Surgical Technology International 36th Edition
New Online Studies
Online First - Mar 2020
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Tips and Tricks to Optimize Surgical
Outcomes After ACL Repair Using
Dynamic Intraligamentary Stabilization
Christiaan HW Heusdens, MD, Lieven Dossche, MD, Katja Zazulia, MSc, Jozef Michielsen, MD, Pieter Van Dyck, MD, Professor of Radiology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Purpose: This paper describes technical difficulties and outcomes for the first 15 patients treated with Dynamic Intraligamentary Stabilization (DIS) for anterior cruciate ligament (ACL) repair.
Methods: The first 15 patients treated with DIS were included. To optimize the inclusion process, a new pre-operative pathway was developed. All intra-operative technical problems were recorded. During the 2-year follow-up period, patient-related outcome measures, return to work, anterior-posterior knee laxity using a Rolimeter and ACL healing as revealed by MRI follow-up scans were recorded.
Results: During 11 DIS procedures, 15 technical problems were encountered. Six were surgeon-related and 9 were material-related. All problems were resolved intra-operatively. Repeat surgery was performed in 4 patients due to arthrofibrosis and in 1 due to a cyclops lesion. The DIS implant was removed in all 5 patients. According to the Tegner score, 7 of 10 (70%) patients returned to the pre-injury level of sporting activity within 6 months. The mean return to work time was 5.4 (SD 3.6) weeks. On MRI, 10 patients showed normal ACL healing (Grade 1) and 3 showed a high repair signal intensity (Grade 2). Although 2 patients showed no signs of ACL healing on MRI (Grade 3), no instability was reported or measured post-operatively or after the DIS implant was removed.
Conclusion: All intra-operative technical problems were resolved and did not lead to conversion to ACL reconstruction. We share tips and tricks that could assist surgeons who are just starting to use the DIS technique.
Do Demographic or Anthropometric Factors Affect Lateralization of the Tibial Tubercle in a Diverse Population? A Magnetic Resonance Imaging Analysis
Isaac Livshetz, MD, Mitchell B. Meghpara, MD, Joseph A. Karam, MD, Benjamin A. Goldberg, MD, Associate Professor of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, Hytham S. Salem, MD, Michael A. Mont, MD, Chief of Joint Reconstruction, Lenox Hill Hospital, New York, New York, Omar T. Hassan, MD, Rosalind Franklin University of Medicine & Science, Chicago, Illinois
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Background: In revision total hip arthroplasty (THA), modular femoral components aid the surgeon in reconstructing joints compromised by loss of bone and soft-tissue integrity, providing customization to address bony deficits, deformity, limb length, and offset challenges. The purpose of this study was to review the survival and outcomes at minimum five-year follow up of patients who underwent revision THA at our center with a single modular femoral revision hip system offering a wide range of proximal body and distal stem geometries and sizing options.
Materials and Methods: A query of our practice arthroplasty registry revealed 66 consented patients (69 hips) who underwent revision THA using a modular femoral stem between December 2009 and July 2013 with minimum five-year follow up. There were 35 men (53%) and 31 women (47%). Mean age was 65.2 years (range, 36–87). Etiology for index revision was 32 aseptic loosening, 20 infection, nine periprosthetic fracture, three nonunion of internal fixation, three instability, one stem breakage, and one metal complication.
Results: Mean follow up was 6.3 years (range, 5–9). Harris Hip Scores improved from a mean of 45.4 preoperatively to 72.0 at most recent evaluations. There have been four re-revisions of the femoral stem: one infection, two periprosthetic femoral fracture, and one (proximal segment only) for instability. Radiographic assessment revealed satisfactory position, fixation, and alignment in all hips. Radiographic subsidence of 6–10mm occurred in four (none revised), and none had subsidence > 10mm. There were no modular junction failures. Kaplan-Meier survival to endpoint of femoral revision was 93.3% (95% CI ±3.3%) at 8.7 years.
Conclusions: The minimum five-year results of this modular THA revision system are promising, with low rates of aseptic failure, minimal subsidence, and no modular junction failures. While there may be roles for the use of non-modular revision stems, the mid-term clinical results in this cohort of patients was found to be acceptable.
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New Technology for Total Knee Arthroplasty Provides Excellent Patient-Reported Outcomes: A Minimum Two-Year Analysis
Arthur L. Malkani, MD, Associate Professor, Langan Smith, BS, University of Louisville, Louisville, Kentucky, Martin W. Roche, MD, Director of Robotic Joint Reconstruction, Rushabh Vakharia, MD, Holy Cross Orthopedic Institute, Ft. Lauderdale, Florida, Frank R. Kolisek, MD, Charles Jaggard, MS, Clinical Trial Manager, OrthoIndy, Greenwood, Indiana, Kenneth A. Gustke, MD, University of South Florida, Temple Terrace, Florida, William J. Hozack, MD, Thomas Jefferson University, Philadelphia, Pennsylvania, Nipun Sodhi, MD, Long Island Jewish Medical Center,, Northwell Health, Queens, New York, Alexander Acuña, BS, Cleveland Clinic Foundation, Cleveland, Ohio, Hytham S. Salem, MD, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York
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Introduction: Robotic-assisted total knee arthroplasty has been demonstrated to help increase various patient-reported, clinical, and surgical outcome metrics (PROMs). However, the current literature is limited regarding PROMs data for longer follow-up periods beyond one year. Therefore, the purpose of this study was to 1) report multicenter patient-reported outcomes with multiple metrics, as well as 2) postoperative surgeon-specific outcomes at a minimum two-year follow-up.
Materials and Methods: Five fellowship-trained, high-volume surgeons performed a total of 188 total knee arthroplasty surgeries using the enhanced preoperative planning and real-time intraoperative feedback of a robotic-assisted device. Patients from all surgeons followed similar postoperative rehabilitation beginning on postoperative day one. Patients were evaluated based on the Short Form-12 Questionnaire (SF-12), the Forgotten Joint Score (FJS), and Knee Society total and subscores (KSS). The SF-12 was subdivided into two components: mental composite score (MCS) and physical composite score (PCS). The KSS was subdivided into functional and knee scores. Additionally, surgical outcomes from the latest follow-up visit were evaluated. All patients were evaluated at a minimum of two years follow-up time.
Results: All patients reported excellent postoperative outcomes for all three PROMs. The mean postoperative SF-12 MCS and PCS scores were both 57 points, with 50 as the threshold for norm-based scoring (MCS range: 42 to 69 points; PCS range: 41 to 68 points). The mean FJS was 75 points (range: 14 to 100 points). The mean KSS functional score was 84 points (range: 20 to 100) while the mean Knee Score was 92 points (range: 40 to 100). Similarly, we found that the aseptic revision rates were low (n=2, 1.06%, one for unexplained pain, and another for a post-traumatic tibial fracture) with few other postoperative complications (n=7 patients [3.7%]) in our cohort.
Conclusion: Our analysis found that patients had excellent outcomes across multiple PROM metrics. Future work can build on these results with large patient populations over longer follow-up intervals. Nevertheless, these results provide the foundation and evidence to support the continued use of this innovative technology for total knee arthroplasties.
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Manipulation Under Anesthesia Rates in Technology-Assisted versus Conventional-Instrumentation Total Knee Arthroplasty
Arthur L. Malkani, MD, Associate Professor, Langan Smith, BS, University of Louisville, Louisville, Kentucky, Martin W. Roche, MD, Rushabh Vakharia, MD, Holy Cross Orthopedic Institute, Ft. Lauderdale, Florida, Frank R. Kolisek, MD, Charles Jaggard, MS, OrthoIndy, Greenwood, Indiana, Kenneth A. Gustke, MD, University of South Florida, Florida Orthopaedic Institute, Temple Terrace, Florida, William J. Hozack, MD, Thomas Jefferson University, Philadelphia, Pennsylvania, Nipun Sodhi, MD, Long Island Jewish Medical Center, Northwell Health, Queens, New York, Alexander Acuña, BS, Cleveland Clinic Foundation, Cleveland, Ohio, Hytham S. Salem, MD, Lenox Hill Hospital, Northwell Health, New York, New York, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York
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Introduction: Various technological advancements, specifically robotic assistance, have been implemented for total knee arthroplasty (TKA) procedures to attempt to improve patient outcomes and decrease complication rates. Manipulations under anesthesia have been considered a surrogate for knee stiffness, an undesired postoperative outcome that can potentially be avoided. Currently, there is a lack of information regarding the impact that these new technologies have on manipulations under anesthesia (MUA) rates following TKA. Therefore, the purpose of this study was to evaluate rates of MUAs between a consecutive series of patients who underwent robotic-assisted surgery compared to patients who underwent TKA with conventional instrumentation.
Materials and Methods: A total of 188 consecutive robotic-assisted total knee arthroplasties were performed by five fellowship-trained, high-volume surgeons at academic and community institutions. Patients were paired to a consecutive equal number of control patients by each of the specific surgeon for comparison. All patients followed similar postoperative rehabilitation starting on postoperative day one. Rates of MUAs were evaluated within and between cohorts. Additionally, the percent difference of rates was calculated to compare cohorts. All patients were evaluated at a minimum of two years follow-up time from the index procedure. Chi-square analyses was performed to statistically compare MUA rates between the cohorts.
Results: The overall manipulation under anesthesia rate for the study cohort was 1.06% (2/188 patients), while it was 4.79% in the control cohort (9/188) (p=0.032). A 127.5% difference in manipulation under anesthesia rates was found between the two cohorts. No individual surgeons had higher MUA rates in their robotic-assisted group.
Conclusion: Our study found that patients undergoing robotic-assisted TKA experienced a significant, 4.5-fold decrease in rates of manipulation under anesthesia (p=0.032). Given that MUAs can be a marker of knee stiffness following total knee arthroplasty, the lower rate indicates that study cohort patients had less knee stiffness and, therefore, greater initial postoperative range of motion than the control cohort. Based on these data, assistive technologies may have an advantageous role contributing to enhanced patient outcomes.
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The Effects of a Concentrated Surfactant Gel on Biofilm EPS
Anne-Marie Salisbury, PhD, Laboratory Manager, Rui Chen, PhD, Senior Scientist, Marc Mullin, BSc, R & D Microbiologist, Lauren Foulkes, MSc, R & D Microbiologist, Steven L. Percival, PhD, CEO, 5D Health Protection Group Ltd., Centre of Excellence in Biofilm Science and Technologies (CEBST), Liverpool, United Kingdom
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Introduction: The aim of this study was to evaluate if a poloxamer-based concentrated surfactant gel (CSG), containing antibacterial preservative agents, had the ability to reduce the levels of biofilm extracellular polymeric substances (EPS), specifically proteins and extracellular DNA (eDNA), as these are found to be the most immunogenic, within an in vitro biofilm.
Materials and Methods: A 24-hour biofilm of P. aeruginosa ATCC 15442 was grown in a 12-well plate and treated for 24 hours with a CSG coated onto Multisorb® (BSN Medical Limited, Hull, United Kingdom). EPS were extracted from each sample using 1M sodium chloride. Protein and DNA in EPS extractions was determined quantitatively using the Pierce™ Coomassie (Bradford) protein assay kit and a microplate SYTO 9™ (ThermoFisher Scientific, Paisley, United Kingdom) fluorescent assay, respectively. Protein and DNA was also determined qualitatively using confocal laser scanning microscopy (CLSM).
Results: Following 24-hour growth of P. aeruginosa ATCC 15442 biofilm, 7.38mg/mL protein was isolated from the extracted EPS in the untreated control. In comparison, the protein concentration found in the extracted EPS from biofilms treated with a CSG was 6.39mg/mL, showing a 13.4% reduction. Following 24-hour growth of P. aeruginosa ATCC 15442 biofilm, 11.71mg/mL eDNA was isolated from the extracted EPS in the untreated control. In comparison, the eDNA concentration found in the extracted EPS from biofilms treated with a CSG was 0.65mg/mL, showing a 94.5% reduction. Following statistical analysis of the data, the decrease in protein isolated following CSG treatment was within error; however, the decrease in eDNA isolated was statistically significant, showing the ability of the CSG to break up biofilm EPS in vitro. Using confocal laser microscopy and staining techniques, a large quantity of protein and eDNA could be observed in samples from the untreated control. In comparison, a reduction in EPS protein and eDNA was observed in samples that had been treated with a CSG.
Conclusion: The data presented here potentially shows the ability of a CSG to reduce components of the P. aeruginosa biofilm EPS. The reduction in eDNA following CSG treatment may contribute to the dispersal of the biofilm, potentially increasing the susceptibility of it to antimicrobials, and should be explored further.
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Three-plane Model to Standardize Laparoscopic Right Hemicolectomy with Extended D3 Lymph Node Dissection
Sergey K. Efetov, MD, PhD, Associate Professor, Arcangelo Picciariello, MD, I.M. Sechenov First Moscow State Medical University, Moscow, Russia, Inna A. Tulina, MD, PhD, Associate Professor, Lyudmila V Sidorova, MD, Karina A Kochneva, MD, Roberto Bergamaschi, MD, PhD, Full Professor, Petr V. Tsarkov, MD, PhD, Full Professor, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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Aim: The purposes of this study were to create a “three-plane model” for laparoscopic right hemicolectomy and to compare short-term outcomes of anterior medial-to-lateral (aM-to-L) and caudal-to-cranial access by retroperitoneal tunneling (Ca-to-Cr), as described based on the three-plane model.
Methods: A three-plane model was developed to clarify the steps of an operation. Consecutive cases of right colon cancer were operated upon with an aM-to-L approach in the earlier period and then with a Ca-to-Cr approach, and postoperative outcomes were evaluated. Short-term results were compared.
Results: Sixty-two patients were divided into aM-to-L (n=29) and Ca-to-Cr (n=33) groups. The two groups did not differ in terms of the patients’ baseline characteristics. Median operative time was 220 min (IQR 190-260) for the aM-to-L group and 222.5 min (IQR 180-255) for the Ca-to-Cr group (p=0.73). Estimated blood loss was similar in both groups (p=0.13). Median length of hospital stay was 6 days (IQR 5-8) in the aM-to-L group and 7 days (IQR 6-9) in the Ca-to-Cr group (p=0.17). Median number of harvested lymph nodes was 45.5 (IQR 25-44.9) in the aM-to-L group and 30 (IQR 18-48.5) in the Ca-to-Cr group (p=0.34).
Conclusion: The approach used to reach the superior mesenteric vessels for laparoscopic right hemicolectomy with D3 lymph node dissection does not affect the short-term outcome of the operation. The present three-plane model gives surgeons additional insight to perform this operation.
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Short-Term Safety of the Direct Superior Approach for Total Hip Arthroplasty
Rami M. Ezzibdeh, MSc , Prerna Arora, M. Tech, Derek F. Amanatullah, MD, PhD, Assistant Professor, Stanford Hospital and Clinics, Redwood City, California, Andrew Barrett, MD, University of Pittsburgh Medical College-Hamot, Erie, Pennsylvania, Lige Kaplan, MD, Beaumont Hospital, Royal Oak, Michigan, Douglas Roger, MD, Desert Regional Medical Center, Palm Springs, California, Daniel Ward, MD, Assistant Professor, New England Baptist Hospital, Boston, Massachusetts, Jesus J. Mas Martinez, MD, Vistahermosa Traumatology, Clinica HLA Vistahemosa Avda, Alicante, Spain
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Introduction: Minimally invasive surgery total hip arthroplasty (MIS-THA) is becoming increasingly popular. There are several approaches to MIS-THA that vary according to anatomical access to the hip joint. The direct superior (DS) approach is a recent modification of an MIS posterior approach that spares the iliotibial band and most of the short external rotators of the hip, particularly the quadratus femoris. While FDA approved, there is a lack of data in the current literature on DS outcomes and the safety of this approach is yet to be systematically evaluated.
Materials and Methods: The goal of this study is to provide a quantitative analysis of the safety and complications of primary DS-total hip arthroplasty at 90 days post-surgery through a retrospective multicenter case series of 301 patients. Special attention was given to intra- and postoperative complications, readmissions, mean operative time, hospital-stay length, and postoperative ambulation distance.
Results: Surgical complications included three (1%) intraoperative calcar fractures and four (1%) postoperative peri-prosthetic fractures. The postoperative medical complication rate was 3% with four (1%) patients requiring readmission. The mean operative time was 70 ± 19 minutes, hospital-stay length 41 ± 19 hours, and the estimated blood loss (EBL) was 213 ± 129 ml. There were no acute episodes of instability at 90-day follow up. The intra- and postoperative results are similar with those reported in the literature for both the anterior and posterior approaches.
Conclusion: This study indicates that the DS approach appears to be safe with a low complication rate at 90 days that is comparable to more conventional approaches, such as the direct anterior and posterior techniques. This information is also valuable for the evaluation of reimbursements for DS-THA as current bundled-payment models heavily emphasize 90-day outcomes and complications. Long-term direct comparative studies with the anterior and posterior approaches is required to fully evaluate DS-THAs.
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Role of Automated Suturing Technology in Minimally Invasive Aortic and Mitral Valve Surgery
Hossein Amirjamshidi, MD, MSc, University of Rochester Medical Center, Rochester, NY, Jude S. Sauer, MD, Clinical Assistant Professor of Surgery, Peter A. Knight, MD, Marjorie B. Morris Professor, of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY
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Minimally invasive cardiac surgery continues to evolve and expand as technology and surgeon experience develops. Among the barriers to the adoption of non-sternotomy minimally invasive valve surgery are the challenges associated with suture placement. Automated technology enables ergonomic remote suture placement that allows for reproducible results while shortening the learning curve. The objective of this review is to describe the latest advancements in automated suturing technology for minimally invasive valve surgery.
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All-Inside Arthroscopic Meniscal Repair with the Arthrex Meniscal Cinch™ II
Joanne M Jenkins, MBBS, BSc, MRCS, Glasgow Royal Infirmary, Glasgow, Scotland, Graeme P Hopper, MBChB, MSc, MRCS, University of Glasgow, Glasgow, Scotland, Gordon M Mackay, MD, FRCS (Orth), FFSEM (UK), Professor, University of Stirling, Stirling, Scotland
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Meniscal tears are the most common indication for knee surgery. An appreciation of the limitations associated with the gold-standard inside-out meniscal repair technique has resulted in the development of newer all-inside techniques that overcome many of these issues. This paper describes, with a video illustration available online, a one-handed all-inside meniscal repair technique using the Meniscal Cinch™ II (Arthrex, Inc., Naples, FL).
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Robotic First Rib Resection for Thoracic Outlet Syndrome
Farid Gharagozloo, MD, Professor of Surgery, Barbara Tempesta, CRNP, Scott Werden, MD, University of Central Florida, Celebration, FL, Mark Meyer, MD, Chief of Surgery, Wellington Regional Medical Center, Wellington, FL
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Purpose: First rib resection is a key component of the treatment of Thoracic Outlet Syndrome (TOS). We report our experience with, and technique for, robotic first rib resection.
Methods: Patients diagnosed with TOS underwent robotic first rib resection of the offending portion of the first rib with disarticulation of the costo-sternal joint. Definitive diagnosis of TOS was made by Magnetic Resonance Angiography (MRA) with maneuvers.
Results: A total of 67 patients underwent robotic first rib resection. Neurogenic TOS: 39 patients underwent robotic resection for Neurologic Symptoms of the upper extremity (Neurogenic TOS). There were 14 men and 25 women, with a mean age of 34 ± 9.5 years. Paget-Schroetter Syndrome (PSS) or Venous TOS: 28 patients underwent transthoracic robotic first rib resection for PSS. There were 16 men and 12 women, with a mean age of 24 ± 8.5 years. Operative time was 87.6 ± 10.8 minutes. There were no intraoperative complications. Hospital stay ranged from 2 to 4 days with a median hospitalization of 3 days. There were no neurovascular complications. There was no mortality. In patients with Neurogenic TOS, QuickDASH Scores (mean ± SEM) decreased from 60.3 ± 2.1 preoperatively to 5 ± 2.3 in the immediate postoperative period and to 3.5 ± 1.1 at 6 months (p<0001). Immediate relief of symptoms was seen in 35/39 patients (91%). Persistent paresthesia was seen in 4/39 (9%) immediately postop, and in 2/39 (2.5%) at 6 months. Thirty-seven of 39 (97.5%) patients reported complete relief of symptoms. Among patients with PSS or Venous TOS, 9/28 (32%) required endovascular venoplasty to completely open the subclavian vein after the relief of extrinsic compression. At a median follow-up of 24 months, all patients with PSS had an open subclavian vein, for a patency rate of 100%.
Conclusions: Robotic transthoracic first rib resection allows for minimally invasive resection of the first rib in patients with TOS, with excellent relief of symptoms and no neurovascular complications.
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Cosmetic Surgery—Use of 3mm Ports and Reduced-Port Techniques for Gynecologic Surgery
Olga Borodulin, MD, Erica Stockwell, DO, MBA, David Howard, MD, PhD, Director of Research, University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada
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As innovation continues to evolve in gynecologic surgery, new “cosmetic” techniques are continually being developed. Minimally invasive surgery offers clear benefits over open surgery, such as decreased postoperative pain, infection, length of hospital stay, and time out of work. It is now possible to perform many laparoscopic gynecologic surgeries with minimal to no visible scars. This article reviews the use of 3mm ports and several reduced-port and single-port techniques for use in gynecologic surgery as well as vaginal natural orifice transluminal endoscopic surgery (vNOTES). We also discuss the advantages and challenges that physicians face regarding the adoption of these procedures into general practice. Lastly, we present our novel economic adaption in approach to reduced-port laparoscopic bilateral salpingectomy versus traditional single-site laparoscopic bilateral salpingectomy. In conclusion, minimally invasive approaches to gynecological surgery are considered feasible and safe.
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Knee Osteonecrosis: Cell Therapy with Computer-assisted Navigation
Philippe Hernigou, MD, Professor of Orthopedic Surgery, University of Paris Est, Paris, France, David Gerber, MD, Henri-Mondor University Hospital, Créteil, France, Jean Charles Auregan, MD, Assistant Professor, Hôpital Antoine-Béclère Université Paris-Sud, Clamart, France
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Background: The knee is the second-most common location for osteonecrosis, although it is affected much less often than the hip. Core decompression by precise drilling into ischemic lesions of the femoral condyle while remaining extra-articular is a challenge, particularly in obese patients. For cell therapy, exact localization of the injection point is important to avoid intra-articular injection.
Methods: The precision of drilling with computer-based navigation was compared to that of conventional fluoroscopy-based drilling. A prospective, randomized study was conducted using both surgical trainees without experience and expert surgeons. First, participants performed the surgical task (core decompression) on a cadaver knee using fluoroscopic guidance or computer-based navigation. Performance was determined by the radiographic analysis of trocar placement. Next, 12 consecutive patients with bilateral symptomatic secondary (corticosteroids) osteonecrosis without collapse were included in a clinical prospective, randomized, controlled study. The 24 knees were treated using conventional fluoroscopy with expert surgeons on one side and computer-based navigation with surgical trainees on the contralateral side. Bone marrow aspirated from the two iliac crests was mixed before concentration. Each side received the same volume of concentrated bone marrow and the same number of cells (95,000 ± 25,000 cells; counted as CFU-F).
Results: In the cadaver tests, the distance to the desired center-point of the lesion in the navigated group (1.6 mm) was significantly less than that in the control group (5.9 mm; p<0.001). Significant differences were also found in the number of drilling corrections (p<0.001), the radiation time needed (p<0.001), the risk of intra-articular penetration, and the risk of ligament injuries. In patients, computer navigation achieved results closer to the ideal position of the trocar, with better trocar placement in terms of tip-to-subchondral distance and ideal center position within the target for injection of stem cells. At the most recent follow-up (5 years), an increase in precision with computer-assisted navigation resulted in less collapse (4 vs. 1) and better volume of repair (11.4 vs 4.2 cm3) for knees treated with the computer-assisted technique. Failures were related to missing the target with intra-articular penetration.
Conclusions: Computer-assisted navigation improved precision with less radiation. The findings of this study suggest that computer navigation may be safely used in a basic procedure for the injection of stem cells in knee osteonecrosis.
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Stapled Diaphragmatic Plication: Is It Better Than Suture Plication?
Terra M Hill, MS, Medical Student, University of Kansas School of Medicine, Kansas City, KS, USA, Osita Onugha, MD, MBA, Assistant Professor , Providence St. John’s Health Center, John Wayne Cancer Institute, Santa Monica, CA, USA
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Diaphragm dysfunction, which can be due to eventration or an abnormally high-positioned diaphragm, can cause respiratory compromise. Eventration is most commonly due to unilateral diaphragm paralysis, which reduces ventilatory function in adults by about 25%. Since the 1920s, this condition has been treated with diaphragm plication, which itself has evolved to include the use of several different techniques and materials. This review explores the relevant literature on diaphragm plication using sutures or staples for the treatment of eventration to determine if either provides a clinical benefit over the other.
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Large Abdominal Wall Defects: A Safe and Reliable Technique for Midline Reconstruction—The Bonheiden Experience
Liza Van Kerckhoven, MD, Gavin Lo, MD , University Hospital , Leuven, Belgium, Koen Vermeiren, MD, Kurt Devroe, MD, Tim Tollens, MD, Head of Department, Imelda Hospital, Bonheiden, Belgium
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This retrospective study reveals the results of our approach to the treatment of complex ventral hernias. A single-center, single-surgeon retrospective chart review on 68 consecutive patients who underwent abdominal wall reconstruction for incisional herniation on the midline between January 2012 and December 2016 is presented. The Bonheiden technique is based on anterior component separation in combination with preperitoneal retromuscular mesh reinforcement of the midline. Data of 68 consecutive cases of incisional midline abdominal wall defects treated electively with the mesh reinforced anterior component separation technique were analyzed. Demographics, patient characteristics, and hernia properties were evaluated. Postoperative complications included 28% of wound infections/dehiscence, 25% seromas, and 7% hematomas. No recurrences have been seen. We conclude this technique to be safe and reliable for large midline defects in patients suffering with several comorbidities.
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Robotic Lobectomy: Experience with 638 Consecutive Cases
Farid Gharagozloo, MD, Professor of Surgery, Surgeon-in-Chief, Barbara Tempesta, Advent Health University of Central Florida Celebration, FL , Mark Meyer, MD, Wellington Regional Medical Center, Wellington, FL
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BACKGROUND: Robotic lobectomy has been evolving over the past decade and has been shown to be an oncologically acceptable procedure. We evaluated our experience with robotic lobectomy for the treatment of early-stage lung cancer.
METHODS: We performed a retrospective review of prospectively accrued patients at our institution who underwent robotic lobectomy for early-stage lung cancer from February 2004 to July 2019.
RESULTS: Of 3304 consecutive patients who underwent a robotic operation by a single surgeon, 638 underwent robotic lobectomy for early-stage primary non-small cell lung cancer (NSCLC; stages I and II). The 427 (67%) men and 211 (33%) women had a median age of 69 y (range 41-86), and 567 (89 %) were former or current smokers. The median operative time was 176 minutes (range 160-456), the median chest tube time was 3 days (2-8), the median air leak time was 0 days (0-3), and the median length of stay was 3 days (1-26). The median tumor size was 2.6 cm (range 06-3.4). The mean number of nodes recovered was 14 ± 3. Pathologic upstaging was noted in 121 patients (19%). Minor complications were observed in 133 patients (21%). Conversion to thoracotomy occurred in 11 (1.7%) patients. Mortality was 0.5%.
CONCLUSION: Robotic lobectomy is a safe, minimally invasive procedure that replicates the oncologic and technical principles of thoracotomy for the treatment of lung cancer.
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Transtrochanteric Anterior Rotational Osteotomy Combined with Re-Sphericalization of the Collapsed Femoral Head Using Calcium Phosphate Cement Filling
Goro Motomura, MD, PhD, Associate Professor, Yusuke Kubo, MD, PhD , Takeshi Utsunomiya, MD, PhD , Satoshi Hamai, MD, PhD , Assistant Professor, Satoshi Ikemura, MD, PhD , Assistant Professor, Masanori Fujii, MD, PhD , Assistant Professor, Yasuharu Nakashima, MD, PhD, Professor and Chairman, Takuaki Yamamoto, MD, PhD , Professor and Chairman, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Introduction: Transtrochanteric anterior rotational osteotomy (ARO) is an established joint-preserving surgery for collapsed osteonecrosis of the femoral head (ONFH) in which the collapsed necrotic lesion is rotated anteriorly. Recently, preoperative collapse of more than 2.98mm was reported to be the most influential factor for progressive collapse of the anteriorly transposed necrotic lesion after ARO, the main cause of secondary osteoarthritic changes and clinical failure. We attempted to prevent progressive collapse with re-sphericalization of the collapsed femoral head using calcium phosphate cement (CPC) filling in conjunction with ARO.
Materials and Methods: Between May 2015 and April 2018, five consecutive hips with ONFH, femoral head collapse of ³3mm, and one-third or more of the posterior region of the femoral head intact, were prospectively recruited for re-sphericalization with ARO. This report describes intraoperative surgical techniques focusing on re-sphericalization of the collapsed femoral head using CPC and short-term effects of this additional procedure on progressive collapse of the transposed necrotic lesion, defined as ³2mm progression on lateral radiographs.
Results: After anterior rotation of the proximal fragment, followed by fixation of the transtrochanteric osteotomy site, a 5mm fenestration was made in the collapsed region of the anterior femoral head cartilage, through which the collapsed surface was carefully lifted with an elevatrium. Subsequently, CPC paste was injected into the lifted subchondral space with a small needle. After CPC paste injection, the femoral head was maintained at 40°C for 10 minutes to promote solidification of the CPC paste. With the re-sphericalization method, the mean level of collapse decreased from 4.1mm before surgery to 2.0mm after surgery. Subsequently, progressive collapse of the transposed necrotic lesion was confirmed in two hips. One of these hips had a deep infection that required complete curettage of CPC three weeks after the initial surgery. All hip joints have been preserved without conversion to prosthesis during a mean follow up of 2.1 years.
Conclusion: A joint-preserving procedure for ONFH with severe collapse remains a challenging problem for surgeons. When ARO is indicated based on one-third or more of the posterior region of the femoral head being intact, the current re-sphericalization method could be worth considering as an additional procedure in cases with severe collapse.
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Robotic-Assisted Distal Gastrectomy for Gastric Cancer Using an Oval-Shaped Port Device
Kazunori Shibao, MD, PhD, FACS, Associate Professor, Yasutaka Kawakita, MD, Masahiro Mitsuyoshi, MD, Yusuke Sawatsubashi, MD, Assistant Professor, Nobutaka Matayoshi, MD, Assistant Professor, Nagahiro Sato, MD, PhD, Assistant Professor, Takayuki Torigoe, MD, PhD, Assistant Professor, Keiji Hirata, MD, PhD, Professor, Department of Surgery I, School of Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
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Introduction: This report describes the techniques and outcomes of robot-assisted distal gastrectomy (RDG) for gastric carcinoma using an oval-shaped port device.
Materials and Methods: A total of 15 patients underwent RDG with lymphadenectomy using the E‧Z Access™/LAP-PROTECTOR™ oval-type device (Hakko Co., Ltd., Tokyo, Japan) performed by a single surgeon between 2018 and 2019. This device was introduced to the umbilicus under two settings, depending on the patient’s figure. A horizontal setting (n=7) was used to reduce the number of trocar skin incisions in thin patients by placing a scope trocar and assist port within the E‧Z Access™. The vertical setting (n=8) was used for large and obese patients, enabling the endoscope position to move 50mm toward the cephalad side by rotating the device 180° to improve the surgical view of the suprapancreatic area (“dual port position” using the E‧Z Access™ oval-type device). The intracorporeal Billroth-I anastomosis or Roux-en-Y method was used for reconstruction. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures.
Results: The E‧Z Access™ oval-type device was useful for maintaining an optimal surgical field and reducing the number of skin incisions and the level of surgeon stress. Furthermore, its removal cap and wound protector allowed for an airtight seal, umbilical wound protection, and smooth specimen removal and re-pneumoperitoneum. R0 resection was accomplished in all cases without the need for conversion to open or conventional laparoscopic surgery. The median operating time was 323 (range, 245–590) minutes, and the median blood loss was 5ml. The median number of retrieved lymph nodes was 30. Neither major postoperative complication, including umbilical skin damage, nor postoperative mortality, was observed. The mean length of the hospitalization was 12.5 days.
Conclusions: Our robotic approach using an oval-shaped port device for gastric cancer patients is feasible in terms of patient safety and curability.
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Review of Procedures and Outcomes of Video-Assisted Thoracic Surgery for the Treatment of Non-Small Cell Lung Cancer in 45 Patients Undergoing Segmentectomy
Rachel Sier, BS, Osita Onugha, MD, MBA, Assistant Professor of Thoracic Oncology, John Wayne Cancer Institute, Santa Monica, CA
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Background: Lung cancer is the leading cause of death due to cancer in the United States and survival is heavily dependent upon the cancer stage at diagnosis. In the treatment of Stage I or Stage II non-small cell lung cancer (NSCLC), cancerous lung nodules are removed through lobectomy or segmentectomy. Lobectomy removes an entire lobe of the lung. Segmentectomy removes only a portion of the lobe, minimizing removal of functional lung parenchyma. Both procedures can be completed through video-assisted thoracic surgery (VATS). In this retrospective review of the outcomes of VATS segmentectomy, the locations of nodules in relation to segmentectomy and the selection of patients to undergo segmentectomy are discussed.
Methods: A retrospective analysis of 60 patients who underwent VATS segmentectomy from January 2016 to December 2017 was performed. Forty-five patients were selected based on a diagnosis of NSCLC and the availability of reported outcomes. Patients were reviewed over 18 to 42 months for evidence of disease recurrence or progression.
Results: The patients had an average age of 71.2 years, and 31 (69%) were former or current smokers. Most of the lung nodules removed were located in the left upper lobe (LUL) and removed by LUL trisegmentectomy. The median lung nodule size was 18 mm. Most of the cancers diagnosed were Stage I adenocarcinoma. The median length of stay in the hospital was 3 days. The median chest tube retention was 2 days. Six patients had nodule recurrence or progression of disease.
Conclusion: In decision-making between segmentectomy and lobectomy, adequate margins are required for the selection of segmentectomy, the most common of which is LUL trisegmentectomy. Technical challenges can be overcome with adequate training and simulation. Additional research could focus on the identification of factors associated with recurrence.
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External Stents for Vein Grafts in Coronary Artery Bypass Grafting: Targeting Intimal Hyperplasia
Luca Paolo Weltert, MD, Heart Surgeon and Professor of Statistics, Lorenzo Guerrieri Wolf, MD, Raffaele Scaffa, MD, Andrea Salica, MD, Alessandro Ricci, PhD, MD, Francesco Giosuè Irace, MD, Samuel Fusca, MD, Salvatore D’Aleo, MD, Alessandro Bellisario, MD, Ruggero de Paulis, MD, Head of Heart Surgery Unit, Heart Surgery Unit, European Hospital, Rome, Italy, Luigi Garufi, MD, Department of Statistics, San Camillus International University for Health Sciences, Rome, Italy, Ilaria Chirichilli MD, Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital Rome, Italy
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Introduction: Progressive saphenous vein graft (SVG) failure remains a key limitation to the long-term success of coronary artery bypass grafting (CABG). SVG disease after the first year is dominated by intimal hyperplasia, which predisposes the SVG to thrombosis and accelerated atherosclerosis. The objective of this study was to review and summarize the latest experimental and clinical data on the use of mechanical external stents for vein grafts.
Methods: In January 2020, the PubMed database was searched using the terms “external stent”, “CABG”, “saphenous vein graft” and “intimal hyperplasia”. The results were reviewed and only randomized experimental and clinical studies that analyzed the effect of external stenting on venous intimal hyperplasia were included in the analysis, together with studies that investigated the clinical benefit of external stenting.
Results: Eight experimental and four clinical trials met the search criteria. Controlled trials in different large animal models concluded that external stenting significantly reduced intimal hyperplasia 3-6 months post implantation, and reduced both thrombosis rates and the development of lumen irregularities. Data from randomized controlled trials with a follow-up period of 1-4.5 years supported the pre-clinical findings and demonstrated that external stents significantly reduced vein graft disease.
Conclusion: Strong evidence indicates that supporting the vein with external stents is safe and leads to clear advantages at both the anatomical and cellular levels. With the further accumulation of consistent positive results, external stenting of SVG may become the standard of care in future CABG.
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