Unplanned Surgeries Research Articles

Safety and Efficacy of Apical Resection Following Growth-friendly Instrumentation in Myelomeningocele Patients With Gibbus: Growing Rod Versus Luque Trolley.

Thoracolumbar/lumbar kyphosis in myelomeningocele patients is a common and severely debilitating condition, amenable only to surgical correction. Several surgical techniques have been proposed. Growth-friendly techniques should be preferred in this patient population due to an already compromised trunk height. The growing rod (GR) and Luque trolley (LT) with Galveston instrumentation are well-known growth-friendly techniques. We compared results and complications in 2 groups of patients who have undergone kyphectomy and fixation, either with the GR (group 1) or the LT with Galveston pelvic fixation (group 2). Ten patients undergoing GR fixation and 5 patients undergoing LT with Fackler fixation following kyphectomy (vertebral column resection or multiple eggshell) were included. GRs were lengthened every 6 months. Unplanned surgery in group 1 was defined as an unscheduled operation due to complication; all subsequent operations in group 2 were considered unplanned. Thoracic and local kyphosis and T1-S1 and T1-12 heights were measured preoperatively, postoperatively, and at final follow-up. Mean age at initial surgery was 6 years and 6.5 years for groups 1 and 2, respectively. Mean age at the last follow-up was 12.5 years for group 1 and 13.1 years for group 2. Mean follow-up was 72.7 months for group 1 and 68.6 months for group 2. Preoperative, postoperative, and final follow-up kyphosis angles in that order for group 1 were 72.3 degrees (10 to 110 degrees), 16.9 degrees (-50 to +55 degrees), and 21.6 degrees (-41 to +97 degrees), and for group 2 106.6 degrees (81 to 132 degrees), 15.6 degrees (-37 to +50 degrees), and 19.2 degrees (-42 to +38 degrees), respectively. Postoperative and final follow-up in that order for mean T1-T12 and T1-S1 heights for group 1 were 14 (11.2 to 18.7) cm, 20.4 (19.3 to 25.7) cm and 21 (17.2 to 23.2) cm, 31.6 (23.6 to 41.5) cm. Postoperative and final follow-up in that order for mean T1-T12 and T1-S1 heights for group 2 were 15.9 (14.3 to 19.7) cm, 20.1 (15.5 to 24.6) cm and 24.4 (17.7 to 27.8) cm, 29.5 (25.3 to 31.3) cm. Growth per year was 1.05 and 0.84 cm for groups 1 and 2, respectively (P=0.297). Fourteen versus 4 unplanned surgeries were performed in groups 1 and 2, respectively, and an additional 4 implant revisions were performed in group 1 during planned lengthenings. Both the LT and the GR system are reasonable alternatives of fixation postkyphectomy, both of which preserve growth to differing degrees. In this patient population with an already severely stunted trunk height, the surgeon must choose whether the amount of extra growth achieved by the GR is worth the risk of an increased number of surgeries.

Functional outcomes of operative fixation of clavicle fractures in patients with floating shoulder girdle injuries.

BackgroundDouble disruptions of the superior suspensory shoulder complex, commonly referred to as ‘floating shoulder’ injuries, are ipsilateral midshaft clavicular and scapular neck/body fractures with a loss of bony attachment of the glenoid. The treatment of ‘floating shoulder’ injuries has been debated controversially for many years. The purpose of this study was to demonstrate the clinical and functional outcomes of patients with ‘floating shoulder’ injuries who underwent operative fixation of the clavicle fracture only.Materials and methodsBetween 2002 and 2010, 32 consecutive floating shoulder injuries were identified in skeletally mature patients at a level I trauma center and followed in a single private practice. Thirteen patients met the inclusion and exclusion criteria for this retrospective study with a minimum 12-month follow-up. Clavicle and scapular fractures were identified by Current Procedural Technology codes and classified based on Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen criteria. ‘Floating shoulder’ injuries were surgically managed with only clavicular reduction and fixation utilizing modern plating techniques. Nonunion, malunion, implant removal, range of motion, need for secondary surgery, pain according to the visual analog scale (VAS), and return to work were measured.ResultsAll injuries were the result of high-energy mechanisms. Fracture union of the clavicle was seen after initial surgical fixation in the majority of patients (12; 92.3 %). Final pain was reported as minimal (11 cases; 1–3 VAS), moderate (1 case; 4–6 VAS), and high (1 case; 7–10 VAS) at last follow-up. Excellent range of motion (180° forward flexion and abduction) was observed in the majority of patients (8; 61.5 %). The Herscovici score was 12.9 (range 10–15) at 3 months. Unplanned surgeries included two clavicular implant removals and one nonunion revision. None of the patients required reconstruction for scapula malunion after nonoperative management. Twelve patients returned to previous work without restrictions.Conclusions‘Floating shoulder’ injuries with only clavicular fixation return to function despite persistent scapular deformity and some residual pain.Level of evidence Level IV.

Growing Rods Versus Shilla Growth Guidance: Better Cobb Angle Correction and T1–S1 Length Increase But More Surgeries

Study DesignRetrospective comparison. ObjectivesTo compare treatment of early-onset scoliosis (EOS) with Shilla growth guidance versus distraction-based dual growing rods (GR). Summary of Background DataWe are not aware of any prior studies comparing the Shilla procedure with other surgical procedures in the treatment of EOS. MethodsThe authors performed a multicenter case-matched comparison of patients with EOS treated with Shilla versus dual spine–spine GR from 1995 to 2009. A total of 36 Shilla patients from 3 centers were matched with 36 GR patients from the database by age at index surgery (±1 year), preoperative Cobb angle (±15°), and diagnosis (neuromuscular, congenital, idiopathic, or syndromic). Average follow-up was similar between groups (GR, 4.3 years; Shilla, 4.6 years; p = .353). ResultsAverage Cobb angle improvement preoperatively to latest follow-up was 36° (range, 72° to 36°) in the GR group versus 23° (range, 69° to 45°) in the Shilla group (p = .0124). T1–S1 length increased 8.8 cm in patients treated with GR, compared with 6.4 cm in Shilla patients (p = .0170). Shilla patients had fewer surgeries (2.8) than patients in the GR group (7.4) (p < .001) but had a higher rate of unplanned surgeries for implant complications (Shilla, 1.3; GR, 0.5; p = .0151). When revisions for implant complications done at the time of scheduled lengthenings and revisions for construct maintenance were included, the groups did not differ significantly in the number of procedures for implant complications (Shilla, 1.4; GR, 1.5; p = .9451). The overall complication rate did not differ significantly between groups (Shilla, 1.9 [range, 0–7]; GR, 1.3 [range, 0–9]; p = .2085). ConclusionsThe GR group had a greater improvement in Cobb angle and a greater increase in T1–S1 length than Shilla. The GR patients had more surgeries but Shilla patients had more unplanned procedures. The rate of complications overall did not differ significantly between groups.

Traditional Growing Rods Versus Magnetically Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis: A Case-Matched 2-Year Study

IntroductionTraditional growing rod (TGR) surgery is a treatment technique commonly used for progressive early-onset scoliosis. Studies have shown that repeated TGR lengthenings can significantly increase the risk of complications. Magnetically controlled growing rods (MCGR) are currently available outside of the United States and early results have been promising. The purpose of this study was to compare the effectiveness of MCGR versus TGR for the treatment of early-onset scoliosis. MethodsMagnetically controlled growing rod patients were selected based on the following criteria: aged less than 10 years, major curve greater than 30°, thoracic height less than 22 cm, no previous spine surgery, and minimum 2-year follow-up. A total of 17 MCGR patients met the inclusion criteria, 12 of whom had complete data available for analysis. Each MCGR patient was matched with a TGR patient by etiology, gender, single versus dual rods, preoperative age, and preoperative major curve. ResultsMagnetically controlled growing rod patients had a mean age of 6.8 years and mean follow-up of 2.5 years. Mean follow-up was greater for TGR patients by 1.6 years. Major curve correction was similar between MCGR and TGR patients throughout treatment. The MCGR patients experienced an average of 8.1 mm/year increase in T1–S1 during the lengthening period, compared with 9.7 mm/year for TGR patients (p = .73). There was a mean increase in T1–T12 of 1.5 mm/year for MCGR patients and 2.3 mm/year for TGR patients (p = .83). The TGR patients had 73 open surgeries, 56 of which were lengthenings. The MCGR patients had 16 open surgeries and 137 noninvasive lengthenings. Three TGR patients underwent 5 unplanned revision surgeries whereas 3 MCGR patients underwent 4 unplanned revisions. ConclusionsMajor curve correction was similar between MCGR and TGR patients throughout treatment. Annual T1–S1 and T1–12 growth was also similar between groups. The MCGR patients had 57 fewer surgical procedures than TGR patients. Incidence of unplanned surgical revisions as a result of complications was similar between groups.

Submuscular Bridge Plating for Complex Pediatric Femur Fractures Is Reliable

Complex, high-energy pediatric femur diaphyseal fractures cannot be treated reliably by conventional methods: casting is not suitable for polytrauma and large children, external fixation is associated with a high rate of malalignment and refractures, elastic nails are unsuitable for unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails cannot address proximal and distal fragments and need relatively large medullary canals. A few centers have reported that submuscular bridge plating (SBP) is associated with minimal complications, but these findings require confirmation. We asked whether SBP (1) reproducibly leads to union in unstable fractures with a low complication rate, (2) leads to reasonable alignment and leg length equality (3), is unaffected by age, weight, or location of fracture, and (4) is associated with no or minimal refracture after hardware removal. We retrospectively reviewed 60 fractures in 58 patients with pediatric diaphyseal femoral fractures treated with SBP from 1999 to 2011. The average age was 9 years. Forty (67%) of the fractures were unstable. Minimum followup was 2.4 months (average, 15.5 months; range, 2.4-50.6 months). All fractures healed well and all patients returned to full activity. Two of the 58 patients (3%) had major complications leading to unplanned surgeries: one implant failure and one deep infection in an old open fracture. None of the patients developed clinically important malalignment or leg length discrepancy. Implant removal was performed in 49 patients without complications. SBP provided reliable fixation and healing for complex pediatric femur fractures and can have a broader application in the orthopaedic community. SBP is our preferred method for unstable fractures or fractures of the proximal and distal shaft.

Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients

To date, most reports on the incidence of adverse events (AEs) in spine surgery have been retrospective and dependent on data abstraction from hospital-based administrative databases. To our knowledge, there have been no previous rigorously performed prospective analysis of all AEs occurring in the entire population of patients presenting to an academic quaternary referral center. To determine the mortality and true incidence and severity of morbidity (major and minor, medical and surgical) in adults undergoing complex spinal surgery, both trauma and elective, in a quaternary referral center. To examine the influence of the introduction of a dedicated weekly multidisciplinary rounds, and a formal abstraction tool, on the recording of this prospective perioperative morbidity data. To examine the validity and inter- and intraobserver reliability of a dedicated Spine AdVerse Events Severity system, version 2 (SAVES V2) AE abstraction tool. Ours is an academic quaternary referral center serving a population of 4.5 million people. Beginning in April 2008, a spine-specific AE-recording instrument, entitled SAVES V2, was introduced at our center for reporting, categorization, and classification of AEs. The use of this system remains an ongoing prospective study. All adult patients admitted to the spine service of a quaternary referral center for a 12-month period. A validity and an inter- and intraobserver reliability examination of the SAVES V2 system, as used at our institution. Morbidity and inhospital deaths, unplanned second surgeries during index admission, wound infections requiring reoperation, and readmissions during the same calendar year. We also examined in detail all intraoperative and nonsurgical postoperative AEs, as well as hospital length of stay (LOS). Data on all patients undergoing surgery over a 12-month period were prospectively collected using a perioperative morbidity abstraction tool at weekly dedicated mortality and morbidity rounds. This tool allows identification of each specific AE and grades the severity. Before the introduction of this system, and using the hospital inpatient database, our documented perioperative morbidity rate (major and minor, medical and surgical) was 23%. Diagnosis, operative data, hospital data, major and minor complications both medical and surgical, and deaths were recorded. One hundred percent of all patients discharged from the unit had complete data available for analysis. Nine hundred forty-two patients with an age range of 16 to 90 years (mean, 54 years; mode, 38 years) were identified. There were 552 males and 390 females. Around 58.5% of patients had undergone elective surgery. Thirty percent of patients were American Spinal Injury Association class D or worse on admission. The average LOS was 13.5 days (range, 1-221 days). Eight hundred twenty-two (87%) patients had at least one documented complication. Thirty-nine percent of these adversely affected hospital LOS. There were 14 mortalities during the study period. The rate of intraoperative surgical complication was 10.5% (4.5% incidental durotomy and 1.9% hardware malposition requiring revision and 2.2% blood loss >2 L). The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%). Major spinal surgery in the adult is associated with a high incidence of intra- and postoperative complications. We identified a very high rate of previously unrecognized postoperative complications, which adversely affect LOS. Without strict adherence to a prospective data collection system, the true complexity of this surgery may be greatly underestimated.

Surgical Technique: Methods for Removing a Compress® Compliant Prestress Implant

The Compress® device uses a unique design using compressive forces to achieve bone ingrowth on the prosthesis. Because of its design, removal of this device may require special techniques to preserve host bone. DESCRIPTION OF TECHNIQUES: Techniques needed include removal of a small amount of bone to relieve compressive forces, use of a pin extractor and/or Kirschner wires for removal of transfixation pins, and creation of a cortical window in the diaphysis to gain access to bone preventing removal of the anchor plug. We retrospectively reviewed the records of 63 patients receiving a Compress® device from 1996 to 2011 and identified 11 patients who underwent subsequent prosthesis removal. The minimum followup was 1 month (average, 20 months; range, 1-80 months). The most common reason for removal was infection (eight patients) and the most common underlying diagnosis was osteosarcoma (five patients). Three patients underwent above-knee amputation, whereas the others (eight patients) had further limb salvage procedures at the time of prosthesis removal. Five patients had additional unplanned surgeries after explantation. Irrigation and débridement of the surgical wound was the most common unplanned procedure followed by latissimus free flap and hip prosthesis dislocation. At the time of followup, all patients were ambulating on either salvaged extremities or prostheses. Although removal of the Compress® device presents unique challenges, we describe techniques to address those challenges.

Factors that influence the expected length of operation: results of a prospective study

BackgroundIn the operating room, factors such as interruptions, communication failures, team familiarity and the unpredictability of unplanned cases can prolong the length of an operation, and lead to inefficiency and...

The Morbidity and Mortality of Fusions from the Thoracic Spine to the Pelvis in the Adult Population

A retrospective analysis. To quantify the risks of surgery and explore the associations of early perioperative complications with patient demographics and surgical variables. Long fusions extending from the thoracic spine to the pelvis in adults are increasingly common. Currently, there are few studies detailing the overall risks of such comprehensive reconstructions or how preoperative demographics may be associated with potential complications. A retrospective study was performed at two tertiary referral institutions. Preoperative patient demographics and intraoperative surgical variables were analyzed to explore the potential association with outcomes. The outcomes recorded were death, length of hospital and intensive care unit (ICU) stay, discharge to a rehabilitation facility, major medical complications, neurologic deficits, and the additional unplanned surgeries that patients subsequently underwent. One hundred three consecutive patients underwent a fusion extending from the thoracic spine to the pelvis for degenerative conditions from 2003 to 2007. There was a 4% mortality rate. The mean hospital stay and mean ICU stay was 12 ± 7 and 2.7 ± 4 days, respectively. Fifty-eight percent of patients were discharged to a rehabilitation facility. Twelve percent of patients experience at least one major medical complication. Seventeen percent of patients had a documented new persistent neurologic deficit that was still present at the final clinic visit. Thirty-five percent of patients underwent at least one unplanned return to the operating theater. There were no perioperative demographics or surgical variables that had a statistically significant association with mortality. Major medical complications were associated with the American Society of Anesthesiologists' (ASA) score (P = 0.030) and the Charlson Comorbidity Index (P = 0.028) but not age (P = 0.273). Complex spine reconstruction involving fusions from the thoracic spine to the pelvis continues to be a high-risk procedure in spite of more advanced surgical and perioperative techniques.

The Incidence of Wound Complications Related to Negative Pressure Wound Therapy Power Outage and Interruption of Treatment in Orthopaedic Trauma Patients

Negative pressure wound therapy (NPWT) using the Vacuum Assisted Closure system is an invaluable tool for use on patients with complex limb and soft tissue problems. Recently, the manufacturer (Kinetic Concepts, Inc, San Antonio, TX) made significant modifications to the NPWT platform, including computer software, battery, alarming systems, electric cord and plug apparatus, and others. Since these modifications, we have seen several cases in which the NPWT device has powered off resulting in an unrecognized interruption of therapy. We sought to evaluate the conditions and clinical effects, if any, to orthopaedic trauma patients who experienced an interruption of NPWT therapy when the device powers off. Retrospective study of consecutive patients. Two neighboring regional trauma centers. One hundred twenty-three consecutive orthopaedic trauma patients treated with NPWT by two orthopaedic trauma surgeons between May and November 2008. Patient/injury, treatment, and perioperative clinical outcomes data (with emphasis on wound complications such as infection, graft loss, and unscheduled surgery) were collected from medical records and wound care databases. Twelve patients (10%) had problems with the NPWT device powering off causing an unrecognized interruption of therapy. Eleven patients underwent early (less than 6 hours) wound débridement and reapplication of NPWT after detection, of which nine required unplanned surgery. Seven of the 12 patients recognized as having failed NPWT of this type ultimately experienced wound complications, including five deep infections and both patients being treated with an Integra graft (loss of graft). We have seen substantial problems in orthopaedic trauma patients treated with the NPWT, in which the device has powered off resulting in an unrecognized interruption of therapy. This has resulted in atypically unhealthy-appearing wounds, unplanned surgeries for débridement, and most importantly, an increased incidence of wound complications, including infection and graft loss (P < 0.05).

Comparison of Complications Among Growing Spinal Implants

Retrospective review. To evaluate the complication rate of various types of growing spinal implants. Previous studies report a complication rate of 0.38 to 1.19 per patient in growing spine surgery, but this may be an underestimate. Medical records of 36 children with early-onset spinal deformity treated with various types of growing implants by a single surgeon were evaluated for complications. Patients with primary chest wall deformities were excluded. Complications were defined as any neurologic injuries, and any unplanned surgeries for implant failure or infection. Patients were separated into 3 groups: (A) standard dual growing rods, (B) hybrid growing rods with rib anchors proximally and spine anchors distally, and (C) VEPTR (vertical expandable prosthetic titanium rib). Statistical analyses were performed to compare the complication rate among the 3 groups and to evaluate the effect of Cobb angle, kyphosis, age, and body mass index on the complication rate. Mean age at initial implantation was 4.8 years; mean follow-up was 51 months (24-117 months). A total of 72 unplanned surgeries occurred in 26 out of 36 patients (72%), including 18 revisions for rod breakage, 31 revisions for migrated anchors, and 18 irrigations and debridements for infection. Two children (5.6%) developed a neurologic deficit that required implant removal. Group A had 23 complications in 10 patients, with a complication rate of 2.3 per patient; group B had 6 complications in 7 patients, with a rate of 0.86 per patient; and group C had 45 complications in 19 patients, with a rate of 2.37 per patient. There was no significant difference between the 3 groups in terms of preoperative Cobb angle, kyphosis, age, and body mass index; these factors did not seem to influence the complication rate. To our knowledge, this is the first study directly comparing the complication rates of various types of growing spine implants. The complication rate in growing spine surgery is uniformly high but varies by implant type, with a trend toward fewer complications in hybrid constructs.

Do Asymptomatic Patients Require Routine Hemoglobin Testing Following Uneventful, Unplanned Cesarean Sections?

Although routine postoperative hemoglobin testing following a cesarean delivery has been proposed to be useful to diagnose occult bleeding, to treat anemia early, and to identify patients requiring blood transfusion several reports have shown that routine testing has limited benefit and does not contribute to treatment. Only a small drop in the hematocrit occurs in women undergoing cesarean deliveries and the risk of cesarean-associated blood transfusion is relatively low for primary as well as repeat cesarean sections. Accordingly, several investigators have suggested that such routine testing be eliminated. The aim of this retrospective chart analysis was to assess whether routine hemoglobin measurement, following unplanned and uneventful cesarean sections in women asymptomatic for anemia, is clinically useful and to identify possible risk factors associated with hemorrhage. Low-risk asymptomatic women who underwent unplanned and uneventful cesarean sections were identified and an extensive chart review was conducted to obtain demographic data, assess pre- and postoperative hemoglobin values, the amount of blood loss and incidence of transfusion, and the presence or absence of symptoms of anemia. Statistical analysis was preformed using Student t test for normally distributed data and Mann-Whitney U test. During the study period, 743 (30.3%) of the 2450 deliveries recorded were cesarean section. Of these cesareans, 421 (56.6%) were found to be unplanned and uneventful surgeries performed in low-risk women who had no postoperative signs or symptoms for anemia. The mean hemoglobin of the low-risk asymptomatic women was 11.7 ± 1.99 g/dL, preoperatively and 11.24 ± 1.99 g/dL, postoperatively (P < 0.001). Postoperatively, a drop in hemoglobin concentrations occurred in 72% of the patients, whereas an increase was found in 24.5%, and there was no change in 3.5%. A drop of more than 30% in hemoglobin concentration was found in only 1 woman who showed no signs of hemodynamic instability or occult bleeding and was not transfused. The investigators conclude from these findings that routine postoperative hemoglobin testing for low-risk women undergoing uneventful, unplanned cesarean sections has no effect on postoperative management and does not improve detection of patients requiring blood transfusion.

Efficacy and safety of VEPTR instrumentation for progressive spine deformities in young children without rib fusions.

This retrospective study analyses 23 children treated with vertical expandable prosthetic titanium rib (VEPTR) for correction of non-congenital early onset spine deformities. After the index procedure (IP), the device was lengthened at 6-month intervals. The average (av) age at the time of IP was 6.5 years (1.11-10.5). The av follow-up time was 3.6 years (2-5.8). Diagnosis included 1 early onset idiopathic scoliosis, 11 neuromuscular, 2 post-thoracotomy scoliosis, 1 Sprengel deformity, 2 hyperkyphosis, 1 myopathy and 5 syndromic. Surgeries (187) included 23 IPs, av 6.5 (4-10) device expansions per patient (149) and 15 unplanned surgeries. 23 complications (0.13 per surgery) included 10 skin sloughs, 5 implant dislocations, 2 rod breakages and 6 infections. Coronal Cobb angle was av 68 degrees (11 degrees -111 degrees ), at follow-up av 54 degrees (0 degrees -105 degrees). Pelvic obliquity was av 33 degrees (13 degrees -60 degrees ), at follow-up av 16 degrees (0 degrees -42 degrees ). T1 tilt was av 29 degrees (5 degrees -84 degrees ), two remained unchanged, the remainder improved 10 degrees -68 degrees. Sagittal plane: All but two had stable profiles, two hyperkyphosis of 110 degrees /124 degrees improved to 56 degrees /86 degrees. Space available for lung ratio was less than 90% in ten before the IP, improved in nine and deteriorated in one. Originally designed for thoracic insufficiency syndromes related to rib and vertebral anomalies, VEPTR proved to be a valuable alternative to dual growing rods for non-congenital early onset spine deformities. The complication rate was lower, the control of the sagittal plane and the pelvic obliquity was as good, but the correction of the coronal plane deformity was less than growing rods. However, VEPTR's spine-sparing approach might provoke less spontaneous spinal fusion and ease the final correction at maturity.

Open Reduction Internal Fixation versus Primary Arthrodesis for Lisfranc Injuries: A Prospective Randomized Study

Dislocations and fracture-dislocations involving the tarsometatarsal joint are a relatively common injury. These injuries are associated with long-term disability from subsequent painful osteoarthritis and residual deformity. This study evaluated whether performing a primary arthrodesis (PA) resulted in improved functional outcome and fewer subsequent surgeries as compared to primary open reduction and internal fixation (PORIF). Forty patients with acute tarsometatarsal joint fractures or fracture dislocations were prospectively randomized to undergo either PORIF or PA. Clinical and radiographic examination, in addition to Short Form-36 (SF-36) and Short Musculoskeletal Function Assessment (SMFA) questionnaires, were evaluated at intervals of 3, 6, 12, and 24 months following surgery in 32 patients. A patient satisfaction phone survey was also performed. The rate of planned and unplanned secondary surgeries, including hardware removal and salvage arthrodesis, between ORIF and PA groups, 78.6% vs. 16.7% was significantly different. No statistically significant differences were found with physical functioning for the PORIF or PA groups with regard to SF-36 or SMFA scores at any followup time interval. However, time from injury had a significant effect with impaired functioning at three months compared to all future intervals. No difference in satisfaction rates were found between PORIF and PA at an average of 53 months in a phone survey. PA of tarsometatarsal joint injuries resulted in a significant reduction in the rate of followup surgical procedures if hardware removal is routinely performed with no significant difference in SF-36 and SMFA outcome scores when compared to PORIF.

Patients with Prosthetic Joint Infection on IV Antibiotics are at High Risk for Readmission

Due to the rise in prosthetic joint implantations, prosthetic joint infections (PJI) are increasing. Most PJI are treated outside the hospital setting via community-based parenteral antiinfective therapy (CoPAT) after initial surgical management, although little is reported about the short-term complications of CoPAT. We therefore ascertained the numbers of unanticipated readmissions, unplanned surgeries, and CoPAT complications within 12 weeks of hospital discharge in patients with PJI on CoPAT. We retrospectively reviewed the charts of 74 patients with PJI. Twenty-seven (73% of readmitted patients) were for unanticipated reasons within 12 weeks of hospital discharge; 16 (43% of readmitted) underwent an unplanned surgery. Nine patients (12% of total cohort) had CoPAT-related adverse events. Our data suggest patients with PJI on CoPAT represent a complex cohort that needs to be monitored closely for complications early after hospital discharge. Level IV, therapeutic study.

Comparison of Bioabsorbable Versus Metallic Implant Fixation for Physeal and Epiphyseal Fractures of the Distal Tibia

Transepiphyseal screw fixation of displaced distal tibial epiphyseal fractures is the most common method of treatment for these intraarticular injuries. Recent literature indicates that retained transepiphyseal metallic screws cause an increase in ankle joint contact pressure, thus favoring screw removal. Our hypothesis is that bioabsorbable screw fixation is an alternative to metallic fixation, which offers similar results without the need for screw removal. This is a retrospective review of distal tibial epiphyseal ankle fractures treated with screw fixation. Two groups, those treated with bioabsorbable screw fixation (group B, n = 24) and those with metallic screw fixation (group M, n = 26), were compared (t test) for differences in clinical and radiographic outcomes. Analysis of demographic data revealed no significant differences between groups for sex, ethnicity, age, and height. Group B was significantly heavier than group M (67.4 vs 55.6 kg; P = 0.0496). Each group had a similar number of Salter-Harris types III and IV medial malleolus fractures and transitional fracture types. There was no significant difference between groups in the time from injury to fixation or in operative time. Radiographically, there were no nonunions in either group, and at final follow-up, 1 patient in group B had distal tibial joint line irregularity versus 3 in group M. Clinically, there were no significant differences between groups in time to full weight bearing or time to full activities.There were fewer complications in group B. A single case of loss of reduction requiring revision fixation occurred in each group. There was one documented growth arrest in group M and 2 suspected growth arrests in each group. Two patients in group M were successfully treated for a superficial wound infection with oral antibiotics. Fourteen patients in group M underwent planned screw removal. Bioabsorbable screw fixation can be used for distal tibial epiphyseal fractures with no increase in operative time, nonunion rate, number of unplanned secondary surgeries, or other complications. The use of bioabsorbable screws eliminates the need for epiphyseal screw removal. A prospective randomized study is planned to eliminate the potential selection bias and to standardize clinical and radiographic follow-up. Level III, case-control study.

Colectomy and the Incidence of Postsurgical Complications Among Ulcerative Colitis Patients With Private Health Insurance in the United States

We sought to describe the types of colectomy, follow-up surgical/diagnostic procedures, and complications occurring within 180 days of colectomy in a population of privately insured individuals with ulcerative colitis (UC). This was a retrospective analysis of claims data of privately insured patients (MarketScan) for the years 2001-2004. We identified a cohort of patients with UC who underwent colectomy. Colectomies were classified into four categories based on the surgery occurring on the first colectomy date: (a) total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA), (b) subtotal colectomy (SC) with ileostomy and Hartmann pouch or ileorectal anastomosis, (c) TPC with ileostomy, and (d) partial colectomy (PC). Follow-up surgical/diagnostic procedures and complications were compared across colectomy categories. A total of 25,586 UC patients were identified, of whom 215 patients had a colectomy and at least 180 days of pre- and postcolectomy follow-up. The colectomy distribution was: TPC-IPAA (52%), SC-ileostomy (22%), TPC-ileostomy (14%), and PC (13%). Within 180 days postcolectomy, 54% of patients had a second colectomy-related surgery (including unplanned surgeries in 15.3%), and 27% had a follow-up diagnostic procedure. Postcolectomy complications included abscesses (11.6% in the first 30 days postcolectomy, 16.3% in the day 31-180 postcolectomy period), fistulas (4.2% early, 6.0% late), and sepsis/pneumonia/bacteremia (7.9% early, 9.3% late). Postcolectomy surgical procedures and complications occur frequently after colectomy in privately insured patients with UC.

Proximal femoral neck penetration after flexible intramedullary nailing for pediatric femur fractures: A rare complication

Flexible intramedullary nailing is a common method used to treat pediatric femur fractures. Complication rates can be high, but most complications are considered minor and do not result in additional unplanned surgeries. Proximal nail penetration is a complication that has only been described once before. The penetration may be asymptomatic, but is still best to be avoided. Two cases of proximal nail penetration of the femoral neck region during nail insertion are presented. A review of the literature with regard to complications and suggestions for avoidance of proximal nail penetration is offered.

Risk Factors for Ulcerative Colitis (UC) Surgery in a Population-Based Cohort

Purpose: We sought to identify clinical and demographic features influencing initial and subsequent surgery in a population-based cohort of UC. Methods: Medical records of Olmsted County residents diagnosed with UC from 1970–2001 were reviewed to identify all surgeries. Colectomies were classified as: total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA), subtotal colectomy (SC) with ileostomy, TPC-ileostomy, and partial colectomy (PC). Planned 2nd-stage surgeries were excluded in counting unplanned follow-up surgeries. Cumulative incidences of initial colectomy from time of diagnosis (dx) and follow-up surgeries from time of colectomy were estimated actuarially. Proportional hazards regression was used to assess association of clinical/demographic features with time to colectomy and time to follow-up surgery (after colectomy). Results: 316 UC pts (57% males) were followed for 3,698 person-yrs. Fifty-three pts (17%) had a surgery for UC, of whom 37 (70%) underwent >1 procedure. See table for cumulative risks of initial colectomy and selected subtypes. Males were more likely to undergo colectomy (hazards ratio[HR], 2.2; 95% CI, 1.1–4.1). Extensive UC was not significantly associated with colectomy (HR, 1.4;95% CI, 0.7–2.6) relative to proctitis/left-sided UC. Use of steroids within 90 days of UC dx was strongly associated with colectomy (HR, 3.2; 95% CI, 1.6–6.5). Initial colectomy subtypes were: TPC-IPAA (62%), SC (6%), TPC-ileostomy (30%), and PC (2%). Second colectomy-related surgeries were common, including ostomy closure in 60%; this varied by colectomy type. The 10-yr cumulative risk of subsequent unplanned surgery was 44.1% overall and varied by colectomy type (see table). Those undergoing TPC-IPAA compared to TPC-ileostomy were 1.9 times more likely to have unplanned follow-up surgeries, but this difference was not significant(95% CI, 0.6–5.9). Conclusion: In this population-based cohort of UC pts, the 20-yr cumulative incidence of colectomy was ∼ 20%. Male gender and early need for corticosteroids were significantly associated with colectomy. The most common surgeries were TPC-IPAA and TPC-ileostomy, and frequent unplanned surgeries post-colectomy were observed.Table: Cumulative Risks