Early Postoperative Treatment Research Articles

SUBTALAR ARTHROERESIS IN THE TREATMENT OF PLANOVALGUS FEET DEFORMITY: THE PROS AND CONS (THE REVIEW OF LITERATURE)

The paper presents an analysis of the scientific literature on the treatment of plano-valgus deformity of the foot (PVDF) in adults and children using subtalar arthroeresis. The indications and contraindications for this intervention discussed and possible complications are shown.It is shown that, on the one hand, most authors emphasize quite high efficiency of the said intervention (from 60 to 95.4 % of excellent and good results) in the presence of the other undoubted benefits — less traumatic and minimally invasive, relative cheapness, early verticalization and timely reha­bilitation that meets modern requirements in orthopedics.On the other hand, the method could provoke different complications that do not exclude the repeated interventions and the development of irreversible states in the posterior part of foot.An algorithm choosing the optimal treatment PVDF in children, including the conditions of cerebral palsy, depending on the grade of foot deformity and characteristics of movement disorders, has not worked out yet. There are no generally accepted clinical-radiographic criteria for the choosingof type and size of implant. Determining the indications and contraindications for subtalar arthroeresis requires clarification in children of different age groups.The issue of early postoperative treatment and further rehabilitation patients (both children and adults) were not practically highlighted. Combination of subtalar arthroeresis with other interventions in different parts of the foot and various anatomical structures (soft tissue and bone) depending on the patient's age and degree of foot deformity remains to be a questionable issue. The authors emphasize that today no papers are found in the scientific literaturethat meet the high level of evidence and efficacy of use of sutalar arthroeresis in the conditions of PVDF in children and adults.

Indications and postoperative treatment for Ex-PRESS(®) insertion in Japanese patients with glaucoma: comparison with standard trabeculectomy.

BackgroundWe investigated indications and early postoperative treatment for Ex-PRESS® insertion for glaucoma by comparing postoperative outcomes with those for standard trabeculectomy.MethodsEx-PRESS insertion was performed in 21 eyes and standard trabeculectomy (TLE) in 22 eyes. Mean intraocular pressure (IOP) in the 6 months after surgery, success rate for postoperative IOP decline, postoperative complications, postoperative treatment, filtering blebs, and indications were then retrospectively investigated.ResultsMean postoperative IOP did not differ significantly between the groups at any observation time for 6 months after surgery. Further, it did not differ between either the groups of patients with primary open-angle glaucoma (POAG) and neovascular glaucoma (NTG), or the patients with primary open-angle glaucoma and NTG in the Ex-PRESS group. Comparison of success rates in reduction of postoperative IOP between the groups under the following four survival conditions showed no significant differences: postoperative IOP <30% of the preoperative IOP, complete success (no additional ophthalmic solution), and qualified success (ophthalmic solution required); 5 mmHg ≤ postoperative IOP ≤21 mmHg, complete success (no additional ophthalmic solution), and qualified success (ophthalmic solution required). With regard to postoperative complications and postoperative treatment, the incidence of hyphema was significantly lower in the Ex-PRESS group, but no other significant intergroup differences were seen. The height of the filtering bleb was lower in the Ex-PRESS group.ConclusionPostoperative outcomes in the Ex-PRESS and TLE groups were comparable. The incidence of hyphema was significantly lower in the Ex-PRESS group. Ex-PRESS insertion appears to be useful in patients with NTG and in those prone to postoperative bleeding. There were no significant intergroup differences in postoperative treatment. Assessment of outcome after Ex-PRESS insertion was difficult in some patients. Postoperative treatment should be developed to suit the specific requirements of Ex-PRESS insertion.

CARD8 gene variant is a risk factor for recurrent surgery in patients with Crohn's disease

Background and aimsPost-operative recurrence is frequent in Crohn's disease. Genetic factors associated with post-operative recurrence remain poorly understood. Identification of genetic variants associated with repeat surgery would allow risk stratification of patients who may benefit from early aggressive therapy and/or post-operative prophylactic treatment. MethodsCrohn's disease patients who had at least one bowel resection were retrospectively identified from the “Nancy IBD cohort”. Covariates and potential interactions were assessed using the Cox proportional hazard model. Kaplan–Meier curves for time to surgical recurrence were developed for 200 genetic variants and analyzed with the log-rank test. Results137 patients had at least 1 resection in our cohort: 38 had a surgical recurrence (28%). In multivariate analysis, current smoker status (OR 6.97, 95% CI 1.85–26.22, p=0.004), post-operative complications after prior surgery (OR 2.72, 95% CI 1.02–7.22, p=0.044), and Caspase recruitment domain-containing protein 8 (CARD8) homozygosity for the risk allele (OR 7.56, 95% CI 1.13–50.37, p=0.036) remained significantly and independently associated with surgical recurrence. ConclusionCurrent smoker status was associated with increased risk of surgical recurrence. A novel association between CARD8 and increased risk of surgical recurrence in Crohn's disease was observed. CARD8 could be a new marker for risk stratification and prevention of recurrent surgery.

Die Doppelplattenosteosynthese der proximalen Ulna

Stable osteosynthesis during early postoperative functional treatment, particularly in patients with osteoporosis. Metaphyseal fractures, small proximal fragments or avulsion fracture of the triceps tendon, osteotomy of the olecranon, and pseudarthrosis of the olecranon or proximal ulna. Skin infection, severe soft tissue lesions. Dorsal approach to the olecranon. Open reduction and internal fixation by two side-mounted angular locking compression (double) plates. Early functional treatment. Full load-bearing after 6-12weeks postoperatively. A total of 14patients were treated with double-plate osteosynthesis between 2011 and 2012. Clinical data were analysed retrospectively. The average follow-up was 11.7months (range, 4-21months). The mean flexion-extension radius was 123° (100°-140°), the pro-supination radius 166° (160°-170°). Using the Mayo Elbow Performance Score, eight patients had excellent and six good results. The mean Quick-DASH score was 15 (0-50).

Su1787 Long-Term Survival Comparing Carcinoma of the Gastroesophageal Junction With Gastric Cancer - Results of the German Gastric Cancer Study 2

Introduction: Data obtained in multicenter studies on quality assurance can reflect the current situation in the treatment of gastric cancer. Adenocarcinoma of the gastroesophageal junction (AGJ) appears to be a separate tumor entity. Methods: Perioperative data on the diagnostic and therapeutic management in gastric cancer patients were collected by means of a prospective multicenter observational study QCGC 2 from 01/01/2007 to 12/31/2009. Early postoperative treatment results and long-term oncological outcome in patients with AGJ with those of the stomach were compared. Results: 2,897 patients with gastric cancer out of 141 hospitals of each profile were enrolled in the study; out of them, 2,788 (96.2 %) underwent surgical intervention. With regard to tumor site, 544 cases with AGJ were operated within 108/141 hospitals (76.6 %) only. Patients with AGJ showed a significantly shorter median survival (25 months) depending on the tumor stage compared with subjects suffering from gastric cancer (38 months). Overall 5-year survival rate of AGJ patients ( 33.1 %) was significantly worse compared with that of individuals with gastric cancer (41.4 %) also depending on single tumor stages according to UICC classification (p<0.001): stage II (46.3 % versus 50 %), III (0 % vs. 22 %) and IV (7.4 % vs. 12 %). Conclusion: The treatment results of gastric cancer patients in hospitals of each profile cannot be satisfying despite a multimodal approach. Prognosis of the carcinoma of the gastroesophageal junction is significantly worse compared with other gastric tumor sites. A centralization of surgical management of these patients seems to be reasonable.

The diagnosis of posttransplantation diabetes mellitus: meeting the challenges.

Posttransplantation diabetes mellitus (PTDM) is a major complication after renal transplantation due to its negative impact on patient and graft survival, and affects up to 40% of renal transplant recipients. The generation of evidence regarding its optimal treatment is now progressing with some emphasis on early postoperative insulin treatment that targets β-cell failure. This therapy seems to benefit renal transplant patients but contrasts with previous PTDM guidelines that were following treatment of type 2 diabetes mellitus (DM): oral antidiabetics first, insulin last. Similarly, in the current PTDM consensus recommendations, diagnostic procedures are in accordance with the American Diabetes Association (ADA) recommendations for diagnosis of DM. PTDM and type 2 DM, however, are distinct disease entities with different pathophysiological backgrounds. This review will discuss the significance of the standard diagnostic criteria for DM in patients after renal transplantation without prior DM. In particular, the role of glycated hemoglobin (HbA1c) and oral glucose tolerance testing (OGTT) will be reviewed. In addition, the potential role of other glycated proteins and continuous glucose monitoring will be covered, although these parameters are not yet part of the consensus recommendations.

Early postoperative treatment of thyroidectomy scars using botulinum toxin: a split-scar, double-blind randomized controlled trial.

Operational scars, especially those located on the exposed parts of the body, can be distressing. Despite high demand for an early intervention to minimize surgical scars, there is yet no universal consensus on optimal treatment. A split-scar, double-blind randomized controlled trial was held to assess the safety and efficacy of early postoperative botulinum toxin type A (BTA) injection in surgical scars. A single session of treatment was performed where BTA was allocated to one half of the scar and 0.9% saline to the control half. Scars were assessed using the modified Stony Brook Scar Evaluation Scale (SBSES) with standardized photographs. Fifteen patients completed the study, and their data were analyzed. At 6 months' follow-up, a significant improvement in SBSES score was noted for the BTA-treated halves of the scars (p < 0.001), with minimal change on the saline-treated side (p = 0.785). The mean calculated difference in SBSES scores (final/initial) between the BTA-treated side and the saline-treated side was also significant (p < 0.001). Early postoperative BTA injection was safe and effective in modulating thyroidectomy scars and may be a promising option for scar prevention.

Fibrin sealant as a carrier for sustained delivery of antibiotics

Objective: To evaluate the activity and sustained release of antibiotics from fibrin sealant against common strains of ocular bacteria. Methods: Vancomycin, ceftazidime, moxifloxacin and lomefloxacin were incorporated into fibrin sealant in the shape of discs. Each antibiotic disc and control fibrin disc without drug was tested in vitro against standard bacterial strains of Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae and Pseudomonas aeroginosa. After 24 hours of incubation at 37 °C, the discs were transferred to new plates of bacteria and triplicated for each antibiotic. Results: All antibiotic discs demonstrated detectable activity after 24 hours. Vancomycin had the longest duration of activity (4 days) on the S. pneumonia grown plate. The moxifloxacin discs showed a prolonged inhibition of S. aureus and S. pneumonia for 3 days and inhibited the other strains for 2 days. Conclusion: Fibrin sealants provided prolonged drug delivery, which indicates that antibiotic-loaded fibrin clots could be useful for early ocular postoperative care and treatment.

SMAD3 gene variant is a risk factor for recurrent surgery in patients with Crohn's disease

Background and aimsMore than 80% of Crohn's disease (CD) patients will require surgery. Surgery is not curative and rates of re-operation are high. Identification of genetic variants associated with repeat surgery would allow risk stratification of patients who may benefit from early aggressive therapy and/or post-operative prophylactic treatment. MethodsCD patients who had at least one CD-related bowel resection were identified from the Prospective Registry in IBD Study at Massachusetts General Hospital (PRISM). The primary outcome was surgical recurrence. Covariates and potential interactions were assessed using the Cox proportional hazard model. Kaplan–Meier curves for time to surgical recurrence were developed for each genetic variant and analyzed with the log-rank test. Results194 patients were identified who had at least 1 resection. Of these, 69 had two or more resections. Clinical predictors for repeat surgery were stricturing (HR 4.18, p=0.022) and penetrating behavior (HR 3.97, p=0.024). Smoking cessation was protective for repeat surgery (HR 0.45, p=0.018). SMAD3 homozygosity for the risk allele was also independently associated with increased risk of repeat surgery (HR 4.04, p=0.001). NOD2 was not associated with increased risk of surgical recurrence. ConclusionStricturing and penetrating behavior were associated with increased risk of surgical recurrence, while smoking cessation was associated with a decreased risk. A novel association between SMAD3 and increased risk of repeat operation and shorter time to repeat surgery was observed. This finding is of particular interest as SMAD3 may represent a new therapeutic target specifically for prevention of post-surgical disease recurrence.

Early Postoperative Treatment of Surgical Scars Using a Fractional Carbon Dioxide Laser: A Split-Scar, Evaluator-Blinded Study

Although focus has recently been directed toward the early treatment of surgical scars, the optimal time at which to initiate treatment with fractional laser and its effect on scar remodeling remains controversial. To assess the safety and efficacy of treating surgical scars using an ablative carbon dioxide (CO2 ) fractional laser during the early postoperative period. We performed a prospective, split-scar, evaluator-blinded study on 16 postoperative scars of 15 patients. Patients began treatment 3weeks after surgery and were treated in two sessions of CO2 fractional laser therapy on half of the scar at 2-week intervals. All patients were followed for 3months after the final treatment session. Three months after the last treatment, a greater decrease in Vancouver Scar Scale score was noted in the treated half of the scars, especially in terms of texture and thickness. Patients also expressed a significantly greater degree of satisfaction with the treated side as assessed using a subjective 4-point scale. Only one patient experienced any adverse effect, which was the development of hypertrophy, on the treated and untreated side of the scar. CO2 fractional laser is an effective treatment modality for surgical scars in the early postoperative period.

Therapeutic options for acute and chronic elbow instability.

Acute elbow instability usually develops after injuries involving the bony or ligamentous stabilizers of the joint. It occurs frequently after dislocation and/or fracture-dislocation, but isolated valgus or varus overloading can also lead to ligament ruptures with subsequent instability. Chronic instability can result from incompletely healed acute injuries or from recurring microtrauma, for example after repetitive strain from participating in certain sports. Stable conditions of the joint are essential for early functional post-traumatic or postoperative treatment of the elbow, as permanent mobility deficits may result otherwise. The following article gives an overview of the current understanding of these injuries and concepts in treatment.

Early Postoperative Treatment of Thyroidectomy Scars Using a Fractional Carbon Dioxide Laser

Early Postoperative Treatment of Thyroidectomy Scars Using a Fractional Carbon Dioxide Laser

Effect of Early Statin Therapy on Risk of Atrial Fibrillation After Coronary Artery Bypass Grafting With or Without Concomitant Valve Surgery

Statins decrease postoperative atrial fibrillation (AF) if given before cardiac surgery. However, whether early administration of statins after surgery decreases the risk of postoperative AF is unknown. The association of early reinstitution of postoperative statin therapy within 48 hours to the occurrence of postoperative AF was studied in propensity-adjusted analyses of 200 consecutive patients in sinus rhythm who had undergone coronary artery bypass grafting with or without valve surgery. Postoperative AF occurred in 36 patients (18%). Of 52 patients who received a statin early after surgery, 4 (7.7%) developed AF compared to 32 (28%) of 148 patients who did not (p = 0.043). In the propensity-adjusted analyses, early postoperative statin treatment was associated with a significantly lower occurrence of AF (odds ratio 0.39, 95% confidence interval 0.15 to 0.99), irrespective of concomitant β-blocker therapy. The length of stay was shorter for the patients who received early postoperative statins (median 6.1 days, interquartile range 4 to 7, vs 7.8 days, interquartile range 5 to 8; p = 0.0031). In conclusion, of preoperative statin users undergoing coronary artery bypass grafting with or without valve surgery, early postoperative reinstitution of statins was associated with a lower occurrence of postoperative AF and a shorter length of stay. Early postoperative statin therapy might be a feasible and safe method of reducing postoperative AF.

Early Postoperative Treatment of Thyroidectomy Scars Using a Fractional Carbon Dioxide Laser

Ablative carbon dioxide fractional laser systems (CO(2) FS) have been effectively used to improve the appearance of scarring after surgical procedures, but an optimal treatment time has not been established. To evaluate the efficacy and safety of CO(2) FS in early postoperative thyroidectomy scars. Twenty-three Korean women with thyroidectomy scars were enrolled in this study. All patients underwent a single session of two passes of a CO(2) FS with a pulse energy setting of 50 mJ and a density of 100 spots/cm(2) 2 to 3 weeks after surgery. Mean Vancouver Scar Scale (VSS) scores were statistically significantly lower after laser treatment. Three months after CO(2) FS treatment of thyroidectomy scarring, 12 of 23 participants showed clinical improvement of more than 51% from 2 to 3 weeks after surgery. The mean grade of clinical improvement based on independent clinical assessment was 2.6 ± 0.9. Early postoperative CO(2) FS treatment of thyroidectomy scars is effective and safe.

Intraoperative cytology—Role in bone lesions

In spite of becoming an integral part of surgical pathology, very few reports are available regarding the utility of intraoperative cytology (IOC) exclusively for bone lesions. This study was undertaken in a view to fill this lacuna. Sixty bone lesions were evaluated intraoperatively with the help of cytology smears prepared by touch, scrape, or crush technique. The diagnosis made on cytological preparation was compared with histopathological diagnosis taking the latter as gold standard. Different parameters like reasons for Intraoperative consultation, best technique for preparation of smear, average time taken to render a diagnosis, and finally the accuracy of IOC was evaluated. Common reasons for the intraoperative consultation were to make or confirm a diagnosis for proper surgical intervention and to evaluate the surgical resection margin. Scrape was found to be the best method for cytological smear preparation. Average time taken to render a diagnosis was 20 minutes. Sensitivity, specificity, and overall diagnostic accuracy was 96.7, 96.6, and 96.6%, respectively. Cytology can play a valuable role in the intraoperative diagnosis of bone lesions. The method is simple, cheap, quick, and has no complication. It should be undertaken routinely, as a rapid intraoperative diagnosis will expedite timely and proper management of the patients, along with early post operative treatment and thus avoid the aggravating delays.

The research of enteral and parenteral nutrition support after gastrointestinal surgery

Objective To investigate the efficacy of early enteral nutrition support. Methods Sixty cases with gastrointestinal tumor resection patients in our hospital were divided into early enteral nutrition group(EN) and parenteral nutrition (PN) group. Two groups of nutrition indicators,the recovery of intestinal function,complications rates were compared. Results Postoperative nutrition indicators had no significant difference, but the EN group had the earlier recovery of intestinal function, the low rate of complications, little hospitalization time. Conclusions Early postoperative EN treatment can reduce the complication rate,hospitalization time,which is a simple,safe and economical method. Key words: Enteral nutrition; Parenteral nutrition; Nursing

Trajectories of psychological distress among Chinese women diagnosed with breast cancer

The distinct trajectories of psychological distress over the first year of the diagnosis with breast cancer (BC) and its determinants have not been explored. 285 of 405 Chinese women receiving surgery for BC were assessed at 5-day, 1-month, 4-month, and 8-month post-surgery on measures of psychological distress, optimism, treatment decision-making (TDM) difficulties, satisfaction with treatment outcome, satisfaction with medical consultation, and physical symptom distress. Latent growth mixture modelling identified trajectories of psychological response to BC. Multinominal logistic regression compared TDM difficulties, satisfaction with treatment outcome, satisfaction with medical consultation, optimism, and physical symptom distress, by distress pattern adjusted for age, education, employment status, and stage of disease. Four distinct trajectories of distress were identified, namely, resilience (66%), chronic distress (15%), recovered (12%), and delayed-recovery (7%). TDM difficulties, optimism, satisfaction with consultation, and physical symptom distress predicted distress trajectories. Psychologically resilient women had less physical symptom distress at early post-surgery compared with women with other distress patterns. Compared with the resilient group, women in the recovered or chronic distress groups experienced greater TDM difficulties, whereas women in the delayed-recovery group reported greater dissatisfaction with the initial medical consultation. Women in the chronic distress group reported greater pessimistic outlook. Optimism and better early post-operative treatment outcomes predicted resilience to distress. Pre-operative interventions helping women to establish a realistic expectation of treatment outcome may minimize disappointment with treatment outcome and resultant distress, whereas post-operative rehabilitation should focus on symptom management.

A phase II study to establish a referential arm for treatment of gastric cancer patients with intraperitoneal micrometastases

15002 Background: Gastric cancer patients with free cancer cells in the peritoneal cavity as detected by cytologic examination of the peritoneal washes (CY1) are known to have dismal prognosis. In vivo studies by the authors suggest prognostic impact of early postoperative treatment with S-1 (Nakanishi H, et al. Cancer Sci 2003;94:112–8) . No standard treatment for this population has been proposed to date. Methods: A phase II study was conducted to evaluate the efficacy of S-1, a new oral fluoropyrimidine, given postoperatively to patients with CY1 disease. Eligibility criteria included histologically confirmed adenocarcinoma of the stomach without distant metastasis (peritoneal seeding allowed if completely resected), curatively resected with negative margins, &lt;80 years of age with adequate organ functions and preoperative PS of 0∼2, and written informed consent. The primary endpoint was 2-year survival rate and secondary endpoints were time to treatment failure and safety. By referring to the historical control (2-year survival rate: 13.3%, 90% CI 3.1∼23.5%), the target 2- year survival rate was set at 36 % with estimated 90% CI&gt;23.5%, and the sample size was calculated as 50. Results: Forty eight patients were accrued before the study was closed, and one patients was found to be ineligible (negative for the cytologic examination). Of 47 patients, 32 were men. Median age was 66 years (range: 39∼79 years). Serosal invasion was confirmed in 44 patients (94%) and node metastasis in 42 (89%). Seven patients had macroscopic but resectable peritoneal deposits. D2 dissection was encouraged and performed in 33 patients (70%). To date, median survival time was 21.7 months with 2-year survival rate of 43.5%. One patient died of ischemic heart disease 5 days after the initiation of treatment, and treatment for 7 other patients was discontinued due to toxicity. Time to treatment failure was 9.8 months and progression-free survival was 12.9 months. The most frequent &gt;G3 toxicity was neutropenia (n=6), followed by anorexia/nausea (n=4). Conclusions: Although further period of observation is required, postoperative S-1 is likely to overwhelm the survival data obtained in the pre-S-1 era. Toxicity was manageable and 80% of the patients tolerated the treatment. No significant financial relationships to disclose.

Postoperative radiotherapy after radical prostatectomy for prostate carcinoma: the experience of the Brescia Radium Institute

The purpose of this study was to evaluate the efficacy of postoperative radiotherapy in reducing the incidence of prostate carcinoma (PCa) recurrences after radical prostatectomy (RP), define the importance of the time interval between surgery and radiotherapy for prognosis and the toxicity of the treatment in comparison with radiotherapy or surgery alone. We examined 97 patients who consecutively underwent postoperative radiotherapy after RP between 1980 and 2003. The treatment was considered "adjuvant" if was conducted less than 6 months after RP, if there was no macroscopic residual disease and if there was no progressive increase in serum prostate-specific antigen (PSA) and "salvage" if performed more than 6 months after RP, for the presence of macroscopic recurrence or with rising PSA. Radiotherapy was salvage in 56 patients and adjuvant in 41. Age range was 60-70 years in 80% of patients, and the Karnofsky index was over 80 in 78% of cases. Histology revealed extracapsular spread in 60% of patients. Preradiotherapy PSA was higher than 1 ng/ml in 36%. Radiotherapy was performed on the surgical bed only in 80%, and the total dose was 70 Gy in 62% of cases. Recurrence-free survival (RFS) at 5 years and 10 years was 53+/-8% and 32+/-14.2%, respectively, for the whole sample; 76+/-9% and 38+/-2.7% for patients treated with adjuvant radiotherapy and 36+/-10% and 28+/-10% for those treated with salvage radiotherapy (p<0.01). Moreover, the 5-year RFS was better in the group treated with adjuvant radiotherapy and PSA less than or equal to 1 ng/ml (p<0.05). Treatment toxicity was acceptable. Postoperative radiotherapy improves RFS and reduces the risk of local recurrence. The best results are obtained with early postoperative treatment ("adjuvant"); adjuvant radiotherapy of high-risk forms yields better results if performed with PSA less than or equal to 1 ng/ml.

Posteror cortex violation unrecognized during LCA reconstructive surgery

One of the most important technical demands in ACL surgery is good fixation of the graft. Integrity of the posterior femoral cortex is necessary for Interference screws fixation. The femoral tunnel, placed as posterior as possible, is also mandatory for good graft position and potentially leads to violation of the cortex. The divergence between screw and tunnel could result in perforation of the posterior wall. Without intraoperative x-ray it is difficult to be sure that position of the screw is correct, even with good graft tension. Still, the problem exists with absorbable screws. The aim of the study is to show results of 6 patients with this complication treated without revision of the femoral fixation with mean follow up of 1.5 year. Potential pitfall in ACL reconstruction is posterior cortex breakout and loss of fixation. If it is recognized during surgery changing the type of fixation can solve the problem, but if not, in the early phase of rehabilitation and weight bear, graft failure is feasible. The tibia tunnel angle and length, the footprint of femoral tunnel reamer and hyper flexion of the knee during screw insertion are methods for preventing the breakout of the posterior wall and screw-tunnel divergence. Modification of the early postoperative treatment and less aggressive rehabilitation protocol reduced the need for revision surgery. Even with best surgical technique, skill and experience this complication is possible to occur.