Chronic expanding hematoma after spinal surgery

Background context

Chronic expanding hematoma after spinal surgery is extremely rare, with no case previously reported in the literature.

Purpose

To report a rare case of a chronic expanding hematoma of the spine that occurred 24 years after thoracic laminectomy and spinal cord tumor resection.

Study design

Case report.

Methods

A 71-year-old man presented with a spinal mass located approximately at the level of the sixth thoracic vertebral body. The patient had undergone thoracic laminectomy with tumor resection 24 years previously. The mass had appeared 5 years after this and had gradually enlarged over 19 years.

Results

The tumor was resected en bloc. The lamina and spinous processes had been partially eroded by the tumor at the fifth and sixth thoracic vertebrae, but the dura was intact. Histopathologic examination confirmed the diagnosis of chronic expanding hematoma. The hematoma had not recurred at the 1-year follow-up.

Conclusion

We report herein an extremely rare case of chronic expanding hematoma after spinal surgery. This entity may be considered a late complication after surgery regardless of the number of years that have passed since the index surgery.     

Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries

Background context

Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies.

Purpose

To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions.

Study design

Retrospective cohort study.

Patient sample

Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to 2007.

Outcome measures

Readmissions within 30 days of discharge, excluding readmissions for rehabilitation.

Methods

Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software).

Results

Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%–33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions.

Conclusions

Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit.     

Robot-assisted Laparoscopic Mitrofanoff Appendicovesicostomy Technique and Outcomes of Extravesical and Intravesical Approaches

Background

With growing experience in pediatric robotic surgery, select centers are now performing robot-assisted, laparoscopic Mitrofanoff appendicovesicostomy (RALMA).

Objective

We present our technique and outcomes of RALMA with or without enterocystoplasties and compare stomal outcomes between two different approaches of the appendicovesical anastomosis: an extravesical (EV) anterior bladder approach and an intravesical (IV) posterior bladder approach.

Design, setting, and participants

Data from 18 children who have undergone RALMA since 2008 were retrospectively reviewed. RALMA was performed by one surgeon in an academic setting.

Surgical procedure

The appendix was anastomosed on the posterior wall of the bladder intravesically when concomitant enterocystoplasty was done. Otherwise, the appendix was anastomosed extravesically on the anterior wall of the bladder.

Outcome measurements and statistical analysis

The primary outcome measured was the overall continence rate. Secondary outcomes included the overall complication rate and stomal complications.

Results and limitations

The entire cohort included 18 patients (10 IV, 8 EV). The mean overall operative time was 494.1 min. The mean overall length of hospitalization was 5.2 d. There were five immediate, postoperative complications (all Clavien grade 1): three postoperative ilea, one stomal site infection, and one clogged suprapubic catheter. Median follow-up was 24.2 mo. The overall stomal continence rate was 94.4%. One patient from the IV group required dextranomer/hyaluronic acid copolymer for stomal incontinence. Among the eight patients in the EV cohort, there was one stomal complication of stomal stenosis (Clavien grade 1). Among the 10 patients in the IV cohort, there were two stomal complications requiring revisions (both Clavien grade 3): parastomal hernia and stomal stenosis. Limitations of the study include retrospective design, small number of patients, and lack of direct comparison of approaches given the nature of the surgery.

Conclusions

Our updated outcomes of RALMA with or without enterocystoplasty continue to be encouraging, with a 94.4% continence rate. We believe that anterior EV reimplantation is a feasible option in isolated RALMA.     

Intratumoral hemorrhage because of primary spinal mixed germ cell tumor presenting with atypical radiological features in an adult

Background context

Germ cell tumors are known to arise in the central nervous system, usually in the intracranial regions. However, primary spinal mixed germ cell tumors are extremely rare.

Purpose

This is the first reported case of intratumoral hemorrhage because of a primary spinal mixed germ cell tumor consisting of germinoma and immature teratoma in the conus medullaris of an adult patient that presented with rapid changes on magnetic resonance image (MRI). We report this rare case and discuss the clinical manifestations of an intramedullary spinal mixed germ cell tumor in adult.

Study design

A case report.

Methods

A 42-year-old woman experienced buttock numbness, and a spinal cord tumor was observed on the conus medullaris on MRI. The patient was scheduled for an operation in 1 month, but she developed sudden-onset neurologic deterioration. Rapid progression of the tumor was observed on follow-up MRI. The tumor was removed by emergency surgery and was identified as a primary mixed germinoma and immature teratoma.

Results

The patient received adjuvant chemotherapy and radiotherapy after gross total resection. The neurologic deficit of the patient was relieved, and recurrence of the tumor was not observed 26 months after the surgery.

Conclusions

We present this rare case and emphasize the necessity of precise diagnosis and early treatment of primary spinal germ cell tumor. Close observation on MRI is required after surgery, and adjuvant chemotherapy and radiotherapy should be considered according to the pathologic features.     

Progressive severe kyphosis as a complication of multilevel cervical percutaneous facet neurotomy: a case report

Background context

Percutaneous facet neurotomy is a procedure commonly used for the treatment of pain thought to originate from zygoapophyseal joint dysfunction. Some practitioners have also used this technique to treat cervicogenic headache. Previously reported complications for this procedure have been minimal and have included dysthesias and local pain.

Study design

Case report.

Methods

Bilateral multilevel cervical percutaneous facet neurotomies were used to treat a patient suffering from a chronic headache and neck pain that had failed to respond to extensive medical management.

Results

Within days of completing the bilateral facet neurotomies, the patient developed head drop. Subsequent electromyography revealed denervation of the patient's paraspinous muscles. Initially the patient was managed conservatively in a cervical collar with the hope that he would recover some function. After few years, the patient developed fixed kyphotic deformity. Correction of the patient's deformity required multilevel anterior cervical discectomy and fusion followed by posterior instrumented fusion.

Conclusions

When performing multilevel percutaneous cervical facet neurotomies, there is a risk of paraspinous muscle denervation, and subsequent kyphotic deformity may occur. The likelihood of this rare and previously unreported complication can probably be reduced by proper needle positioning and by minimizing the number of levels at which the procedure is performed.     

Total Phallic Reconstruction in Female-to-Male Transsexuals

Background

The goal of total phallic construction is the creation of a sensate and cosmetically acceptable phallus. An incorporated neourethra allows the patient to void while standing, and the insertion of a penile implant allows the patient to resume sexual activities, thus improving quality of life.

Objective

To report our experience of total phallic construction with the use of the radial artery free flap in female-to-male transsexuals.

Design, settings, and participants

The notes of the 115 patients who underwent total phallic construction with the use of the radial artery–based forearm free flap between January 1998 and December 2008 were reviewed retrospectively.

Measurements

The surgical outcome, cosmesis of the phallus, complications, eventual need for revision surgery, and patient satisfaction were recorded during the follow-up.

Results and limitations

This technique allowed the reconstruction of a cosmetically acceptable phallus in 112 patients; 3 patients lost the phallus due to venous thrombosis in the immediate postoperative period. After a median follow-up of 26 mo (range: 1–270 mo), 97% of patients are fully satisfied with cosmesis and size of the phallus. Sensation of the phallus was reported by 86% of patients. Urethral strictures and fistulae in the phallus and join-up site were the most common complications, occurring respectively in 9 and 20 patients; however, after revision surgery, 99% of patients were able to void from the tip of the phallus while standing.

Conclusions

The radial artery–based forearm free flap technique is excellent for total phallic construction, providing excellent cosmetic and functional results.     

Primary amyloidoma in epidural and paravertebral space of the lumbar spine

Background context

Localized amyloid deposits result in a mass, that is, so-called amyloidoma; it has been reported in every anatomic site, although systemic amyloid deposition is much more common. However, primary lumbar epidural amyloidoma without bony involvement is extremely rare. To the best of our knowledge, only one case has been reported previously.

Purpose

To report and review the clinical presentations, imaging studies, and treatment of epidural and paravertebral amyloidoma.

Study design

A case report and review of the literature.

Methods

Lumbar epidural and paravertebral amyloidoma in a 75-year-old man with neurologic compromise is presented. Laminectomy with mass resection was performed.

Results

After surgery, almost complete neurologic improvement was observed. Histologically, definite diagnosis was obtained only after the specific staining of tissue. No sign of local recurrence was evident 1 year after surgery.

Conclusions

Primary amyloidoma, although rare, should be included in the differential diagnosis of epidural mass of the spine. Diagnosis before surgery is difficult as there were no characteristic findings in clinical and imaging studies. Special histologic technique and stains are useful to make a definite diagnosis.     

Robotic Kidney Transplantation with Regional Hypothermia: A Step-by-step Description of the Vattikuti Urology Institute–Medanta Technique (IDEAL Phase 2a)

Background

We recently reported on preclinical and feasibility studies (Innovation, Development, Exploration, Assessment, Long-term study [IDEAL] phase 0–1) of the development of robotic kidney transplantation (RKT) with regional hypothermia. This paper presents the IDEAL phase 2a studies of technique development.

Objectives

To describe the technique of RKT with regional hypothermia developed at two tertiary care institutions (Vattikuti Urology Institute and Medanta Hospital). We report on the safety profile and early graft function in these patients.

Design, setting, and participants

This is a prospective study of 50 consecutive patients who underwent live-donor RKT at Medanta Hospital following a 3-yr planning/simulation phase at the Vattikuti Urology Institute. Demographic details, and perioperative and postoperative outcomes are reported for the initial 25 recipients who have completed a minimum 6-mo follow-up.

Surgical procedure

Positioning and port placement were similar to that used for robotic radical prostatectomy. Allograft cooling was achieved by ice slush delivered through a GelPOINT device. The accompanying video details the operative technique.

Outcome measurements and statistical analysis

The primary outcome was posttransplant graft function. Secondary outcomes included technical success or failure and complication rates.

Results and limitations

Fifty patients underwent RKT successfully, 7 in the phase 1 and 43 in the phase 2 stages of the study. For the initial 25 patients, mean console, warm ischemia, arterial, and venous anastomotic times were 135, 2.4, 12, and 13.4 min, respectively. All grafts were cooled to 18–20°C with no change in core body temperature. All grafts functioned immediately posttransplant and the mean serum creatinine level at discharge was 1.3 mg/dl (range: 0.8–3.1 mg/dl). No patient developed anastomotic leaks, wound complications, or wound infections. At 6-mo of follow-up, no patient had developed a lymphocele detected on CT scanning. Two patients underwent re-exploration, and one patient died of congestive heart failure (1.5 mo posttransplant).

Conclusions

RKT with regional hypothermia is safe and reproducible when performed by a team skilled in robotic surgery.

Patient summary

RKT is safe and effective when performed by surgeons experienced in robotic techniques.     

Utilization of morning report by acute care surgery teams: results from a qualitative study

Background

The rigor of handoffs is increasingly scrutinized in the era of shift-based patient care. Acute care surgery (ACS) embraced such a model of care; however, little is known about handoffs in ACS programs.

Methods

Eighteen open-ended interviews were conducted with ACS leaders representing diverse geographic and practice settings. Two independent reviewers analyzed interviews using an inductive approach to elucidate themes regarding use of morning report (using NVivo qualitative analysis software).

Results

Twelve of 18 respondents reported using morning report, but only 6 of 12 included attending surgeon–to–attending surgeon handoffs. One of 12 incentivized attending surgeons to participate, 2 of 12 included nursing staff members, and 2 of 12 included physician extenders. Cited benefits of morning report were safe and effective information exchange (2 of 12), quality improvement (2 of 12), multidisciplinary discussion (1 of 12), and resident education (2 of 12). Three of 12 respondents cited time commitment as the main limitation of morning report.

Conclusions

Morning report is underused among ACS programs; however, if implemented strategically, it may improve patient care and resident education.     

Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) Classification of Renal Tumours in Patients who are Candidates for Nephron-Sparing Surgery

Background

Besides clinical tumour size, other anatomical aspects of the renal tumour are routinely considered when evaluating the feasibility of elective nephron-sparing surgery (NSS).

Objective

To propose an original, standardised classification of renal tumours suitable for NSS based on their anatomical features and size and to evaluate the ability of this classification to predict the risk of overall complications resulting from the surgery.

Design, setting, and participants

We enrolled prospectively 164 consecutive patients who underwent NSS for renal tumours at a tertiary academic referral centre from January 2007 to December 2008.

Intervention

Open partial nephrectomy without vessel clamping.

Measurements

All tumours were classified by integrating size with the following anatomical features: anterior or posterior face, longitudinal, and rim tumour location; tumour relationships with renal sinus or urinary collecting system; and percentage of tumour deepening into the kidney. We generated an algorithm evaluating each anatomical parameter and tumour size (the preoperative aspects and dimensions used for an anatomical [PADUA] score) to predict the risk of complications.

Results and limitations

Overall rates of complication were significantly correlated to all the evaluated anatomical aspects, excluding clinical size and anterior or posterior location of the tumour. By multivariate analysis, PADUA scores were independent predictors of the occurrence of any grade complications (hazard ratio [HR] for score 8–9 vs 6–7: 14.535; HR for score ≥10 vs 6–7: 30.641). Potential limitations were the limited number of patients with T1b tumours included in the study and the lack of laparoscopically treated patients. Further external validation of the PADUA score is needed.

Conclusions

The PADUA score is a simple anatomical system that can be used to predict the risk of surgical and medical perioperative complications in patients undergoing open NSS. The use of an appropriate score can help clinicians stratify patients suitable for NSS into subgroups with different complication risks and can help researchers evaluate the real comparability among patients undergoing NSS with different surgical approaches.     

Major abdominal surgery in octogenarians: should high age affect surgical decision-making?

Background

Over the last decades longevity has increased significantly, with more octogenarians undergoing surgery. Here, we assess surgical outcomes after major abdominal surgery in octogenarians.

Methods

Observational cohort of 874 patients undergoing major abdominal elective surgery between January 2009 and March 2014. Seventy-six octogenarians were propensity matched to 76 younger patients, corrected for sex, body mass index, American Society of Anesthesiologists classification, comorbidity, indication, and type of surgery.

Results

Minor complications were more prevalent in octogenarians (P = .01) and consisted mainly of respiratory complications; progressing to respiratory insufficiency requiring intubation in 28.6%. Preoperative weight loss (odds ratio 3 [1.1 to 8.3]) and upper gastrointestinal surgery (odds ratio 11 [2 to 60]) were associated with minor complications.

Conclusions

Octogenarians are at increased risk of minor complications after major abdominal surgery. Major complication rates were similar, indicating the importance of preoperative assessment and standardized surgical techniques. Taking into account preoperative morbidities and type of surgery and techniques. Implementation of quality control algorithms may further improve outcomes in octogenarians.     

Feasibility of Transvaginal NOTES-Assisted Laparoscopic Nephrectomy

Background

Recently, the feasibility of a transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy was demonstrated in a 23-yr-old woman with a nonfunctional atrophic kidney.

Objective

To evaluate the feasibility and reproducibility of transvaginal NOTES-assisted laparoscopic nephrectomy in female patients with and without renal cancer.

Design, setting, and participants

Between March 2008 and June 2009, 14 female patients were submitted to transvaginal NOTES-assisted laparoscopic nephrectomy for T1–T3a N0M0 renal cancer (n = 10), lithiasis (n = 2), or renal atrophy (n = 2) at the Hospital Clinic of Barcelona, Spain.

Surgical procedure

Under general anaesthesia, female patients underwent laparoscopic nephrectomy by transvaginal NOTES using a deflectable camera by vaginal access and two additional 5- and 10-mm trocars in the abdomen. The renal artery and vein were dissected and taken separately between clips. The dissected kidney was removed via the vagina after enlarging the vaginal trocar incision.

Measurements

All data referring to patient demographics, surgery, pathology, and perioperative outcomes were recorded.

Results and limitations

The procedure was completed in all patients. The mean age of the women was 59.1 yr. The mean operative time was 132.9 min and the mean estimated blood loss was 111.2 ml. None of the patients required a blood transfusion and the use of analgesics was low. The mean hospital stay was 4 d. In one case, a major complication (a colon injury) occurred. The patient underwent surgery and a temporary colostomy was performed. The patient has already undergone reconstruction.

Conclusions

Transvaginal NOTES-assisted laparoscopic nephrectomy is feasible and reproducible and may be an alternative technique for treatment of women with renal cancer. Proper selection of patients is warranted for success of this new approach. However, longer follow-up in an increasing number of patients is needed to establish its role in the treatment of renal cancer.     

Postoperative spinal deformity after treatment of intracanal spine lesions

Background context

Surgical treatment of intracanal (both intramedullary and extramedullary) spine lesions requires posterior decompressive techniques in nearly all instances. Postoperative spinal deformities, most notably sagittal and coronal decompensation, are of significant concern for both the patient and the spinal surgeon.

Purpose

To review and define principles and features of spinal deformities after posterior spinal decompression for intracanal spinal lesions, and to define patients who may benefit from the concomitant spinal fusion.

Methods

A systematic review of MEDLINE was conducted, including articles published between 1980 and 2011. Articles related to spinal deformities after posterior decompression for the treatment of intracanal spine lesions were identified.

Results

Ten articles met all inclusion and exclusion criteria. All were case series with limited evidence (Level IV). Many risk factors to deformity were implied but with limited evidence. Young age was the most commonly identified risk in these articles.

Conclusions

Spinal deformity after posterior decompression is a common complication, most notably in children and young adults, after the removal of intramedullary tumors. Many risk factors have been implied to increase the postoperative development of spinal deformity, including young age, laminectomy extension, preoperative deformity, and extensive facet resection, among others. However, there is a lack of high-quality evidence to propose an algorithm for treatment or preventive measures. New studies with larger series of patients and standardized clinical outcomes are necessary to establish optimal treatment protocols.     

Huge thoracolumbar extradural arachnoid cyst excised by recapping T-saw laminoplasty

Background context

Spinal extradural arachnoid cysts are rare expanding lesions in the spinal canal. Total removal of the cyst and repair of the dural defect is the primary treatment for symptomatic spinal extradural arachnoid cysts.

Purpose

To report the usefulness of recapping T-saw laminoplasty in treating huge extradural arachnoid cyst.

Study design

Case report.

Methods

We report the case of a 43-year-old man who presented with a 2-year history of progressive muscle weakness and numbness of the lower extremities. Magnetic resonance imaging (MRI) showed a huge extradural arachnoid cyst at the T12–L3 level extending into bilateral neural foramina and severe posterior compression of the spinal cord and cauda equina.

Results

The patient underwent total resection of the cyst and closure of the communication. En bloc recapping T-saw laminoplasty of T12–L2 including the T12–L1 and L1–L2 facet joints was performed to obtain extensive exposure and preserve posterior stability. Postoperatively, the patient achieved complete recovery of neurologic functions. Follow-up MRI demonstrated no recurrence of the cyst. Bone union after laminoplasty was obtained within 6 months.

Conclusion

Total resection of the cyst and closure of the communication is curative for this rare lesion. Recapping T-saw laminoplasty provides extensive exposure for removal of a large cyst while allowing complete preservation of the posterior spinal elements.     

Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

Background

Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery.

Objective

To assess the feasibility of LESS radical nephrectomy (LESS-RN).

Design, setting, and participants

Ten patients with body mass index (BMI) ≤30 underwent LESS-RN for renal tumour by two experienced laparoscopists.

Surgical procedure

TriPort (Olympus Winter &; Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30° camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed.

Measurements

Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded.

Results and limitations

Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4–8 cm). The mean patient age was 63.5 yr (22–77 yr), and median BMI was 23.56 (18.2–26.6). The mean operative time was 146.4 min (120–180 min), and the mean blood loss was 202 ml (50–900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted.

Conclusions

LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.     

Outcomes of thyroidectomy from a large California state database

Background

Thyroidectomy is an operation with infrequent but potentially significant complications. This study aimed to determine risk factors for complication after thyroidectomy in California.

Methods

The California Office of Statewide Health Planning and Development database was retrospectively analyzed from 1995 to 2010. Main outcome measures were complications including death. Logistic regression identified risk factors for complications.

Results

There were 106,773 patients; 61% were women and 44% Caucasian; 16,287 (15%) thyroidectomies were performed at high-volume centers. Complication rates included voice change (.5%), vocal cord dysfunction (1.1%), hypocalcemia (4.5%), tracheostomy (1.62%), hematoma (1.75%), and death (.3%). There was significantly increased risk of complications for patients older than 65 compared with those younger than 40 years (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.3; P < .01). High-volume hospitals were protective against complication (odds ratio, .8; 95% confidence interval, .6 to .97; P = .026).

Conclusions

Older age was a significant risk factor for complication after thyroidectomy. High-volume hospitals had lower risk. This information is useful in counseling patients about the risks of thyroid surgery.     

EAU Policy on Live Surgery Events

Context

Live surgery is an important part of surgical education, with an increase in the number of live surgery events (LSEs) at meetings despite controversy about their real educational value, risks to patient safety, and conflicts of interest.

Objective

To provide a European Association of Urology (EAU) policy on LSEs to regulate their organisation during urologic meetings.

Evidence acquisition

The project was carried out in phases: a systematic literature review generating key questions, surveys sent to Live Surgery Panel members, and Internet- and panel-based consensus finding using the Delphi process to agree on and formulate a policy.

Evidence synthesis

The EAU will endorse LSEs, provided that the EAU Code of Conduct for live surgery and all organisational requirements are followed. Outcome data must be submitted to an EAU Web-based registry and complications reported using the revised Martin criteria. Regular audits will take place to evaluate compliance as well as the educational role of live surgery.

Conclusions

This policy represents the consensus view of an expert panel established to advise the EAU. The EAU recognises the educational role of live surgery and endorses live case demonstration at urologic meetings that are conducted within a clearly defined regulatory framework. The overriding principle is that patient safety must take priority over all other considerations in the conduct of live surgery.

Patient summary

Controversy exists regarding the true educational value of live surgical demonstrations on patients at surgical meetings. An EAU committee of experts developed a policy on how best to conduct live surgery at urologic meetings. The key principle is to ensure safety for every patient, including a code of conduct and checklist for live surgery, specific rules for how the surgery is organised and performed, and how each patient's results are reported to the EAU. For detailed information, please visit www.uroweb.org.     

Time to surgery and 30-day morbidity and mortality of periprosthetic hip fractures

Background and aim

The management of femoral periprosthetic fractures following hip replacement surgery is a complex and challenging situation. Whilst the early complications for both primary hip arthroplasty and proximal femoral fracture surgery have been widely documented, there is a paucity of published data regarding early outcomes following periprosthetic fracture surgery.Delay to surgery for native proximal femoral fractures has been clearly documented as a predictor towards adverse outcome. This study therefore aims to correlate the timing of operative intervention with the complication rate following periprosthetic fracture surgery. In addition, the study aims to identify further factors in the perioperative period that positively predict a poor postoperative outcome.

Methods

Sixty patients who were operatively managed for a femoral implant periprosthetic fracture were identified and each case assessed retrospectively.

Results and conclusion

There was an overall complication rate of 45% including a 30-day mortality of 10%. An abbreviated mental test score of 8 out of 10 or less and a delay to surgery of >72 h were found to be significant risk factors for adverse outcome. Both the patient cohort in this study and the predictors for poor postoperative outcome were comparable to those for native proximal femoral fractures.     

Laparoscopic radiofrequency ablation for traumatic splenic rupture

Background

Laparotomy was formerly the routine approach for treating traumatic splenic rupture. Traumatic splenic rupture has traditionally been treated with open splenectomy. The advent of laparoscopy and radiofrequency ablation (RFA) has ushered in new approaches to this surgical problem. The purpose of this study was to evaluate the use of laparoscopic RFA to treat traumatic splenic rupture.

Methods

Four patients with traumatic splenic ruptures underwent laparoscopic RFA-assisted spleen-preserving surgery between September 2011 and April 2012. RFA electrodes were used for traumatic rupture repair or partial splenectomies using classic laparoscopic procedures. Safety and efficacy parameters were documented, including surgery time, intraoperative blood loss, postoperative drainage quantities, and recovery conditions.

Results

Three patients received laparoscopic splenic rupture repair and one patient received a partial splenectomy. Three surgeries were successful, based on 1-mo follow-up with computerized tomography and ultrasound examinations that indicated the restoration of satisfactory splenic blood supply. The fourth patient received a laparotomy for a total splenectomy because of massive postoperative bleeding 24 h after surgery.

Conclusions

Laparoscopic RFA-assisted spleen-preserving surgery is another modality that may be considered in the management of splenic trauma. This small sample size and limited clinical experience does not justify its use on a routine basis and requires additional clinical research to fully evaluate its efficacy in certain critical traumatic scenarios compared with traditional open splenectomy.