Accuracy of S2 Alar-Iliac Screw Placement Under Robotic Guidance.

STUDY DESIGN: Case series. OBJECTIVES: To determine the safety and feasibility of S2 alar-iliac (S2AI) screw placement under robotic guidance. SUMMARY OF BACKGROUND DATA: Similar to standard iliac fixation, S2AI screws aid in achieving fixation across the sacropelvic junction and decreasing S1 screw strain. Fortunately, the S2AI technique minimizes prominent instrumentation and the need for offset connectors to the fusion construct. Herein, we present an analysis of the largest series of robotic-guided S2AI screws in the literature without any significant author conflicts of interest with the robotics industry. METHODS: Twenty-three consecutive patients who underwent spinopelvic fixation with 46 S2AI screws under robotic guidance were analyzed from 2015 to 2016. Screws were placed by two senior spine surgeons, along with various fellow or resident surgical assistants, using a proprietary robotic guidance system (Renaissance; Mazor Robotics Ltd., Caesara, Israel). Screw position and accuracy was assessed on intraoperative CT O-arm scans and analyzed using three-dimensional interactive viewing and manipulation of the images. RESULTS: The average caudal angle in the sagittal plane was 31.0° ± 10.0°. The average horizontal angle in the axial plane using the posterior superior iliac spine as a reference was 42.8° ± 6.6°. The average S1 screw to S2AI screw angle was 11.3° ± 9.9°. Two violations of the iliac cortex were noted, with an average breach distance of 7.9 ± 4.8 mm. One breach was posterior (2.2%) and one was anterior (2.2%). The overall robotic S2AI screw accuracy rate was 95.7%. There were no intraoperative neurologic, vascular, or visceral complications related to the placement of the S2AI screws. CONCLUSIONS: Spinopelvic fixation achieved using a bone-mounted miniature robotic-guided S2AI screw insertion technique is safe and reliable. Despite two breaches, no complications related to the placement of the S2AI screws occurred in this series. LEVEL OF EVIDENCE: Level IV, therapeutic.

Comparison of Automated Titanium Fasteners to Hand-Tied Knots in Open Aortic Valve Replacement.

OBJECTIVE: Aortic cross-clamp and cardiopulmonary bypass times are independent predictors of postoperative morbidity and mortality. Reducing ischemic times with automated titanium fasteners may improve surgical outcomes. This study compared operative times and costs of titanium fasteners versus hand-tied knots for prosthesis securement in open aortic valve replacement. METHODS: A randomized control trial was conducted during a 16-month period at a single university medical center. Patients undergoing elective aortic valve replacement were randomized to the titanium fastener (n = 37) or hand-tied groups (n = 36). Knotting, aortic cross-clamp, cardiopulmonary bypass, and total operating room times were recorded. Hospital charges were also calculated for these procedures. RESULTS: Baseline characteristics, concomitant procedures, prosthetic valve size, and sutures were similar between groups. The titanium fastener group had significantly reduced knotting (7.4 vs. 13.0 minutes, P < 0.001), aortic cross-clamp (69 vs. 90 minutes, P < 0.05), cardiopulmonary bypass (86 vs. 114 minutes, P < 0.05), and total operating room times (234 vs. 266 minutes, P < 0.05). Intraoperative complications occurred more frequently in the hand-tied group compared with the titanium fastener group. Postoperative complications were similar between groups. Operating room costs were significantly higher in the titanium fastener group (US $10,428 vs. US $9671, P = 0.01). Hospitalization costs did not differ significantly between the titanium fastener and hand-tied group (US $23,987 vs. US $21,068, P = 0.12). CONCLUSIONS: Titanium fastener use was associated with shorter knotting, aortic cross-clamp, cardiopulmonary bypass, and operating room times and fewer intraoperative complications in open aortic valve replacement, without significantly increasing hospitalization cost.

An assessment of pelvic binder placement at a UK major trauma centre.

Introduction Pelvic binders are used to reduce the haemorrhage associated with pelvic ring injuries. Application at the level of the greater trochanters is required. We assessed the frequency of their use in patients with pelvic ring injuries and their positioning in patients presenting to a single major trauma centre. Methods A retrospective review of our trauma database was performed to randomly select 1000 patients for study from April 2012 to December 2016. Patients with a pelvic binder or a pelvic ring injury defined by the Young and Burgess classification were included. Computed tomography was used to identify and measure pelvic binder placement. Results 140 patients were identified: 110/140 had a binder placed. Of the total, 54 (49.1%) patients had satisfactory placement and 56 (50.9%) had unsatisfactory placement; 30/67 (44.8%) patients with a pelvic ring injury had no binder applied, of whom 6 (20%) had an unstable injury; 9/67 patients died. Discussion This is the first study assessing pelvic binder placement in patients at a UK major trauma centre. Unsatisfactory positioning of the pelvic binder is a common problem and it was not used in a large proportion of patients with pelvic ring injuries. This demonstrates that there is a need for continuing education for teams dealing with major trauma.

Reconstrucción mandibular en una deformidad posquirúrgica por trauma / Mandibular reconstruction of a post-surgical deformity due to trauma

La necesidad de una reconstrucción mandibular está dictada por la pérdida de hueso debido, entre otras causas, a trauma. El propósito de este trabajo es caracterizar un caso de reconstrucción mandibular de una deformidad posquirúrgica por trauma. Se trata de un paciente masculino de 34 años que acude a consulta por inconformidad estética y dificultad para masticar. Aproximadamente un año atrás había padecido un trauma facial, por lo cual fue atendido de urgencia e intervenido quirúrgicamente. Se realizó estabilización ósea y colocación de placa de reconstrucción mandibular. Presentaba asimetría facial, disminución del tercio inferior facial y movilidad de los segmentos óseos mandibulares, por tal motivo se decide realizar retirada de la placa existente, reacomodamiento de los segmentos óseos, colocación de injerto autólogo de cresta ilíaca y fijación. Se observó buena evolución posoperatoria. La repercusión estética y funcional, en un paciente joven con una deformidad posquirúrgica por trauma; motivó el planeamiento de una reconstrucción mandibular mediante placa rígida e injerto de creta ilíaca. El tratamiento de este caso constituyó un reto profesional por tratarse de una deformidad posquirúrgica provocada por un trauma de alta energía; pero el trabajo quirúrgico en equipo aseguró resultados satisfactorios(AU)

The need for mandibular reconstruction is dictated by bone loss due to trauma among other causes. The purpose of the study was to present a case of mandibular reconstruction of a post-surgical deformity due to trauma. A 34-year-old male patient presents with dissatisfaction with his dentofacial appearance and difficulty chewing. About one year before he had undergone facial trauma, for which had been cared for at the emergency service and had been operated on. Bone stabilization was performed as well as placement of a mandibular reconstruction plate. The patient presented facial asymmetry, a diminished lower facial third and mobility in mandibular bone segments. Therefore, it was decided to perform removal of the existing plate, rearrangement of the bone segments, placement of an autologous iliac crest bone graft and surgical fixation. Good post-operative evolution was observed. Esthetic and functional impairment in a young patient with a post-surgical deformity due to trauma led to planning a mandibular reconstruction with a rigid plate and an iliac crest graft. Treatment in this case was professionally challenging, for the post-surgical deformity had been due to high energy trauma, but the surgical work performed ensured satisfactory results(AU)

Early results of MitraClip system implantation by real-time three-dimensional speckle-tracking left ventricle analysis.

AIMS: To appraise the early effect of percutaneous mitral valve repair with the MitraClip system on myocardial function using real-time three-dimensional speckle-tracking echocardiography (3D-STE). METHODS: Consecutive patients with moderate-to-severe or severe mitral regurgitation, undergoing mitral valve repair with the MitraClip system, were prospectively evaluated during the peri-procedural workout and follow-up. Left ventricular deformation was evaluated by a two-dimensional and 3D speckle-tracking analysis. 3D-STE acquisitions were elaborated obtaining real-time 3D global longitudinal strain evaluation, and by appraising both volumetric and hemodynamic parameters (i.e. left ventricular end-diastolic volume, left ventricular end-systolic volume, left ventricular ejection fraction, cardiac output, and stroke volume). RESULTS: In all, 30 patients were included. At 1-month follow-up, 3D-STE analysis revealed no changes in left ventricular end-diastolic volume (162.6 ±â€Š73.7 ml at baseline vs. 159.8 ±â€Š64.5 ml at 1-month follow-up; P = 0.63) and a downward trend in left ventricular end-systolic volume (104.7 ±â€Š52.0 vs. 100.1 ±â€Š50.4 ml, respectively; P = 0.06). Left ventricular ejection fraction did not significantly increase (38.1 ±â€Š11.3% at baseline vs. 39.4 ±â€Š11.0% at 1-month follow-up; P = 0.20). No significant changes were reported in cardiac output (4.3 ±â€Š2.0 l/min at baseline vs. 4.0 ±â€Š1.5 l/min at follow-up; P = 0.377) and in stroke volume (59.5 ±â€Š25.5 ml at baseline vs. 59.9 ±â€Š20.7 ml at follow-up; P = 0.867). On the contrary, left ventricular deformation capability significantly improved, with the real-time 3D global longitudinal strain value changing from -9.8 ±â€Š4.1% at baseline to -11.0 ±â€Š4.4% at follow-up (P = 0.018). CONCLUSIONS: Accurately assessing myocardial function by the use of 3D-STE, this study reported irrelevant early changes in left ventricular size, but a positive effect on left ventricular deformation capability following mitral valve repair with the MitraClip system. These preliminary results need to be confirmed in larger series and extended to long-term follow-up.

Endoscopic laterofixation in bilateral vocal cords paralysis in children.

INTRODUCTION: Vocal cords paralysis is the second most frequent cause of laryngeal stridor in children. Symptoms of congenital vocal cords paralysis can occur shortly after birth or later. Vocal cords paralysis can be unilateral or bilateral. Symptoms of unilateral paralysis include hoarse weeping or stridor during a deep inhalation. In children unilateral vocal cords paralysis often retreats spontaneously or can be completely compensated. Children with bilateral vocal cords paralysis present mainly breathing disorders while phonation is normal. Symptoms are different, starting from complete occlusion of respiratory tracts and ending on small symptoms connected with the lack of effort tolerance. When symptoms are severe, patients from this group require a tracheotomy. The lack of restoration of normal function of vocal cords or lack of complete compensation and maintenance of symptoms are an indication for surgical treatment. OBJECTIVE: The aim of this study is to present results of the treatment of bilateral vocal cords paralysis in children using the endoscopic method of laterofixation of vocal cords. MATERIAL AND METHODS: In the Pediatric ENT Department between 1998 and 2009 sixty four children with dyspnoea and/or phonation disorders caused by vocal cords paralysis were treated. RESULTS: In ten cases laterofixation of vocal cords was performed, in most cases with good result. In this article the authors present the method of endoscopic laterofixation and achieved results. CONCLUSIONS: Endoscopic laterofixation of vocal cords in children is a safe and an easy method of surgical treatment of bilateral vocal cords paralysis. This method can be used as a first and often as a one stage treatment of vocal cords paralysis. In some cases this procedure is insufficient and has to be completed with other methods.

Factors affecting patient selection of graft type in anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to assess factors associated with patient selection of graft type for anterior cruciate ligament (ACL) reconstruction. METHODS: We retrospectively identified 1,038 patients who underwent ACL reconstruction over a 5-year period. Surgery was performed by 5 different surgeons. A questionnaire was sent to patients at a minimum of 24 months' follow-up to determine which type of graft was used, why they chose that graft, whether they were satisfied with their graft and outcome, and whether they would choose another graft and, if so, which one; it also included a visual analog scale to rate their recovery. RESULTS: Questionnaires were received from 240 patients. The mean follow-up from the time of surgery was 41.3 months (range, 24 to 96 months). There were a variety of allografts and autografts used. Overall, allograft was used in 63.3% of patients and autograft in 35.4%. The most common factor influencing graft selection was physician recommendation (74.2%). Patients rated their recovery on average as 8.48 (+/-1.8) out of 10 on the visual analog scale (range, 0 to 10). Of the patients, 93% were satisfied with their graft selection. Only 12.7% would choose another graft if in the situation again. Of these patients, 63.3% would change from an autograft to allograft. CONCLUSIONS: This study suggests that the most important factor for a patient choosing a graft for ACL reconstruction is physician recommendation. Our study has shown an increasing trend in our group toward the use of allograft materials for ACL reconstruction (63.3% of all graft materials selected). Of the individuals who were dissatisfied with their graft, 63% who originally chose autograft would choose allograft as a source in the future. LEVEL OF EVIDENCE: Level III, prognostic case-control study.

Device-associated infection rates in intensive care units of Brazilian hospitals: datos de la Comunidad Científica Internacional de Control de Infecciones Nosocomiales / Tasa de infecciones asociadas a aparatos en unidades de cuidados intensivos de hospitales brasileños: datos de la Comunidad Científica Internacional de Control de Infecciones Nosocomiales

OBJECTIVES: To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, extra length of stay, and attributable mortality in intensive care units (ICUs) in three Brazilian hospitals that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS: Prospective cohort surveillance of DAIs was conducted in five ICUs in three city hospitals in Brazil by applying the definitions of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS). RESULTS: Between April 2003 and February 2006, 1 031 patients hospitalized in five ICUs for an aggregate 10 293 days acquired 307 DAIs, a rate of 29.8 percent or 29.8 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 20.9 per 1 000 ventilator-days; the rate for central venous catheter-associated bloodstream infections (CVC-BSI) was 9.1 per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 9.6 per 1 000 catheter-days. Ninety-five percent of all Staphylococcus aureus DAIs were caused by methicillin-resistant strains. Infections caused by Enterobacteriaceae were resistant to ceftriaxone in 96.7 percent of cases, resistant to ceftazidime in 79.3 percent of cases, and resistant to piperacillin-tazobactam in 85.7 percent of cases. Pseudomonas aeruginosa DAIs were resistant to ciprofloxacin in 71.3 percent of cases, resistant to ceftazidime in 75.5 percent of cases, and resistant to imipenem in 27.7 percent of cases. Patients with DAIs in the ICUs of the hospitals included in this study presented extra mortality rates of 15.3 percent (RR 1.79, P = 0.0149) for VAP, 27.8 percent (RR 2.44, P = 0.0004) for CVC-BSI, and 10.7 percent (RR 1.56, P = 0.2875) for CAUTI. CONCLUSION: The DAI rates were high in the ICUs of the Brazilian hospitals included in this study. Patient safety can be improved through the implementation of an ...

OBJETIVOS: Determinar las tasas de infección asociadas a aparatos (IAA), los perfiles microbiológicos, la resistencia bacteriana, la estancia hospitalaria adicional y la mortalidad atribuible en las unidades de cuidados intensivos (UCI) de tres hospitales brasileños miembros de la Comunidad Científica Internacional de Control de Infecciones Nosocomiales (INICC). MÉTODOS: Se realizó una vigilancia prospectiva de cohorte de las IAA en cinco UCI de tres hospitales urbanos de Brasil, según las definiciones del Sistema Nacional de Vigilancia de Infecciones Nosocomiales de los Centros para el Control y la Prevención de Enfermedades (CDC-NNIS) de los Estados Unidos de América. RESULTADOS: Entre abril de 2003 y febrero de 2006 se hospitalizaron 1 031 pacientes en las cinco UCI estudiadas, con un total de 10 293 días en los que se adquirieron 307 IAA, para una tasa de 29,8 por ciento (29,8 IAA por 1 000 días-UCI). Las tasas fueron: de 20,9 casos por 1 000 días-ventilador en neumonía asociada a respiradores (NAR); de 9,1 por 1 000 días-catéter en infecciones circulatorias asociadas con cateterismo venoso central (IC-CVC); y de 9,6 por 1 000 días-catéter en infecciones urinarias asociadas con el uso de catéteres (IUAC). De las IAA causadas por Staphylococcus aureus, 95 por ciento se debieron a cepas resistentes a la meticilina. De las infecciones causadas por Enterobacteriaceae, 96,7 por ciento fueron resistentes a la ceftriaxona, 79,3 por ciento a la ceftazidima y 85,7 por ciento a la combinación piperacilina-tazobactam. De las IAA causadas por Pseudomonas aeruginosa, 71,3 por ciento resultaron resistentes a la ciprofloxacina, 75,5 por ciento a la ceftazidima y 27,7 por ciento al imipenem. Los pacientes con IAA en las UCI estudiadas presentaron tasas de mortalidad adicional de 15,3 por ciento (riesgo relativo [RR] = 1,79; P = 0,0149) por NAR, 27,8 por ciento (RR = 2,44; P = 0,0004) por IC-CVC y 10,7 por ciento (RR = 1,56; P = 0,2875) por IUAC. ...

Device-associated infection rates in intensive care units of Brazilian hospitals: findings of the International Nosocomial Infection Control Consortium.

OBJECTIVES: To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, extra length of stay, and attributable mortality in intensive care units (ICUs) in three Brazilian hospitals that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS: Prospective cohort surveillance of DAIs was conducted in five ICUs in three city hospitals in Brazil by applying the definitions of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS). RESULTS: Between April 2003 and February 2006, 1 031 patients hospitalized in five ICUs for an aggregate 10 293 days acquired 307 DAIs, a rate of 29.8% or 29.8 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 20.9 per 1 000 ventilator-days; the rate for central venous catheter-associated bloodstream infections (CVC-BSI) was 9.1 per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 9.6 per 1 000 catheter-days. Ninety-five percent of all Staphylococcus aureus DAIs were caused by methicillin-resistant strains. Infections caused by Enterobacteriaceae were resistant to ceftriaxone in 96.7% of cases, resistant to ceftazidime in 79.3% of cases, and resistant to piperacillin-tazobactam in 85.7% of cases. Pseudomonas aeruginosa DAIs were resistant to ciprofloxacin in 71.3% of cases, resistant to ceftazidime in 75.5% of cases, and resistant to imipenem in 27.7% of cases. Patients with DAIs in the ICUs of the hospitals included in this study presented extra mortality rates of 15.3% (RR 1.79, P = 0.0149) for VAP, 27.8% (RR 2.44, P = 0.0004) for CVC-BSI, and 10.7% (RR 1.56, P = 0.2875) for CAUTI. CONCLUSION: The DAI rates were high in the ICUs of the Brazilian hospitals included in this study. Patient safety can be improved through the implementation of an active infection control program comprising surveillance of DAIs and infection prevention guidelines. These actions should become a priority in every country.