Uncommon Procedure Research Articles

Forequarter amputations at the Moi teaching and referral hospital

Background : Forequarter amputation is an uncommon procedure. It is performed for high grade sarcomas of the proximal humerus, scapula and axillary region; that are not responding to induction chemotherapy or tumour progression with vascular invasion. Objective : To document the indications and results of forequarter amputations done at the Moi Teaching and Referral Hospital. Methods : Records of patients that had received a forequarter amputation in Moi Teaching and Referral Hospital between February 2012 and February 2017 were retrieved. The patient’s demographics, indication for surgery, complications and duration of survival post-operatively were noted and further analyzed. Results : A total of twelve patients were found that had a forequarter amputation done on their upper extremity. Eight were male while four were female. Ten patients (83.3%) were operated on for sarcomas including: synovial sarcoma, neurofibrosarcoma, Ewing’s sarcoma, Kaposi’s sarcoma, rhabdomyosarcoma, enchondroma, osteosarcoma and poorly differentiated sarcoma. Two patients (15.4%) were operated for squamous cell carcinoma. All the amputations were primary surgeries. Survival was 77.7% at six months and 44.4% after one year. Conclusion : The most common indication for forequarter amputation was a limb sarcoma. A one-year survival rate of 44.4% was found following forequarter amputation of a limb.

Scope of practice and supervision of orthodontic therapists in the United Kingdom: Part 2: a national cross-sectional survey of orthodontic therapists

Orthodontic therapists (OTs) are the most recent addition to the orthodontic clinical team. The General Dental Council (GDC) and the British Orthodontic Society have formulated guidance and guidelines relating to their scope of practice and level of supervision, however there has been no contemporary UK-based research investigating practice and supervision of OTs. The aim of this study was to investigate the scope of practice and level of supervision of OTs working in the UK. Ethical approval was received from the University of Manchester Research Ethics Committee. An anonymous postal questionnaire was dispatched using postal details acquired through the British Orthodontic Societies mailing list. Three mailings of the questionnaire were conducted. A 74% response rate was achieved. OTs routinely conducted 16 of the 20 procedures from their scope of practice. Uncommon procedures included fitting headgear (24%), lingual appliances (27%), inserting or removing temporary anchorage devices (20%), and taking facebow record (18%). A total of 62% of OTs took patient consent for treatment. 59% were supervised through a written prescription with no direct supervision. OTs were directly supervised for only a quarter of their clinical practice. Orthodontists viewing frequency for OTs varied significantly, and was found to be the following: every 2-4 visits (36%), every other visit (35%), and every visit (26%). OTs mostly carried out the scope of practice as permitted by the GDC. Procedures uncommon to routine orthodontic practice were also uncommon to Orthodontic therapist clinical practice. OTs work mostly through written prescription with no direct supervision.

Total elbow arthroplasty

Although the first resection and interposition arthroplasties of the elbow were reported at the beginning of the 20th century, modern total elbow arthroplasty (TEA) started in the late 1960s with a cemented hinge design described by Dee and Sweetnam.1-3 Since then, other implants have been introduced with advances in design.4 Total elbow arthroplasty can be used to treat elbow joint pathology such as rheumatoid arthritis (RA), osteoarthritis (OA), trauma, and post-traumatic sequelae.5-7 In addition, TEA is used in rarer conditions, such as in haemophilic arthropathy, as well as in tumour reconstruction.8,9 From the early 1970s to the late 1990s, RA was the most common indication globally for TEA. In this millennium, the development of effective biologic drugs such as anti-TNFα – a medication for treatment of RA – has resulted in a marked decrease in the number of TEAs (Fig. 1).5-7,10,11 Simultaneously, TEA has been used more and more to treat primary osteoarthritis and post-traumatic sequelae such as instability, as well as acute elbow fractures in elderly patients who are both increasingly frail and have greater functional demands. Fig. 1 Annual numbers of TEAs over time. Figure reprinted from Jenkins PJ, Watts AC, Norwood T, et al. Total elbow replacement: outcome of 1,146 arthroplasties from the Scottish Arthroplasty Project. Acta Orthop 2013;84:119-123. Compared with lower limb arthroplasty, TEA can be considered an uncommon procedure, with an annual incidence of 1.4 per 100 000 people in Western countries.12,13 In Europe, TEA incidence has slightly but constantly decreased from the late 1990s (Fig. 1).12,14 Conversely, in the United States there has been an annual rise of 6.4% between 1993 and 2007, from 1000 to 2400 procedures per year. This …

Deceased donor liver transplant: Experience from a public sector hospital in India.

Deceased donor liver transplant (DDLT) is an uncommon procedure in India. We present our experience of DDLT from a public sector teaching hospital. A retrospective analysis of all DDLT was performed from April 2012 till September 2016. Demographics, intraoperative, donor factors, morbidity, and outcome were analyzed. During the study period, 305 liver transplants were performed, of which 36 were DDLT (adult 32, pediatric 4; 35 grafts; 1 split). The median age was 42.5 (1-62) years; 78% were men. The median donor age was 28 (1-77) years; 72.2% were men. About 45% of organs were procured from outside of Delhi and 67% of all grafts used were marginal. Three of 38 liver grafts (7.8%) were rejected due to gross steatosis. Commonest indication was cryptogenic cirrhosis (19.4%). The median model for end-stage liver disease sodium and pediatric end-stage liver disease scores were 23.5 (9-40) and 14.5 (9-22), respectively. Median warm and cold ischemia times were 40 (23-56) and 396 (111-750) min, respectively. Major morbidity of grade III and above occurred in 63.8%. In hospital (90days), mortality was 16.7% and there were two late deaths because of chronic rejection and biliary sepsis. The overall survival was 77.8% at median follow up of 8.6 (1-54) months. DDLT can be performed with increasing frequency and safety in a public sector hospital. The perioperative and long-term outcomes are acceptable despite the fact that most organs were extended criteria grafts.

Discharges with surgical procedures performed less often than once per month per hospital account for two-thirds of hospital costs of inpatient surgery

Study ObjectiveMost surgical discharges (54%) at the average hospital are for procedures performed no more often than once per month at that hospital. We hypothesized that such uncommon procedures would be associated with an even greater percentage of the total cost of performing all surgical procedures at that hospital. DesignObservational study. SettingState of Texas hospital discharge abstract data: 4th quarter of 2015 and 1st quarter of 2016. PatientsInpatients discharged with a major therapeutic (“operative”) procedure. MeasurementsFor each of N=343 hospitals, counts of discharges, sums of lengths of stay (LOS), sums of diagnosis related group (DRG) case-mix weights, and sums of charges were obtained for each procedure or combination of procedures, classified by International Classification of Diseases version 10 Procedure Coding System (ICD-10-PCS). Each discharge was classified into 2 categories, uncommon versus not, defined as a procedure performed at most once per month versus those performed more often than once per month. Main resultsMajor procedures performed at most once per month per hospital accounted for an average among hospitals of 68% of the total inpatient costs associated with all major therapeutic procedures. On average, the percentage of total costs associated with uncommon procedures was 26% greater than expected based on their share of total discharges (P<0.00001). Average percentage differences were insensitive to the endpoint, with similar results for the percentage of patient days and percentage of DRG case-mix weights. ConclusionsApproximately 2/3rd (mean 68%) of inpatient costs among surgical patients can be attributed to procedures performed at most once per month per hospital. The finding that such uncommon procedures account for a large percentage of costs is important because methods of cost accounting by procedure are generally unsuitable for them.

Surgical outcomes of isolated tricuspid valve procedures: repair versus replacement.

Isolated tricuspid valve (ITV) operations are infrequent and the decision to operate is controversial. We report a series of ITV operations to outline the current disease status requiring this uncommon procedure with an emphasis on the results of tricuspid valve repair (TVr) versus replacement (TVR). Using our prospective cardiac surgery database, 57 patients who underwent ITV operations between 01/02-03/14 were identified. Median follow up time was 3.5 years [interquartile range (IQR), 0.8-6.7 years]. Fifty-seven patients underwent ITV surgery with a mean age of 54.4±14.9 yrs and 61% were women. Baseline characteristics were similar between patients who underwent TVr (n=18) or TVR (n=39). The etiologies of TV dysfunction were: ITV endocarditis 14/57 (25%), persistent TV regurgitation after left-sided valve surgery in 12/57 (21%), traumatic biopsies and iatrogenic injury from pacing leads in 11/57 (19%), orthotopic heart transplant 9/57 (16%), carcinoid syndrome 3/57 (5%), congenital 2/57 (5%) and idiopathic 5/57 (9%). Overall, 32/57 (56%) patients had prior heart surgery; of which 10/32 (31%) were TV procedures. Bioprosthetic prostheses were used in 34/39 (87%) patients. Of those who had repair, 11/18 (61%) had ring annuloplasty, 3/18 (17%) bicuspidization, and 3/18 (17%) De Vega annuloplasty and one had vegetectomy. Operative mortality was 5.1% (n=2) and 16.7% (n=3) for TVR and TVr groups, respectively (P=0.32), with an overall mortality rate of 8.6%. Postoperative complications included new onset renal failure in 6/39 (15%) of TVr and 2/18 (11%) of TVR (P=0.71) and there were no strokes. Overall survival rates and degree of residual RV dysfunction were similar for the two groups (both P=0.3). Five-year survival was 77% and 84% for TVr and TVR respectively (P=0.52). There was no difference in rates of recurrent tricuspid regurgitation for TVr and TVR (35.7% vs. 23.5%, respectively, P=0.4). ITV surgery is associated with improved but still relatively high operative mortality. Mid-term outcomes for TVr and TVR are similar with regards to postoperative complications, survival, and freedom from recurrent tricuspid regurgitation.

Indications for a laparoscopic common bile duct exploration in a community hospital setting: a review of a single-center's experience with laparoscopic common bile duct exploration in the current decade

Objective: Although laparoscopic cholecystectomies and IOC have become the standard, LCBDE haven't gained universal popularity despite increasing enthusiasm within the literature, pre-operative ERCP remains the procedure of choice. In the last few years there's been an increase in LCBDE in our large multi-disciplinary institution with gastroenterologists skilled in ERCP. We reviewed operative experience determining the prevalence, indications, success rates, techniques of LCBDE, and training of those surgeons performing them. Methods: Review of a prospective operative database at KP Riverside between 2010 and 2015 identified 20 LCBDE out of 5800 cholecystectomies, 25% in the first two years, and 50% in the last two, reflecting an increasing trend. The most common indication being choledocholithiasis in gastric bypass patients (55%), and failed ERCP (45%). Results: All 20 explorations were attempted transcystically, three required a choledochotomy to remove large stones. A T-Tube was placed laparoscopically through the choledochotomy in two and one had a laparoscopic choledochoduodenostomy for suspected ampullary stenosis. Laparoscopic clearance of CBD stones whether transcystic or in conjunction with choledochotomy was 85% (17/20). Of successful transcystic explorations, choledochoscopy was used in 30%. The most common technique was basket retrieval (40%), although a Seldinger technique using a glidewire and dilator/sheath under fluoroscopy was used successfully (30%). Conclusion: LCBDE with cholecystectomy was successful in the majority of patients when a team approach was undertaken. Despite the initial enthusiasm for LCBDE, it remains an uncommon procedure within our facility where skilled endoscopists are available. However, based on the results of our study LCBDE is an important technique to know.

A national audit of colonic interposition for esophageal replacement.

Esophageal replacement by colonic interposition is an uncommon procedure. This study sought to identify the frequency of this operation in England, identify techniques and associated problems, and also assess health-related quality of life (HR QOL) from the two largest centers performing this procedure. Hospital Episode Statistics were used to identify patients and centers undertaking colon interposition between March 2001 and March 2015. An online survey of UK consultants discussed methods and experience. HR QOL was assessed using the Short Form 36(SF-36v2) with additional gastrointestinal questions. Hospital Episode Statistics identified 328 interpositions (22 in pediatric hospitals). The two highest volume units did 42 and 45 operations, respectively. Thirty-four surgeons (79% response rate) replied to the survey. Fifty-two percent preferred to use the left colon with 81% preferring a substernal placement. The HR QOL survey was performed on 24 patients with a median of 3 years after surgery (ranging from 9 months to 10 years) from the two largest centers and a 56% response rate. Five patients had physical QOL scores above population average and 10 had mental scores above population average. All patients had early satiety, 20 described dysphagia, and 18 regularly took antireflux medication. There was an estimated mean loss of 13.1% body weight (10.6 kg) postoperatively and three patients still relied on a feeding tube for nutrition after an average of 3 years. Colon interposition results in an acceptable long-term QOL. Few centers regularly perform this operation, and centralizing to high-volume centers may lead to better outcomes.

Traitement d’un syndrome de Brodie unilatéral par contraction chirurgicale des maxillaires

Brodie's syndrome consists in a transverse occlusal discrepancy in relation with an excessive width of the maxilla, a narrow mandible or a combination of both, leading to lateral scissors bite. This kind of infrequent malocclusion is usually treated by orthodontics alone in children. In adults, additional orthognathic surgery id often required. We present a case of unilateral Brodie's syndrome treated by surgical contraction of the maxillae. A 22-year-old patient presented with a left scissors bite and severe unilateral molar overbite. After failure of an attempt to ingress the left molars by help of a sub-apical corticotomy and anchorage mini-screws, the patient was referred for surgery. The mandible being considered as normal, a segmented Le Fort I osteotomy was planned, combining a contraction (4mm) and an impaction (4mm) of the left maxilla. This allowed for an immediate correction of the skeletal discrepancy and for the achievement of orthodontics in less than 6 months. Le Fort I osteotomy provides a good access to the sagittal suture. Maxillary contraction is an uncommon procedure that enables a quick management of scissors bite and doesn't need any patient cooperation. Treatment time is reduced and the need for intraoral devices is limited.

Reflection and Rationalization: Making Sense of the Literature on Endocarditis After Transcatheter Pulmonary Valve Replacement.

In previous editorial comments, my focus has tended to settle on issues concerning how to develop and interpret the body of literature related to uncommon or new procedures, particularly when the literature comprises mainly small and observational studies with nonuniform or limited follow-up after implantation of devices that are likely to have much longer-term implications. This general theme is fundamental to the fields of congenital and structural interventional cardiology and pervades my editorial perspective and practice with Circulation: Cardiovascular Interventions . The topic I take on below is in the same vein, although it includes a more thorough review of a specific issue that I have been struggling with for several years: endocarditis after transcatheter pulmonary valve replacement (TPVR). Endocarditis after TPVR with the Melody valve (Medtronic, Inc, Minneapolis, MN) was first described by Khambadkone et al1 in a 2005 article summarizing their first 59 procedures. That initial patient was again reported, along with 4 others, in a 2008 update of their experience.2 Since those early reports, endocarditis has emerged as one of the most important and vexing adverse outcomes after TPVR. Endocarditis has been observed in general case series of TPVR2–8 and has been the organizing feature of several multicenter or single-center cohort studies9–14 and several small case series and case reports.15–24 It has also been the topic of several reviews that did not include new cases.25–27 In addition, endocarditis has been reported after TPVR with Sapien valves as well.28,29 Although the published data have brought the issue of post-TPVR endocarditis to light, the picture, both in isolation and in the broader context of this patient population, remains disconcertingly unclear. The literature, although growing, may be best characterized as nascent and ambiguous. …

Sonographic imaging of physiological ovaries in the cat

Ultrasound evaluation of the ovaries is an important element of the gynaecological examination. Although it is a well-established method used for many domestic animals, it is an uncommon procedure in cats. This article describes the technical requirements, the examination procedure, and the sonographic appearance of the physiological ovary in the cat. The examination can be performed with the cat in lateral position or dorsal recumbency. Usually the ovaries are found caudal to the kidneys which serve as lead structure. The median size of an ovary in anestrous is 0.9 cm (length) x 0.5 cm (height) x 0.4 cm (width). The ovaries of cyclical (follicular and luteal phase) cats are easier to detect than ovaries of cats in interestrous or anestrous.

Arthroscopic arthrodesis of the shoulder in brachial plexus palsy

Shoulder arthroscopic arthrodesis is an uncommon and non-standardized procedure. Results are poorly evaluated. We describe the findings in 8 patients who underwent shoulder arthroscopic arthrodesis for brachial plexus injury. The humeral head and glenoid were excised through standard arthroscopic portals. A Hoffmann external fixator and cannulated screws were used to stabilize the shoulder. Standard clinical assessment and radiographic evaluation were performed each month until bony fusion occurred. With a mean follow-up of 28 months, functional evaluation included pain level (on a 0- to 10-mm visual analog scale); American Shoulder and Elbow Surgeons index; Disabilities of the Arm, Shoulder and Hand score; and Simple Shoulder Test score. Mobility was systematically investigated. Blood loss was assessed by measuring hematocrit proportion. Glenohumeral fusion was achieved in all 8 patients. The mean time to arthrodesis was 3 months (range, 2-8 months). At last follow-up, the mean pain level was 1 (range, 0-4); the mean American Shoulder and Elbow Surgeons score was 69; the mean Disabilities of the Arm, Shoulder and Hand score was 36; and the mean Simple Shoulder Test score was 4. Mean active flexion and abduction were 80° (range, 60°-90°) and 59° (range, 40°-80°), respectively. Mean blood loss during the perioperative period was 432 mL (range, 246-792 mL). We observed one superficial wound infection and one migration of an acromiohumeral screw. These complications did not compromise the final results. Arthroscopic arthrodesis of the shoulder can be a reliable procedure and associated with a low rate of complications.

Release of nickel and chromium in common foods during cooking in 18/10 (grade 316) stainless steel pots.

Literature data on the release of nickel and chromium from stainless steel cookware during food preparation are contrasting, have often been obtained with uncommon foods and/or procedures, and are thus not widely applicable. To assess the release of nickel and chromium from 18/10 (grade 316) stainless steel pots in cooking conditions that are common in an urban lifestyle. Tomato sauce and lemon marmalade were cooked for 1 h, alone or with added EDTA, in used or unused stainless steel pots from different manufacturers. Additionally, aqueous solutions at pH 2.3, 7.7 and 9 were boiled for 1 h in the same pots. Metal release was assessed with inductively coupled plasma mass spectrometry. The release of nickel and chromium increased with cooking/boiling time, was higher with unused pots, at low pH or with EDTA, and was sometimes remarkably different between manufacturers. In all experiments, the amounts released were below known allergy-triggering thresholds. Under common conditions, the use of 18/10 stainless steel pots is considered to be safe for the majority of nickel-allergic and/or chromium-allergic subjects. However, the total amount of nickel contained in foods and released from pots may exceed the individual threshold for triggering allergy, potentially causing problems for highly sensitive patients, or, conversely, contribute to induction of immunotolerance by oral low-dose exposure.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2016 Update on Research

The Society of Thoracic Surgeons General Thoracic Surgery Database has grown to more than 500,000 case records. Clinical research supported by the database is increasingly used to advance patient outcomes. This research review from the General Thoracic Surgery Database in 2014 and 2015 discusses 6 recent publications and an ongoing study on longitudinal outcomes in lung cancer surgery from The Society of Thoracic Surgeons Task Force for Linked Registries and Longitudinal Follow-up. A lack of database variables specific for certain uncommon procedures limits the ability to study these operations; inclusion of clinical descriptors for selected infrequent but clinically important thoracic disorders is suggested.

Don't fix it if it isn't broken: a survey of preparedness for practice among graduates of Fellowship Council-accredited fellowships.

General surgery residency may not adequately prepare residents for independent practice. It is unclear; however, if non-ACGME-accredited fellowships are better meeting training needs. The purpose of this mixed-method study was to determine perceived preparedness for practice and to identify gaps in fellowship training. A survey was developed using an iterative qualitative methodology based on interviews and focus groups of graduated fellows and program directors. Five central themes emerged and were used as a framework: professional development, job marketability, autonomy, networking, and practice management. The survey was then circulated by email to fellows who graduated from Fellowship Council (FC)-accredited programs within the past 3years. Of 201 respondents (response rate=41%), 95 and 97% were highly satisfied with their operative and non-operative experiences; 83% acquired jobs aligned with their skills and expectations, while 17% sought additional training after fellowship. Respondents who intended to learn a given procedure felt competent after fellowship to perform 51(85%) of the 60 procedures listed. They would have liked more experience in advanced therapeutic endoscopy, complex and revisional bariatric surgery, and uncommon laparoscopic procedures such as esophagectomy, adrenalectomy, and common bile duct exploration. Thirty-one percent expressed the desire for more autonomy in the management of complications. Educational gaps existed mostly in areas of coding and billing (42%), hiring administrative staff (42%), and managing insurance issues (34%). FC-accredited fellowships seem to adequately prepare surgeons for independent practice and bridge training gaps after residency. Graduates are highly satisfied with the individualized training experience and acquire desired jobs aligned with their career goals.

Neoesophagus from Colonic Interposition: A Now Uncommon Procedure

Neoesophagus from Colonic Interposition: A Now Uncommon Procedure

Down to the Wire? Ventilation during Intubated Stretcher Helicopter Winching

The stretcher winching of intubated patients into a helicopter is an uncommon procedure. Positive pressure ventilation is required, which can be performed either manually with a self-inflating bag or automatically using a mechanical ventilator. The optimal method of ventilation has not been studied. Automatic ventilation has theoretical advantages in maintaining better oxygenation and stable arterial carbon dioxide levels, with less risk of airway disconnection. There is also likely to be better performance and situational awareness of the stretcher attendant during the winch, contributing to crew and patient safety. However, the ability to diagnose and manage airway disconnections and ventilator failure is of concern. To compare automatic vs manual ventilation during intubated stretcher helicopter winching. There were 2 phases to the trial. An initial static winch with a hoisting simulator was performed with 10 stretcher attendants, followed by a live helicopter winch at 30 feet into a Bell 412 with 5 attendants. Each attendant performed 2 separate winches with an intubated mannequin. During one winch the mannequin was ventilated with manual (bag) ventilation; an automatic ventilator was used for the other. Airway pressures were measured. The results showed no failure of automatic ventilation. Automatic ventilation was superior to manual ventilation. Automatic ventilation allowed for better situational awareness and perceived performance in winching maneuvers. There was one airway disconnection during a manual ventilation winch into the aircraft. Automatic ventilation is superior in providing stable, reliable, uninterrupted ventilation during simulated helicopter winching. The risk of ventilator failure and disconnection is low. Medical retrieval organizations should develop standard operating procedures, equipment, and training to facilitate automatic ventilation during helicopter winching.

Abstract PR265

Background & Objectives: Congenital cleft palate repair (palatoplasty) is not an uncommon procedure in children. Such procedure holds the risk of postoperative airway obstruction 1, which may be increased together with respiratory depression, with the use of opioids for pain control. Both greater palatine and suprazygomatic maxillary nerve blocks are considered effective regional anesthesia techniques for perioperative analgesia in such cases. They spare those children these complications and help early resumption of feeding 2 after the repair. The aim of this work was to compare the analgesic effect and complications of both bilateral greater palatine and suprazygomatic maxillary nerve blocks as modes of perioperative regional analgesia in children undergoing palatoplasty. Materials & Methods: Forty children, ASA I to III, aged 6 months to 5 years were enrolled in a prospective, randomized, comparative study. Subjects were divided into 2 equal groups, 20 patients received bilateral greater palatine nerve block (GPN group) and 20 patients received bilateral suprazygomatic maxillary nerve block (SMN group). All regional blocks were received after induction of general anesthesia and 20 minutes before surgical incision. Intraoperative hemodynamics, number of analgesia doses and complications were recorded. Postoperative analgesia (objective pain score), complications and parents’ satisfaction were also documented. Results: Number of patients who needed intraoperative analgesia were significantly higher in SMN group than GPN group (p value 0.048) (Table). Also, the need for postoperative rescue analgesia was significantly lower in GPN than that in SMN group (p value 0.024). Objective pain score was higher in SMN than GPN group in almost all recorded times. No significant difference between both groups were found concerning complications or parents’ satisfaction.Table:: Frequency and percentage of patients who needed extra intraoperative analgesia in the two groups. (P value = 0.048)Conclusion: Study demonstrated that the use of GPN block in children undergoing palatoplasty was accompanied by superior levels of intra and postoperative analgesia as compared to the use of SMN block in the same population.

Mid- to Long-Term Follow Up of the Salto Mobile Bearing Total Ankle Arthroplasty with Radio Graphic Analysis

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) remains a relatively uncommon procedure in New Zealand compared to total hip arthroplasty (THA) and total knee arthroplasty (TKA). Survivorship and clinical results of TAA have been mixed and inferior to both THA and TKA. There is a relative paucity of large series with long-term follow-up. The Salto mobile bearing prosthesis is now the most common prosthesis for TAA in New Zealand. We analysed a large series from a single surgeon with the purpose of reporting mid- to long-term survivorship, and performing radiographic analysis for radiolucencies and cytic changes. Methods: The New Zealand joint registry (NZJR) was used to obtain all Salto mobile bearing ankle replacements performed by the senior author between November 2005 and June 2012. The NZJR is a nationwide register of all joint arthroplasties performed in New Zealand and data on TAA has been collected since January 2000. Individual notes on each patient were reviewed to verify revision rate and reasons for revision. Post-op radiographs were analysed for alignment, radiolucencies, cystic changes and subsidence. Results: Of the 165 Salto mobile bearing ankle replacements in 150 patients, 62% were performed in males and 38% in females. Mean age at TAA was 65 years. Follow-up ranged from 5 to 121 months. Indications for primary included primary osteoarthritis (85%), inflammatory arthritis (9%), and post-traumatic arthritis (6%). 8% of patients (12 ankles) deceased during the follow-up although none had undergone revision. Over the course of the study, 8 ankles were revised giving a revision rate of 4.8% with mean time till revision of 69 months. Reasons for revision included aseptic loosening (3 ankles), talar collapse/avascular necrosis (2 ankles), broken polyethylene spacer without exchange of either component (2 ankles) and infection (1 ankle). At the time of study completion, 145 ankle replacements were still implanted in 130 patients which represents 94.7% survivorship in those patients still living. Post-operative radiographs demonstrated mean tibial alignment 90.7°, talar alignment 90.1°, tibial slope 82.6°, and talocalcaneal angle 11.2°. 49.1% demonstrated radiolucencies and 27.6% demonstrated cystic changes at long term. 7.2% showed subsidence over time. Conclusion: Our data represents one of the longest follow-up studies of the Salto mobile bearing TAA in the world. Our results show acceptable mid- to long-term survivorship. There is a notable percentage with radiolucencies and cystic changes but this does not seem to correlate with early failure. Component migration is uncommon. Further long-term follow-up of this cohort is necessary to determine the significance of the radiolucencies and cystic changes.

Rethinking Chemoprophylaxis for Total Ankle Replacement

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) is a relatively uncommon joint replacement procedure. Only 631 TAR operations were performed in the UK in 2014. However, its popularity is increasing as a suitable alternative to ankle fusion in patients with end stage ankle arthritis. A rare complication of TAR surgery is the development of a Venous Thromboembolism (VTE), including Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). We sought to investigate the effectiveness of our own peri-operative management and VTE prophylaxis protocol in the prevention of symptomatic VTE, in patients undergoing TAR surgery in our tertiary referral hospital. Methods: We conducted a retrospective cohort study of prospectively collected data in patients undergoing TAR with Mobility TAR (Depuy™, Leeds, United Kingdom) between March 2006 and May 2012. All patients were treated according to a pre-defined protocol. Patients undergoing TAR were not given VTE prophylaxis unless there were specific indications of increased risk of VTE - such as cardiac risk factors or post-operative air travel. A Vacuum Assisted Closure (VAC™) device was applied post operatively to increase the speed of wound healing, creating a negative pressure environment preventing dehiscence. Patients were not immobilised post operatively but rested for 5 days with the index leg elevated, while ankle movement was encouraged. Patients were mobilised early (5-7days). We reviewed all post-operative clinical follow up for 6 months, the time chosen as a cut off for an incident of DVT to be attributable to the surgery. Results: A cohort of 200 TARs were assessed. The mean age of the cohort was 61.7 years of age (range 31.0-89.4). There were no recorded deaths. There were 125 male and 75 female patients with 85 Left and 115 Right TAR procedures performed. In total 31 patients (15.5%) were given chemoprophylaxis in the post-operative period on clinical grounds. 187 (73.4%) patients were mobilised early (5-7days) post-operatively; with 2 (0.8%) mobilised with partial weight bearing and 21 (4.6%) mobilised non-weight bearing. In the mobilised early subgroup of patients only 10 (5%) had problems and required subsequent immobilisation. The majority of post-operative problems were caused by post-operative peri-prosthetic fracture (n=8, 4%) and wound break down (n=2, 1%). Conclusion: This study highlights that there is a need for further research into the use of VTE prophylaxis in TAR. In addition we feel that chemoprophylaxis should not be considered the panacea for reducing the incidence of VTE in patients undergoing TAR. We suggest post-operative limb elevation, haematoma evacuation and use of VAC treatment should be prioritised with early mobilisation and full weight bearing. Furthermore this study suggests judicious VTE chemoprophylaxis should be given on clinicians’ judgement tailored to individual patient requirements. This will hopefully avoid unnecessary costs and possible complications of anticoagulation such as bleeding, delayed wound healing and thrombocytopenia.