Surgical anatomy for subfascial endoscopic perforating vein surgery of laterally located perforating veins

AbstractObjectivesEndoscopic ligation of perforating veins is useful in treatment of perforating vein incompetence. Over the last few years the topic of interest has been the medial side of the lower leg; however, laterally located venous ulcers (10% of all) are of equal importance. Our poor results with lateral subfascial endoscopic perforating vein surgery (SEPS) procedures led us to study the anatomy of the perforating veins in the lateral leg. The presence of persistent insufficient perforating veins in our patients suggests that our procedure failed because of misinterpreted perforator anatomy.Methods and resultsAnatomic dissection was performed in 16 cadavers in two stages, subcutaneously and subfascially. Perforating veins were classified relative to the short saphenous vein and intermuscular septa, with coordinates. Three hundred fifty-one perforating veins were found, for an average of 21.9 perforating veins per leg. The results showed that there is alignment of the perforating veins according to the septa between the anterior and peroneal compartment and between the peroneal compartment and the superficial dorsal compartment. Most of the perforating veins did not correlate with the short saphenous vein.ConclusionPoor clinical results of lateral SEPS procedures might be improved after adjustment of the procedure for new anatomic information, which shows alignment of perforating veins along the intermuscular septa, obligating full septa dissection on the lateral side

Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients

Purpose Modern management of the elderly with a hip fracture is complex and costly. The aim of this study was to compare the treatment-related hospital length of stay (HLOS) before and after implementing a clinical pathway for patients undergoing hip fracture surgery. Methods This was a retrospective, before-and-after study. The first period ranged from June 21, 2008 to November 1, 2009 (N = 212), and the second was from January 7, 2010 to July 7, 2011 (N = 314). The electronic hospital system and patients records were reviewed for demographics, HLOS, mortality, complications and readmissions. Results In the first period 53 % had a femoral neck fracture, of which 57 % were treated with hemiarthroplasty. In the second period this was 46 % and 71 %. Pertrochanteric fractures were treated with a Gamma nail in 85 % in the first period, and in 92 % in the second period. The median HLOS decreased from nine to six days (p < 0.001). For the hemiarthroplasty group HLOS decreased from nine to seven days (p < 0.001); for internal fixation there was no significant difference (five versus six days, p = 0.557) and after Gamma nailing it decreased from ten to six days (p < 0.001). For mortality no statistically significant difference was found (6 % versus 5 %, p = 0.698). Complications decreased for the Gamma nail group (44 % versus 31 %, p = 0.049). Readmissions for the total group were not different (16 % versus 17 %, p = 0.720). Conclusions Implementing a clinical pathway for hip fractures is a safe way to reduce the HLOS and it improves the quality of care

Fixation using alternative implants for the treatment of hip fractures (FAITH): design and rationale for a multi-centre randomized trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures

BACKGROUND: Hip fractures are a common type of fragility fracture that afflict 293,000 Americans (over 5,000 per week) and 35,000 Canadians (over 670 per week) annually. Despite the large population impact the optimal fixation technique for low energy femoral neck fractures remains controversial. The primary objective of the FAITH study is to assess the impact of cancellous screw fixation versus sliding hip screws on rates of revision surgery at 24 months in individuals with femoral neck fractures. The secondary objective is to determine the impact on health-related quality of life, functional outcomes, health state utilities, fracture healing, mortality and fracture-related adverse events. METHODS/DESIGN: FAITH is a multi-centre, multi-national randomized controlled trial utilizing minimization to determine patient allocation. Surgeons in North America, Europe, Australia, and Asia will recruit a total of at least 1,000 patients with low-energy femoral neck fractures. Using central randomization, patients will be allocated to receive surgical treatment with cancellous screws or a sliding hip screw. Patient outcomes will be assessed at one week (baseline), 10 weeks, 6, 12, 18, and 24 months post initial fixation. We will independently adjudicate revision surgery and complications within 24 months of the initial fixation. Outcome analysis will be performed using a Cox proportional hazards model and likelihood ratio test. DISCUSSION: This study represents major international efforts to definitively resolve the treatment of low-energy femoral neck fractures. This trial will not only change current Orthopaedic practice, but will also set a benchmark for the conduct of future Orthopaedic trials. TRIAL REGISTRATION: The FAITH trial is registered at ClinicalTrials.gov (Identifier NCT00761813)