Rathke's cleft cysts: A single-center case series.

Background: Rathke's cleft cysts (RCCs) are common benign sellar or suprasellar lesions. The aim of this study is to report our experience on the management of 27 RCC cases. Methods: We retrospectively analyzed a series of 27 patients with symptomatic RCC who were referred to our department between January 2016 and January 2020. Data regarding patients' demographics, clinical evaluations, laboratory and neuroimaging findings, pathologic records, surgical treatment, and complications were extracted from our electronic database. All patients underwent RCC removal through a direct endoscopic endonasal transsphenoidal (EETS) approach, except for two cases. Results: Data of 27 patients (3 men and 24 women; mean age: 38 years) with symptomatic RCC were reviewed. The most common presenting symptom was headache, occurring in 20 (74.0%) patients. In 16 (59.2%) cases, the tumor was primarily located in the sella turcica. Nine (33.3%) cases exhibited a secondary suprasellar extension. Conclusion: Our experience with RCC patients showed that EETS is a safe method of treatment, with minimal recurrence.

Aortic arch repair: lessons learned over three decades at Baylor College of Medicine.

The treatment of complex aortic arch disease continues to be among the most demanding cardiovascular operations, with a considerable risk of death and stroke. Since January 1990, our single-practice service has performed over 3000 repairs of the aortic arch. Our aim was to describe the progression of our technical approach to open aortic arch repair. Our center's surgical technique has evolved considerably over the last three decades. When it comes to initial arterial cannulation, we have shifted away from femoral artery cannulation to innominate and axillary artery cannulation. During difficult repairs, this transition has made it easier to use antegrade cerebral perfusion rather than retrograde cerebral perfusion, which was commonly used in the early days. Brain protection tactics during open aortic arch procedures have evolved from profound (≤14 °C) hypothermia during circulatory arrest to moderate (22-24 °C) hypothermia. Aortic arch repair is performed through a median sternotomy and may treat acute aortic dissection, chronic aortic dissection, or degenerative aneurysm. Reoperative repair - that necessitating redo sternotomy - is common in patients undergoing aortic arch repair. The majority of repairs will include varying portions of the ascending aorta and may involve the aortic valve or the aortic root. In some patients, repair may extend into the proximal descending thoracic aorta; this includes elephant trunk, frozen elephant trunk, and antegrade hybrid approaches.

Left Ventricle Mass Regression After Surgical or Transcatheter Aortic Valve Replacement in Veterans.

BACKGROUND: Differences in left ventricular mass regression (LVMR) between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have not been studied. We present clinical and echocardiographic data from veterans who underwent TAVR and SAVR, evaluating the degree of LVMR and its association with survival. METHODS: We retrospectively reviewed TAVR (n = 194) and SAVR (n = 365) procedures performed in veterans from 2011 to 2019. After 1:1 propensity matching, we evaluated mortality and secondary outcomes. Echocardiographic data (median follow-up 957 days, interquartile range 483-1652 days) were used to evaluate LVMR, its association with survival, and predictors of LVMR. RESULTS: There was no difference between SAVR and TAVR patients in mortality (for up to 8 years), stroke at 30 days, myocardial infarction, renal failure, prolonged ventilation, reoperation, or structural valve deterioration. SAVR patients (67.3% [101 of 150]) were more likely to have LVMR than TAVR patients (55.7% [44 of 79], P = .11). The magnitude of LVMR was greater for the SAVR patients (median, -23.3%) than for the TAVR patients (median, -17.8%, P = .062). SAVR patients with LVMR had a survival advantage over SAVR patients without LVMR (P = .016). However, LVMR was not associated with greater survival in TAVR patients (P = .248). CONCLUSIONS: SAVR patients were more likely to have LVMR and had a greater magnitude of LVMR than TAVR patients. LVMR was associated with better survival in SAVR patients, but not in TAVR patients.

Ninety-Day Readmission After Open Surgical Repair of Stanford Type A Aortic Dissection.

BACKGROUND: Investigations into readmissions after surgical repair of acute Stanford type A aortic dissection (TAAD) remain scarce. We analyzed potential risk factors for readmission after TAAD. METHODS: The 2013 to 2014 US Nationwide Readmissions Database was queried for TAAD index hospitalizations and 90-day readmissions indicated by diagnostic and procedural codes. Multivariable analysis was completed to identify risk factors and the most common reasons for readmission. RESULTS: We identified 6975 patients (65% men; mean age, 60.0 ± 0.4 years) who underwent surgical repair for TAAD. Overall 2062 patients (29.6%) were readmitted within 90 days: 634 (30.7%) during the first 30 days and 1428 (69.3%) during days 31 through 90. Readmitted patients had a higher prevalence of chronic kidney disease at index admission (18.0% vs 11.6%, P = .002), greater overall index length of stay (17.8 ± 0.6 vs 15. 5 ± 0.4 days; P = .0003), and greater index hospitalization cost ($90,637 ± $2691 vs $80,082 ± $2091; P = .0003). Mortality during readmission was 3.6% (n = 74). Indications for readmission were most commonly cardiac (26.2%), infectious (17.8%), and pulmonary (11.7%). Multivariate analysis identified 2 independent risk factors for readmission: acute kidney injury (odds ratio, 1.49; 95% confidence interval, 1.24-1.78; P < .0001) and an Elixhauser comorbidity index > 4 (odds ratio, 1.26; 95% confidence interval, 1.06-1.49; P = .009). CONCLUSIONS: After surgical repair of TAAD, approximately 30% of patients were readmitted within 90 days, two-thirds of them during the 31- to 90-day period. Targeted improvements in perioperative care and postdischarge follow-up of patients with multiple comorbidities could mitigate readmission rates. Efforts to reduce readmissions should be continued throughout the 90-day period.

Clinical outcome of selective amygdalectomy in a series of patients with resistant temporal lobe epilepsy.

BACKGROUND: Selective amygdalohippocampectomy is one of the main approaches for treating medial temporal lobe epilepsy (TLE). We herewith describe seven cases of amygdala lesions treated with selective amygdalectomy with the hippocampus saving procedure. Furthermore, we explain the trans-middle temporal gyrus transventricular approach for selective amygdalectomy. METHODS: We studied patients with TLE who underwent selective amygdalectomy with hippocampal saving procedure between March 2012 and July 2018. We preferred the trans-middle temporal gyrus transventricular approach. We adopted pterional craniotomy with extensive exposure of the base and posterior of the temporal lobe. The posterior margin of resection in the intraventricular part of the amygdala was considered the inferior choroidal point. Medially anterior part of the uncus was resected until reaching the ambient cistern. We applied the transcortical transventricular approach for selective amygdalectomy in all patients. RESULTS: We present 11 cases having an amygdala lesion in our series, seven of whom underwent selective amygdalectomy with hippocampal sparing. Nine patients had neoplastic lesions, and in two of them, gliosis was evident. Total resection of the lesion was achieved in all cases based on postoperative magnetic resonance imaging. No unusual complication or surgically-related new neurological deficit occurred. CONCLUSION: We consider the resection of the amygdala until the inferior choroidal point sufficient for the disconnection of its circuits, which results in more effective control of seizures and reduction of surgery time and complications.

Development of a Risk Score to Predict 90-Day Readmission After Coronary Artery Bypass Graft.

BACKGROUND: Readmission after coronary artery bypass grafting (CABG) is used for quality metrics and may negatively affect hospital reimbursement. Our objective was to develop a risk score system from a national cohort that can predict 90-day readmission risk for CABG patients. METHODS: Using the National Readmission Database between 2013 and 2014, we identified 104,930 patients discharged after CABG, for a total of 234,483 patients after weighted analysis. Using structured random sampling, patients were divided into a training set (60%) and test data set (40%). In the training data set, we used multivariable analysis to identify risk factors. A point system risk score was developed based on the odds ratios. Variables with odds ratio less than 1.3 were excluded from the final model to reduce noise. Performance was assessed in the test data set using receiver operator characteristics and accuracy. RESULTS: In the United States, overall 90-day readmission rate after CABG was 19% (n = 44,559 of 234,483). Nine demographic and clinical variables were identified as important in the training data set. The final risk score ranged from 0 to 52; the 2 largest risks were associated with length of stay greater than 10 days (score = +10) and Medicaid insurance (score = +7). The final model's C-statistic was 0.67. Using an optimal cutoff of 18 points, the accuracy of the risk score was 77%. CONCLUSIONS: Ninety-day readmission after CABG surgery is frequent. A readmission risk score higher than 18 points predicts readmission in 77% of patients. Based on 9 demographic and clinical factors, this risk score can be used to target high-risk patients for additional postdischarge resources to reduce readmission.

Surgical Outcomes of Sphenoorbital En Plaque Meningioma: A 10-Year Experience in 57 Consecutive Cases.

OBJECTIVE: Sphenoorbital en plaque meningioma is located in a sensitive and complex cranial region. Therefore the therapeutic approach for this type of tumor is of great importance. We aimed to examine the clinical and radiologic outcomes of patients diagnosed with sphenoid wing en plaque meningioma undergoing surgery. METHODS: In this case series, the results of clinical and functional assessments, as well as appearance before and after surgery, were examined in 57 patients with sphenoorbital en plaque meningioma undergoing surgery with the frontotemporal approach during 2007-2017. Data were entered in the designed forms and statistically analyzed. RESULTS: Proptosis, headache, and vision impairment were detected in 47 (83%), 33 (58%), and 16 (28%) patients, respectively. Eight (14%) patients complained of diplopia, while 3 (8%) patients complained of ptosis. In all patients, proptosis improved following surgery. Complete treatment of proptosis was reported in 42 cases, and significant improvement was observed in 5 cases. Sixteen patients experienced visual impairment before surgery, 7 of whom showed improvements after surgery, while 1 showed deteriorated visual acuity after surgery. Total tumor resection was achieved in 48 (84%) patients. Tumor relapse was reported in 7 (12.5%) patients during follow-up. One patient had undergone repeated surgery, 1 patient was treated with radiotherapy alone, and 5 patients underwent combined treatment. CONCLUSIONS: Total tumor resection can be achieved with minimal complications by using microscopic dissection and sufficient bone and orbital wall resection. An important point in the treatment of these patients is the appropriate restoration of the orbital wall.

Weight-Bearing Radiographic Analysis of the Tibiofibular Syndesmosis.

Background: Diagnosis of distal tibiofibular syndesmotic injuries includes assessment of radiographs; however, there exist no agreed on standard diagnostic criteria. Previous studies lack consistency with radiographic evaluation methods. The dynamic nature of the ankle joint supports analyzing anatomical parameters using weight-bearing films to assess for tibiofibular syndesmotic integrity. Methods: Weight-bearing tibiofibular syndesmosis radiographs of 39 male and 40 female patients were retrospectively analyzed by 3 investigators, at different levels of orthopaedic training. Measurements 1 cm above the tibial plafond for the anterior tibiofibular overlap (TFO) and tibiofibular clear space (TCS) were recorded and standardized by the fibular width (FW) at 2 time points. Data were compared to check for agreement between the sets of measurements for each rater and agreement between investigators, and to ascertain underlying gender differences. Results: There was good intraobserver correlation (intraclass correlation coefficient [ICC] > 0.90) among investigators for each parameter. A significant difference in the TFO was noted between genders (P < .05). We establish the following radiographic (anteroposterior view) parameters for an intact syndesmosis: male patients, TCS <4.57 mm or TCS/FW <29% and TFO >9.29 mm or TFO/FW > 57%; female patients, TCS <4.28 mm or TCS/FW <30% and TFO >7.41 mm or TFO/FW >51%. Conclusions: Our study provides a more objective approach by utilizing weight-bearing radiographs and performing all measurements 1 cm above the tibial plafond. Levels of Evidence: Level IV.

Stability of two versus three peripheral pegs of the glenoid component in modern total shoulder arthroplasty.

PURPOSE: In total shoulder arthroplasty (TSA), the optimum number of peripheral pegs required for stability in the glenoid component is unknown. This study compared the stability of two versus three peripheral pegs in cemented glenoid components possessing a central press-fit peg. METHODS: Six unmodified glenoid components with three peripheral pegs, a large, central press-fit peg and six modified glenoid components with one inferior peripheral peg sharply removed were cemented into bone substitute polyurethane blocks. A modified rocking-horse test was completed by comparing superior- and inferior-edge displacement before and after 100,000 vertical motion cycles. Then, a torsional failure test applied 2 N axial load, followed by a rotational force to the glenoid component at 0.5 °/s until failure. RESULTS: Modified rocking-horse testing showed no statistically significant edge displacement at the superior or inferior aspect of the glenoid component before or after testing. During torsional testing, peak torque and degrees of rotation at failure also showed no significant difference. CONCLUSION: Two peripheral pegs offer equivalent stability as three peripheral pegs, as assessed by cyclic rocking and rotational failure testing. Fewer peripheral pegs during glenoid component implantation may lead to less dissection, less strain on soft tissues and decreased operative time.

Biomechanical Comparison of Bicortical, Unicortical, and Unicortical Far-Cortex-Abutting Screw Fixations in Plated Comminuted Midshaft Clavicle Fractures.

PURPOSE: The objective of this study was to assess the biomechanical properties of bicortical locking screws, unicortical locking screws, and unicortical far-cortex-abutting locking screw fixation in a cadaver model of comminuted midshaft clavicle fractures stabilized with a locking plate placed on the superior surface of the clavicle. METHODS: Nine pairs of adult fresh-frozen cadaver clavicles were allocated into 3 groups for either bicortical, unicortical, or unicortical far-cortex-abutting locking plate fixation. After a 1-cm osteotomy to simulate a comminuted fracture and instrumentation with an 8-hole locking plate placed on the superior surface of the clavicle, the specimens were mounted in a custom dual-gimbal fixture in a materials-testing system and tested in axial compression, torsional, and torsional load to failure. RESULTS: Axial stiffness and axial osteotomy site stiffness did not demonstrate differences between constructs. In cyclical torsion, both the bicortical and the unicortical far-cortex-abutting constructs were significantly stiffer than the unicortical construct. For torsional failure stiffness, both the bicortical and the unicortical far-cortex-abutting constructs were significantly stiffer than the unicortical construct. There was no difference between bicortical and unicortical far-cortex-abutting for torsional failure stiffness. The bicortical construct exhibited significantly higher peak failure torque compared with the unicortical construct. CONCLUSIONS: Unicortical far-cortex-abutting locking screw fixation provides comparable mechanical properties under axial and torsional loads to bicortical fixation, without penetrating the far cortex. CLINICAL RELEVANCE: Unicortical far-cortex-abutting locking screw fixation obviates far cortex penetration, and thereby protects nearby anatomical structures, may ease symptomatic implant removal, alleviates refracture risk, and eases conversion to bicortical fixation in the case of revision surgery.