Excellent Long-term Clinical Outcomes Research Articles

Highly Cross-Linked Polyethylene in Patients 50 Years of Age and Younger: A 20-year Follow-Up Analysis

BackgroundHighly cross-linked polyethylene (HXLPE) has been an excellent bearing for total hip arthroplasty (THA) due to improved wear characteristics compared to conventional materials. Patients 50 years of age or younger are at high risk for wear-related complications of their THA, and few studies have followed these patients who have HXPLE into the third decade. MethodsIn a retrospective review of 88 consecutive THAs performed in 77 patients aged 50 years and younger (mean 41; range, 20 to 50), in which HXLPE was utilized, they were evaluated for their clinical and radiographic results at an average of 20-year follow-up (range, 18 to 24). The current study reports on longer-term follow-up from our previously published series at shorter follow-up times. Patients were categorized by femoral head material: cobalt chrome (n = 14), ceramic (n = 30), and oxidized zirconium (n = 22) and by femoral head size: 26 mm (n = 12), 28 mm (n = 46), and 32 mm (n = 8). Harris Hip Scores were collected preoperatively and at the most recent follow-up. Radiographs were evaluated for linear and volumetric wear, radiolucent lines, and osteolysis. ResultsMean Harris Hip Scores improved from 47.1 (standard deviation [SD] 8.8) preoperatively to 92.0 (SD 7.7) (P < .0001) at 20-year follow-up. There was one hip that was revised for recurrent instability, and no hip demonstrated radiographic evidence of loosening or osteolysis. The mean polyethylene linear wear rate was 0.017 (SD 0.012) mm/y, and the mean polyethylene volumetric wear rate was 3.15 (SD 2.8) mm3/year, with no significant differences based on articulation type or head size. ConclusionsTotal hip arthroplasty with HXLPE in patients ≤ 50 years of age continues to demonstrate excellent long-term clinical and radiographic outcomes with low wear characteristics at 20-year follow-up, regardless of femoral head material or size.

Influence of humeral position of the Affinis Short stemless shoulder arthroplasty system on long-term survival and clinical outcome

The purpose of this study was to evaluate the influence of humeral position of the Affinis Short implant in stemless anatomic total shoulder arthroplasties (STSAs) on clinical and radiologic results and mid- to long-term survival in the treatment of primary osteoarthritis (OA) of the shoulder. Eighty patients treated with a stemless shoulder arthroplasty for OA of the shoulder were evaluated with a mean follow-up of 92±14 months (range 69-116 months) by the Constant Score (CS), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), and active range of motion (ROM). Radiographic assessment for bone adaptations and humeral implant position was performed by plain radiographs. Comparison of the pre- and postoperative centers of rotation (CORs) was used to assess the restoration of the geometry of the humeral head. The appraisal of proper humeral component positioning was correlated with the functional outcomes. A Kaplan-Meier analysis was performed to investigate the influence of humeral implant position compared to survival time. Complications were noted. The ROM (P<.001), CS (P<.001), and DASH scores (P<.001) showed significant improvements after surgery for the entire series. The COR restoration was anatomic in 75% (n=60) of all implants and in 25% (n=20) nonanatomic implants (pre- and postoperative COR deviation of 2.7±1.8 mm vs. 5.1±3.2 mm, P=.0380). The humeral component position did not affect the functional outcome whereas the 10-year unadjusted cumulative survival rate for the anatomic group was significantly higher in comparison with the nonanatomic group (96.7% vs. 75%, P=.002). The radiologic evaluation revealed minor periprosthetic bone adaptions in various forms without clinical significance or further intervention. No revision was necessary because of a failed fixation of the stemless humeral component. Regarding the treatment of primary OA of the shoulder, STSA shows excellent long-term survival and clinical outcomes. In particular, STSA implants are able to restore the geometry of the humeral head. Nonanatomic reconstruction may influence the survival over the long term in different pathways. Further studies are necessary to elucidate the effect of humeral component position in STSA on function, pain, and implant survival rates.

Prospective Study Comparing Outcome following Complete Polypropylene Suture Ligation versus Partial Thin Film Band Attenuation of Congenital Portosystemic Shunts in Dogs.

The main objective was to conduct a prospective study reporting the outcome for dogs with an extrahepatic congenital portosystemic shunt (CPSS) treated with a 'complete ligation where possible' philosophy. The second aim was to compare the outcomes following complete (C) polypropylene suture ligation versus partial thin film band (TFB) attenuation of a CPSS in dogs. Dogs that could not tolerate acute complete shunt ligation at surgery received partial shunt attenuation with TFB. Peri-operative complications, mortality, follow-up imaging findings, pre- and post-operative bile acid stimulation test results and details of any revision surgery performed were recorded. A follow-up health-related quality of life questionnaire enabled the calculation of a postoperative clinical shunt score, a quality of life score, and determined if any dogs were still on a hepatic diet and/or other medical management at a minimum of 6 months after surgery. Of the 110 dogs enrolled, 57 received complete ligation and 53 received partial TFB attenuation. Peri-operative mortality, the occurrence of post-attenuation neurological complications, the occurrence of multiple acquired shunts, the postoperative clinical shunt score and quality of life score were not significantly different between the two groups. Dogs in the C group were older, heavier and demonstrated a greater number of shunt classifications where the entry into the systemic circulation was the phrenic vein or azygous vein. Dogs in the TFB group had a greater number of unchanged bile acid concentrations after surgery, were more likely to remain on the hepatic diet and/or medical management after surgery and underwent a greater number of revision surgeries. There was variability in the precision of both ultrasound and computed tomographic angiography follow-up imaging compared to intra-operative mesenteric portovenography findings at revision surgery. Overall, dogs with an extrahepatic portosystemic shunt receiving either complete acute shunt ligation or partial TFB shunt attenuation are expected to have an excellent long-term clinical outcome and there is no reason to suggest that a dog able to tolerate complete acute shunt closure should be denied the benefit of this.

Ganglioneuroblastoma intermixed: Clinicopathological implications of diagnosis at presentation and genomic correlations.

Ganglioneuroblastoma intermixed (GNBI) is classified as "favorable" histology by International Neuroblastoma Pathology Classification system. However, the International Neuroblastoma Risk Group (INRG) stratifies patients using wider clinicopathological and cytogenetic/molecular parameters. While the diagnosis of GNBI is typically made on resected tumor, it may sometimes be rendered on initial biopsy. We studied GNBI noted at diagnosis to evaluate its correlation with INRG staging and other clinicopathological and molecular features. In this retrospective study, clinical, radiological, pathological, cytogenetic, and molecular information from patients with GNBI at diagnosis seen between 1995 and 2021 was analyzed. INRG staging was performed. Of the 15,827 neuroblastoma specimens, GNBI was noted in 237 patients. Of these, 53 had the initial pathological diagnosis of GNBI; median follow-up 3.5 (range: 0.2-14) years. Disease was locoregional in 41 (77%, 16 stage L1 and 25 L2); none relapsed. Twelve (23%) had metastatic disease at presentation; six (50%) relapsed, and two died of disease. MYCN was amplified in two metastatic tumors. Six of 31 (19%) tumors tested had recurrent cytogenetic abnormalities and nonrecurrent somatic gene mutations in 10/23 (43%). The presence of any adverse molecular/cytogenetic findings was associated with metastatic disease (p<.05). For patients with localized GNBI undergoing both biopsy and resection, GNBI was diagnosed in both in 17/19 (90%). Localized GNBI at diagnosis has excellent long-term clinical outcome even without cytotoxic therapy. For localized GNBI, a biopsy sample is adequate to make the diagnosis. When associated with metastasis at diagnosis, prognosis is poorer, possibly due to associated adverse biological features.

Electrophysiological characteristics and long-term outcome of substrate-based catheter ablation for left posterior fascicular ventricular tachycardia targeting fragmented antegrade Purkinje potentials during sinus rhythm.

The aim of this study was to investigate the electrophysiological characteristics and long-term outcome of patients undergoing substrate-based ablation of left posterior fascicular ventricular tachycardia (LPF-VT) guided by targeting of fragmented antegrade Purkinje potentials (FAPs) during sinus rhythm. This study retrospectively analysed 50 consecutive patients referred for ablation. Substrate mapping during sinus rhythm was performed to identify the FAP that was targeted by ablation. FAPs were recorded in 48 of 50 (96%) patients during sinus rhythm. The distribution of FAPs was located at the proximal segment of posterior septal left ventricle (LV) in two (4.2%) patients, middle segment in 33 (68.8%) patients, and distal segment in 13 (27.1%) patients. In 32 of 48 (66.7%) patients, the FAP displayed a continuous multicomponent fragmented electrogram, while a fragmented, split, and uncoupled electrogram was recorded in 16 (33.3%) patients. Entrainment attempts at FAP region were performed successfully in seven patients, demonstrating concealed fusion and the critical isthmus of LPF-VT. Catheter ablation targeting at the FAPs successfully terminated the LPF-VT in all 48 patients in whom they were seen. Left posterior fascicular (LPF) block occurred in four (8%) patients after ablation. During a median follow-up period of 61.2 ± 16.8 months, 47 of 50 (94%) patients remained free from recurrent LPF-VT. Ablation of LPF-VT targeting FAP during sinus rhythm results in excellent long-term clinical outcome. FAPs were commonly located at the middle segment of posterior septal LV. Region with FAPs during sinus rhythm was predictive of critical site for re-entry.

Temporal encephalocele: a rare but treatable cause of temporal lobe epilepsy

Although rare, temporal encephalocele is an important causative agent in surgically remediable drug-refractory epilepsy. The ideal treatment for temporal encephalocele remains unclear with a variety of resective surgeries recommended. Here, we analyse patient data on temporal encephalocele with a view to highlighting diagnostic clues and management strategies. Comprehensive databases at Deenanath Mangeshkar Hospital, Pune from January 2015 to June 2019 were reviewed for this observational study. Of 107 temporal lobe epilepsy surgery patients, nine individuals with temporal encephalocele were identified, who formed the study cohort. Their clinical, neuropsychological, EEG, imaging and long-term outcome data were analysed. The study cohort consisted of seven males and two females with a mean age of 22 years. Epilepsy onset age varied from 4.5 to 19 years. Seven patients had focal non-motor seizures with impaired awareness, while two patients had focal motor seizures. Temporal encephalocele detection by MRI was reported in only two patients, and was missed in seven individuals. Three patients underwent standard anterior temporal lobectomy while the remaining six underwent resection of the temporal encephalocele with surrounding temporal pole. Eight patients showed Engel Class I outcome and one showed Class IIa outcome after a mean follow-up duration of 27 months (17-44 months). Histopathology confirmed gliosis in seven, hippocampal sclerosis type I in one and suspicious dyslamination with prominent gliosis in one patient. Six of eight patients reported an improvement in their psychological state (mood, anxiety and motivation) over time. A careful review of MRI in patients with temporal lobe epilepsy is necessary, followed by investigations for the presence of an encephalocele. When temporal lobe epilepsy is associated with encephalocele, tailored resection of the encephalocele and the surrounding temporal pole, sparing mesial temporal structures, demonstrates excellent long-term clinical and neuropsychological outcome.

Long-term outcomes of aortic root procedures for heterogenous ascending aneurysm disease in bicuspid aortic valve syndrome

ObjectiveSurgery for ascending aneurysms in bicuspid aortic valve syndrome primarily includes Bentall root replacement, aortic valve replacement with supracoronary ascending aorta replacement (AVRSCAAR), and valve-sparing root reimplantation (VSRR). Comparative analysis of long-term clinical and functional outcomes of these procedures is detailed. MethodsFrom 1997 to 2017, 635 patients with bicuspid aortic valve undergoing root complex-focused procedures electively were stratified by valvulopathy (ie, aortic stenosis vs aortic insufficiency) and substratified into ascending or root aneurysm phenotype. Inverse probability weights were calculated to adjust for baseline differences. ResultsKaplan-Meier curves for all-cause mortality demonstrated no difference between Bentall versus AVRSCAAR for aortic stenosis and aortic insufficiency presentations (log-rank P > .05). In patients with aortic stenosis, multivariable Cox regression showed significantly decreased risk of stroke for biologic AVRSCAAR (hazard ratio, 0.04; P = .013). Aortic reoperation rates were similar for biologic versus mechanical valves (P = .353).In patients with aortic insufficiency, similar long-term mortality (hazard ratio, 0.95; P = .93), but lower stroke risk in biologic AVRSCAAR group by Cox regression, and lower aortic reoperation rate was noted (coefficient < 0.01; P < .001). Comparing Bentall to VSRR, mortality (hazard ratio, 0.12; P = .022) was significantly improved in patients undergoing VSRR, but recurrence of moderate or greater aortic insufficiency was higher in VSRR by multistate model (beta coefficient 2.63; P < .001). ConclusionsA tailored approach to heterogeneous ascending aneurysm pathologies in bicuspid aortic valve syndrome utilizing Bentall, AVRSCAAR, and VSRR procedures renders excellent long-term clinical and functional outcomes, with biologic conduits showing equivalent to improved clinical outcomes.

Impact of diabetes mellitus on long-term clinical and graft outcomes after off-pump coronary artery bypass grafting with pure bilateral skeletonized internal thoracic artery grafts

BackgroundThe effect of diabetes mellitus (DM) on the long-term outcomes of coronary artery bypass graft (CABG) remained debatable and various strategies exist for CABG; hence, clarifying the effects of DM on CABG outcomes is difficult. The current study aimed to evaluate the effect of DM on clinical and graft-related outcomes after CABG with bilateral internal thoracic artery (BITA) grafts.MethodsFrom January 2001 to December 2017, 3395 patients who underwent off-pump CABG (OPCAB) with BITA grafts were enrolled. The study population was stratified according to preoperative DM. The primary endpoint was cardiac death and the secondary endpoints were myocardial infarction (MI), revascularization, graft failure, stroke, postoperative wound infection, and a composite endpoint of cardiac death, MI, and revascularization. Multiple sensitivity analyses, including Cox proportional hazard regression and propensity-score matching analyses, were performed to adjust baseline differences.ResultsAfter CABG, the DM group showed similar rates of cardiac death, MI, or revascularization and lower rates of graft failure at 10 years (DM vs. non-DM, 19.0% vs. 24.3%, hazard ratio [HR] 0.711, 95% confidence interval [CI] 0.549–0.925; P = 0.009) compared to the non-DM group. These findings were consistent after multiple sensitivity analyses. In the subgroup analysis, the well-controlled DM group, which is defined as preoperative hemoglobin A1c (HbA1c) of < 7%, showed lower postoperative wound infection rates (well-controlled DM vs. poorly controlled DM, 3.7% vs. 7.3%, HR 0.411, 95% CI 0.225–0.751; P = 0.004) compared to the poorly controlled DM group, which was consistent after propensity-score matched analysis.ConclusionsOPCAB with BITA grafts showed excellent and comparable long-term clinical outcomes in patients with and without DM. DM might have a protective effect on competition and graft failure of ITA. Strict preoperative hyperglycemia control with target HbA1c of < 7% might reduce postoperative wound infection and facilitate the use of BITA in CABG.

Initial hospital length of stay and long-term survival of patients successfully resuscitated using extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest.

The long-term outcomes of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory ventricular tachycardia/ventricular fibrillation (VT/VF) out-of-hospital cardiac arrest (OHCA) remain poorly defined. The purpose of this study was to describe the hospital length of stay and long-term survival of patients who were successfully rescued with ECPR after refractory VT/VF OHCA. In this retrospective cohort study, the length of index admission and long-term survival of patients treated with ECPR after OHCA at a single centre were evaluated. In a sensitivity analysis, survival of patients managed with left ventricular assist device (LVAD) implantation or heart transplantation during the same period was also evaluated. Between 1 January 2016 and 12 January 2020, 193 patients were transferred for ECPR considerations and 160 underwent peripheral veno-arterial extracorporeal membrane oxygenation cannulation. Of these, 54 (33.7%) survived the index admission. These survivors required a median 16 days of intensive care and 24 days total hospital stay. The median follow-up time of the survivors was 1216 (683, 1461) days. Of all, 79.6 and 72.2% were alive at 1 and 4 years, respectively. Most deaths within the first year occurred among the patients requiring discharge to a long-term acute care facility. Overall survival rates at 4 years were similar in the ECPR and LVAD cohorts (P = 0.30) but were significantly higher for transplant recipients (P < 0.001). This data suggest that the lengthy index hospitalization required to manage OHCA patients with ECPR is rewarded by excellent long-term clinical outcomes in an expert ECPR programme.

Poster 211: Anatomic Factors Associated with Osteochondral Allograft Matching for Trochlear Cartilage Defects: A Computer-Simulated Study

Objectives: Osteochondral allograft transplantation (OCA) for cartilage defects provides excellent long-term clinical outcomes. Articular step-off between the donor and recipient has been shown to significantly alter contact pressures, potentially contributing to worse long-term survival. The trochlea in particular is at risk for graft mismatch due to the complexity and variability of trochlear anatomy. Currently, commercial allograft donor selection is primarily based on simple anatomical parameters such as trochlear length, trochlear width, and tibial width. However, there is limited guidance in literature on factors which best predict an adequate match, as defined by ≤1.0 mm articular step-off. We hypothesize that more complex anatomic parameters which better describe trochlear morphology, including sulcus angle, sagittal angle, and radius of curvature, may help optimize donor selection to reduce articular step off for trochlear osteochondral allograft transplantation. Methods: Ten deidentified, cadaveric trochlear specimens were utilized for this study (JRF Ortho, Denver, CO). Computed tomography (CT) images of the specimens were obtained, and three-dimensional (3D) point cloud models of the trochleae were then created and exported using a medical segmentation software program (Mimics, Materialise Inc., Leuven, Belgium). Circular defect models were created virtually in each point-cloud model of the recipient trochlea at both supero-lateral (18 mm and 22.5 mm) and central (18 mm, 22.5 mm, 30 mm) locations (Figure 1A). Circular graft models were created on all possible locations on the articular cartilage surface models of the donor trochleae. The graft models were virtually placed on the defect models, and a mean value of the minimum distances between the graft and recipient surfaces was calculated for each position of the graft model. This was repeated for all points in the articular surface model of the donor patella and the best possible match was identified. Step-off was calculated as the least mean square difference between the defect and graft along the periphery. Ideal match was defined as ≤0.5 mm articular step-off, and an acceptable match was defined as ≤1.0 mm articular step-off. Demographic and anatomic factors measured include age, sex, laterality, lateral facet width, medial facet width, lateral condyle radius of curvature, trochlear groove radius of curvature, trochlear length, and trochlear width. Sulcus angle and sagittal angle at the center of the defect and grafts for the central trochlear location were calculated by a custom-designed program (Figure 1B). Tibial width for each specimen was provided by the tissue bank. Differences between the donor and recipient trochleae were calculated for each factor and the absolute value of the difference was utilized for analysis. Pearson correlation ( r) or Spearman rank correlation (ρ) were calculated for continuous or categorical variables, respectively. Linear regression multivariate analysis for was performed with significant univariate predictors. Statistical analysis was performed in STATAv16.1 (Statacorp, Houston TX) and RStudio (software version 4.1.0, R Foundation for Statistical Computing, Vienna, Austria). Results: Ideal graft matches were identified in all superolateral trochlear defects, while central defects had a decreasing frequency of ideal matches with increasing defect size (18 mm: 53.4%, 22.5 mm: 35.21%, 30 mm: 14.8%) (Table 1). Univariate predictors of articular step-off are presented in Table 2. On multivariate analysis, sulcus angle difference (β=0.019, p=0.002), sagittal angle difference (β=0.018, p=0.001), and lateral condyle radius of curvature (β=0.015, p=0.003) remained significant predictors of articular step-off for 18 mm central defects (R2=0.45). For 22.5 mm central defects, sulcus angle difference (β=0.029, p&lt;0.001), sagittal angle difference (β=0.025, p&lt;.001), medial facet width (β=0.026, p=0.021), and lateral radius of curvature (β=0.013, p=0.025) were significant. Similarly, for 30 mm central defects, sulcus angle difference (β=0.03, p=0.001), lateral radius of curvature (β=.032, p=0.004), and trochlear length (β=0.041, p&lt;0.001), were significant predictors of articular step-off (Figure 2). For 18 mm superolateral defects, medial facet width was the only factor with univariate significance. However, on multivariate analysis considering all factors, no significant predictors were identified. For 22.5 mm superolateral trochlear defects, medial facet width (β=.006, p&lt;0.001) was a significant multivariate predictor of articular step-off. For 22.5 mm superolateral defects, trochlear length (β=.002, p=0.003) was also a significant multivariate predictor. Conclusions: Central trochlear defects of increasing size become more difficult to find ideal and acceptable graft matches for based on articular step-off. Tibial width did not correlate with articular step-off in the setting of a computer-simulated model of osteochondral allograft for central or superolateral trochlear defects. Minimizing mismatch in anatomic factors such as sulcus angle, sagittal angle, lateral condyle radius of curvature, and medial facet width may contribute to a more optimal graft. Limitations of this computer-simulated study include the inability to account for surgeon technique in ultimate graft matching outcome. [Figure: see text][Table: see text][Table: see text][Figure: see text]

Clinical outcomes following resection of paraspinal ganglioneuromas: a case series of 15 patients.

Paraspinal ganglioneuromas are rare tumors that arise from neural crest tissue and can cause morbidity via compression of adjacent organs and neurovascular structures. The authors investigated a case series of these tumors treated at their institution to determine clinical outcomes following resection. A retrospective review of a prospectively collected cohort of consecutive, pathology-confirmed, surgically treated paraspinal ganglioneuromas from 2001 to 2019 was performed at a tertiary cancer center. Fifteen cases of paraspinal ganglioneuroma were identified: 47% were female and the median age at the time of surgery was 30 years (range 10-67 years). Resected tumors included 9 thoracic, 1 lumbar, and 5 sacral, with an average maximum tumor dimension of 6.8 cm (range 1-13.5 cm). Two patients had treated neuroblastomas that matured into ganglioneuromas. One patient had a secretory tumor causing systemic symptoms. Surgical approaches were anterior (n = 11), posterior (n = 2), or combined (n = 2). Seven (47%) and 5 (33%) patients underwent gross-total resection (GTR) or subtotal resection with minimal residual tumor, respectively. The complication rate was 20%, with no permanent neurological deficits or deaths. No patient had evidence of tumor recurrence or progression after a median follow-up of 68 months. Surgical approaches and extent of resection for paraspinal ganglioneuromas must be heavily weighed against the advantages of aggressive debulking and decompression given the complication risk of these procedures. GTR can be curative, but even patients without complete tumor removal can show evidence of excellent long-term local control and clinical outcomes.

Paper 18: Effect of Bone Marrow Aspirate Concentrate on Osteochondral Allograft Transplantation Incorporation: A Prospective, Randomized, Single Blind Investigation

Objectives:Osteochondral allograft transplantation for cartilage defects of the knee has demonstrated excellent long-term clinical outcomes and survival, which largely depends on successful graft osseointegration. Biologics have been suggested as a viable adjunct to enhance successful healing in several musculoskeletal applications. In the context of OCA, early results have suggested that BMAC may improve cellular repopulation and viability within the osseus portion of an implanted graft. However, few clinical studies to date have investigated the impact of BMAC on patient outcomes following OCA. The purpose of this study was to investigate the effect of bone marrow aspirate concentrate (BMAC) on osseointegration and patient-reported outcome metrics (PROMs) after osteochondral allograft transplantation in a prospective, randomized controlled single-blinded trial.Methods:Patients undergoing osteochondral allograft transplantation of the knee were consented and enrolled. Prior to surgery, patients were randomized into either the BMAC or sham incision groups. In the BMAC group, the osteochondral allograft plug was soaked in BMAC for a minimum of 2 minutes prior to implantation. All patients underwent postoperative computed tomography (CT) scanning at 6 months postoperatively and completed PROMs preoperatively, 6 months, and 1 year postoperatively. Two board-eligible orthopaedic surgeons blinded to treatment allocation independently assessed and graded each CT according to the ACTOCA system proposed by Gelber et al.Results:Thirty-six patients enrolled between April 2018 to December 2020 (17 female, 19 male) were included for analysis. There were no significant differences between the BMAC and non-BMAC groups in graft signal density (Grader 1: p=0.283, Grader 2: p=0.467), osseous integration (both graders: p=0.489), surface percentage with discernible cleft (Grader 1: 0.287, Grader 2: 0.469), or intra-articular fragments (Grader 1: p=0.617, Grader 2: p=0.810) (Table 1). A significantly greater number of patients receiving BMAC demonstrating cystic changes <3 mm (Grader 1: p=0.015, Grader 2: p=0.05) (Figure 1). At 1 year, BMAC patients reported significantly better WOMAC Pain (87.82±14.26 vs 75.80±15.56, p=0.043) and trended towards improved PROMIS Pain (54.14±8.31 vs 61.79±5.24, p=0.09).Conclusions:Patients receiving BMAC soaked OCA grafts demonstrated no difference from controls with respect to graft signal intensity, osseous integration, intra-articular fragments, or discernible graft-host clefts at 6-months postoperatively. BMAC patients had a significantly greater occurrence of small (<3 mm) cystic changes. At 1 year, BMAC patients reported significantly less pain than controls on WOMAC Pain, with similar trends on PROMIS Pain Interference.Table 1.Postoperative Imaging Characteristics (ACTOCA) by Grader.Figure 1.Distribution of cystic changes between BMAC and control groups.

Cemented acetabular components combined with trabecular metal augments provide excellent long-term survivorship for severe acetabular bone loss.

Acetabular bone loss is a challenging problem for revision hip surgeons. This study aimed to explore long-term outcomes of patients who have undergone cemented acetabular revision in conjunction with trabecular metal augmentation and impaction bone grafting in cases with significant segmental bone loss. All patients who underwent cemented acetabular revision requiring impaction bone grafting and trabecular metal augments with a minimum Paprosky score of 2B and minimum follow up of 5 years were identified. Pre- and postoperative WOMAC scores were compared. An assessment of pre- and postoperative hip centre of rotation was performed and compared to native centre of rotation. Immediate postoperative centre of rotation was then compared to radiographs at latest follow up to measure for migration of acetabular components. 42 patients were identified. Mean age was 53 years old with 7 males and 35 female patients. Mean follow-up was 9.5 years. Preoperative WOMAC score was 30 and there was an increase to 90 (p < 0.01) at latest follow-up. No hips were revised for loosening or infection. There was a mean improvement in centre of rotation of 6.80 mm (CI, 4.57-9.03 mm) which was significant (p < 0.00002). There was no change of position of centre of rotation from immediate postoperative radiographs and those at latest follow up (p = 0.3). Cemented acetabular components work well in conjunction with trabecular metal augments and impacted bone grafts in reconstructing complex acetabular defects. Together they provide immediate and long-term component stability, with excellent long-term clinical and radiological outcomes.

Navigation-Guided Single-Position Lumbar Lateral Interbody Fusion and Minimally Invasive Tubular Decompression: 2-Dimensional Operative Video.

Lateral lumbar interbody fusion (LLIF) has several advantages over the other fusion techniques; by allowing the placement of a larger implant, LLIF results in better indirect decompression and increased disk height, foraminal height, and cross-sectional area of the dural sac.1,2 However, one of the primary drawbacks of the LLIF has been the need for repositioning to perform posterior stabilization. Furthermore, patients with severe central and lateral recess stenosis were found to be prone to indirect decompression failure after the LLIF procedure.3 In this video, we demonstrate a step-by-step technique for intraoperative navigation-guided lateral single-position LLIF with pedicle screw instrumentation and minimally invasive tubular decompression. We present a case of a 64-year-old female patient with a history of low back pain which radiates to the buttocks and posterior legs to her knees. The patient was treated by a single-position LLIF with posterior pedicle screw fixation using a portable intraoperative computed tomography scanner (Airo, Brainlab AG), combined with 3-dimensional computer navigation and minimally invasive tubular decompression at the L3-4 level. The patient was discharged at postoperative day 1 with excellent long-term clinical outcomes. Patient consent was obtained before performing the procedure. The participants and any identifiable individuals consented to publication of his/her image.

Retrospective comparison of outcomes following tibial plateau levelling osteotomy and lateral fabello-tibial suture stabilisation of cranial cruciate ligament disease in small dogs with high tibial plateau angles

ABSTRACT Aims To compare short and long-term outcomes after tibial plateau levelling osteotomy (TPLO) and lateral fabello-tibial suture (LFTS) techniques for the management of cranial cruciate ligament disease in small dogs with high tibial plateau angles (TPA). Methods In this retrospective study, the medical records of two veterinary specialist practices in the United Kingdom were searched for dogs (<20 kg) that underwent TPLO or LFTS between 2000 and 2010, and had a preoperative radiographic TPA >30° with either short-term (6 weeks) and/or long-term (>3 months) follow-up data. Data collected at a 6-week post-surgical re-examination was derived from orthopaedic examination and radiographic assessment and included the incidence of major and minor complications and scoring of the short-term outcome. Long-term outcome was scored based on results of a subjective owner questionnaire and veterinary orthopaedic examination. Results A total of 61 (84 stifles) dogs were included in the study: 24 (30 stilfes) and 37 (54 stifles) dogs underwent LFTS and TPLO, respectively. Long-term clinical outcome was different (p = 0.017) between groups; 15/15 stifles in the TPLO group had a good or excellent long-term clinical outcome, compared to 4/8 (50%) in the LFTS group. There was no evidence of a difference in short-term post-operative outcome or owner subjective long-term outcome between treatment groups. Stifles in the LFTS group were more likely (p = 0.027) to have palpable stifle pain at long-term follow-up. Owners reported that 5/16 (31.3%) dogs in the LFTS group required oral non-steroidal anti-inflammatory drug (NSAID) treatment at least monthly (4/5 required daily treatment), whereas no dogs in the TPLO group required treatment with NSAID more frequently than three times per year (p = 0.011). No correlation was found between short-term outcome and owner subjective long-term outcome but there was a positive correlation between short-term outcome and long-term clinical outcome. There was no evidence of a difference in overall major complication rates between treatment groups. The occurrence of complications was associated with heavier body weight at the time of surgery. No other variables were shown to be risk factors for complications. Conclusion and clinical relevance Small breed dogs with high TPA that underwent TPLO had better long-term clinical outcomes and were less likely to require NSAID administration than those that underwent LFTS. The risk of complication increased with the weight of the dog at surgery. There was a positive correlation between short-term outcome and long-term clinical outcome.

Early-stage Triple-negative Breast Cancer: Time to Optimize Personalized Strategies.

Triple-negative breast cancer (TNBC) accounts for approximately 15%-20% of breast cancers diagnosed worldwide, which amounts to almost 200 000 cases each year. Although historically TNBC is considered difficult to treat with a poor prognosis, there is emerging evidence showing excellent response rates in a subset of TNBC patients. Attempts to de-escalate chemotherapy in hormone-receptor-positive (HR+) and HER2-neu amplified breast cancer subtypes have been successful. At present, robust strategies to personalize therapy in early-stage TNBC do not exist, and despite excellent response rates in a subset of patients, all patients are exposed to the same several cycles of cytotoxic chemotherapy. Personalizing therapy in TNBC represents a challenge due to the scarcity of treatment options outside of cytotoxic chemotherapy and limited predictive and prognostic biomarkers to tailor treatment. Recent developments in understanding TNBC biology have sparked interest in exploring treatment optimization and personalization with the goal of achieving excellent response rates and long-term clinical outcomes, while simultaneously reducing physical, psychological, and financial toxicities for select patients. Here, we provide an update on the current evidence to support future studies examining de-escalating chemotherapy in patients with low-risk TNBC and adjuvant intensification strategies to improve outcomes for patients who are at high risk for systemic failure despite current standard-of-care treatments.

Prospective 5-year clinical evaluation of posterior zirconia fixed dental prostheses veneered with milled lithium disilicate (CADon).

Bi-layer zirconia-based posterior fixed dental prostheses (FDPs) have reportedly a high incidence of veneering ceramic fractures. The CADon technique employs zirconia frameworks veneered with milled lithium disilicate glass-ceramic to overcome these shortcomings but long-term clinical studies are missing. This study evaluated the clinical efficacy of posterior 3-unit CADOn FDPs over a 5-year period. A total of 25 patients, 16 male and 9 female with a mean age of 55.6 years, received a total of 25 posterior three-unit CADOn FDPs. Patients were recalled for baseline and for follow-up visits at 6, 12, 24, and 60 months. Parameters evaluated were fracture, marginal adaptation, marginal discoloration, wear, polish, color match, surface staining, and retention of these restorations as well as secondary caries of the abutment teeth. A total of 21 FDPs evaluated at 60-months revealed a 100% survival rate. All evaluated clinical parameters were satisfactory (alpha or bravo) and there was no statistically significant difference at different time points, except for surface staining, which was also worse at 60 months compared to baseline (p 0.001). CADOn three-unit posterior FDPs demonstrate excellent fracture resistance after 5 years of clinical function. All evaluated clinical parameters were satisfactory, except for surface stain, which also increased over time. Conventionally veneered bi-layer zirconia-based posterior FDPs have limited clinical success. Based on this study, alternative methods such as zirconia frameworks veneered with milled lithium disilicate glass-ceramic provide a viable alternative with excellent long-term clinical outcomes.

Degenerative occipitocervical dislocation – Uncommon entity at extreme of Life: A case report and review of literature

Traumatic occipitocervical dislocation (OCD) has been reported numerous times both in children and adults. Nontraumatic OCD is rare. An 85-year-male referred with 2 months history of motor and sensory complaints in all four limbs. There was no history of trauma. Neck movements were restricted. A lateral radiograph of the cervical spine was suggestive of extensive degenerative changes in the cervical spine. Computed tomography scan of the cervical spine revealed posterior OCD with degenerative changes. Magnetic resonance imaging revealed compressive myelopathy at the cervico-medullary junction. Posterior occipitocervical fixation was performed. His neurological symptoms significantly improved. The procedure resulted in an excellent immediate and long-term clinical outcome.

S1045 EUS-Guided Primary, Secondary Prophylaxis Treatment of Gastric Varices: A Systematic Review With Meta-Analysis

Introduction: Gastric varices (GV) increase the risk of gastrointestinal bleeding and carry a significant mortality risk, especially in the setting of portal hypertension. A major treatment modality for GV includes endoscopic ultrasound (EUS) guided glue and/ or coil injection. In this meta-analysis study, we aim to address the efficacy of EUS guided glue and/ or coil injection in the treatment of GV in primary and secondary prophylaxis. Methods: We conducted a comprehensive search of several databases including Medline, Scopus, Embase to identify studies from 2000-2019 that evaluated EUS guided therapy in the treatment of GV for primary and/or secondary prophylaxis. Our primary goals were to estimate the pooled rates of treatment efficacy, GV obliteration, GV recurrence, early re-bleeding, and late re-bleeding with EUS guided therapy of GV in primary and secondary prophylaxis. Calculation was done by standard meta-analysis methodology using the random-effects model and heterogeneity was assessed using the I2% statistics. Results: A total of 13 studies were included in the final analysis. The EUS guided treatment efficacy of primary prophylaxis was 95% (95% CI [85.7-98.4%]) and secondary prophylaxis was 94.3% [83.6-98.1]. GV obliteration was 68.3% [43.4-85.8] for primary prophylaxis and 65.8% [38.8-85.4] for secondary prophylaxis. GV recurrence was 10% [2.5-32.8] in primary prophylaxis and 4.3% [1.7-10.5] in secondary prophylaxis. Early re-bleeding was seen in 6.7% [1.7-23.1] of primary prophylaxis cases and 5.5% [2.3-12.6] of secondary prophylaxis. Late re-bleeding was seen in 6% [2.3-14.9] of primary prophylaxis cases and 12.6% [9.3-16.8] of secondary prophylaxis cases. We conducted sub-group analysis with respect to studies published as abstracts and full manuscripts, and by sample-size. The results summarized in Table 1. Conclusion: Our meta-analysis study illustrates that EUS-guided therapy of GV may demonstrate excellent short and long-term clinical outcomes in both primary and secondary prophylaxis. This was shown by high EUS guided treatment efficacy of 95% and 94.3% in primary and secondary prophylaxis respectively. In addition, a low GV recurrence of 4.5% in secondary prophylaxis is a key positive finding; however, the late re-bleeding rate of 12.6% in secondary prophylaxis needs further evaluation and future study. Nevertheless, our study highlights that early EUS-guided therapy should be considered in the treatment of GV regardless of primary or secondary prophylaxis.Table 1.: Summary of pooled results

Immediate vaginal and perineal reconstruction after abdominoperineal excision using the Inferior Gluteal Artery Perforator Flap (V-IGAP)

The fasciocutaneous inferior gluteal artery perforator (IGAP) has been previously demonstrated to be a robust reconstructive choice after abdominoperineal excision (APE), with comparably low morbidity relative to other flaps. In patients who undergo concurrent vaginectomy, we demonstrate in this retrospective cohort study how IGAP modification allows simultaneous vaginal reconstruction with a favourable complication profile and long-term return to sexual activity. Oncological resection was completed with the patient prone. Unilateral or bilateral IGAP flaps may be used based on vaginal defect size and surgeon preference. In this study, important features of flap design, mobilisation and inset are presented, together with a retrospective cohort study of all cases who underwent vaginal reconstruction. Clinical outcomes were determined by the length of stay, early to late complications, and quality of life assessment including a return to sexual function. Over a 10-year period, 207 patients underwent abdominoperineal resection (APE) in our cross-centre study (86% subject to neoadjuvant chemoradiotherapy), with 22/84 female patients electing for vaginal reconstruction (19 partial, 3 total vaginectomies). Minor complications were observed in 6/22 cases, with two patients progressing to healing after-theatre debridement (major). The median follow-up time was 410 days. Quality of life questionnaires reported high patient satisfaction, with 70% of patients returning to sexual activity. For patients undergoing APE with concurrent vaginectomy, the IGAP flap can be used alone for both perineal dead space management and neovaginal reconstruction, negating the need for an alternative second flap and avoiding significant donor morbidity. This study shows excellent long-term clinical outcomes, including a return to sexual activity.