Aortic valve stenosis (AVS) is an incidental finding in many patients who require coronary artery bypass grafting (CABG). Although aortic valve replacement (AVR) is indicated when AS is severe, experts have struggled with crafting evidence-based recommendations in the presence of mild or moderate AS, which has led to inconsistent practices and surgical guidelines.

In an effort to identify the long-term outcomes for moderate AS and pinpoint the threshold at which patients with untreated AS should undergo AVR, a team of surgeons from the Mayo Clinic conducted a 

 of 312 patients with mild or moderate AS — defined as an aortic valve area (AVA) of 1-2 cm

— who underwent isolated CABG between 1993 and 2006. The researchers then compared the patients to a control group of AS-free subjects who underwent CABG in the same period.

In the study, patients with untreated moderate AS had significantly lower late survival rates than those with mild or no AS. After adjusting for age, ejection fraction, heart failure, creatinine, diabetes, and peripheral vascular disease, patients with moderate AS were more likely to die than those with mild or no AS.

— the upper limit of moderate AS &mdash; experienced the highest rate of late postoperative mortality, as they were more than twice as likely to die.

The study authors hypothesized that the prognostic impact of untreated moderate AS results from the disease’s progressive nature. The estimated average decline in AVA is 0.1 cm

/year, and at that rate, AS that is approaching the upper limit of moderate disease could progress to severe stenosis within 2 or 3 years of CABG.

The authors suggested that further clinical trials are needed to define AS severity thresholds, as well as determine whether AVR should be performed earlier.

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Although valve replacement is indicated when aortic valve stenosis (AS) is severe, experts have struggled with crafting evidence-based recommendations in the presence of mild or moderate AS, which has led to inconsistent practices and surgical guidelines. 

Left Untreated, Moderate Aortic Valve Stenosis Has High Mortality Risk

Although the Caprini Thrombosis Risk Assessment Tool is widely used and well validated, many surgeons struggle to implement it appropriately and accurately when automated calculators are unavailable.

Concerned about incorrect risk stratification in the intensive care unit (ICU), a team of surgeons from the University of Pennsylvania recently 

 physicians’ aptitudes in completing a manual 2005 Caprini Risk Assessment Model (RAM) for venous thromboembolism (VTE). After the surgeons filled out the forms for all patients admitted to their high-volume, tertiary care surgical ICU between 2009 and 2012, the researchers compared their manual scores to their validated, computer-generated scores.

Across the study period, 3,338 consecutive surgical ICU admissions took place. In slightly more than half of those admissions, the computer-generated Caprini RAM scores were higher than the physician-reported scores, which indicated the patients’ VTE risk was higher than the staff realized. Additionally, inter-rater reliability between the scores was poor.

The overall inpatient VTE rate was 5.73%. When the surgeons underestimated risk scores by 2 points or more, patients were significantly more likely to develop VTE, and for each day the surgeon failed to prescribe chemoprophylaxis, the odds of a patient developing VTE increased.

Other factors that appeared to elevate the risk of inpatient VTE included higher admission APACHE score, personal history of VTE, recent pneumonia, and younger age.

According to the study authors, the repercussions of wrongly assuming that patients are at lower risk for VTE are far-reaching, as surgeons may prescribe chemoprophylaxis at too low a dose, frequency, or duration than what is actually needed to avoid VTE. In addition, surgeons may be less likely to encourage early ambulation, or they may allow patients to desist with sequential compression devices too early.

The researchers concluded that surgeons often experience difficulties in manually calculating 2005 Caprini RAM scores and, as a result, they fail to provide adequate VTE prophylaxis roughly 40% of the time. Since computer-calculated scores were shown to improve VTE risk stratification, the authors said they are proponents of incorporating the Caprini RAM into electronic medical records (EMRs) and daily practice.

Automated Calculator Accurately Estimates Venous Thromboembolism Risk

Young patients with progressive adolescent idiopathic scoliosis (AIS) may also experience impaired lung function. In fact, many AIS patients exhibit mean forced expiratory volumes (FEV

) and forced vital capacities (FVC) at least 3 standard deviations below normal levels prior to undergoing spinal surgery.

While the purpose of the surgery is to prevent lung decline and poor quality of life (QOL), it remains unclear whether the procedure actually produces those outcomes. Therefore, a team of researchers from the Royal Hospital for Sick Children in the United Kingdom set out to determine whether AIS patients’ lung function and QOL return to normal levels after combined anterior and posterior spinal fusion (A/PSF).

 followed 12 patients who underwent A/PSF around age 14. Using spirometry and the Scoliosis Research Society-22 (SRS-22) questionnaire to assess outcomes, the researchers found the patients’ heights increased from a mean 169 cm preoperatively to 175 cm at follow-up, which indicated that their statures and postures improved. The patients’ lung function also improved after A/PSF, as FEV

 and FVC returned to preoperative or expected values at long-term follow-up.

The patients were extremely satisfied with the outcomes of their surgeries and indicated their QOL significantly improved at 2 years, with additional improvement accruing over the next 4 years. However, the study was limited by the fact that a single surgeon performed all of the operations, and the study subjects had more severe scoliosis than subjects enrolled in previous trials.

Nevertheless, the authors indicated patients with AIS who experience pain, cosmetic deformity, or impending respiratory compromise will benefit from surgery.

Adolescent idiopathic scoliosis patients who experience pain, cosmetic deformity, or impending respiratory compromise can benefit from spinal surgery.

Assessing the Long-term Pulmonary Outcomes of Scoliosis Surgery

What does a medical institution do when National Surgical Quality Improvement Program (NSQIP) data reveals it is an outlier on a performance measure? Ideally, it analyzes the data internally, finds the root causes for the deficiencies, and implements interventions to reduce unacceptable outcomes. 

Boston Medical Center (BMC) took those steps when NSQIP data identified it as a high outlier for postoperative venous thromboembolism (VTE), a potentially life-threatening complication that can be difficult to address. Although the NSQIP reported that the odds of a patient experiencing a VTE after a general or vascular surgery procedure at BMC was 3.4 times greater than expected in 2010, the hospital implemented a successful quality improvement process soon after, which was 

Journal of the American College of Surgeons

In 2011, BMC adopted an electronic physician orders (EPO) system to execute a strategy to decrease VTE complications using the Caprini grading system, which mandates a type and duration of VTE prophylaxis. In addition to calculating the Caprini score, the EPO prompted physicians to employ early postoperative mobilization and mandatory VTE risk stratification for every patient, and it also sent automatic preoperative, postoperative, and discharge electronic reminders about appropriate VTE prophylaxis.

After comparing NSQIP VTE outcomes before and after implementing the standardized risk-stratified protocol combined with a postoperative mobilization program, BMC staff found the incidence of deep venous thrombosis (DVT) decreased by 84%, while the incidence of pulmonary embolism (PE) was halved. Additionally, risk-adjusted VTE outcomes steadily declined from an odds ratio of 3.41 to 0.94.

By emphasizing early postoperative mobilization alongside mandatory VTE risk stratification and concurrent electronic prophylaxis recommendations, BMC significantly reduced the likelihood of VTE complications among its surgical patients. Among the hospital’s surgeons, compliance with program recommendations was high, especially since the program allowed them to note why they chose not to follow the recommendations, which removed some of the “cookbook medicine” feel of most automated systems.

By emphasizing early postoperative mobilization alongside mandatory venous thromboembolism (VTE) risk stratification and concurrent electronic prophylaxis recommendations, hospitals can significantly reduce the likelihood of VTE complications among surgical patients.

Prophylaxis Protocols Improve Post-op Venous Thromboembolism Outcomes

Although shoulder replacement is less common than hip or knee replacement, aging Baby Boomers are undergoing the surgery at increasing rates, and one of the unintended, challenging consequences is deep infection.

Nevertheless, only a few studies have been conducted to determine whether patient-specific factors can predict deep infection. In addition, the results have been limited by the trials’ narrow scopes or populations.

Clinical Orthopaedics and Related Research

, investigators from Kaiser Permanente set out to identify the risk factors for deep infection, as well as create a pathogen profile.

The researchers identified a total of 4,528 patients who underwent shoulder arthroplasty. Of those subjects, 622 either died or were lost to follow-up, leaving 3,906 patients for whom follow-up records for an average of 2.7 years were available.

Overall, the incidence of deep infection requiring revision surgery was quite low, as only 45 infections were reported. Though authors found the risk of infection decreased by 5% with every one-year increase in age, males were 2.59 times more likely to develop deep infection than females, and patients undergoing primary reverse total shoulder arthroplasty had a 6 times greater risk of infection than those undergoing primary unconstrained total shoulder arthroplasty. Traumatic arthroplasties were also associated with approximately 3 times more deep infections than elective procedures.

However, the researchers found no associations between deep infection and body mass index (BMI), race, preoperative physical status reflected by American Society for Anesthesiologists scores, or diabetes.

 as the most common pathogen, it did indicate 

infections might be underestimated. In the current study, approximately 31% of bacterial isolates grew 

, making it the most common infective agent — a finding the researchers attributed to improved laboratory recognition techniques. Of note, 4 deep infections were caused by methicillin-resistant 

Factors that Contribute to Deep Infection in Shoulder Replacement Surgery

Although patients who would have been considered high risk 10 years ago can now successfully undergo percutaneous cardiac intervention, those with severe sclerotic lesions in the ascending aorta still present a challenge to surgeons.

General Thoracic and Cardiovascular Surgery

, Kazuyoshi Tajima, MD, reviewed strategies to handle such cases of bad aorta and outlined the approach utilized by the Nagoya Daini Red Cross Hospital in Japan.

According to Tajima, sclerotic lesions between the ascending aorta and the aortic arch elevate risk for cerebral and visceral vessel embolization, with operative mortality and cerebrovascular accident rates hovering around 10%. Depending on whether the patient presents with severe aortic wall calcification, liquid-rich atheroma in the aorta, or both, surgeons may refer to bad aorta by another name, such as shaggy aorta, porcelain aorta, or eggshell aorta.

These aortic diseases create fragile situations for surgeons. While preoperative unenhanced computed tomography (CT) scanning is often used to assess the ascending aorta and identify calcification, this visualization misses atheroma. However, enhanced dual-helical CT with thin sections can increase  atheroma detection, and transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) can also be utilized.

Since the goal of imaging studies is to detect the degree of disease prior to surgery, the Nagoya Daini Red Cross Hospital uses high-quality intraoperative epiaortic ultrasound via a handheld probe to increase its surgeons’ awareness of aortic problems with little burden to patients.

While reviewing several operative procedures that address special circumstances, Tajima noted the selection of an appropriate technique depends on the cannulation site for a cardiopulmonary bypass, whether it is possible to clamp the ascending aorta safely, and whether incision and suture of the ascending aorta are possible. Tajima felt optimistic that cardiac surgery outcomes in bad aorta cases will continue to improve as techniques are refined and surgeons become more skilled at selecting the best procedures.

How to Best Handle Cases of Bad Aorta

When most people think about oil-contaminated wounds, they envision gloved volunteers washing oily birds with dish soap in the aftermath of an oil spill. However, oil-related injuries in humans can occur in other venues, since petroleum is present in all types of fuels, , roofing tar, plastics, and asphalt and road oil.

In the United States, approximately 200,000 people currently work in the oil and gas extraction industry — a field that is expanding rapidly, yet extremely dangerous. As a result, injured workers and bystanders often suffer oily wounds in accidents that must be cleaned prior to surgery.

Researchers from Denver Health Medical Center in Colorado developed an 

 to help guide the decontamination of injuries exposed to petroleum compounds — especially crush injuries, which are both common and difficult to treat because the excision of the affected area may be impossible.

Currently, there is no standard of care for effective cutaneous oil decontamination. After analyzing case reports, animal models, and 

 studies, the reviewers determined that water and soap cleansing might be inappropriate, and instead recommended “like dissolves like” decontamination using lipophilic, petroleum-derived solvents to attract and dissolve oil contaminants.

The researchers also discussed various oil-based cleansers, including petrolatum, petroleum-based solvents, and a 1% surfactant made from the stool softener dioctyl sulfosuccinate, which they noted is significantly better than traditional chlorhexidine.

Although the authors endorsed the use of a petrolatum-based cleanser, they made no specific recommendations on products. 

Injured workers and bystanders often suffer oily wounds in accidents that must be cleaned prior to surgery.

When Removing Oil from Wounds, Remember 'Like Dissolves Like'

When accidents result in the loss of fingertips, surgeons are often called in to determine whether reattachment is possible and, more importantly, whether hand function can be restored.

While refined techniques have boosted the reattachment success rate to about 90% if patients present in a timely manner with an amputated digit in good shape, many reattached fingertips have limited motion, sensation deficits, and intolerance to cold.

Modern microsurgical practices are highly successful, but when they fail, flap congestion from inadequate venous outflow due to lack of suitable veins for microsurgical anastomosis is the most common cause. One technique that can improve outcomes is cross-finger dermal pocketing, which was described in the May 2014 issue of 

Techniques in Hand and Upper Extremity Surgery.

, a team of researchers from Singapore discussed modifying previous methods to augment venous outflow by “utilizing dermal flaps raised from the adjacent digit in the form of a cross-finger flap.”

“The key differences are the partial deepithelization of the replanted fingertip and subsequent replacement of the dermal flap to the donor digit to minimize donor site morbidity,” the authors explained. “During the period where the 2 digits are attached, interphalangeal joint mobilization is permitted to maintain joint mobility.”

According to the researchers, the advantage of cross-finger dermal pocketing stems from the fact that capillary density is inversely proportional to skin depth, since higher capillary density provides a larger surface area of vascular conduits for plasmatic exchange. The authors also noted venous outflow is maintained by seepage through surgical incision to dressings, as well as passive plasmatic exchange between the de-epithelized area and the dermal surface of the trapdoor flap. 

Restoring Function in Severed Fingertips

What initially appears as soft, unstable artery plaque can rupture and calcify over time, indicating advanced atherosclerosis.

, researchers from the Netherlands published a 

 on coronary calcification’s long-term prognostic implications for obstructive coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI).

Although previous studies have looked at the efficacy of drug-eluting stents (DES) in heavily calcified lesions, some demonstrated marked reduction in lesion revascularization, while others reported patients with calcified lesions are more likely to develop stent thrombosis and major adverse events.

For the current study, researchers analyzed data on 6,296 CAD patients from 7 DES trials and identified those with severe coronary calcification. Their endpoints at 3-years follow-up included all-cause mortality, death from myocardial infarction (MI), and a composite of mortality from any cause, MI, or any revascularization.

According to the authors, the 20% of patients who had severe calcification were significantly less likely to have undergone complete revascularization and had higher mortality rates than with those without it. Additionally, patients with severely calcified lesions were more than twice as likely to experience the combined endpoint of death from MI and significantly more likely to experience all-cause mortality, MI, or any revascularization. Nevertheless, the presence of severely calcified lesions was not linked to an increased risk of stent thrombosis.

In light of their findings, the investigators concluded severe coronary calcification was an “independent predictor of worse prognosis, and should be considered as a marker of advanced atherosclerosis.”

Severe coronary calcification is an independent predictor of worse prognosis in obstructive coronary artery disease patients undergoing percutaneous coronary intervention.

Severe Calcification Predicts Poor Prognosis in Obstructive Coronary Artery Disease

Roughly 18% of human skeletal fractures occur at the distal radius (DR), making it the most common fracture of all. The high volume of DR procedures combined with an elevated risk for adverse outcomes such as malunion, loss of radial length, inclination, and volar or dorsal angulation make surgeries in the forearm ripe for malpractice claims. 

Surgeons from the Starr Hand Surgery Center at St. Luke’s-Roosevelt Hospital in New York recently reviewed a lawsuit database to identify patterns in DR fracture malpractice. The surgeons mainly believed malunions resulting from nonsurgical treatment would precipitate the most claims, though they were also interested in costs associated with claims, independent risk factors for making indemnity payments, and other trends.

 from 70 closed malpractice claims filed for alleged negligent treatment of DR fractures by orthopedic surgeons insured by New York’s largest medical professional liability insurer. The cases spanned from 1981 to 2005, though each defendant’s personal closed malpractice claim history from 1975 to 2011 was also retrieved and reviewed.

Overall, the incidence of malpractice claims for DR fracture management was low, but just as the researchers hypothesized, patient complaints most often involved malunion regardless of treatment type.

Over the years, claims for surgically treated fractures increased — most of which concerned poor doctor-patient relationships, though other issues included inadequate follow-up and/or patients’ noncompliance, poor explanation of treatment options, and verbal arguments.

According to the surgeon authors, women experienced 3.3 times more forearm and wrist fractures than men and were more likely to file suit. However, age predicted lawsuits among men, as male plaintiffs were significantly older than the average male treated for DR fractures in the state.

Very few surgeon defendants were fellowship-trained in hand surgery and most had histories of multiple malpractice suits, with an average of 9. According to the authors, more than half of the cases resulted in indemnity payments with a median total of $440,000, and those who were not certified by the American Board of Orthopedic Surgery (ABOS) were significantly more likely to make indemnity payments. 

June 2014