Incidence and risk factors for shoulder stiffness after open and arthroscopic rotator cuff repair.

INTRODUCTION: The aim of this study was to estimate the incidence of stiffness during the first 6 months after rotator cuff repair and to evaluate postoperative stiffness with respect to its risk factors and its influence on the outcome at 6 months postoperatively. METHODS: In a prospective cohort of 117 patients (69 women, 48 men; average age 59) from our institutional rotator cuff registry, who underwent either arthroscopic (n = 77) or open (n = 40) rotator cuff repair, we measured shoulder range of motion (ROM) at 3 and 6 months post-surgery. We evaluated the incidence of stiffness and analyzed functional outcomes, comparing various preoperative and intraoperative factors in patients with stiffness to those without at the 6-month mark. RESULTS: Shoulder stiffness was observed in 31% of patients (36/117) at 3 months postoperatively, decreasing to 20% (23/117) at 6 months. No significant link was found between stiffness at 6 months and demographic factors, preoperative stiffness, tear characteristics, or the type of repair. Notably, patients undergoing arthroscopic repair exhibited a 4.3-fold higher risk (OR 4.3; 95% CI 1.2-15.6, p = 0.02) of developing stiffness at 6 months compared to those with mini-open repair. Despite these differences in stiffness rates, no significant variation was seen in the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, or Visual Analog Scale (VAS) scores at 6 months between the groups. CONCLUSION: The incidence of postoperative shoulder stiffness following rotator cuff repair was substantial at 31% at 3 months, reducing to 20% by 6 months. Mini-open repair was associated with a lower 6-month stiffness incidence than arthroscopic repair, likely due to variations in rehabilitation protocols. However, the presence of stiffness at 6 months post-surgery did not significantly affect functional outcomes or pain levels.

One-stage or two-stage elective coronary artery bypass graft surgery and abdominal aortic aneurysm open repair in low and moderate cardiac surgical risk patients.

OBJECTIVES: Coronary artery disease (CAD) and abdominal aortic aneurysm (AAA) are common arterial pathologies that might occur simultaneously; however, there is not enough evidence about the optimal strategy for patients with concomitant indications of coronary artery bypass grafting (CABG) and open repair of the AAA (AAOR). This study aims to present the outcomes in low and moderate cardiac surgical risk patients who underwent one-stage or two-stage elective CABG and AAOR in a middle-income country. METHODS: An observational, retrospective case series study was conducted. Patients who had low and moderate cardiac surgical risk (less than 8% mortality risk on the STS score) and had the concomitant indication for CABG and AAOR between December 2005 and August 2021 were included. Patients were assigned to one of three strategies: Group 1 underwent one-stage surgery for CABG and AAOR, Group 2 underwent two-stage surgery within the same in-patient stay, and Group 3 underwent two-stage surgery in a new in-patient stay within 6 months. RESULTS: Twenty seven, patients with simultaneous requirements of CABG and AAOR were identified, with a mean age of 69.5 ± 6.1 years and 92.6% were male. The most common comorbidities were hypertension at 77.8% and dyslipidemia at 55.6%. The average mortality risk calculated by the STS score was 2.09% ± 1.53%. In Group 1 (n = 9), 1/9 had in-hospital mortality and no reinterventions were needed. In Group 2 (n = 10), 1/10 had in-hospital mortality, and the most common postoperative complication was acute kidney injury 2/10. Furthermore, 2/10 required a reintervention. In Group 3 (n = 8), no in-hospital mortality was present, however, complications such as sepsis, atrial fibrillation, and acute kidney injury occurred in 2/8 patients each, and 2/8 required a reintervention. CONCLUSION: Patients with CAD and AAA that need a concomitant surgical correction with CABG and an AAOR are uncommon in contemporary practice, given the advances in endovascular therapy. When indicated, one-stage surgery can be performed in patients with low cardiac surgical risk, proper patient selection plays a fundamental role and might be performed in experienced centers. However, two-staged surgeries at the same or different inpatient stay may be considered for asymptomatic AAA with close monitoring during the postoperative period. These findings can hold significance for addressing sociodemographic barriers in low and middle-income countries. More robust and extensive studies are needed to make clear comparisons between the different strategies.

Aneurisma de arteria carótida interna. Caso clínico

Introducción: Los aneurismas de la arteria carótida extracraneal (ACEC) son poco frecuentes en comparación con las lesiones oclusivas. Los ACEC son menos del 1% de todos los aneurismas arteriales y solo el 10% son considerados aneurismas verdaderos. Caso Clínico: Paciente femenina de 84 años, en excelentes condiciones generales, hipertensa e hiperlipidémica, neurológicamente asintomática, con hallazgo de aneurisma de carótida interna derecha en el contexto de una arteria elongada, estenosis moderada ostial y oclusión de arteria carótida interna contralateral. Se realiza resección de aneurisma con anastomosis término terminal, endarterectomía del ostium y angioplastía con parche. Su evolución fue favorable, manteniéndose asintomática y con la reconstrucción permeable a 6 meses de seguimiento en eco duplex. Discusión: La elección del manejo del ACEC va a depender de sus características morfológicas, en este caso la presencia de tortuosidad extrema de la arteria carótida interna dificultaba la posibilidad de manejo endovascular, pero facilitaba la resección del aneurisma con anastomosis primaria término terminal. Conclusión: La aneurismectomía y reconstrucción es una modalidad de manejo disponible para los ACEC.

Introduction: Extracranial carotid artery aneurysms (ECAA) are rare compared to occlusive disease, less than 1% of all arterial aneurysms and only 10% are considered true aneurysms. Clinical case: A 84-year-old female, active and in excellent general health, with a prior history significant only for hypertension and hyperlipidemia was referred for a right internal carotid artery aneurysm and elongation in the context of contralateral internal carotid artery occlusion. The patient denied neurologic symptoms. Resection of the aneurysm and end-to-end anastomosis, endarterectomy of the ostium and patch angioplasty was performed. The patient had an uneventful recovery, remaining asymptomatic and the reconstruction patent on duplex scan at 6 month follow up. Discussion: The choice of repair alternatives for EICA depend on its morphological characteristics. The presence of extreme tortuosity of the internal carotid artery in this case, on one hand make difficult to consider endovascular alternatives, but facilitates aneurysm resection and primary end-to-end anastomosis. Conclusion: Aneurysmectomy and arterial reconstruction is a treatment alternative for EICA repair.

Transcervical approach to distal extracranial internal carotid aneurysm.

We report the case of a 77-year-old woman presenting with an asymptomatic internal carotid artery (ICA) aneurysm arising at the skull base. The distal right extracranial ICA aneurysm presented as a challenging case due to difficulty in obtaining adequate surgical exposure and preserving the facial nerves present near the ICA aneurysm. Transcervical open repair with a team of vascular and otolaryngology surgeons was completed successfully. In this report, we detail the operative steps needed to complete this exposure and our perioperative management.

Surgical management of primary aortic thrombus in thoracic aorta.

Background: Primary aortic thrombus (PAT) in the absence of underlying aortic pathology such as atherosclerosis or aneurysm is quite rare and presents with various symptoms related to distal embolization. Treatment options include anticoagulation alone, open surgical thrombectomy, endovascular repair, and a combination of these approaches. The optimal management strategy remains controversial. Methods: Between 2016 and 2020, 10 patients (6 females; mean age, 49.1 years) presented to our institution with PAT in the thoracic aorta. All 10 patients were active tobacco users, and 6 patients were found to have an underlying hypercoagulable state. Locations of the PAT included the ascending aorta in 4 patients, the descending thoracic aorta in 3 patients, and the aortic root, aortic arch, and thoracoabdominal aorta in 1 patient each. At presentation, 2 patients had developed myocardial infarction, and 2 others had cerebral infarction. All patients but 1, who was managed medically for PAT, underwent open surgical thrombectomy via either sternotomy or left thoracotomy. Concomitant procedures included coronary artery bypass grafting in 2 patients and pulmonary thromboembolectomy in 1 patient. There were no operative deaths. During a median follow-up of 18 months, 2 patients developed recurrent PAT, owing primarily to poor compliance with anticoagulation. One patient required redo open thrombectomy. Two patients had mesenteric ischemia necessitating small bowel resection. Conclusions: Open surgical thrombectomy of the thoracic aorta can be performed with low mortality and morbidity; however, PAT can recur, especially in patients who have difficulty managing anticoagulation.

Giant abdominal aortic aneurysms.

Giant abdominal aortic aneurysms (AAAs) are defined as AAAs >10 to 13 cm in the maximum transverse diameter. We have described a case of a patient who had presented for open repair of an 18-cm AAA and a review of reported cases of giant AAAs >10 cm in the maximum transverse diameter. Forty cases were compiled. The average maximum AAA diameter was 14.5 ± 4.1 cm. The AAA was ruptured on presentation in 12 patients (30%). Of the 40 cases, 34 (85%) were repaired with open surgery. The reported mortality was 15%. Despite the case complexity, five endovascular repairs were attempted.

Blunt aortic injury: Surgical treatment of the ascending and descending aorta.

Traumatic aortic injury is potentially fatal. Although uncommon, involvement of the aortic arch and the ascending aorta can occur. This case shows concomitant dissection of the ascending and descending sections of the aorta after blunt chest trauma where the open surgical approach was successfully performed to treat both aortic injuries.

Symptomatic duodenal perforation by a Bird's Nest vena cava filter.

This case describes a patient with a permanent Bird's Nest inferior vena cava filter in the setting of spinal cord injury and paraplegia who presented with epigastric pain resulting from duodenal perforation of his filter. After confirming that the patient was stable hemodynamically with normal laboratory values, he underwent open exploration with trimming of the extraluminal struts and wires, leaving the intact filter in place, with resolution of his pain. Although percutaneous removal of inferior vena cava filters is preferred for retrievable filters, this case demonstrates the safety and efficacy of open surgical management for permanent filters, not designed for retrieval.

Síndrome compartimental abdominal en el contexto de ruptura de aorta abdominal: posibles factores de manejo terapéutico que aumenten incidencia de este síndrome / Abdominal compartment syndrome in the context of ruptured abdominal aorta: possible therapeutic management factors that increase incidence of this syndrome

El síndrome compartimental abdominal (SCA) es cuando la presión intaabdominal (PIA) es sostenida mayor a 20 mmHg asociada con nuevo fallo/disfunción de órganos. Este síndrome se puede presentar por causas primarias abdomino-pélvicas o causas secundarias. Una de las causas primarias es la presencia de aneurisma de aorta abdominal, su ruptura y complicaciones como hematomas retroperitoneales. Se ha discutido sobre la ventaja de realizar reparación endovascular (RE) en el contexto de ruptura de aneurisma de aorta abdominal (RAAA) versus la tradicional reparación por cirugía abierta (CA), tanto en reducción de mortalidad como de complicaciones postquirúrgicas. En cuanto a causas secundarias, estas están relacionadas con el manejo perioperatorio del paciente con RAAA. Se ha evidenciado que una correcta monitorización y manejo del paciente en el pre, trans y postoperatorio, indistintamente de la técnica quirúrgica empleada, tiene mayor incidencia en la disminución de SCA.

Abdominal compartment syndrome (ACS) happens when the intra-abdominal pressure maintains above 20 mmHg with new organ failure. This syndrome has primary abdominal pelvic causes or secondary causes. One of the primary etiologies can be the presence of an abdominal aorta aneurysm, its rupture and complications such as retroperitoneal hematoma. It has been discussed about the advantage of endovascular repair (EVAR) in patients with rupture of abdominal aorta aneurysm (RAAA) vs open repair (OR), reducing mortality and complications after surgery. About de secondary etiologies of ACS, these have been linked with perioperative treatment of patients with RAAA. It has been stablished that the right monitoring and treatment of the patient in the pre, trans and postoperative time, regardless of the surgery technique, has a better influence diminishing the incidence of SCA.

Comparacion entre la cirugia abierta y el metodo minimamente invasivo para roturas agudas del tendon de aquiles / Comparison between open surgery and the minimally invasive method for acute achilles tendon ruptures

Introducción: La reparación quirúrgica puede realizarse mediante cirugía abierta o por técnicas mínimamente invasivas. La técnica percutánea combina las ventajas del tratamiento quirúrgico abierto con el tratamiento ortopédico. El objetivo de este trabajo es comparar la técnica mínimamente invasiva de Dresden descrita por Amlang con la cirugía abierta convencional. Materiales y Métodos: Entre marzo de 2010 y septiembre de 2013, 45 pacientes fueron operados, 15 casos con técnica abierta convencional y 15 casos con la técnica percutánea de Dresden. Se dividió a los pacientes en dos grupos según el método quirúrgico utilizado y, luego, se analizaron comparativamente los resultados. El criterio de elección del método quirúrgico fue al azar, siempre que se realizara dentro de los siete días de la rotura. Resultados: Se mencionan los resultados comparativos del tiempo quirúrgico, el trofismo, la longitud de la cicatriz, la diferencia comparativa en el perímetro del gemelo. El puntaje de la AOFAS a los 5 meses fue 90 para el grupo A y 95 para el grupo B. Tiempo promedio de retorno a la actividad laboral: grupo A, 7 meses; grupo B, 3.53 meses. Media del retorno a la actividad deportiva: grupo A, 12.22 meses; grupo B, 6.53 meses. Conclusiones: La reparación percutánea de Dresden es una buena opción para las roturas del tendón de Aquiles; la evolución clínico-funcional es buena y se minimizan los riesgos de otra rotura y lesiones del nervio sural.

Introduction: Surgical repair can be performed by open or minimally invasive surgery techniques. The percutaneous technique combines the advantages of the open treatment with orthopedic surgery. The aim of this study is to compare minimally invasive Dresden technique described by Amlang with conventional open surgery. Methods: Between March 2010 and September 2013, 45 patients were surgically treated using conventional open surgery (15 cases) or percutaneous Dresden technique (15 cases). Patients were divided into two groups according to the surgical method used and then the results were comparatively analyzed. Surgical method was selected at random, provided that it was performed within 7 days after rupture. Results: Comparative results of surgical time, muscle trophism, length of scar, and comparative difference in the twin perimeter calf are reported. AOFAS score at 5 months: 90 in group A and 95 in group B. Average time to return to work: group A, 7 months; group B, 3.53 months. Mean time to return to sport activity: group A, 12.22 months; group B, 6.53 months. Conclusions: Dresden technique is a good option for Achilles tendon ruptures; with good clinical and functional outcome minimizing the risk of rupture and sural nerve injury.

Petit lumbar hernia--a double-layer technique for tension-free repair.

This report describes an alternative technique for Petit hernia repair. The treatment of lumbar hernias should follow the concept of tension-free surgery, and the preperitoneal space can be the best place for prosthesis placement. An obese patient had a bulge in the right lumbar region, which gradually grew and became symptomatic, limiting her daily activities and jeopardizing her quality of life. She had previously undergone 2 surgical procedures with different incisions. We created a preperitoneal space and attached a mesh in this position. Another prosthesis was placed on the muscles, with a suitable edge beyond the limits of the defect. There were no complications. It has been described as a safe and tension-free repair for Petit hernia. In larger defects, a second mesh can be used to prevent further enlargement of the triangle and also to provide additional protection beyond the bone limits.