BackgroundObstetric brachial plexus injury (OBPI) is a weakening or paralysis of the upper arm caused by brachial plexus injury followed by a muscle paralysis with severe repercussions on the movement of the shoulder joint following a progressive glenohumeral joint deformity.This case series analyzes the clinical and radiological outcomes of reverse total shoulder arthroplasty (RSA) in OBPI patients with a follow-up of 2 years.Materials and methodsOBPI patients with secondary end-stage glenohumeral arthritis were enrolled in the study and they were treated with RSA. Patient demographics and clinical outcomes [Range of Motion (ROM), Visual Analog Scale (VAS), Oxford Shoulder Score (OSS)] were evaluated. A novel Shoulder motion analysis was carried out to investigate specific movement patterns of scapulothoracic movements in these patients. This study is a prospective cohort study.ResultsFour Patients (M: F = 1:3) were enrolled in the study, the mean age was 49.3 years (+ 2.75), the mean OSS (Oxford Shoulder Score) decreased from 48.8 (± 2.5) preoperatively to 18.30 (± 2.78), the mean VAS (Visual Analog Scale) decreased from 7.25 (± 0.5) to 1.7 (± 0.3) in the follow up (∆% relative pain reduction:− 76.5%), Shoulder ROM obtained an improvement (p < 0.05) except for abduction and external rotation. The average follow-up time was 26.3 months (+− 4.5). Shoulder motion analysis showed a complete loss of the scapular tilting above 90 degrees of flexion compared to the typical one of standard RSA with a pattern shifted towards scapular retraction (engaging trapezius and rhomboid muscles) to compensate the loss of the posterior tilting.ConclusionsRSA in OBPI patients demonstrated a significant improvement of pain symptoms and a moderate improvement in daily activities, anyway with a more appreciable quality of life over time even if the marked hypotrophy especially of the posterior shoulder muscles showed some limits in maintaining suspension of the upper limb and a minor external rotation, with an internal rotation attitude during the movements.Level of evidence: Level IV, Case series.

Due to delayed diagnosis and a lower surgical indication rate, left-sided pancreatic ductal adenocarcinoma (PDAC) is often associated with a poor prognosis in comparison to pancreatic head tumors. Multi-visceral resections (MVR) associated with distal pancreatectomy could be proposed for patients presenting with locally infiltrating disease. We retrospectively analyzed a multi-centric cohort of left-sided PDAC patients operated on from 2009 to 2020. Thirteen European high-volume HPB centers participated in this study. We analyzed patients who underwent distal pancreatectomy (DP) associated with MVR and compared them to standard DP patients. Among 258 patients treated curatively for PDAC of the body and tail, 28 patients successfully underwent MVR. A longer operative time was observed in the MVR group (295 min +/- 74 vs. 250 min +/- 96, p= 0.248). The post-operative complication rate was comparable between the two groups (46.4% in the MVR group vs. 62.2% in the control group, p= 0.108). The incidence of positive margin (R1) was similar between the two groups (28.6% vs. 26.6%; p=0.827). After a median follow-up of 25 (9-111) months, overall survival was comparable between the two groups (p= 0.519). Multi-visceral resection in left-sided pancreatic ductal adenocarcinoma is safe and feasible and should be considered in selected cases as it seems to provide acceptable surgical and oncological outcomes.

Few studies have focused on elderly (>80 years) amyotrophic lateral sclerosis (ALS) patients, who represent a fragile subgroup generally not included in clinical trials and often neglected because they are more difficult to diagnose and manage. We analyzed the clinical and genetic features of very late-onset ALS patients through a prospective, population-based study in the Emilia Romagna Region of Italy. From 2009 to 2019, 222 (13.76%) out of 1613 patients in incident cases were over 80 years old at diagnosis, with a female predominance (F:M = 1.18). Elderly ALS patients represented 12.02% of patients before 2015 and 15.91% from 2015 onwards (p = 0.024). This group presented with bulbar onset in 38.29% of cases and had worse clinical conditions at diagnosis compared to younger patients, with a lower average BMI (23.12 vs. 24.57 Kg/m2), a higher progression rate (1.43 vs. 0.95 points/month), and a shorter length of survival (a median of 20.77 vs. 36 months). For this subgroup, genetic analyses have seldom been carried out (25% vs. 39.11%) and are generally negative. Finally, elderly patients underwent less frequent nutritional- and respiratory-supporting procedures, and multidisciplinary teams were less involved at follow-up, except for specialist palliative care. The genotypic and phenotypic features of elderly ALS patients could help identify the different environmental and genetic risk factors that determine the age at which disease onset occurs. Since multidisciplinary management can improve a patient's prognosis, it should be more extensively applied to this fragile group of patients.

Reverse shoulder arthroplasty (RSA) is a valid and increasingly popular treatment option in eccentric arthrosis and cuff arthropathy. We know that the deltoid is the motor of RSA. However, the role of scapular motion has been poorly documented in the literature. The aim of our study is to analyze and quantify the role of the scapular contribution in the functional outcome of patients undergoing RSA. Fourteen patients who underwent primary RSA were included in the study. In all cases, a reverse prosthesis with lateralizing stem was implanted. All patients underwent clinical examination, video recording, and motion analysis. X-ray and postoperative CT examinations were collected to evaluate positioning and any loosening. ShowMotion (NCS Lab srl, Modena, Italy) 3D kinematic tracking system was used to evaluate and measure the scapular motion in 3 planes. All patients show substantial amount of posterior tilting and lateral rotation starting at 30° in forward elevation. A further difference is the anticipation of the retraction during the range of motion in the RSA side. The contribution of scapular motion in the RSA shoulder was greater than in the healthy shoulder. In patients with bilateral RSA, the contribution of scapular motion was higher in tilting and lateral rotation in the worse shoulder side in terms of range of motion. This means that to compensate for the loss of glenohumeral motion in RSA, more scapula-thoracic motion is needed to obtain the same thoraco-humeral elevation angle. In the light of what has been measured, the post-RSA scapular kinematics has typical characteristics that must be achieved in order to obtain a good functional outcome. We can conclude that on the RSA side, the patients anticipate upward rotation both in flexion and abduction. The contribution of the upward rotation to elevation in the RSA group is therefore more significant. In addition to this, to facilitate elevation movements, there is an anticipation of the scapular retraction and a more prominent tilt resulting in different scapular kinematics. The analysis of scapular motion could be useful in the postoperative follow-up of patients undergoing RSA surgery and improve adaptative physiotherapy protocols. It potentially can even be included in future arthroplasty planning systems.

A male patient aged 11 years presented a large dentigerous cyst in the lower left quadrant associated with retained deciduous lower lateral incisor and canine and impacted, unerupted corresponding permanent ones. The treatment consisted in marsupialisation and placement of a modified lingual arch that held a tube for decompression used for irrigation of the cystic cavity in a comfortable way for the patient and for the clinician.The same lingual arch was later used as an anchorage method for traction of the retained teeth. The final records showed complete resolution of the cyst and retained teeth were successfully Aligned into the oral cavity.

Background: Ductal left-sided pancreatic adenocarcinoma is often associated with poor prognosis due to the delayed diagnosis, with a lower resectability rate compared to pancreatic head tumours. Multivisceral resections (MVR) associated with distal pancreatectomy could be proposed for patients presenting with locally advanced disease. Methods: We retrospectively analyzed a multicentric cohort of patients operated for ductal left-sided locally-advanced pancreatic adenocarcinoma over 11 years (from 2009 to 2020). Thirteen European high-volume HPB Units participated to this study. We analyzed patients who underwent distal pancreatectomy (DP) associated with MVR and compared them to standard DP. Results: Among 258 patients treated curatively for locally advanced pancreatic adenocarcinoma of the body and tail, 28 patients successfully underwent MVR. A longer operative time was observed in MVR group (295 min +/- 74 vs. 250min +/- 96, p= 0,248). Post-operative complication rate was comparable between the two groups (46,4 % in MVR group vs. 62,2% in control group, p= 0,108). The incidence of positive margin (R1) was similar between the two groups (8/28, 28,6% vs. 61/230, 26,6%; p=0,827). After a median of follow-up of 25 (9-111) months, overall survival was comparable between the two groups (14/28, 50% vs. 116/230, 50%; p= 0,519). Conclusions: Multivisceral resection in locally-advanced left-sided pancreatic adenocarcinoma is safe and feasible and should be considered in selected cases as it seems provide acceptable surgical and oncological outcomes.

Studies on epidemiology ALS epidemiology are numerous and an increasing incidence rate with aging is well known across different Western Countries. Despite this, few studies explored epidemiological and clinical features of the oldest ALS patients.

Introduction The aim of this study is to assess the outcomes of Laser Pile Ablation (LPA) in patients affected by II-III degree symptomatic hemorrhoidal disease. Material and Methods Consecutive patients suffering of II-III degree symptomatic HD were enrolled to undergo LPA. The primary study endpoint was to assess the post-operative pain using NRS scale (0-10) and the use of painkiller. Secondary endpoints were: intraoperative, postoperative complications and recurrence rate (including bleeding and prolapse). Patients satisfaction was assessed at 6- and 12-months using VAS scale (0-10) and also through the questions “Would you undergo this surgery again?” and “Would you recommend this procedure to a relative or friend?”. Results Twenty-five patients (7F–18M) were enrolled in the study. All the procedures were performed under spinal anesthesia and the mean amount of energy delivered was 472.6±50.7 J. The mean follow-up was 9 months (range 6-12). Mean postoperative pain, assessed through NRS scale, was 4.7±1.5 at 12 h, 4.4±1.3 at 24 h and 2.2±1.0 at day 10. The pain was managed with paracetamol 1 gr only 30.7 % required NSAIDs in addition for 3 days. Recurrence rate was 7.7% at 3 and 6 months after the procedure referring persistent bleeding. The mean time interval to return to work is 2.7±2.1 days. All the patients were extremely satisfied of the procedure VAS 9. Conclusion LPA resulted to be a safe, effective and minimally invasive procedure to treat II-III degree HD with optimal management of post-operative pain and excellent patient satisfaction.

This study aimed to evaluate the skeletal and dental changes after distalization with a pendulum appliance in growing patients with Class II malocclusion, focusing on the occlusal plane (OP). The sample included 24 patients with Class II malocclusion (10 boys, 14 girls); their mean age was 12.1 years. All patients underwent molar distalization and had 2 serial cephalograms traced at baseline (T1) and after distalization (T2). Angular and linear dental changes were calculated by taking the sella-nasion (SN), palatal plane (PP), and pterygoid vertical as reference. OP inclination was compared with SN, PP, and mandibular plane. The collected data were computed for all the tested variables, and one-way paired t-test was used to assess the significance of the differences between the time points. α was set at 0.05. Multiple linear regressions were used to predict the OP changes. The mean total treatment time was 8±2 months to obtain a super Class I molar relationship. In T1-T2 interval, statistically significant incisor buccal tipping of 5°±3.6° (p<0.05), first molar distal tipping of 8.9°±8.3° (p<0.001), and second molar tipping of 8.2°±8.1° (p<0.001) were observed. The maxillary first and second molars moved significantly backward by 2.8±3.2 mm (p<0.05) and 3.7±2.7 mm (p<0.001), respectively. Only the premolars showed a statistically significant anchorage loss of 2.7±3.3 mm (p<0.05); overjet increased significantly at 1.3±1.2 mm (p<0.05). Regarding the OP, none of the tested variables showed any statistically significant changes between T1-T2. The pendulum appliance showed efficacy in distalizing the maxillary first and second molars at the expense of anterior anchorage loss. The OP did not show statistically significant changes after molar distalization.

Background: Literature shows that Closed Incision Negative Pressure Therapy (ciNPT) is used for various surgical procedures and that may be beneficial for reducing surgical site complications in high risk patients.