Surgeon Preference Research Articles

Management of chronic Achilles tendon ruptures

Achilles tendon ruptures are fairly common injuries that are often unfortunately missed, leading to the development of chronic tendoachilles (TA) ruptures. Patients present with gait abnormalities and significant ankle plantarflexion weakness. Imaging modalities such as ultrasound (US) and magnetic resonance imaging (MRI) are used to confirm the diagnosis and help in surgical planning. Most chronic TA ruptures require surgical management, with non-operative management being reserved for medically unfit patients due to generally poor outcomes. A multitude of surgical reconstruction options have been described in the literature, each with its benefits and disadvantages. Ultimately, the choice of surgical technique depends on the residual gap that is present following debridement of the scar tissue that forms a bridge between the ruptures ends of the Achilles tendon, graft availability and the treating surgeon's preference. Surgery results in an improvement in patient-reported outcomes, with the majority going back to their pre-injury level activities. However, surgery is also associated with a fair number of complications, the most common being wound healing problems, infections, neurological injury and deep vein thromboses for which patients need to be appropriately counselled for.

Comparison of transperitoneal and retroperitoneal robot partial nephrectomy for kidney tumors

Background: Surgical techniques for small kidney tumors have been developed for decades, from open to robotic surgery. There are two approaches for partial nephrectomy: transperitoneal and retroperitoneal. We divided robotic partial nephrectomy cases into transperitoneal robotic partial nephrectomy (TRPN) and retroperitoneal robotic partial nephrectomy (RRPN) and compared the outcomes.Methods: We retrospectively evaluated patients who underwent robotic partial nephrectomy at our hospital between November 2019 and May 2022. We reviewed patients’ demographic and perioperative data. Results: Seventy robotic partial nephrectomies were performed (35 TRPN and 35 RRPN). There were significant differences in operation time, estimated blood loss (EBL), tumor size, and the RENAL Nephrometry Score (RNS) between those who underwent TRPN and those who underwent RRPN. Larger tumors were noted in the TRPN group, and the RNS was higher. In contrast, the operation time was shorter, EBL was lower, and tumors were more likely to be located in the posterior and lower portions in the RRPN group than in the TRPN group.Conclusions: In our study, RRPN had advantages over TRPN in terms of operation time and EBL. However, TRPN tended to be performed rather than RRPN for tumors that were more complex in terms of size or RNS. Although the choice between RRPN and TRPN depends on the surgeon's preference, RRPN seems effective for treating small kidney tumors if selected appropriately.

Is Stent on a String the New Gold Standard for Postureteroscopy Ureteral Drainage? Evidence from a Systematic Review.

Introduction: Ureteral stents are widely used throughout urologic surgery, most commonly following ureteroscope (URS) procedures. This systematic review aims to assess the current evidence concerning stent on string (SOS) placed after URS and compare it with stents without strings (SWOSs). Methods: A systematic review was conducted on several databases using the preferred reporting items for systematic review and meta-analysis (PRISMA) methodology for studies in English language, for patients of all age groups, who had an SOS after URS for stone disease. Results: Of 1210 records identified, a total of 22 studies (20 adult and 2 pediatric studies) were included, with a total of 8382 patients. Of these, 3427 (40.9%) had SOSs inserted and 434 (11%) were in the pediatric age group. Our results show that SOS provides several advantages, and compared with SWOS, they were in situ for less time, with no difference in complications such as urinary tract infection or urinary symptoms. Furthermore, significant cost savings, less pain on removal, and high rates of safe home removal were reported in SOS, with >90% patients reporting that they would be happy to remove their SOSs at home. However, a small risk of stent dislodgment must be considered when making decisions regarding SOS placement after URS. Conclusion: SOS provides an excellent option after URS, especially in those patients with no intraoperative complication, and their placement is done as a routine insertion based on surgeon preference. These stents reduce dwell time, pain, cost, risks, and suffering involved from prolonged stenting, and majority of patients are happy to remove it themselves at home. Although their use seems to be still restricted in the current endourology practices, they are likely to become the new gold standard for routine URS in future, with more shared decision making and patient-reported outcome measures coming into the mainstream.

Does Flipping From Prone to Supine for Medial Malleolar Fixation of Trimalleolar Ankle Fractures Improve Results?

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow-up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep, and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p = .047), longer operative time in minutes (p < .001), and a higher use of plate and screw constructs for medial malleolar fixation (p = .019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.

Comparative Assessment of Mitomycin C versus Limbal Conjunctival Autograft for Primary Pterygium Removal: An Evaluation of Efficacy

Objective: This study aims to evaluate and contrast the outcomes achieved by application of mitomycin C 0.02% intra-operatively versus employing limbal conjunctival autograft after the removal of primary pterygium. Study Design: Randomized controlled trial (RCT) Place and duration: The research was carried out at the Ophthalmology Department of Ghazi Hospital in Dera Ghazi Khan, spanning from October 2021 to September 2022. Methodology: The research included 62 participants who were divided into two groups; one group receiving Mitomycin C and the other group underwent limbal conjunctival autograft. The main variables assessed in the study were the laterality of pterygium, size of pterygium extending over the limbus, preoperative and postoperative best corrected visual acuity, and the rate of pterygium recurrence in both groups. The analysis of data was conducted utilizing SPSS version 24. Results: In Group MMC, 48.4% of patients showed right laterality, while in Group LCAU, 58.1% (p=0.445) showed it. The average size of pterygium crossing the limbus, as well as preoperative and postoperative best corrected visual acuity, were similar between both groups (p&gt;0.050). Regarding recurrences, the percentages at 3, 6, and 9 months, as well as after 1 year, were higher in Group MMC (12.9%, 6.5%, 16.1%, 9.7%, 45.2%) compared to Group LCAU (9.7%, 9.7%, 3.2%, 6.5%, 29%), but these differences were not statistically significant (p=0.526). Conclusion: Limbal conjunctival autograft appears to be more effective in preventing recurrence following the excision of primary pterygium compared to intraoperative application of Mitomycin C. However, both techniques, whether simple excision with LCAU or MMC application, demonstrate acceptable outcomes with only minor differences in recurrence rates. Surgeon expertise and preferences in local practice play significant roles as main risk factors influencing the choice between these two methods.

Innovations with the scapula and subscapular system for head and neck microvascular reconstruction

Microvascular free flap reconstruction based on the subscapular system is an established and versatile method of reconstructing complex head and neck defects. Since the first published description in the mid-1980s, advances have been made to the harvest technique, positioning, use of virtual surgical planning, and endosseous implants. Here, the most recent literature is reviewed for innovations related to the subscapular system. Microvascular head and neck surgeon preferences related to the subscapular system are surveyed and discussed. The concordance between virtual surgical plans using scapula cutting guides and pre-contoured plates with the postoperative result is assessed, and novel applications of the scapula free flap are presented. Subscapular system free flaps are an established and essential component of the reconstructive armamentarium for head and neck defects with minimal limitations and low donor site morbidity.

The Long-Term Patency of the Internal Jugular Vein and the Common Facial Vein as Entrance Sites for Venous Access in Ventriculoatrial Shunts: A Comparative Analysis from a Single-Center Study

The ventriculoatrial (VA) shunt is a surgical intervention used to manage hydrocephalus, although it is less often utilized compared to the ventriculoperitoneal (VP) shunt or endoscopic third ventriculostomy. Placement of the distal catheter typically involves the utilization of either the common facial vein (CFV) or the internal jugular vein (IJV), 2 frequently employed options for venous access. This study aims to determine whether there is a statistically significant difference between the long-term patency (2years) of the distal end of the VA shunt of these 2 options. A retrospective cohort analysis was conducted of patients who received VA shunt surgeries with the employment of the CFV or IJV as access veins at Rajavithi Hospital in Thailand between January 2015 and December 2020. The analysis focused on long-term patency and potential complications. The study comprised a total of 42 participants. Twenty-six (61.9%) individuals underwent ventriculoatrial (VA) shunt surgery via the CFV, while the other 16 (38.1%) underwent the same procedure using the IJV. Neither of the 2 groups required shunt revision due to distal catheter malfunction. Most cases exhibited no significant complications apart from a single instance of shunt system infection. In VA shunt surgery, both the CFV and IJV can be used as venous access sites for the right atrium because there is no discernible difference between their complications or long-term patency. Anatomical considerations, patient-specific characteristics, and the surgeon's preference should all be considered when choosing the venous access location for the placement of a VA shunt.

Risk factors for spinal subdural hematoma after minimally invasive transforaminal lumbar Interbody Fusion (MI-TLIF): a multivariate analysis

BackgroundSpinal subdural hematoma (SSH) is a rare cause of compression of the neutral elements of the spinal cord. However, little is known about the presentation of acute SSH after lumbar spine surgery. The reason for this may be that symptomatic SSH occurs rarely and is not given enough attention by spine surgeons. Currently, the decision to perform MRI postoperatively is more dependent on surgeon preference; therefore, no high-quality studies have been published. Our team reports our experience in the diagnosis and management of SSH after lumbar decompression and fusion surgery.MethodsWe retrospectively studied 215 patients who underwent routine MRI following minimal invasive transforaminal lumbar interbody fusion (MI-TLIF) between 2020-01-01 and 2022-06-30. The patients were divided into SSH group (17 cases) and non-SSH group (198 cases) according to the occurrence of SSH. Univariate analysis and multivariate logistic regression analysis were performed to identify relevant risk factors that increase the risk of SSH postoperatively.ResultsNone of the patients presented with serious neurologic symptoms, such as lower extremity paralysis or cauda equina syndrome that required emergency hematoma debridement. SSH was found in 17 (7.9%) patients and non-SSH in 198 (92.1%). Factors affecting SSH were presence of hypertension, presence of diabetes and postoperative anticoagulant therapy. The significantly independent risk factor of postoperative SSH were diabetes (P = 0.008, OR: 6.988) and postoperative anticoagulant therapy (P = 0.003, OR: 8.808).ConclusionsSSH after MI-TLIF is not a rare condition, with generally no requirement of emergency evacuation. Comprehensive anti-symptomatic treatment could achieve satisfactory results. Diabetes mellitus and postoperative anticoagulant therapy are independent risk factors for SSH. Spine surgeons should hold applicability of the use of anticoagulants after lumbar surgery.

Access site complications in thoracic endovascular aortic repair

BackgroundPercutaneous access and use of vascular closure devices facilitate thoracic endovascular aortic repair (TEVAR) procedures during local anesthesia and allow immediate detection of signs of spinal ischemia. However, the very large bore access (usually ≥22F sheath) associated with TEVAR increases the risk of vascular complications. In this study, we sought to define the safety and feasibility of two percutaneous femoral artery closure devices during TEVAR, in terms of access site vascular complications and major, life-threatening, or fatal bleeding (≥major) within 48 hours. Access site vascular complications were defined as technical failure of vascular closure or later formation of pseudoaneurysm. MethodsFrom March 2010 to December 2022, 199 transfemoral TEVAR were performed at Helsinki University Central Hospital, Finland. We retrospectively categorized these into three groups, based on surgeon preference for the access technique and femoral artery closure method: (1) surgical cut-down and vessel closure, n = 85 (42.7%), (2) percutaneous access and vascular closure with suture-based ProGlide, n = 56 (28.1%), or (3) percutaneous access and vascular closure with ultrasound-guided plug-based MANTA, n = 58 (29.1%). The primary outcome measure was technical success of vascular closure and access site vascular complications during index hospitalization. Secondary outcome measures were ≥major bleeding, early mortality, and hospital stay. ResultsThe technical success rate was 97.6% vs 91.1% vs 93.1% for surgical cut-down, ProGlide, and MANTA, respectively (P = .213). The rate of access site vascular complication was 3.5% vs 8.9% vs 10.3%, respectively (P = .290), with two pseudoaneurysms detected postoperatively and conservatively managed in the MANTA group. The vascular closure method was not associated with increased risk of ≥major bleeding, early mortality, or hospital stay on univariate analysis. Predictors for ≥major bleeding after TEVAR in multivariable analysis were urgent procedure (odds ratio: 2.8, 95% confidence interval: 1.4-5.5; P = .003) and simultaneous aortic branch revascularization (odds ratio: 2.7, 95% confidence interval: 1.3-5.4; P = .008). ConclusionsIn this study, the technical success rates of the percutaneous techniques demonstrated their feasibility during TEVAR. However, the number of access site complications for percutaneous techniques was higher compared with open approach, although the difference was not statistically significant. In the lack of evidence, the safety of the new MANTA plug-based vascular closure for TEVAR warrants further investigation.

Surgical approaches for thoracic outlet decompression in the treatment of thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is a controversial and uncommon syndrome. Three different diagnoses can be made based on the compressed structure: arterial TOS, venous TOS, and neurogenic TOS. Diagnosing TOS, especially neurogenic TOS, remains difficult since a single diagnostic tool does not exist. Although this resulted in a lot of confusion, standardization of care and outcome improved daily care practice measures in the last decade. Current treatment algorithms consist of both conservative and surgical treatment approaches, which should be chosen depending on the type of TOS and extend of the complaints. Surgical treatment of TOS is performed via thoracic outlet decompression (TOD). TOD surgery includes complete resection of the first rib (cartilage to cartilage), transection of the scalene muscles and complete neurolysis/venolysis or arteriolysis. Four different approaches can be chosen for TOD surgery: the transaxillary (TA), supraclavicular (SC), paraclavicular (PC), and infraclavicular (IC) approach. The TA, SC, and PC approach can be used for every form of TOS. However, the PC approach is mostly used for treating venous TOS. The IC approach has no role in treating neurogenic or arterial TOS and is only used for venous TOS. Every approach has its own benefits and limitations and literature does not agree on what approach is best. Therefore, the used surgical approach for TOD should be based on the surgeon's preference and experience. The aim of this review is to present an overview of the diagnostic pathway and provide an in-depth description of the surgical approach in each form of TOS.

Intramedullary Nails vs Open Reduction in Internal Fixation for Humeral Shaft Fractures: A Meta-Analysis of Randomized Control Trials.

The purpose of this study was to perform a meta-analysis of randomized controlled trials (RCTs) to compare outcomes following intramedullary nailing (IMN) vs. open reduction and internal fixation (ORIF) of humeral shaft fractures. A literature search of three databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing IMN and ORIF for humeral shaft fractures were included. Clinical outcomes were compared using Revman. P value < 0.05 was considered to be statistically significant. Ten RCTs with 512 patients were included. Overall, 8.4% of patients treated with IMN and 6.4% of patients with ORIF had a non-union (p = 0.57, I2 = 0%), with a significantly faster time to union with IMN (10 weeks vs 11.9 weeks , p < 0.05). There was no significant difference in re-operations (11.6% IMN vs 7.6% ORIF, p = 0.26) or radial nerve palsies (2.8% IMN vs 4.2% ORIF, p = 0.58). A lower rate of infection was noted with IMN (1.2% vs 5.3%, p < 0.5). Additionally, there was a lower operative time with IMN (61 minutes vs 88 minutes, p < 0.05). The level I evidence in the literature does not show a significant difference in union rates, re-operations or radial nerve palsies between IMN and ORIF for humerus shaft fractures. Overall, treatment with IMN results in lower infection rates, less operative time, and modestly quicker time to union. Optimal treatment strategy for humeral shaft fractures may be best informed by fracture pattern and surgeon preference.

Management of cerebrospinal fluid pseudocysts in the laparoscopic age.

Abdominal CSF pseudocysts are an uncommon but challenging complication of ventriculoperitoneal shunts. Pseudocysts consist of a loculated intraperitoneal compartment that inadequately absorbs CSF and may be infected or sterile at diagnosis. The treatment goal is to clear infection if present, reduce inflammation, and reestablish long-term function in an absorptive (intraperitoneal) space. This aim of this paper was to study the efficacy of primary laparoscopic repositioning of the distal shunt catheter for treatment of sterile abdominal CSF pseudocysts. All patients treated for abdominal CSF pseudocysts at Dallas Children's Health from 1991 to 2021 were retrospectively reviewed. Patient history and pseudocyst characteristics were analyzed, with a primary outcome of pseudocyst recurrence at 1 year. Of 92 primary pseudocysts, 5 initial treatment strategies (groups) were used depending on culture status, clinical history, and surgeon preference: 1) shunt explant/external ventricular drain (EVD) placement (23/92), 2) distal tubing externalization (13/92), 3) laparoscopic repositioning (35/92), 4) open repositioning (4/92), and 5) other methods such as pseudocyst drainage or direct revision to another terminus (17/92). Seventy pseudocysts underwent shunt reimplantation in the peritoneal space. The 1-year peritoneal shunt survival for groups 1 and 2 combined was 90%, and 62% for group 3. In group 3, 1-year survival was better for those with normal systemic inflammatory markers (100%) than for those with high markers (47%) (p = 0.042). In a univariate Cox proportional hazards model, the risk of pseudocyst recurrence was increased if the most recent abdominal procedure was a nonshunt abdominal surgery (p = 0.012), and it approached statistical significance with male sex (p = 0.054) and elevated inflammatory markers (p = 0.056. Multivariate Cox analysis suggested increased recurrence risk with male sex (p = 0.05) and elevated inflammatory markers (p = 0.06), although the statistical significance threshold was not reached. The length of hospital stay was shorter for laparoscopic repositioning (6 days) than for explantation/EVD placement (21 days) (p < 0.0001). Ultimately, 62% of patients had a peritoneal terminus at the last follow-up, 33% (n = 30) had an extraperitoneal terminus (19 pleura, 8 right heart, and 3 gallbladder), and 5 patients were shunt free. Some sterile pseudocysts with normal systemic inflammatory markers can be effectively treated with laparoscopic repositioning, resulting in a significantly shorter hospitalization and modestly higher recurrence rate than shunt explantation.

Comparative Review of Outcomes of Totally Extraperitoneal (TEP) and Transabdominal Preperitoneal (TAPP) Primary Inguinal Hernia Repair.

There is an ongoing debate about the efficacy and postoperative outcomes of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) inguinal hernia repair. Our aim is to assess the surgical outcomes of each technique, focusing predominantly on postoperative components to determine if establishing a policy to advocate for a single technique is warranted. A literary review of randomized control trials and cohort studies to delineate recurrent concerns or points of contention was undertaken. A retrospective, comparative analysis was performed of TEP and TAPP primary inguinal hernia repairs performed by surgeons with more than five-yearexperience with their preferred technique over a three-year period (January 2020 to December 2022) at three separate institutions. A total of 279 applicable cases were reviewed of which 38% (n=106) were performed as TEP and 62% (n=173) performed as TAPP. The demographic of the cohort was heavily skewed towards the male population as expected; however, there were no differences between each subgroup. TEP hernia repair showed a significantly improved postoperative pain score at one and 24 hours, respectively(1.67 ± 0.45, p < 0.05 and 1.97 ± 0.31, p < 0.05). No discernible difference was noted in the categories of length of hospital stay, recurrence rate, and overall patient satisfaction. The study showed overall improved results using the TEP inguinal hernia repair technique; however, no statistically significant results were demonstrated in the long term to advocate for changes to pre-existing surgeon preferences.

Outcomes of coronary artery bypass surgery using modified del Nido cardioplegia in patients with poor ventricular function

Backgrounddel Nido cardioplegia (DN) has been shown to be safe in adult patients undergoing isolated coronary artery bypass grafting with normal left ventricular ejection fraction. We sought to determine whether it was also safe in adult patients with diminished left ventricular function.MethodsAll patients with preoperative left ventricular ejection fraction ≤ 40% undergoing isolated coronary artery bypass grafting between 1/1/2019 and 7/10/2022 were retrospectively analyzed. Off-pump and beating heart cases were excluded. Patients were divided by surgeon preference between conventional cardioplegia (CCP) and DN. Baseline and intraoperative characteristics and short-term postoperative outcomes were compared.ResultsSix surgeons performed 829 isolated coronary artery bypass operations during the study. Two-hundred seventy-two met study criteria. Three surgeons used exclusively CCP for the duration of the study, two used exclusively DN and one switched from CCP to DN mid-way through. Group totals were: CCP n = 181 and DN n = 91. There were no significant differences in baseline characteristics including mean left ventricular ejection fraction (CCP 32.5 ± 7.4% vs. DN 33.4 ± 7.29%, p = 0.939). Other than a significant decrease in bypass time for DN (113.20 ± 37.2 vs. 122.43 ± 34.3 min, p = 0.043) there were no intergroup differences in urgency, number of grafts, ischemic time or incidence of blood transfusion. Postoperative outcomes between CCP and DN were similar including incidence of atrial fibrillation (12.2% vs. 8.8%, p = 0.403), intensive care length of stay (3.7 ± 2.3 vs. 4.3 ± 3.7 days, p = 0.886), total length of stay (5.7 ± 3.7 vs. 6.3 ± 4.4 days, p = 0.922) and 30-day mortality (3.85% vs. 1.10%, p = 0.205).ConclusionCompared to conventional cardioplegia, del Nido cardioplegia provides equivalent short-term outcomes in patients with low left ventricular ejection fraction undergoing isolated coronary artery bypass grafting.

Bankart Repair Versus Bristow-Latarjet Procedure in Treating Anterior Shoulder Dislocation: A Systematic Review

Introduction: Anterior shoulder dislocation affects an estimated 11/100,000 individuals annually, primarily involving the inferior glenohumeral ligament and causing recurrent instability. Surgical approaches like anatomical labral repair and the Bristow-Latarjet procedure are common for managing these issues. This systematic review aimed to compare the clinical and functional outcomes of Bankart repair and the Bristow-Latarjet procedure in treating anterior shoulder dislocation. Methods: Following PRISMA guidelines, a comprehensive search was conducted across PubMed, Google Scholar, Science Direct, and the Cochrane Library, resulting in 154 studies. From these, 4 studies were selected: two retrospective cohorts, one prospective cohort, and one case-control, encompassing 414 patients. Among them, 257 patients underwent the Bristow-Latarjet procedure, while 157 received Bankart repair. Inclusion criteria covered English-language studies evaluating clinical outcomes such as SSV, WOSI, Rowe scores, movement loss, and arthropathy rates, with no demographic restrictions, while non-English studies were excluded. Quality evaluation employed classifications by the Oxford Center for Evidence-based Medicine, GRADE criteria, and AHRQ for assessing evidence strength, bias, and quality. Results: The systematic review selected 4 studies from the 154 identified, incorporating a total of 414 patients. Of these, 257 underwent the Bristow-Latarjet procedure, and 157 received Bankart repair. The studies comprised two retrospective cohorts, one prospective cohort, and one case-control study. Conclusion: The review revealed no significant difference in functional outcomes between Bankart repair and the Bristow-Latarjet procedure for anterior shoulder dislocation. The choice between these methods depends largely on surgeon preference and technological accessibility. However, more comprehensive, high-quality studies are needed to better guide the selection between these procedures. Keywords: Anterior shoulder dislocation; Glenohumeral ligament; Bankart repair; Bristow-Latarjet procedure.

Complication rates and efficacy of single-injection vs. continuous interscalene nerve block: a prospective evaluation following arthroscopic primary rotator cuff repair without a concomitant open procedure

To compare the complications and efficacy of pain relief of the interscalene anesthetic block using either a single-injection (SI) vs. a continuous, indwelling catheter (CIC) for arthroscopic rotator cuff repair surgery. Patients undergoing primary, arthroscopic rotator cuff repair without concomitant open procedure or biceps tenodesis were prospectively enrolled by 4 fellowship-trained sports medicine and shoulder surgeons. Patients received either a SI or CIC preoperatively based on surgeon preference. Patients were contacted by phone to complete a standard questionnaire on postoperative days (PODs) 1, 3, 7, 14, and 28. Patients were asked to rate the efficacy of their subjective pain relief (scale of 0-10), document issues with the catheter, describe analgesic usage, and report pharmacological and medical complications. The primary outcome was measured as complication rate. Postoperative narcotic use, patient satisfaction, and visual analog scale pain scores were measured as secondary outcomes. Seventy patients were enrolled, 33 CIC patients (13 male, 20 female, mean age 61±8 years) and 37 SI patients (20 male, 17 female, mean age 59±10 years). There were significantly more injection/insertion site complications in the CIC group (48%) vs. the SI group (11%, P=.001). The incidence of motor weakness was higher in the CIC group on POD 1 (P=.034), but not at any subsequent time points. On POD 1, CIC patients had a clinically significantly lower pain score compared to SI (3.2 vs. 5.4; P=.020). Similar scores were observed at subsequent time points until POD 28, when CIC again had a lower pain score (0.8 vs. 2.7; P=.005). However, this did not reach clinical significance. All patients in both groups rated a satisfaction of 9 or 10 (scale 0-10) with the anesthesia provided by their nerve block. CIC interscalene nerve blocks had an increased risk for injection site complications and minor complications in the immediate postoperative period when using the CIC for arthroscopic rotator cuff repair without any concomitant open procedures. CIC blocks demonstrated clinically significant superior pain relief on POD 1 but were equal to SI blocks at every time point thereafter. Superior pain relief of CIC at POD 28 was not clinically significant. CIC catheters do not appear to markedly decrease the use of postoperative narcotics. Despite this trend in complication rates and pain scores, all patients in both groups were satisfied with their nerve block.

ATTUNE TOTAL KNEE REPLACEMENT: IS THERE EVIDENCE OF INCREASED TIBIAL COMPONENT LOOSENING? A RETROSPECTIVE ANALYSIS OF 10,202 KNEES

AbstractObjectiveUp to 20% of patients can remain dissatisfied following TKR. A proportion of TKRs will need early revision with aseptic loosening the most common. The ATTUNE TKR was introduced in 2011 as successor to its predicate design The PFC Sigma (DePuy Synthes, Warsaw, In). However, following reports of early failures of the tibial component there have been ongoing concerns of increased loosening rates with the ATTUNE TKR. In 2017 a redesigned tibial baseplate (S+) was introduced, which included cement pockets and an increased surface roughness to improve cement bonding. Given the concerns of early tibial loosening with the ATTUNE knee system, this study aimed to compare revision rates and those specific to aseptic loosening of the ATTUNE implant in comparison to an established predicate as well as other implant designs used in a high-volume arthroplasty centre.MethodsThe Attune TKR was introduced to our unit in December 2011. Prior to this we routinely used a predicate design with an excellent long-term track record (PFC Sigma) which remains in use. In addition, other designs were available and used as per surgeon preference. Using a prospectively maintained database, we identified 10,202 patients who underwent primary cemented TKR at our institution between 01/04/2003–31/03/2022 with a minimum of 1 year follow-up (Mean 8.4years, range 1–20years): 1) 2406 with ATTUNE TKR (of which 557 were S+) 2) 4652 with PFC TKR 3) 3154 with other cemented designs. All implants were cemented using high viscosity cement. The primary outcome measures were all-cause revision, revision for aseptic loosening, and revision for tibial loosening. Kaplan-Meier survival analysis and Cox regression models were used to compare the primary outcomes between groups. Matched cohorts were selected from the ATTUNE subsets (original and S+) and PFC groups using the nearest neighbor method for radiographic analysis. Radiographs were assessed to compare the presence of radiolucent lines in the Attune S+, standard Attune, and PFC implants.ResultsAt a mean of 8.4 years follow-up, 308 implants underwent revision equating to 3.58 revisions per 1000 implant-years. The lowest risk of revision was noted in the ATTUNE cohort with 2.98 per 1000-implant-years where the PFC and All Other Implant groups were 3.15 and 4.4 respectively. Aseptic loosing was the most common cause for revision across all cemented implants with 76% (65/88) of involving loosening of the tibia. Survival analysis comparing the ATTUNE cohort to the PFC and All Other Cemented Implant cohorts showed no significant differences for: all-cause revision, aseptic loosening, or tibial loosening (p=0.15,0.77,0.47). Radiolucent lines were detected in 4.6%, 5.8%, and 5.0% of the ATTUNE S+, standard ATTUNE, and PFC groups respectively. These differences were not significant.ConclusionThis study represents the largest non-registry review of the original and S+ ATTUNE TKR in comparison to its predicate design as well as other cemented implants. There appears to be no significant increased revision rate for all-cause revision or aseptic loosening. Radiographic analysis also showed no significant difference in peri-implant radiolucency. It appears that concerns of early loosening may be unfounded.Declaration of Interest(a) fully declare any financial or other potential conflict of interest

Perioperative Cerebrospinal Fluid Drain Placement Does Not Increase Venous Thromboembolism Risk After Thoracic and Fenestrated Endovascular Aortic Repair

Venous thromboembolism (VTE) incidence after thoracic and fenestrated endovascular aortic repair (TEVAR/FEVAR) is high (up to 6-7%) relative to other vascular procedures; however, the etiology for this discrepancy remains unknown. Notably, patients undergoing TEVAR/FEVAR commonly receive cerebrospinal fluid drains (CSFDs) for neuroprotection, requiring interruption of perioperative anticoagulation and prolonged immobility. We hypothesized that CSFDs are a risk factor for VTE after TEVAR/FEVAR. Consecutive TEVAR/FEVAR patients at a single center were reviewed (2011-2020). CSFDs were placed based on surgeon preference preoperatively or for spinal cord ischemia (SCI) rescue therapy postoperatively. The primary end-point was VTE occurrence, defined as any new deep venous thrombosis (DVT) or pulmonary embolism (PE) confirmed on imaging within 30-days postoperatively. Routine postoperative VTE screening was not performed. Patients with and without VTE, and subjects with and without CSFDs were compared. Logistic regression was used to explore associations between VTE incidence and CSFD exposure. 897 patients underwent TEVAR/FEVAR and 43% (n=387) received a CSFD at some point during their care (preoperative: 94%[n=365/387]; post-operative SCI rescue therapy: 6%[n=22/387]). CSFD patients were more likely to have previous aortic surgery (44% vs. 37%; p=.028) and received more postoperative blood products (780 vs. 405mL; p=.005). The overall VTE incidence was 2.2% (n=20). 70% (14) patients with VTE had DVT, 50% (10) had PE, and 20% (4) had DVT and PE. Among TEVAR/FEVAR patients with VTE, 65% (n=13) were symptomatic. Most VTEs (90%, n=18) were identified in-hospital and the median time to diagnosis was 12.5 (IQR 7.5-18) days postoperatively. Patients with VTE were more likely to have non-elective surgery (95% vs. 41%; p<.001), had higher ASA classification (4.1 vs. 3.7; p<.001), required longer ICU admission (24 vs. 12-days; p<.001), and received more blood products (1386 vs. 559mL; p<.001). VTE incidence was 1.8% in CSFD patients compared to 3.5% in non-CSFD patients (OR 0.70 [95% CI 0.28-1.78, p = .300). However, patients receiving CSFDs postoperatively for SCI rescue therapy had significantly greater VTE incidence (9.1% vs. 1.1%; p=.044). CSFD placement was not associated with an increased risk of VTE in patients undergoing TEVAR/FEVAR. VTE risk was greater in patients undergoing nonelective surgery and those with complicated perioperative courses. VTE risk was greater in patients receiving therapeutic CSFDs compared to prophylactic CSFDs, highlighting the importance of careful patient selection for prophylactic CSFD placement.

Surgical Strategy for Sternal Closure in Patients with Surgical Myocardial Revascularization Using Mammary Arteries.

Coronary artery bypass grafting has evolved from all venous grafts to bilateral mammary artery (BIMA) grafting. This was possible due to the long-term patency of the left and right internal mammary demonstrated in angiography studies compared to venous grafts. However, despite higher survival rates when using bilateral mammary arteries, multiple studies report a higher rate of surgical site infections, most notably deep sternal wound infections, a so-called "never event". We designed a prospective study between 1 January 2022 and 31 December 2022 and included all patients proposed for total arterial myocardial revascularization in order to investigate the rate of surgical site infections (SSI). Chest closure in all patients was performed using a three-step protocol. The first step refers to sternal closure. If the patient's BMI is below 35 kg/m2, sternal closure is achieved using the "butterfly" technique with standard steel wires. If the patient's BMI exceeds 35 kg/m2, we use nitinol clips or hybrid wire cable ties according to the surgeon's preference for sternal closure. The main advantages of these systems are a larger implant-to-bone contact with a reduced risk of bone fracture. The second step refers to presternal fat closure with two resorbable monofilament sutures in a way that the edges of the skin perfectly align at the end. The third step is skin closure combined with negative pressure wound therapy. This system was applied to 217 patients. A total of 197 patients had bilateral mammary artery grafts. We report only 13 (5.9%) superficial SSI and only one (0.46%) deep SSI. The preoperative risk of major wound infection was 3.9 +/- 2.7. Bilateral mammary artery grafting was not associated with surgical site infection in a univariate analysis. We believe this strategy of sternal wound closure can reduce the incidence of deep surgical site infection when two mammary arteries are used in coronary artery bypass surgery.

SURG-29. APPROACH SELECTION FOR COMPLEX, MULTI-COMPARTMENTAL PETROCLIVAL MENINGIOMAS: A SYSTEMATIC REVIEW OF ENDOSCOPIC AND TRANSCRANIAL APPROACHES TO AN EXCEEDINGLY DIFFICULT CLASS OF SKULL BASE LESIONS

Abstract INTRODUCTION Petroclival meningiomas are among the most formidable and technically challenging tumors in skull base surgery owing to their deep-seated location and proximity to critical neurovascular structures. Herein, we seek to understand why skull base surgeons preoperatively plan the staged excision of petroclival meningiomas. METHODS Three databases were queried per PRISMA to identify studies describing the indications for staging surgical resection of petroclival meningiomas. RESULTS Fourteen studies describing 187 patients (59.3% female, age range: 5 – 81 years) met inclusion criteria. The most common presenting symptom at diagnosis was headache (24.6%). Other common symptoms included cerebellar signs (16.0%) and gait disturbances (13.4%). Petroclival meningiomas were most commonly observed extending to the cavernous sinus (52.88%) and meckel’s cave (49.04%). With respect to critical neurovasculature, the trigeminal nerve was involved in a majority (54.59%) of petroclival meningiomas, while other relevant cranial nerves with tumor involvement included the facial (16.22%) and vestibulococcular (12.43%). Additionally, the most commonly involve vascular structures were the basilar (2.16%) superior cerebellar arteries (1.62%). Of the 187 patients who underwent surgical resection of petroclival meningioma, 144 (77%) underwent surgery involving a single stage, while 43 (23%) underwent surgery in which a two-stage approach was used. The most common single-stage approaches were the retrosigmoid (n = 35) and transpetrosal (n = 22), while the most common approaches employed in a multi-stage fashion were the subtemporal (n = 6), pterional (n = 5), and suboccipital (n = 4) approaches. To clarify, these approaches were each performed as one half of a two-stage surgery involving a second, separate approach. CONCLUSION Common approaches used in multi-stage procedures included the retrosigmoid, anterior petrosectomy, posterior petrosectomy, orbitozygomatic, translabrynthine, and various combinations thereof. Indications for performing surgery in this manner include coexistence of lesion in both middle and posterior skull base compartments, absence of meaningful hearing function, tumor size, and surgeon preference.