RESUMEN
â¤: Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation. â¤: In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF). â¤: In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty. â¤: Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time.
Asunto(s)
Artroplastía de Reemplazo de Hombro , Fijación de Fractura/métodos , Hemiartroplastia , Fracturas del Hombro/terapia , Anciano , Anciano de 80 o más Años , Reducción Cerrada , Fijación Interna de Fracturas , Humanos , Inmovilización/métodos , Reducción Abierta , Ensayos Clínicos Controlados Aleatorios como Asunto , Rango del Movimiento Articular , Reoperación , Sarcopenia/complicaciones , Fracturas del Hombro/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Addition of en bloc segmental venous reconstruction (VR) to pancreaticoduodenectomy (PD) for venous involvement of pancreatic tumors increases the complexity of the operation and may increase complications. The long-term mesenteric venous patency rate and oncologic outcome has not been well defined. METHODS: Our prospective database was reviewed to assess 90-day postoperative outcomes for patients who underwent PD or PD + VR (September 2004-June 2016). Two independent observers reviewed CT scans to determine long-term vein patency. In patients with pancreatic ductal adenocarcinoma, the impact of VR on 5-year overall survival was assessed using multivariate Cox proportional hazards regression. Student's t-test was used to evaluate continuous variables and the chi-square test for categorical variables. RESULTS: Three hundred ninety-three patients underwent PD (51 PD + VR). Patients undergoing PD + VR had longer operations (561 ± 119 versus 433 ± 89 min, P < 0.00001) and greater blood loss (768 ± 812 versus 327 ± 423 cc, P < 0.00001). There was no difference in 90-day mortality, overall postoperative complication rates, complication severity grades, reoperation, readmission, or length of stay. 26.7% experienced venous thrombosis. Most thromboses occurred in the first year after surgery, but we also observed late thrombosis in 1 patient after 89-month follow-up. Among 135 patients with pancreatic ductal adenocarcinoma, survival was significantly longer in the PD-alone group (31.3 months [95% confidence interval: 22.9-40.0] versus 17.0 [95% confidence interval: 13.0-19.1], plog-rank = 0.013). CONCLUSIONS: PD + VR does not increase short-term morbidity, but venous thrombosis is frequent and can occur long after surgery. Survival is inferior when VR is required especially in the absence of neoadjuvant chemotherapy.