Reoperative Surgery for Chronic Pancreatitis: Is It Safe?

Introduction Eleven percent to fifty-six percent of patients do not achieve adequate pain relief with initial operative treatment for chronic pancreatitis, and reoperations for recurrent or persistent pain are common. This study evaluates the influence of prior pancreatic procedures on operative morbidity for chronic pancreatitis. Methods The records of 336 consecutive patients who underwent pancreaticoduodenectomy (PD, n = 78), lateral pancreaticojejunostomy (LPJ, n = 152), distal pancreatectomy (DP, n = 83), transduodenal sphincteroplasty (SP, n = 20), and total pancreatectomy (TP, n = 3) for chronic pancreatitis were retrospectively reviewed and analyzed. Results Seventy-four patients underwent reoperation after failed prior pancreatic surgery. Patients with de novo pancreatic operations had a similar complication rate as those with reoperation (PD: 48% versus 65%, P > 0.05; LPJ: 23% versus 23%, P > 0.05; DP: 26% versus 28%, P > 0.05; SP: 21% versus 100%, P > 0.05). Major complications such as pancreatic leak or abdominal abscess were similar in the two groups. Minor complications such as delayed gastric emptying or wound infections were more common in the reoperation group. There was no difference in postoperative hospital length of stay. Conclusions Patients who undergo reoperative surgery for chronic pancreatitis have an increased risk for minor perioperative complications. The overall complication rate and the incidence of major complications are similar compared to de novo procedure. Reoperative surgery therefore appears feasible and safe in experienced hands.     

Femoral Neck Notching in Dual Mobility Implants: Is This a Reason for Concern?

BackgroundDual mobility (DM) total hip arthroplasty (THA) implants have been advocated for patients at risk for impingement due to abnormal spinopelvic mobility. Impingement against cobalt-chromium acetabular bearings, however, can result in notching of titanium femoral stems. This study investigated the incidence of femoral stem notching associated with DM implants and sought to identify risk factors.MethodsA multicenter retrospective study reviewed 256 modular and 32 monoblock DM components with minimum 1-year clinical and radiographic follow-up, including 112 revisions, 4 conversion THAs, and 172 primary THAs. Radiographs were inspected for evidence of femoral notching and to calculate acetabular inclination and anteversion. Revisions and dislocations were recorded.ResultsTen cases of femoral notching were discovered (3.5%), all associated with modular cylindrospheric cobalt-chromium DM implants (P = .049). Notches were first observed radiographically at mean 1.3 years after surgery (range 0.5-2.7 years). Notch location was anterior (20%), superior (60%), or posterior (20%) on the prosthetic femoral neck. Notch depth ranged from 1.7% to 20% of the prosthetic neck diameter. Eight cases with notching had lumbar pathology that can affect spinopelvic mobility. None of these notches resulted in stem fracture, at mean 2.7-year follow-up (range 1-7.6 years). There were no dislocations or revisions in patients with notching.ConclusionFemoral notching was identified in 3.5% of DM cases, slightly surpassing the dislocation rate in a cohort selected for risk of impingement and instability. Although these cases of notching have not resulted in catastrophic failures thus far, further study of clinical sequelae is warranted. Component position, spinopelvic mobility, and implant design may influence risk.     

Overnight Admission After Total Ankle Replacement: Is It Safe?

To evaluate readmission, complication, and nonscheduled contact rates to the out-patient clinic within the first 3 months following total ankle replacement in patients planned for overnight admission. Data were collected retrospectively on all patients treated during the period the December 11, 2015 to the December 1, 2019 with 3 months of follow-up for all patients. In the study 116 patients were included. No difference in patient characteristics, readmission rates, complication rates or number of nonscheduled contacts to the outpatient clinic was found between patients discharged after 1 day when compared to those admitted >1 day. Around 58.6% was discharged as planned. The overall readmission and complication rates were 2.6% and 6.0% respectively, 20.7% had a nonscheduled contact to the out-patient clinic. No differences in prevalence of the different complications, reasons for readmission or reasons for contact to the out-patient clinic were found between overnight admission and inpatient admission. Total ankle placement with overnight admission is safe, but patient selection with a thorough plan for analgesics after discharge and optimal cast appliance is necessary.     

Outpatient Simultaneous Bilateral Total Knee Arthroplasty: Is It Safe?

BackgroundIt is currently unknown if simultaneous bilateral total knee arthroplasty (si-BTKA) can also be safely performed in the outpatient setting. The primary aim of this study was to compare 30-day postoperative complication rates between outpatient and inpatient si-BTKA.MethodsAdults undergoing simultaneous bilateral total knee arthroplasty (si-BTKA) from 2015-2019 were queried using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Our primary analysis compared the rates of complications between outpatient si-BTKA and inpatient si-BTKA using bivariate comparisons and multivariable logistic regression of outpatient and inpatient cases controlling for differences in baseline demographics and comorbidities.ResultsFrom 2015 to 2019, the utilization of outpatient si-BTKA increased from 0.6% to 10.5%. Outpatient si-BTKA were found to have significantly lower odds of any complication (OR = 0.49), minor complication (OR = 0.50), and postoperative transfusion (OR = 0.66) compared to inpatient cases. Outpatient si-BTKA also had a significantly shorter operative time.ConclusionCompared to inpatient si-BTKA, patients who undergo outpatient si-BTKA do not demonstrate increased rates of any complication, severe complications, and minor complications within 30-days postoperatively. Further insight is needed on the effect of outpatient si-BTKA on long-term outcomes.     

Is It Safe to Initiate Selective Cerebral Perfusion with Normothermia?

OBJECTIVE: Preceding selective cerebral perfusion (P-SCP) is a method whereby SCP and systemic perfusion start simultaneously, and the arch vessels are clamped. Cerebral circulation is isolated from systemic circulation to avoid cerebral embolization due to detachment of atherosclerotic material from the aorta, caused by the "sandblasting" effect of high-velocity jets of blood exiting the aortic cannula. However, neither the safety of SCP at normothermia nor the influence of extended SCP time has been sufficiently clarified. To clarify the safety of P-SCP, the comparison study of P-SCP and conventional SCP (C-SCP) was performed retrospectively. METHODS: Fifty-seven patients (C-SCP group: 29 patients; P-SCP: 28 patients) underwent surgery between 1992 and 2002. RESULTS: Nine (15.8%) in-hospital death occurred; 4 in the C-SCP group (13.8%) and 5 in the P-SCP group (17.9%) (NS). The SCP time was 136.6 +/- 68.5 minutes in the C-SCP group and 195.8 +/- 30.7 minutes in the P-SCP group (p < 0.05). One patient in each group exhibited postoperative neurological dysfunction. CONCLUSION: It may be little dangerous to initiate the SCP with normothermia. P-SCP may be useful in cases in which there is pedunculated atherosclerotic material, or mural thrombus in the ascending and arch aorta.     

Buddy Taping: Is It a Safe Method for Treatment of Finger and Toe Injuries?

Background

Buddy taping is a well known and useful method for treating sprains, dislocations, and other injuries of the fingers or toes. However, the authors have often seen complications associated with buddy taping such as necrosis of the skin, infections, loss of fixation, and limited joint motion. To our knowledge, there are no studies regarding the complications of buddy taping. The purpose of this study was to report the current consensus on treating finger and toe injuries and complications of buddy taping by using a specifically designed questionnaire.

Methods

A questionnaire was designed for this study, which was regarding whether the subjects were prescribed buddy taping to treat finger and toe injuries, reasons for not using it, in what step of injury treatment it was use, indications, complications, kinds of tape for fixation, and special methods for preventing skin injury. Fifty-five surgeons agreed to participate in the study and the survey was performed in a direct interview manner at the annual meetings of the Korean Pediatric Orthopedic Association and Korean Society for Surgery of the Hand, in 2012.

Results

Forty-eight surgeons (87%) used buddy taping to treat finger and toe injuries, especially proximal interphalangeal (PIP) injuries of the hand, finger fractures, toe fractures, metacarpophalangeal injuries of the hand, and PIP injuries of the foot. Sixty-five percent of the surgeons experienced low compliance. Forty-five percent of the surgeons observed skin injuries on the adhesive area of the tape, and skin injuries between the injured finger and healthy finger were observed by 45% of the surgeons.

Conclusions

This study sheds light on the current consensus and complications of buddy taping among physicians. Low compliance and skin injury should be considered when the clinician treats finger and toe injuries by using buddy taping.     

Is Single-stage Microvascular Reconstruction for Facial Mucormycosis Safe?

Introduction This is a retrospective therapeutic series of eight cases of facial mucormycosis treated over a 15-year period to determine the safety of simultaneous debridement and free-flap reconstruction in facial mucormycosis. Methods Surgical debridement was done for three cases that presented acutely with systemic manifestations (group 1) and five cases that presented in the subacute phase without systemic manifestations (group 2). The debridement involved total maxillectomy with orbital exenteration in three cases, total maxillectomy with orbital preservation in two, and subtotal maxillectomy in three cases. A total of seven out of eight patients underwent reconstruction with free flap for defect closure; in one patient, only primary closure of mucosa was done. Results The mean follow-up was 20.5 months. Two patients with acute disease, where reconstruction was done, died in the postop period (on the 27th and 6th day post reconstruction, respectively) due to continuing infection and septic shock. One of the three (group 1), who presented acutely and underwent debridement alone, survived. Four of five patients in group 2 underwent successful free-flap reconstruction. The patient with free-flap loss was salvaged with an extracorporeal radial forearm flap. All except one patient had a soft-tissue free-flap reconstruction. Three of the six living patients reported for secondary surgery. The inability to achieve clear nonnecrotic surgical margins due to extensive disease was the reason for mortality in two patients in group 1. There was no mortality in any of the group 2 patients, even when debridement and free-flap coverage was done simultaneously. Conclusion Simultaneous debridement and free flap can be successfully implemented in select cases of facial mucormycosis     

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BackgroundWith the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.MethodsGeriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.ResultsThis study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).ConclusionOverall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.     

Long-Term Consequences of Complex Living Renal Donation: Is It Safe?

Introduction

As there is a paucity of literature regarding the long-term outcomes of complex living donors, we conducted this study to assess the effect of kidney donation on the complex living kidney donor.

Is It Possible and Safe to Perform Acetabular-preserving Resections for Malignant Neoplasms of the Periacetabular Region?

Background

Primary malignant tumors located near the acetabulum are usually managed by resection of the tumor with wide margins that include the acetabulum. These resections are deemed P2 resections by the Enneking and Dunham classification. There are various methods to perform the subsequent hip reconstruction. Unfortunately, there is no consensus as to the best management. In general, patients undergoing resection at this level will have substantial levels of pain and disability as measured by the Musculoskeletal Tumor Society (MSTS) scoring system. We believe there is a subset of patients whose tumors in this location can be resected while preserving all or most of the weightbearing acetabulum using navigation and careful surgical planning.

Questions/purposes

(1) What complications were associated with this resection; (2) what oncological outcomes (histological margins and local recurrence) were achieved; and (3) what is the function achieved by these patients?

Methods

This was a retrospective study of patients with periacetabular primary malignancy. From 2008 to 2014, we treated 12 patients who had periacetabular primary malignant tumors and in five, we performed resection with the weightbearing portion spared. During this period, our general indications to perform a resection that spared the acetabulum were the tumor with its resection margin not involving the weightbearing portion of the acetabulum. However, we did not perform this procedure in patients who had more cranial lesion involving the weightbearing portion or whose hip stability might be in question after the tumor excision. Three patients were women and the other two were men. Four were chondrosarcomas, whereas the other one was synovial sarcoma. Ages ranged from 46 to 60 years (average, 53 years). Minimum followup was 14 months (median, 37 months; range, 14–88 months); no patients were lost to followup before a 1-year minimum was achieved, and all patients have been seen within the last 9 months.

Results

There were no intraoperative or early postoperative complications. None of the five patients had a positive margin by histological assessment. No local recurrences were detected. The median functional score by MSTS was 28 out of 30 (range, 27–30).

Conclusions

The roof of the acetabulum is the weightbearing portion of the acetabulum. It also maintains the stability of the hip. With precise preoperative planning of the resection and accurate execution of the procedure, the hip-sparing approach through partial acetabular resection can be performed in selected patients with malignant periacetabular neoplasms. Navigation makes it possible to minimize the amount of bone resection. In this preliminary report of a small number of patients, we had adequate short-term local tumor control. We believe the function is good, but we do not have a comparison group of patients to document improved function.

Level of Evidence

Level IV, therapeutic study.

     

Damage Assessment of Retrieved Birmingham Monoblock Cups: Is Conversion to Dual-Mobility Head a Viable Revision Option?

Background

A novel revision technique for failed hip resurfacings involves retention of the acetabular cup, if well-fixed, which is mated to dual-mobility (DM) prosthesis in a traditional hip replacement configuration. It is unknown whether existing damage on the retained cup will result in unacceptable wear of the DM prosthesis.