Open Primary Repair Research Articles

Modified gift box technique for acute compound posttraumatic Achilles tendon repair in young patients

<p class="abstract"><strong>Background:</strong> <span lang="EN-IN">Treatment of Achilles tendon rupture in young active patient remains controversial. Open primary repair remains the mainstay of treatment with prolonged rehabilitation and high wound complication rate (20%). In compound injuries it becomes the default treatment. Newer techniques are being tried to decrease re-rupture rate, decrease local complications and facilitate early rehabilitation. Modified gift box technique of open repair, which has shown higher strength of repair in in-vitro studies and good clinical results in the hands of its inventor. The aim of our study was to evaluate the clinical results of this technique in young active patients with compound Achilles tendon injury.</span></p><p class="abstract"><strong>Methods:</strong> This is a retrospective study. The parameters recorded at follow up included general demography, ability to single toe raise (on neutral, incline, decline), toe walking for 40 feet, and pain on VAS scale. Achilles tendon total rupture score and modified Rupp score were administered.<strong></strong></p><p class="abstract"><strong>Results:</strong> Out of the 8 patients included in the study, 7 patients had unilateral tear and 1 patient had bilateral tear. The mean age was 27 yrs (20-35) and mean duration of follow up was 17.4 months (08-24 months). Single toe raise and toe walking for 40 ft. was possible in all patients. Two patients complained of grade 2 pain on VAS Scale. The ATRS score was 97.1 (94-99) and modified Rupp score was 28.3 (26-29)<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> Modified gift box technique gives excellent results in young active patients with compound Achilles tendon injury with no re-rupture and return of pre-injury activity<span lang="EN-IN">.</span></p>

Arthroscopic Primary Anterior Cruciate Ligament Repair With Suture Augmentation

Historically, poor results of open primary repair of anterior cruciate ligament (ACL) injuries have been reported. In hindsight, however, appropriate patient selection (i.e. proximal tears and good tissue quality) was not performed, because it has recently been recognized that good outcomes of primary ACL repair are possible when selectively performed in patients with proximal tears and good tissue quality. Moreover, with modern-day advances, arthroscopic primary repair can be an excellent treatment option for patients with proximal tears. Preserving the native ACL has several advantages, including maintaining native proprioceptive function and biology. The procedure is also minimally invasive and prevents the need for formal ACL reconstruction. Recently, it has been suggested that additional suture augmentation of the primary repair technique may be beneficial for protecting ligament healing during early range of motion. In this Technical Note, we present the surgical technique of arthroscopic primary repair with suture augmentation for patients with proximal ACL tears.

Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears: No Deterioration at Mid-Term Follow-Up

Open primary repair of the anterior cruciate ligament (ACL) was a popular surgical treatment for ACL injuries in the 1970s and 1980s. Although the short-term outcomes were excellent, the results deteriorated at mid-term follow-up, which ultimately led to the abandonment of open primary repair. Recently, however, excellent short-term outcomes of primary repair using arthroscopy in 11 patients with only proximal ACL tears have been reported with one failure (9%) and good clinical outcomes. Goal of this study was to assess the mid-term outcomes of these patients. The first 11 consecutive patients with proximal avulsion tears and excellent tissue quality treated with arthroscopic primary repair were evaluated at mid-term follow-up. Physical examination and laxity examination were performed and patients completed several outcome questionnaires. Eleven patients were seen at mean follow-up of 5.6 years (range: 4.2–8.4 years). No patients had failure of the repair besides the earlier failure at short-term follow-up (9%). One additional patient (9%) underwent reoperation for a medial meniscus tear. The other ten patients had full range of motion, negative Lachman test, eight patients had a negative pivot shift and two patients +1 pivot shift. IKDC objective score was A in 8 patients and B in 2. Lysholm was 97 (range 92-100), modified Cincinnati 97 (range 87-100), mean SANE score 96 (range 90-100), preinjury Tegner 7.2 (range 5-9), and postoperative Tegner 6.8, (range 3-9) and IKDC subjective score 95 (range 82-100). Seven patients had a MRI that showed ligament continuity. Historically, studies showed that the results of open primary repair deteriorated at mid-term follow-up. With appropriate patient selection (only treating patients with proximal tears and excellent tissue quality) and arthroscopy, results in this study did not deteriorate at mid-term follow-up. Arthroscopic primary repair of proximal ACL tears is an excellent, minimally invasive treatment option in these patients.

TEP or TAPP for recurrent inguinal hernia repair\u2014register-based comparison of the outcome

IntroductionThe guidelines of the international hernia societies recommend laparo-endoscopic inguinal hernia repair for recurrent hernias after open primary repair. To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. A Swiss registry study identified only minor differences between the two techniques, thus suggesting the equivalence of the two procedures.Materials and Methods Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n = 1,464) or TEP technique (n = 782).Results Univariable and multivariable analysis did not find any significant difference between TEP and TAPP with regard to the intraoperative complications, complication-related reoperations, re-recurrences, pain at rest, pain on exertion, or chronic pain requiring treatment. The only difference identified was a significantly higher postoperative seroma rate after TAPP, which was influenced by the surgical technique, previous open primary operation and EHS-classification medial and responded to conservative treatment.Conclusion TEP and TAPP are equivalent surgical techniques for recurrent inguinal hernia repair following previous open primary operation. The choice of technique should be tailored to the surgeon’s expertise.

Clinical and functional outcome of open primary repair of triangular fibrocartilage complex tears associated with distal radius fractures.

We evaluate the clinical and functional outcome of open primary repair of acute TFCC tears in distal radius fracture, when there is gross intraoperative distal radioulnar joint (DRUJ) instability after fixation of the distal radius, in the absence of an ulnar styloid fracture or when the ulnar fracture fragment is too small to be fixed. A retrospective review of our institution's distal radius fracture database over a 4-year period (January 2010 to December 2013). A total of 12 (1.38%) out of 3379 patients had an open TFCC repair in the same setting as fixation of distal radius. Assessment of outcome involved the analysis of objective and subjective clinical and functional outcomes. All patient regained Activities of Daily Living (ADL) independence; eleven out of 12 patients (91.7%) returned to pre-injury function and 8 out of 11 patients (72.7%) returned to their jobs. DRUJ stability was preserved in 10 patients (83.3%) with 10 patients (83.3%) having grip strength of at least 50%, compared to the uninjured hand, and 7 (58.3%) with grip strength of more than or equal to 75%. Complications of surgery identified can be classified into 4 broad categories: infection, neurological complications, persistent DRUJ instability and prolonged pain. The authors believe a primary open repair of the TFCC should be considered when patients present with instability during intra-operative DRUJ ballottement test after distal radius fixation, in the absence of an ulnar styloid fracture or when the ulnar fracture fragment is too small to be fixed.

The presentation and management of aneurysms of the pancreaticoduodenal arcade

ObjectiveGastroduodenal artery aneurysms (GDAAs) and pancreaticoduodenal artery aneurysms (PDAAs) are uncommon lesions associated, however, with a significant risk of rupture. This study describes the clinical presentation, associated imaging findings, and operative strategies for these aneurysms. MethodsThe records of all patients with GDAAs or PDAAs identified through an institutional database by axial imaging between 1994 and 2014 were retrospectively reviewed. Data on presenting symptoms, comorbid conditions, imaging findings, and outcomes after operative intervention were collected and examined. ResultsWe identified 11 GDAAs and 25 PDAAs in 35 patients. Mean size of the GDAAs was 31.1 mm (range, 10-60 mm) and mean size of the PDAAs was 19.1 mm (range, 10-48 mm). At presentation, 13 aneurysms (36%) were symptomatic and seven aneurysms (19.4%) were ruptured. Median size of ruptured aneurysms was 20 mm (range, 10-60 mm). On axial imaging, 24 aneurysms (67%) were associated with a severe stenosis or occlusion of the celiac axis origin, and 11 aneurysms (31%) were thought to be associated with compression of the celiac axis in the setting of median arcuate ligament syndrome. Twenty-four aneurysms (67%) underwent repair. Of these aneurysms, 18 (75%) were successfully managed with primary endovascular repair (coil embolization with or without celiac stent), whereas endovascular therapy failed in two (8%) and required open repair. Four aneurysms (17%) were treated with primary open repair. Overall 30-day morbidity and mortality after aneurysm repair were 29% and 4%, respectively. ConclusionsGDAAs and PDAAs are uncommon lesions that are often associated with a celiac axis stenosis/occlusion leading to altered hemodynamics in the pancreaticoduodenal arcade. These aneurysms are prone to rupture regardless of size, and intervention is accordingly recommended for all aneurysms upon recognition. Despite the concordant celiac axis obstruction and concern for maintenance of hepatic circulation, endovascular repair of these aneurysms is generally successful and should be considered as the initial operative approach.

Arthroscopic anterior cruciate ligament repair for proximal anterior cruciate ligament tears in skeletally immature patients: Surgical technique and preliminary results

BackgroundAnterior cruciate ligament (ACL) tears in children are increasingly common and present difficult treatment decisions due to the risk of growth disturbance. Although open primary ACL repair was abandoned in the historical literature, recent studies have suggested that there is a role for arthroscopic primary repair in patients with proximal tears. MethodsThis is a retrospective review of five consecutive patients aged 9.2years (range 8 to 10) who underwent suture anchor ACL reinsertion. Patients were included if they were Tanner stages 1–2 and proximal ACL tears with adequate tissue quality confirmed arthroscopically. The time frame was 81days. Arthroscopic ACL reinsertion was performed with bioabsorbable suture anchor. Clinical evaluation, KT-1000™, and MRI were re-evaluated. Clinical outcomes were measured using International Knee Documentation Committee (IKDC), Lysholm and Tegner activity score. ResultsAt a mean follow-up of 43.4months (range 25 to 56), no re-injury and leg length discrepancies were observed. Four patients had negative Lachman tests. The remainder had a grade 1 Lachman test. The mean side-to-side difference was 3 (2–4mm). In MRI obtained at the last follow-up, no articular lesions or growth arrest were observed and the reinserted ACL was recognized in every exam. All patients returned to previous level of activity and presented normal and nearly normal IKDC score. The mean Lysholm score was 93.6. ConclusionArthroscopic ACL repair can achieve good short-term results with joint stability and recovery of sport activity in skeletally immature patients, with proximal ACL avulsion tear.

A Rare Case of Spontaneous Umbilical Hernia Rupture- Flood Syndrome

A 54-year-old female with alcoholic cirrhosis and massive ascites presented with acute leakage of ascitic fluid from umbilical hernia. Prior to presentation, patient reported progressive increase in abdominal distension due to increasing ascites over several years. She was recently evaluated by a dermatologist for pruritus. Skin examination at that time had revealed excoriated papules, likely due to insect bites or liver disease. 24 hours prior to current presentation, she had been scratching the region of her umbilical hernia, which resulted in a sudden gush of clear fluid. In the emergency department (ED), she denied, fever, chills, cough, vomiting or straining but reported soreness at the site of umbilical hernia. She was tachycardic and appeared icteric. Other vital signs were within normal ranges. Abdominal examination revealed distended abdomen and left lower quadrant tenderness on palpation. A large (10 x 10 cm) umbilical hernia containing bowel was noted which was draining serosanguinous fluid. She was diagnosed with flood syndrome- spontaneous rupture of umbilical hernia. Workup revealed macrocytic anemia with Hemoglobin of 11mg/dl, a platelet count of 100,000 and total bilirubin of 13mg/dl. Broadspectrum antibiotics were initiated and she underwent primary open surgical repair of umbilical hernia with JP drain placement. The drain was eventually removed after 6 days. She was transitioned to oral antibiotics and discharged to a nursing facility. At her 8 month follow-up, she was noted to be doing well with no recurrence.Figure 1Figure 2

Management of esophageal perforation in the endoscopic era: Is operative repair still relevant?

With the introduction of new treatment paradigms for esophageal perforation, the management of this highly morbid condition is evolving. We reviewed our experience to investigate the modern management and outcomes of esophageal perforations with a focus on operatively repaired patients. A retrospective review of all esophageal perforations was conducted between August 2003 and January2016. A total of 48 patients were identified, with iatrogenic injury in 19 (40%), spontaneous perforation in 18 (38%), and traumatic/foreign body causes in 11 (23%). The distal esophagus was the site of perforation in 63% of the patients, and the duration of time between perforation and treatment was <24hours in 60%. Nonoperative management was employed in 18 (38%) and operative repair in 30 (primary operative repair=20, drainage=4, esophagectomy=6). Iatrogenic and traumatic perforations were more likely to be treated nonoperatively (68%), while all spontaneous perforations were treated by operative intervention. There were no complications or mortalities in the nonoperative group and only a 5% reintervention rate. In the operative group, complications occurred in 10 (33%), reinterventions in 13 (43%), and mortality in 2 (7%) patients. Our study highlights the importance of considering the etiology of a perforation when planning management and the success of nonoperative treatment with careful patient selection. In addition, operative repair in septic patients yielded excellent outcomes and should be the standard for comparison in future studies exploring endoscopic approaches.

Evaluation of Brake Response Time Following Primary Achilles Tendon Repair Surgery

Category: Sports. Introduction/Purpose: Although surgical repair of Achilles tendon ruptures are common procedures, there are no studies investigating postoperative driving safety in these patients. Active contracture of the Gastroc-soleus-Achilles mechanism is required during a braking maneuver while driving. There is concern that these patients may be hesitant to rapidly apply braking pressure, putting themselves and others at potential risk. The purpose of this study was to evaluate postoperative brake response time (BRT) in right-sided Achilles rupture repair patients as a means to determine driving preparedness. BRT is defined as the time, in milliseconds, between presentation of a perceived hazardous stimulus and the application of pressure to the brake pedal in a driving simulator model. We hypothesized patients would demonstrate BRTs comparable to control subjects 6-week after repair. Methods: Following IRB approval, 50 right-sided acute primary Achilles rupture repair patients were prospectively identified and enrolled. All patients were managed with a standardized postoperative protocol. Exclusion criteria were age under 18, those not in possession of a valid driver’s license, those undergoing non standard open primary repair, and those declining to participate in the study. All patients were tested for their BRT utilizing a validated driving simulator at their 6-week postoperative follow-up appointment. Those patients that failed to achieve a safe brake response time less than 0.850 seconds were re-tested at weekly intervals until a safe breaking time was achieved. The passing brake response time of 0.850 seconds was determined from the published control data and from testing 20 healthy volunteers in the same simulator. At each testing, patients also filled out an AOFAS Ankle Hindfoot Scale, an Achilles Tendon Total Rupture Scale (ATRS) Questionnaire and a Driving Preparedness survey. Results: Each subject underwent 3 sequential drive-braking simulation tests, with their BRT being calculated as an average of the 3 times. At six weeks post repair the overall average BRT for all 50 patients was 0.658 seconds. 47 of the 50 patients (94%) demonstrated safe average BRT at their 6-week post operative testing of equal to or less than 0.850 seconds, with the remaining 3 patients achieving a safe BRT after 7 weeks. All 47 patients whose test demonstrated a safe BRT at 6 weeks responded in their survey that they “Agreed” or “Strongly Agreed” they were ready to drive at the time of testing. At six weeks post repair, the average AOFAS-AH score was 78.7/100, and the average ATRS score was 54.0. Conclusion: The present study revealed that 94% of primary right-sided acute Achilles tendon rupture repair patients were able to demonstrate a safe BRT comparable to those of healthy control subjects 6 weeks after their surgical procedure, and all by seven weeks following surgery. 100% of these patients also reported that after completing the test, they felt ready to return to driving. Therefore, we believe that it is reasonable to offer primary Achilles tendon repair patients an estimate of 6-weeks recovery time before driving.

Traumatic Posterior Tibial Pseudoaneursym: A rare late complication repaired conventionally

Posterior tibial artery pseudoaneurysms are extremely rare. They commonly present as a late complication of trauma or iatrogenic injury. Diagnosis can be elusive. Treatment has been described in the context of open primary repair, endovascular stenting, and coil embolization. There has been increasing interest in the use of endovascular treatment options for this type of injury. If left untreated, pseudoaneurysms can rupture, partially thrombose, expand and cause adjacent local compression and compartment syndrome. The following case presented is of a young gentleman with a posterior tibial pseudoaneurysm incidentally discovered after stepping on glass and the management of his posterior tibial pseudoaneurysm.

Functional Outcomes Of Primary Open Repair With Augmentation And Without Augmentation In Achilles Tendon Rupture

PURPOSE: The aim of this study was to compare the functional outcomes between two surgical techniques for Achilles tendon rupture: primary open repair (POR) versus open repair augmented with flexor hallucis longus tendon transfer (POR_FHL). METHODS: Twenty six patients (Age:44.7±8.6 years, Body Mass:83.4±14.5 kg, Height:177.7±23.4 cm, BMI:27.6±4.2 kg/m2, time after surgery to experiment: 3.13±1.96 yrs) who were operated either with POR (Group 1, n=14) or POR_FHL (Group 2, n=12) for achilles tendon rupture were included in this study. For evaluating dynamic balance, Star Excursion Balance Test (SEBT) with anterior, posteromedial and posterolateral reach distances was used and for evaluating hop performance, One Leg Hop Test (OLHT) was used. To measure ankle dorsiflexion range of motion, Weight Bearing Lunge Test (WBLT) was performed and Functional Squat Test (FST) was used for evaluating lower extremity concentric and eccentric strength. Limb symmetry index was calculated for each test. Student t test was performed for statistical analysis. RESULTS: The physical characteristics of the patients were not different between groups (p>0.05). There were no differences between groups in SEBT anterior (p=0.46), posteromedial (p=0.28) and posterolateral reach distances (p=0.71), OLHT (p=0.77), WBLT (p=0.13) and FST for concentric (p=0.96) and eccentric (p=0.78) strength. CONCLUSION: The results of the study showed that primary open repair with and without augmentation techniques for achilles tendon repair had similar effect on dynamic balance, hop distance, ankle dorsiflexion motion and lower extremity strength in long term after surgery.

Randomized clinical trial comparing self-gripping mesh with a standard polypropylene mesh for open inguinal hernia repair.

The introduction of mesh for open inguinal hernia repair has reduced the rate of recurrence, allowing research to focus on prevention of postoperative pain. In an effort to reduce chronic pain, a semiresorbable, lighter and self-gripping mesh was developed. A double-blind randomized clinical trial was conducted comparing the self-gripping mesh with a standard polypropylene mesh repair. Patients over 18 years of age undergoing open primary hernia repair were included. Pain was measured on a six-point verbal rating scale (VRS) and a 150-mm visual analogue scale (VAS). Postoperative pain reduction from baseline pain (ΔVAS), complications and return to work/hobbies were studied. Data were collected at baseline, 3 weeks, 3 months and 1 year after surgery (primary outcome). A total of 363 patients were analysed. Median age was 59 (range 19-88) years. Baseline VRS and VAS scores were similar for the two groups. There was no difference in VRS scores at 1-year follow-up. Duration of surgery was significantly shorter with the self-gripping mesh (mean 40 min versus 49 min for standard mesh repair; P < 0·001). At 3 weeks, ΔVAS in patients receiving the self-gripping mesh was significantly larger (-10·6 versus -5·0 respectively; P = 0·049) and less subjective discomfort was reported (P = 0·016). Complication rates, return to work and recurrence rates were similar, although there were more recurrences in the self-gripping mesh group (5·5 versus 2·2 per cent; P = 0·103). A self-gripping mesh for hernia repair may result in less pain in the early postoperative phase but chronic postherniorraphy pain is not affected. Recurrence rates may be a potential disadvantage. NTR1212 (http://www.trialregister.nl).

Long-Term Outcomes of Patients with Tracheoesophageal Fistula/Esophageal Atresia: Survey Results from Tracheoesophageal Fistula/Esophageal Atresia Online Communities.

Introduction Outcome studies of tracheoesophageal fistula (TEF) and/or esophageal atresia (EA) are limited to retrospective chart reviews. This study surveyed TEF/EA patients/parents engaged in social media communities to determine long-term outcomes. Materials and Methods A 50-point survey was designed to study presentation, interventions, and ongoing symptoms after repair in patients with TEF/EA. It was validated using a test population and made available on TEF/EA online communities. Results In this study, 445 subjects completed the survey during a 2-month period. Mean age of patients when surveyed was 8.7 years (0-61 years) and 56% were male. Eighty-nine percent of surveys were completed by the parent of the patient. Sixty-two percent of patients underwent repair in the first 7 days of life. Standard open repair was most common (56%), followed by primary esophageal replacement (13%) and thoracoscopic repair (13%). Out of 405, 106 (26%) patients had postoperative leak. Postoperative leak was least likely in primary esophageal replacement (18%) and standard open repair (19%). Leak occurred in 32% of patients who had thoracoscopic repair; 31% (128/413) reported long-gap atresia, which was significantly associated with increased risk of postoperative leak (54/128, 42%) when compared with standard short-gap atresia (odds ratio, 3.5; p = 0.001). Out of 409, 221 (54%) patients reported dysphagia after repair, with only 77/221 (34.8%) reporting resolution by age 5. Out of 381, 290 (76%) patients reported symptoms of gastroesophageal reflux disease (GERD). There was no difference in dysphagia rates or GERD symptoms based on type of initial repair. Antireflux surgery was required in 63/290, 22% of patients with GERD (15% of all patients) and 27% of these patients who had surgery required more than one procedure antireflux procedure. The most common was Nissen fundoplication (73%), followed by partial wrap (14%). Reflux recurred in 32% of patients after antireflux surgery. Conclusion TEF/EA patients have long-term dysphagia and GERD that may be under reported. Retrospective studies of outcomes after TEF/EA repair may underestimate long-term esophageal dysmotility, dysphagia, GERD, and strictures that occur regardless of the type of repair and adversely affect quality of life. Fifteen percent of all TEF/EA patients surveyed required an antireflux procedure during childhood, and more than one-quarter of those required repeat surgery. These data demonstrate the need for long-term follow-up as pediatric patients transition to adult care.

Defining risk and identifying predictors of mortality for open conversion after endovascular aortic aneurysm repair

Risk of open conversion after endovascular aortic aneurysm repair (EVAR-c) is poorly defined. The purpose of this analysis was to determine outcomes of elective EVAR-c compared with elective primary open abdominal aortic aneurysm repair (PAR) in the Vascular Quality Initiative. Vascular Quality Initiative patients who underwent elective EVAR-c and PAR (2002-2014) were reviewed. Candidate predictors of major adverse cardiac event (MACE) and/or 30-day mortality were entered into a multivariable model, and stepwise elimination was used to reduce the number of covariates to a best subset of predictors. To estimate the additive risk of EVAR-c for MACE or 30-day mortality over PAR, this variable was added along with the best subset of predictors into generalized estimating equations logistic regression models. We identified 159 EVAR-c and 3741 PAR patients. EVAR-c patients were older (73.5± 8.1 vs 69.5± 8.4years; P<.0001), more likely to have diabetes (21% vs 15%; P= .03), and history of lower extremity bypass (9% vs 4%; P=.0006). EVAR-c was associated with a higher incidence of retroperitoneal aortic exposure (41%; n= 64 vs PAR, 26%, n= 976; P<.0001), use of a bifurcated graft (65%; n= 101 vs PAR, 52%; n= 1923; P= .001), greater blood loss (median [interquartile range], 2000mL [1010-3500] vs PAR, 1200mL [750-2000]; P< .0001) and longer procedure times (EVAR-c, 275± 122minutes vs PAR, 232± 9minutes; P< .0001). However, PAR more frequently was completed with a suprarenal and/or mesenteric cross-clamp (74%, n= 2749 vs EVAR-c, 53%, n= 83; P< .0001) and had a higher incidence of concomitant procedures (26%; n= 972 vs EVAR-c, 18%; n= 28; P= .03). Nonadjusted 30-day mortality was greater after EVAR-c: EVAR-c, 8% (n= 10) vs PAR, 3% (n= 105); P= .009. There was no difference in complication rates: EVAR-c, 33% (n= 52) vs PAR, 28% (n= 1056); P=.3. Preoperative 30-day mortality predictors included age (odds ratio [OR], 1.06/y, 95% confidence interval [CI], 1.04-1.1; P< .0001), chronic obstructive pulmonary disease (OR, 2.4; 95% CI, 1.6-3.5; P< .0001), history of leg bypass (OR, 2.3, 1.2-4.4;P=.01), suprarenal cross-clamp (OR 2.2, 1.2-4.1;P=.01), prior carotid revascularization (OR 2.2; 95% CI, 1.3-3.8; P= .0004), congestive heart failure (OR, 1.8; 95% CI, 0.9-3.5; P= .08), and female sex (OR, 1.6; 95% CI, 1.1-2.3; P= .02; area under the curve, 0.75). When controlling for covariates, EVAR-c was not significantly associated with MACE (OR, 1.2; 95% CI, 0.7-2.0; P= .4) or 30-day mortality (OR, 2.0; 0.9-4.2; P= .08). EVAR-c patients are typically older, have more comorbidities, and experience greater blood loss and longer procedure times compared with PAR patients. However, postoperative morbidity and mortality are primarily driven bypatient covariates and intraoperative factors, rather than the need for endograft explantation. Several preoperative variables were identified as predictors of 30-day mortality after elective EVAR-c and should be considered during the decision-making process for remedial treatment of failed endovascular PAR.

Ultrasound-guided transversus abdominis plane block in patients undergoing open inguinal hernia repair: 0.125% bupivacaine provides similar analgesic effect compared to 0.25% bupivacaine

Study objectiveTo evaluate the effectiveness of 0.125% bupivacaine compared to 0.25% bupivacaine for ultrasound-guided transversus abdominis plane (TAP) block in patients undergoing open inguinal hernia repair. DesignRandomized, double-blind study. SettingEducational and research hospital. PatientsForty adult patients of American Society of Anesthesiologists physical status I-III undergoing elective primary unilateral open inguinal hernia repair under spinal anesthesia. InterventionsPatients in group I received 20 mL of 0.25% bupivacaine, whereas patients in group II received 20 mL of 0.125% bupivacaine for TAP block at the end of the surgery. MeasurementsPain intensity was assessed at rest and during coughing using 10-cm visual analog scale score at 5, 15, 30, and 45 minutes and 1, 2, 4, 6, 12, and 24 hours after TAP block. Morphine consumption and time to first morphine requirement were recorded. Main resultsVisual analog scale scores at rest and during coughing were not significantly different between groups at all time points measured. Twenty-four hours of morphine consumption (7.72±7.33 mg in group I and 6.06±5.20 mg in group II; P=.437) and time to first morphine requirement (182.35±125.16 minutes in group I and 143.21±87.28 minutes in group II; P=.332) were not different between groups. Conclusions0.125% Bupivacaine provides similar analgesic effect compared to 0.25% bupivacaine for ultrasound-guided TAP block in patients undergoing open inguinal hernia repair.

Inadvertent Arterial Placement of Central Venous Catheters: Diagnostic and Therapeutic Strategies

Central venous catheterization (CVC) is among the most ubiquitous medical procedures. Inadvertent arterial placement of the catheter presents a challenging dilemma to the interventionalist. Treatment options include: removal and manual compression, off-label use of percutaneous closure devices and/or stent grafts, and open surgical removal. Potential sequelae include bleeding, thrombosis, stroke, limb ischemia, neurologic deficit, and death. Our aim is to evaluate the use of open and endovascular techniques for the management of iatrogenic carotid, subclavian, and brachiocephalic arterial injuries related to inadvertent arterial CVC placement. Retrospective chart review revealed 13 patients with iatrogenic arterial injuries related to inadvertent arterial CVC placement over a 5-year period at Northwestern Memorial Hospital using Current Procedural Terminology codes and interventional radiology and vascular databases. Presenting features, radiographic diagnosis, therapeutic maneuvers, and outcomes were reviewed. Endovascular therapy was instituted in 10 cases with 3 requiring an adjunctive open procedure. In the endovascular therapy group, stent grafts were used in 5 patients and 4 patients were managed with percutaneous closure devices. In 1 patient, multiple embolization procedures were performed in an attempt to close a large innominate artery arteriovenous fistula (AVFs) that ultimately required sternotomy and surgical ligation for complete closure. Primary open repair was carried out in 3 patients. Two patients developed embolic stroke before therapy and removal, with 1 death reported at 36-month follow-up. Overall success rate with a single intervention was 100% (4 of 4) with closure devices, 80% (4 of 5) covered stents, 0% (0 of 1) with embolization, and 100% (3 of 3) with open intervention. Overall complication rate was 7% (1 of 13) requiring further open, invasive intervention. Management of carotid, subclavian, and brachiocephalic arterial injuries from attempted jugular or subclavian venous cannulation can be challenging. The risk of embolic phenomenon associated with arterial catheterization, and the noncompressible anatomic location at the base of the neck frequently prevent simple removal. We use a strategy of immediate computed tomography or magnetic resonance to facilitate the most appropriate therapy. Endovascular treatment with covered stent grants, percutaneous closure devices, and embolization offer good results when selected appropriately based on imaging evaluation. However, more complex cases with associated pseudoaneurysms and/or AVFs with larger catheters may require definitive open repair.

Endovascular Versus Open Repair as Primary Strategy for Ruptured Abdominal Aortic Aneurysm: A National Population-based Study

In randomized trials, no peri-operative survival benefit has been shown for endovascular (EVAR) repair of ruptured abdominal aortic aneurysm (rAAA) when compared with open repair. The aim of this study was to investigate the effect of primary repair strategy on early and midterm survival in a non-selected population based study. The Swedish Vascular Registry was consulted to identify all rAAA repairs performed in Sweden in the period 2008-12. Centers with a primary EVAR strategy (treating > 50% of rAAA with EVAR) were compared with centers with a primary open repair strategy. Peri-operative outcome, midterm survival, and incidence of rAAA repair/100,000 inhabitants aged > 50 years were assessed. In total, 1,304 patients were identified. Three primary EVAR centers (pEVARc) operated on 236 patients (74.6% EVAR). Twenty-six primary open repair centers (pORc) operated 1,068 patients (15.6% EVAR). Patients treated at pEVARc were more often referrals (28.0% vs. 5.3%; p < .01), had a higher rate of respiratory comorbidity (36.5% vs. 21.9%; p < .01), and higher pre-operative systolic blood pressure (84.3 vs. 72.3 mmHg; p < .01). There was no difference in mortality based on primary treatment strategy at 30 days (pEVARc 28.0%, n = 66; pORc 27.4%, n = 296 [p = .87]), 1 year (pEVARc 39.9%, n = 93; pORc 34.7%, n = 366 [p = .19]), or 2 years (42.1%, n = 94; 38.3%, n = 394 [p = .28]), either overall or in subgroups based on age or referral status. Overall, patients treated with EVAR were older (mean age 76.4 vs. 74.0 years; p < .01), and had a lower 30 day mortality (EVAR 21.6%, n = 74; odds ratio 29.6%, n = 288 [p = < .01]). Incidence of rAAA repair was lower in pEVARc regions (6.07, 95% confidence interval [CI] 5.01-7.13) when compared with pORc regions (8.15, 95% CI 7.64-8.66). There was no difference in mortality after rAAA repair among centers with a primary EVAR approach when compared with a primary open repair strategy, either peri-operatively or in the midterm. The study supports the early findings of the randomized controlled trials in a national population based setting.

Use of blood-sparing surgical techniques and transfusion algorithms: association with decreased blood administration in children undergoing primary open craniosynostosis repair.

OBJECT Craniofacial reconstruction surgery (CFR) is often associated with significant blood loss, coagulopathy, and perioperative blood transfusion. Due to transfusion risks, many different approaches have been used to decrease allogeneic blood transfusion for these patients during the perioperative period. Protocols have decreased blood administration during the perioperative period for many types of surgeries. The object of this study was to determine if a protocol involving blood-sparing surgical techniques and a transfusion algorithm decreased intraoperative blood transfusion and blood loss. METHODS A protocol using transfusion algorithms and implementation of blood-sparing surgical techniques for CFR was implemented at Vanderbilt University on January 1, 2013. Following Institutional Review Board approval, blood loss and transfusion data were gathered retrospectively on all children undergoing primary open CFR, using the protocol, for the calendar year 2013. This postprotocol cohort was compared with a preprotocol cohort, which consisted of all children undergoing primary open CFR during the previous calendar year, 2012. RESULTS There were 41 patients in the preprotocol and 39 in the postprotocol cohort. There was no statistical difference between the demographics of the 2 groups. When compared with the preprotocol cohort, intraoperative packed red blood cell transfusion volume decreased from 36.9 ± 21.2 ml/kg to 19.2 ± 10.9 ml/kg (p = 0.0001), whereas fresh-frozen plasma transfusion decreased from 26.8 ± 25.4 ml/kg to 1.5 ± 5.7 ml/kg (p < 0.0001) following implementation of the protocol. Furthermore, estimated blood loss decreased from 64.2 ± 32.4 ml/kg to 52.3 ± 33.3 ml/kg (p = 0.015). Use of fresh-frozen plasma in the postoperative period also decreased when compared with the period before implementation of the protocol. There was no significant difference in morbidity and mortality between the 2 groups. CONCLUSIONS The results of this study suggested that using a multidisciplinary protocol consisting of transfusion algorithms and implementation of blood-sparing surgical techniques during major CFR in pediatric patients is associated with reduced intraoperative administration of blood product, without shifting the transfusion burden to the postoperative period.

Repair of Acute Superficial Deltoid Complex Avulsion During Ankle Fracture Fixation in National Football League Players.

Infolding and retraction of an avulsed deltoid complex after ankle fracture can be a source of persistent increased medial clear space, malreduction, and postoperative pain and medial instability. The purpose of this descriptive case series was to analyze the preliminary outcomes of acute superficial deltoid complex avulsion repair during ankle fracture fixation in a cohort of National Football League (NFL) players. We found that there is often complete avulsion of the superficial deltoid complex off the proximal aspect of the medial malleolus during high-energy ankle fractures in athletes. Between 2004 and 2014, the cases of 14 NFL players who underwent ankle fracture fixation with open deltoid complex repair were reviewed. Patients with chronic deltoid ligament injuries or ankle fractures more than 2 months old were excluded. Average age for all patients was 25 years and body mass index 34.4. Player positions included 1 wide receiver, 1 tight end, 1 safety, 1 running back, 1 linebacker, and 9 offensive linemen. Average time from injury to surgery was 7.5 days. Surgical treatment for all patients consisted of ankle arthroscopy and debridement, followed by fibula fixation with plate and screws, syndesmotic fixation with suture-button devices, and open deltoid complex repair with suture anchors. Patient demographics were recorded with position played, time from injury to surgery, games played before and after surgery, ability to return to play, and postoperative complications. Return to play was defined as the ability to successfully participate in at least 1 full regular-season NFL game after surgery. All NFL players were able to return to running and cutting maneuvers by 6 months after surgery. There were no significant differences in playing experience before surgery versus after surgery. Average playing experience before surgery was 3.3 seasons, 39 games played, and 22 games started. Average playing experience after surgery was 1.6 seasons, 16 games played, and 15 games started. Return to play was 86% for all players. There were no intraoperative or postoperative complications noted, and no players had clinical evidence of medial pain or instability at final follow-up with radiographic maintenance of anatomic mortise alignment. Superficial deltoid complex avulsion during high-energy ankle fractures in athletes is a distinct injury pattern that should be recognized and may benefit from primary open repair. The majority of NFL players treated surgically for this injury pattern are able to return to play after surgery with no reported complications or persistent medial ankle pain or instability. Level IV, retrospective case series.