Complications of Open Trigger Finger Release

Open trigger finger release is an elective surgical procedure that serves as the gold standard treatment for trigger digits. The aim of this procedure is to release the A1 pulley in a setting in which the pulley is completely visible, ultimately allowing the flexor tendons that were previously impinged on to glide more easily through the tendon sheath. Although A1-or the first annular pulley-is the site of triggering in nearly all cases, alternative sites include A2, A3, and the palmar aponeurosis1. Typically, the surgical procedure can be conducted in an outpatient setting and can vary in duration from a few minutes to half an hour. The surgical procedure involves the patient lying in the supine position with the operative hand positioned to the side. A small incision, ranging from 1 to 1.5 cm, is made on the volar side of the hand, just proximal to the A1 pulley in the skin crease in order to minimize scarring. Once the underlying neurovascular structures are exposed, the A1 pulley is released longitudinally at least to the level of the A2 pulley, followed by decompression of the flexor tendons that were previously impinged on. In order to confirm the release, the patient is asked to flex and extend the affected finger. The wound is irrigated and closed once the release is confirmed by both the patient and surgeon. Aside from an open release, trigger finger can be treated nonoperatively with use of splinting and corticosteroid injection. Alternative operative treatments include a percutaneous release, which involves the use of a needle to release the A1 pulley2. Trigger finger can initially be treated nonoperatively. If unsuccessful, surgical intervention is considered the ultimate remedy2. Because of their efficacious nature, corticosteroid injections are indicated preoperatively, particularly in non-diabetic patients3. Splinting is often an appropriate treatment option in patients who wish to avoid a corticosteroid injection1. However, if nonoperative treatment modalities fail to resolve pain and symptoms, surgical intervention is indicated2. In comparison with a percutaneous trigger finger release, an open release provides enhanced exposure and may be safer with respect to avoiding iatrogenic neurovascular injury2. However, in a randomized controlled trial, Gilberts et al. found no difference in the rates of recurrence when comparing open versus percutaneous trigger finger release4. With reported success rates ranging from 90% to 100%, the open release of the A1 pulley is considered a common procedure associated with minimal complications2. Complications of the procedure were assessed in a retrospective analysis of 43 patients who underwent 78 open trigger releases performed by 1 surgeon. In that study, the authors reported a minor complication rate of 28% and a major complication rate of 3%5. Specifically, the 2 major complications noted by the authors were a synovial fistula and a proximal interphalangeal joint arthrofibrosis. In a larger study that included 543 patients who underwent 795 open trigger releases, the authors reported a minor complication rate of 9.6% and major complication rate of 2.4%6. Furthermore, the most common complications involved persistent stiffness, swelling, or pain. In that analysis, the authors suggested that sedation, male gender, and general anesthesia may be associated with greater risk6. At the discretion of the surgeon, a longitudinal, transverse, or oblique incision is made directly on top of the tendon at the level of the metacarpophalangeal joint, which is the preferred incision site because it provides maximal accessibility to the A1 pulley.Local anesthesia is preferred because it allows the patient and surgeon to confirm the release immediately.If conducting an open trigger release on the thumb, the surgeon should identify and protect the radial digital nerve, which courses directly over the A1 pulley. MCP = metacarpophalangeal.

Office-Based Open Trigger Finger Release Has a Low Complication Rate

Push versus pull gastrostomy in cancer patients: A single center retrospective analysis of complications and technical success rates.

Safety and Efficacy of Arterial Closure Devices in an Office-Based Angiosuite

Objectives:Tibial tubercle osteotomy (TTO) is a common procedure that is frequently used in the treatment of recurrent patellar instability and/or patellar chondrosis. Medialization of the tubercle decreases the lateral quadriceps vector of the patella resulting in load shifting away from the lateral patella. Distalization of the tubercle decreases patella height and allows for earlier containment of the patella in the bony walls of the trochlear groove. Anteriorization has been shown to be an effective treatment to unload the inferior lateral patella when chondrosis of the patella is present in this region. Current estimates of this procedure’s complication rates range from 0% to 11%. The purpose of this study was to review the complication rate following TTO performed within an academic sports medicine practice. The hypothesis was that complication rate for TTO is greater than 10% and that the rate of complications with distalization exceeds that of medialization alone.Methods:All patients between May 2009 and May 2015 who underwent a TTO were retrospectively identified. Those with at least 6 months of follow up or a complication within the first 3 months were included for data analysis. Complications were identified and labeled as either major or minor. Major complications were defined as fracture of the tibia, deep infection requiring surgical debridement, nonunion requiring revision fixation, delayed union requiring bone graft, bone stimulation, or screw exchange, arthrofibrosis requiring manipulation under sedation and/or open lysis of adhesions, loss of fixation of the tubercle fragment, and deep vein thrombosis (DVT) whereas minor complications were defined as removal of symptomatic hardware, superficial wound infection, disturbance of cutaneous sensation, and delay in wound healing not requiring surgery.Results:During the study period, 126 TTO were performed. Representing the study cohort are 111 patients, who have at least 6 months of follow up or a complication within 3 months. The mean follow up was 23 months. There were 62 of 126 (49.2%) TTO performed for patellofemoral instability and 23 of 126 (18.2%) for patellofemoral chondral damage. Thirty-eight osteotomies were performed for both instability and cartilage damage (30.2%). Two osteotomies were performed solely for patella alta and one TTO was performed for unspecified reason (2.4%). Of the complications, 28 came following distalization of the tubercle and 4 of these complications represent subsequent tibia fracture. Overall, the complication rate was 28.7 percent; major (17.1%) and minor (11.6%) complication rates are shown in Table 1. Subgroup analysis shows a complication rate of 54% for tubercles that were distalized versus 46% for medialization alone.Conclusion:The rate of total complication for TTO was 28.7%, this is greater than the estimated rate of complication in the current literature. Further, the rate of complications when the tibial tubercle was distalized was greater than when medialized alone suggesting that special considerations be made with this cohort. This high rate of complication is accompanied by a high rate of arthrofibrosis when compared to current literature suggesting the need for preoperative discussion as well as a detailed plan for postoperative rehabilitation to improve motion in patients and decrease the need for subsequent intervention. This study’s findings may redirect patient and physician discussions regarding risks of tibial tubercle osteotomies.Table 1:Complication FrequencyMajor Complication17.1%Fracture of Tibia33%Deep Infection0.0%Loss of Fixation1.7%Nonunion0.6%Delayed Union2.8%DVT1.1%Arthrofibrosis requiring surgery8.3% Concomitant Intraarticular Procedures33.3% Concomitant Extraarticular Procedures66.7%Minor Complication11.6%Removal of Hardware9.4%Superficial Infection1.7%LosstDecrease of Cutaneous Sensation3.9%Wound Dehiscence0.6%

Background: Midsubtance Achilles tendon ruptures remain the most common tendon injury within the lower extremity. While the incidence continues to rise, changing immobilization protocols, surgical techniques, and surgeon preferences have evolved over the past few decades. Purpose: To compare the overall complication rate among 3 major surgical techniques (open, percutaneous, and suture anchor) across a large, heterogeneous orthopaedic group in a major metropolitan area. Study Design: Case series; Level of evidence, 4. Methods: Achilles tendon repairs (Current Procedural Terminology code 27650) performed from January 2018 through December 2022 with a minimum 2-month follow-up were identified and retrospectively reviewed. Patients were excluded if they had chronic tears that required reconstruction, underwent a revision repair/reconstruction, or were initially treated nonoperatively. A total of 1035 acute midsubstance Achilles tendon ruptures met inclusion criteria. The primary outcome measure was total complication rate, which consisted of major complications (reoperation, deep infection, tendon rerupture, and loss of Achilles tension requiring reoperation) and minor complications (sural neuritis, superficial infection, delayed wound healing, heel pain, painful repair site, and loss of Achilles tension not requiring reoperation). Total, major, and minor complication rates by surgical technique were recorded. Standard demographic data were noted. Descriptive statistics and multivariate regression were utilized. Results: The overall complication rate was 15.7%, with 3% (n = 31) having major complications. Patients were significantly more likely to encounter any complication (26.3% complication rate with suture anchor, 14.3% with percutaneous, and 14.4% with open) (P = .004) or minor complication (P = .0304) with suture anchor fixation (20.2% rate) compared with the percutaneous (10.8%) or open (12.3%) technique. Patients with suture anchor fixation were more likely to experience clinically significant heel pain (10.5%; P < .001). There was no difference between incidence of sural neuritis with open (1.4%), percutaneous (3.2%), and suture anchor fixation (0.9%) (P = .104). Conclusion: Acute Achilles tendon repair is associated with a major complication rate of 3% requiring reoperation. Patients undergoing suture anchor fixation of Achilles tendon injuries experience all complications and minor complications at a significantly higher rate than those undergoing percutaneous or open procedures.

Robot-assisted radical prostatectomy (RARP) is a popular treatment option for localized prostate cancer. Literature is lacking on the effect of advanced age on complication rates in men undergoing robotic prostatectomy. We performed a comparative analysis of complication rates for men ≤69 and ≥70 years undergoing RARP. After IRB approval, we reviewed our initial 1000 consecutive patients who underwent RARP from 6/2002 to 6/2011 for intraoperative and postoperative complications, and we compared complication rates stratified by age ≤69 and ≥70 years. Complications were graded according to the Clavien-Dindo classification system. The Fischer's exact test was used to compare complication rates, and a p-value of <0.05 was considered statistically significant. In our cohort, 868 men were ≤69 and 129 men were ≥70. Overall, the intraoperative and postoperative complication rates for the entire cohort were 0.90% and 10.2%, respectively. There was no statistically significant difference in individual postoperative complications between the two groups, however, the overall postoperative complications rates for men ≤69 and ≥70 were 9.4% and 15.4%, respectively (p-value=0.043). Major complication rates for men ≤69 and ≥70 were 6.7% (58) and 10.8% (14), respectively (p=0.10); minor complications rates were 2.8% (22) and 4.6% (6), respectively (p=0.25). In our study, men ≥70 had a significantly higher overall complication rate after RARP compared with men ≤69 years; however, the individual, minor, and major complications were not different between the two groups. RARP is relatively safe in this older age group. Identifying complications and proposing insightful working solutions have decreased both minor and major complication rates after RARP.

MP57-20 SHORTER STANDARD HOSPITAL ADMISSION FOLLOWING RADICAL PROSTATECTOMY IS ASSOCIATED WITH LOWER RISK OF POSTOPERATIVE COMPLICATIONS

It was the aim of this prospective study to evaluate the outcome of laparoscopic surgery for diverticular disease. All patients who underwent elective laparoscopic colectomy for diverticular disease within a 10-year period were prospectively entered into a PC database registry. Indications for laparoscopic surgery were acute complicated diverticulitis (Hinchey stages I and IIa), chronically recurrent diverticulitis, sigmoid stenosis or outlet obstruction caused by chronic diverticulitis. Surgical procedures (sigmoid and anterior resection, left colectomy and resection rectopexy) included intracorporeal dissection and colorectal anastomosis. Parameters studied included age, gender, stage of disease, procedure, duration of surgery, intraoperative technical variables, transfusion requirements, conversion rate, total complication rate including major (requiring re-operation), minor (conservative treatment) and late-onset (post-discharge) complication rates, stay on ICU, hospitalisation, mortality, and recurrence. For objective evaluation, only laparoscopically completed procedures were analysed. Comparative outcome analysis was performed with respect to stage of disease and experience. A total of 396 patients underwent laparoscopic colectomy. Conversion rate was 6.8% ( n=27), so that laparoscopic completion rate was 93.2% ( n=369). Most common reasons for conversion were directly related to the inflammatory process, abscess or fistulas. The most common procedure was sigmoid resection ( n=279), followed by anterior resection ( n=36) and left colectomy ( n=29). Total complication rate was 18.4% ( n=68). Major complication rate was 7.6% ( n=28), whereas the most common complication requiring re-operation was haemorrhage in 3.3% ( n=12). Anastomotic leakage occurred in 1.6% ( n=6). Minor complications were noted in 10.7% ( n=40), late-onset complications occurred in 2.7% ( n=10). Mortality was 0.5% ( n=2). Mean duration of surgery was 193 (range 75-400) min, return to normal diet was completed after 6.8 (range 3-19) days. Mean hospital stay was 11.8 (range 4-71) days. No recurrence of diverticulitis occurred. Laparoscopic surgery for diverticular disease is safe, feasible and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.

In November 2014, the US Food and Drug Administration (FDA) issued a black box warning against the use of power morcellation for excision of uterine fibroids to decrease the risk of disseminating malignant cells and worsening survival outcomes of patients with unexpected malignant neoplasms. After the FDA statement was issued, studies showed decreased rates of minimally invasive surgery and increased rates of open abdominal hysterectomy. However, there are limited and controversial data on the association of these changed rates with 30-day hysterectomy complications. To assess changes in the rates of 30-day major and minor complications of hysterectomy for benign gynecologic indications following the FDA-issued statement. This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database and included 603 hospitals participating between January 1, 2013, and December 31, 2015. Thirty-day posthysterectomy complications were compared before and after the FDA-issued warning. Women who underwent hysterectomy for benign gynecologic indications (n = 75 487), including hysterectomies with indication of uterine fibroids (n = 25 571), were included. Complication rates and procedure distributions between the periods were compared with χ2 tests and multivariable logistic regression controlling for patient and operative factors. Major and minor 30-day complication rates before (from 2013 through the first quarter of 2014) and after (from the fourth quarter of 2014 through 2015) the FDA-issued warning. Of 75 487 women (mean [SD] age, 47.8 [10.7] years) who underwent hysterectomy for benign gynecologic indications, 32 186 (42.6%) were treated before and 43 301 (57.4%) after the FDA-issued warning. Non-Hispanic white women comprised most (59.4%) of the total population, followed by African American women (15.1%). Overall, major and minor complications remained stable before and after the FDA-issued warning. By contrast, among a subset of 25 571 women (33.9%) who underwent hysterectomy for uterine fibroids, major complications significantly increased after the FDA-issued warning from 1.9% to 2.4% (adjusted odds ratio [OR], 1.23; 95% CI, 1.04-1.47; P = .02), and minor complications significantly increased from 2.7% to 3.3% (adjusted OR, 1.21; 95% CI, 1.04-1.40; P = .01). In this subgroup, the rate of open abdominal surgery increased from 37.2% to 43.0%, and the rate of minimally invasive surgery (total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, and laparoscopic-assisted vaginal hysterectomy) decreased from 56.1% to 49.7% (P < .001). Major and minor 30-day complication rates among women undergoing hysterectomy for uterine fibroids increased following the FDA-issued statement. This increased risk corresponding with a decreased use of minimally invasive surgery should be balanced against the potential harms of morcellation during a shared decision-making process between clinician and patient. Regulatory bodies and medical societies should consider these findings when issuing relevant communications.

IntroductionRoux-en-Y gastric bypass (RYGB) is considered the gold standard bariatric procedure with documented safety and effectiveness. Laparoscopic sleeve gastrectomy (LSG) is a newer procedure being done with increasing frequency. Randomized comparisons of LSG and other bariatric procedures are limited. We present the results of the first prospective randomized trial comparing LSG and RYGB in the Polish population.AimTo assess the efficacy and safety of LSG versus RYGB in the treatment of morbid obesity and obesity-related comorbidities.Material and methodsSeventy-two morbidly obese patients were randomized to RYGB (36 patients) or LSG (36 patients). Both groups were comparable regarding age, gender, body mass index (BMI) and comorbidities. The follow-up period was at least 12 months. Baseline and 6 and 12 month outcomes were analyzed including assessment of percent excess weight lost (%EWL), reduction in BMI, morbidity (minor, major, early and late complications), mortality, reoperations, comorbidities and nutritional deficiencies.ResultsThere was no 30-day mortality and no significant difference in major complication rate (0% after RYGB and 8.3% after LSG, p > 0.05) or minor complication rate (16.6% after RYGB and 10.1% after LSG, p > 0.05). There were no early reoperations after RYGB and 2 after LSG (5.5%) (p > 0.05). Weight loss was significant after RYGB and LSG but there was no difference between both groups at 6 and 12 months of follow-up. At 12 months %EWL in RYGB and LSG groups reached 64.2% and 67.6% respectively (p > 0.05). There was no significant difference in the overall prevalence of comorbidities and nutritional deficiencies.ConclusionsBoth LSG and RYGB produce significant weight loss at 6 and 12 months after surgery. The procedures are equally effective with regard to %EWL, reduction in BMI and amelioration of comorbidities at 6 and 12 months of follow-up. Laparoscopic sleeve gastrectomy and RYGB are comparably safe techniques with no significant differences in minor and major complication rates at 6 and 12 months.

This study evaluated the safety and efficacy of alteplase in catheter-directed treatment for peripheral arterial and venous thrombosis and considered the optimal dosing regimen. Forty-four patients (49 encounters) underwent transcatheter therapy using alteplase between January and November 1999. The most common indications for thrombolysis were peripheral arterial occlusion (PAO) and venous thrombosis (38 patients, 43 encounters). Each encounter was reviewed for indication, dosage of alteplase, duration of infusion, concomitant use of anticoagulation, degree of lysis, and complications. Patients were divided into low-dose (0.5 to 1.0 mg/hr), mid-dose (1.0 to 1.5 mg/hr), and high-dose (>1.5 mg/hr) groups. For PAO, there was no significant difference in the success rate between the 3 dose groups. A lower complication rate was achieved in the low-dose group. For venous thrombosis, there was no difference in the overall success or complication rates for each of the 3 groups. Partial lysis was achieved more readily in the mid- and high-dose groups, but the risk of serious complications was greater. Overall, the complete thrombolysis rate was 71% for PAO and 55% for venous thrombosis. Major and minor complication rates were 7% and 19%, respectively. An equivalent success rate with a lower complication rate can be achieved using a low-dose constant catheter-directed infusion of alteplase for cases of PAO. Cases of venous thrombosis had a lower overall success rate compared with PAO. A mid-dose infusion of alteplase can achieve greater complete and partial thrombolysis rates without increasing the complication rate. Major and minor complication rates were similar to the rates given in the published literature.

Complications of Fluoroscopically Guided Percutaneous Gastrostomy With Large-bore Balloon-retained Catheter in Patients With Head and Neck Tumors

We conducted a retrospective study to evaluate two different types of percutaneous fluoroscopic gastrostomy procedures and catheters. Between July 8, 1999, and August 4, 2000, 80 percutaneous gastrostomy catheters were placed in 80 patients in 80 attempts. Twenty-five 16-, 18-, or 20-French balloon-retained catheters and 55 20-French mushroom-retained catheters were inserted. Typically, the type of catheters placed was based on operator preference. However, balloon-retained tubes were preferred for use in patients with obstructive head and neck or esophageal malignancies, and mushroom-retained catheters were preferred for use in demented or combative patients. Follow-up was conducted through chart reviews and telephone interviews. The technical success, procedural complications, and catheter complications were recorded. Chi-square statistical analysis was performed. Technical success was 100% (80/80 patients), and no procedural complications occurred. In patients who received balloon-retained catheters, the major complication rate was 0%, the minor complication rate was 8% (2/25 patients), and the tube complication rate was 68% (17/25 patients). The following complications occurred: catheter dislodgment (n = 17), superficial cellulitis (n = 1), and bleeding gastric ulcer (n = 1). In patients who received mushroom-retained catheters, the major complication rate was 0%, the minor complication rate was 3.6% (2/55 patients), and the tube complication rate was 3.6% (2/55 patients). The following complications occurred: superficial cellulitis (n = 2), tube occlusion (n = 1), and peristomal tube leakage (n = 1). No significant differences in major or minor complications were found between the gastrostomy procedures. Balloon-retained catheters had a significantly higher rate of tube complications (p < 0.001). Compared with balloon-retained catheters, mushroom-retained gastrostomy catheters are significantly more durable, more secure, and less prone to tube dysfunction. Mushroom-retained catheters should be the preferred type of gastrostomy catheter to place in patients whenever possible.

To examine the changes in indications, patient characteristics, safety and outcomes in consecutive patients undergoing percutaneous core liver biopsies in a major Australian teaching hospital over a period of two decades. A retrospective audit was carried out on all percutaneous core liver biopsies from a single institution between 1996 and 2005. This was combined with 10 years of data already reported on for the years 1986-1995 to detect trends in indications and outcomes. Medical records from 1398 patients were included for analysis. Over a 20-year period, the most common indications for liver biopsy were hepatitis C (37.8%), hepatitis B (26.4%) and abnormal liver function tests (22.2%). Twelve major complications (1.0%) were seen; 10 episodes of haemorrhage, 1 bile leak and 1 visceral perforation. Seven of these patients had an abnormal baseline coagulation profile; a significant risk for major haemorrhage (P < 0.001), resulting in three deaths. All deaths occurred in inpatients with major comorbidities. Minor complications occurred in 13.6% of patients, with multiple passes a significant risk factor. Whereas the overall major and minor complication rates were independent of operator experience inadequate specimens were more frequently obtained by the registrar. This large series extending over two decades shows that despite advances in biopsy techniques, the rates of both minor and major complications remain significant. Of particular concern are the procedure-related deaths. Identifying factors that may increase risk requires further scrutiny and careful patient selection needs to be undertaken.