Trial Of Conservative Management Research Articles

(234) USING PERCUTANEOUS ULTRASOUND-GUIDED THROMBIN INJECTION AS A TREATMENT OF HIGH-FLOW PRIAPISM

Abstract Introduction Nonischemic priapism typically occurs secondary to penile trauma, resulting in increased blood flow into the penis without decreased outflow resulting in a clinically non-painful, partially rigid erection. Per the American Urologic Association guidelines, surgical treatment is discouraged, and following conservative management, first line treatment is arteriography with selective arterial embolization. This procedure is generally highly successful but it does carry a risk of erectile dysfunction as well as priapism recurrence. Objective Herein we present the first known case of ultrasound guided thrombin injection in an adult for nonischemic priapism treatment after persistent priapism and arterial blush following arterial embolization. Methods A 44-year-old male presented with an eight-month history of partial tumescence and erectile dysfunction after an episode of unwitnessed loss of consciousness resulting in the subsequent development of gross hematuria and dysuria. Physical examination revealed a semi-firm penis with suspected high-flow priapism. He initially presented to the emergency department, whereby a cystogram and cross sectional abdominal imaging were unrevealing. Initial outpatient cystoscopy revealed a urethral polyp which resolved on subsequent repeat testing. Following this an outpatient penile duplex doppler ultrasound was performed demonstrating a right pseudoaneurysm at the penile base measuring 13 mm in diameter with an arteriovenous fistulous communication to the corpus cavernosum. MRI demonstrates fibrotic changes within the right corpus cavernosum and tunica albuginea indicating prior traumatic penile injury. At the time the patient had approximately 25% tumescence at rest and was only able to obtain a slightly firmer erection, but was still able to achieve orgasm. After extensive conversation and given a trial of conservative management, the patient elected to proceed with angioembolization. An angiogram was completed which demonstrated a blush of contrast in the area of the bulbourethral artery. Despite successful deployment and coil embolization of the pseudoaneurysm, there was noted continued filling of the patent pseudoaneurysm from small branched collateral vessels. The patient tolerated the procedure well, and had reduction of his baseline penile tumescence and some erectile function recovery, requiring oral phosphodiesterase-5 inhibitors. There was concern for complete occlusion of the dorsal penile artery with repeat embolization, which may ultimately worsen erectile dysfunction. He remained incompletely satisfied with response to oral therapy. Results It was ultimately decided to pursue an ultrasound guided thrombin injection, which has been reported in a handful of cases as a primary intervention for priapism. During the procedure, 200 units of thrombin was injected into the pseudoaneurysm under ultrasound guidance resulting in immediate cessation of arterial flow. Post-procedure angiography demonstrated effective resolution. Conclusions High-flow priapism is a relatively uncommon condition, managed generally with embolization as first line treatment, with success rates reported at 89 to 100% and recurrence only occurring in 30% of patients. Recurrence is generally treated with repeat embolization which has been reported to cause erectile dysfunction in 15 to 22% of cases. Percutaneous ultrasound-guided thrombin injection has the potential to be an excellent second-line treatment option for pseudoaneurysm closure in correcting nonischemic priapism, albeit with limited data, but suspected high efficacy and potentially diminished rates of erectile dysfunction. Disclosure No.

Interval operative management in patients admitted with acute obstruction due to incarcerated paraesophageal hernia.

Acute incarcerated paraesophageal hernias (PEH) have historically been considered a surgical emergency. Emergent operations have a higher rate of morbidity and mortality compared to elective surgery. Our institution has adopted a strategy of initial conservative management in patients presenting with acute obstruction from an incarcerated PEH who are clinically stable. Patients are given at least 24h for their symptoms to improve (selective nasogastric decompression). If symptoms resolve, contrast on an upper GI study passes to the small bowel, and liquids are tolerated, patients are discharged with planned interval repair. We sought to characterize the outcomes of this interval surgical strategy for incarcerated PEH. A retrospective chart review was performed to identify patients admitted to a single institution between October 2019 and September 2023 with an incarcerated PEH. Patients taken directly to surgery within 24h were excluded. A total of 45 patients admitted with obstruction from an incarcerated PEH were identified. Ten patients (22%) were taken urgently to surgery due to clinical instability and were excluded. Of the remaining 35 patients, 23 (66%) resolved their obstruction with conservative non-operative management and were offered planned interval PEH repair (successful conservative management). In the successful conservative management cohort, there was one unplanned readmission before interval PEH repair. Average time between discharge and repair was 25days. Complication rates did not differ in those who failed and in those who had a successful conservative management result. The cumulative length of stay for those who succeeded in conservative management (including days for the interval surgery) was equivalent with those who underwent PEH repair during the index admission. A trial of conservative management in clinically stable patients with symptomatic incarcerated PEH appears to be safe and often avoids emergent repair without increasing perioperative complications or total days in the hospital.

A case report on spontaneous intracranial hypotension

A 38-year-old lady with bronchial asthma, psychiatric illness, and a suicidal attempt 6 years ago presented with persistent headache for more than 2 weeks. She was diagnosed with recurrent sinusitis and migraine and was on treatment at a local hospital and referred to a higher center for persistent headache which was orthostatic in nature. Clinically, the patient was alert, oriented, and systemic examination was unremarkable. MRI spine showed extensive extradural collection separating the anterior dural sac from the bony canal extending from C3 to D1. CT Myelogram showed cervical dural leak anteriorly at C7-D1 and bony osteophyte impinging on the dural sac – likely cause of leak. Diagnosis of Spontaneous Intracranial Hypotension was made. As no improvement was noted with trial of conservative management, we proceeded with advanced imaging-guided Epidural blood patch repair, following which the symptoms improved.

891 A Systematic Review and Narrative Synthesis on the Efficacy of Bisphosphonate Therapy in the Management of Diffuse Sclerosing Osteomyelitis

Abstract Aim Diffuse Sclerosing Osteomyelitis (DSO) of the mandible is a rare condition, characterised by recurrent severe pain, and functional disturbances such as trismus. Management of DSO through antibiotics, steroids, and analgesia has been generally unsatisfactory. Several articles have suggested the use of bisphosphonate therapy as an alternative treatment option to achieve long-lasting symptom improvement. We aim to summarise all evidence relating to the efficacy of bisphosphonate therapy in DSO. Method A systematic review protocol was registered with PROSPERO and reported in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses. Comprehensive electronic search strategies of six databases were developed. Studies were screened according to the inclusion and exclusion criteria by two independent reviewers. Results Eight articles were eligible for inclusion. A total of 102 patients with a confirmed diagnosis of DSO received bisphosphonate treatment following a trial of conservative management. All studies reported significant reduction in levels of pain and swelling, and a reduction in cumulative doses of analgesics. Majority of patients reported that bisphosphonate therapy provided long-lasting symptom improvement. Three studies reported improvements in maximal mouth opening, with one study reporting a mean increase of 9.6mm. Improvements in panoramic radiographs and cone beam CT scans were also observed in five studies, with four patients demonstrating almost normal-to-normal bone architecture. Finally, all studies reported no long-term complications. Conclusions Bisphosphonate therapy does appear to be a promising treatment option for DSO. It has shown to improve symptoms and radiological features, providing long-term benefits. Further prospective studies are required to finetune treatment protocols.

682 Accidental Toothpick Ingestion Causing Liver Abscess – a Case Report and Review of Literature

Abstract Introduction Perforation due to foreign body ingestion leading to pyogenic liver abscess is an unusual but fatal event. We present a rare case of accidentally ingested toothpick that perforated the duodenum and migrated to the liver causing abscess. Case Presentation A 40-year-old gentleman presented with symptoms and signs of sepsis. He reported having eaten dry fish and chicken with bones 4 days prior to presentation. Abdominal computed tomography (CT) scan revealed hepatic collection containing a linear object in the middle. Non-operative management improved patient’s general condition but an increase in the size of collection lead to operative management. Discussion Usual course of formation of a pyogenic liver abscess is due to ascending cholangitis or infections causing hematogenous spread. Such an event due to a foreign body perforating the gastro-intestinal tract and migrating to liver is rarely seen. Presentation ranges from mild abdominal pain to full blown septicemia. Diagnosis is challenging as patients may present with vague symptoms, or sometimes don’t even remember having ingested an indigestible object. A trial of conservative management can be given to stable patients who improve, but deterioration necessitates surgical intervention. Conclusions Pyogenic liver abscess due to foreign body ingestion leading to intestinal perforation and displacing to liver is seldom encountered, and a toothpick leading to such an event is a very rare event. Patients may improve clinically with non-operative management; definitive management lies in the surgical removal of foreign body.

Management of paediatric post-tonsillectomy bleeds - does everyone need observation?

The management of patients who present with a post-tonsillectomy bleed (PTB) who are not actively haemorrhaging is contentious. In our institution, those without an active bleed are admitted for a period of observation, due to the theoretical risk of further bleeding. This paper aims to review PTB admissions to ascertain the risk of rebleeding while under observation and to identify whether there is a low-risk group who can be safely discharged without observation. Review of current literature. Retrospective chart review of all patients who presented to Perth Children's Hospital between February 2018 and February 2022 with a PTB. Exclusion criteria included primary PTB, known blood dyscrasias and patients >16 years of age. A total of 826 presentations of secondary PTB (sPTB) were reviewed, with 752 admitted for a period of observation. Twenty-two (2.9%) patients rebled while under observation, with 17 managed operatively. The average age of patients who rebled was 6.2 years and they presented at an average 7.14 post-operative days. The median time to rebleed was 4.4h. Four patients with no oropharyngeal clot at presentation subsequently re-bled (0.53%) while under observation, with 2 (0.26%) managed surgically. In patients observed with an oropharyngeal clot at presentation 18 (3.1%) rebled, with 15 (2.6%) managed operatively. Patients presenting with a sPTB have a low risk of rebleeding while under observation. Patients with a normal oropharyngeal examination at presentation have a very low risk of rebleed and should be considered for early discharge if they meet other low risk criteria. Patients who present with an oropharyngeal clot can be safely observed with a low risk of further bleeding. Patients who rebleed while under observation should have a trial of conservative management if clinically appropriate.

Image-Guided Percutaneous Multilevel Pediculosynthesis for Treatment of Contiguous Pedicle Stress Fractures: Technical Case Report

Nontraumatic pedicle fracture is uncommon, with sparsely described cases of conservative management versus surgical treatment by open fusion or percutaneous fixation. We report the case of a 60-year-old woman with nontraumatic L4 and L5 pedicle fracture who developed additional pedicle fractures at L3 while undergoing conservative management in a brace. The patient underwent percutaneous pediculosynthesis with screw fixation without fusion at L3-5 bilaterally. The treatment led to fracture healing with good radiographic result and resolution of her symptoms. A trial of conservative management is typically warranted in most cases of nontraumatic pedicle fracture, but there is risk of refractory or progressive symptoms and subsequent fracture. Minimally invasive fixation is a viable surgical option that can be used in multilevel fractures.

Treatment of acute traumatic central cord syndrome: a score-based approach based on the literature.

Acute traumatic central cord syndrome (ATCCS) accounts for up to 70% of incomplete spinal cord injuries, and modern improvements in surgical and anaesthetic techniques have given surgeons more treatment options for the ATCCS patient. We present a literature review of ATCCS, with the aim of elucidating the best treatment option for the varying ATCCS patient characteristics and profiles. We aim to synthesise the available literature into a simple-to-use format to aid in the decision-making process. The MEDLINE, EMBASE, CENTRAL, Web of Science and CINAHL databases were searched for relevant studies and improvement in functional outcomes were calculated. To allow for direct comparison of functional outcomes, we chose to focus solely on studies which utilised the ASIA motor score and improvements in ASIA motor score. A total of 16 studies were included for review. There were a total of 749 patients, of which 564 were treated surgically and 185 were treated conservatively. There was a significantly higher average motor recovery percentage amongst surgically-treated patients as compared to conservatively treated patients (76.1% vs. 66.1%, p value = 0.04). There was no significant difference between the ASIA motor recovery percentage of patients treated with early surgery and delayed surgery (69.9 vs. 77.2, p value = 0.31). Delayed surgery after a trial of conservative management is also an appropriate treatment strategy for certain patients, and the presence of multiple comorbidities portend poor outcomes. We propose a score-based approach to decision making in ATCCS, by allocating a numerical score for the patient's clinical neurological condition, imaging findings on CT or MRI, history of cervical spondylosis and comorbidity profile. An individualised approach to each ATCCS patient, considering their unique characteristics will lead to the best outcomes, and the use of a simple scoring system, can aid clinicians in choosing the best treatment for ATCCS patients.

Talocalcaneal Coalition Resection in the Adult Population: A Systematic Review.

Tarsal coalition is a congenital malformation of the tarsal bones of the foot that typically presents with features such as pain, recurrent sprains, and flat foot in childhood. In a small number of patients, a delayed presentation may be apparent, with symptoms instead presenting in adulthood. The most commonly accepted hypothesis is that the tarsal coalition becomes more symptomatic as the coalition progressively ossifies. To this date, no author has systematically evaluated the literature to identify the best approach when surgically managing these patients, in particular concerning the resection of the coalition.This study aims to systematically review the literature, searching EMBASE, MEDLINE, Web of Science, Google Scholar, and the Cochrane Library to identify and evaluate studies that presented an outcome for resection of the adult talocalcaneal coalition. Alongside overall outcomes, details on the extent of the coalition, surgical method, post-operative regimen, and presenting symptoms were extracted for each patient studied. This was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.With 72 patients, this is the largest evaluation of an adult tarsal coalition population to date. Our findings indicate that talocalcaneal coalition in adulthood presents differently from the classical peroneal spasm found in childhood. Better scores were reported for coalitions either managed with an endoscopic approach or with interposition of the flexor hallucis longus tendon. Despite some reported benefits in the literature, a trial of conservative management or the use of a rehabilitation regimen had a limited impact on the overall patient outcome.Tarsal coalition in adulthood requires rigorous clinical evaluation to identify appropriate management options. Resection of the coalition is a safe approach to definitively managing these patients, but consideration should be given to the surgical method to ensure each patient has the best outcomes. In particular, consideration should be given to using an endoscopic approach or interposition of the flexor hallucis longus tendon in order to achieve the best patient outcomes. However, there remains a paucity of literature evaluating this demographic and further high-impact studies are required to comprehensively evaluate this population.

An Unusual Cause of Biliary Peritonitis on the Background of Acute Pancreatitis: A Case Report

Introduction Acute pancreatitis can cause a wide variety of local complications, sometimes pretty unusual. In the present report, we present a rather unusual cause of biliary peritonitis on the background of acute pancreatitis. Case Presentation A 41-year-old female patient with biliary acute pancreatitis and concomitant choledocholithiasis required an urgent laparotomy due to signs of sepsis and peritoneal irritation after a trial of conservative management. During laparotomy, the diagnosis of biliary peritonitis was established. Surprisingly, a residual gallstone obstructing the common bile duct at the level of the ampulla was causing bile to reflux, through the common channel, into the main pancreatic duct and subsequently into a partially ruptured acute pancreatic necrotic collection. Conclusion Dealing with the unexpected is a constant challenge for the surgical team dealing with acute pancreatitis patients. Although deferring surgical intervention during the course of acute pancreatitis, as much as possible, is the ideal strategy, this is not always possible. Deciding the treatment strategy based on the patients' clinical condition represents the most appropriate approach.

Inflammatory myofibroblastic tumor of intestine presenting as intussusception

Inflammatory myofibroblastic tumor (IMFT) is a rare mesenchymal tumor predominantly seen in the lungs. Intestinal IMFT is extremely rare and may cause intussusception. Surgery is the mainstay of treatment as IMFTs are resistant to conventional chemoradiation. Long term follow up is required as there is high recurrence risk. About 50% of IMFTs have translocations involving the anaplastic lymphoma kinase (ALK) gene which has been therapeutically targeted using Crizotinib. We report a 1-year-old boy with ileo-ileal intussusception who was operated after a trial of conservative management. Laparotomy revealed an ileal mass that was resected and histopathology confirmed IMFT. Recovery was uneventful.

Rate of continued conservative management versus progression to surgery at minimum 1-year follow-up in patients with pre-arthritic hip pain.

Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown. To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum 1-year follow-up. Retrospective cohort study. Single tertiary care academic medical center. Patients ages 13 to 40 years who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n=713 patients, 830 hips). Not applicable. The primary outcome was the rate of progression to surgery at minimum 1-year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures. In a cohort with a mean age of 25.4 (SD 8.1) years, 72.7% female, and mean follow-up of 2.6 (range 1.0-4.8) years, 429 of 830 hips (51.7%, 95% confidence interval [CI] 48.2% to 55.1%) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year, 95% CI 0.93 to 0.98), pain duration longer than 6 months (ORs 1.87-2.03, p ≤ .027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System [PROMIS] point, 0.92 to 0.99), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47, 2.05 to 5.89), acetabular dysplasia (OR 2.75, 1.73 to 4.35), and/or labral tear (OR 10.71, 6.98 to 16.47). Radiographic dysplasia (lateral center edge angle <20 degrees) increased the likelihood of surgery in all subgroups (ORs 2.05-8.47, p ≤ .008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α > 63 degrees) (OR 1.03/degree, 1.00 to 1.06). Almost half of patients with pre-arthritic hip pain did not progress to surgery at a minimum 1-year follow-up. A trial of conservative management is likely worthwhile in most patients.

58 Should Single Group and Save (G&amp;S) Sampling be Implemented in Spinal Cord Stimulation Surgery (SCSS)?

Abstract Aim SCSS is offered to patients who have persistent chronic neuropathic pain after trials of conservative management. Although severe bleeding complications are rare, it is common practice to take two G&amp;S samples from patients pre-operatively. Unnecessary testing can induce patient anxiety and is a financial burden to the NHS. We aim to determine if a single G&amp;S sample before SCSS would be beneficial, and to assess the association between number of risk factors for bleeding and blood loss in SCSS. Method Retrospective analysis of 100 patients in one centre who had SCSS over a 3-year period. Bleeding risk factors, haemoglobin levels and complications were recorded for each patient. A review of current literature along with a cost analysis was subsequently performed. Results An average drop in haemoglobin levels of 9g/L post-operatively was seen. No patients required blood transfusions. There was no statistically significant difference (P = 0.364) between number of risk factors and blood loss. Conclusions The results obtained suggest that SCSS carries a low risk of adverse bleeding requiring blood transfusions. With the lack of guidelines for preoperative G&amp;S samples it is difficult to make decisions on the amount of samples needed before SCSS. Single G&amp;S sampling in patients without bleeding risk factors can reduce patient burden, save costs, and reduce environmental footprints left by laboratory tests. Those with risk factors may still benefit from two pre-operative G&amp;S samples to ensure patient safety.

796 Chronic Pneumoperitoneum: Cause or Consequence of Pneumatosis Cystoides Intestinalis

Abstract Pneumatosis cystoides intestinalis (PCI), ‘gas cysts’ in the wall of the bowel, is a rare sign that can be found as a result of many different conditions, ranging from benign and asymptomatic, to life threatening. Its pathogenesis is not yet fully understood, and patients found to have PCI are treated in a heterogeneous manner. Pneumoperitoneum, however, is much more commonly seen by the General Surgeons, and most often occurs as a result of a perforated viscus; usually necessitating an emergent surgical intervention. Spontaneous pneumoperitoneum occurs very rarely, although it is seen more frequently with small bowel PCI, compared to large bowel PCI. We present here an unusual case of a patient with acute-on-chronic pneumoperitoneum and subsequently subacute small bowel obstruction associated with small bowel pneumatosis cystoides intestinalis. The patient also had extensive pan colonic and jejunal diverticulosis, although the area of perforation and PCI was discrete and located in the mid-ileum. It is unclear whether the patient had chronic pneumoperitoneum secondary to perforated PCI, or if the PCI developed secondary to an ileum perforation of unknown origin (fitting with the bacterial or mechanical theory of pathogenesis). The patient went onto to have an emergency laparotomy and small bowel resection 28 months after initial presentation and a trial of conservative management.

1494 An Audit on The Management of Adhesional Small Bowel Obstruction at St Helier Hospital

Abstract Aim To compare our current management of adhesional small bowel obstruction (ASBO) with the BMJ best practice treatment algorithm1 and National audit for small bowel obstruction 20172 guidelines and produce a flow chart to aid stasndardised : Method Data collected prospectively from the general surgical take list over a three-month. Results Thirty-five patients were diagnosed with ASBO. All patients were prescribed IV fluids. Thirty-four (97.1%) and 31 patients (88.6%) received analgesia and anti-emetics, respectively. Twenty-one patients (82.9%) had a NG tube inserted. Five patients (14.3%) underwent laparotomies within 37 hours from time of admission. Thirty patients (85.7%) underwent a trial of conservative management. Twenty-four patients (80%) received water-soluble contrast, of whom 13 (59.1%) were managed successfully. Eight patients (36.3%) failed to resolve and underwent emergency laparotomy within 70 hours from admission. One patient (2.9%) failed conservative management and was palliated. Conclusions Our results are in line with national standards. Our first line management for ASBO (analgesia, anti-emetics and NG insertion) could be instituted more promptly. Failure of NG insertion is multifactorial, an improved insertion rate may have further positive impact on conservative management outcome. A step-by-step sequential flow chart could introduce on induction at the beginning of general surgical rotation could help to re-iterate this management.

Efficacy of intra-articular corticosteroid and hyaluronic acid injections in preventing progression of early osteoarthritis of the knee in Indian population – A single centre prospective study with a follow-up of 18 months

Introduction: Osteoarthritis is a degenerative joint disease affecting middle aged to elderly population. Trial of conservative management in form of intra-articular injection with drugs like corticosteroid and hyaluronic acid have been in use for quite some time. We aim to test the efficacy of these drugs when given individually as well in combination in providing pain relief in patients with early-stage osteoarthritis. Materials and Methods: A prospective study conducted over a period of 4 years (2015-2019) was conducted with a sample size of 150 patients with 50 patients divided equally into 3 groups receiving corticosteroid, hyaluronic acid and combination of both respectively. Patients in age group of 40 – 65 years and with Kellgren Lawrence Grade I and II were included in the study. Functional scoring was evaluated pre –procedure, post-procedure at 1 month, and at regular interval of 3 months till 18 months. Visual analogue scale (VAS) and Knee society scoring (KSS) were used to evaluate the results. Results: Mean age of the patients included in the study was 57.3 years with 59% female and 41% male patients. Mean VAS score and mean KSS in corticosteroid group (CS) at 3 months follow-up were 4.92 and 152.81 respectively (p< 0.01). For the hyaluronic acid (HA) group, patients had a good relief till 9 months with a mean VAS at 9 months-4.91 and Mean KSS at 9 months-155.26 (p

Algorithmic approach to the lymphatic leak after vascular reconstruction: a systematic review

BackgroundTo date, there are no consensus guidelines for management of lymphatic leak in groin vascular reconstruction patients. The goal of this study is to review the relevant literature to determine alternatives for treatment and to design an evidence-based algorithm to minimize cost and morbidity and maximize efficacy.MethodsA systematic review of the literature was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Two independent reviewers applied agreed-upon inclusion and exclusion criteria to eligible records. Studies that included patients who underwent groin dissection for oncologic diagnoses and level 5 data were excluded. Interventions were then categorized by efficacy using predetermined criteria.ResultsOur search yielded 333 records, of which eight studies were included. In four studies, the success of lymphatic ligation ranged from 75% to 100%, with average days to resolution ranging from 0 to 9. Conservative management in the form of elevation, compression, and bedrest may prolong time to resolution of lymphatic leak (14–24 days) and therefore cost.ConclusionsThe majority of patients should be offered early operative intervention in the form of lymphatic ligation with or without a primary muscle flap. If the patient is not an operative candidate, a trial of conservative management should be attempted before other nonsurgical interventions.

A case of acute limb ischemia due to ulnar artery thrombosis: a rare surgical challenge

Ulnar artery thrombosis (UAT) is an uncommon cause of digital ischemia which occurs in less than 3% of population presenting with hand ischemia. The superficial palmar arch of which the ulnar artery is the main contributor can develop intimal damage following repetitive trauma. We present a uncommon case of a 60-year-old male farmer who presented with features of digital ischemia of right hand and found to have long segment UAT on color Doppler imaging and was managed in a step wise manner with a trial of conservative management initially followed by embolectomy, thrombectomy, and interposition vein graft as the last option. This case report brings out the rarity of UAT manifesting as digital ischemia in patient with complete SPA and the challenges faced by a surgeon in retrieving thrombi from distal segmental arteries of SPA. It also highlights the predisposing factors like occupation, presentation, and length of thrombosed segment that are crucial in determining the primary modality of treatment which was resection of thrombosed segment and RIVG in our case.

Does a delay in surgery for distal radial fractures affect patient outcome?

Current guidelines from the British Orthopaedic Association state that if fractures of the distal radius are operated on then this should take place within 3 days of injury for intra-articular fractures, 7 days for extra-articular fractures and 3 days when a trial of conservative management has failed. This retrospective cohort study aimed to assess whether there was any difference in outcome between patients receiving timely or delayed surgery, using the Patient-Rated Wrist Evaluation score at >12 months after injury as the primary outcome measure. Data from 380 patients treated at two district general hospitals over a 5-year period were obtained using electronic databases to capture the demographics and treatment details and postal questionnaires to assess current function. The study showed no statistical or clinical differences in outcome measures between the timely or delayed cohorts in any of the three treatment groups.Level of evidence: III.

Sacral insufficiency fractures after lumbosacral arthrodesis: salvage lumbopelvic fixation and a proposed management algorithm.

Sacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors' operative experience managing this complication, review pertinent literature, and propose a treatment algorithm. The authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication. Nine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8-96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score -1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8-90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to-lumbar lordosis (LL) mismatch. A high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5-S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.