Conservative Surgical Techniques Research Articles

New Targeted Therapies and Immunotherapies for Locally Advanced Periocular Malignant Tumours: Towards a New 'Eye-Sparing' Paradigm?

Simple SummaryManaging locally advanced periocular malignant tumours, especially those invading the orbit, is challenging. Orbital exenteration has long been considered the gold standard. The development of conservative surgical techniques in the early 2000s, followed by the emergence of new targeted therapies and immunotherapies over the past decade, has led to a paradigm shift towards the use of ‘eye-sparing’ strategies.The management of periocular skin malignant tumours is challenging. Surgery remains the mainstay of treatment for localised eyelid cancers. For more locally advanced cancers, especially those invading the orbit, orbital exenteration has long been considered the gold standard; however, it is a highly disfiguring and traumatic surgery. The last two decades have been marked by the emergence of a new paradigm shift towards the use of ‘eye-sparing’ strategies. In the early 2000s, the first step consisted of performing wide conservative eyelid and orbital excisions. Multiple flaps and grafts were needed, as well as adjuvant radiotherapy in selected cases. Although being incredibly attractive, several limitations such as the inability to treat the more posteriorly located orbital lesions, as well as unbearable diplopia, eye pain and even secondary eye loss were identified. Therefore, surgeons should distinguish ‘eye-sparing’ from ‘sight-sparing’ strategies. The second step emerged over the last decade and was based on the development of targeted therapies and immunotherapies. Their advantages include their potential ability to treat almost all tumours, regardless of their locations, without performing complex surgeries. However, several limitations have been reported, including their side effects, the appearance of primary or secondary resistances, their price and the lack of consensus on treatment regimen and exact duration. The aim of this article was to review the evolution of the management of locally advanced periocular malignant tumours over the last three decades and highlight the new paradigm shift towards the use of ‘eye-sparing’ strategies.

421 Hysteroscopic evaluation of the uterine cavity after conservative surgical management of placenta previa

To assess the consequences of different conservative surgical techniques used for management of intraoperative hemorrhage due to placenta previa through hysteroscopic evaluation of the uterine cavity. A cross sectional study encompassing all women managed by conservative surgical techniques during cesarean section after intraoperative hemorrhage due to placenta previa. The The study conducted in tertiary university between January 2017 and December 2018. All women were counseled for inclusion in the study before delivery during the preoperative counseling about the consequences of placenta previa. Patients who were managed by conservative surgical techniques were followed up till hospital discharge then they were contacted by phone calls for scheduled follow-up after 3 months. Office hysteroscopy for uterine cavity evaluation was done by expert gynecologist in the proliferative phase of the menstrual cycle if menses were resumed. Forty-seven women were included in the study; 14 (29.8%) were managed by compression uterine sutures, 7 (14.9%) were managed by bilateral uterine ligation only and 26 (55.3%) were managed by both of them. Regarding menses resumption, 22 (46.8%) still had amenorrhea, 13 (27.7%) had regular menses, and 12 (25.5%) had irregular menses. Hysteroscopic evaluation of the uterine cavity revealed normal cervical canal and uterine cavity with no adhesions in all cases Conservative surgical techniques for management of placenta previa had no late consequences on the uterine cavity and subsequent fertility.

No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review.

To conduct a scoping review to clarify the management of acromioclavicular joint osteoarthritis, as well as to identify any existing gaps in the current knowledge. Studies were identified by electronic databases (Ovid, Pubmed) from their inception up to April 2nd, 2020. All studies reporting functional outcomes after conservative or surgical treatment of acromioclavicular joint osteoarthritis, either primary or secondary to trauma or distal clavicle osteolysis, were included. Following data were extracted: authors, year of publication, study design (prospective or retrospective), LOE, number of shoulders treated conservatively or surgically, patients' age, OA classification, type of conservative treatment, surgical approach, surgical technique, functional outcomes, complications, revisions, and length of follow-up. Descriptive statistics was used. Quality appraisal was assessed through the Cochrane risk of bias tool for LOE I/II studies, while the MINORS checklist was used for LOE III/IV studies. Nineteen studies were included for a total of 861 shoulders. Mean age of participants was 48.5 ± 7.4years. Mean follow-up was 43.8 ± 29.9months. Four studies reported functional results after conservative treatment, whereas 15 studies were focused on surgical management. No studies directly compared conservative and surgical treatment. Seven studies reported a surgical approach after failure of previous conservative treatment. All studies reported functional improvement and pain relief. Complication rate was low. Overall methodological quality of included studies was very low. Conservative and surgical treatments are both effective in acromioclavicular joint osteoarthritis management. However, available data did not allow to establish the superiority of one technique over another. Level IV.

Ex-Vivo Resection with Small-Bowel Auto-Transplantation for Tumors at the Root of the Mesentery

Tumors involving the root of the mesentery can be extremely challenging and even defined non-resectable when considering conservative surgical techniques alone. Surgical resection of these tumors can result in resection of large portions of the intestine. As a consequence, patients may develop short bowel syndrome and remain dependent on either total parenteral nutrition or need for intestinal transplantation for survival.

Surgical Features after Neoadjuvant Treatment for Breast Cancer.

To establish the main implications of therapeutic management of the cases of breast cancer treated initially with chemotherapy followed by surgery. 35 breast cancer patients operated in 2020 after NACT (neoadjuvant chemotherapy) in Surgery Clinic of Coltea Hospital are analyzed, and the response after treatment is pathologicaly evaluated using the Residual Cancer Burden method Results: The results of the analysis of the group of patients showed that most patients presented downstaging of the disease after neoadjuvant treatment with a proportion of 17,14% with complete pathologic response. We performed clinical and imagistic evaluation of patients before and after NACT and pathologic evaluation of the surgical specimen using residual tumor burden method, taking into account the age of the patients, clinical and pathological staging and the status of hormone receptors and Her 2. Conclusions: Neoadjuvant chemotherapy is currently part of the therapeutic arsenal of breast cancer being followed in most cases by downstaging of tumors and increasing the number of cases that can be operated. 17.1% of cases achieved pathologic complete response, 2 of them being Her 2 positive carcinomas. The use of conservative and oncoplastic surgical techniques is possible after downstaging tumors by NACT.

CONSERVATIVE VERSUS K-WIRE PINNING OF ACUTE MALLET FINGER IN ADULTS

Mallet finger lesions are common. The diagnosis of mallet finger is essentially clinical, the patient's recent history includes the mechanism of injury. A radiographic lateral and anteroposterior views of the DIPJ usually see bony avulsion of distal phalanx or it may be a ligamentous injury with normal bony anatomy, Wehbe and Schneider described a method to measure the size and displacement of the bony fragment. The aim of this study is to compare the results between of conservative and K-wire pinning management of acute mallet finger Doyle type I in adult patients. Patients were divided into two groups. Group (A) were treated with aluminum orthosis that immobilized the DIPJ in full extension for six weeks. And Group (B) were treated with percutaneous fixation of the distal interphalangeal joint using a smooth Kirschner wire. No external splint age was used and the wire was removed after six weeks. A total of 40 patients suffering from acute mallet finger type I Doyle's classification admitted in orthopedics and traumatology department of Sohag university hospital from February 2019 to November 2019. All patients had Follow up radiographs taken of the affected finger at one week, four weeks, and eight weeks. Functional outcomes were determined using Crawford’s evaluation criteria. The final extensor lag was significantly better in the pin group (12.3 vs 6.6°). The amount of improvement between the groups was statistically significant and in favor of percutaneous pinning (16.15 vs 20.55°), also the flexion loss was lesser in pin group (5.4 vs 4.1°). The optimal treatment for mallet finger injuries remains controversial in the literature. Many orthotic devices for conservative management and surgical techniques have been described in the past. This study shows that closed reduction by use of K-wires provide functionally better result in acute mallet finger cases. Surgical treatment by a single k-wire is better than conservative treatment as regard clinical and radiological results. Conservative technique may have less complications, but the difference in final clinical results is in favor of surgical treatment

Sleeve Resection for Rectosigmoid Endometriosis

Study Objective The purpose of this video is to demonstrate the technical bases of a new conservative surgical technique, called Sleeve Resection (SR), for the treatment of endometriosis infiltrating the rectosigmoid wall. Design The SR technique was used as an alternative to the shaving and discoid resection techniques. Setting Lesions infiltrating the muscular layer of the wall of the low, medium, high rectum or sigmoid, separated or contiguous, were excised using a endoscopic linear stapler inserted through intentional colpotomy or using the existing vaginal opening during hysterectomy or endometriosis resection infiltrating the posterior vaginal fornix. Patients or Participants From June 2013 to May 2020, 82 patients, diagnosed preoperative or during surgery, underwent resection of all lesions. Interventions Lesions located in the retosigmoid were identified. Vicryl-00 stitches, transfixed in a long way in the longitudinal direction of the intestinal loop and drawn ventrally, provided an adequate individualization of the lesion margins. The endoscopic linear stapler was inserted parallel to the axis of the rectosigmoid through vaginal route for the excision of one or more lesions. Intestinal permeability was ensured through the placement of a 2.0 cm transanal probe. Additional stapling, sequential or interspersed, were used for total excision of one or multiple lesions. Measurements and Main Results All lesions were fully resected. At postoperative, there was no evidence of leakage or stenosis and neither immediate nor late intestinal obstruction up to a maximum followup of 7 years. Conclusion The laparoscopic sleeve resection technique, using the vaginal route as an access for the endoscopic linear stapler, proved to be safe and feasible for the short and medium followup and can be an alternative to traditional shaving and discoid resection techniques. A significant number of segmental resections were avoided. Future studies are needed to assure the effectiveness of this technique.

Abstract B39: Role of supracricoid partial laryngectomy in the aging era

Abstract Introduction: Supracricoid laryngectomy (SCL) is a conservative surgical technique for the treatment of selected laryngeal carcinomas, currently adopted also in old patients. But in the aging era, elderly patients represent the fastest-growing section of the population. The aim of this study is to compare the oncologic and functional results in elderly and younger patients following SCL. Materials and Methods: We retrospectively reviewed the medical records of 114 patients who underwent SCL between 1994 and 2013. All of the patients underwent surgery at least 5 years before the study was undertaken. We took the cut-off age of elderly patients as 70 years old, and there were 15 elderly patients. We chose another 15 patients with age younger than 60 years who are matched in stage, primary site, and reconstruction methods. Patients older than 70 years were classified to group I, and patients younger than 60 years were classified to group II. In group 1, the mean age was 53.2 years of age (range 46-60), and in group 2 it was 73.3 years of age (range 71-77). Functional evaluation was performed by evaluating the time of decannulation and nasogastric tube removal, final diet, and duration of hospital stay. Patients’ voice quality was assessed perceptually using GRABS scale. Postoperative complications, especially pulmonary complication such as aspiration pneumonia, were also evaluated. Oncologic results were also evaluated in both groups. Results: The total GRABS score of group I was 8.7 and that of group II was 7.3, and there was no significant statistical difference in these two values. The average time of decannulation was slightly longer in group I; however, these values were not significantly different. The average time of nasogastric tube removal and hospitalization time was significantly longer in group I patients. This was due to the longer duration of swallowing exercise. However, all patients could finally intake orally without gastrostomy. The rate of aspiration pneumonia was slightly higher in group I but failed to show statistical difference. All patients underwent surgery as a primary treatment mordality. In group I, one patient underwent adjuvant radiation, and two patients in group II underwent adjuvant radiation. The 5-year overall survival was 66.6%, 5-year disease-specific survival was 72.1%, and the survival rates of the two groups were not significantly different. Conclusion: Age by itself does not have a significant impact on functional and oncologic results following SCPL. Though elderly patients need more time to take oral diet, that is, need longer time of swallowing exercise, they can finally intake oral diet after swallowing training. Meticulous selection of the candidate to SCPL allows the application of this surgical technique with adequate oncologic and functional results. Citation Format: Inn-chul Nam, Choung-soo Kim, Keun-jeon Kim, MIn-sik Kim. Role of supracricoid partial laryngectomy in the aging era [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr B39.

Reducing the morbidity of parotidectomy for benign pathology.

Conservative surgical approaches, reconstructive techniques and technology are increasingly used in parotid surgery. The aim of this study was to determine the surgeon-modifiable factors which impact the rates of post-operative complications following parotidectomy for benign pathology. A retrospective cohort study of patients undergoing parotidectomy for benign pathology by or under the supervision of the senior author between 2006 and 2019 was performed. Clinicopathological variables, operative techniques and post-operative complications were recorded using standardized templates. Multivariable logistic regression models were used to obtain odds ratios (ORs) whilst adjusting for the effect of other clinically relevant covariates. In total, 357 parotidectomies were performed. Independent factors associated with post-operative facial paresis were re-operative surgery (OR 3.51, 95% CI 1.19-10.33, P = 0.023), nerve integrity monitoring (OR 0.50, 95% CI 0.26-0.99, P = 0.046) and operation type, with focused tumour dissection (FTD) having the lowest rate of paresis (OR 0.19, 95% CI 0.040-0.92, P = 0.038) compared to limited parotidectomy. Factors associated with reduced wound complications on adjusted analysis were dermofat grafting (OR 0.10, 95% CI 0.01-0.72, P = 0.023), lesion size (OR 0.68, 95% CI 0.50-0.92, P = 0.01) and FTD (OR 0.16, 95% CI 0.05-0.59, P = 0.005) compared to limited parotidectomy. FTD, nerve integrity monitoring and dermofat grafting are surgeon-modifiable variables associated with lower rates of post-operative complications following parotidectomy for benign pathology. However, the benefit of these operative techniques relies on their appropriate utilization by performing surgeons.

Neurolysis versus anterior transposition of the ulnar nerve in cubital tunnel syndrome: a 12years single secondary specialist centre experience.

Various conservative treatments and surgical techniques have been reported in the literature as efficient and feasible measures to treat the cubital tunnel syndrome. However, there has been no consensus on the best management of the syndrome, and uniform standardised guidelines have not yet been accepted or introduced. With our study, we present our experience on the clinical efficacies and outcomes of the surgical techniques of neurolysis alone and neurolysis associated with ulnar nerve anterior transposition at the elbow joint in patients with neuropathic symptoms due to cubital tunnel syndrome. A total of 107 patients with cubital tunnel syndrome were retrospectively enrolled, surgically treated and followed up in our study. The cohort was divided into two groups: 41 patients treated only with neurolysis of the ulnar nerve (Group 1), and 66 patients treated with neurolysis and anterior transposition (Group 2). Of the participants, 35 were women and 72 were men. The average age was 54years. Significant comorbidities were preoperatively diagnosed in 26 patients. Conservative measures had been considered, followed by surgical management if appropriate. A pre-op electromyography was performed for all patients. All surgical procedures were performed by the same surgical team. A post-operative follow-up was carried out, and the findings were recorded. The "McGowan" and "Wilson and Krout" classifications and the DASH score were used. A satisfaction questionnaire was administered to all patients post-operatively at 2weeks). Ulnar nerve neurolysis and anterior transposition surgery were all successfully performed. Overall complications were post-operative haematoma (8%) and wound problems (5%). In 6% there was recurrence of symptoms. In 11% there was no improvement of symptoms. Pre-op McGowan classifications for groups 1 and 2 were 0% and 0% (grade 0), 21% and 24% (grade 1), 46% and 44% (grade 2), and 33% and 34% (grade 3), respectively. The post-op McGowan classifications were 34% and 37% (grade 0), 39% and 40% (grade 1), 23% and 20% (grade 2), and 4% and 3% (grade 3), respectively. The post-op Wilson and Krout classifications were 45% and 46% (excellent), 26% and 28% (good), 19% and 15% (fair), and 10% and 11% (poor), respectively. The DASH score means for groups 1 and 2 were 14.8 and 15.2, respectively. A negative Froment's sign was present in 73.2% and 71.2%, respectively. In Group 1, the post-op satisfaction questionnaire scores were 0 for one patient, 1 for four patients, 2 for seven patients, 3 for ten patients, 4 for twelve patients and 5 for seven patients. In Group 2, the post-op satisfaction questionnaire scores were 0 for three patients, 1 for nine patients, 2 for twelve patients, 3 for fifteen patients, 4 for eighteen patients and 5 for nine patients. In our experience, the surgical technique to treat the cubital tunnel syndrome most efficiently and feasibly has not yet been established in terms of indications and outcomes. This is supported by the data present in the international literature. Good and similar results were obtained with neurolysis alone and neurolysis associated with anterior transposition of the ulnar nerve (in line with the international data). In conclusion, more high-quality studies of greater statistical power are needed to provide a consensus on the surgical indications and techniques to treat the cubital tunnel syndrome and to establish internationally standardised guidelines.

Avaliação funcional do membro superior em pacientes submetidos ao esvaziamento cervical

Objetivo: Avaliar a funcionalidade do membro superior dos pacientes submetidos ao esvaziamento cervical. Método: Trata-se de um estudo prospectivo, de antes e depois que consistia de duas avaliações, a primeira foi realizada 24 horas antes da cirurgia e a segunda avaliação foi realizada no intervalo de 20 a 60 dias. Os instrumentos de avaliação utilizados foram: Goniometria, Dinamometria manual, Disabilities of the Arm, Shoulder and Hand (DASH) e Escala Visual Analógica (EVA). Resultados: O estudo verificou que 68% dos pacientes relataram dor, com o escore de média da EVA de 3,18 ±2,74 na avaliação pós-cirúrgico. A média da pontuação do DASH antes e após a cirurgia foi de 0,1075 e 15,28 respectivamente, demostrando uma redução na funcionalidade no membro superior. relação a amplitude de movimento do membro superior houve diferença comparando antes e após a cirurgia, na flexão, extensão e abdução. Conclusão: Concluindo que os pacientes que foram submetidos ao esvaziamento cervical mesmo com a utilização de técnicas cirúrgicas mais conservadoras, apresentam alterações na amplitude de movimento interferindo diretamente na perda da funcionalidade do membro acometido.

Outcome of modified interlaminar decompression: A conservative decompressive surgery for lumbar spine stenosis.

Objective:To evaluate the outcomes of modified interlaminar decompression in patients with degenerative lumbar spinal stenosis (LSS).Methods:This descriptive observational study was conducted at the Department of Neurosurgery, Lady Reading Hospital Peshawar from July 2014 to June 2018. All patients with degenerative LSS who underwent modified interlaminar decompression during the study period were included in the study. The patients were followed up to one year after surgery. The data was entered into a structured questionnaire designed according to the study which was then analyzed using SPSS version 21.Results:A total of 182 LSS cases were included in the study and 236 levels were operated during the study period. According to the records increased prevalence of LSS was found among males i.e. 58.8%. The common level with degenerative stenosis involved was L4-5. Good to excellent outcomes were observed in 93.9% patients in the 1st follow-up visit. The most common complication of surgery was dural tear followed by wound infection.Conclusion:Modified interlaminar decompression is a conservative surgical technique, proved to be a potential approach with acceptable complications, satisfactory outcomes and it is easy to learn.

Management of Frontal Sinus Fractures.

Fractures of the frontal sinus occur from extreme forces and are often associated with other injuries. Management of frontal sinus fractures is variable and dependent on involvement of the anterior table, posterior table, and frontal outflow tract. Severe complications can developed from poorly managed fractures, such as meningitis, mucocele, mucopyocele, and brain abscess. Surgeons should be aware of appropriate management and surgical techniques for addressing frontal sinus fractures. Herein, we review the presentation and management of frontal sinus fractures, including conservative, endoscopic, and open surgical techniques.

Retrospective analysis of a TMJ ankylosis protocol with a 9 year follow up

ObjectiveTemporomandibular joint ankylosis (TMJa) is a debilitating condition that causes difficulty in mastication, speech and mouth opening. Its treatment poses surgical and rehabilitative challenges along with a high incidence of reankylosis. This study was designed to assess the long-term outcomes with a new two phase physiotherapy protocol following conservative resection of the ankylotic mass. Materials and methods143 patients who were treated for TMJa were initially recruited, among whom 98 were inducted into the study and retrospectively evaluated using clinical records and 3-dimensional computed tomography. All the patients underwent a minimal pre auricular incision and conservative interpositional gap arthroplasty with collagen membrane. This was followed by the new two phase physiotherapy protocol with the use of a bite block. The primary outcome measures were the maximum interincisal distance, vertical ramus height and complications. The patients were followed up at monthly intervals during the first year, quarterly intervals during the second year, and at intervals of 6 months during subsequent follow-up years. The mean follow up period was 6.38 ± 2.36 years after ankylotic release. Paired student t test was used for statistical analysis. ResultsThe mean scores for mouth opening at T1, T2 and T3 were statistically significantly different at all intervals (p < 0.0005). The mean scores for ramal length were statistically significantly different at T1 and T2 interval (p < 0.0005) and insignificant at T2 and T3 interval. No reankylosis was observed in patients who followed the physiotherapy protocol. ConclusionsIn the management of TMJa, the success of the conservative surgical technique with interpositional arthroplasty is less dependent on the longevity and rigidity of the interpositional material but more indebted to the patient compliance in following the proposed physiotherapy protocol.

Conservative Surgical Novel Technique of Placenta Accreta in Menoufia University Hospital

Conservative Surgical Novel Technique of Placenta Accreta in Menoufia University Hospital

Decompression or Marsupialization; Which Conservative Treatment is Associated with Low Recurrence Rate in Keratocystic Odontogenic Tumors? A Systematic Review.

Various treatment modalities have been reported for keratocystic odontogenic tumors (KOT), with different recurrence rates. Marsupialization and decompression are two different conservative surgical techniques for the treatment of KOTs. This study aimed at comparing the recurrence rate between marsupialization and decompression in the treatment of KOTs with or without adjunctive treatments. This is a systematic review study. The research sources utilized were PubMed (MEDLINE), Google scholar, Ovid MEDLINE and Cochrane Library. The keywords which were selected based on Medical Subject Heading (MeSH) terms and PICOS criteria were odontogenic keratocyst, keratocyst odontogenic tumor AND marsupialization OR decompression OR cystectomy OR enucleation OR curettage. Statistical analyses were performed to compare the recurrence rate between marsupialization and decompression with or without adjunctive treatments, regarding various follow-up times. The number of subjects that underwent marsupialization was 182. There was a significant difference for the recurrence rate between the marsupialization and decompression groups without considering adjunctive treatments (p= 0.001). However, considering adjunctive treatments, there was no difference between marsupialization and the decompression groups (p= 0.18). It appears that decompression without any adjuvant treatment may have a lower recurrence rate than marsupialization. The recurrence rate was not different when enucleation or cystectomy was performed after decompression and marsupialization.

Manejo del endometrioma ovárico

afecta aproximadamente a 55% de las pacientes con endometriosis. Es el marcador de severidad de la enfermedad e, independiente de su tamaño, está asociado con lesiones profundas, siendo habitualmente el compromiso multifocal. Comúnmente diagnosticado en mujeres en edad reproductiva, también puede desarrollarse en niñas adolescentes y aún antes de la menarquia. El tratamiento del endometrioma ovárico puede ser médico o quirúrgico. El tratamiento médico está orientado básicamente a aliviar el dolor, pero sobre todo al tratamiento coadyuvante posquirúrgico, con la finalidad de disminuir la recurrencia. El tratamiento quirúrgico tiene rol fundamental, a pesar de sus efectos sobre la reserva ovárica; los beneficios en términos de alivio del dolor y tasas de embarazo espontáneo favorecen este enfoque. Cuatro técnicas quirúrgicas conservadoras son utilizadas en la actualidad, con sus ventajas y desventajas y todas perfectamente realizables por vía laparoscópica: escisión de la pseudocápsula (quistectomía), ablación, la técnica en dos etapas y la técnica combinada. Más importante que la cirugía en sí misma, es la calidad de la cirugía y el uso juicioso de la energía con la que se trabaja. La mejor visión del manejo es la individualización de cada caso, teniendo en consideración las necesidades de la paciente y los factores asociados.

CURRENT PRACTICE TRENDS IN THE SURGICAL MANAGEMENT OF PATELLOFEMORAL INSTABILITY; A SURVEY OF THE PEDIATRIC RESEARCH IN SPORTS MEDICINE (PRiSM) SOCIETY

Background: Patellofemoral instability in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. Surgical options and treatments are heterogeneous among orthopaedic surgeons. The purpose of this study is to survey members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding their practice and treatment for patellofemoral instability and to identify trends in management of patellofemoral instability in children and adolescents nationwide. Methods: A 27-question multiple choice online survey was distributed to the members of the PRiSM Society. The survey was sent via email 3 times over a six week time span after which time the survey was closed. Members were asked about clinical and imaging evaluation, methods of conservative treatment, surgical indications, and surgical techniques when treating patellofemoral instability. Results: 65/70 (93%) of respondents reported performing surgery for patella instability more than 5 times in the past year. Of these 65, 56 respondents completed the questionnaire in its entirety. While some trends regarding treatment emerged, the respondent data demonstrated the large discrepancies in practice patterns that exist nationwide. 48% (27/56) of respondents obtained an MRI for patients with a 1+ knee effusion or greater on exam within one week after a first-time traumatic patellar dislocation while 20% (11/56) obtain an MRI in all patients presenting with a patella dislocation. To assess skeletal maturity, 75% (42/56) of respondents obtained knee x-rays to evaluate the physes around the knee, whereas 53% (30/56) obtained a hand x-ray to assess bone age. 41% (23/56) of respondents reported that surgical intervention for fragment refixation or loose body removal is indicated anytime there is evidence of a loose body or osteochondral fragment regardless of fragment size. 11% (6/56) reported only performing osteochondral fracture repair when the fragment was large enough to repair. If surgery is performed for an osteochondral loose body, 38% (21/56) of respondents performed an MPFL reconstruction. 59% (33/56) reported performing the MPFL reconstruction in children and adolescent athletes with hamstring allograft, while 30% (17/56) prefer autograft (hamstring, quadriceps). MRI was strongly preferred over CT when considering a tibial tubercle anteromedialization. TT-TG distance is the diagnostic measurement of choice with no respondents selecting TT-PCL as their preferred diagnostic measurement. The indication for surgical correction of angular deformity in the setting of patellar instability had mixed responses. 18% (10/56) would indicate surgery when the mechanical axis is lateral to the center of the lateral femoral condyle, while others considered this angular correction only when the patient is skeletally immature or when the mechanical axis is lateral to the lateral tibial spine. For surgical recommendations in a patient with significant trochlear dysplasia, 46% (26/56) reported no surgical management of trochlear dysplasia in first-time surgery while 41% (23/56) reported no surgical management of trochlear dysplasia in first-time or revision surgery. Conclusion: There was significant heterogeneity among respondents that highlights a lack of consensus regarding optimal diagnostic and treatment algorithms. Understanding management trends nationwide may help practicing surgeons gain insights and develop evidence based treatment algorithms to best serve patients with this condition.

Clinical Analysis on the Effectiveness of Conservative Compression Suture Technique to Conserve Fertility on Pernicious Placenta Previa

Objective: To evaluate the effectiveness of conservative compression surgical suture techniques used for the management of pernicious placenta previa to conserve fertility in the subsequent pregnancies. Study Design: This was a non-comparative retrospective study of 188 patients diagnosed with pernicious placenta previa who underwent cesarean section in The First Hospital of Jilin University, China, from 1 January 2013 to 1 January 2018. Successful group was defined as those in which the intraoperative bleeding was managed by either modified CHO or by B-lynch suture technique and those who had further intervention including hysterectomy were designated as failure group. Results: Out of 217 patients, 188 met inclusion criteria and 29 patients were excluded. In 188 cases, 183 (97.34%) cases successes and 5 (2.65%) cases had hysterectomy. Among included group, 118 patients (62.76%) had undergone emergency cesarean section and 70 patients (37.23%) underwent elective cesarean section. The emergency group had significantly lesser gestation period of gestation at the time of cesarean section (P = 0.021) and lower neonatal weight (P = 0.001) than that of elective group. The estimated blood loss during surgery was 500 - 3200 ml (mean: 925 ml). Additionally, the amount of bleeding was found to be significantly more in patient with intraoperative complication (P = 0.007) and in patient with implanted placenta (P 0.001). Conclusion: The conservative compression suture technique including modified CHO and B-lynch suture technique during the cesarean delivery is a feasible, safe and effective alternative conservative surgical technique for the management of bleeding in case of pernicious placenta previa. Besides good surgical outcome and proper neonatal result this technique also reduces the rate of hysterectomy, thus conserving the fertility.

Functional outcomes in supracricoid laryngectomy

Supracricoid laryngectomies (SCLs) are conservative surgical techniques for the treatment of selected laryngeal carcinomas and are considered an organ-sparing alternative to total laryngectomy and chemo-radiotherapy. The main characteristics of SCLs are the preservation of the main laryngeal functions as respiration, phonation and swallowing, without a permanent tracheostomy. Supracricoid laryngectomies have been questioned for many years as regarding functional and oncological outcomes and are currently accepted, although patient selection criteria and functional results are still debated. The mainstream of this surgery is the maintenance of one functioning cricoarytenoid unit to allow restoring of swallowing and phonation. Thus, post-operative rehabilitation protocol is required to archive functional outcomes and avoid functional failure of this surgery; an early rehabilitation protocol improves functional results, in particular regarding swallowing. Swallowing and voice functional outcomes differ among several centres and are often related to the post-operative management, although SCLs provide commonly good swallowing and respiratory outcomes. To date, SCLs are proven surgical procedures for the treatment of laryngeal cancer and should be a valuable option to total laryngectomy and chemo-radiotherapy for selected advanced laryngeal squamous cell carcinoma. In this clinical review, we discuss the clinical outcomes in patients treated with SCLs with particular attention to rehabilitation protocol and functional outcomes for swallowing and voice rehabilitation.