Surfing injuries: A US epidemiological study from 2009–2020

BackgroundThe sport of surfing has grown exponentially. Early studies of surfing injuries are outdated as newer and more accessible surf technology has become available. This study's goal was to describe surfing injury patterns, incidence, and disposition of pediatric and adult surfers.Study designA retrospective review of surfing injuries from 2009 to 2020 of adult (>18 years of age) and pediatric (<18 years of age) patients was performed using the National Electronic Injury Surveillance System (NEISS) database. The consumer product code 1261 (Surfing) was used to identify injury patterns. Chi-squared test was performed on all categorical variables. Logistic regression was used on significant variables from the frequency tables. All analysis was performed with R-statistical programming software.ResultsThere was an overall decreasing trend of surfing injuries over time. Injuries for both adult and pediatric patients tended to occur most within the summer season (p<0.001). The odds of an adult surfing injury victim being male is 2.89 (95% CI 1.87–4.44). The head/neck/face were the most injured body part in both groups. The pediatric group had a significantly higher rate of concussions at 6.5% compared to the adult group at 3.2%. Overall, the most common injury type was to the skin (p<0.001). Disposition between groups were similar with most patients being discharged home. Mortality was rare with three reported fatalities in the adult group and none in the pediatric group.ConclusionThe incidence of surfing injuries is continuing to decline despite more people surfing, revealing the improved safety of the sport over the last decade. Head/neck/face injuries are common injury locations, and pediatric surfers are particularly at increased risk of concussions. Continued education, usage of safety equipment such as protective headgear, and awareness of injury patterns, could further lessen potential injuries.     

Fate of mild aortic valve disease after mitral valve intervention

OBJECTIVE: This study was performed to assess the long-term outcome of untreated mild aortic valve disease present at the time of initial mitral valve intervention. METHODS: A total of 284 patients with rheumatic heart disease aged 7 to 62 years (mean, 23.5 +/- 12.2 years) who underwent mitral valve intervention and had mild aortic valve disease initially were followed up for 2 to 18 years (mean, 10.8 +/- 3.7 years). At initial intervention, 232 patients had pure mild aortic regurgitation, and 52 patients had mild aortic stenosis with or without aortic regurgitation. RESULTS: Among patients with mild aortic regurgitation initially, 11 (5%) patients progressed to moderate (n = 6) or severe (n = 5) regurgitation over an interval of 9 to 17 years (mean, 12.1 +/- 2.8 years), and 1 patient had moderate aortic stenosis and severe aortic regurgitation after 10 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic regurgitation was 100%, 97.0% +/- 1.7%, and 87.4% +/- 4.6% at 5, 10, and 15 years, respectively. Seventeen (35%) patients with initial mild aortic stenosis (with or without regurgitation) had moderate or severe stenosis (with or without moderate-severe regurgitation) after an interval of 4.9 +/- 3.8 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic stenosis was 75.6% +/- 6.2%, 61.5% +/- 8.5%, and 46.1% +/- 11.2% at 5, 10, and 15 years, respectively. Ten patients required aortic valve replacement for aortic valve dysfunction. CONCLUSIONS: Mild aortic regurgitation present at the time of mitral valve intervention progresses very slowly and less frequently requires reintervention. However, mild aortic stenosis diagnosed initially progresses more often and more rapidly and thus needs closer follow-up.     

Car surfing: case studies of a growing dangerous phenomenon

Car surfing is a dangerous new pastime for American youth. Car surfing is an activity that is defined as standing (or lying) on a vehicle while it is being driven. This activity frequently results in severe injuries that often require significant surgical intervention. Despite its destructive nature, however, there are many Internet sites that encourage this behavior and view it as amusing. As a result, car surfing is becoming increasingly popular. We conducted a retrospective chart review of all patients injured as a result of car surfing over the last 4 years at our Urban Level II trauma center. Data collected included Injury Severity Score (ISS), Revised Trauma Score (RTS), age, gender, injury pattern, surgical intervention, and length of stay. Eight car surfers were identified. The average age was 17. The average Revised Trauma Score was 6.8 with an average Injury Severity Score of 16.9. Five patients were admitted to the intensive care unit. Four of these five patients needed to be intubated for ventilatory support. Five of the eight patients had significant intracranial injuries. Two patients had epidural hematomas that required evacuation. Two other patients had subdural hematomas that were treated nonoperatively, and one patient had a subarachnoid hemorrhage that was also treated nonoperatively. Four of the eight patients required surgical intervention. There were no deaths in this study. Car surfing leads to severe injuries that can result in significant morbidity. American youth have access to Internet sites that project this activity as an acceptable behavior. Five of our eight patients had a significant intracranial injury. Trauma surgeons need to be more aware of this injury phenomenon.     

Mild acute kidney injury after pediatric surgery is not-associated with long-term renal dysfunction: A retrospective cohort study

Background and study objectiveAcute kidney injury (AKI) is a sudden deterioration in renal function and is common in pediatric patients undergoing cardiac and non-cardiac surgery. Few studies have investigated the association of postoperative AKI with kidney dysfunction seen long-term and other adverse outcomes in pediatric patients. The study aimed to determine the association between postoperative AKI (mild AKI vs. no AKI and mild AKI vs. moderate-severe AKI) and chronic kidney dysfunction (CKD) seen long-term in pediatric patients undergoing cardiac and non-cardiac major surgery.DesignRestrospective, cohort study.SettingTertiary care hospital.PatientsThis retrospective cohort study included patients aged 2–18 years who underwent cardiac and non-cardiac major surgery lasting >2 h at the Cleveland Clinic Main Campus between June 2005 and December 2020.MeasurementsPostoperative AKI and CKD seen in long-term were defined and staged according to the Kidney Disease: Improving Global Outcomes criteria.Main resultsAmong 10,597 children who had cardiac and non-cardiac major surgery, 1,302 were eligible. A total of 682 patients were excluded for missing variables and baseline kidney dysfunction and 620 patients were included. The mean age was 11 years, and 307 (49.5%) were female. Postoperative mild AKI was detected in 5.8% of the patients, while moderate-severe AKI was detected in 2.4%. There was no significant difference in CKD seen in long-term between patients with and without postoperative AKI, p = 0.83. The CKD seen in long-term developed in 27.7% of patients with postoperative mild AKI and 33.3% of patients with postoperative moderate and severe AKI. Patients without postoperative AKI had an estimated 1.09 times higher odds of having CKD seen in long-term compared with patients who have postoperative mild AKI (odds ratio [95% CI] 1.09 [0.48,2.52]).ConclusionIn contrast to adult patients, the authors did not find any association between postoperative AKI and CKD seen in long-term in pediatric patients.     

Pretransplant left ventricular hypertrophy in association with postoperative myocardial injury in liver transplantation

Pretransplant left ventricular hypertrophy (LVH) is a common finding during preoperative cardiac evaluation. We hypothesized that patients with pretransplant LVH were associated with a higher risk of postoperative myocardial injury (PMI) in adult patients undergoing liver transplantation (LT). A retrospective cohort analysis was performed by reviewing the medical records of adult patients who underwent LT between January 2006 and October 2013. Of 893 patients, the incidences of mild, moderate, and severe LVH were 7.8%, 5.6%, and 2.5%, respectively. Propensity match was used to eliminate the pretransplant imbalance between the LVH and non-LVH groups. In after-match patients, 23.5% of LVH patients developed PMI compared to 11.8% in the control group (P = .011). The incidence of PMI in patients with moderate-severe degrees of LVH was significantly higher compared with that in patients with mild LVH (27.9% vs 19.1%, P = .016). When controlling intraoperative variables, patients with LVH had 4.5 higher odds of developing PMI (95% CI1.18-17.19, P = .028). Patients experiencing PMI had significantly higher 1-year mortality (37.5% vs 15.7%, log-rank test P < .001). Our results suggest that patients with pretransplant LVH were at a high risk of developing PMI and should be monitored closely in the perioperative period. More studies are warranted.     

Abdominal Aortic Calcification and Exostoses at the Hand and Lumbar Spine: The Framingham Study

Bony proliferation (exostoses) and vascular calcification are common in elderly men and women, but it is unclear whether they have a common etiology. Lateral lumbar and hand radiographs were obtained (1967–1970) in 777 men and 1,241 women (mean age 59, range 47–80 years) from the Framingham Heart Study. Each group of hand exostoses, specifically apiostoses (tufting), enthesophytes, and osteophytes, was graded on a scale of 0–3 (absent to severe) and summed across phalanges of digits 2–5. Anterior lumbar osteophytes were assessed in intervertebral spaces T12−L5 and abdominal aortic calcification (AAC) at lumbar segments L1-L4. Information on age, sex, body mass index, smoking, alcohol consumption, physical activity, systolic blood pressure, total cholesterol level, diabetes, and estrogen replacement therapy in women was obtained at the time of radiography and adjusted for in multivariate analyses. We used multivariable logistic regression models to assess the relationship between AAC (dependent variable) and exostoses for each sex. Multivariable adjusted logistic regression revealed a significant association between increased anterior lumbar osteophytes and prevalent AAC in men [odds ratio (OR) = 1.20, 95% confidence interval (CI) 1.1–1.3 per unit increase in osteophytes] and in women (OR = 1.25, 95% CI 1.1–1.4). There also was an inverse association between enthesophytes and AAC in women only (OR = 0.82, 95% CI 0.73–0.92). Apiostoses were weakly associated with AAC in men only. Hand osteophytes were not associated with AAC. In conclusion, in this cross-sectional study, anterior lumbar osteophytes and AAC occurred in the same individuals after adjustment for age and other covariates. In general, hand exostoses were not associated with aortic calcification.     

Comparison of transurethral prostate resection and plasmakinetic prostate resection according to cautery artefacts in tissue specimens

Objectives The objectives were to evaluate cautery artifacts histopathologically in tissue specimens after plasmakinetic prostate resection (PKRP) and transurethral prostatectomy (TURP), and compare the results of the two procedures. Materials and Methods The histopathological specimens of 65 patients who underwent PKRP and TURP were examined retrospectively. Tissue chips for examination were selected randomly. Artifactual pathological patterns that were identified in the specimens included: abnormal cellular orientation and spindling, artifactual cellular detachment from the underlying basement membrane, atypical cytological changes and stromal coagulative necrosis. Each pattern identified was awarded 1 point. The severity of the cautery artefact was graded as absent, mild, moderate or severe according to the sum of points in each specimen. Results In TURP, the artefacts were graded absent (9%), mild (6%), moderate (18.7%), and severe (65.6%) changes. In PKRP, the artefacts were graded absent (6%), mild (18.1%), moderate (36.3%), and severe (39.4%) changes. While the number of mild and moderate artefacts observed was higher in PKRP (P = 0.023), severe artefacts were observed in higher numbers with TURP (P = 0.034). No prostate cancer was detected during the follow-up period. Conclusions It has been observed that the application of TURP causes fewer mild to moderate artefacts and PKRP causes fewer severe artefacts in the histopathological evaluation of specimens in comparison to each other.     

Predictors of moderate-severe functional limitation 2 and 5 years after revision total knee arthroplasty

In patients who underwent revision TKA from 1993 to 2005 and responded to follow-up questionnaires 2 or 5 years postrevision TKA, we studied whether body mass index (BMI), comorbidity (measured by validated Deyo-Charlson index), sex, and age predict activity limitation 2 and 5 years after revision TKA. Overall moderate-severe activity limitation was defined as 2 or more activities (walking, stairs, rising chair) with moderate-severe limitation. Multivariable logistic regressions also adjusted for income, diagnosis, and distance from medical center and American Society of Anesthesiologists physical status score. The prevalence of overall moderate-severe activity limitation was high: 46.5% (677/1456) at 2 years and 50.5% (420/832) at 5 years postrevision TKA. At both 2 and 5 years of follow-up, BMI of 40 or higher, higher Deyo-Charlson score, female sex, and age greater than 80 years, each significantly predicted higher odds of moderate-severe overall activity limitation.     

Significance of the early postoperative duplex result in infrainguinal vein bypass surveillance.

BACKGROUND: Duplex surveillance of infrainguinal vein grafts may not be efficient. METHODS: Consecutive patients who had received infrainguinal vein grafts were enrolled in a duplex surveillance program. A first scan at 6 weeks after surgery categorized grafts into four groups: (a) low risk grafts, (b) mild flow disturbance, (c) intermediate stenosis and (d) critical stenosis. Disease progression was assessed over time. RESULTS: Of 364 grafts followed-up for a median of 23 months, 236 (65%) had no flow abnormality at 6-weeks, and had a 40-month cumulative patency rate of 82%. The remaining 128 (35%) grafts had a flow disturbance. Of 29 critical stenoses, 15 were repaired, 11 occluded and three did not change. Of 57 intermediate lesions, 32 progressed to critical, nine occluded, two were repaired and 14 did not change or improved. Of 42 mild lesions, 16 progressed to a higher grade, four occluded and 22 did not change or improved. There was no significant difference in graft patency between grafts with repaired stenoses and those without stenoses, but grafts with untreated critical stenoses were associated with lower patency (p<0.001). CONCLUSIONS: A duplex scan 6 weeks after operation can predict those patients who require continuing duplex surveillance.     

The time course of beta cell dysfunction in chronic ethanol-induced pancreatitis: a prospective analysis

Insulin-glucose homeostasis was examined in 62 patients with chronic pancreatitis (CP). All patients were graded on the basis of test results from five studies: (1) endoscopic retrograde cholangiopancreatography, (2) fat-stimulated release of pancreatic polypeptide (PP), (3) NBT-bentiromide PABA test, (4) 72-hour fecal fat test, and (5) oral glucose tolerance test (OGTT). Patients with CP were graded as either mild/moderate or severe by means of a scoring system that we devised and have previously reported. Nineteen patients were graded as mild/moderate and 43 patients were graded as severe. The endocrine function of non-beta and beta islet cells was compared by assessing release of PP after fat and by release of insulin during OGTT. Release of PP was depressed in 58%, and the depressed output was found in only patients with a severe grade of CP. Forty-four of 62 patients (71%) with CP had abnormal OGTT findings; the distribution of this abnormality was not greatly different between mild/moderate and severe grades. Depressed release of insulin was seen in 58% (36 of 62)--more commonly in patients with a severe grade (10%) but also in 32% of patients with a mild/moderate grade. A subset of patients with CP sustains early beta-cell dysfunction. We conclude that decreased output of PP is a more reliable measure of functional deficit and stage in CP.     

护士与病人癌痛评估差异性比较

目的观察护士与病人对癌痛程度评估差异及护士的癌痛评估对止痛治疗效果的影响.方法 85例癌痛病人和护士分别用目测模拟疼痛程度分级法进行疼痛评估,随即按病人意愿分为病人评估组(轻度疼痛20例,中、重度疼痛29例)和护士评估组(轻度疼痛14例,中、重度疼痛22例)进行止痛治疗.结果以病人评估为基准,护士评估轻、中、重度疼痛的符合率分别为85.3%、63.0%和58.3%;护士与病人对中、重度癌痛评估存在明显差异(均P＜0.05);病人与护士评估轻度疼痛完全缓解率分别为95.0%、85.7%,差异无显著性意义(P＞0.05);中、重度疼痛完全缓解率分别为82.8%、45.6%,病人评估组准确性明显优于护士评估组(P＜0.05).结论护士对癌症疼痛严重程度的评估存在不足并导致止痛效果不佳,对癌痛的治疗应基于病人的自评.     

Significance of multimodality evoked potentials (MEPs) in severe head injuries

Clinical significance of multimodality evoked potentials (MEPs) consisting of auditory evoked brainstem response (ABR), cortical somatosensory evoked potential (SEP) and visual evoked potential (VEP) was studied in 14 cases with severe head injuries. The cases in this series associated with cerebral contusion and/or intracranial mass lesions such as acute subdural, intracerebral and acute epidural hematomas and Glasgow Coma Scale (GCS) score was less than 8 in all instances. MEPs were recorded for 14 days after injury and evaluated by MEP grade modified from Greenberg, et al. Intracranial pressure (ICP) was monitored from the extradural space on main lesion side in all cases for 3 to 5 days. Transtentorial herniation on CT scan was also graded according to the status of subarachnoid cisterns around the tentorium. The outcome was assessed by Glasgow Outcome Scale at 3 months after injury and was classified into good, poor and dead. MEPs on admission showed mild to severe abnormalities determined by single or all modalities in all cases and they were fairly well correlated with GCS score on admission and initial ICP. In the cases with good outcome, initial MEPs showed mild to moderate abnormalities determined by single modality and improved within 3 days after injury. They returned to normal or remained at mild abnormality at 7 days. But abnormality on initial MEPs was more severe in the cases with poor outcome and they were deteriorated within 3 to 7 days when elevation of ICP above 25 mmHg was observed. MEPs remained at moderate abnormality even at 14 days after injury in these cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

The correlation between pes planus and anterior knee or intermittent low back pain

BACKGROUND: Anterior knee pain and intermittent low back pain are among the most common orthopedic complaints of adolescents. However, little is known about pes planus and its relative risk for these symptoms. The goal of the study was to track the prevalence of pes planus in adolescents, and examine its associated risk to anterior knee pain and intermittent low back pain, respectively. MATERIALS AND METHODS: A retrospective study of 97,279 military recruits presenting to recruitment centers was conducted. Pes planus was graded by an orthopedist as mild, moderate or severe according to the flattening of the plantar arch and its rigidity to standing on one's toes. Anterior knee pain was diagnosed when symptoms were attributed to the patellofemoral joint. Intermittent low back pain was diagnosed when there was pain but neither abnormal clinical nor radiographic findings. RESULTS: Pes planus was present in 15,698 (16%) individuals. 11,549 (74%), 3,341 (21%) and 808 (5%) were diagnosed as having mild, moderate and severe pes planus, respectively. The prevalence of intermittent low back pain was 5% in both the control and mild pes planus groups, while it was 10% in the moderate and severe pes planus groups (p < 0.0001). The prevalence of anterior knee pain was 4% in both the control and mild pes planus groups, while it was 7% in the moderate and severe pes planus groups (p < 0.0001). CONCLUSION: Moderate and severe pes planus was associated with nearly double the rate of anterior knee pain and intermittent low back pain, while mild pes planus was associated with no higher rate for these problems. Prophylactic measures may be helpful only in those adolescents with moderate and severe pes planus.     

Simple classification and clinical outcomes of angiographic dissection after balloon angioplasty for femoropopliteal disease

Objective

Angiographic dissection is considered to be associated with restenosis. However, little is known about the impact of the severity of angiographic dissection on future restenosis.

Long-term outcomes following 282 consecutive cases of infrapopliteal PTA and association of risk factors with primary patency and limb salvage

We aimed to determine the long-term results after infrapopliteal PTA (primary patency, limb salvage, survival) and examine for association with risk factors (e.g. diabetes, infection, etc). We studied 268 patients with 282 critically ischemic limbs treated with PTA of at least one crural artery during a six-year period. Data included TASC II morphological classification of lesions and risk factors. Technical success rate was 97.2%, and overall mortality 0.7%. Patients with milder TASC lesions preserved primary patency longer than patients with more severe lesions. Similar results were obtained for limb salvage and survival. Fontaine stage, TASC class and postoperative infection of operated limb increased the risk for loss of primary patency and major amputation. Concomitant carotid stenosis was associated with loss of primary patency. Diabetes mellitus, preoperative ulcer or gangrene were associated with need of major amputation. PTA was a safe and effective treatment for CLI due to lesions of infrapopliteal vessels.     

Risk factors for ankle valgus in children with hereditary multiple exostoses: a retrospective cross-sectional study

PurposeThe aim of this study was to identify risk factors for ankle valgus in children with hereditary multiple exostoses (HME).MethodsWe retrospectively reviewed the medical records of patients with HME who were examined at our hospital between 2010 and 2020. Patients’ age and sex were recorded along with radiographic variables including mechanical axis deviation (MAD), mechanical lateral distal tibia angle (LDTA), fibula/tibia length ratio (F/T); distal fibula station according to Malhotra’s classification, location of exostoses at the ankle joint and fibular neck/physis width (N/P) ratio, which were measured from radiographs. Binary logistic regression analysis was performed to identify significant independent risk factors for ankle valgus.ResultsThere were 61 children (20 girls and 41 boys; 122 ankles) who met the inclusion criteria. The mean age was 10.4 years (sd 3.4) and mean LDTA was 83° (sd 7°). Ankle valgus was found in 64 ankles (52%). In addition to younger age, exostoses involving the lateral aspects of the distal tibial and the medial aspect of the distal fibula (odds ratio (OR) = 4.091; 95% confidence interval (CI) 1.065 to 15.712; p = 0.040), F/T ratio < 0.96 (OR = 4.457; 95% CI 1.498 to 13.261; p = 0.007) and N/P ratio > 1.6 (OR = 2.855; 95% CI 1.031 to 7.907; p = 0.043) were associated with an increased risk of developing ankle valgus, while sex and MAD were unrelated to its occurrence.ConclusionYoung age, exostoses involving both the distal tibia and fibula, the F/T ratio < 0.96 and fibular N/P width ratio > 1.6 seemed to be risk factors of developing ankle valgus.Levels of evidencePrognostic studies, IV     

Operative drainage of the pancreatic duct delays functional impairment in patients with chronic pancreatitis. A prospective analysis.

In a prospective study, 85 patients with chronic pancreatitis have been subjected to evaluation by morphologic analysis (endoscopic retrograde cholangiopancreatography), by exocrine function tests (bentiromide PABA and 72-hour fecal fat testing), and by endocrine function tests (oral glucose tolerance test and fat-stimulated release of pancreatic polypeptide). All patients were graded on a five-point system, with 1 point assessed for an abnormal result in each of the five tests performed. Zero score denoted mild disease; 1-2 points signaled moderate disease; and 3-5 points indicated severe disease. In 68 patients, both an initial and late (mean follow-up period of 14 months) evaluation were performed. Forty-one patients underwent modified Puestow side-to-side Roux-en-Y pancreaticojejunostomy. The Puestow procedure alone was performed in 18 patients. Eight patients also had drainage of pseudocysts, seven also had a biliary bypass, and eight had pseudocyst drainage plus bypass, in addition to the Puestow. There were no deaths. Of the 68 patients who were studied twice, 30 had operations and 38 did not. None of the patients with severe disease improved their grade during follow-up. Of 24 patients who did not undergo operation, 17 (71%) who were graded mild/moderate progressed to a severe grade at follow-up. By contrast, only three of the 19 patients operated on (16%) and who were initially graded as mild/moderate progressed to severe disease at follow-up testing. More than 75% of all of the patients had a history of weight loss. Twenty-six of 30 patients operated on (87%) (all of whom had lost weight before surgery) gained a mean 4.2 kg (range 1.4-2.7 kg) after surgery, compared with no significant weight change (range -3.6-2.7 kg) among patients not operated on. These findings support a policy of early operation for chronic pancreatitis, perhaps even in the absence of disabling abdominal pain.     

Preoperative Anemia Independently Predicts Significantly Increased Odds of Short-Term Complications Following Aseptic Revision Hip and Knee Arthroplasty

BackgroundPreoperative anemia is an important risk factor for developing complications following revision hip (rTHA) and knee (rTKA) arthroplasty. We aim to determine the effect of anemia severity on 30-day postoperative complications following revision hip and knee arthroplasty.MethodsA retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program Database. All patients who underwent revision joint arthroplasty (rTJA) between 2006 to 2017 were identified and grouped based upon the hematocrit (Hct) level. Anemia was defined as Hct <36% for women and <39% for men, and further stratified into mild anemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe anemia (Hct <33% for both men and women). Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after TJA.ResultsA total of 8932 patients undergoing rTHA and 13,313 patients undergoing rTKA were included for analysis. On multivariate adjustment, patients undergoing rTHA with moderate to severe anemia had an increased odds of 5.437 (95% Confidence Interval (CI) 4.604 to 6.421; P < .001) of developing any postoperative complication. On multivariate adjustment, patients undergoing rTKA with moderate to severe anemia had increased odds of 6.731 (95% Confidence Interval (CI) 5.540 to 8.179; P < .001) of developing any postoperative complication.ConclusionThe increasing severity of anemia was associated with an increasing risk of developing any postoperative complication and death following revision hip and knee arthroplasty. There is a significant trend between diminishing preoperative hematocrit levels and increasing odds of postoperative complication.     

Compartment syndrome. A complication of intravenous regional anesthesia in the reduction of lower leg shaft fractures

Forty-one consecutive patients who had closed reduction of closed lower leg shaft fractures under an intravenous regional anesthetic are reviewed for the complication of compartment syndrome. Four patients were graded as having mild compartment syndrome, two as moderate, and five as severe, giving an overall rate of 27%. This was compared with a control group of 39 consecutive patients who also underwent closed reduction of closed lower leg shaft fractures, but under general anesthesia or intravenous analgesia alone rather than an intravenous regional anesthetic. In the control group, three patients were graded as having mild compartment syndrome, and two as severe, giving an overall complication rate of 13%. The authors feel that the use of the thigh tourniquet with the intravenous regional anesthetic technique increases the frequency of compartment syndrome as a complication in lower leg fractures.     

Target lesion characteristics in failing vein grafts predict the success of endovascular and open revision

OBJECTIVES: This study examined the association of anatomic and temporal characteristics of graft-threatening lesions with the efficacy of percutaneous and open graft revision for failing infrainguinal vein grafts. METHODS: Consecutive open and endovascular revisions for graft threatening lesions were reviewed. We evaluated graft durability and individual target lesion response to open and endovascular treatment to determine characteristics that may influence outcomes. Treatment failure was defined as target lesion restenosis or graft occlusion. RESULTS: Eighty-four (58 endovascular, 26 open) infrainguinal vein graft revisions were performed in 67 failing, nonthrombosed infrainguinal vein grafts. Primary assisted graft patency at 5 years was 63% (95% confidence interval [CI], 46% to 77%). Follow-up was 29.5 +/- 19.2 months. Grafts treated for early lesions (<6 months) failed (occlusion or need for additional interventions) more frequently than those with late occurring lesions (P = .03). Overall target lesion revascularization patency was 45% (95% CI, 32% to 58%) at 3 years. Average time to target lesion revascularization failure was 7.5 months, with no significant difference noted between endovascular and open treatment groups. Overall target lesion revascularization patency at 3 years was also not significantly different between open and endovascular groups at 54% (95% CI, 30% to 73%) vs 41% (95% CI, 25% to 56%; P = .15). When divided by early and late-occurring target lesions, endovascular treatment of early lesions was associated with inferior patency compared with open procedures; no difference in patency was seen between treatment groups for late lesions. When divided by target lesion location (anastomotic vs mid-graft), treatment for both proximal and distal anastomotic target lesion was associated with inferior patency compared with mid-graft revision at 32% (95% CI, 17% to 47%) vs 62% (95% CI, 37% to 87%) at 3 years (P = .03). In addition, although results of anastomotic target lesion treatment significantly favored open repair, even open repair of anastomotic target lesions was associated with a <50% patency rate at 3 years. In contrast, mid-graft target lesions treated with open revisions were uniformly successful compared with a 54% patency at 3 years with endovascular treatment (P = .24). Short lesions (<2 cm) fared equally well with either endovascular or open treatment. Univariate analysis noted only anastomotic treatment was associated with significantly increased odds of failure. CONCLUSION: Grafts that develop early lesions fare poorly regardless of treatment modality. Lesions involving anastomoses of failing grafts are better treated with open revision, but patency after treatment of such lesions is still worse than treatment of mid-graft lesions. In contrast, the method of treatment does not influence outcome after treatment of mid-graft target lesions. Thus, endovascular therapy should be reserved for focal, late-appearing lesions involving the mid-graft.