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Background: The deltoid ligament is a key component of ankle fracture stability. Clinical tests to assess deltoid ligament injury have low specificity. In supination external-rotation (SER) type-IV ankle fractures, there is either a medial malleolus fracture or deltoid ligament injury. These injuries are often considered unstable, requiring surgical stabilisation. We look to identify the anatomical basis for this instability. This study investigates the anatomical basis for such instability by re-creating SER type ankle fractures in a standardised cadaveric study model, investigating the anatomical basis for such instability., Aim: To investigate the anatomical basis for fracture instability in SER type ankle fractures., Methods: Four matched pairs of cadaveric limbs were tested for stability both when axially loaded and under external rotation stress. Four matched pairs of cadaveric limbs (8 specimens) were tested for stability when axially loaded to 750 N with a custom rig. Specimens were tested through increasing stages of SER injury in a stepwise fashion before restoring the lateral side with open reduction and internal fixation (ORIF). Clinical photographs and radiographs were recorded at each step. We defined instability in accordance with well accepted radiological parameters: > 4 mm medial clear space opening on a mortise-view radiograph or > 7 degrees of talar tilt., Results: All specimens with an intact posterior deep deltoid ligament were stable. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Stabilisation of the lateral side prevented talar shift, but not talar tilt., Conclusion: If the posterior deep deltoid ligament is intact then SER fractures can be managed without surgery. If the posterior deep deltoid is incompetent, ORIF and cautious rehabilitation is recommended because the talus can still tilt in the mortise., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objectives: Type A aortic dissection (ATAAD) is hypothesised as a progression of aneurysmal dilation, but 60% of patients in the International Registry of Acute Aortic Dissection (iRAD) registry had a maximum aortic diameter (MAD)<55 mm. We aim to demonstrate that size ratios and aortic wall stress, assessed using a simplified markers, are unique to aortic patients who have had adverse events (ATAAD) compared to those who have not (thoracic aortic aneurysm [TAA])., Methods: A retrospective cohort analysis of patients who underwent aortic intervention at Waikato Hospital, New Zealand between 2015-2020, comparing dissection (ATAAD) to TAA patients. MAD; ratio of MAD to standardised-points within the aorta; and MAD-to-height collected from computed tomography (CT)-scans of all patients was undertaken. Receiver operating characteristic (ROC)-analysis to determine cut-off point for each marker was undertaken together with multivariable logistic regression comparing both cohorts, cross-validated by propensity-score matched analysis., Results: Cohort of 215 patients, 78 (36.3%) ATAAD and 137 (63.7%) TAA; median age at intervention 63.3 years, 52 (24.2%) females, both cohorts matched for size. Using the entire cohort, the MAD: sinus of Valsalva (SoV) ratio>1.06 (cut-off value) had 4.5-times greater association with ATAAD (95%CI 1.46-13.8) and a 0.1-unit increased conferred 1.45-times greater association with ATAAD (95%CI 1.00-2.08). MAD>55 mm only seen in 33.3% of ATAAD (n=26/78), and not associated with ATAAD (OR 1.88, 95%CI 0.64-5.51). Compared to MAD, MAD:SoV ratio had greater sensitivity (33% vs 73%), lower number-needed-to-treat (17.9 vs 2.7) and superior discrimination (area under the curve [AUC] 0.54 vs 0.71). Findings were consistent with propensity score matched analysis., Conclusions: MAD:SoV ratio significantly correlates with ATAAD (4.5 times), with superior sensitivity, discrimination, and attributable-risk-percentage compared to MAD alone., Competing Interests: Conflict of Interest None declared., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Aims: Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis., Methods: This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. Symptoms or signs recorded were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. The lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance., Results: Three hundred and ten patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician and 96 (31%) patients were asymptomatic. Incidental diagnosis was demonstrated in 121 (39.4%) patients. Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12) and 28% chest pain (n=12)., Conclusions: In New Zealand, a large amount of lung cancer is still diagnosed incidentally with symptoms of cough, dyspnoea and chest pain. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted., Competing Interests: Nil.

Background: Simulation training is a useful adjunct to surgical training and education (SET) in Cardiothoracic Surgery yet training opportunities outside the Royal Australasian College of Surgery or industry-sponsored workshops are rare due to high cost and limited training faculty, time, assessment tools or structured curricula. We describe our experience in establishing a low-cost cardiac simulation programme., Methods: We created low-cost models using hospital facilities, hardware stores, abattoirs and donations from industry. Three workshops were conducted on coronary anastomoses, aortic and mitral valve replacement., Results: Whole porcine hearts were sourced from local farms. Industry donations of obsolete stock were used for suture and valve material-stations constructed using ironing-board, 2-L buckets and kebab-skewers. Suture ring holders were fashioned from recycled cardboard or donated. All participants were asked to complete pre and post simulation self-assessment forms. Across three workshops, 45 participants (57.8% female) with a median age 27 (interquartile range 24-31) attended. Training level consisted of nurses (8, 17.8%), medical students (17, 37.8%), residents/house officers (6, 13.3%) and registrars (14, 31.1%). There were improvements in knowledge of anatomy (mean difference 18%; 95% confidence interval 12%-24%), imaging (16%; 10%-22%) and procedural components (34%; 28%-42%); and practical ability to describe steps (30%; 24%-38%), partially (32%; 26%-38%) or fully complete (32%; 28%-38%) the procedure., Conclusions: Simulation-based training in cardiac surgery is feasible in a hospital setting with low overhead costs. It can benefit participants at all training levels and has the potential to be implemented in training hospitals as an adjunct to the SET programme., (© 2021 Royal Australasian College of Surgeons.)

Background: The updated Australian System for Cardiac Operative Risk Evaluation (AusSCORE II) and the Society of Thoracic Surgeons (STS) Score are well-established tools in cardiac surgery for estimating operative mortality risk. No validation analysis of both risk models has been undertaken for a contemporary New Zealand population undergoing isolated coronary bypass surgery. We therefore aimed to assess the efficacy of these models in predicting mortality for New Zealand patients receiving isolated coronary artery bypass grafting (CABG)., Material and Methods: A prospective database was maintained of patients undergoing isolated CABG at a major tertiary referral centre in New Zealand between September 2014 and September 2017. This database collected the patients' demographic, clinical, biochemical, operative and mortality data. The primary outcome measure was the correlation between the predicted AusSCORE II and STS Score mortality risks and the observed 30-day mortality events for all patients in the database using discrimination and calibration statistics. Discrimination and calibration were assessed using receiver operating characteristic (ROC) curves and the Hosmer-Lemeshow test respectively., Results: A total of 933 patients underwent isolated CABG during the 3-year study period. There were seven deaths in the study cohort occurring within 30 days of surgery. Discrimination analysis demonstrated the area under the ROC curve (AUC) of the AusSCORE II and STS Score as 88.2% (95% CI: 85.9-90.2, p<0.0001) and 92.1% (95% CI: 90.2-93.7, p<0.0001) respectively. Calibration analysis revealed Hosmer-Lemeshow test p-values for the AusSCORE II and STS Score as 0.696 and 0.294 respectively., Discussion: ROC curve analysis produced very high and statistically significant AUC values for the AusSCORE II and STS Score. Hosmer-Lemeshow test analysis revealed that both risk scoring tools are well calibrated for our study cohort. Therefore, the AusSCORE II and STS Score are both strongly predictive of 30-day mortality for isolated coronary artery bypass grafting surgery in our New Zealand patient population. Both risk models have performed with excellent discrimination and calibration. There is, however, a need to consider the performance of these risk stratification models in other cardiac surgical procedures outside isolated coronary bypass surgery where appropriate., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Inflammatory markers, such as neutrophils and lymphocytes, for risk stratification of postoperative morbidity and mortality in patients with cardiovascular disease may provide benefit for patient selection for cardiac surgery. This study aimed to investigate the association between preoperative neutrophil to leucocyte ratio (NLR) after cardiac surgery., Methods: A retrospective study from September 2014 to November 2017 undergoing cardiac surgery at Waikato Hospital was conducted. Preoperative haematological profiles, patient factors and primary and secondary endpoints were obtained. The primary endpoint was 30-day new postoperative atrial fibrillation requiring treatment, new neurological insult, readmission within 30 days and 30-day mortality. The secondary endpoint was long-term all cause mortality., Results: Of the 1,694 patients included in the study, 21% (356/1,694) of patients had new atrial fibrillation (AF), 3.0% (51/1,694) strokes, 10.6% (180/1,694) readmissions and 2.8% (47/1,694) deaths within 30 days were observed. Receiver operator curve (ROC) returned a cut-off value of NLR equal to or greater than 3.23 (high NLR) to be associated with greatest mortality. Subsequently, a high NLR was compared to the endpoints. High NLR was associated with higher postoperative (p<0.001) and discharge creatinine, longer ICU stay (p=0.012), prolonged intubation and ventilation (p<0.001), new neurological status (p=0.002) and increased risk of returning to theatre (p=0.009). After logistic regression, high NLR was associated with increased mortality (OR 3.36, p=0.001)., Conclusions: The interpretation and utilisation of readily available haematological markers can provide further risk stratification data to the surgeon when considering the postoperative cardiac surgery risks., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Osteoarthritis of the medial compartment, where the lateral compartment and patella-femoral joint are relatively spared, is a common orthopaedic presentation.Most frequently, the treatment of choice would be a total knee replacement, which involves removing healthy joint surfaces in such patients.Arthroscopic debridement in the osteoarthritic knee has fallen out of favour due to poor clinical results.A trend has developed towards less invasive surgery with uni-compartmental knee replacement (UKR) and high tibial osteotomy (HTO) gaining increasing popularity.Surgeons differ in their relative indications and contraindications to performing these procedures.Total knee replacement (TKR) continues to have the lowest overall revision rate of the available options.Growing evidence demonstrates more favourable patient-reported outcome measures in UKR and HTO patients, compared to TKR.Knee joint distraction (KJD) has been demonstrated as an alternative method of treatment in such patients. Cite this article: EFORT Open Rev 2021;6:113-117. DOI: 10.1302/2058-5241.6.200102., Competing Interests: ICMJE Conflict of interest statement: The authors declare no conflict of interest relevant to this work., (© 2021 The author(s).)

Background: We aimed to study prospectively the nature and effect of sleep apnea-hypopnea syndrome (SAHS) in patients undergoing coronary artery bypass graft (CABG) surgery over five years of follow-up., Methods: Patients undergoing CABG surgery (N.=145) were assessed longitudinally (baseline, 1 year, and 5 years post-surgery) using the 'STOP-BANG' screen of sleep apnea risk. Additionally, all patients had a preoperative multiple-channel sleep-study, providing acceptable data for an obstructive and central apnea, and desaturation index in 97 patients., Results: Preoperatively, over half (63%) of patients obtained an apnea-hypopnea index score (combining apnea types) in the moderate-severe range for SAHS, and STOP-BANG threshold score (>3/8) was reached by most (95%) patients. Despite some improvement in 'STOP symptoms' at 1-year follow-up, most patients (98%) remained at risk of SAHS at 5 years post-surgery. There was an underlying and chronic relationship between STOP-BANG score and cardiac symptoms at both baseline and 5-year follow-up. Additionally, SAHS variables were associated with greater incidence of acute postoperative events, and generally with increased length of stay on the intensive care unit., Conclusions: We confirm that SAHS is common in CABG-surgery patients, presenting additional clinical challenges and cost implications. The underlying pathophysiology is complex, including upper airway obstruction and cardiorespiratory changes of heart failure. In patients presenting for CABG-surgery, we show chronic susceptibility to SAHS, likely associated with traditional risk factors e.g. obesity but perhaps also with gradual decline in heart function itself. Superimposed on this, there is potential for exacerbated risk of morbidity at the time of CABG surgery itself.

Background: Enhanced recovery programs within cardiothoracic surgery are a well described benefit to patient postoperative outcomes. We describe our Australasian unit's experience of a day zero discharge enhanced recovery unit from the intensive care department., Methods: A retrospective study was conducted on a prospectively maintained database at Waikato Cardiothoracic Unit from September 2014 till October 2017 with 1,739 patients undergoing cardiac surgery. Twenty-two (22) patients were excluded as deaths either intraoperative or in the intensive care unit (ICU) and therefore never discharged. Total population of the study was 1,717 patients. The primary endpoint of this study was to determine if there is no survival disadvantage for the day zero discharge unit compared to standard treatment in ICU at follow-up. The secondary endpoint of the study was to highlight the association between pre and postoperative variables and the impact on discharge from the ICU., Results: One hundred sixty-eight (168) patients were discharged to the enhanced recovery unit (ERU) day zero. Mean number of hours spent in ICU for the day zero cohort was 7.18 (±1.59. Mean Age 62.5 (±11.22), M:F 4.25:1. Patients were more likely to be discharged day zero if they had a lower EuroSCORE II 1.57 (±1.67) and lower preoperative creatinine 89.4 (±27.5). Those admitted to the ERU on day zero postoperatively were more likely to be discharged with a lower creatinine level, a higher haemoglobin level and have less readmissions per 30days (p<0.05). Survival analysis demonstrated that the patients who were discharged early from ICU had significantly better follow-up survival compared to those who were discharged after 24hours (p<0.05)., Conclusions: A fast track unit increases the efficiency of an ICU and cardiac surgical department. With the advancements of cardiac surgery a higher number of patients will be suitable for a fast track method. Our unit has demonstrated that a day zero fast track unit in New Zealand can perform with adequate patient safety with no increased risk of mortality and with low rates of failure of the day zero discharge fast track therapy., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: The updated European System for Cardiac Operative Risk Evaluation (EuroSCORE II) is a well-established cardiac surgery risk scoring tool for estimating operative mortality. This risk stratification system was derived from a predominantly European patient cohort. No validation analysis of this risk model has been undertaken for the New Zealand population across all major cardiac surgery procedures. We aim to assess the efficacy (discrimination and calibration) of the EuroSCORE II for predicting mortality in cardiac surgical patients at a large New Zealand tertiary centre., Methods: Data was prospectively collected on patients undergoing cardiac surgery from September 2014 to September 2017 at Waikato Hospital, New Zealand. Patient demographic information, preoperative clinical risk factors and outcome data were entered into a national database. Included patients received either isolated coronary artery bypass grafting (CABG), isolated valve surgery, isolated thoracic aortic surgery, or a combination of these procedures. The primary outcome was the discrimination and calibration of predicted EuroSCORE II risk scores compared with observed 30-day mortality events., Results: 1,666 cardiac surgery patients were included during the study period, with an average EuroSCORE II of 2.97% (95% confidence interval (CI): 2.76-3.18). Nine hundred thirty-three (933) patients underwent isolated CABG, 384 underwent isolated valve surgery, 48 received isolated thoracic aortic surgery and 301 received combination procedures. Thirty-day (30-day) mortality events in each of these groups was 7, 4, 2 and 13 deaths respectively. There were 26 deaths across the total cohort at 30-days (observed mortality rate 1.56%). Discrimination analysis using receiver operating characteristic curves demonstrated the area under the curve (AUC) of the EuroSCORE II in each of these groups as 93.4% (95% CI: 91.6-94.9, p<0.0001), 66.3% (95% CI: 61.3-71.0, p=0.37), 37.0% (95% CI: 15.7-58.2, p=0.23) and 74.8% (95% CI: 69.5-79.6, p<0.0001) respectively. The total cohort AUC was 83.1% (95% CI: 81.2-84.9, p<0.0001). Calibration analysis using Hosmer-Lemeshow tests for the subgroups revealed p-values of 0.848, 0.114, 0.638 and 0.2 respectively. The total cohort Hosmer-Lemeshow p-value was 0.317., Conclusions: EuroSCORE II showed a strong discriminative ability for isolated CABG 30-day mortality in a New Zealand patient cohort. However, the scoring system discriminated poorly across valvular, thoracic aortic or complex combination cardiac surgical procedures. Good calibration of the EuroSCORE II was achieved across both the total cohort and subgroups. It is important to consider the performance of other cardiac surgery risk stratification models for the New Zealand population., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

A best evidence topic was constructed according to a structured protocol. The question addressed was whether the configuration of bilateral internal thoracic arteries (BITAs) influences survival, patency or repeat revascularization in patients undergoing coronary artery bypass grafting. Five hundred and seventy-one papers were found using the reported searches, of which 8 represented the best evidence to answer the clinical question. One systematic review, 4 randomized trials and 3 observational studies were selected. The authors, date, journal, study type, population, main outcome measures and results are tabulated. All 4 prospective randomized trials found no significant difference in graft patency or mortality when comparing Y-graft and in situ configurations. Three of the 4 randomized trials found no difference in major adverse cardiovascular and cerebrovascular events or repeat revascularization at follow-up. An exception was Glineur et al. (Bilateral internal thoracic artery configuration for coronary artery bypass surgery: a prospective randomized trial. Circ Cardiovasc Interv 2016;9:7), who found that the Y-configuration resulted in lower rates of major adverse cardiovascular and cerebrovascular events. All 3 observational studies reviewed found no alteration in survival, cardiac events or repeat revascularization between in situ and Y-graft BITA configurations. One systematic review found similar outcomes with respect to mortality, cardiac events and repeat revascularization with in situ and composite BITA. In summary, existing literature demonstrates no difference in clinical outcomes between composite and in situ graft configurations. Furthermore, the configuration of BITA does not affect mortality, graft patency or repeat revascularization.

Coarctation of the aorta can require multiple redo surgeries. It is extremely pertinent to plan for this and ensure that each operation is performed with future repair in mind. We present a rare case and the subsequent management of competitive flow in coarctation of the aorta requiring a fourth operation for repair.

Our aim in this paper was to investigate the guidelines and laws governing informed consent in the English-speaking world. We noted a recent divergence from medical paternalism within the United Kingdom, highlighted by the Montgomery v Lanarkshire Health Board ruling of 2015. We investigated the situation in the United Kingdom, Australia, New Zealand, Canada, and the United States of America. We read the national guidance regarding obtaining consent for surgical intervention for each country. We used the references from this guidance to identify the laws that helped inform the guidance, and reviewed the court documents for each case. There has been a trend towards a more patient-focused approach in consent in each country. Surgeons should be aware of the guidance and legal cases so that they can inform patients fully, and prevent legal problems if outdated practices are followed. Cite this article: Bone Joint J 2018;100-B:687-92.

Acute limb ischemia due to type B aortic dissection is rare and continues to be a management challenge. A case series is presented here with the aim of assessing the outcomes of treatment with a femorofemoral crossover graft with or without thoracic stent graft insertion. This is a combined retrospective and prospective review of nine cases of acute lower limb ischemia secondary to acute type B aortic dissection. The presenting features, radiological findings, treatment and outcomes were reviewed. Five patients had a femorofemoral crossover graft (FFXO) alone, two an FFXO with a thoracic stent graft and the eighth a thoracic and iliac stent. The other case was initially treated conservatively but subsequently required an FFXO. The mean follow-up was 16 (3-51) months. A further two thoracic stents were placed during the follow-up period. Thus five out of nine patients (56%) required aortic stenting. This series suggests that an FFXO is a reliable treatment for acute limb ischemia due to type B aortic dissection. However, these patients are often complex with ischemia in other vascular beds and are at risk of subsequent aneurysmal dilation.

Aortic valve reoperation after homograft root implantation is high risk and may be technically challenging. Dense calcification of the annulus may prevent suture placement and often necessitates impromptu high-risk redo root replacement. Although transcutaneous aortic valve implantation is an attractive option in such scenarios, in the context of endocarditis it is contraindicated. We describe a novel approach to aortic valve replacement in a patient with infective endocarditis of a heavily calcified homograft root, using a sutureless valve. This approach successfully avoided the need for redo root replacement with its attendant risks., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A best evidence topic was written according to a structured protocol, asking 'does surgery improve prognosis in patients with small-cell lung carcinoma (SCLC)?' One hundred and thirteen papers were identified, of which the nine papers best able to answer the question were selected and the details of each tabulated. The prohibitive attitude of clinicians toward surgery in SCLC has prevailed since the 1960s, informed by a prospective randomized trial in which 144 patients were assigned to surgical treatment or to radical radiotherapy. Surgery conferred no survival benefit when compared with radical radiotherapy as assessed at 6 monthly intervals up to 10 years post-treatment. Patients with metastatic disease were excluded; however, diagnostic advances subsequent to these trials justify a re-evaluation of the issue, given the greater degree of accuracy with which sub-groups of patients who might benefit from surgery can now be defined. Only one further prospective, randomized trial features in the literature. This study also discerned that no survival benefit was accrued by adding surgery to chemotherapy. However, this study only included patients who responded to an initial course of chemotherapy and also excluded patients with peripheral nodules only. Subsequent investigators have asserted the value of surgery in SCLC. A retrospective case-control study found that surgery significantly improved median survival in patients with stage I disease when compared with patients undergoing medical therapy. One British centre reported survival rates of 52% at 5 years amongst patients undergoing resection and nodal dissection for stage II-IIIA disease. In a retrospective analysis of the Norwegian cancer database, 5-year survival for patients with stage I undergoing surgery was 44.9%, as opposed to 11.3% amongst those treated medically. This finding was echoed in the analysis of the surveillance epidemiology and end results database in the USA, which found improved median survival amongst patients undergoing surgery for limited SCLC. Prospective studies of carefully selected patients have documented good median survival in patients whose tumour was completely resected. We conclude that surgery for early-stage SCLC improves prognosis as part of a multi-modality approach. This echoes the advice of the 2011 national institute of health and clinical excellence guidelines regarding surgery in SCLC.

A best evidence topic was written according to a structured protocol. The question addressed was whether muscle-sparing thoracotomy (MST), as opposed to posterolateral thoracotomy (PLT), results in better recovery. A total of 108 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. A recent large prospective, randomized, double-blinded, controlled study demonstrated a shorter length of stay in patients undergoing MST. It failed to demonstrate any significant difference in pain reported or pulmonary function. A separate prospective randomized controlled trial focussed on pain, pulmonary function, late shoulder range of motion and late muscle strength. It failed to show any significant difference in these domains between PLT and MST. While the mean 'opening time' is greater when performing a MST, this is negated by a shorter mean 'closing time' when compared with PLT. Overall, the evidence suggests that MST results in greater early (1 week) preservation of skeletal muscle strength and range of motion over PLT. This difference has disappeared at 1 month. There is little evidence to suggest a difference in pulmonary function or pain dependent on the thoracotomy type. Moreover, analgesic consumption is similar. However, there is an inverse relationship between the incision length and the post-thoracotomy syndrome.

A best evidence topic was written according to a structured protocol. The question addressed was whether cardiopulmonary bypass can be used safely with satisfactory maternal and foetal outcomes in pregnant patients undergoing cardiac surgery. A total of 679 papers were found using the reported searches of which 14 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were maternal and foetal mortality and complications, mode of delivery, cardiopulmonary bypass and aortic cross-clamp times, perfusate flow rate and temperature and maternal NYHA functional class. The most recent of the best evidence studies, a retrospective observational study of 21 pregnant patients reported early and late maternal mortalities of 4.8 and 14.3%, respectively, and a foetal mortality of 14.3%. Median cardiopulmonary bypass and aortic cross-clamp times were 53 and 35 min, respectively, and the median bypass temperature was 37°C. Three larger retrospective reviews of the literature reported maternal mortality rates of 2.9-5.1% and foetal mortality rates of 19-29%. Mean cardiopulmonary bypass times ranged from 50.5 to 77.8 min. Another retrospective observational study reported maternal mortality of 13.3% and foetal mortality of 38.5%. Mean cardiopulmonary bypass and aortic cross-clamp times were 89.1 and 62.8 min, respectively, with a mean bypass temperature of 31.8°C. A retrospective case series reported no maternal mortality and one case of foetal mortality. Median cardiopulmonary bypass and aortic cross-clamp times were 101 and 88 min, respectively. Eight case reports described 10 patients undergoing cardiopulmonary bypass. There were no reports of maternal mortality and one report of foetal mortality. Mean cardiopulmonary bypass and aortic cross-clamp times were 105 and 50 min, respectively. We conclude that while the use of cardiopulmonary bypass during pregnancy poses a high risk for both the mother and the foetus, the use of high-flow, high-pressure, pulsatile, normothermic bypass and continuous foetal and uterine monitoring can allow cardiac surgery with the use of cardiopulmonary bypass to be performed with the greatest control of risk in the pregnant patient.

A best evidence topic was written according to a structured protocol. The question addressed was whether smoking cessation prior to cardiac surgery would result in a greater freedom from postoperative complications. A total of 564 papers were found using the reported searches, of which five represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were operative mortality, pulmonary complications, infective complications, neurological complications, transfusion requirements, duration of ventilation, intensive care unit and hospital stay, intensive care unit re-admission, postoperative gas exchange parameters and postoperative pulmonary function. The largest of the best evidence studies demonstrated a significant reduction in pulmonary complications in non-smokers (P < 0.001); however, there was an increased requirement for transfusion in this cohort (P = 0.002). There were non-significant reductions in neurological complications, infective complications and re-admissions to intensive care. Another large cohort study demonstrated significant reductions in non-smokers in mortality (P < 0.0001), pulmonary complications (P = 0.0002), infection (P < 0.0007), intensive care unit re-admission (P = 0.0002), duration of mechanical ventilation (P = 0.026) and intensive care unit stay (P = 0.002). A larger cohort study again demonstrated significant reductions in non-smokers in pulmonary complications (P < 0.002), duration of mechanical ventilation (P < 0.012) and intensive care unit stay (P < 0.005). A smaller prospective cohort study reported significantly raised PaO(2) (P = 0.0091) and reduced PaCO(2) (P < 0.0001) levels in the non-smokers as well as improved FVC and FEV(1) (P < 0.0001). There were also reductions in duration of intubation (P < 0.0001), intensive care unit stay (P < 0.0001) and hospital stay (P < 0.0013). Another small cohort study reporting outcomes of heart transplantation demonstrated significant improvement in non-smokers in terms of survival (P = 0.031), duration of intubation (P = 0.05) and intensive care unit stay (P = 0.021). We conclude that there is strong evidence demonstrating superior outcomes in non-smokers following cardiac surgery and advocate the necessity of smoking cessation as soon as possible prior to cardiac surgery.

Coronary artery bypass graft (CABG) surgery is an established treatment for complex coronary artery disease. There is a widely held belief that cognitive decline presents post-operatively. A consensus statement of core neuropsychological tests was published in 1995 with the intention of guiding investigation into this issue. We conducted a meta-analysis evaluating the evidence for cognitive decline post-CABG surgery. Twenty-eight published studies, accumulating data from up to 2043 patients undergoing CABG surgery, were included. Results were examined at 'very early' (<2 weeks), 'early' (3 months) and 'late' (6-12 months) time periods post-operatively. Two of the four tests suggested an initial very early decrease in psychomotor speed that was not present at subsequent testing. Rather, the omnibus data indicated subtle improvement in function relative to pre-operative baseline testing. Our findings suggest improvement in cognitive function in the first year following CABG surgery. This is contrary to the more negative interpretation of results of some individual publications included in our review, which may reflect poor outcomes in a few patients and/or methodological issues., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

A best evidence topic was written according to a structured protocol in order to identify the mode of anticoagulation that has the best safety profile for both the mother and the foetus in pregnant patients with mechanical prosthetic heart valves. A total of 281 papers were identified using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The reported measures were foetal mortality, maternal mortality, congenital abnormalities and embryopathy, and maternal thromboembolic and haemorrhagic complications. The medical orthodoxy has warned of the combination of oral anticoagulation and pregnancy due to the well-documented warfarin embryopathy. Yet only one of the reported papers identified a greater incidence of foetal aberrations among warfarin use, with the highest reported rate being 6.4% and two of the assessed papers reporting no embryopathy at all. Foetal mortality with oral anticoagulation use ranged from 1.52 to 76%. All reported publications demonstrated a superior maternal outcome with warfarin use, with a range of thromboembolic events from 0 to 10% in comparison with 4 to 48% where heparin was used. Thus, it is concluded that warfarin is a more durable anticoagulant with a better maternal outcome despite it carrying a greater foetal risk. Although, in contrast to previous teaching, the risks of embryopathy are not the major drawback of oral anticoagulation. Heparin is consistently less effective, but may be preferred for the superior foetal outcome. Heparin usage during the first trimester reduces the foetal risk but is still associated with an adverse maternal outcome. While the focus for clinicians looking after pregnant women with mechanical heart valves may be to prevent maternal thromboembolic complications, the overriding concern for many women is to avoid any harm to their unborn child, even when this places their health at risk. Thus women with mechanical heart valves must be fully informed of the risks involved with different anticoagulation for an informed decision to be made.

We addressed the question of whether or not the currently available evidence base supports heparinization in the context of a patient requiring cardiovascular support with an intra-aortic balloon pump (IABP). A best evidence topic was written according to a previously defined structured protocol. A literature search returned 443 papers, 3 of which were deemed relevant. Jiang et al. randomized 153 patients requiring IABP to heparin or no heparin, matched for age, sex and comorbidities. There was no significant difference in limb ischaemia; however, incidence of bleeding was significantly increased in the heparinized group (14.1 vs 2.4%). One cohort study compared two management strategies of IABP in which patients either received heparin universally or selectively with heparin only given for certain pre-defined indications. They reported increased bleeding with universal heparinization (39.2 vs 31.8%) but similar other complication rates. Another cohort study in which patients with IABP were initially treated with glycoprotein IIb/IIIa antagonists only, reported bleeding and ischaemia rates within accepted ranges for heparinized patients. The use of anticoagulation with IABP is intended to reduce the risk of thrombus, thromboembolus or limb ischaemia whilst generating an increased risk of bleeding as a side-effect. The aforementioned studies demonstrate that omitting or implementing a selective use strategy of heparinization during IABP counterpulsation can significantly decrease the incidence of bleeding without an increase in ischaemic events. One study also performed angiography prior to IABP insertion on some of their patients, selecting the less diseased side to insert the IABP. Current evidence on this topic is sparse, especially as relates to patients in the context of cardiothoracic surgery. Just one study specifically looked at surgical patients. However, the existing data suggest that it is safe to omit heparinization when using IABP counterpulsation. The decision to heparinize should be weighed in the context of other indications or contraindications rather than being an automatic response to the use of IABP.

A best evidence topic was written according to a structured protocol. The question addressed was to identify which thoracotomy closure method lends itself to the least postoperative pain. Altogether 109 papers were found using the reported search; of which, seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the closure by intracostal sutures with intercostal nerve sparing offers a superior postoperative pain profile for thoracotomy patients when compared with conventional techniques. Up to 1-year follow-up has shown that this technique (avoiding strangulation of the intercostal nerve) leads to lower postoperative pain and analgesic use, better ambulation and a quicker return to daily activities. Three papers (including two randomized trials) found intracostal sutures with intercostal nerve sparing techniques to be superior to conventional methods such as pericostal suture closure. Rib approximation with intercostal nerve sparing was found to be superior to rib approximation without nerve sparing in one study. Two studies associated with the creation of an intercostal muscle flap prior to the insertion of a rib retractor to be associated with significantly reduced postoperative pain. One study described a novel 'edge-closure' technique, comparable to the closure with intracostal sutures without drilling, to be superior to conventional closure with pericostal sutures. Postoperative pain is a significant issue faced by thoracic surgeons both in-hospital and in the longer term where patients may complain of chronic thoracotomy pain. We would therefore recommend that some form of intercostal nerve protection be implemented during thoracotomy opening and closure.

A best-evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether screening asymptomatic individuals for an abdominal aortic aneurysm (AAA) is feasible and improves disease-free survival. Seven studies presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and limitations of the studies are tabulated. In total, four randomized population-based studies have evaluated ultrasound screening for AAA: two British studies, Multicentre Aneurysm Screening Study (MASS) and the Chichester trial, and one each in Viborg County, Denmark and Western Australia. Participants were randomized to receive an invitation to screen or not. The MASS trial randomized 67 770 men, followed participants over 10 years and concluded that screening would almost half AAA-related deaths in men aged 65-74 years. The smaller Chichester trial included only 6040 men but demonstrated a 42% reduction in AAA-related mortality at 5 years, with ongoing benefit at 15 years (11% reduction). The Viborg County trial recruited 12 639 men aged 64-73 years, showed a 66% reduction in AAA-related mortality over 14 years. Finally, the Western Australia trial evaluated 41 000 men but included an older population of 65-83 years old. No benefit was seen in this age group but subgroup analysis of men aged 65-74 showed a significant mortality benefit. Only a small or insignificant benefit in all-cause mortality was seen in any of these studies. A recent meta-analysis of these trials has shown a significant benefit in AAA-related mortality in the long term and concluded that AAA screening is superior to other established screening programmes. The cost-effectiveness of screening was assessed in the MASS and Viborg County trials and was found to be substantially below the cost threshold set by the National Institute of Clinical Excellence for acceptance of interventions. Quality of life was assessed in the MASS and in a case-control study and showed no adverse effects that outweigh the benefits. We concluded that ultrasound screening for AAAs has met all the criteria to become a screening programme and would substantially reduce disease-related death with no adverse effect on quality of life.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether posterior pericardiotomy (PP) reduces the incidence of atrial fibrillation (AF) after coronary artery bypass grafting surgery. Twelve papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. One non-randomized prospective cohort controlled study generated early evidence that PP reduced the rate of postoperative AF and pericardial effusion. The operative details of PP were clearly explained in this paper. The efficacy of this procedure was subsequently examined in five prospective randomized controlled trials performed with some limitations, listed in the table. Meta-analysis of the randomized control trials examined a group of 763 patients (PP = 389, control = 374). It revealed a highly significant reduction in total arrhythmias and AF in the PP group (odds ratio 0.31 and 0.33, respectively). There was a 10.8% AF rate in the PP group (41/379) and a 28.1% AF rate in the control group (108/384). Furthermore, the PP group had a significant reduction in the rate of early and late pericardial effusion (P < 0.001). Moreover, the reduction in the incidence of arrhythmias was significantly associated with the reduction in the incidence of pericardial effusion. Referring to these studies, two guidelines recommend PP to reduce postoperative AF with grade B strength of recommendation. We conclude that PP significantly reduces the incidence of postoperative AF. The number needed to treat to prevent one case of AF is six.

A best evidence topic was written according to a structured protocol. The question addressed was whether video-assisted mediastinoscopy (VAM) has a better lymph node yield and safety profile than the conventional mediastinoscopy (CM). A total of 194 papers were found, using the reported searches, of which five represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Two studies to date have directly compared CM and VAM with respect to lymph node yield, calculated diagnostics performance and complication rate. In both of these, lymph node yield is shown to be higher using VAM with better sensitivity, negative predictive value and accuracy rates. The favourable figures of lymph node sampling are found to be statistically significant in the single study providing such analysis. Complication rates using VAM are low, however, in the one instance where it is reported as higher than CM, the extensive lymph node dissection used in this technique may be a reasonable explanation for this finding. All studies described here exemplify VAM as a safe and useful tool in mediastinal staging, lymph node dissection and tissue diagnosis of mediastinal diseases given its superior visualization of surrounding structures and advantage of bimanual dissection. The future scope for diagnostic and therapeutic indications of cervical mediastinscopy is anticipated with recent advances and new techniques, such as video-assisted mediastinoscopic lymphadenectomy and virtual mediastinscopy.

A best evidence topic was written according to a structured protocol. The question addressed was whether harvesting the saphenous vein (SV) as a conduit for coronary artery bypass grafting (CABG) using a no-touch technique would result in better patency rates. This technique involves the harvest of the SV with a pedicle of peri-vascular tissue left intact and the avoidance of distension of the vein prior to anastomosis. A total of 405 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The studies found analysed the ultrastructural and mechanical properties of the endothelium and vessel walls of the two harvesting techniques; the protein and enzymatic expression and activity observed; the early atherosclerotic changes detected; and the overall patency of the grafts during short- and long-term angiographical follow-up. Three small prospectively randomised studies compared the patency of grafts harvested using the two techniques and found significant improvements in graft patency using the no-touch harvesting technique in comparison to both the conventional technique and more importantly comparable to the left internal thoracic artery (LITA) patency. The most favourable difference was that of graft patency after 8.5 years of follow-up [90% vs. 76% (P = 0.01), LITA patency 90%], and incidence of graft stenosis [11% vs. 25% (P = 0.006)]. These findings were supported by the demonstrated improvements in the cellular integrity of the vessels and the reduction in the mechanisms leading to graft failure seen in the no-touch harvested SV grafts. These morphological and cellular analyses were carried by five small comparative studies, demonstrating improved endothelial integrity and reduced injury, decelerated atherosclerotic processes, intact adventitial collagen layers, increase in the total area of vasa vasorum, elevated endothelial nitric oxide synthase expression and activity, and increased peri-vascular leptin levels and activity. We conclude that there are clear enhancements in vessel wall properties at a cellular level and angiographical evidence of superior graft patency when the no-touch SV harvesting technique is employed.

A best evidence topic was written according to a structured protocol. The question addressed was, in what proportion of patients is the nerve of Kuntz identifiable? A total of 55 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The nerve of Kuntz was originally described in 1927 as being a connection from the second intercostal nerve to the first thoracic ventral ramus. Controversy exists as to whether it is present universally and thus whether it should be identified during thoracoscopic sympathectomy. The six studies highlighted involved dissection of the upper thoracic sympathetic chain of adult cadavers with descriptions of the anatomical variations. A study by Cho et al. [Cho HM, Lee DY, Sung SW. Anatomical variations of rami communicants in the upper thoracic sympathetic trunk. Eur J Cardiothorac Surg 2005;27:320-324] suggested that anatomical variation was more common at T2 compared to T3 and T4, of which 60% corresponded to the original description of the nerve of Kuntz. A similar prevalence was found by Marhold and colleagues [Marhold F, Izay B, Zacherl J, Tschabitscher M, Neumayer C. Thoracoscopic and anatomic landmarks of Kuntz's nerve: implications for sympathetic surgery. Ann Thorac Surg 2008;86:1653-1658], who also suggested that open dissection led to significantly easier identification of this anatomy than thoracoscopy. The same authors frequently found that the nerve of Kuntz was associated with a superior intercostal vein located parallel to it, meaning that these subpleural veins may act as an anatomical landmark. In four of the papers where cadavers where dissected bilaterally, variations in the anatomy of the sympathetic chain were not always symmetrical. We conclude that most patients will have some form of variation in the anatomy of their T2 ganglion, which often corresponds to the original description of the nerve of Kuntz. The appreciation of this variation may be more difficult during thoracoscopy as compared to open anatomic dissection.

A best evidence topic was written according to a structured protocol. The question addressed was 'Is it safe to perform coronary angiography (CA) in acute endocarditis?' Three hundred and ninety-seven papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, key results and limitations of these papers are tabulated. One of the papers is a case report, which reported a fatal vegetation embolism from an infected aortic valve into the left main coronary artery 14 h after angiography. The remaining five papers are cohort studies. Four of these studies were performed between 1970 and 1980 before the era of echocardiography and were aimed at quantifying the severity of valvular regurgitation. No embolic complications or dislodgement of vegetations occurred in any of the five studies (186 patients). Guidelines published by the European Society of Cardiology (ESC) in 2009 recommended CA in the context of infective endocarditis (IE) for men >40 years old, postmenopausal women, and patients with at least one cardiovascular risk factor or a history of coronary artery disease. Exceptions include patients with large aortic vegetations which may be dislodged during catheterisation, and when emergency surgery is necessary - 1) native aortic or mitral IE with severe acute regurgitation or valve obstruction, or prosthetic valve IE with severe prosthetic dysfunction (dehiscence or obstruction) causing refractory pulmonary oedema or cardiogenic shock; 2) native aortic, mitral, or prosthetic valve IE with fistula into a cardiac chamber or pericardium causing refractory pulmonary oedema or shock. This is reiterated by the guidelines on the management of valvular heart disease published by the ESC in 2007. From the findings of the six papers, it can be concluded that coronary angiography can be performed safely in IE and should be performed if deemed necessary, unless the patients are haemodynamically unstable requiring emergency surgery, or have large vegetations of the aortic valve. This is consistent with the ESC guidelines.

A best evidence topic was written according to a structured protocol. The question addressed was whether chlorhexidine gluconate is equivalent or superior to the use of povidone-iodine during surgical hand scrub. A total of 593 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. We conclude that whilst both chlorhexidine and povidone-iodine reduce bacterial count after scrubbing, the effect of chlorhexidine is both more profound and longer lasting. The studies found analysed the difference in reduction in colony forming units or bacterial count following surgical scrub in order to conclude that chlorhexidine was superior. Four studies went further to analyse cumulative and residual activity by testing for bacterial reduction after using a scrub solution for a number of days, an area in which chlorhexidine showed consistent advantages over povidone-iodine. These findings are given more credibility by the clinical finding of a recent meta-analysis of over 5000 patients in which chlorhexidine as an antiseptic skin preparation was associated with significantly reduced surgical site infection (SSI) in clean-contaminated surgery. Despite this, there is no evidence suggesting the use of chlorhexidine during hand scrub reduces SSI, which perhaps explains why guidelines from the World Health Organization, the Centers for Disease Control and Prevention and the Association for Perioperative Practice do not recommend one specific antimicrobial over another for hand scrub.

A best evidence topic was written according to a structured protocol. The question addressed was whether incidentally found patent foramen ovale (PFO) during isolated coronary surgery should be closed. A total of 573 papers were found using the reported searches of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. There is currently no evidence to suggest that incidental PFO in patients undergoing cardiac surgery is linked with increased morbidity, mortality or decreased long-term survival. The most significant study identified examined the outcomes of 2277 patients with incidentally found PFO during cardiac surgery of whom 639 underwent closure. After propensity matched analysis, the authors found closure was associated with a significantly higher risk of postoperative stroke with no advantage in terms of long-term survival. A recent survey of 438 cardiac surgeons from the USA showed no consensus on decision-making behind closure, but that factors taken in to account include PFO size, right atrial pressure and a history of paradoxical embolism. This is not surprising given that morphological research has confirmed that larger PFO size is indeed associated with cryptogenic stroke.

Biomaterial-related infections continue to hamper the success of reconstructive and arthroplasty procedures in orthopaedic surgery. Staphylococci are the most common etiologic agents, with biofilm formation representing a major virulence factor. Biofilms increase bacterial resistance to antimicrobial agents and host immune responses. In staphylococci, production of polysaccharide intercellular adhesin (PIA) by the enzyme products of the icaADBC operon is the best understood mechanism of biofilm development, making the ica genes a potential target for biofilm inhibitors. In this study we report that the antibacterial agent povidone-iodine (PI) also has anti-biofilm activity against Staphylococcus epidermidis and Staphylococcus aureus at sub-inhibitory concentrations (p < 0.001). Inhibition of biofilm by PI correlated with decreased transcription of the icaADBC operon, which in turn correlated with activation of the icaR transcriptional repressor in Staphylococcus epidermidis. These data reveal an additional therapeutic benefit of PI and suggest that studies to evaluate suitability of PI as biomaterial coating agent to reduce device-related infections are merited., ((c) 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Expression of the icaADBC-encoded polysaccharide intercellular adhesion by Staphylococcus epidermidis promotes biofilm formation and represents an important virulence factor in biomaterial-related infections following orthopedic surgery. Biofilm development by the pathogen can be viewed as a protective reaction to environmental stressors including osmotic stress, thermal stress, and antimicrobial chemotherapy. Oxidative stress, arising from the release of toxic oxygen radicals by polymorphonuclear cells, is encountered by bacteria entering the body perioperatively. Evasion of this and other cell-mediated immune responses by pathogenic bacteria plays an important role in the development of chronic biomaterial-related infection. Here we investigated the impact of sublethal oxidative stress induced by H2O2 (<18 mM) on S. epidermidis biofilm formation. S. epidermidis grown in brain heart infusion (BHI) media supplemented with 5 mM H2O2 or 10 mM H2O2 formed significantly less biofilm (p < 0.01 and p < 0.001, respectively) than bacteria grown in BHI alone. Consistent with this, using reverse transcription-polymerase chain reaction expression of the ica locus was also shown to be reduced by subinhibitory concentrations of H2O2. Furthermore, diminished ica operon expression correlated with increased expression of icaR, which encodes a repressor of icaADBC. Thus, these data suggest that mild oxidative stress downregulates biofilm development by S. epidermidis and may have potential in a therapeutic context., (Copyright 2008 Orthopaedic Research Society)

The effects of keyguard use and pelvic positioning (neutral versus posterior tilt) on typing proficiency was studied in an 8-year-old boy with athetoid and spastic cerebral palsy. Speed and accuracy were measured with the Mastertype computer software program (Zweig, 1984). The results showed that the use of a keyguard increased the subject's typing accuracy and decreased his speed. Neither neutral nor posterior pelvic positioning appeared to have a significant effect on typing speed or on accuracy.