Treatment of grossly dislocated supracondylar humerus fractures after failed closed reduction: a retrospective analysis of different surgical approaches

INTRODUCTION

The supracondylar humerus fracture (SCHF) is one of the most common pediatric injuries. Highly displaced fractures can be very challenging. If closed reduction fails, the therapy algorithm remains controversial.

MATERIALS AND METHODS

In total, 41 patients (21 boys and 20 girls) with irreducible Gartland type III SCHF, treated with open reduction through three different approaches and cross-pin fixation, were retrospectively evaluated. The mean follow-up was 46 months (min.: 12, max.: 83, SD: 23.9). The Mayo elbow performance score (MEPS) as well as the quick disabilities of arm, shoulder and hand (qDASH) score were used to assess the functional outcome. Baumann's angle and the anterior humeral line (AHL, Roger's line) were obtained from follow-up radiographs. Time to surgery, postoperative nerve-palsy, rate of revision surgery, and complication rate were examined.

RESULTS

Two revision surgeries were reported. One due to inadequate reduction and one due to secondary loss of reduction. In this context, the AHL was a sufficient tool to detect unsatisfactory reduction. According to the MEPS the functional outcome was excellent (> 90) in 37/41 patients and good (75-89) in 4/41 at the final visit. Fair or poor results were not documented. The qDASH score was 1.8 (min.: 0, max.: 13.6, SD: 3.4). There were no significant differences between the utilized surgical approaches. An iatrogenic injury of the ulnar nerve was not reported in any case. Overall, one heterotopic ossification without impairment of the range of motion and one preliminary affection of the radial nerve were documented.

CONCLUSION

In the rare case of an irreducible SCHF, an anatomical reduction can be achieved by open approaches with excellent functional outcome and a high grade of patient satisfaction. All described open approaches can be utilized with a high safety-level.

Improved Morbidity, Mortality, and Cost with Minimally Invasive Colon Resection Compared to Open Surgery

Background and Objectives:

Despite the growth of minimally invasive surgery (MIS) in many specialties, open colon surgery is still routinely performed. The purpose of this study was to compare outcomes and costs between open colon and minimally invasive colon resections.

Methods:

We analyzed outcomes between January 1, 2016 and December31, 2018 using the Vizient® clinical database. Demographics, hospital length of stay, readmissions, complications, mortality, and costs were compared between patients undergoing elective open and minimally invasive colon resections. For bivariate analysis, Wilcoxon rank-sum test was used for continuous variables and χ² test was used for categorical variables. Multiple Logistic and Quintile regression were used for multivariable analyses.

Results:

A total of 88,405 elective colon resections (open: 56,599; minimally invasive: 31,806) were reviewed. A significantly larger proportion of patients undergoing minimally invasive surgery were obese (body mass index > 30) compared to those undergoing open surgery (71.4% vs. 59.6%; p < 0.0001). As compared to minimally invasive colectomy, open colectomy patients had: a longer median length of stay [median (range): 7 (4–13) days vs. 4 (3 – 6) days, p < 0.0001], higher 30-day readmission rate [n = 8557 (15.1%) vs. 2815 (8.9%), p < 0.0001], higher mortality [n = 2590 (4.4%) vs. 107 (0.34%), p < 0.0001], and a higher total direct cost [median (range): $13,582 (9041–23,094) vs. $9013 (6748 – 12,649), p < 0.0001]. Multivariable models confirmed these findings.

Conclusion:

Minimally invasive colon surgery has clear benefits in terms of length of stay, readmission rate, mortality and cost, and the routine use of open colon resection should be revaluated.

The External Rhinoplasty Approach

The nose is a complex three-dimensional structure with critical structural and functional roles; its relationship to surrounding structures is, in part, responsible for a harmonious, pleasing visage as a whole. There are many variables and dimensions that can be adjusted to alter the esthetic appearance, structural components, and functional role of the nose and many tools and maneuvers available to the rhinoplasty surgeon to adjust these numerous variables. Although every rhinoplasty operation should be individualized, a systematic order and algorithm may be helpful in operative planning as well as establishing a logical progression of steps and maintaining stability. While each adjustment may have a primary anticipated effect, it will invariably have a secondary impact.

Postoperative outcomes after laparoscopic or open gastrectomy. A national cohort study of 10,343 patients

BACKGROUND

Laparoscopy for gastric cancer has not been as popular compared with other digestive surgeries, with conflicting reports on outcomes. The aim of this study focuses on the surgical techniques comparing open and laparoscopy by assessing the morbi-mortality and long-term complications after gastrectomy.

METHODS

A retrospective study (2013-2018) was performed on a prospective national cohort (PMSI). All patients undergoing resection for gastric cancer with a partial gastrectomy (PG) or total gastrectomy (TG) were included. Overall morbidity at 90 post-operative days and long-term results were the main outcomes. The groups (open and laparoscopy) were compared using a propensity score and volume activity matching after stratification on resection type (TG or PG).

RESULTS

A total of 10,343 patients were included. The overall 90-day mortality and morbidity were 7% and 45%, with reintervention required in 9.1%. High centre volume was associated with improved outcomes. There was no difference in population characteristics between groups after matching. An overall benefit for a laparoscopic approach after PG was found for morbidity (Open = 39.4% vs. Laparoscopy = 32.6%, p = 0.01), length of stay (Open = 14[10-21] vs. Laparoscopy = 11[8-17] days, p<0.0001). For TG, increased reintervention rate (Open = 10.8% vs. Laparoscopy = 14.5%, p = 0.04) and increased oesophageal stricture rate (HR = 2.54[1.67-3.85], p<0.001) were encountered after a laparoscopic approach. No benefit on mortality was found for laparoscopic approach in both type of resections after adjusted analysis.

CONCLUSIONS

Laparoscopy is feasible for PG with a substantial benefit on morbidity and length of stay, however, laparoscopic TG should be performed with caution, with of higher rates of reintervention and oesophageal stricture.

Open approaches for cruciate ligament reconstruction in knee dislocations: A technical note and case series

INTRODUCTION

Arthroscopic surgery is the gold standard for cruciate ligament reconstruction in multi-ligament knee injuries. However, hospitals in limited-resource settings often lack arthroscopic-trained surgeons or equipment. Open approaches for treating knee dislocations can overcome many of these limitations.

METHODOLOGY

This study aims to describe techniques for open approaches in a supine patient to address the cruciate ligaments in multi-ligament knee injuries and to review associated complications and clinical outcomes in a retrospective case series.

RESULTS

Ten patients with multi-ligament knee injuries who had undergone open cruciate ligament reconstruction between July 2016 and November 2018 were retrospectively identified. Open approaches were performed owing to the extravasation of arthroscopy fluid into the posterior compartment (3) or a large traumatic arthrotomy (7). Complications and patient-reported outcomes were analysed. Eight of the 10 patients were followed up at 10 months postoperatively (range, 5-23 months). None had iatrogenic neurovascular damage. Median outcomes scores were: visual analogue scale, 45 (range, 0-100); Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, 81.4 (range, 75-100); Lysholm, 85 (range, 67-92).

DISCUSSION

Open approaches were safe and useful in treating cruciate ligaments and should be considered in arthroscopy fluid extraversion and large traumatic arthrotomies.

Endoscopic open rhinoplasty enables a cosmetic approach for a rare case of intraosseous cavernous hemangioma in the nasal bone

A rare case of intraosseous cavernous hemangioma was identified in the nasal root. Using a combination of endoscopic surgery and open rhinoplasty, an osteotomy was performed and resection of the hemangioma was successfully achieved with transcolumellar and infracartilaginous incisions and 2 stab incisions. No adverse side effects were observed after the procedure, no tumor recurrence was observed at the 16-month-postoperative follow-up. The preserved periosteum contributed to the osteogenesis and thus, a need for a reconstructive surgery was indicated. The favorable outcomes associated with this approach justify and authenticate the use of endoscopy-assisted open rhinoplasty in the treatment of intraosseous cavernous hemangiomas without leaving ventral surgical scarring.

Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears

BACKGROUND

Rupture of the Achilles tendon (AT) is frequent in young recreational athletes. Conservative management, open surgery and percutaneous/minimally invasive approaches are all advocated, and conflicting data are available. This study compared functional and anthropometric outcomes of patients who underwent open or percutaneous repair.

METHODS

A retrospective comparative study, in which 38 patients underwent open and percutaneous techniques to manage AT ruptures. For functional assessment, the calf circumference of both injured and uninjured legs was evaluated. Isokinetic testing included total plantar flexion work, peak plantar flexion torque, total dorsiflexion work peak and dorsiflexion torque. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) were evaluated at a final minimum follow-up of 12months.

RESULTS

No major complications were observed. The average time to return to sport was 9months. AOFAS and ATRS values did not differ statistically between groups. Isokinetic variables and circumference were similar in the operated and non-operated limb in both groups, and did not differ either when comparing open and percutaneous repair.

CONCLUSIONS

Open and percutaneous repair of a torn Achilles tendon produced similar functional outcomes.

Highlights, limitations and future challenges of laparoscopic resection for colorectal liver metastases

The liver is the most common site for metastatic colorectal cancer (CRLM). Despite advances in oncologic treatment, resection of metastases is still the only curative option. Although laparoscopic surgery for primary colorectal cancer is well documented and widely used, laparoscopic surgery for liver metastases has developed more slowly. However, in spite of some difficulties, laparoscopic approach demonstrated strong advantages including minimal parietal damage, decreased morbidity (reduced blood loss and need for transfusion, fewer pulmonary complications), and simplification of subsequent iterative hepatectomy. Up to now, more than 9 000 laparoscopic procedures have been reported worldwide and long-term results in colorectal liver metastases seem comparable to the open approach. Only one recent randomized controlled trial has compared the laparoscopic and the open approach. The purpose of the present update was to identify the barriers limiting widespread acceptance of laparoscopic approach, the benefits and the limits of laparoscopic hepatectomies in CRLM.

Outcomes of Open and Laparoscopic Appendectomy With Single Endoloop Stump Closure

Background and Objectives:

Although laparoscopic appendectomy (LA) has been used for 35 years, the open approach (OA) is preferred worldwide. Widespread access to instrumentation in a number of centers has reduced economic and logistical obstacles. The aim of this work is to compare the results for patients with suspected appendicitis treated using an OA versus patients treated using LA.

Methods:

A retrospective study of all patients (N = 290) who underwent operation due to suspected appendicitis in the General Surgery Department from 2014 to 2017 was conducted. LA was performed in 91 patients, and OA was performed in 199 patients.

Results:

Average surgery duration was 67.8 minutes in the LA group and 62.9 minutes in the OA group (P =.082). It was necessary to perform 3 conversions (3.3%) from LA to OA. Wound infections occurred in 2.2% of patients in the LA group and in 12.6% of patients in the OA group (P = .007). A reduced duration of hospitalization was noted in the LA group (3.3 days) compared with the OA group (4.7 days) (P < .001).

Conclusion:

The duration of LA is not considerably longer than that of OA. LA in patients with suspected appendicitis reduces the number of operation site infections compared with OA. LA with single endoloop stump closure is a safe method and may be recommended for wider applications.

Primary Rhinoplasty

Rhinoplasty is inherently a difficult procedure given the complexity of its structure and the functional and aesthetic impact of this anatomy. This report explores some of the remaining questions regarding the use of spreader grafts and autospreader flaps in the management of the middle vault in rhinoplasty, the performance of the open approach versus the endonasal rhinoplasty approach, corrective rhinoplasty in the younger patient, the use of the rib and other cartilage donor sites for grafting in rhinoplasty, and the use of filler materials in rhinoplasty.

Columellar Scar Perception in Open Rhinoplasty. Interplay of Scar Awareness, Body Cathexis and Patient Satisfaction

INTRODUCTION

Open and closed approaches for rhinoplasty have individual advantages and disadvantages; however, the resultant columellar scar of the open approach is directly considered as a disadvantage. This study focuses on the columellar scar awareness and its implications on overall satisfaction of the patients after open rhinoplasty.

PATIENTS AND METHODS

A total of 91 patients who have undergone open rhinoplasty were included in this study. A written questionnaire algorithm consisting of 4 sequential questions was applied. Except for the first question [Do you have any scar(s) caused by any trauma, operation or any other reason on your face?], every question was answered on a scale from 1 to 5. The respondents were given the 25-question "Modified Body Cathexis Scale (MBCS)"and their scars graded using the "Columellar Scar Assessment Scale" (CSAS). The data were statistically interpreted.

RESULTS

Of the 91 open rhinoplasty patients, 12 of them responded with a "yes" to the first question reporting their columellar scars. There was no significant difference with regards to patient satisfaction regarding these patients (p > 0.05). However, those who reported the scar yielded a significantly lower MBCS scores. 9 patients declared that they exerted effort to conceal their scars. Those who concealed their scars and those who did not yielded a significant difference in patient satisfaction. The CSAS scores of those who reported the columellar scar were significantly higher than those who did not.

CONCLUSION

Our study suggests that MBSC can be a valuable tool for determining the impact of outcomes from the patient's standpoint, and awareness of the columellar scar is not related to patient satisfaction but with bodily perception.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictive variables of open reduction in intertrochanteric fracture nailing: a report of 210 cases

BACKGROUND

Factors that impede closed reduction in intertrochanteric fractures remain unknown. This study was designed with the aim of establishing radiological variables that can predict an open reduction when nailing those type of fractures.

MATERIALS AND METHODS

Observational prospective study carried out between March 2013 and March 2015. Patients of both gender who suffered an intertrochanteric fracture, and who were surgically treated by intramedullary nailing (PFN-A), were included. Patients were evaluated by means of a questionnaire designed in 12 de Octubre Trauma department. Radiological parameters assessed preoperatively, after fracture reduction in the traction table, and after fixation were: calcar, lateral wall and posterior buttress integrity or disruption; lesser trochanter location, varus or valgus deformities, and flexion or extension of the proximal fragment.

RESULTS

Association between open reduction and the following types of fractures was statistically significant (p<0.001): subtypes A2.3, A3.2 and A3.3 of AO classification and subtypes IV and V of Evans classification. There were four radiological parameters associated with the need for open reduction: disruption of lateral wall (p<0.0000), posterior wall fracture (p<0.001), calcar (p<0.004) and malalignment in the axial view (p<0.001).

CONCLUSIONS

Open reduction seems to be necessary for complex fracture patterns such as A2.3, A3.2 and A3.3 types of AO/OTA classification, as well as types IV and V of Evans classification. There are four major radiological parameters that can predict the need of approaching the fracture site: posterior buttress, calcar disruption, lateral wall disruption and proximal fragment flexion. The development of high quality evidence regarding this topic is necessary due to the vast impact that open reduction can have on elderly patients.

The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications

Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.

Minimally invasive versus open transforaminal lumbar interbody fusion

Background

Available clinical data are insufficient for comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). To date, a paucity of literature exists directly comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). The purpose of this study was to directly compare safety and effectiveness for these two surgical approaches.

Materials and Methods

Open or minimally invasive TLIF was performed in 63 and 76 patients, respectively. All consecutive minimally invasive TLIF cases were matched with a comparable cohort of open TLIF cases using three variables: diagnosis, number of spinal levels, and history of previous lumbar surgery. Patients were treated for painful degenerative disc disease with or without disc herniation, spondylolisthesis, and/or stenosis at one or two spinal levels. Clinical outcome (self-report measures, e.g., visual analog scale (VAS), patient satisfaction, and MacNab's criteria), operative data (operative time, estimated blood loss), length of hospitalization, and complications were assessed. Average follow-up for patients was 37.5 months.

Results:

The mean change in VAS scores postoperatively was greater (5.2 vs. 4.1) in theopen TLIF patient group (P = 0.3). MacNab's criteria score was excellent/good in 67% and 70% (P = 0.8) of patients in open and minimally invasive TLIF groups, respectively. The overall patient satisfaction was 72.1% and 64.5% (P = 0.4) in open and minimally invasive TLIF groups, respectively. The total mean operative time was 214.9 min for open and 222.5 min for minimally invasive TLIF procedures (P = 0.5). The mean estimated blood loss for minimally invasive TLIF (163.0 ml) was significantly lower (P < 0.0001) than the open approach (366.8 ml). The mean duration of hospitalization in the minimally invasive TLIF (3 days) was significantly shorter (P = 0.02) than the open group (4.2 days). The total rate of neurological deficit was 10.5% in the minimally invasive TLIF group compared to 1.6% in the open group (P = 0.02).

Conclusions:

Minimally invasive TLIF technique may provide equivalent long-term clinical outcomes compared to open TLIF approach in select population of patients. The potential benefit of minimized tissue disruption, reduced blood loss, and length of hospitalization must be weighted against the increased rate of neural injury-related complications associated with a learning curve.