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With improved chemotherapeutic treatment, patients with primary or metastatic bone tumor have improved prognoses and longer life expectancies; therefore, durable limb-salvage constructs are critical. For tumors of the proximal femur, endoprosthetic replacement is an option for treatment in primary and metastatic disease, with the goals being tumor and pain control, earlier mobilization, shorter recovery period, and, in primary tumors, cure. This study provides a summary of current concepts in the treatment of oncologic lesions in the proximal femur with endoprostheses. Discussion of the inherent complications of these constructs is presented as well as the risks and treatment of reconstruction failure.

To describe a novel modification of technique to improve efficacy of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in infants.Between April 2017 and July 2019, sixteen infants with primary obstructive megaureter (POM) (Age range: 4-12 months) underwent robot-assisted ureteral reimplantation were reviewed in this series. In addition to the conventional Lich-Gregoir technique, the detrusor tunnel has been extended to the mobilized anterior bladder wall to guarantee sufficient tunnel length/ureter diameter ratio and avoid ureteral angulation. All patients underwent repeated ultrasound, diuretic renal dynamic imaging and voiding cystourethrography (VCUG) perioperatively and the outcomes were documented.All operations were completed with robotic assisted approach without conversion. Bilateral and unilateral reimplantation were respectively performed in two and fourteen patients. The mean operative time was 115.0 ± 19.5 min and the mean blood loss was 10.0 ± 1.8 ml. There were no high-grade complications (III-IV on Clavien-Dindo classification) except for one patient. The distal ureteric diameter was reduced from pre operative 1.7 ± 0.5 to 0.6 ± 0.5 cm 6 months post operatively (p 0.05). One child (6.3%) required the second reimplantation for stenosis. The overall operative success rate was 94.4% (17 of 18 ureters) with a mean follow-up of 15.9 ± 7.4 months with no flux detected.Our preliminary experience suggests that our modified robot-assisted laparoscopic extravesical ureteral reimplantation is feasible in infants with good results.

Foot injuries due to vehicular or other accidents are common. However, complete toe amputation is rare. This study explored the current protocols and clinical significance of toe replantation.From December 2011 to December 2018, ten patients with 13 severed toes underwent toe replantation in our hospital. Seven cases were replanted antegrade, and three cases were replanted retrograde.All patients were followed for two to three years after toe replantation. One big toe underwent necrosis, while the other 12 toes survived completely. The appearance and feel of the successfully replanted toes were satisfactory, and the patients exhibited a normal gait.Toe replantation can achieve an acceptable appearance and function of the foot and considerably reduce the psychological effects experienced by the patients. Increased clinical attention and application of toe replantation are needed.Level IV, retrospective case series.

Background Acute flexor tendon injuries are challenging injuries for patients, surgeons, and therapists alike. There is ongoing debate about the optimal timing and amount of therapy after these injuries. Purpose We sought to investigate the relationship between hand therapy utilization and reoperation rates after flexor tendon repair and quantify reoperation rates and costs associated with flexor tendon repair. We hypothesize there will be an inverse relationship between the number of hand therapy visits and later reoperation rates and a positive correlation between reoperation rates and total cost of care. Study Design A retrospective cohort study of patients undergoing primary flexor tendon repair was pursued. Methods A commercially available database was utilized to access insurance claims data for 20.9 million patients in the US from 2007 to 2015. Patients undergoing primary flexor tendon repair were included and followed for one year. Patients with fractures, vascular injuries, or digit replantation were excluded. We studied post-operative rehabilitation utilization, reoperation rates, and costs. Chi-Square tests and multivariable logistic regressions were used to assess the relationship between therapy utilization and reoperation rates and costs. Results The one-year reoperation rate was 11.4 percent at a median time of 100.0 days amongst 1,129 patients undergoing primary tendon repair. In multivariable analysis, age between 30 and 59, male sex, and utilization of over 21 therapy sessions were associated with increased odds of reoperation. Mean insurance reimbursement one year following primary flexor repair was $14,533 per patient but $27,870 if patients went on to reoperation. Conclusion Continued therapy utilization after primary flexor tendon repair is an independent predictor of reoperation need. These findings may help surgeons counsel patients who require a large number of visits after flexor tendon repair on when to revisit surgical options.

The variation of plasma d-dimer, an inflammatory marker, from pre-explantation to pre-reimplantation in two-stage revision remains unclear. Our objective was to evaluate delta-changes (Δ) in d-dimer, erythrocyte sedimentation rate (ESR), and C-reactive-protein (CRP), to ascertain whether these delta-changes are associated with the outcome of reimplantation. We hypothesized a decrease in d-dimer before reimplantation.A retrospective review was performed on a consecutive series of 95 two-stage revisions indicated for periprosthetic joint infection. Surgeries were performed by 3 surgeons at a single institution (2018-2020). The minimum follow-up was 1 year. The inclusion criteria comprised availability of d-dimer results at pre-explantation and pre-reimplantation. As a result, only 30 reimplantations were included. Success of reimplantation was defined by Musculoskeletal Infection Society outcome reporting tool: Tier 1/Tier 2 vs Tier 3/Tier 4. Nonparametric tests and Mann-Whitney U-tests were conducted to compare Δd-dimer% (pre-explantation value - pre-reimplantation value/pre-explantation value × 100). The bootstrapped receiver operating characteristic curve analyses with 2,000 replicates of 30 cases were conducted.The median time between explantation and reimplantation was 86 days (interquartile range [IQR] = 77.7-138.5 days). Overall, a paradoxical median percent increase (Δd-Dimer% [INCREMENT] = 12.6%) in d-dimer was found from pre-explantation to pre-reimplantation (IQR = -28.06% to 77.3%). However, there was a percentage decrease in ESR (ΔESR% [DECREMENT] = -40%; IQR = -70.52% to 3.85%) and CRP (ΔCRP% [DECREMENT] = -75%; IQR = -87.43% to -61.34%). The changes in all these markers were not different between Musculoskeletal Infection Society Tier 1/2 and 3/4 outcomes (Δd-Dimer%, P = .146; ΔESR%, P = .946; ΔCRP%, P = .463). With area under curve of 0.676, Δd-dimer% (INCREMENT) appeared to be performing best in diagnosing infection control, which was nonexplanatory.Plasma d-dimer paradoxically increases before reimplantation while other inflammatory markers (ESR/CRP) decrease, emphasizing that surgeons shall adopt caution using d-dimer to make clinical decisions.

Mitral valvuloplasty using GORE-TEX as the artificial chordae is often associated with difficulties in determining the length of the artificial chordae, achieving the correct artificial chordae length, and preventing knot slippage, especially for beginners. We describe a simple technique involving a novel device called the "Mitral Plate," which enables surgeons to automatically determine the correct length of the artificial chordae and tie slippery knots without performing excessive saline tests.

The aim of this study was to evaluate the impact of cochlear reimplantation (CR) on hearing performance in children and adults with severe to profound hearing loss.Retrospective observational study.The main objective of this study was to determine whether there was a difference in hearing performance before and after CR. Secondary objectives were to analyze reasons for CR; to assess correlations between auditory performance and complete electrode reinsertion during CR, age, gender, explantation-to-CR interval, and interval between first implantation and CR; and to assess difference in APCEI score and the French evaluation protocol for implanted patients before and after CR.Comparison of speech perception scores before and after explantation-reimplantation showed no significant difference (P0.005) at 1 year or at 2 years after CR. In 80% of cases, reimplantation was due to hard implant failure. In other cases, it was undertaken for soft failure (diminished performance but no abnormalities on integrity testing) (8%), medical reasons (6%), or undetermined reasons (6%). There was no significant correlation between auditory performance at 1 or 2 years and complete or incomplete reinsertion of electrodes, age, gender, explantation-to-CR interval, or interval between first implantation and CR (P0.005). For the adult subgroup, the French evaluation protocol scores did not differ after reimplantation (P=0.62). Likewise, for the child sub-group, APCEI and CAP results did not deteriorate after reimplantation.Reimplantation had no negative impact on hearing and speech perception, but provided performance equivalent to or better than after initial implantation.

Degloving injury is a common and intractable injury with the bone and tendon exposed and contamination, the stripped skin cannot be replanted immediately and will be discarded, although auto-graft is needed for subsequent wound repair. In this study, autologous skin cryopreservation technique was applied to the treatment of severe limb degloving injuries. The clinical data of 9 patients from January 2016 to December 2018 were analyzed retrospectively. Among the 9 cases, 1 case developed necrosis due to wound infection, and the rest survived 60-100%. The replanted cryopreserved skin were soft and resilient, with poor sensory recovery, varying degrees of discoloration and no hair growth. Cryopreservation provides more time for improving the wound and whole-body condition. The frozen skin had good quality and high survival rate. Our study can effectively use the degloving skin, reduce the damage of the donor area.

Testicular replantation represents a unique circumstance. There are very few reports documenting their experience with testicle replantation and to the best of the authors' knowledge, this is the first case that has been reported in the peer-reviewed literature following a wrong site surgery. Therefore, we detail our technique and outcome when faced with such a rare event. In addition we review the literature, in order to compare and report the experience of others. This case highlights the value of applied microsurgical knowledge and the importance of cross-disciplinary efforts to improve patient outcomes.

A successful case of crossover replantation of the left foot to the stump of the right leg was described. The lower extremities were amputated at different levels. On the left side, there was a complete amputation in the distal part of the lower leg with comminuted fracture of the distal tibia. On the right side, there was a complete amputation in the hindfoot with comminuted fracture of both the talus and calcaneus. Since anatomical replantation was impossible, we performed crossover replantation of the left foot to the right lower leg. At the latest follow-up examination, forty-six months after the accident, the patient walked independently with a prosthesis on the stump of the left leg. Crossover replantation should be considered in bilateral amputations for the salvage of at least one extremity.

Consensus recommendations are lacking regarding appropriate timing of reimplantation following 2-stage resection arthroplasty for prosthetic joint infections (PJIs). We investigated whether the time from resection arthroplasty to reimplantation was associated with treatment outcome at 2 years.Retrospective cohort review was conducted for 101 patients undergoing resection arthroplasty with an antibiotic spacer for PJI at a single tertiary academic referral institution. Time from explantation and spacer placement to reimplantation was categorized into 3 groups:12, 12-18, and18 weeks. Baseline patient and treatment course characteristics across these groups were obtained. Multivariate binary logistic regression was used to characterize association between treatment failure and time to reimplantation, controlling for American Society of Anesthesiologists (ASA) score and prior revision surgery.Time to reimplantation (TTR)18 weeks demonstrated statistically significant increased odds of treatment failure, after controlling for ASA score and prior revision surgery (odds ratio 7.00, confidence interval 2.14-25.42, P = .002). After excluding patients requiring second spacer or Girdlestone prior to replant, this increased odds of failure remained (odds ratio 4.12, confidence interval 1.18-15.37, P = .029). TTR groups were similar with respect to demographics, except for ASA (2.96 for time to reimplantation18 weeks vs 2.55 for time to reimplantation12 weeks; P = .011). Patients with TTR18 weeks were more likely to have an unplanned readmission during the spacer period (48%, 19%, and 6% for time to reimplantation18, 12-18, and 0-12 weeks, respectively; P.002).Although decision regarding TTR is largely patient specific, surgeons should be aware that TTR18 weeks may be associated with higher rates of treatment failure at 2 years.

Background: We evaluated the reliability of intraoperative assessment of leukocyte esterase (LE) in synovial fluid samples from patients undergoing reimplantation following implant removal and spacer insertion for periprosthetic joint infection (PJI). Our hypothesis was that a positive intraoperative LE test would be a better predictor of persistent infection than either serum C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) or the combination of serum CRP and ESR. Methods: The records of 76 patients who received a 2-stage exchange for PJI were retrospectively reviewed. Synovial fluid was collected for LE measurement during surgery before arthrotomy in 79 procedures. Receiver operating characteristic curves were generated. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve (AUC) of LE, CRP, ESR, and CRP + ESR were calculated. Results: Sensitivity, specificity, positive predictive value, and negative predictive value of the LE assay were 82%, 99%, 90%, and 97%, respectively. Receiver operating characteristic analysis revealed an LE threshold of 1.5 between the first (negative) and the second (positive) level of the ordinal variable, so that a grade starting from 1+ was accurate for a diagnosis of persistent infection (AUC 0.9044). The best thresholds for the CRP and the ESR assay were 8.25 mg/L (82% sensitivity, 84% specificity, AUC 0.8416) and 45 mm/h (55% sensitivity, 87% specificity, AUC 0.7493), respectively. Conclusion: The LE strip test proved a reliable tool to diagnose persistence of infection and outperformed the serum CRP and ESR assays. The strip test provides a valuable intraoperative diagnostic during second-stage revision for PJI.

Management of soft tissue avulsion after facial bites could be challenging in some situation. We presented the case of a 32 years old men suffering from a full thickness avulsion of the left lower lip and cheek after a dog bite. Even if the lip fragment was initially put on the bin, a microvascular replantation was performed. The vascularization was based on the left inferior labial artery. No veins were found. We used post-operative leech therapy to avoid venous congestion during 10 days. A large antibiotherapy was conducted. Adaptation of antibiotics blood concentration was also necessary due to the permanent bleeding caused by leech therapy. At the 6 month consultation, the patient recovered an impressive labial function and sensibility. Replantation gives the best functional and esthetical outcomes in these rare and complex cases. Artificial blood drainage, large antibiotic therapy and close post-operative follow-up are significant parts of the replantation success.

BACKGROUND Two-stage exchange is a commonly used approach for treating chronic periprosthetic joint infections (PJI). A pre-reimplantation threshold value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to determine infection eradication and the proper timing of reimplantation remains ill-defined. METHODS We retrospectively reviewed 483 potential patients for eligibility. In total, 178 patients were excluded. In addition, 305 joints were eligible who underwent 2-stage revision for prosthetic hip or knee joint infection (PJI). Serum ESR and CRP were recorded at 8 weeks post resection prior to stage 2 reimplantation. ESR and CRP were analyzed with receiver operating characteristic curves (ROC) for response failure. RESULTS In total, 252 patients had resections for chronic infections while 53 septic patients had resections for acute infections. Forty-one of 252 (16.3%) patients failed reimplantation. Median ESR at the time of reimplantation was 17 (normal less than 20 mm/h). Median CRP was 0.6 (normal less than 0.5 mg/dL). ROC plot for response failure in analyzing ESR found an area under the curve (AUC) of 0.47. ROC plot analyzing CRP found an AUC of 0.57. The ratio of ESR/CRP was also utilized and found an AUC of 0.60. All of the AUC data are in the "fail to discriminate category." CONCLUSION Although improvements in serology can be somewhat reassuring, there are no statistically significant values of ESR or CRP that would predict failure of reimplantation in the 2-stage treatment of PJI. Because we are flying blind consideration should be made for mandatory pre-reimplantation aspirates. LEVEL OF EVIDENCE Level IV, Retrospective Case Series.

Successful replantation relies on proper preservation of traumatically amputated parts. The established protocol for preservation, however, is inconsistently adhered to. The objective of this study is to examine the rate of proper preservation in multiple patient populations.A retrospective review of patients from 2015 to 2019 at a single academic institution was conducted. Patients were included if they suffered a traumatic amputation, the amputated part was present for evaluation by the hand surgery team, and modality of preservation was documented. Additional data including method of patient transport, replantation attempt, and operative outcome were assessed. Patients were stratified based on whether proper preservation was employed and compared using chi-square tests.Ninety-one patients were included, thirty-one (34.1%) of whom had amputated parts which were properly preserved. Patients from referring facilities were more likely to present with properly preserved parts (45.0%) than those presenting from home (25.5%), though this did not meet significance (P = .051). In total, 74 patients arrived via EMS with 35.1% adherence to preservation protocol. Of the 31 patients who had properly preserved parts, 58.1% underwent attempted replant; of the 60 patients who had improperly preserved parts, 23.3% underwent attempted replantation (P = .001).The majority of patients who suffer traumatic amputations do not present with properly preserved amputated parts, limiting potential replantation. With a direct correlation to attempted replantation, proper preservation is a crucial aspect of care and should not be overlooked when seeking to optimize efforts and results.Level IV.

The favorable conditions for revascularization of replanted immature primary teeth after avulsion are not well understood. We report a case of replantation of an avulsed immature mandibular primary central incisor in a 7-month-old male infant. The avulsed incisor was replanted and fixed. Five months later, root canal obliteration was observed. The replanted incisor showed root formation a year later without negative symptoms and was replaced by its successor after 6 years. Based on the outcomes, the clinical course of revascularization after replantation and treatment protocol of avulsed immature primary teeth might be comparable to those of immature permanent teeth.

The management of mangled upper extremity is very challenging because the anatomical complexity of the region, the large number of possible involved anatomical elements, and the necessity of obtaining a good functionality. The impressive development of microsurgical techniques in the last decades contributed a lot to the salvage of several extreme injuries with mangled extremities considered untreatable in the past. Such injuries can nowadays be successfully managed by means of replantation/revascularization or complex reconstruction by using simple or complex microsurgical flaps. The more important steps in managing a mangled upper extremity are the decision making, the moment of reconstruction, the debridement, and the reconstruction by using customized methods. The decision regarding extremity salvage or amputation has to be individualized taking into account general and local factors. These factors influence the absolute or relative indication, but the final decision is up to the experience of every single surgical team. The timing of reconstruction is still a large debated subject, but it seems that the reconstruction as soon as possible is in the advantage of obtaining a much better functional recovery. The debridement should be very carefully performed in the attempt to preserve all the essential anatomical elements able to allow the obtaining of enough functionality. Most of these lesions are accompanied by simple or complex tissue defects. The coverage of these defects needs customized simple or composite flaps used both as free and local/regional microsurgical flaps. Based on the experience regarding the strategy and management of the mangled upper extremity in two European hand trauma centers, we conclude that the keystone in savaging this kind of lesions is represented by a very carefully assessment of the patient and lesion, an enough aggressive debridement, and an as soon as possible reconstruction.

A persistent challenge that has limited access and delivery of digit replantation surgery is timing, as ischemia time has traditionally been considered an important determinant of success. However, reports that the viability of amputated digits decreases after 6 hours of warm ischemia and 12 hours of cold ischemia are largely anecdotal. This review evaluates the quality and generalizability of available evidence regarding ischemia times after digit amputation and reported outcomes of “delayed” replantation. We identify substantial limitations in the literature supporting ischemia time cutoffs and recent evidence supporting the feasibility of delayed digit replantation. The current treatment approach for amputation injuries often necessitates transfers or overnight emergency procedures that increase costs and limit availability of digit replantation nationwide. Evidence-based changes to digit replantation protocols could lead to broader availability of this service, as well as improved care quality.

The objective of this work was to assess whether the injury mechanisms are responsible for histological arterial lesions. This prospective single-center study included adults with wrist or hand arterial injury. Arterial resection of at least 2 mm from the proximal and distal stumps was performed before the arterial anastomosis. Histological analysis of the arterial stumps was performed. An ultrasound was performed 1 month postoperatively to check arterial patency. A clinical and functional evaluation was done at 1 month postoperative, then every 3 months. From 2018 to 2020, 46 patients were included with a maximum follow-up of 13 months. There were 35 cuts, 2 crush injuries, 8 amputation and 1 blast injury. Macroscopically, 37% of the margins were considered damaged. Histological analysis showed significant damage in 59% of the sections (27 out of 46 patients) with 50% for crush injury, 55% for cuts by mechanical tool, 62% for cuts by power tool, 62% for amputations and 100% for blasts. The failure rate was 9%: 2 replantations and 2 asymptomatic thromboses diagnosed by ultrasound. Postoperative pain on VAS was 1.75/10, range of motion was 87%, Quick DASH was 8%, SF36 PCS was 69% and SF36 MCS was 70%. Factors influencing the success or failure of anastomosis were the mechanism of injury (p = 0.02), associated nerve damage (p = 0.014) and length of proximal arterial cut (p = 0.046). Histological arterial lesions seem to correlate with the injury mechanism. Cuts caused by glass or crush injuries do not seem to require arterial resections of more than 2 mm. A continuation of the study with a larger number of subjects may generate statistically significant results.

Objectives We sought to evaluate the early outcomes of patients undergoing a Bentall procedure after previous cardiac surgery. Methods From 1990 to 2014, 473 patients underwent a Bentall procedure after previous cardiac surgery with a composite valve graft at a single institution: composite valve graft with a mechanical prosthesis (n = 256) or composite valve graft with a bioprosthesis (n = 217). Patients were excluded if their index operation was less than 30 days before the reoperation. The primary outcome was 30-day mortality. The secondary outcome was a composite of major morbidity and operative mortality: stroke, renal failure, prolonged mechanical ventilation, deep sternal infection, or reoperation during the same admission. Multivariable logistic regression was used to identify risk factors associated with the primary and secondary outcomes of interest. Results Median age was 57 (interquartile range, 44-67) years, and 349 patients (74%) were male. Median time between index surgery and reoperation was 13 (interquartile range, 8-21) years. A total of 178 patients (38%) underwent urgent or emergency intervention, 61 patients (13%) had active endocarditis/abscess, 87 patients (19%) had left ventricular ejection fraction less than 40%, and 262 patients (55%) had undergone more than 1 previous operation. Previous operations (not mutually exclusive) included coronary artery bypass grafting (n = 58, 12%), aortic valve/root replacement (n = 376, 80%) or repair (n = 36, 8%), and other surgical interventions (n = 245, 52%). Ninety-six patients (20%) had undergone coronary reimplantation during the previous operation, which consisted of a Bentall procedure in 81 patients, a Ross operation in 8 patients, a valve-sparing root replacement in 4 patients, and an arterial switch in 3 patients. At the time of the reoperative Bentall, both coronary arteries were reimplanted directly in 357 patients (77%), whereas 79 patients (17%) received at least 1 interposition graft. In 26 patients (5%), at least 1 of the native coronary arteries was oversewn and a vein graft bypass was performed. Thirty-day mortality occurred in 37 patients (7.8%), and 152 patients (32%) had major morbidity and operative mortality. On multivariable analysis, risk factors associated with increased 30-day mortality included older age and coronary reimplantation by a technique other than direct anastomosis. Indirect coronary reimplantation was also associated with a higher incidence of major morbidity and operative mortality, as were more than 1 previous cardiac operation and preoperative New York Heart Association functional class III/IV or greater. Conclusions In the largest reported cohort of aortic root replacement after previous cardiac surgery, the reoperative Bentall procedure was associated with a significant operative risk. The need for complex coronary reimplantation techniques was an important factor associated with adverse perioperative events.

The diagnostic significance of coagulation parameters in periprosthetic joint infection (PJI) is currently attracting increasing attention. We assessed the diagnostic accuracy of thromboelastography (TEG) for PJI and compared the values of various coagulation indicators for PJI diagnosis and reimplantation timing.We enrolled 250 patients undergoing revision for aseptic failure (Group A), revision for PJI (Group B), or reimplantation (Group C) during 2013-2020. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), representative coagulation-related indicators (reaction time [R], clotting time [K], angle and maximum amplitude [MA]) of TEG and routine coagulation indicators, including fibrinogen, D-dimer, fibrin degradation product (FDP), platelets count (PC), mean platelet volume (MPV), distribution width (PDW) and plateletcrit (PCT) as well as PC/MPV ratio(PVR)were measured preoperatively. Receiver operating characteristic (ROC) curves were used to evaluate the utility of all tested indicators for assessing infection.All the indicators showed significant differences between groups A and B (P 0.05) and, except for D-dimer, FDP, MPV and R, between groups B and C (P 0.05). Similar differences were also observed in biomarkers before first-stage revision and second-stage reimplantation. ROC curves showed that fibrinogen, K, angle and MA outperformed the other coagulation indicators, with areas under the curve of 0.864 to 0.893 and threshold values of 3.55 g/L, 1.2 min, 72.4 deg and 69.1 mm, respectively. The multiple tests of TEG indices (K, angle and MA) and traditional inflammatory markers (CRP and ESR) or conventional coagulation indicators (fibrinogen, PC and PVR) had good sensitivity and specificity for PJI diagnosis, and the diagnostic values of TEG and platelet-associated indicators (PC and PVR) varied in the different subgroups.TEG was closely related to PJI and could serve as a valuable technique for identifying residual infection before reimplantation. Fibrinogen showed high diagnostic accuracy for PJI and effectively guided the timing of reimplantation.

Background We evaluated the range of prosthetic size-to-weight ratio to optimize valve survival in small children. Methods A single-institution retrospective review of mechanical mitral valve replacements from 1995 to 2019 was performed. Prosthetic valve size-to-weight ratio was calculated as the prosthetic valve diameter divided by the patient’s operative weight in children less than or equal to 35 kg. Patient death or reoperation on the valve was analyzed by size-to-weight ratio. Identifying a U-shaped distribution of events, patients were stratified as being in the nadir of the distribution or on the edges. Results Mechanical mitral valve replacements were performed in 56 (75%) children weighing less than or equal to 35 kg. Median follow-up time was 3.7 (interquartile range, 0.46-12) years. Median size-to-weight ratio was 1.5 (interquartile range, 1.0-2.0). A second replacement was required in 15 (27%) patients. Death occurred in 6 (11%) patients, including 3 after reoperation. The nadir of U-shaped distribution of events by size-to-weight ratio was bounded by a ratio from 1 to 2, which included 29 (52%) patients. A size-to-weight ratio from 1 to 2 provided optimal outcomes regardless of patient age. Reoperation-free survival at 5 years was 96% for patients with a ratio from 1 to 2 and 46% for patients with a ratio less than 1 or greater than 2. Patients with size-to-weight ratio 1 to 2 had longer reoperation-free survival than patients with a ratio less than 1 or greater than 2 (P Conclusions Regardless of patient age, in patients less than or equal to 35 kg, optimal reoperation-free survival after prosthetic mitral valve replacement can be obtained by placing a prosthetic valve whose diameter is between 1 and 2 times the patient’s weight in kilograms.

Background The best approach for aortic root disease remains controversial. Composite valve-graft conduit (CVG) replacement offers good results at short-term and long-term follow-up; on the other hand, valve-sparing aortic root replacement (VSARR) has proven to be an excellent treatment alternative. This study aimed to analyse the outcomes after VSARR and compare whether preoperative moderate or severe aortic regurgitation (AR) and or the need for aortic valve repair (AVR) during this procedure influenced survival and freedom from reoperation rates. Methods From September 2005 to June 2018, 104 patients underwent VSARR using the reimplantation technique: 64% presented with preoperative moderate or severe AR, concomitant AVR was performed in 43.3%, Marfan syndrome was present in 16.3%, and 12.5% had a bicuspid aortic valve. Complete follow-up was obtained in 91% of the sample, echocardiographic results were available for 86% and the mean follow-up time was 1,893 days. Results In-hospital mortality was 2.9% and one death occurred 42 days after hospital discharge. In the latest echocardiographic assessment, 88.3% presented with mild AR or better. Freedom from reoperation at 8 years was 95.4%. There was no case of endocarditis and one patient had a stroke 2 years after the operation. There were no between-group differences in morbidity, mortality and complications during the follow-up. Conclusion VSARR can be performed with low mortality rates and reasonable durability of the aortic valve. Neither moderate or severe AR nor the need for aortic valve repair during the procedure altered survival and freedom from reoperation.

Summary Composite grafting involves non-microvascular reattachment of amputated fingertips. One area of contention is whether time to surgery impacts graft survival and/or outcomes. Our aim was to conduct a systematic review of the literature addressing time from injury to composite grafting of amputated fingertips in a paediatric population with the endpoint being graft survival. An electronic and systematic search of the literature in PubMed/Medline, EMBASE and The Cochrane Library databases was conducted from 1959 to 2019. This search was limited to the English language, paediatric patients ( All four studies eligible for inclusion were single centre retrospective case series. The total population was n= 343 patients with n=343 amputated fingertips. Composite grafts veered towards partial take (46%). Time to surgery was reported in all studies albeit non-uniformly and to varying levels of detail accounting for delay causes and factors. Three studies (n=293 patients) did not find time to surgery to be a significant factor impacting graft survival. It is our view that there is little evidence in the literature to suggest a particular time window which impacts graft survival and no causal relation translating full take to improved outcomes. Addressing whether time to surgery is a significant factor and the ideal time frame is important as it carries implications throughout the patient's journey.

The study aimed to provide a guideline for continuous rehabilitation nursing for patients with severe finger replantation, and establish a satellite contact point for patients with severe finger replantation after discharge, so as to ensure scientific and effective rehabilitation training after discharge and explore the role of continuous rehabilitation nursing measurement in severe finger rehabilitation and neurovascular preservation.A total of 380 patients accepting neurovascular preservation finger replantation in the hand surgery department were divided into an observation group and a control group according to the number of hospitalizations. All patients underwent reconstructive surgery of severed finger. X-ray filming was used to monitor the postoperative nursing effect of neurovascular preservation of severed finger. The discharged patient information questionnaire was filled 3 days before the discharge. Then, a patient information database was established, and rehabilitation training was performed. Finally, sexual rehabilitation nursing follow-up intervention, telephone follow-up, and cross-referring intervention were carried out. Postoperative x-ray images were taken regularly to observe the recovery of reconstructed finger.There was no difference in daily life ability scores and hand function scores between the 2 groups at discharge (P0.05). The daily life ability scores and hand function scores of the observation group were better than those of the control group at 1 and 6 months after discharge (P0.05), the difference is statistically significant. As the discharge time prolonged, the daily life ability score and hand function score of the 2 groups of patients gradually increased. X-ray images showed that the replanted finger body was well developed, phalanx was in good antithesis, and there was no epiphysis.Continuous rehabilitation nursing measures should be taken after the replantation of the severed finger after neurovascular preservation, which provides standardized rehabilitation training standards for patients with replantation of severed finger after discharge, improves patient training compliance, promotes hand function recovery as soon as possible, and enables patients to return to society as soon as possible, which is worthy of clinical promotion and application.

Background Anomalous origin of one pulmonary artery from the ascending aorta (AOPA) is a rare and potentially deadly anomaly. Little research, aside from case reports on APOA, has been published, especially for patients with late referrals. Methods This study was a retrospective review of 57 patients with AOPA who underwent reimplantation of the pulmonary artery (PA) from 2009 to 2019. Two different reimplantation methods were used to correct the anomaly, including direct anastomosis in 36 patients and angioplasty with autologous tissue in 21 patients. Results The median age at repair was 2.8 months (range, 8 days to 3.6 years). In-hospital death occurred in 2 patients (3.5%). Five patients (9.1%) with a median age of 9.3 months (range, 5.2 months to 3.6 years) experienced a pulmonary hypertensive crisis. Patients older than 4.9 months were more likely to have a pulmonary hypertensive crisis (P = .001). The 2-year freedom from postoperative PA stenosis rate was 75.3% in patients who underwent direct anastomosis and 46.8% in patients who underwent autologous tissue angioplasty (χ2 = 4.878; P = .027). Angioplasty with autologous tissue (hazard ratio, 5.03; 95% confidence interval, 1.61 to 15.71; P = .005) and an innately smaller diameter of the aberrant PA (hazard ratio, 0.65; 95% confidence interval, 0.45 to 0.92; P = .015) were 2 independent risk factors for postoperative PA stenosis. Conclusions Surgical reimplantation of the PA in patients with AOPA has resulted in favorable early and midterm outcomes. Pulmonary hypertensive crisis occurs more commonly in patients who receive a diagnosis after the age of 4.9 months. Reimplantation with autologous tissue augmentation and an intrinsically smaller diameter in affected PAs are 2 independent risk factors for postoperative PA stenosis.

Hand replantation is a common surgical procedure worldwide. However, this practice is underdeveloped in many resource-constrained countries in part due to a lack of surgical microscopes. We present a patient successfully managed using loupe magnification. A 17-year-old patient presented with an amputated right hand secondary to a chaff cutter. After an 8-hour surgical procedure, the amputated hand was successfully re-attached to the stump using loupes. The patient's functional recovery was satisfactory after two years of follow-up. In conclusion, replantation of extremities can be successfully achieved using loupe magnification. Loupes should be considered an alternative to operating microscopes for replantation of extremities especially in resource-constrained countries.

Objective To describe the technical aspects of robot assisted laparoscopic ureteral reimplantation (RALUR) for the management of primary obstructive megaureter (POM) and report initial outcomes, safety, and feasibility of the procedure. Methods Using an IRB- approved robotic surgery registry, we performed a retrospective chart review of patients undergoing RALUR for POM between April 2009 and May 2019. Results A total of 18 patients underwent RALUR using a modified Lich-Gregoir technique for management of POM and 7 (38.9%) of these underwent intracorporeal ureteral tapering at the time of surgery. At median follow up of 27.5 (IQR 11-50) months, no patient required reoperation for recurrent obstruction and all patients had improvement in hydronephrosis postoperatively. 30-day complications were low with 1 Grade I, 2 Grade II and 1 Grade III Clavien-Dindo complication. The most common issue postoperatively was febrile urinary tract infection, occurring in 6 patients (33.3%), at an average of 3.2 months after surgery. Increased operative time was the only significant difference between the tapered verses nontapered group. Conclusion We present the largest series of RALUR for POM to date. Based upon our initial experience with this technique we believe it is technically feasible and reproducible with good outcomes and low complication rates. Future studies are needed to track long-term outcomes and better understand indications for and the utility of ureteral tapering as well as how to minimize febrile UTIs postoperatively. Additional follow up is needed to determine the efficacy of RALUR as compared to open ureteral reimplantation for POM.

BACKGROUND Patients undergoing a 2-stage revision for periprosthetic joint infection (PJI) often require a repeat spacer in the interim due to persistent infection. This study aims to report outcomes for patients with repeat spacer exchange and to identify risk factors associated with interim spacer exchange in 2-stage revision arthroplasty. METHODS A total of 256 consecutive 2-stage revisions for chronic infection of total hip arthroplasty and total knee arthroplasty with reimplantation and minimum 2-year follow-up were investigated. An interim spacer exchange was performed in 49 patients (exchange cohort), and these patients were propensity score matched to 196 patients (nonexchange cohort). Multivariate analysis was performed to analyze risk factors for failure of interim spacer exchange. RESULTS Patients in the propensity score-matched exchange cohort demonstrated a significantly increased reinfection risk compared to patients without interim spacer exchange (24% vs 15%, P = .03). Patients in the propensity score-matched exchange cohort showed significantly lower postoperative scores for 3 patient-reported outcome measures (PROMs): hip disability and osteoarthritis outcome score physical function (46.0 vs 54.9, P = .01); knee disability and osteoarthritis outcome score physical function (43.1 vs 51.7, P < .01); and patient-reported outcomes measurement information system physical function short form (41.6 vs 47.0, P = .03). Multivariate analysis demonstrated Charles Comorbidity Index (odds ratio, 1.56; P = .01) and the presence of Enterococcus species (odds ratio, 1.43; P = .03) as independent risk factors associated with 2-stage reimplantation requiring an interim spacer exchange for periprosthetic joint infection. CONCLUSION This study demonstrates that patients with spacer exchange had a significantly higher risk of reinfection at 2 years of follow-up. Additionally, patients with spacer exchange demonstrated lower postoperative PROM scores and diminished improvement in multiple PROM scores after reimplantation, indicating that an interim spacer exchange in 2-stage revision is associated with worse patient outcomes.

Hand trauma has always been a common etiology treated by the hand surgeon. However, the amount of severe hand trauma in the United States has decreased as the safety of working environments have improved and the amount of heavy industry jobs has decreased. Largely because of this, the typical hand surgery trainee is now exposed relatively infrequently to pathologies such as brachial plexus injuries, replantation surgery, and upper-extremity reconstructive microsurgery. Our hand surgery colleagues in countries such as India and China have a different experience, though. This difference provides an opportunity for educational exchange through the form of well-structured international fellowships. The American Society for Surgery of the Hand International Traveling Fellowship is specifically designed to supplement the training of young US hand surgeons in brachial plexus surgery, replantation surgery, and reconstructive microsurgery by spending short but intensive periods at some of the premier institutions in China and India.

Fingertip replantation is technically challenging, but in a motivated patient excellent aesthetic and functional outcomes can be achieved. Fingertip microanatomy by zone is described to facilitate the classification and treatment of these injuries. In this article, we outline our preferred techniques for fingertip replantation and review the current body of evidence surrounding indications, techniques, and outcomes while highlighting opportunities for future study.

Upper tract urothelial carcinoma is a rare malignancy for which surgery provides definitive management. Open radical nephroureterectomy was the gold standard treatment, but laparoscopic and robot-assisted approaches are alternative options. Kidney-sparing approaches are feasible for carefully selected patients with ureteral cancer. This article discusses the evaluation of patients with upper tract urothelial carcinoma and definitive management using robot-assisted surgical approaches. Patients with urothelial carcinoma of the upper tract can be treated with robot-assisted nephroureterectomy, distal ureterectomy, and segmental ureterectomy.

Robotically assisted laparoscopic techniques may be used for proximal and distal ureteral strictures. Distal strictures may be approached with ureteroneocystotomy, psoas hitch, and Boari flap. Ureteroureterostomy, buccal mucosa graft ureteroplasty, and appendiceal flap ureteroplasty are viable techniques for strictures anywhere along the ureter. Ileal ureteral substitution is reserved for more extensive disease, and autotransplantation is reserved for salvage situations.

Surgical management of mitral valve disease in neonates and infants is challenging. When repair is no longer feasible, replacement may become inevitable, but should only be considered as an option of last resort due to the remarkably high rate of associated morbidity and mortality. Mechanical valves are the preferred choice in large annuli, while stented conduits seem promising in smaller ones. In patients with a preoperative mitral valve annulus equal or larger than 15-16 mm, an intra-annular placement of the smallest mechanical valve available should be attempted. In patients with smaller annuli, the placement of a stented valved conduit seems to display a lower mortality risk. Supra-annular implantation of prostheses should be reserved for exceptional cases and to those familiar with this technique because of the high rate of associated complications.

Although replantation of an amputated extremity has been successfully performed, occasionally the surgeon is forced to amputate in the case of an unsalvageable open fracture. These appendages can theoretically act as an autologous 'bone and tissue bank' for patients if they have reconstructable contralateral injuries. We present a case of an athlete who sustained a Gustilo and Anderson IIIC injury on 1 leg resulting in a below knee amputation. Her other lower leg had a traumatic amputation of the heel pad, partial amputation of the calcaneus, and complete Achilles tendon loss. Tissues from this amputated appendage were utilised to restore the anatomy of the contralateral extremity. The distal tibia and the tibialis anterior from the amputated limb were used to reconstruct the missing posterior tuberosity of the calcaneus and the Achilles tendon respectively. The soft tissue deficiency of the heel pad was restored with an anterolateral thigh free flap. At 2-year follow-up, the patient is pain free and back to playing soccer. This case highlights the opportunistic use of amputated parts to reconstruct a calcaneus and Achilles tendon. A multidisciplinary approach with plastic surgeons is required. The main advantage of this 'Spare Part Surgery' philosophy is to provide autologous graft of a similar geometry and to avoid harvesting tissues from an additional donor site.

Introduction : Thumb replantation following complete amputation is a relatively frequent and well-established surgical procedure. In literature many studies report a discrepancy between the objective measurements and the subjective satisfaction of the patients. Nowadays, evaluation of the patient long-term benefit obtained by replantation is uncertain. The aim of this study was to consider the long-term results of 33 thumb replantation procedures. Methods : The period considered is from January 1997 to December 2015, 33 subjects fulfilled the study inclusion criteria and were included in the study. We evaluated in each patient: ROM (performing Kapandji test), level and mechanism of amputation, force peak of three grips using Dexter dynamometer (five-handle, key, tri-digital grips), sensibility (using Disk-Criminator and aesthesiometers of Semmes-Weinstein) and subjective perception of disability (using DASH questionnaire). Results : All patients were males, 94% of them returned to their previous occupation. Average follow-up was 9±4 years. The prevalent mechanism of injury was a combined amputation in 58% of cases. Levels involved in more than half of patients were interphalangeal joints and proximal phalanxes. Ratios of strength recovery were: for the five-handle grip equal to 0.90±0.28 kg (p=0.63), 0.78±0.30 kg (p=0.64) for key grip and 0.75±0.32 kg (p=0.78) for tri-digital grip. Results for Kapandji test was 8±2 and for DASH test was 16±21. The protective tactile threshold was recovered in 49% of patients; S2PD test resulted positive in 54% and D2PD test in 39% of cases. Conclusions : Results confirm and strengthen evidence of positive long-term functional outcomes of thumb replantation interventions.

This study evaluated the feasibility and durability of the modified Cabrol coronary reattachment technique after aortic root replacement.The study retrospectively reviewed 370 patients who underwent aortic root replacement, during 1991 and 2018, and who were separated into 2 groups: a modified Carol (mCabrol) group (n = 84), consisting of patients with 1 or both coronary ostia reimplanted using a modified Cabrol technique; and a Carrel group (n = 286), consisting of patients with both coronary ostia reimplanted using the Carrel button technique.Baseline characteristics were similar in the 2 groups, except the mCabrol group had higher rates of redo sternotomy (74% vs 16%), chronic aortic dissection (58% vs 19%), and infection (14% vs 3%). In the mCabrol group, 60% had both coronary arteries reattached with the technique, and 40% of the procedures were unilateral. Operative mortality was significantly higher in mCabrol group compared with the Carrel group. However, in the stratified analysis for resternotomy, operative mortality between 2 groups were similar (16% vs 13%; P = .786). The survival rate at 5 years and 10 years was 68 ± 6% and 44 ± 6%, respectively, in the mCabrol group and 87 ± 2% and 80 ± 3%, respectively, in the Carrel group (log-rank P.001). After propensity adjustment, chronic kidney disease and prior coronary artery bypass grafting, but not the modified Cabrol technique, were independent predictors of both operative mortality and follow-up mortality (operative, P = .518; follow-up, P = .080). A total of 47 (66%) of 71 discharged patients in the mCabrol group had follow-up imaging, and no Cabrol graft was occluded. Two patients in the mCabrol group required interventions related to the reattachment technique: 1 coronary ostial anastomosis stenosis and 1 graft-to-graft anastomosis pseudoaneurysm.The modified Cabrol reattachment technique was not predictive of increased mortality and has excellent patency.

Background Bone distraction lengthening has been used for hand reconstruction. The healing process involved in this technique is affected by many factors. Here, the effectiveness and rates of healing of the phalanges and the metacarpals were evaluated in cases of traumatic finger amputation treated using an Ilizarov mini-fixator. Methods Fourteen phalanges and twelve metacarpals in 15 patients (13 males and 2 females) were treated with distraction lengthening using an Ilizarov mini-fixator between 2014 and 2017. All the digits had been subjected to traumatic amputation, and shortening of the remaining digit had occurred despite successful replantation in some cases. The healing indices of phalanges and metacarpals were analyzed. Results The mean patient age was 42.8 years. The mean lengthening of the phalanges was 13.3 mm, while that of the metacarpals was 26.5 mm. The mean consolidation times were 144.4 days for the phalanges and 154.1 days for the metacarpals. The mean healing indices of the phalanges and metacarpals were 114 days/cm and 60 days/cm, respectively. No bone grafts were needed in any of the patients. Conclusions Distraction lengthening of the digits after traumatic amputation is an effective procedure for hand reconstructive surgery for either the phalanges or the metacarpals and is less invasive than other techniques. The rate of healing of the metacarpals is two times faster than that of the phalanges.

Replantation of lower extremity is a very complex and difficult procedure. There are still a lot of controversies about indications, even numerous scoring systems are now available that can facilitate the surgeon's decision. We present the functional results of a replanted below-knee amputation in an elderly patient, 27 years after the injury and discuss the indication for replantation.

Summary Objective When considering treatment for vesico ureteric reflux via inimally invasive surgery there is a dilemma to choose between laparoscopic extravesical (LEVUR) and transvesicoscopic (TVUR) ureteric reimplantation. In this systematic review and meta-analysis we have analyzed the articles on LEVUR and TVUR and compared the outcomes. Methods We searched the databases to identify all papers pertaining to TVUR and LEVUR in the pediatric population. Duplicate publications, review articles, incomplete articles and robotic assistance were excluded. Systematic review was performed to identify patient data, reflux grades, laterality, duration of surgery, time to discharge, success rate and complications. Meta-analysis of heterogeneity was reported with I 2 statistics. Once heterogeneity was found low, the pooled outcomes were compared with students t test and Fishers exact test, wherever appropriate. Results After screening a total of 45 articles, 23 articles were included (13 articles on TVUR and 10 articles on LEVUR). The I 2 statistics for TVUR and LEVUR showed low heterogeneity with I 2 of 0% (95% C.I 0–37%) and 25% (95% C.I 0–64%) respectively. With low heterogeneity both were suitable to be considered to have been conducted under similar conditions with possibility of using fixed effect model. The percentage of Grade 5 VUR was significantly higher (p = 0.001; X 2) in TVUR (11.9%) compared to LEVUR (2.2%). The proportion of bilateral reimplantation was significantly higher (p = 0.001; X 2) in TVUR compared to LEVUR (summary table). The success rate of LEVUR was significantly higher at 96.7% compared to TVUR at 93.7% (p = 0.007 X 2). Unilateral/Bilateral TVUR took significantly longer duration of surgery (155/194 min vs 107/161 min) compared to LEVUR (p = 0.001; Fishers). The mean (s.d) time to discharge was longer at 3.2 (1.6) days for TVUR compared to 1.6 (0.4) days for LEVUR (p = 0.001; Fishers). The complication rate was comparable, 7.35% for TVUR and 5.35% for LEVUR (p = 0.167; X 2). Discussion In this meta-analysis we found that LEVUR had shorter operating time, higher success, and shorter hospital stay compared to TVUR. A probable explanation could be higher number unilateral VURs and lower number of grade 5 VUR cases in LEVUR group. Both the techniques had comparable overall complication rate: LEVUR had more post-operative urinary retention while TVUR had more port-related problems. Summary table . Meta analysis comparing all outcomes between TVUR & LEVUR Summary TVUR (530 patients; 873 ureters) LEVUR (523 patients; 696 ureters) Difference (p value) Mean (s.d) age in years 5.5 (1.8) 5.6 (2.9) 0.501 Bilateral cases 360/530 (67.9%) 173/523 (33.1%) 0.001 % of Grade 5 VUR (among papers that provided grade) 77/643 (11.9%) 12/552 (2.2%) 0.001 Surgery Duration (minutes)Mean (s.d) Unilateral Bilateral Unilateral Bilateral 154 (53.1) 194 (54.4) 107 (30.1) 161 (35.8) 0.001 0.001 Time to discharge (days)Mean (s.d) 3.2 (1.6) 1.6 (0.4) 0.001 Success rate 818 (93.7%) 673 (96.7%) 0.007 Complication rate 39/530 (7.35%) 21 port related 28/523 (5.35%) 9 retention, 9 leak 0.167

Summary Tamai zone I fingertip replantation remains a challenging problem for surgeons. Tamai zone I fingertip replantation with venous anastomosis and without venous anastomosis is compared in this study. Though there is no difference in the survival rate between the two techniques, Tamai zone I fingertip replantantion with venous anastomosis had a better aesthetic results and fewer complications than that without venous anastomosis. Our results suggest that replantation with venous anastomosis should be encouraged in Tamai zone I fingertip amputation if there are any available veins.

Background Intraoperative cultures are important in the diagnosis and targeted treatment of periprosthetic joint infection (PJI). Positive cultures at reimplantation during a two-stage exchange are discussed as a risk factor for reinfection. The aim of this study is the investigation of the incidence and risk factors for positive cultures during reimplantation. Methods We retrospectively identified 204 patients (111 knees, 93 hips) who were treated between 2012 and 2016 for PJI using a two-stage exchange protocol at a median follow-up of 42 months. PJI was diagnosed using the criteria of the musculoskeletal infection society (MSIS) of 2011. All cultural findings from first and second stage surgery were recorded. The primary endpoint was revision for infection. Risk factors for positive cultures and reinfection were analyzed. Results During reimplantation 25% (51/204) of patients had at least one positive culture, in 19.1% (39/204) only a single culture. Patients with culture-negative infections had a higher risk for positive cultures at reimplantation (HR 2.946 (95% CI 1.247-6.961), P = .014) and patients with infected total hip arthroplasty (THA) (HR 3.547 (95% CI 1.7-7.4), P = .001). Patients with positive cultures during reimplantation had a higher risk for reinfection (HR 2.27 (95% CI 1.181-4.363), P = .014) as well as patients with a single positive culture (HR 2.421 (95% CI 1.139-5.143), P = .021). Conclusion As positive cultures are common and increase reinfection risk irrespective of their numbers, longer antibiotic therapy following reimplantation can be an option. Single positive cultures in reimplantation surgery should not be considered contamination.

In cases of complete scalp loss where the calvarium is exposed and reconstruction cannot be achieved using replantation, or local or far flaps, using trephination to create holes to the depth of the spongeous layer followed by grafting once granulation has covered all defects is an important reconstruction alternative. However, growth of the granulation after trephination and waiting for the entire defect to be covered is a slow process. Since the introduction of platelet-rich plasma (PRP), several researchers have investigated the efficacy of different bone healing and grafting procedures. We present a case with full-thickness partial scalp defect in which we support the development of granulation through holes drilled to the spongeous layer by trephination with PRP.

Background The aim of this study was to compare the short- and long-term outcomes of patients who underwent aortic valve-sparing reimplantation (David) vs aortic root replacement (Bentall) operations in a propensity-matched analysis. Methods The study compared the data of propensity-matched patients who underwent David (n = 261) or Bentall (n = 262) procedures from 2000 to 2015. The mean age at surgery in the entire cohort was 53 ± 13 years, and 19.7% (n = 103) of the study patients were female. Connective tissue disease was present in 9.4% (n = 49) of patients, whereas 37.1% (n = 194) presented with a bicuspid aortic valve. Results The overall 30-day mortality was 1.1% (n = 6) and was not significantly different in patients with the David compared with the Bentall operation (0.4% [n = 1] vs 1.9% [n = 5]; P = .1). The 5- and 10-year survival rates were 93.7 ± 1.8% vs 93.8 ± 1.6% and 84.4 ± 4.7% vs 89.5 ± 3.2% for David vs Bentall, respectively (log-rank P = .98). Cox regression analysis identified age, smoking and previous cardiac surgery as independent predictors of long-term mortality. Freedom from reoperation did not significantly differ between patient groups (89.5 ± 3.4% vs 87.8 ± 4.1% 10 years postoperatively; log-rank P = .71). Bentall-treated patients had a higher rate of serious bleeding during follow-up (P = .025). Conclusions Both the David and Bentall operations are associated with excellent early and long-term results in patients with aortic root aneurysmal disease. The David operation is associated with less bleeding than the Bentall operation, without an increased risk of reoperation. Because of avoidance of bleeding and other long-term complications associated with prosthetic heart valves, the David operation is preferable to the Bentall operation in patients with appropriate pathoanatomy.