In vivo axial load-share ratio measurement using a novel hexapod system for safe external fixator removal.

BACKGROUND: External fixation is widely used in the treatment of traumatic fractures; however, orthopedic surgeons encounter challenges in deciding the optimal time for fixator removal. The axial load-share ratio (LS) of the fixator is a quantitative index to evaluate the stiffness of callus healing. This paper introduces an innovative method for measuring the LS and assesses the method's feasibility and efficacy. Based on a novel hexapod LS-measurement system, the proposed method is to improve the convenience and precision of measuring LS in vivo, hence facilitating the safe removal of external fixators. METHODS: A novel hexapod system is introduced, including its composition, theoretical model, and method for LS measurement. We conducted a retrospective study on 82 patients with tibial fractures treated by the Taylor Spatial Frame in our hospital from September 2018 to June 2020, of which 35 took LS measurements with our novel method (Group I), and 47 were with the traditional method (Group II). The external fixator was removed when the measurement outcome (LS < 10%) was consistent with the surgeon's diagnosis based on the clinical and radiological assessment (bone union achieved). RESULTS: No significant difference was found in the fracture healing time (mean 25.3 weeks vs. 24.9 weeks, P > 0.05), frame-wearing duration (mean 25.5 weeks vs. 25.8 weeks, P > 0.05), or LS measurement frequency (mean 1.1 times vs. 1.2 times, P > 0.05). The measurement system installation time in Group I was significantly shorter compared to Group II (mean 14.8 min vs. 81.3 min, P < 0.001). The LS value of the first measurement in Group I was lower than that of Group II (mean 5.1% vs. 6.9%, P = 0.011). In Group I, the refracture rate was 0, but in Group II it was 4.3% (2/47, P > 0.05). CONCLUSION: The novel hexapod LS-measurement system and involved method demonstrated enhanced convenience and precision in measuring the LS of the external fixator in vivo. The LS measurement indicates the callus stiffness of fracture healing, and is applicable to evaluate the safety of removing the fixator. Consequently, it is highly recommended for widespread adoption in clinical practice.

Nexplanonectomy-the surgical removal of an embolized implanted contraceptive device: a case report and review of the literature.

BACKGROUND: Nexplanon implants are a common hormonal contraceptive modality. Though rare, these devices can embolize into the injured wall of the basilic vein, through the right heart, and finally wedge itself into a pulmonary artery. With adherence to the arterial wall over time, it becomes less amenable to endovascular retrieval. Patients may present with symptoms mimicking a pulmonary embolism, or without any symptoms at all. In asymptomatic cases, endovascular retrieval and/or surgery is required when patients wish to begin having children prior to biological inactivity. The current literature showed as little as nine case reports detailing lung tissue removal in the aim of reversing a patient's implanted contraceptive device. CASE PRESENTATION: A 22-year-old asymptomatic active-duty Caucasian female presented for elective outpatient Nexplanon removal. The suspicion of possible implant migration arose when it was discovered to be non-palpable in her left arm. After plain film x-rays failed to localize the implant, a chest x-ray and follow-up Computed Tomography (CT) scan revealed that the Nexplanon had migrated to a distal branch of the left pulmonary artery. Due to the patient's strong desires to begin having children, the decision was made for removal. Initial endovascular retrieval failed due to Nexplanon encapsulation within the arterial wall. Ultimately, the patient underwent a left video-assisted thoracoscopic surgery (VATS) for exploration and left lower lobe basilar S7-9 segmentectomy, which successfully removed the Nexplanon. CONCLUSIONS: Implanted contraceptive devices can rarely result in migration to the pulmonary vasculature. These radiopaque devices are detectable on imaging studies if patients and clinicians are unable to palpate them. An endovascular approach should be considered first to spare lung tissue and avoid chest-wall incisions, but can be complicated by encapsulation and adherence to adjacent tissue. A VATS procedure with single-lung ventilation via a double-lumen endotracheal tube allows surgeons to safely operate on an immobilized lung while anesthesiologists facilitate single-lung ventilation. This patient's case details the uncommon phenomenon of Nexplanon migration, and the exceedingly rare treatment resolution of lung resection to remove an embolized device.

Surgical Technique And Clinical Implications Of Transcatheter Aortic Valve Bioprosthesis Explantation.

There has been a worldwide rapid adoption of transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis. Currently, more TAVR explants with SAVRs are performed than TAVR-in TAV. TAVR explantation is a technically hazardous procedure mainly due to significant aortic neo-endothelialization which incorporates the TAVR valve. Surgical techniques for TAVR explantation are not well established and surgeon experience at present is limited. In this manuscript, we describe our technique for surgical explantation of transcatheter aortic bioprosthesis. Familiarity with the procedure and its clinical implications is essential for all cardiac surgeons.

Biomechanical changes in the proximal femur before and after removal of femoral neck system.

BACKGROUND: As an innovative internal fixation system, FNS (femoral neck system) is increasingly being utilized by surgeons for the treatment of femoral neck fractures. At present, there have been numerous finite element analysis experiments studying the immediate stability of FNS and CSS in treating femoral neck fractures. However, there is scarce mechanical analysis available regarding the effects post internal fixation removal. This study aimed to investigate the alterations in mechanical parameters of the proximal femur before and after the removal of FNS (femoral neck system), and to assess potential distinctions in indicators following the extraction of CSS (Cannulated Screws). METHODS: A proximal femur model was reconstructed using finite element numerical techniques. The models for CSS and FNS were formulated utilizing characteristics and parametric definitions. The internal fixation was combined with a normal proximal femur model to simulate the healing state after fracture surgery. Within the framework of static analysis, consistent stress burdens were applied across the entirety of the models. The total deformation and equivalent stress of the proximal femur were recorded before and after the removal of internal fixation. RESULTS: Under the standing condition, the total deformation of the model before and after removing CSS was 0.99 mm and 1.10 mm, respectively, indicating an increase of 12%. The total deformation of the model before and after removing FNS was 0.65 mm and 0.76 mm, respectively, indicating an increase of 17%. The equivalent stress for CSS and FNS were 55.21 MPa and 250.67 MPa, respectively. The average equivalent stress on the cross-section of the femoral neck before and after removal of CSS was 7.76 MPa and 6.11 MPa, respectively. The average equivalent stress on the cross-section of the femoral neck before and after removal of FNS was 9.89 MPa and 8.79 MPa, respectively. CONCLUSIONS: The retention of internal fixation may contribute to improved stability of the proximal femur. However, there still existed risks of stress concentration in internal fixation and stress shielding in the proximal femur. Compared to CSS, the removal of FNS results in larger bone tunnels and insufficient model stability. Further clinical interventions are recommended to address this issue.

A rare complication of tension band fixation of olecranon osteotomy: Distal migration of K-wire.

Tension band wiring (TBW) is one of the most commonly used fixation techniques to fix olecranon osteotomies. Hardware prominence has been the most commonly reported complication of TBW. However, distal migration of Kirschner (K)-wire after TBW fixation for olecranon osteotomy has not been reported. In this case report, we presented distal migration of K-wire detected nine months after initial surgery in a 46-year-old male patient. The patient was operated on for an intraarticular distal humerus fracture using an olecranon osteotomy. The osteotomy was fixed with TBW fixation. The patient missed routine follow-ups and presented to the outpatient clinic with a complaint of skin irritation at the elbow nine months after the surgery. On radiological examination, distal migration of one K-wire was detected. The K-wire was surgically removed without any complication. Physicians should be aware of possible complications of TBW and remove fixation after fracture union to avoid unexpected complications.

Inferior vena cava filter use at a large community hospital: a retrospective cohort study.

Inferior vena cava (IVC) filters are considered when patients with venous thromboembolism (VTE) develop a contraindication to anticoagulation. Use of IVC filters is increasing, despite associated complications and lack of data on efficacy in reducing VTE-related mortality. We characterized the pattern of IVC filter use at a large community hospital between 2018 and 2022. Specifically, we assessed the indications for IVC filter insertion, filter removal rates, and filter-associated complications. Indications for IVC filters were compared to those outlined by current clinical practice guidelines. We reviewed 120 consecutive filter placement events. The most common indications included recent VTE and active bleeding (40.0%) or need for anticoagulation interruption for surgery (25.8%). Approximately one-third (30.0%) of IVC filters were inserted for indications either not supported or addressed by guidelines. Half (50.0%) of patients had successful removal of their IVC filter. At least 13 patients (10.8%) experienced a filter-related complication. In a large community-based practice, nearly one-third of IVC filters were inserted for indications not universally supported by current practice guidelines. Moreover, most IVC filters were not removed, raising the risk of filter-associated complications, and supporting the need for development of comprehensive guidelines addressing use of IVC filters, and post-insertion monitoring practices.

Outcomes of Transvenous Lead Extraction in a Referral Center in Northern Israel.

BACKGROUND: Cardiac implantable electronic devices (CIEDs) are increasingly being used; thus, there is an increasing need for transvenous lead extraction (TLE). OBJECTIVES: To summarize our experience with TLE at single referral center in northern Israel. METHODS: The study included all patients who underwent TLE at our center between 2019 and 2022, regardless of the indication. RESULTS: The cohort included 50 patients. The mean age was 69 ± 10.36 years; 78% were males. A total of 99 electrodes were targeted. The mean number of electrodes was 1.96 (range 1-4) per patient. The time between lead implantation and extraction ranged between 1.1 and 34 years with an average of 8.14 ± 5.71 years (median of 7.5 years). Complete lead removal was achieved in 98% of patients and in 98.99% of leads. The complete procedural success rate as well as the clinical procedural success rate was 96%. The procedural failure rate was 4% (1 patient died 2 days after the index procedure and 1 patient remained with large portion of lead). The indication for TLE was infection in 78% of the cohort group. Powered mechanical sheaths were used in 36 patients (72%), laser sheaths in 27 (54%), and a combination of laser and mechanical sheaths in 16 (32%). CONCLUSIONS: The clinical and procedural success rates of TLE, primarily for CEID-related infection, were high. A combination of laser and mechanical sheaths was needed in one-third of patients.

Tracheostomy decannulation readiness: A cross sectional study comparing standardised evaluation for tacheostomy decannulation to flexible endoscopic evaluation of swallowing examination.

INTRODUCTION: Tracheostomy is a procedure commonly performed in neurocritical and mechanically ventilated patients in the intensive care unit. Dysphagia and impaired airway protection are the main causes for a delay in tracheostomy decannulation in patients with neurological disorders. Endoscopic evaluation is an objective examination of readiness for tracheostomy decannulation with flexible endoscopic evaluation of swallowing (FEES) as the most commonly used method, yet it requires special expertise and is heavily dependent on its operator in assessing the parameters. A relatively new method for assessing decannulation readiness in neurologic disorder, the Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation (SESETD) was introduced in 2013 by Warnecke, et al. This method includes stepwise evaluation of secretion management, spontaneous swallowing and laryngeal sensitivity. This study aims to find conformity between the SESETD and FEES in assessing readiness for tracheostomy decannulation in patients with neurologic disorders. MATERIALS AND METHODS: This study is a cross-sectional study conducted on 36 neurologic patients at Cipto Mangunkusumo General Hospital which was aimed to find the agreement between two modalities for tracheostomy decannulation readiness, FEES and SESETD based on parameters, standing secretion, spontaneous swallowing and laryngeal sensitivity. RESULT: A total of 36 subjects were examined and 22 of them underwent successful tracheostomy decannulation. The agreement between FEES and SESETD showed significant results with p-value <0.0001 and Kappa value = 0.47. CONCLUSION: There was conformity between FEES and SESETD in evaluating tracheostomy decannulation readiness based on three parameters: standing secretion, spontaneous swallowing and laryngeal sensitivity.

An Improvised Cost-Effective Repair Technique for Management of Broken Luer Connections of Tunneled Dialysis Catheter and Salvage Existing Catheter.

Mechanical problems like break or crack in Luer connectors or hubs, clamps, and tubings are common non-infectious complications of tunneled dialysis catheters (TDC), which may lead to other TDC complications and the need to insert a new catheter. These can be tackled using TDC repair kits or spare parts, which are often not available, resulting in the insertion of a new TDC that increases morbidity, TDC-related procedures, and healthcare costs. We discuss two cases of broken Luer connections of TDC, which were managed by exchanging the broken Luer connector of TDC with the similar Luer connector of a temporary dialysis catheter. Both the repaired TDCs are thereafter functioning well. This improvised technique provides an easy, effective, long-lasting option that salvages the existing TDC and reduces the cost factor.

Technical feasibility and safety of the alternative snare technique using a 0.018-inch guide wire and 5-French catheter for double-J ureteral stent removal.

To evaluate the technical feasibility of the alternative snare technique using a 0.018-inch guide wire and 5-French (Fr) catheter for double-J ureteral stent (DJUS) removal. In this retrospective study, 11 DJUS were removed in 9 consecutive patients between July 2023 and October 2023. We evaluated patient characteristics, DJUS characteristics, and procedure characteristics. Out of 11 cases, 8 (72.7%) were successful in removing the DJUS using the alternative snare technique without major complications. The average time between DJUS insertion and removal was 47.4 ±â€…50.0 days. The most common DJUS size was an 8-Fr, with proximal tips predominantly in the proximal ureter and renal pelvis. The mean procedure time for successful cases was 15.2 ±â€…16.8 minutes. Three failed cases, attributed to obstructions like debris, were later successfully addressed using the ALN inferior vena cava filter removal kit, forceps, and modified snare technique. The alternative snare technique using a 0.018-inch guidewire and Fr catheter is safe and effective in cases of DJUS removal.

Efficacy and safety of long-term indwelling plastic stents after resolution of pancreatic fluid collections with endoscopic transmural drainage: a systematic review and meta-analysis.

BACKGROUND: Pancreatic fluid collections (PFCs) may recur after resolution with endoscopic transmural drainage (ETD) and standard stent removal (SSR). Herein, we compared the efficacy and safety of leaving long-term indwelling plastic stents (LTIS) vs. standard stent removal after PFC resolution with ETD. METHODS: We performed a systematic review of MEDLINE, EMBASE, CINAHL, Scopus, and Cochrane databases from inception to September 2022. Full-text articles comparing long-term (> 6 months) outcomes of LTIS and SSR were eligible, as well as single-arm studies with ≥ 10 patients with LTIS. Two independent reviewers selected studies, extracted data, and assessed the risk of bias using the Newcastle-Ottawa Scale. Measured outcomes included the following: (A) PFC recurrence; (B) interventions for PFC recurrence; (C) technical success; and (D) adverse events (AEs). Meta-analysis was carried out using random-effects models. RESULTS: We included 16 studies, encompassing 1285 patients. Compared to SSR after PFC resolution with ETD, LTIS was associated with significantly lower risk of PFC recurrence (3% vs. 23%; OR 0.22 [95%CI 0.09-0.52]; I2 = 45%) and need for interventions (2% vs. 14%; OR 0.35 [95%CI 0.16-0.78]; I2 = 0%). The superiority of LTIS on reducing PFC recurrence was found with walled-off necrosis, with or without disconnected pancreatic duct, and with placement of ≥ 2 LTIS. When using LTIS, the pooled proportion of AEs was 8% (95%CI 4-11%) and technical success was 93% (95%CI 86-99%). CONCLUSIONS: Our results show that LTIS after PFC resolution with ETD is feasible, safe, and superior to SSR in reducing the risk of PFC recurrence and need for interventions.

Update on pediatric tracheostomy.

Pediatric tracheostomy has been widely performed since the 1800s, and in recent years, with advances in neonatal medicine, it has been performed at younger ages, starting at 0. In addition, advances in surgical techniques and postoperative tube management have reduced complications. This review will discuss the entire process of pediatric tracheostomy, starting with the history of tracheostomy and ending with indications, contraindications, techniques (slit, Björk, EXIT), complications, tube management, and decannulation. Pediatric tracheostomy patients require long-term care and management as they grow after the surgery itself, so otolaryngologists and pediatric tracheostomists are particularly involved in tube management and decannulation. We believe that sharing this information with all healthcare professionals will lead to better care for children with tracheostomies.

Postmortem Protocols of Implantable Neurosurgical Devices: A Cross-Sectional Survey.

BACKGROUND: Implantable devices are increasingly more common for management of movement disorders, pain, and epilepsy. These devices are often complex and constructed of nonbiodegradable or hazardous materials. Therefore, proper postmortem handling of these devices is exceedingly important. Unfortunately, there is no consolidated resource available for postmortem neuromodulation device protocols. Thus, we surveyed and catalogued the protocols for implantable devices to summarize proper postmortem device protocols for implantable neurosurgical devices currently on the market. METHODS: We performed a cross-sectional study of companies producing commonly implanted neurosurgical devices. Using information from company websites, user manuals, and catalogs we categorized devices into 3 groups: A (formal recommendation for explantation), B (recommendation for explantation without formal company protocol), and C (explantation is not necessary). We then compiled the data into a stoplight diagram, providing a clear postmortem disposal algorithm for each device category. RESULTS: Twelve companies were queried regarding 46 devices. Postmortem protocols were available for 50% (23/46) of devices; the remaining devices did not have formal recommendations. Overall, 50% of devices were classified as category A "red light" on the stoplight diagram based on recommendations, 10.9% as category B "yellow light," and the remaining 39.1% were classified as category C "green light" indicating they are safe to bury or cremate. CONCLUSIONS: Evolution in therapies and growth in functional neurosurgery has expanded the range of implantable neurosurgical devices. We provide an educational document summarizing their postmortem protocols. This resource aims to aid health-care providers and encourage proper disposal practices during burial or cremation.

The use of Microsurgical Exploration of the External Carotid Artery for Removal of a Retained Microcatheter After Middle Meningeal Artery Embolization Using Live Fluoroscopy: A Technical Note.

BACKGROUND: Fragmentation, disconnection, or entrapment of an in-use microcatheter during neuro-endovascular procedures is a known risk. Often a benign entity, retained catheters are not infrequently observed, but severe complications including thrombus, thromboembolic events, pseudoaneurysm, and limb ischemia have been described, necessitating retrieval. This technical case report demonstrates the safe use of an external carotid artery (ECA) approach for ligation and removal of a retained microcatheter after middle meningeal artery (MMA) embolization. This article also demonstrates the use of live intraoperative fluoroscopy as a surgical adjunct to ensure that the catheter is fully removed without any injury, shearing, or breakage during removal. METHODS: A 66-year-old male patient presented with bilateral subdural hematomas to an outside hospital. He subsequently underwent evacuation of the hematomas followed by a right-sided MMA embolization, complicated by Onyx (Medtronic, Minneapolis, MN) entrapment of the microcatheter in the MMA. The patient was asymptomatic, but there was significant concern about continuing antiplatelet/anticoagulation therapy in the presence of the subdural hematoma. We proceeded with an open surgical approach for catheter retrieval. As the catheter was withdrawn, intraoperative fluoroscopy demonstrated complete removal without any retained fragments. RESULTS: The patient recovered without event and was discharged on postoperative day 1. On follow-up the patient continued to do well without any complications from the fragment that remained in the external carotid circulation. CONCLUSIONS: This case and accompanying video demonstrates the effective use of open ECA surgical approach to retrieve the retained microcatheter after an MMA embolization. This approach allowed for safe and effective removal of the microcatheter while significantly reducing complication risks.

Robotic-assisted intravesical mesh excision following retropubic midurethral sling.

INTRODUCTION AND HYPOTHESIS: Intravesical mesh is an uncommon complication following synthetic midurethral sling placement. Management options have included endoscopic techniques such as laser ablation or surgical excision. We present our technique for robotic-assisted excision of intravesical mesh following a retropubic midurethral sling. METHODS: The patient is a 66-year-old woman with a remote history of laser ablation of intraurethral mesh after midurethral sling, and persistent symptomatic intravesical mesh with associated stone at the bladder neck and right bladder wall. Robotic excision of the intravesical mesh and stone was performed by entering the space of Retzius, carrying the dissection along the right arm of the retropubic sling, performing two cystotomies to free and remove the mesh, and finally closing the cystotomies in two layers. RESULTS: The patient was discharged on postoperative day 1. A cystogram prior to catheter removal showed no extravasation and a competent bladder neck. She reported no new stress incontinence and had improvement in overactive bladder symptoms. CONCLUSIONS: Robotic excision of intravesical mesh after synthetic midurethral sling was safely performed in this patient who had multiple areas of intravesical mesh. Management aspects reported here may be helpful for complex presentations of intravesical mesh.