Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 2Horton JD Dezee KJ Ahnfeldt EP Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases.Am J Surg. 2008; 196: 207-212Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar, 3Zhang P Sun Y Zhang C et al.Cesarean scar endometriosis: presentation of 198 cases and literature review.BMC Womens Health. 2019; 19: 14Crossref PubMed Scopus (23) Google Scholar]. Cesarean scar endometriosis is likely secondary to direct implantation of endometrial tissue in the incision [2Horton JD Dezee KJ Ahnfeldt EP Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases.Am J Surg. 2008; 196: 207-212Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar]. Surgical excision allows pathologic evaluation and therapeutic resection [4Karapolat B Kucuk H. A rare cause of abdominal pain: scar endometriosis.Emerg Med Int. 2019; 20192584652Crossref PubMed Google Scholar,5Behbehani S Magtibay P Chen L Wasson M. Clear cell carcinoma of the anterior abdominal wall secondary to iatrogenic endometriosis.J Minim Invasive Gynecol. 2020; 27: 1230-1231Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. Excision is often planned with preoperative ultrasound or magnetic resonance imaging. Previously reported surgical approaches to AWE include ablative techniques such as percutaneous cryoablation or ethanol injection [6Welch BT Ehman EC VanBuren WM et al.Percutaneous cryoablation of abdominal wall endometriosis: the Mayo Clinic approach.Abdom Radiol (NY). 2020; 45: 1813-1817Crossref PubMed Scopus (6) Google Scholar]. If AWE involves the fascia, surgical excision can still be performed by a minimally invasive approach with endoscopic mesh placement and fascial repair by general surgery. Intraoperative techniques to assist with excision include injecting the lesion with methylene blue or ultrasound-guided wire localization [7Lee MMH Robson NK Carpenter TT. Ultrasound-guided wired localisation for resection of impalpable anterior abdominal wall scar endometriomas.Gynecol Surg. 2012; 9: 103-105Crossref Scopus (2) Google Scholar,8Takmaz T Kiran G Ozcan P Sahin N Tanoglu B. Total surgical excision by ultrasound–guided wire localization for spontaneous abdominal-wall endometriosis.J Gynecol Surg. 2020; 36: 76-79Crossref Scopus (1) Google Scholar]. Ultrasound-guided localization with spinal needles is a simple, practical technique that can assist with complete excision of abdominal wall endometriomas.

Hepaticojejunostomy vs. Hepaticoduodenostomy after Excision of Choledochal Cyst in Paediatric Population- A Retrospective Study

Introduction: Choledochal cyst is a rare congenital anomaly of the bile duct with female predominance. Surgical excision of the choledochal cyst with hepaticoduodenostomy or hepaticojejunostomy is the standard of care in the last few decades. Many surgeons favour hepaticojejunostomy. Aim: To evaluate the outcomes of open hepaticoduodenostomy vs. hepaticojejunostomy procedure in excision of choledochal cyst in paediatric population. Materials and Methods: This was a retrospective cohort study conducted from January 2015 to December 2019 on data of 16 paediatric patients who underwent choledochal cyst excision with biliary reconstruction in a tertiary health institute. The data of these patients were collected from Medical Records Department (MRD) on type of surgery performed, mean operating time, postoperative hospital stay, the onset of oral feeds and complications associated with the surgery and were analysed and evaluated in July 2021. All statistical analyses were performed with Statistical Package for Social Sciences (SPSS) version 23.0. A p-value of <0.05 was considered as statistically significant. Results: A total of 16 patients (5 males and 11 females) were included, out of them 9 (56%) had undergone hepaticoduodenostomy and 7 (44%) had undergone hepaticojejunostomy. The most common typeofcholedochalcystwasType1(n=7,43.7%).Operativetimewas longer for the hepaticojejunostomy than the hepaticoduodenostomy (212.86±31.33 vs 88.89±15.16 min; p-value 0.001). Patients who underwent hepaticoduodenostomy early feeds were started as compared to the hepaticojejunostomy (2.22 vs 5.29 days; p-value 0.001). Hospital stay was longer with the hepaticojejunostomy than the hepaticoduodenostomy (14.71±7.76 days vs 8.11±4.48 days; p-value 0.05). There were three complications (biliary enteric fistula that opened into the anterior abdominal wall at the previous surgical site incision, jejunal stump formed the fistulous tract with high output bile leak and surgical site infection was noted) in total noted in both groups. Conclusion: The present study concluded that hepaticoduodenostomy had a better outcome in factors such as operating time, the onset of feeds and hospital stay than with the hepaticojejunostomy.

2723 Success of Surgical Myofascial SCAR Release in Women with Chronic Abdominal Wall Pain After Previous Pelvic Surgery: A Case Series

Study Objective To demonstrate the efficacy of a surgical technique to relieve abdominal wall pain associated with myofascial scar formation provoked by previous surgical incisions. Design Retrospective cohort study. Setting Community teaching hospital. Patients or Participants 51 women who underwent surgical myofascial scar release from 2011-2018 in a MIGS-focused private practice, identified by manual chart review of surgical schedule. Interventions An incision was made over the surgical scar and area of pain. The fascia was incised, exposing the underlying rectus or oblique muscle. Adhesions between the fascia and muscle were bluntly lysed and a myofascial nodule was excised if present. The ilioinguinal nerve was skeletonized and preserved if identified. The fascial incision was closed, taking care to avoid tethering the muscle to the fascia. Measurements and Main Results All patients experienced reproducible abdominal wall pain adjacent to a surgical scar in the absence of an organic pain source. 31 patients had at least one previous pfannenstiel incision with pain at the lateral end of the incision. 48 patients had a previous laparoscopy with pain adjacent to the site of a lower quadrant trocar site. Patients were assigned a pre and post-operative pain score based on severity of symptoms and disruption to quality of life. Overall pain reduction averaged 58%, with 88% of all patients reporting an improvement in their pain. Pathology was benign in all cases. 40 patients had a history of endometriosis, but only 2 abdominal wall nodules were positive for endometriosis. Conclusion Abdominal wall pain due to restricted muscle fiber mobility where it is adhesed to fascia at the site of a previous surgical incision is an often overlooked source of pelvic pain. Surgical lysis of a myofascial scar in the appropriate candidate is a straightforward and efficient intervention that should be considered to treat this unique source of pelvic pain.

MRI of the Placenta Accreta Spectrum (PAS) Disorder: Radiomics Analysis Correlates With Surgical and Pathological Outcome.

Placenta accreta spectrum (PAS) in women with previous cesarean delivery has become increasingly prevalent. Depending on the severity, patient management may involve cesarean hysterectomy. To investigate textural analyses as the radiomics in MRI of the placenta in predicting the PAS requiring cesarean hysterectomy in a high-risk population. Retrospective. Sixty-two women with prior cesarean delivery referred for MRI because of sonographic suspicion for PAS. 1.5T with T1 W, T2 W, and diffusion-weighted imaging (DWI). Two reviewers independently evaluated MR images based on five established PAS variables. Placental regions of interest (ROIs) were generated on T2 W, DWI, and an apparent diffusion coefficient (ADC) map, based on definitions of areas of placenta in proximity to and remote from previous surgical incision sites. Reader agreement was assessed by simple kappa and prevalence adjusted bias adjusted kappa (PABAK). T-tests and chi-square analyses between the primary outcome (hysterectomy vs. no hysterectomy) were performed. Thirteen Haralick texture features calculated from gray-level co-occurrence matrixes were extracted from manually drawn placental ROIs within each of three MR acquisitions. Univariate and multivariable logistic regression were used to assess the association with cesarean hysterectomy. Of 62 pregnancies at risk for PAS, 40 required cesarean hysterectomy (65%), with excellent correlation between need for hysterectomy and pathology confirmation of PAS in the hysterectomy specimen [κ = 0.82 (0.62, 1)]. Reader agreement was fair to moderate. Of the 13 Haralick variables within each of three acquisition groups, significant differences (P < 0.05) were seen in 22 of 39 parameters comparing placental ROIs in proximity to incision scar(s) to those ROIs remote from scar. A stepwise selection algorithm indicated that the combination of T2 W Fcm.sum.var , ADC Fcm.diff.entr , and DWI Fcm.energy gave the highest leave-one-out-AUC of 0.80 (0.68, 0.91). Assessment of PAS severity is subjective and dependent on radiologist expertise. We identified textural features on placental MR images in the region of the prior uterine scar that differentiated pregnancies requiring cesarean hysterectomy based on clinical suspicion of PAS from those that did not, suggesting predictive capabilities of these objective radiomics features. 3 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2020;51:936-946.

Comparative Study between Heavy-Weight Mesh and Light-Weight Mesh in Ventral Hernia Repair

Background: Ventral hernia may be spontaneously (primary ventral hernia) or at the site of a previous surgical incision (incisional hernia). Ventral hernias are classified according to their location and etiology, a primary ventral hernia is classified as a (para-) umbilical, epigastric or Spigelian hernia (between the muscles of the abdominal wall). Objective: This work aims to study and compare the use of the heavy-weight mesh and light-weight mesh in ventral hernia repair. Patients and Methods: This study was conducted on patients (male and females) suffering from ventral hernia “primary or incisional” admitted to the General Surgery Department, at Nasser Institute Hospital and Al-Azhar University Hospital during the period from June 2018 to May 2019. Results: Quality of life (QOL) values in the 3rd postoperative month were not statistically significant higher in the LW group than that of the HW group. QOL values of the both groups in the 3rd postoperative month were significantly higher when compared to the baseline (preoperative values). Foreign body sensation was significantly less frequent in the LW group than that of the HW group. Conclusion: The lightweight mesh offers benefits over heavyweight mesh for ventral hernia repair by reducing the incidence of chronic pain and foreign body sensation.

Anatomical basis for surgical approaches to the hip.

The hip joint is one of the most surgically exposed joints in the body. The indications for surgical exposure are numerous ranging from simple procedures such as arthrotomy for joint drainage in infection to complex procedures like revised total hip replacement. Tissue dissections based on sound knowledge of anatomic orientations is essential for best surgical outcomes. In this review, the anatomical basis for the various approaches to the hip is presented. Systematic review of the literature was done by using PubMed, Cochrane, Embase, OVID, and Google databases. Out of the initial 150 articles selected from the the review and selection criteria, only 37 that suited the study were eventually used. Selected articles included case reports, clinical trials, review and research reports. Each of these approaches has various modifications that seek to correct certain difficulties or problems encountered with previous descriptions. An ideal approach for a procedure should be safe and provide satisfactory exposure of the joint. It should avoid bone and soft tissue damage as well as avoid unnecessary devascularization. Among the factors that determine the choice of surgical approach to the hip are the indication for the procedure; the influence of previous surgical incisions as well as the personal preferences and training of the operating surgeon.

Single-port Laparoscopic Adhesiolysis for Torsion Ileus

Single-incisional laparoscopic surgery (SILS) has emerged as an attempt to further enhance the cosmetic benefits and reduce the morbidity of minimally invasive surgery. We present an approach of SILS adhesiolysis to adhesive strangulated ileus. A 70-year-old female patient, who had undergone laparoscopic low anterior resection 6 years before, underwent SILS adhesiolysis to a midline surgical incision wound adhesion site. The surgery was performed with only a 2.5-cm left-side transrectus incision using the SILS port. Laparoscopy revealed intestinal torsion and congestion with adhesion of the ileum to the previous surgical incision wound. SILS adhesiolysis was successfully carried out. The patient was discharged 4 days after surgery. SILS adhesiolysis is a feasible and efficient procedure in certain cases.

The Use of Mitek Bone Anchors for Synthetic Mesh Fixation to Repair Recalcitrant Abdominal Hernias

Repair of recurrent abdominal hernias is a surgical challenge. These patients usually present to the plastic surgeon as a last resort for treatment. Such recalcitrant hernias cause enormous morbidity and constitute a financial burden to any health service. It is important to explore novel and potentially effective repair methods. We report on a technique using overlay prolene mesh fixed to bone by Mitek anchors. All patients who had Mitek bone anchor fixation of synthetic mesh, to repair recurrent iatrogenic abdominal hernias between 2003 and 2010 by one surgeon (C.M.M.), were retrospectively reviewed. The indications, operative details, and clinical outcomes were documented. A total of 7 patients (6 females, 1 male) aged 35 to 60 (average 53) years were included in the study. The causes of herniation were previous surgical incisions (3) and abdominal flap harvests (4). They had had a median of 3 hernia repairs before referral to plastic surgery. The operations lasted for a mean of 6 hours (range, 3-10½ hr). There were no major intra- and postoperative problems although 1 patient requested removal of 2 of his 8 Mitek anchors because of persistent localized pain and tenderness. After a mean follow-up of 24 months (range, 4-34), only 1 patient developed a recurrent lower abdominal bulge. Our single operator series demonstrated that Mitek bone anchor fixation of prosthetic mesh reinforcement of abdominal wall hernia repair is an effective treatment technique associated with a low morbidity. This method of recalcitrant hernia repair may be a useful addition to the armamentarium of the plastic surgeon.

Lower Extremity Cutaneous Lesions as the Initial Presentation of Metastatic Adenocarcinoma of the Colon

Cutaneous metastases from colorectal cancers are rare and are usually present on the abdominal wall or previous surgical incision sites. Remote cutaneous lesions have been reported, however, often occur in the setting of widespread metastatic disease including other visceral secondaries. We present a case of lower extremity cutaneous metastases as the first sign of metastatic disease in a patient with adenocarcinoma of the colon. This case illustrates that new skin lesions may be the initial presentation of metastatic disease in a patient with a history of cancer.

Single-port laparoscopic access for Crohnʼs disease complicated by enterocutaneous fistula

appeared few days later. Endoscopy with biopsies of the terminal ileum confirmed the diagnosis of CD. Computed tomography showed a thickened terminal ileum with an enterocutaneous fistula penetrating through the previous surgical incision; no other proximal sites of disease were detected with a small bowel enema. Despite medical treatment and good general and nutritional status, the fistula persisted, and the patient was referred for surgery. The patient consented to the intervention and was fully informed about the risk of conversion. He was positioned in the supine position, and a single port type Olympus asc-Triport (distributed by Olympus M.S.C., Japan) was inserted through the umbilicus. A 5-mm deflectable video laparoscope type Olympus HD EndoEYE (Olympus M.S.C., Japan) was used. The terminal ileum was grossly inflamed for 15 cm and adherent to the right iliac fossa. Adhesions were carefully liberated, and a full mobilization of the ascending colon was obtained starting by the right colic flexure. An incision contouring the previous McBurney’s site was realized, and the enterocutaneous fistula tract was extracted en bloc with the ileocecal region. Mesenteric vessel ligation and a hand-sewn side-to-side anastomosis was performed extracorporeally. Intraoperative as well as postoperative and specimen images are showed in Figure 1. Operative time was 115 minutes,

Right Inframammary Mini-Thoracotomy Approach to the Mitral Valve in Women with Breast Implants

: Minimally invasive cardiac surgery in patients with breast implants is challenging. Obtaining access to cardiac structures without injuring the prosthesis and at the same time maintaining cosmesis is of particular concern in these patients. Mitral valve surgery can be performed using a right mini-inframammary thoracotomy in female patients with breast implants. We describe our experience with this approach to preserve the cosmetic results of previous breast augmentation. : Six female patients with previous breast implantation presented for isolated mitral valve surgery for degenerative disease. Surgery was performed through an inframammary incision, in most cases using the previous surgical incision from breast implantation. Peripheral cannulation was used for cardiopulmonary bypass. The breast prosthesis was explanted through a 6-cm skin incision, and then the mitral valve was approached through a right mini anterior thoracotomy. At the end of mitral surgery, the implant was replaced. : All patients had satisfactory outcomes. The mitral valve was repaired in five patients and replaced in one patient. Average length of stay was 5.3 days (range, 4-8 days). There were no conversions to median sternotomy. There were no bleeding complications. There were no wound complications or implant infections. Cosmesis was preserved. : Our experience with this approach has allowed both mitral valve repair and replacement at the same time preserving cosmetic results. This minimally invasive technique may also have applications in performing atrial septal defect closure, Maze procedures for atrial fibrillation, and tricuspid valve surgery in patients with breast implants.

Periprosthetic Knee Fractures

Fractures of the distal femur, proximal tibia, and patella that occur adjacent to a total knee replacement may be very difficult to treat. Fixation options are compromised because of the short articular segment, frequent comminution, pre-existing osteoporosis, previous surgical incisions, and the presence of the knee implant itself. This review article summarizes current concepts regarding the incidence, classification, treatment options, and outcomes for periprosthetic fractures of the knee.

Misleading Gram Stain Findings on a Smear from a Cerebrospinal Fluid Specimen

History of Present Illness The patient was taken to surgery, the previous CNS surgical incision was opened, and a large amount of CSF that had pooled under the incision was collected and submitted to the laboratory. The laboratory requisition that accompanied this pink and hazy fluid indicated a diagnosis of “meningitis” and requests for Gram stain, cell count, glucose, total protein, and culture and susceptibility testing.