Removal Of Prosthesis Research Articles

(178) Exploring Intraoperative and Postoperative Penile Prosthetic Complications in the Solid Organ Transplant Population: A Propensity-Score Matched Analysis

Abstract Introduction Solid-organ transplant (SOT) patients are highly susceptible to adverse post-operative outcomes given they are on one or multiple immunosuppressant medications. This makes surgeons performing elective surgeries, such as penile prosthetic implant surgery, understandably concerned given the higher risk of potential infection and perioperative complications. However, data regarding the safety and efficacy related to the penile prosthesis in the SOT population is mixed. Our study aimed to analyze adverse intraoperative and post-operative complications related to the penile prosthesis using the TriNetX database. Objective To observe whether SOT patients experienced more intraoperative and postoperative penile prosthetic complications when compared to the general population using the TriNetX US Collaborative Network, a large real-world database consisting of deidentified patient data from 56 healthcare organizations across the United States. Methods We used the TriNetX database to perform a propensity score-matched cohort study comparing five-year outcomes between SOT patients (kidney, heart, lung, liver, pancreas, and intestine by ICD-10) who underwent either an inflatable or non-inflatable penile prosthetic procedure (SOT) and non-SOT patients who underwent a similar procedure(s) (non-SOT). Patients were excluded from the analysis if they had any instance of priapism (treatment or dx) or Peyronie disease (treatment or diagnosis) in their medical record prior to the penile prosthetic procedure. Cohorts were matched on age, race/ethnicity, CKD, diseases of the prostate or prostatectomy, overweight and obesity status, T2DM, cardiovascular disease, psychiatric disorders, substance-use disorders, and spinal cord injury. Outcomes of interest included intraoperative and perioperative complications as well as post-operative complications related to the prosthetic implant (mechanical malfunction, fibrosis, displacement, hemorrhage, pain, stenosis, removal with or without replacement, and complex [all post-operative complications]). Results There were 223 patients in each group after matching (SOT, non-SOT). Mean age at penile prosthesis procedure 60.4 ± 10.2, 52% were White, and 8.9% were Hispanic/Latino. Kaplan-Meier analysis revealed that there was no significant difference found for the incidences of intraoperative complications (0.49% vs 0.53%, p = 0.99). In regards to postoperative complications, we found significantly higher incidences of complex prosthetic complications (28.76% vs 18.28%, p = 0.01) and mechanical malfunction of the penile prosthesis (8.56% vs 3.45%, p = 0.03) in the SOT cohort when compared to the non-SOT cohort. No significant difference was found between the cohorts for 5-year incidences of fibrosis (p = 0.81), hemorrhage (p = 0.97), pain (p = 0.69), stenosis (p = 0.81), infection (p =0.34), displacement (p = 0.68), removal with replacement (p = 0.72), and removal without replacement (p = 0.91). Conclusions In our analysis of this large, real-world database, we found that SOT patients were more likely to experience complex penile prosthetic complications as well as mechanical malfunction of the penile prosthesis. However, we observed no difference in 5-yr incidences of stenosis, fibrosis, hemorrhage, pain, infection, displacement, and prosthesis removal between the cohorts. Our analysis reveals that surgeons performing penile prosthetic surgeries, should be aware of potential long-term mechanical malfunction complications related to the penile prosthesis in the SOT population. Disclosure No.

Patient-reported outcomes of mesh in minimally invasive (laparoscopic/robot-assisted) immediate subpectoral prosthesis breast reconstruction: a retrospective study.

Although there is increasing interest in minimally invasive prosthesis breast reconstruction (PBR), whether meshes application in minimally invasive PBR can improve complications and cosmetic effects remains controversial. The author retrospectively analyzed postoperative complications and evaluated patient-reported quality-of-life outcomes in minimally invasive PBR with and without mesh. This study enrolled patients who underwent minimally invasive nipple-sparing mastectomy (NSM) followed by PBR. We used the TiLOOP bra for the mesh-assisted procedure. Patient demographics and postoperative complications data were compared between the procedures. Patient-reported outcomes were evaluated with the Breast-Q. A total of 158 patients underwent 160 minimally invasive NSM-PBR (with mesh, n = 64; without, n = 94). Postoperative complications were comparable in the mesh-assisted (5 [7.7%]) and non-mesh-assisted (5 [5.3%]) groups (p = 0.533). The most common complication in non-mesh-assisted group was infection, with four (4.2%) cases. In mesh-assisted group, implant exposure occurred in two (3.1%) patients. Removal of prosthesis was uncommon, with two (3.1%) and three (3.2%) cases in the mesh-assisted and non-mesh groups, respectively (p = 0.977). The BREAST-Q questionnaire was completed by 52 (81.3%) patients in the mesh-assisted group and 68 (72.3%) in the non-mesh-assisted group. Comparing the non-mesh group, patients in mesh-assisted group had improved scores on the BREAST-Q Satisfaction with breast (66.0) (p < 0.05), Physical Well-being (80.0), and Sexual Well-being (56.0). Mesh-assisted minimally invasive NSM-PBR has good aesthetic outcomes and high patient satisfaction. There were no significant differences in complication rates between the mesh-assisted and non-mesh-assisted groups.

What Is the Most Effective Treatment for Periprosthetic Joint Infection After Total Joint Arthroplasty in Patients with Rheumatoid Arthritis?: A Systematic Review.

Rheumatoid arthritis (RA) is a risk factor for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of this study was to perform a systematic review comparing the failure rates of debridement, antibiotics, and implant retention (DAIR), one-stage exchange arthroplasty/revision (OSR), and 2-stage exchange arthroplasty/revision (TSR) for RA patients with PJI and identify risk factors in the RA population associated with increased treatment failure rate. PubMed, Ovid MEDLINE, and Ovid Embase databases were screened with the terms "rheumatoid arthritis," "total joint arthroplasty," "prosthetic joint infection," and "treatment for PJI" on August 29, 2021. Four hundred ninety-one studies were screened, of which 86 were evaluated. The primary outcome evaluated was failure of surgical treatment for PJI. Ten retrospective cohort studies were included after full-text screening, yielding 401 patients with RA. Additional demographic and PJI management data were obtained for 149 patients. Patients with RA who underwent TSR demonstrated a lower failure rate (26.8%) than both DAIR (60.1%) and OSR (39.2%) (χ2 = 37.463, p < 0.00001). Patients with RA who underwent DAIR had a 2.27 (95% CI, 1.66-3.10) times higher risk of experiencing treatment failure than those who underwent TSR. Among risk factors, there was a significant difference in the C-reactive protein of patients who did vs. did not experience treatment failure (p = 0.02). TSR has a higher rate of success in the management of PJI patients with RA compared with DAIR and OSR. The complete removal of the infected prosthesis and delayed reimplantation may lower the treatment failure rate. Level III. See Instructions for Authors for a complete description of levels of evidence.

A retrospective cohort study of the postoperative prothesis-related complications of single-port endoscopic assisted versus open surgery on nipple sparing mastectomy and immediate prosthesis breast reconstruction

Objective: To examine the postoperative prosthesis-related complications, short-term surgical outcomes and patient satisfaction with breast reconstruction between patients who underwent endoscopic assisted versus conventional nipple sparing mastectomy and immediate prothesis breast reconstruction. Methods: This study was a retrospective cohort study. A retrospective analysis was performed on clinical data of 104 women with breast cancer who received nipple sparing mastectomy and immediate prothesis breast reconstruction from August 2021 to August 2022 at the Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University. They were divided into two groups according to the surgical approach. A total of 53 patients, aged (43.3±9.9) years (range: 25 to 66 years), underwent endoscopic nipple sparing mastectomy (E-NSM group) and immediate prothesis breast reconstruction. The other 51 patients aged (39.9±7.8) years (range: 25 to 54 years) underwent conventional open surgery (C-NSM group). Short-term surgical outcomes including operation time, postoperative hospital stay, postoperative blood loss, and postoperative drainage volume in 2 days were recorded. Patient satisfaction with breast reconstruction was compared using the Wilcoxon rank sum test. Postoperative prothesis-related complications were investigated to determine the experience to deal with them. Results: No postoperative prosthesis-related infection, prosthesis loss, or necrosis of the nipple-areola complex occurred in the E-NSM group, while 1 patient suffered from hematoma, whose wound was skinned with resuture after disinfection. Five patients in the C-NSM group had prosthesis-related infection, 2 of them received prosthesis removal surgery combined with sufficient antimicrobial agent, another one underwent surgery for subcutaneous placement of the drain, as well as antimicrobial agent therapy, and the rest of them healed up only with antimicrobial agent therapy. All recovered well after treatment. One patient recovered from necrosis of the nipple-areola complex through periodic iodophor disinfection and dressing which ended in improvement of necrotic areas, another patient who had hematoma accepted the same treatment mentioned above and also healed. All the patients mentioned above are now in stable conditions. Patients in the E-NSM group had higher satisfaction with the cosmetic results of the breast prosthesis implant than those in the C-NSM group (Z=-4.511, P<0.01). Conclusions: Both surgical approaches were proven to be safe and effective with a low rate of postoperative prosthesis-related complications. Patients in the E-NSM group were more satisfied with the cosmetic results of breast reconstruction than those in the C-NSM group.

Vacuum-assisted closure for chest wall reconstruction infection caused by Streptococcus mitis after surgery of lung cancer: a case report

BackgroundAmong a cohort of patients who underwent chest wall resection and reconstruction by rigid prosthesis, 6% required removal of the prosthesis, and in 80% of these cases the indication for prosthesis removal was infection. Although artificial prosthesis removal is the primary approach in such cases of infection, the usefulness of vacuum-assisted closure (VAC) has also been reported.Case presentationA 64-year-old man with diabetes mellitus underwent right middle and lower lobectomy with chest wall (3rd to 5th rib) resection and lymph node dissection because of lung squamous cell carcinoma. The chest wall defect was reconstructed by an expanded polytetrafluoroethylene (PTFE) sheet. Three months after surgery, the patient developed an abscess in the chest wall around the PTFE sheet. We performed debridement and switched to VAC therapy 2 weeks after starting continuous drainage of the abscess in the chest wall. The space around the PTFE sheet gradually decreased, and formation of wound granulation progressed. We performed wound closure 6 weeks after starting VAC therapy, and the patient was discharged 67 days after hospitalization.ConclusionsWe experienced a case of chest wall reconstruction infection after surgery for non-small cell lung cancer that was successfully treated by VAC therapy without removal of the prosthesis. Although removal of an infectious artificial prosthesis can be avoided by application of VAC therapy, perioperative management to prevent surgical site infection is considered essential.

Radial Head Replacement: Management of Elbow and Forearm Instability after Comminuted Radial Head Fractures Associated with Elbow Dislocation

This manuscript aims to identify an indication algorithm for the surgical treatment of radial head fractures associated with elbow dislocation. The study compares the mid-term functional outcomes of patients with multifragment radial head fracture treated by resection with the outcomes of patients treated with radial head replacement. The cohort of 34 patients who sustained a radial head fracture at the mean age of 42.5 years (age range 20-81 years) was broken down into two groups by type of surgery. The EXT group consists of 20 patients with the radial head fracture treated by radial head resection. The END group includes 14 patients treated with the radial head replacement. In all patients, the radial head fracture was associated with elbow dislocation (type IV fracture according to the Mason-Johnston classification). The modified Kocher's surgical approach was used in all patients of both the groups. In the EXT group, resection of the fragmented radial head was performed. In the END group, the ExploR® Modular Radial Head System (Zimmer, Biomet, USA) was used, consisting of a CoCr (cobalt chromium) alloy head and a titanium stem. The pain and the range of motion of the elbow and forearm were evaluated after the completion of the outpatient rehabilitation (the mean follow-up period was 2.4 years). Simultaneously, the elbow joint stability was assessed. Radiographs were taken to detect heterotopic ossifications, proximalization of the radius, and any signs of prosthesis loosening. The frequency of reoperations was followed-up. The MEPS (Mayo Elbow Performance Score) was calculated. In the EXT group, the mean elbow flexion was 117.5° and the mean pronation/supination was 166.9°. In 50% of patients, the MEPS obtained was greater than 90 points, which means an excellent functional outcome. In 1 patient (5%), recurrent elbow dislocation occurred which was the reason for revision surgery (elbow transfixation with the Kirschner wires and medial collateral ligament suture). Revision surgery was also performed in 2 patients (10%) in whom not all the radial head fragments were removed. Moreover, also observed was elbow joint instability (2 patients) and temporary radial nerve paralysis (1 patient). In 1 case discrete proximalization of the radius developed. The patients in the END group showed the mean elbow flexion of 112° and the mean pronation/supination of 135°. The MEPS obtained from 69% of patients was greater than 90 points, which means an excellent outcome. The pain under load was reported by 3 patients (21%). In 5 patients (35%), the X-rays showed radiolucent zone around the stem of the prosthesis. Neither revision surgery, nor prosthesis removal has been performed yet in any patient. No instability, neurological complications or infections have been reported. In both EXT and END group heterotopic ossifications have developed in 4 patients. Radial head replacement compared to the radial head resection in the management of multifragment fractures associated with elbow dislocations increase the elbow and forearm stability. The group of patients with an implanted radial head prosthesis shows a higher percentage of patients achieving excellent functional outcome than the group of patients with radial head resection. radial head, elbow, fracture, dislocation, resection, prosthesis.

Predictors of postoperative complications after sternectomy on oncologic patients

Background: Chest wall tumors are uncommon. The surgical objective is local disease control and the relief of symptoms. Due to the heterogeneity of cases, the great variety of reconstructions, size of resection, and clinical and surgical outcomes are still uncertain.Methods: Patients were submitted to sternectomies for tumors between 1997 and 2019. Oncological, and surgical characteristics were taken into consideration. The outcomes were related to the size of resection and classified into local and systemic complications. The authors used univariate and multivariate analyses to determine predictors of complications. Survival analysis and Kaplan-Meier curves were obtained.Results: Thirty resections were performed due to metastatic disease. Partial sternectomy was accomplished in 48.8 %, followed by subtotal in 40 %. Primary closure using Pectoralis major was performed in 48.8 %, and Latissimus dorsi in 35.5 %. Polypropylene mesh was used in 86.6 % of reconstructions. The prosthesis removal was necessary in 6.66 %. Respiratory failure was evidenced in 6.66 %. The resection area was a predictor of local and systemic complications (p = 0.0029; p = 0.0004 respectively) in univariate analysis. However, the size of resection was the only predictor of systemic complications regarding multivariate analysis (p = 0.014, 95 % CI 1.00‒1.07).Conclusion: The size of the resection was related to systemic complications, and the mesh reconstruction resulted in a low percentage of prosthesis removal and respiratory failure. This suggests a high resistance to local issues and a low respiratory failure rate.

The microbiology of periprosthetic joint infections as revealed by sonicate cultures in Korea: Routine use of fungal and mycobacterial cultures is necessary?

Although sonication is a valuable diagnostic tool for periprosthetic joint infections (PJI), it is not commonly utilized. We analyzed sonicate and intraoperative tissue culture results obtained from three hospitals to define the microbial etiology of PJIs in Korea. Furthermore, we investigated necessity of conducting regular fungal and mycobacterial cultures. We retrospectively analyzed data for patients with suspected orthopedic-related infections between 2017 and 2022, who had undergone prostheses removal surgery. We included 193 patients with suspected PJIs, and bacterial (n = 193), fungal (n = 193), and mycobacterial (n = 186) cultures were conducted on both sonicate and intraoperative tissue samples. The diagnosis of PJI was based on the European Bone and Joint Infection Society (EBJIS) criteria. Out of 193 patients, 121 (62.7%) had positive sonicate cultures, while 112 (58.0%) had positive periprosthetic tissue cultures. According to EBJIS criteria, a total of 181 patients were diagnosed with PJI, and 141 patients received microbiological confirmation through sonicate fluid culture or tissue culture. Of the 181 patients, 28 were classified with acute PJI (within 3 months of implantation) and 153 with chronic PJI. Among 141 patients, staphylococci were the most common organisms, accounting for 51.8% of cases, followed by Gram-negative organisms (15.6%), fungus (8.5%), and mycobacteria (3.5%). Nearly 91.7% of fungal isolates were Candida species, which also grew in bacterial cultures. In total, 11 cases cultured positive only in tissue culture, whereas 20 cases cultured positive only in sonicate culture. The antibiotic treatment plans were adjusted according to culture results. Utilizing sonicate culture has greatly assisted in identifying pathogens responsible for chronic indolent PJIs, allowing suitable antimicrobial treatment. Based on few cases involving non-Candida and mycobacterial infections, it appears that routine fungal and mycobacterial cultures may not be necessary.

Dual Organism Periprosthetic Joint Infection Following Total Knee Arthroplasty: A Case Report and One Year Follow-Up

Abstract Periprosthetic joint infections (PJI) of the knee are mostly due to a single organism, very rarely, it is due to dual organisms, and even rarer are dual Gram-negative bacilli and fungal infections. Most fungal infections are caused by Candida albicans; however, very few case reports are available for nonalbicans Candida in immunocompetent patients. We report an unusual case of nonalbicans Candida infection with Gram-negative bacilli in the knee joint with no predisposing risk factors. A 59-year-old man reported following mild pain, swelling, and restricted knee movements in a case of a primary total knee arthroplasty. The patient had minimal symptoms but had gross lysis around implants on imaging. His inflammatory markers were significantly high and knee aspiration was turbid, with raised polymorphs without any conclusive staining result. The culture reports revealed a fungal and Gram-negative organism infection. The patient was managed by debridement, prosthesis removal and antibiotic-loaded cement spacer insertion, and culture-specific antibiotics, followed by revision TKA and oral fluconazole therapy. The patient had a good clinical performance at 3 months and 1-year follow-up visits, with a painless range of motion of 10°–90° and there was no evidence of recurrence of infection. Dual Gram-negative and fungal prosthetic joint infection is a rare but serious complication. In the presence of mild clinical symptoms, but extensive lysis around the implant, fungal pathology should be considered irrespective of the immune status of the patient.

Survival and Clinical Outcomes after Unconstrained Total Knee Arthroplasty for Tibial Plateau Fractures–A Retrospective Study with Minimum 4-Year Follow-Up

This study investigated survival, complications, revisions, and patient-reported outcomes (PROs) for unconstrained total knee arthroplasty (TKA) in posttraumatic osteoarthritis (PTO) caused by intraarticular tibial plateau fractures with minimum four years follow-up. Forty-nine patients (71.4% male; 58.7 years) were included. Kaplan–Meier analysis was performed with failure defined as TKA removal. Patients without failure underwent pre- and postoperative evaluation (range of motion (ROM), Oxford Knee Score (OKS), Knee Society Score (KSS), anatomical femorotibial angle (aFTA), proximal tibial slope (PTS)) and Short Form-12 (SF-12) Physical (PCS) and Mental Component Summary (MCS) assessment at final follow-up. Fifteen (30.6%) patients had a complication, and eight (16.3%) patients underwent prosthesis removal at median 2.5 years. Cumulative survival rate of TKA was 79.6% at 20 years. A total of 32 patients with a mean follow-up of 11.8 years underwent further analyses. ROM (p = 0.028), aFTA (p = 0.044), pPS (p = 0.009), OKS (p &lt; 0.001) and KSS (p &lt; 0.001) improved significantly. SF-12 PCS was 42.3 and MCS was 54.4 at final follow-up. In general, one third of patients suffer a complication, and one in six patients has their prosthesis removed after TKA for PTO due to tibial plateau fractures. In patients who do not fail, TKA significantly improves clinical and radiographic outcomes at long-term follow-up.

Is large unstained cell percentage (%LUC) a novel diagnostic marker for periprosthetic joint infections?

BACKROUND: Periprosthetic joint infection (PJI) is a very important complication that occurs after total joint replacement. Diagnosing PJI is at least as difficult as this disease. There is no biomarker that alone can diagnose PJI. OBJECTIVE: This study aimed to evaluate the effectiveness of large unstained cell percentage (%LUC) in diagnosing PJI and deciding on re-implantation in two stage septic exchange arthroplasty. METHODS: Patients who underwent revision arthroplasty between 2019 and 2023 were screened retrospectively. These patients were grouped as those who underwent two-stage septic exchange and those who underwent aseptic exchange. Prosthesis removal from the patients who underwent two-stage septic exchange, before spacer application, and on the 3rd post-operative day after spacer application, Blood parameters were collected at the 1st month and before the second stage after the spacer application, and before the revision surgery from the patients who underwent aseptic exchange. White blood cell, neutrophil percentage, %LUC, albumin, sedim and CRP values were checked and recorded one by one from all patients. RESULTS: The data of a total of 233 patients, including 133 patients in the two stage septic exchange group and 100 patients in the aseptic exchange group, were included in the study. When the predictive value of %LUC in PJI was accepted as cut-off 1.75, the sensitivity was 69.2% and the specificity was 73%. The change in %LUC over time in patients who underwent two-stage septic exchange was statistically significant (p= 0.0001). A positive correlation was found between the value of .%LUC after spacer application and the value of CRP before prosthesis protrusion/spacer application surgery, and the Spearman correlation coefficient was found to be 0.005. CONCLUSION: %LUC value can be a promising biomarker for the diagnosis of PJI by considering both sensitivity and specificity rates. Apart from this, it is an easily accessible and effective biomarker for re-implantation decision making and evaluation of response to treatment, especially in two-stage septic exchange surgeries.

Candida endocarditis: Update on management considerations.

The rise in incidence rates of invasive candidiasis warrants an increase in attention and efforts toward preventing and treating this virulent infection. Cardiac involvement is one of the most feared sequelae and has a poor prognosis. Despite the introduction of several novel antifungal agents over the past quarter century, complications and mortality rates due to Candida endocarditis have remained high. Although fungal endocarditis has a mechanism similar to bacterial endocarditis, no specific diagnostic criteria or algorithm exists to help guide its management. Furthermore, recent data has questioned the current guidelines recommending a combined approach of antifungal agents with surgical valve or indwelling prostheses removal. With the emergence of multidrug-resistant Candida auris, a focus on improved prophylactic measures and management strategies is necessary.

Integrated analysis of comorbidity, pregnant outcomes, and amniotic fluid cytogenetics of fetuses with persistent left superior vena cava.

Persistent left superior vena cava (PLSVC) is the most common venous system variant. The clinical characteristics and amniotic fluid cytogenetics of fetuses with PLSVC remain to be further explored. To develop reliable prenatal diagnostic recommendations through integrated analysis of the clinical characteristics of fetuses with PLSVC. Cases of PLSVC diagnosed using prenatal ultrasonography between September 2019 and November 2022 were retrospectively studied. The clinical characteristics of the pregnant women, ultrasonic imaging information, gestational age at diagnosis, pregnancy outcomes, and amniocentesis results were summarized and analyzed using categorical statistics and the chi-square test or Fisher's exact test. Of the 97 cases diagnosed by prenatal ultrasound, 49 (50.5%) had isolated PLSVC and 48 (49.5%) had other structural abnormalities. The differences in pregnancy outcomes and amniocentesis conditions between the two groups were statistically significant (P < 0.05). No significant differences were identified between the two groups in terms of advanced maternal age and gestational age (P > 0.05). According to the results of the classification statistics, the most common intracardiac abnormality was a ventricular septal defect and the most common extracardiac abnormality was a single umbilical artery. In the subgroup analysis, the concurrent combination of intra- and extracardiac structural abnormalities was a risk factor for adverse pregnancy outcomes (odds ratio > 1, P < 0.05). Additionally, all abnormal cytogenetic findings on amniocentesis were observed in the comorbidity group. One case was diagnosed with 21-trisomy and six cases was diagnosed with chromosome segment duplication. Examination for other structural abnormalities is strongly recommended when PLSVC is diagnosed. Poorer pregnancy outcomes and increased amniocentesis were observed in PLSVC cases with other structural abnormalities. Amniotic fluid cytogenetics of fetuses is recommended for PLSVC with other structural abnormalities.

Excisional arthroplasty of hip for complex periprosthetic fracture: A case report

Excisional Arthroplasty of hip is an old modality of treatment meant to gain mobility of hip at the cost of stability, limping and shortening of limb for post infective fibrous ankylosis of hip or arthrodesis of hip. At present with frequent use of total hip replacement, the use of excisional arthroplasty in hip is limited. A case of periprosthetic fracture in femur occurring 14 years after the surgery and managed with the excisional arthroplasty is reported due to difficulties in prosthesis removal. The case report highlights the utility of Excisional arthroplasty in complex periprosthetic fractures which cannot not be managed by total hip arthroplasty, thus indicating its relevance even today.

Surgical Decision Making in Genetically High-Risk Women: Quantifying Postoperative Complications and Long-Term Risks of Supplemental Surgery After Risk-Reducing Mastectomy.

Risk-reducing mastectomy (RRM) helps prevent breast cancer in high-risk women but also carries a risk of unanticipated supplemental surgeries. We sought to determine the likelihood of supplemental surgeries following RRM. We performed a retrospective cohort study of female patients with a confirmed germline pathogenic variant (GPV) in a breast cancer susceptibility gene (BRCA1/2, PALB2 and others) who underwent bilateral or contralateral RRM at our institution between 2006 and 2022. Supplemental surgeries were defined as any operation requiring general or local anesthesia performed outside of the initially planned procedure(s). The Kaplan-Meier method was used to estimate the 5-years cumulative incidence of supplemental surgery. Of 560 GPV carriers, RRMs were performed in 258 (46.1%) women. The median age of the cohort was 44 years (interquartile range 37-52 years), with 33 (12.8%) patients undergoing RRM without reconstruction and 225 (87.2%) undergoing RRM with reconstruction. Following surgery, 34 patients (13.2%) developed early (< 30 days) postoperative complications, including infection, hematoma, seroma, loss of the nipple areola complex, flap necrosis, implant exposure and/or prosthesis removal. At a median follow-up of 3.8 years, 94 (36.4%) GPV carriers underwent at least one reoperation. Participants who experienced an early postoperative complication had the highest rate of reoperation (85.3% vs. 29.0%; p < 0.001) and a significantly higher likelihood of multiple additional surgical interventions (41.2% vs. 10.7%; p < 0.001). The 5-years rate of supplemental surgery was 39.2% [95% confidence interval (CI) 32.7-46.5] in the overall cohort and 31.5% (95% CI 24.9-39.3) in patients without an early postoperative complication. Unanticipated supplemental surgeries occur in 40% of GPV carriers following RRM andin nearly one-third of patients without early postoperative complications.

Case Report of Complex Chest Wall Repair for Sternal Dehiscence After Bilateral Lung Transplantation

We report a case of a complex chest wall reconstruction because of sternal dehiscence, requiring different surgical procedures for its complete resolution. A 54-year-old man patient with Langerhans cell histiocytosis and chronic obstructive pulmonary disease underwent bilateral sequential lung transplantation through a clamshell incision, using nitinol thermo-reactive clips for sternal closure. One year later, he consulted because of chest pain, fever, and purulent secretions. Physical examination and chest X-ray revealed a right pulmonary hernia due to post-clamshell wound dehiscence. Chest wall repair was performed, placing an expanded-polytetrafluoroethylene synthetic mesh, and the sternum was realigned and fixated with titanium plates and screws. However, in the immediate postoperative period, there was a large amount of serous drainage through the surgical wound, needing negative pressure therapy. Unfortunately, the wound became necrotic with exposure to the osteosynthesis material. In addition, a chest computed tomography scan showed fluid accumulation in the anterior chest wall. Therefore, two-stage revision surgery was indicated: first, the removal of the previous prosthesis and, the definite one, the use of a pedicled latissimus dorsi myocutaneous flap to provide effective coverage of the wound. Sternal dehiscence is not an uncommon complication after clamshell incision in patients undergoing bilateral sequential lung transplantation, and it is associated with significant morbidity. In the presence of chest wall instability, surgical repair is mandatory.

The use of an aortic allograft in infection of an aortic prosthesis in a patient with a multi-storey lesion of the arterial bed of the lower extremities

The article presents a clinical case of treatment of patient K, 61 years old, with previously performed aorto-femoral bifurcation bypass surgery for critical lower limb ischemia. 6 months after the initial surgery, the patient developed thrombosis of the right arm of the prosthesis. After another 3 months, a persistent subfebrile body temperature appeared, multiple fistula passages formed with the release of pus in the areas of postoperative scars on the hips. Infection of a synthetic prosthesis was diagnosed. A decision was made to perform repeated surgical intervention in the volume of abdominal aortic reprosthetics with a cadaveric allograft. The surgery was performed at the clinic of the Faculty of Surgery of SamSMU: removal of the bifurcation synthetic prosthesis; rehabilitation of the prosthesis bed; reprosthetics of the aorta with vascular aortic allograft; endarterectomy from the deep artery of the thigh on both sides; bifurcation aorto-femoral reprosthetics; femoral-popliteal bypass with allograft on the right. The postoperative period was uneventful. Healing of wounds on the hips by secondary tension due to marginal skin necrosis. Critical limb ischemia was stopped. The patient was discharged on the 20th day in a satisfactory condition.CONCLUSION. The use of allografts makes it possible to perform reprosthetics of the abdominal aorta in case of infection of synthetic prosthesis and simultaneous reconstruction of the femoral-popliteal segment.

Intermediate-term Outcomes Following a Case Series of Reoperations for Medtronic Freestyle Stentless Aortic Valves

BackgroundData are limited on long-term outcomes in patients who have undergone a reoperation following failure of a stentless aortic valve. MethodsBetween 2006 and 2016, a retrospective analysis was performed on 24 patients who underwent open aortic valve replacement surgery for a failed stentless aortic valve prosthesis at Health Sciences North, Sudbury, Ontario, Canada. The primary outcome was a low mortality rate from cardiac-related deaths after 5 years. ResultsAll patients underwent insertion of a Medtronic Freestyle bioprosthesis (Minneapolis, MN) implanted using the modified subcoronary technique for their initial operation. The interval from the first operation to the stentless redo surgery ranged from 6 to 13 years. Aortic valve reoperation was performed for structural valve deterioration in 96% (n = 23) of the cases. Reoperations involved a removal of the stented valve leaflets and standard aortic valve replacement within the stentless casing in 20% (n = 5) of the cases, with the remaining cases requiring complete removal of the stentless prosthesis and aortic valve replacement. In those in whom a complete removal of the stentless valve was possible (n = 19), no disruption of the native aortic root occurred, with a 0% rate of conversion to a Bentall procedure. No intraoperative mortality occurred. The 30-day and 10-year operative mortality rates were 4% and 16%, respectively. ConclusionsRedo surgery for failing stentless valves can be done with relatively low risk and with acceptable long-term outcomes without resorting to root-replacement techniques.

Cone repair after tricuspid valve replacement in Ebstein anomaly.

Cone repair after tricuspid valve replacement in Ebstein anomaly.

Prosthetic Joint Infection Due to Mycobacterium goodii/smegmatis

Total hip arthroplasty is among the most frequently performed elective surgical procedures in the United States. Infection of the implant is a rare but catastrophic complication. Generally, patients require multiple surgical procedures and intravenous antibiotics to eradicate the infection. We present the case of a patient diagnosed with a strain of rapidly growing mycobacteria not frequently encountered. He was successfully treated with retention of implants and chronic oral antibiotic therapy. A literature review was performed to identify similar cases, and the results showed that most of the patients underwent successful revision of the implant along with antibiotic therapy. We present this case to illustrate an alternative method of management for appropriate patients who may not be an adequate surgical candidate for prosthesis removal.