Time Of Index Surgery Research Articles

Incidence, Risk Factors, and Functional Outcomes of Symptomatic Postoperative Spinal Epidural Hematoma: Case-Control Study.

Symptomatic postoperative spinal epidural hematomas (PEDHs) are rare complications with significant implications on patients' functional outcomes. Strategies for PEDH prevention are poorly understood. This study sought to evaluate preoperative and intraoperative variables predicting the risk of PEDH, and patients' functional outcomes after PEDH evacuation. This is a single institution study of all PEDH cases requiring a reoperation and matched controls over six year period. The incidence of PEDH was calculated by region and operative technique. The preoperative and intraoperative parameters of 40 cases and 40 matched controls were compared. 5,941 spine surgeries and 40 symptomatic PEDH cases requiring reoperation were identified (0.67% overall incidence). The highest incidence of PEDH was observed after minimally invasive lumbar laminectomimes. Higher preoperative diastolic blood pressure was a risk factor for PEDH. Of the 17 PEDH cases that had a drain placed at the time of index surgery, 8 patients (47%) still had the drain in place at the time of diagnosis of PEDH. Among the posterior index approaches, 18 cases (51.43%), one cervicothoracic and seventeen lumbar, did not develop paresis at the time of PEDH diagnosis. 17 cases (48.57%), nine cervicothoracic and eight lumbar, developed paresis. Ten of the patients with paresis had complete resolution of motor weakness, while seven never achieved complete resolution. While the incidence of PEDH was below one percent, nearly half of the patients developed motor weakness as a presenting symptom and a third of the patients never had resolution of the weakness.

Impact of postsurgical vaginal microbiome on high-risk HPV infection and recurrence risk in patients with cervical cancer and intraepithelial neoplasia: A retrospective study

PurposeThis study aimed to determine the effect of postsurgical vaginal microbiome (VM) on high-risk human papillomavirus (hrHPV) infection and the risk of disease recurrence in patients surgically treated for cervical cancer (CC) or intraepithelial neoplasia (CIN). Methods207 women who underwent surgical treatment for CC or CIN at the Department of Gynecologic Oncology of the First Affiliated Hospital of University of Science and Technology of China from November 2016 to October 2023 were included. The patients’ clinical data, including age, surgical modality, and diagnosis at time of index surgery, were collected retrospectively and analyzed. Associations between postsurgical VM indices, hrHPV infection, cervical cytology, and recurrence were also evaluated. ResultsPatient age, surgical modality (whether complete excision of the cervix was performed), and diagnosis at time of index surgery (cervical dysplasia vs. cervical carcinoma) showed no significant association with postsurgical hrHPV infection, cervical cytology, or disease recurrence. However, postsurgical VM imbalance was significantly associated with hrHPV infection status (OR = 4.640, 95 % CI = 2.085–10.460, P < 0.001), abnormal cervical cytology (OR = 3.994, 95 % CI = 1.154–13.826, P = 0.020), and disease recurrence (OR = 3.789, 95 % CI = 1.091–13.154, P = 0.026). Among the specific VM indices, a vaginal pH above 4.5 (OR = 4.570, 95 % CI = 1.640–12.690, P = 0.002), a lactobacilli proportion below 50 % (OR = 3.938, 95 % CI = 1.299–11.934, P = 0.010), and the presence of aerobic vaginitis (AV, OR = 2.425, 95 % CI = 0.996–5.901, P = 0.046) were risk factors for postsurgical recurrence. ConclusionPostsurgical VM imbalance, especially abnormal indices, such as a pH above 4.5, a lactobacilli proportion below 50 %, and the presence of AV, was associated with an increased risk of postsurgical recurrence in patients who underwent surgical treatment for CIN and CC. Monitoring and potentially intervening in the VM may improve the prognosis of these patients.

Preoperative CT findings predict the development of metachronous contralateral inguinal hernia after unilateral inguinal hernia repair: a single-center retrospective cohort study.

To identify potential clinical and preoperative CT risk factors that can predict the development of metachronous contralateral inguinal hernia (MCIH) after unilateral inguinal hernia repair (IHR). This study included unilateral inguinal hernia patients seen from 2016 to 2019 who underwent CT and subsequent IHR and had at least five years of follow-up. Preoperative CT scans were retrospectively reviewed for the presence of asymmetric spermatic cord fat and weakness of the transversalis fascia. The correlations of each CT feature and other clinical characteristics with the development of MCIH were calculated. The Kaplan-Meier model and multiple logistic regression were used to evaluate the associations among CT features, clinical variables and MCIH. A total of 677 male patients aged > 40 years were included in the study cohort. After more than 5 years of follow-up, 162 patients developed MCIH, representing an incidence of 23.9%. Patients with radical prostatectomy or peritoneal dialysis [P < 0.0001, HR 4.189 (95% CI 2.369 to 7.406)], primary left-sided IHR [P = 0.0032, HR 1.626 (95% CI 1.177 to 2.244)], and direct, femoral or pantaloon hernias were predisposed to MCIH. Asymmetric spermatic cord fat [P = 0.0002, HR 1.203 (95% CI 0.8785 to 1.648)] and weakness of the transversalis fascia [P < 0.0001, HR 7.914 (95% CI 5.666 to 11.05)] on preoperative CT were also identified as risk facts and demonstrated to be independent predictive factors for MCIH development. Asymmetric spermatic cord fat and weakness of the transversalis fascia were predictive factors for MCIH development. For decision making regarding prophylactic contralateral IHR at the time of index surgery, preoperative CT findings as well as clinical characteristics should be considered.

Clinical characteristics and long-term outcome of patients with bioprosthetic mitral valve- Experience from a South Asian country.

Due to rheumatic heart disease, young people are more likely to develop valvular heart disease in developing countries. In countries like Pakistan, surgeons implant more bioprosthetic mitral valves (MVs) in younger patients. However, bioprosthetic valves degenerate rapidly in younger people, leading to bioprosthetic MV dysfunction (BMVD). This study aims to evaluate the clinical characteristics and long-term outcomes of patients with bioprosthetic MV replacement (MVR) at a tertiary care hospital in a South Asian country. This is a retrospective observational study, conducted at a tertiary care hospital. We included a total of 502 patients who underwent bioprosthetic MVR from the year 2006 to 2020. Clinical and surgical characteristics along with transthoracic echocardiographic findings (pre-surgery and recent most follow-up studies) were noted. Follow-up data were also collected. Out of 502 patients, 322 (64%) were female, mean age at the time of surgery was 49.42 ± 14.56 years. Mitral regurgitation was more common, found in 279 (55.6%) patients followed by mitral stenosis in 188 (37.5%) patients. MVR was done as an elective procedure due to the New York Heart Association (NYHA) II to IV symptoms at the time of surgery in 446 (88.8%) patients. In the mean follow-up of 6.59 ± 2.99 years, BMVD was observed in 183 (36.5%) patients. However, re-do MV surgery was done in only 49 (9.8%) patients. Patients were divided into two groups based on normal functioning bioprosthetic MV and BMVD. Comparing the two groups, individuals with normal functioning bioprosthetic MV had a mean age of 51.6 ± 14.27 years, while those with BMVD had a mean age of 45.639 ± 14.33 years at the time of index surgery (P = 0.000). There were more long-term complications including heart failure (n = 16, 8.74%), atrial fibrillation (n = 11, 6.01%), and death (n = 6, 3.28%) in the BMVD group which were statistically significant. This study is distinct because it demonstrates the outcomes of bioprosthetic valve replacement in a relatively younger South Asian population. Due to rapid degeneration of bioprosthetic valve in younger patients, significant number of patients developed BMVD along with poor long-term clinical outcomes, even at a short follow-up period of <10 years. These findings are similar to international data and signify that mechanical MVR may be a more reasonable alternative in younger patients.

Poster 339: Outcomes of Anterior Cruciate Ligament Reconstruction in Competitive Ice Hockey Players: Outcomes, Reoperations, and Return to Play at 7 Years Mean Follow-Up

Objectives: Ice hockey is a physically demanding sport, with young athletes prone to anterior cruciate ligament (ACL) injuries. Currently, there is a paucity of data examining the results of ACL reconstruction (ACLR) in competitive hockey players. The purpose of this study was to assess return to hockey (RTH) and reoperation rates following ACLR for ACL injuries in a cohort of competitive hockey players. Methods: All competitive ice hockey players (including, youth, high school, juniors, collegiate, or professional) with a history of ACL injury and subsequent ACLR at a single academic institution between 2000 and 2022 were identified. Exclusion criteria included ACL injuries that did not occur during hockey, history of ACLR prior to hockey injury, and recreational hockey players. Graft failure was defined as a retear (as determined via clinical or advanced imaging evaluation) and/or revision ACLR. Results: Ultimately, 50 knees in 44 hockey players were included at a mean (± standard deviation) follow-up time of 7.0 years ± 5.4 years (Table 1). The mean age at the time of index surgery was 18.9 years ± 3.0 years, with 38 males (76%), and the distribution of bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts was 40 (80%) and 10 (20%), respectively. RTH occurred in 66% of hockey players at a mean of 10.2 months ± 6.2 months. Graft failure occurred in 9 knees (18%) at a mean of 5.9 years ± 5.8 years after the index ACLR. All patients who sustained a retear underwent reoperation. Kaplan-Meier survivorship free from surgical failure of the entire cohort was 94% at 1 year, 88% at 5 years, 74% at 10 years, and 67% at 15 years (Figure 1A). BPTB autograft demonstrated a lower failure rate compared with HT autograft (13% vs 40%; P = 0.041) and was associated with better survival compared with HT autograft up to 15 years after the index ACLR (80% vs 39%; P = 0.047; Figure 1B). Conclusions: ACL injury remains a concern for competitive hockey players after ACLR. Return to competitive ice hockey was observed in 66% of athletes after ACLR, with 18% of hockey players experiencing graft failure and undergoing subsequent reoperation. BPTB autograft was associated with better survival than HT autograft.

Evaluating Surgical Outcomes Between Estrogen Receptor Positive Invasive Lobular and Invasive Ductal Carcinoma of the Breast—A Propensity Matched Analysis

IntroductionInvasive lobular carcinoma (ILC) contributes significantly to the global cancer burden and is the most common of the histological “special types” of breast cancer. ILC has unique features setting it apart from the more common invasive ductal carcinoma (IDC). Despite differences, treatment algorithms do not consider histological differences. AimTo determine the differences in treatment and outcomes of ILC relative to IDC in a strict case-matched cohort study at a tertiary referral, specialist, breast cancer center. MethodsAll Estrogen receptor positive (ER+) ILCs from 1999 to 2015 were matched for; age, tumor size, grade, PR/HER2 status, nodal stage and metastases with ER+ IDCs from the same period. Surgical and systemic treatments were assessed along with overall (OS) and disease-free survival (DFS). Results762 cases in total were analyzed (1:1 matching; ILC:IDC). ILC cases were more often treated with mastectomy (37.5% vs. 28.6%, P .009) and those who received breast conserving surgery (BCS) more often had an incomplete resection (30.2% vs. 19.6%, P .01). IDC were more often treated with NACT (5.5% vs. 14.4%, P < .001). Mean DFS were similar between ILC and IDC; 148.3 vs. 141.4 months (P .112) but OS was significantly longer in the ILC group; 165.7 vs. 134 months (P .002). This trend was consistent among the subset of patients undergoing BCS. For ILC undergoing BCS, mean DFS was 129.8 vs. 128.3 months for IDC (P .418) and OS was 155.4 and 110.7 months respectively (P < .001). Incomplete resection at the time of index surgery did not alter the disease free or overall survival in either the ILC or IDC patients to a level that reached statistical significance. ConclusionIn this cohort study, the strict matching of ILC and IDCs for a number of prognostic indicators, demonstrates the impact of lobular histology with a clarity not previously observed. ILCs have comparable survival outcomes to patients with IDC but at the expense of more extensive index and revisional surgery. There is a need for awareness of these facts among surgeons and patients for optimal treatment prioritization and provision.

Clinical Characteristics and Long-Term Outcome of Patients with Bio-Prosthetic Mitral Valve – Experience From a South Asian Country

Objectives: The aim of this study is to evaluate clinical characteristics and long-term outcome of the patients with bio-prosthetic mitral valve replacement at a tertiary care hospital of a South Asian country.&#x0D; Methodology: The study is a retrospective observational observational study involving patients who underwent bio-prosthetic mitral valve replacement at a tertiary care hospital in Karachi, Pakistan, between 2006 and 2020, and had at least two complete echocardiograms. Patients with incomplete clinical data, no electronic reports of echocardiograms, and mechanical mitral valve replacement were excluded.&#x0D; Results: This is a retrospective observational study, conducted at a tertiary care hospital. We included a total of 502 patients who underwent bio-prosthetic mitral valve replacement from the year 2006 to 2020. Patients were divided into two groups based on normal functioning bio-prosthetic mitral valve and bio-prosthetic mitral valve dysfunction (BMVD). Out of 502 patients, 322 (64%) were female, mean age at the time of surgery was 49.42 ± 14.56 years. Mitral regurgitation was more common, found in 279 (55.6%) patients followed by mitral stenosis in 188 (37.5%) patients. Mitral valve replacement was done as an elective procedure due to NYHA II to IV symptoms at the time of surgery in 446 (88.8%) patients. In the mean follow-up of 6.59 + 2.99 years, bio-prosthetic mitral valve dysfunction (BMVD) was observed in 183 (36.5%) patients. However, re-do mitral valve surgery was done in only 49 (9.8%) patients. Comparing the two groups, individuals with normal functioning bio-prosthetic mitral valve had a mean age of 51.6 + 14.27 years, while those with BMVD had a mean age of 45.639 + 14.33 years at the time of index surgery (p value=0.000). There were more long-term complications including heart failure (n = 16, 8.74%), atrial fibrillation (n = 11, 6.01%) and death (n = 6, 3.28%) in BMVD group which were statistically significant.&#x0D; Conclusion: This study is distinct because it demonstrates the outcomes of bio-prosthetic valve replacement in a relatively younger South Asian population. Due to rapid degeneration of bio-prosthetic valve in younger patients, a significant number of cases developed BMVD along with poor long-term clinical outcomes even at a short follow up period of less than ten years. These findings are like international data and signify that mechanical mitral valve replacement may be a more reasonable alternative in younger patients.

Use of locked plates and mono-rail fixator in segmental tibial defects: A prospective interventional study

IntroductionThe management of gap non-union is a major challenge to both the clinician and the patient as it is technically difficult, time-intensive, and physically arduous for the patient along with an unpredictable result. Gap non-union can arise from extrusion of bony fragment at the time of trauma or after debridement of unhealthy bone later. Moreover, Tibia because of its subcutaneous anatomy can easily undergo bone-loss and segmental defect. Among various methods available for managing gap non-union of tibia distraction osteogenesis using either ilizarov fixator or mono-rail fixator is the most popular one. Here we present functional and bony outcomes of combined use of locking plate and Limb Reconstruction System (LRS) in tibial gap non-union and assess whether it decreases fixator time and related complications. Patients and methodsA prospective intervention study constituting 10 patients with Paley's type B1 tibial gap non-union over a period of 22months. In first stage, debridement was done; tibial locking plate and mono-rail fixator were applied along with corticomy at proximal tibia. Distraction was started 7–14 days later. At the end of distraction phase, fixator was removed and transported segment was fixed with screws with or without bone grafting at docking site. Patients were followed up every 6 weeks for radiological and clinical assessment. Functional assessment using Application for the Study and Application of the Method of Ilizarov (ASAMI) functional score, and Musculoskeletal Tumour Society (MSTS) functional score while bone outcome was assessed with ASAMI bone score. Quality of regenerate was assessed by Fernandez-Esteve grading. Detailed scoring was done at the time of index surgery, at the time of LRS removal and at the time of consolidation phase. ResultsAll the 10 patients were male with mean age of 33 years. The mean defect size was 4.94 cm after debridement. Minimum duration of follow up was 30 weeks after removal of LRS. Mean duration between trauma and inclusion in the study was 17.7 months. The median external fixator index was 15.63 days/cm. The complication rate was 1.3/patient. According to Paley's classification, there were eleven problems and two obstacles, and no true complications. Both ASAMI bone score and functional scores were excellent in three and good in six patients. The median MSTS composite score was 76.66%. ConclusionThe integrated fixation is an effective and satisfactory method enabling early external fixator removal with low rate of complication. So, this technique can be recommended for the management of segmental tibial defects. Level of evidenceII.

Does the Sleeper Plate Application for Temporary Epiphysiodesis Make Life Easier or Complicated? Increased Risk of Tethering.

The present study aims to investigate the frequency of recurrence and tethering effect after only metaphyseal screw removal (sleeper plate technique) compared with the conventional complete plate removal in the treatment of lower extremity deformities with guided growth surgery. Seventy-two patients (107 limbs) treated by an 8-plate hemiepiphysiodesis technique around the knee joint were evaluated. After the desired correction, only metaphyseal screw was removed (sleeper plate group) in 35 limbs (25 patients), whereas both screws and plate were removed (plate removal group) in 72 limbs (47 patients). An increase of 5 degrees or more in joint orientation angles in the direction of the initial deformity was considered as recurrence. The rate of rebound, tethering, and maintenance of correction in groups was analyzed at the latest follow-up (mean of 49mo). The mean age of the patients was 97 months (range: 80 to 129mo) at the time of index surgery. After a mean of 49 months (range: 16 to 86), 17 (48.5%) limbs maintained the desired stable correction in the sleeper plate group compared with 59 stable limbs (72.2%) in the plate removal group ( P <0.001). There was no statistically significant difference regarding recurrence between the sleeper plate group and the plate removal group (34.3% vs. 27.8%, respectively) ( P =0.216). Reinsertion of the metaphyseal screw was possible 8/12 limbs, and the remaining 4 limbs underwent further surgeries. There were 6 limbs (17.3%) of tethering in the sleeper plate group, and 4/6 limbs required further corrective surgeries. The remaining 2 limbs with slight tethering did not require further surgeries. Removing only metaphyseal screw increases the risk of tethering. In addition, reinsertion of the screw may not be possible in all cases due to bony growth, and further corrective surgeries may be necessary. Close follow-up is required if the sleeper plate technique is to be applied. Level III.

Blade Plate With Autogenous Bone Grafting to Salvage Peri Ankle Nonunions.

Salvage surgery for a nonunion around the ankle is challenging. Poor bone stock, stiffness, scarring, previous (or persistent) infection, and a compromised soft tissue envelope are common in these patients. We describe 15 cases that underwent blade plate fixation as salvage for a nonunion around the ankle, including patient/nonunion characteristics, Nonunion Scoring System (NUSS), surgical technique, healing rate, complications, and long-term follow-up with 2 patient-reported outcome measures. This is a retrospective case series from a level 1 trauma referral center. We included all patients that underwent blade plate fixation for a long-standing nonunion of the distal tibia, talus, or failed subtalar fusion. All patients had autogenous bone grafting, including 14 with posterior iliac crest grafts and 2 with femoral reamer irrigator aspirator grafting. Median follow-up was 24.4 months (interquartile range [IQR], 7.7-40). Main outcome measures were (time to) union, and functional outcomes using the 36-item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), and the Foot and Ankle Outcome Score (FAOS). We included 15 adults with a median age of 58 years (IQR, 54-62). The median NUSS score at the time of index surgery was 46 (IQR, 34-54). Union was achieved after the index procedure in 11 of 15 patients. Additional surgery was performed in 4 of 15 patients. Union was achieved in all patients at a median of 4.2 months (IQR, 2.9-11). The median score for the PCS was 38 (IQR, 34-48, range 17-58, P = .009), for the MCS 52 (IQR, 45-60, range 33-62, P = .701), and for the FAOS 73 (IQR, 48-83). In this series, our use of blade plate fixation with autogenous grafting was an effective method for managing a nonunion around the ankle allowing for alignment correction, stable compression and fixation, union, and fair patient-reported outcome scores. Level IV, therapeutic.

P344 Diverting ileostomy in Inflammatory Bowel Disease's surgery: the real clinical cost analysis

Abstract Background A loop ileostomy does not prevent an anastomotic leak and it is not risk-free, but it can decrease the clinical impact of dehiscence. Inflammatory bowel disease condition is more complex than other benign situations candidated to colorectal surgery. The aim of our study was to assess the risk of complications related to the stoma presence and to identificate variables related with complications in a series of IBD’s patients undergoing various colorectal surgeries along with primary diverting stoma. Methods We conducted a retrospective study of patients who underwent sphincter-preserving elective surgery for IBD between January 2014 to December 2020 at IRCCS Sacro Cuore Don Calabria Hospital. Data were collected regarding baseline demographics, operative techniques and complications. Ileostomy-related complications were separated into three categories: complications related to stoma creation at the time of index surgery within 30 days; complications of having an ileostomy; complications of ileostomy closure. Results Fifty-six diverting loop ileostomies were performed and included in our study (table 1). Seventeen patients (30%) at index procedures had the following complications: 5 had anastomotic leak or pelvic abscess (8.9%), 3 had bowel obstruction (5.4%) and 7 (12.5%) bleeding requiring transfusion. Two patients had complications related to ileostomy creation: 1 had prolapse (1.8%) and 1 rotation with obstruction (1.8%). Seven patients (12.5%) required reoperation. Seven patients (12.5%) were readmitted within 30 days after index surgery for dehydratation. Twenty-four patients (42.1%) suffered during the same time from ileostomy management’s problems. Eighteen patients (32.1%) at stoma closure had the following complications: 6 had anastomotic leak or pelvic abscess (10.7%), 7 had SSI (12.5%), 5 had bowel obstruction (8.9%) and 2 bleeding requiring transfusions (3.6%). Nine patients (16%) required reoperation. At univariate analysis complications of ileostomy status are more frequent in male (p=0.01) and in patients who had ileostomy creation complications (p=0.04). Ileostomy closure complications are more common in male patients (p=0.005). Complications at the time of ileostomy creation were found at multivariate analysis statistically related to complications during ileostomy maintenance. Conclusion Ileostomy alone cannot mitigate the overall high rate of complications expected in IBD’s patients, also in consideration of potential problems stoma it-self related. Even if our study is retrospective and presents a small court, when resection is necessary despite patient's conditions we propose to resect without anastomosis at the time of index procedure and restore the bowel continuity only after patient's status optimization.

Maintenance of curve correction and unplanned return to the operating room with magnetically controlled growing rods: a cohort of 24 patients with follow-up between 2 and 7 years.

Early onset scoliosis (EOS) is defined as spinal curvature affecting children below 10years of age. Non-operative treatment can consist of casting and bracing. When curvature progresses despite these treatments, operative intervention is indicated. Traditional growing rods (TGR) have been a mainstay of treatment. Unfortunately, TGR's require planned return to the operating room every 6-9months. Magnetic controlled growing rods (MCGR) ideally provide curve correction and allow the spine to grow without frequent surgeries. However, the ability to correct and maintain correction after MCGR has not been well-characterized. The purpose of this study is to evaluate maintenance of curve correction in patients treated primarily with MCGR and analyze the rate of complications including unplanned return to the operating room (UPROR). 24 patients with EOS were retrospectively reviewed. These patients were subdivided into 4 subcategories: congenital, idiopathic, neuromuscular (NMS), and syndromic. The major curve correction (%) and T1-S1 distance were assessed utilizing scoliosis plain film radiographs over time. Complications and return to the operating room for any reason were recorded. Patients were followed until conversion to posterior spinal fusion (PSF) or most recent lengthening of MCGR. There were 11 male and 13 female patients averaging 8 years at the time of index surgery. The average preoperative curve angle was 61.1°. Initial curve correction with MCGR obtained at the index procedure was 46.2%, reducing the mean curve angle to 32.7° (p < 0.05). Curve correction at a mean 6.2years (2.4-7.4) follow-up was 36.1°, 40.9% curve correction. 75% of patients underwent conversion to PSF during the study period 4.8years (2.4-7.0) after initial MCGR surgery. 15% of patients were still undergoing MCGR lengthening after 6.1years. 54.2% of patients had at least one UPROR. For patients with EOS with curve progression, MCGRs can maintain curve correction well after 2years. Furthermore, MCGR allowed patients to grow over time to safely delay timing to definitive fusion. On average, patients underwent conversion to PSF after 4.7years at an average age of 13.5. Although the complication rate in the first 2years is relatively low, 54.2% of patients underwent an UPROR. As the use of MCGR increases, surgeons should be aware of possible complications associated with this technology and counsel patients accordingly. Further research is needed to continue to evaluate the efficacy and safety of MCGR in this challenging patient population.

Retrospective Review of Multilevel Anterior Cervical Discectomy and Fusion without Posterior Instrumentation

<h3>Research Objectives</h3> To report on clinical outcomes, reoperation rates and rates of return to operating room. <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Single center, ambulatory care center. <h3>Participants</h3> 109 subjects who underwent four or more level anterior cervical discectomy and fusion without posterior instrumentation. <h3>Interventions</h3> Subjects ages 18-88 who underwent multilevel (four or more level) anterior cervical discectomy and fusion without posterior instrumentation at time of index surgery between May 2016 and December 2019 were retrospectively reviewed. 104 patients who underwent 4-level fusion and 5 patients who underwent 5-level fusion were included in this study. Revision rates were analyzed. Preoperative and postoperative lordosis measured. Preoperative and postoperative pain scores compared. <h3>Main Outcome Measures</h3> Return to the operating room, preoperative vs. postoperative cervical lordosis, patient reported outcomes. <h3>Results</h3> Of the 104 patients included in this review 3 patients (2.75%) returned to surgery within 6 months. One patient returned for cervical posterior spinal interbody fusion, one patient returned for anterior plate hardware removal, and one patient returned for wound irrigation & debridement. <h3>Conclusions</h3> Our study shows multi-Level Anterior Cervical Discectomy and Fusion without Posterior Instrumentation to have great clinical outcomes in restoring lordosis and have low reoperation rates. <h3>Author(s) Disclosures</h3> None.

Surgical Repair and Augmentation of a Large Type-2 Re-tear of the Rotator Cuff with a Novel Biocomposite Scaffold: A Case Report

Case A 55-year-old female presented with pain and weakness in her right shoulder after a new traumatic event occurred. She had undergone a rotator cuff repair to this right shoulder 4 months earlier with dermal strip augmentation secondary to poor tissue quality at the time of index surgery. For historical context, her contralateral shoulder had undergone a previous primary rotator cuff repair with xenograft, which failed, and was ultimately revised to a full thickness repair 2 years prior. A repeat MRI demonstrated a recurrent large type-II rotator cuff tear with grade 3 Goutallier fatty infiltration. A novel biocomposite scaffold (BioBrace™) was used to augment a revision double row bridge repair with margin convergence. MRI at three and eight months after surgery suggested functional remodeling and growth of new tissue. At 10 months, arthroscopy was performed to evaluate bicipital pain and arthroscopic images demonstrated full incorporation of the biocomposite scaffold within the underlying native tendon and an intact repair. The source of bicipital pain was unrelated to the implant and a biceps tenodesis was performed to resolve the pain. Clinical outcomes were assessed preoperatively and at 1 year postoperatively using the Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, and Single Assessment Numeric Evaluation (SANE). Conclusion The use of a novel biocomposite scaffold augmentation for revision rotator cuff repair demonstrated evidence of healing, incorporation, and remodeling at 10 months post-procedure. VAS, ASES, and SANE pre- and post-operative outcome scores were analyzed at 1 year demonstrating significant improvement across all metrics. This case report suggests the use of a novel biocomposite rotator cuff augment can provide a via option for revision rotator cuff repair.

Early Revisions, Reoperation, and Survivorship of the Exactech Vantage Fixed-Bearing Total Ankle Arthroplasty Implant

Category: Ankle Arthritis; Ankle Introduction/Purpose: In the last decade, there has been a rapid increase in the number of total ankle arthroplasties (TAA) performed annually. In addition, multiple novel TAA implants have been introduced onto the market. The Exactech Vantage TAA is a fixed-bearing implant that has been in use since 2016. The tibial component is low-profile with vertically oriented pegs and a cage, while the talus is curved with an anterior flange to prevent subsidence. This study sought to describe the early experience with the Vantage TAA, including reoperation, revision, and radiographic outcomes. Methods: This is a single-center retrospective review of patients who underwent primary TAA using the Vantage Total Ankle (Exactech, Gainesville, FL). Concomitant procedures at the time of index surgery were recorded. Five surgeons contributed patients. Demographics, clinical and operative data, postoperative complications, reoperations, and revisions were collected. Revisions and reoperations were classified by standardized criteria. Radiographs were reviewed by a fellowship-trained foot and ankle surgeon to assess for alignment and peri-implant complications. There were 190 patients included in the study who were all minimum 2 years post-TAR, with mean clinical follow-up of 1.8 years (range: 1-48 months), and mean age 63.3 +- 9.4 years. Ankle arthritis etiologies were 45% post-traumatic (fracture history), 33% instability, 12% primary osteoarthritis, 5% flatfoot, 2% inflammatory arthritis, and 4% other. Thirteen patients (7%) had hindfoot fusion performed previously or at the time of index surgery. Concomitant procedures are shown in Table. Results: Overall implant survivorship was 95.3%. There were 5 intraoperative complications: 4 anterolateral tibial fractures and 1 medial malleolar fracture, all treated with internal fixation at the time of surgery with no further complications. Nine patients (4.8%) underwent revision: 7/9 for tibial loosening, 1 for talar loosening, and 1 for periprosthetic joint infection. Eleven patients (5.8%) underwent reoperation: open gutter debridement (5); irrigation and debridement for superficial infection (4); and bone grafting for cysts (2). Radiographically, preoperative coronal alignment was mean 10.1°, with 87 (49%) ankles with &gt;10° deformity. Three patients had tibial component subsidence that was stable, 3 had stable radiolucency around the tibial component, and 1 had valgus failure through the ankle joint. Nineteen had asymptomatic peri-implant cysts; 16/19 were at the tibia. Conclusion: Short-term results of the Vantage TAA implant demonstrate survivorship of 95.3% at 2 years, which is comparable to similar studies of low-profile, non-stemmed implants. Asymptomatic radiographic complications were primarily cystic changes at the tibial component. Revisions occurred primarily due to loosening of the tibial component. Additional follow-up and multi- institutional support are warranted to further quantify survivorship and risk factors.

Anterior Vertebral Body Tethering for Scoliosis Patients With and Without Skeletal Growth Remaining: A Retrospective Review With Minimum 2-Year Follow-Up.

Anterior vertebral body tethering (AVBT) has been approved for skeletally immature (IM) adolescent idiopathic scoliosis patients, but the role of AVBT in patients with minimal remaining skeletal growth is controversial. The purpose of this study was to compare minimum 2-year (YR2) outcomes in skeletally IM patients vs those with minimal remaining skeletal growth. Patients with single thoracic AVBT were grouped by their preoperative (PR) skeletal maturity: IM (n = 16, Risser 0-2) vs mature (M, n = 19, Risser 3-5). Outcomes were assessed at PR, first erect (FE), and YR2. Median (range) was compared with nonparametric tests (P < 0.05). The PR age was 12.5 (9-16) vs 15 (12-18) years with major Cobb 51° (36°-69°) and 49° (40°-69°) for IM and M, respectively. At FE, there was no difference in correction; however, at YR2, the IM group yielded a lower residual curve (15° [-16° to 38°] vs 29° [12°-42°], P = 0.008). Thoracolumbar/lumbar curves were corrected without group differences. Clinically successful correction (<35°) (15 [94%] vs 15 [79%]) and suspected cord breakages (2 [13%] vs 2 [12%]) were similar at YR2. Two overcorrections occurred, both in IM patients. Scoliosis Research Society-22 outcomes at final follow-up were similar between groups. No revision reoperations or conversions to spinal fusion were needed. Skeletally IM patients benefit from greater growth-modulated curve correction than M patients, however, at the increased risk of overcorrection. M patients maintained clinically significant correction at latest follow-up. Longer-term follow-up is required to determine durability of outcomes for patients undergoing AVBT who have minimal remaining growth at the time of index surgery. This study is relevant to spine surgeons, spine physiotherapists, and patients with idiopathic scoliosis. It offers evidence of clinical correction of scoliosis in mature patients.

Anatomic Factors Associated With the Development of an Anterior Cruciate Ligament Rerupture in Men: A Case-Control Study

Background: Although several factors are associated with anterior cruciate ligament (ACL) rerupture, the effect of anatomic factors associated with ACL rupture on ACL rerupture development has not been evaluated. Purpose: To determine individual anatomic parameters independently associated with ACL rerupture and the diagnostic values of these parameters. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 91 male patients with ACL rerupture and 182 age-, sex-, body mass index–, and side dominance–matched patients without rerupture who underwent ACL reconstruction with a 5-year follow-up were included. In all, 35 parameters that were previously defined as risk factors for primary ACL rupture were compared between the 2 groups. Uni- and multivariate logistic regression models were created to evaluate independently associated factors. Receiver operating characteristic curve analysis was performed for independently associated parameters to predict sensitivity, specificity, and cutoff values. Results: The mean ± standard deviation age of patients at the time of index surgery was 26.5 ± 6.7 years. Notch shape index (P = .014), tibial proximal anteroposterior (AP) distance (TPAPD) (P < .001), lateral femoral condylar AP distance (LCAPD)/TPAPD ratio (P < .001), medial meniscal cartilage bone height (P < .001), and lateral meniscal bone angle (P = .004) were found to be significantly different between the 2 groups. Only the LCAPD/TPAPD ratio (odds ratio, 2.713; 95% CI, 1.998-5.480; P < .001) was found to be independently associated with ACL rerupture development. The LCAPD/TPAPD ratio revealed 78.9% sensitivity and 75.5% specificity (area under the curve, 0.815; 95% CI, 0.760-0.870) for values above 1.52. Conclusion: The LCAPD/TPAPD ratio can be used to distinguish patients who are at risk of developing ACL rerupture from patients who are not. In the clinical practice, findings of this study may help to develop surgical and nonsurgical preventive strategies in ACL rerupture development.

Characteristics of patients undergoing revision surgery for proximal junctional failure after adult spinal deformity surgery: revalidation of the Hart-International Spine Study Group proximal junctional kyphosis severity scale.

Score on the proximal junctional kyphosis severity scale (PJKSS) has been validated to show good correlations with likelihood of revision surgery for proximal junctional failure (PJF) after surgical treatment of adult spinal deformity (ASD). However, if the patient has progressive neurological deterioration, revision surgery should be considered regardless of severity based on PJKSS score. This study aimed to revalidate the correlation of PJKSS score with likelihood of revision surgery in patients with PJF but without neurological deficit. In addition, the authors provide the cutoff score on PJKSS that indicates need for revision surgery. A retrospective study was performed. Among 360 patients who underwent fusion of more than 4 segments including the sacrum, 83 patients who developed PJF without acute neurological deficit were included. Thirty patients underwent revision surgery (R group) and 53 patients did not undergo revision surgery (NR group). All components of PJKSS and variables other than those included in PJKSS were compared between groups. The cutoff score on PJKSS that indicated need for revision surgery was calculated with receiver operating characteristic curve analysis. Multivariate analysis with logistic regression was performed to identify which variables were most predictive of revision surgery. The mean patient age at the time of index surgery was 69.4 years, and the mean fusion length was 6.1 segments. All components of PJKSS, such as focal pain, instrumentation problem, change in kyphosis, fracture at the uppermost instrumented vertebra (UIV)/UIV+1, and level of UIV, were significantly different between groups. The average total PJKSS score was significantly greater in the R group than in the NR group (6.0 vs 3.9, p < 0.001). The calculated cutoff score was 4.5, with 70% sensitivity and specificity. There were no significant between-group differences in patient, surgical, and radiographic factors (other than the PJKSS components). Three factors were significantly associated with revision surgery on multivariate analysis: instrumentation problem (OR 8.160, p = 0.004), change in kyphosis (OR 4.809, p = 0.026), and UIV/UIV+1 fracture (OR 6.462, p = 0.002). PJKSS score positively predicted need for revision surgery in patients with PJF who were neurologically intact. The calculated cutoff score on PJKSS that indicated need for revision surgery was 4.5, with 70% sensitivity and specificity. The factor most responsible for revision surgery was bony failure with > 20° focal kyphotic deformity. Therefore, early revision surgery should be considered for these patients even in the absence of neurological deficit.

Paper 74: Psychopathology and Volitional Instability: Who should we be operating on?

Objectives:There has been a hesitation by surgeons to operate on shoulder instability patients with maladaptive psychopathological traits, especially those with volitional instability, as these may portend a poor prognosis. The purpose of this study was to investigate the prevalence of maladaptive psychopathological traits, volitional instability, and their effect on two-year outcomes in patients undergoing shoulder stabilization surgery.Methods:A prospective multi-center cohort study led by the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group targeted all subjects having surgical shoulder stabilization and collected patient-reported outcomes at baseline and at two years postoperatively. Psychopathological traits were assessed using the Personality Assessment Screener (PAS), a validated personality assessment tool. Longitudinal analyses were performed using multivariable regression models to determine predictors of two-year outcomes adjusting for confounders measured at index such as age, sex, smoking, BMI, volitional instability, and intraarticular pathology.Results:The cohort (n = 890) was 80% male with a median age of 21.5 years. The prevalence of psychopathological traits was 20%. While all patients improved between baseline and 2 years, with adjusted analyses, the presence of maladaptive psychological traits present at the time of index surgery were predictive of lower WOSI (p = 0.001), ASES (p = 0.016), SANE (p = 0.03), and SF-36 MCS (p = 0.001) scores as well as a higher risk of failure (p = 0.04) at two years. As a main effect, volitional instability was not a predictor of WOSI, ASES, SANE, SF-36 or failure at two years. However, all models allowed for the interaction between volitional instability and the PAS, and this interaction was significant for WOSI (p = 0.006), SANE (p = 0.03), and SF-36 MCS (p = 0.003) scores at two years. In other words, the effect of volitional instability on the WOSI, SANE, and SF-36 MCS scores depends on the value of the PAS, and with high PAS scores it is associated with worse outcomes. This data is depicted in Figures 1-3.Conclusions:While all patients improved, the presence of maladaptive psychopathological traits at the time of index surgery was a predictor of poorer outcomes at two years. Voluntary dislocators did similarly as non-voluntary dislocators up to a PAS score of ˜ 20, where above this they had worse WOSI, SANE, SF-36 MCS and higher failure rates at 2 years post-operatively.Figure 1.Adjusted effects of PAS score and volitional instability on WOSI score at 2 yearsFigure 2.Adjusted effects of PAS score and volitional instability by gender on predicted MCS Score at two yearsFigure 3.Adjusted effects of PAS score and volitional instability on probability of failure

Association between biopsy method and development of peritoneal metastases in perihilar cholangiocarcinoma.

In patients with perihilar cholangiocarcinoma (PHC), there is concern that transperitoneal (TP) biopsy may seed tumor in the peritoneal cavity, increasing risk of peritoneal metastases (PM). A retrospective review of patients undergoing surgery for PHC (1991-2014) was performed. Clinicopathologic characteristics and incidence of PM at the time of index surgery, and one and two years after surgery were compared in patients who did vs. did not undergo TP biopsy. Among 262 patients who underwent surgery, 37 had undergone TP biopsy, and 225 had undergone intraluminal biopsy or had no biopsy. No differences in demographic or clinicopathologic characteristics were noted between groups. The incidence of PM at surgery was not significantly different between TP and non-TP biopsy patients (5.4% vs. 7.6%, p>0.9). Among 243 patients who did not have PM at surgery, the cumulative incidence of PM in the TP and non-TP biopsy groups were not different at one year (11.4% [95%CI 3.5-24.4] vs. 10.8% [95%CI 7.0-15.5]) or two years (20.3% [95%CI 8.7-35.2] vs. 20.1% [95%CI 14.9-25.9]) (p=0.7). Although PM commonly occurs in patients with PHC, TP biopsy was not associated with higher incidence of PM at surgery or at one or two years after surgery.