Explantador de Cabrera: un nuevo dispositivo para explantar endoprótesis aórticas después de reparo endovascular de aneurisma de aorta, un estudio experimental ex vivo / Cabrera explanter: a new device to explant aortic stents after endovascular aortic aneurysm repair, an ex vivo experimental study

Introducción. Las complicaciones posteriores a la reparación endovascular de aneurisma (EVAR) pueden resolverse con técnicas endovasculares. Sin embargo, cuando está indicada, la explantación de una endoprótesis es un procedimiento complejo, que se asocia a lesiones vasculares o viscerales, con alta morbimortalidad, en pacientes con edad avanzada y múltiples comorbilidades, y por lo tanto, alto riesgo quirúrgico. No existen dispositivos producidos por la industria para explantar las endoprótesis aórticas, por lo que el objetivo de este trabajo fue desarrollar un dispositivo para la explantación de endoprótesis aórticas. Métodos. Se llevó a cabo un estudio experimental, en fase preclínica, para desarrollar un dispositivo para la explantación de endoprótesis aórticas, con pruebas en modelos 3D y en un modelo animal porcino cadavérico. Resultados. Es factible desarrollar un modelo experimental de un nuevo dispositivo para explantar endoprótesis aórticas, denominado explantador de Cabrera, y comprobar su funcionamiento en un modelo animal cadavérico. El uso del explantador de Cabrera limitó el daño de la pared aórtica por parte de la endoprótesis en un 100 % al momento de su explantación en un modelo experimental ex vivo. Conclusión. Usando una jeringa septo, el explantador de Cabrera es superior a la técnica estándar de explantación de una endoprótesis al limitar la lesión de la pared aórtica, al colapsar y liberar los ganchos de fijación suprarrenal de forma controlada y segura al interior de la luz aórtica y, posteriormente, extraerla de forma rápida y efectiva, conservando la mayor cantidad de aorta sana para la posterior reconstrucción aorto-ilíaca.

Introduction. Complications after endovascular aneurysm repair (EVAR) can be resolved with endovascular techniques; however, when indicated, stent explantation is a complex procedure, which is associated with vascular or visceral injuries, with high morbidity and mortality in patients, with advanced age and multiple comorbidities, and therefore high surgical risk. There are no devices produced by the industry to explant aortic endoprostheses, so the objective of this work was to develop a device for the explantation of aortic endoprostheses. Methods. An experimental study was carried out, in the preclinical phase, to develop a device for the explantation of aortic endoprostheses, with tests in 3D models and in a cadaveric porcine animal model. Results. It is feasible to develop an experimental model of a new device for explanting aortic endoprostheses, called Cabrera explanter, and verify its operation in a cadaveric animal model. The use of the Cabrera explanter limited damage to the aortic wall by the endoprosthesis by 100% at the time of explantation in an ex vivo experimental model. Conclusions. Using a septum syringe, the Cabrera explanter is superior to the standard stent explantation technique by limiting injury to the aortic wall, collapsing and releasing the adrenal fixation hooks in a controlled and safe manner into the aortic lumen, and subsequently, extract it quickly and effectively, preserving the greatest amount of healthy aorta for the subsequent aorto-iliac reconstruction.

Removal Rate of the Tomofix® System after High Tibial Osteotomy is Higher Than Reported / A taxa de remoção do sistema Tomofix® após a osteotomia tibial alta é superior à relatada

Abstract Objective Medial open wedge high tibial osteotomy (MOWHTO) significantly relieves pain in the medial joint line in medial compartment osteoarthritis of the knee. But some patients complain of pain over the pes anserinus even 1 year after the osteotomy, which may require implant removal for relief. This study aims to define the implant removal rate after MOWHTO due to pain over the pes anserinus. Methods One hundred and three knees of 72 patients who underwent MOWHTO for medial compartment osteoarthritis between 2010 and 2018 were enrolled in the study. Knee injury and osteoarthritis outcome score (KOOS), Oxford knee score (OKS), and visual analogue score (VAS) were assessed for pain in the medial knee joint line (VAS-MJ) preoperatively, 12 months postoperatively, and yearly thereafter; adding VAS for pain over the pes anserinus (VAS-PA). Patients with VAS-PA ≥ 40 and adequate bony consolidation after 12 months were recommended implant removal. Results Thirty-three (45.8%) of the patients were male and 39 (54.2%) were female. The mean age was 49.4 ± 8.0 and the mean body mass index was 27.0 ± 2.9. The Tomofix medial tibial plate-screw system (DePuy Synthes, Raynham, MA, USA) was used in all cases. Three (2.8%) cases with delayed union requiring revision were excluded. The KOOS, OKS, and VAS-MJ significantly improved 12 months after MOWHTO. The mean VAS-PA was 38.3 ± 23.9. Implant removal for pain relief was needed in 65 (63.1%) of the103 knees. The mean VAS-PA decreased to 4.5 ± 5.6 3 months after implant removal (p < 0.0001). Conclusion Over 60% of the patients may need implant removal to relieve pain over the pes anserinus after MOWHTO. Candidates for MOWHTO should be informed about this complication and its solution.

Resumo Objetivo A osteotomia tibial alta com cunha de abertura medial (MOWHTO, do inglês medial open wedge high tibial osteotomy) alivia de forma significativa a dor na linha articular medial em casos de osteoartrite do compartimento medial do joelho. Alguns pacientes, porém, se queixam de dor nos tendões dos músculos sartório, grácil e semitendinoso (pata de ganso) mesmo 1 ano após a osteotomia, o que pode exigir a remoção do implante. Este estudo define a taxa de remoção do implante após a MOWHTO devido à dor nos tendões dos músculos sartório, grácil e semitendinoso. Métodos Cento e três joelhos de 72 pacientes submetidos à MOWHTO para tratamento da osteoartrite do compartimento medial entre 2010 e 2018 foram incluídos no estudo. A pontuação de desfecho de lesão no joelho e osteoartrite (KOOS, do inglês Knee Injury and Osteoarthritis Outcome Score), a pontuação dejoelho de Oxford (OKS, do inglês Oxford Knee Score) e a escala visual analógica (EVA) de dor na linha articular medial do joelho (EVA-MJ) foram avaliados antes da cirurgia. A EVA nos tendões dos músculos sartório, grácil e semitendinoso (EVA-PA) foi adicionada a essas avaliações, também realizadas 12 meses após o procedimento e, a seguir, anualmente. A remoção do implante foi recomendada em pacientes com EVA-PA ≥ 40 e consolidação óssea adequada em 12 meses. Resultados Trinta e três (45,8%) pacientes eram homens e 39 (54,2%), mulheres. A média de idade foi de 49,4 ±8,0, e o índice de massa corpórea (IMC) médio foi de 27,0 ± 2,9. O sistema placa-parafuso tibial medial Tomofix (DePuy Synthes, Raynham, MA, EUA) foi utilizado em todos os casos. Três (2,8%) casos foram excluídos devido ao retardo de consolidação e à necessidade de revisão. Os resultados nas escalas KOOS, OKS e EVA-MJ melhoraram significativamente 12 meses após a MOWHTO. A EVA-PA média foi de 38,3 ± 23,9. A remoção do implante para alívio da dor foi necessária em 65 (63,1%) dos 103 joelhos. Três meses após a remoção do implante, a EVA-PA média diminuiu para 4,5 ± 5,6 (p < 0,0001). Conclusão A remoção do implante pode ser necessária em mais de 60% dos pacientes para alívio da dor nos tendões dos músculos sartório, grácil e semitendinoso após a MOWHTO. Os candidatos à MOWHTO devem ser informados sobre esta complicação e sua resolução.

Intravenous malposition of double J stent: a case report and literature review / 现代泌尿外科杂志

【Objective】 To investigate the causes of intravenous malposition of double J stent and treatment strategies, in order to improve clinicians’ awareness of this complication. 【Methods】 Clinical data of a patient with intravenous malposition of double J stent were analyzed and relevant literature was reviewed. 【Results】 A 51-year-old female was admitted with post-hysterectomy urinary fistula and diagnosed with right intravenous malposition of double J stent and ureterovaginal fistula. Da Vinci robot-assisted laparoscopic right double J stent removal and ureteral reimplantation were performed. 【Conclusion】 Intravenous malposition is a rare and life threatening complication of double J stent placement, which can migrate further. The surgical method should be selected according to the location of the stent and general condition of the patients. Minimally invasive surgery is the first choice of treatment.

Application of our self-made Kirschner wire connecting rod in difficult extraction of intramedullary implants / 中华创伤骨科杂志

Objective:To report the application of our self-made Kirschner wire connecting rod combined with a conventional intramedullary nail extractor in difficult extraction of intramedullary devices.Methods:From January 2012 to August 2017, 10 patients with a hard-to-remove intramedullary device were treated at Department of Orthopaedics, The Fifth Hospital Affiliated to Xinjiang Medical University. They were 7 males and 3 females with a mean age of (40.0±9.0) years. In cases where no relevant extractor was available for the intramedullary device or it was impossible to connect the extractor connecting rod to the tail of the intramedullary device, the Kirschner wire was bent and pulled through the screw hole or the hole newly drilled at the tail of the intramedullary device to be tied or fixed with a conventional extractor connecting rod to form an effective connection. Next, our self-made Kirschner wire connecting rod was used to pull out the intramedullary device. In this cohort, 7 intramedullary nails in the tibia, 1 femoral intramedullary nail, 1 humeral intramedullary nail, and 1 tibial elastic nail were removed. The difficult extraction was due to "cold welding" of the tail cap of the intramedullary nail in 3 cases, mismatch between the screw rod of the extractor and the tail screw hole of the intramedullary nail in 4 cases, and unavailability of relevant removal tools in 3 cases. The time for intramedullary device removal, blood loss and postoperative adverse reactions were recorded.Results:Of this cohort, 9 patients underwent simple removal of the intramedullary device and 1 patient replacement of the intramedullary device. The total time for removal of an intramedullary device was (2.3±0.8) h, ranging from 1.0 to 3.2 h. The amount of blood loss was (159.0±61.0) mL, ranging from 80 to 250 mL. The follow-up was (14.5±2.2) months, ranging from 11 to 18 months. There was no infection or fracture associated with implant removal.Conclusion:Application of our self-made Kirschner wire connecting rod in combination with a conventional intramedullary nail extractor is an easy operation to successfully extract hard-to-remove intramedullary implants, requiring no more special instruments.

The rationality and surgical errors in countermeasures against difficult removal of screws / 中华创伤骨科杂志

Objective:To investigate the rationality and surgical errors in countermeasures against difficult removal of screws so as to provide reference for standardization of technical procedures.Methods:A retrospective study was conducted to analyze the data of 99 patients who had encountered difficult removal of screws in operative removal of internal fixation at Department of Orthopaedics, Wuxi NO.9 People's Hospital Affiliated to Suzhou University from January 2018 to May 2022. There were 62 males and 37 females with an average age of 38.8±14.7 years. Their internal fixation time ranged from 7 months to 11 years. The irrationality was defined as insufficient preoperative preparation or a countermeasure that failed to follow the surgical indications or scientific principles of minimal injury or priority of simplicity. A surgical error was defined as unnecessary injury, failed removal or complications related to operation. Cases of irrationality and surgical errors were analyzed to find associations between them.Results:The operative removal was successful in 92 cases and failed in 7 cases. Of the patients who experienced difficult removal of screws, irrationality was found in 26.3% (26/99) and a surgical error or errors occurred in 28.3% (28/99). In the patients with countermeasure irrationality, the incidence of surgical errors was 53.9% (14/26) while in those without countermeasure irrationality, the incidence of surgical errors was 19.2% (14/73), showing a statistically significant difference ( χ2=11.360, P<0.001). In the patients with surgical errors, the incidence of countermeasure irrationality was 64.3% (18/28) while in the patients without surgical errors, the incidence of countermeasure irrationality was and 11.3% (8/71), showing a statistically significant difference ( χ2=29.148, P<0.001). In the patients with failed removal, the rate of countermeasure irrationality was 85.71% (6/7) while in those with successful removal, the rate of countermeasure irrationality was 21.7% (20/92), showing a statistically significant difference ( χ2=13.748, P<0.001). Conclusions:Close relationships exist between countermeasure irrationality, surgical errors and failed removal. The higher proportion of countermeasure irrationality, the higher possibility of surgical errors. Therefore, following the rationality principle may avoid or reduce surgical errors in difficult removal of screws.

Clinical Predictors of Postintubation Bilateral Vocal Fold Immobility

Abstract Introduction Iatrogenic bilateral vocal fold immobility (BVFI) often arises from posterior glottic stenosis (PGS) after endotracheal intubation, whereby posterior commissure mucosal disruption leads to fibrosis and ankylosis of the cricoarytenoid joints. Sequelae can be devastating, resulting in dyspnea, stridor, and death due to asphyxiation. Objectives We sought to review features associated with PGS to better understand how to prevent this condition. A secondary aim is to analyze factors correlating to tracheostomy dependence. Methods Charts from January 2010 to November 2020 were retrospectively reviewed, and adult patients with the diagnosis of BVFI after intubation were included. Data on comorbidities, duration of intubation, laryngoscopy, and decannulation status was analyzed. Results Out of the 68 patients included in the present study, 60.3% were male, and the mean duration of intubation 14.3 ± 8.5 days. A total of 94% of the patients were intubated for at least 7 days, diabetic, and/or obese. Although association with prolonged intubation >7 days was not significant (p = 0.064), complete BVFI on fiberoptic exam (n = 47) was significantly associated with tracheostomy dependence both in the entire cohort (p = 0.036) and in the 56 patients with tracheostomy (p = 0.0086). Patients without cardiovascular disease (CVD) were less likely to be tracheostomy dependent compared with those with CVD (odds ratio [OR]: 0.23 [0.053-0.79]; p = 0.028). Conclusions We identified duration of intubation, DM, and obesity as potential risk factors for PGS. Complete immobility and CVD were significantly associated with tracheostomy dependence. Our findings may have important implications for earlier tracheostomy in high-risk intubated patients, as well as for closer monitoring of disease progression and earlier intervention in those predisposed to tracheostomy dependence.

Clinical application of local anesthesia for TiRobot-assisted removal of sacroiliac screws / 中华创伤骨科杂志

Objective:To explore the feasibility and advantages and disadvantages of local anesthesia for TiRobot-assisted removal of sacroiliac screws by comparison with general anesthesia for TiRobot-assisted removal of sacroiliac screws.Methods:A retrospective study was performed in 39 patients with posterior pelvic ring fracture-dislocation who had undergone removal of percutaneous sacroiliac screws after fracture union from January 2017 to December 2020 at Department of Orthopaedic Surgery, Hospital Affiliated to Chengdu University. Their sacroiliac screws were removed with TiRobot assistance under local anesthesia (LA group) or general anesthesia (GA group). In the LA group of 18 cases, there were 10 males and 8 females, aged (43.3 ± 8.4) years (from 25 to 58 years); in the GA group of 21 cases, there were 12 males and 9 females, aged (44.9 ± 9.0) years (from 23 to 60 years). The 2 groups were compared in terms of time for planning screw removal path, fluoroscopy frequency, fluoroscopy time, operation time, anesthesia time, anesthesia cost, postoperative visual analogue scale (VAS) and postoperative ambulation time.Results:There was no statistically significant difference in baseline data between the 2 groups, showing comparability ( P>0.05). Follow-ups revealed grade A wound healing in all patients. There were no significant differences between the 2 groups in time for planning screw removal path, fluoroscopy frequency, fluoroscopy time or operation time ( P>0.05). The anesthesia time [(41.6 ± 8.3) min], anesthesia cost [(653.5 ± 102.6) yuan] and postoperative ambulation time [(2.6 ± 0.6) h] in the LA group were significantly less than those in the GA group [(52.3 ± 9.5) min, (2,475.6 ± 261.8) yuan and (8.7 ± 2.4) h] while the VAS score in the former group (3.8 ± 1.5) was significantly higher than that in the latter group (2.5 ± 1.3) (all P<0.05). Conclusions:It is feasible to use local anesthesia for TiRobot-assisted removal of sacroiliac screws. In TiRobot-assisted removal of sacroiliac screws, compared with general anesthesia, local anesthesia may lead to shorter anesthesia time, lower anesthesia cast and shorter ambulation time, but the patients need to be compliant enough.

Energy Required for Fracture in Synthetic Proximal Femoral Models After Synthesis Material Removal: a Biomechanical Study Using Cannulated Screws, Dynamic Hip Screws, and Proximal Femoral Nails / Energia necessária para a ocorrência de fratura em modelos sintéticos de fêmur proximal após retirada de material de síntese: Um estudo biomecânico com parafuso canulado, parafuso dinâmico do quadril e haste femoral proximal

Abstract Objective The present study aims to identify the energy required for synthetic proximal femoral fracture after removal of three implant types: cannulated screws, dynamic hip screws (DHS), and proximal femoral nail (PFN). Methods Twenty-five synthetic proximal femur bones were used: 10 were kept intact as the control group (CG), 5 were submitted to the placement and removal of 3 cannulated screws in an inverted triangle configuration (CSG), 5 were submitted to the placement and removal of a dynamic compression screw (DHSG), and 5 were submitted to the placement and removal of a proximal femur nail (PFNG). All samples were biomechanically analyzed simulating a fall on the greater trochanter using a servo-hydraulic machine to determine the energy (in Joules [J]) required for fracture. Results All samples presented basicervical fractures. The energy required for fracture was 7.1 J, 6.6 J, 6 J, and 6.7 J for the CG, CSG, DHSG and PFNG, respectively. There was no statistically significant difference (considering a 95% confidence interval) in energy among the study groups (p = 0.34). Conclusion There was no statistically significant difference in the energy required to cause a synthetic proximal femoral fracture after removing all three implant types and simulating a fall over the greater trochanter.

Resumo Objetivo Identificar a energia necessária para ocorrência de fratura do fêmur proximal em osso sintético após retirada de três modelos de implantes: parafusos canulados, parafuso dinâmico do quadril (dynamic hip screw-DHS) e haste femoral proximal (proximal femoral nail-PFN). Métodos Foram utilizados 25 modelos de ossos sintéticos da extremidade proximal do fêmur: 10 unidades de grupo controle (GC), 5 unidades após colocação e retirada de 3 parafusos canulados colocados em configuração de triângulo invertido (GPC), 5 unidades após colocação e retirada do parafuso de compressão dinâmico (GDHS), e 5 unidades após colocação e retirada da haste de fêmur proximal (GPFN). Uma análise biomecânica foi realizada em todas as amostras simulando uma queda sobre o grande trocânter utilizando uma máquina servo-hidráulica com o objetivo de verificar a energia (em Joules [J]) necessária até a ocorrência de fratura nos diferentes grupos. Resultados Todos os grupos apresentaram fratura basocervical. Os grupos GC, GPC, GDHS e GPFN apresentaram, respectivamente, valores de 7.1J, 6.6J, 6J e 6.7J de energia até ocorrência da fratura. Não houve diferença estatisticamente significativa (intervalo de confiança de 95%) na energia entre os grupos de estudo (p = 0,34). Conclusão Não houve diferença estatisticamente significativa nos valores de energia necessária para ocorrência de fratura da extremidade proximal do fêmur após a retirada de três tipos de implantes utilizando modelos sintéticos simulando queda sobre o grande trocânter.

Prevalencia y factores asociados al abandono del implante subdérmico de Etonogestrel, Azogues, Ecuador, 2014-2017 / Prevalence and associated factors of subdermal Etonogestrel implant discontinuation, Azogues, Ecuador, 2014-2017

INTRODUCCIÓN: El plan nacional de reducción de muerte materna y neonatal considera a la pla-nificación familiar como una de las mejores tácticas para reducir los embarazos no deseados, los abortos no terapéuticos y las muertes maternas; en este sentido el abandono precoz del implante subdérmico de Etonogestrel constituye un problema de salud pública. El objetivo de este estudio es determinar la prevalencia y factores asociados al abandono del implante subdérmico de Etonoges-trel en pacientes atendidas en el Distrito de salud 03D01 de Azogues, durante el 2014-2017. MATERIALES y MÉTODOS: Estudio observacional, descriptivo, transversal. El universo estuvo cons-tituido por todas las usuarias del implante subdérmico de Etonogestrel, la muestra incluyó 234 pacientes, seleccionada de forma aleatoria simple. Los datos se obtuvieron y se analizaron con el Software SPSS, versión 2015. La asociación significativa fue considerada con valor de p < 0.005. RESULTADOS: La edad de la población en estudio fluctuó entre 13 y 46 años, el 58.5 % eran casadas, el 49.1 % residían en el área urbana. La prevalencia de retiro precoz del implante fue del 33.3% [IC 95 % 26.98 ­ 39.02] y estuvo asociado a alteraciones del sangrado menstrual que afectan la calidad de vida [RP 3.9; IC 95 % 3.1 ­ 5.0; p < 0.001 ], incremento de peso > 10 Kg [RP 3.5; IC 95 % 2.8 ­ 4.0; p < 0.001], cefalea intensa [ RP 3.7; IC 95 % 3.0 ­ 5.0; p < 0.001], dolor en el sitio de inserción [RP 3.1; IC 95 % 2.6 - 4.0; p 0.004] y deseo de embarazo [RP 3.3; IC 95 % 2.7 ­ 4.0; p < 0.001]. CONCLUSIÓN: La prevalencia de abandono precoz del implante subdérmico de Etonogestrel en nuestro medio es del 33.3% y está asociado a la presencia de efectos no deseados del mismo.

BACKGROUND: The national plan for maternal and neonatal death reduction considers birth control as one of the best methods to reduce unwanted pregnancies, non-therapeutic abortions and maternal deaths, in this way the discontinuation of subdermal Etonorgestrel implant is a public health issue. The aim of this study is to determine the prevalence and associated factors of contraceptive discontinua-tion, of subdermal Etonorgestrel implant, in patients from Azogues (03D01 Health District), from 2014 to 2017. METHODOlOGY: Observational, descriptive, cross-sectional study. The study universe included all sub-dermal Etonorgestrel implant users, the study sample included 234 patients, selected by simple ran-dom sampling. The data was obtained and analyzed with the SPSS Software, 2015 version. Significant association was considered with a value of p < 0.005. RESUlTS:The sample age was between 13 and 46 years, 58.5 % were married, 49.1 % lived in the urban area. The prevalence of contraceptive discontinuation for Etonorgestrel implant was 33.3 % [95 % CI 26.98 - 39.02]; and it was associated with: menstrual cycle disturbances that affected quality of life [PR 3.9, 95 % CI 3 .1 ­ 5.0, p < 0.001], with weight increase> 10 kg [RP 3.5, 95 % CI 2.8 ­ 4.0,p < 0.001], severe headache [RP 3.7, 95 % CI 3.0 ­ 5.0, p < 0.001], pain at the insertion site [RP 3.1, 95 % CI 2.6 ­ 4.0, p 0.004] and pregnancy planning [RP 3.3, 95 % CI 2.7 ­ 4.0, p < 0.001]. CONClUSION: The prevalence of contraceptive discontinuation of the subdermal Etonogestrel implant in our population was 33.3% and it is associated with the drug side effects.