Final Follow-up Visit Research Articles

Importance of the Occipitoaxial Angle and Posterior Occipitocervical Angle in Occipitocervical Fusion.

ObjectiveTo observe the effects of occipitoaxial angle (O‐C2 angle, OC2A) and posterior occipitocervical angle (POCA) selection on postoperative clinical efficacy and lower cervical curvature in patients with acute acquired atlantoaxial dislocation after occipitocervical fusion (OCF).MethodsA total of 150 healthy subjects without cervical disease (healthy group) were randomly selected based on gender and age. Three spine surgeons measured the OC2A and POCA of the healthy group and averaged the values. A total of 30 patients with an average age of 51.0 years (range, 18–70 years; 16 male and 14 female) with trauma or rheumatoid arthritis (disease group) who underwent occipitocervical fusion (OCF) for atlantoaxial dislocation between January 2012 and June 2016 were reviewed. OC2A, POCA, and cervical spinal angle (CSA) were measured postoperative/soon after surgery and ambulation, and at the final follow‐up visit. The preoperative and final follow‐up visual analog scale (VAS), Japanese orthopedics association score (JOA), neck disability index (NDI), and dCSA (change of CSA from postoperative/soon after surgery and ambulation to final follow‐up) were recorded.ResultsThe values of OC2A and POCA in 150 healthy subjects were 14.5° ± 3.7° and 108.2° ± 8.1°, respectively, and the 95% confidence interval (CI) were 7.2°–21.8° and 92.3°–124.0°, respectively. There was a negative correlation between OC2A and POCA (r = −0.386, P < 0.001). There were 18 patients (group one) of ideal OC2A and POCA (both within 95% CI of the healthy group) postoperative/soon after surgery and ambulation with a mean follow‐up time of 26.3 ± 20.9 months in disease group. The remaining patients (group two) with a mean follow‐up time of 31.3 ± 21.3 months. There was no statistically significant difference in the baseline data as well as pre‐operative outcomes, including VAS score, JOA score, and NDI between the two groups. Likewise, the post‐operative outcomes in final follow‐up, including VAS and JOA score, had no distinct difference in the two groups. However, NDI (11.0 ± 2.9) in group two at the final follow‐up was significantly higher than that in group one (7.0 ± 2.3) (P < 0.001). And group two showed statistically greater dCSA (5.9 ± 7.5°) than group one (−2.3° ± 6.2°) (P = 0.003).ConclusionsThe negative correlation between OC2A and POCA plays an important role in maintaining the biodynamic balance of the occipital‐cervical region. OC2A and POCA should be controlled of a normal population in patients with acute acquired atlantoaxial dislocation during OCF, which can further improve the clinical efficacy and prevent loss of lower cervical curvature after surgery.

Coronal Remodeling Potential of Pediatric Distal Radius Fractures

Purpose: Distal radius fractures in the pediatric population are common injuries with a remarkable capability to remodel. The degree of angulation that can reasonably be expected to remodel is controversial though, particularly when it comes to angulation in the coronal plane. The purpose of this study was to quantify the rate of remodeling via the distal radius physis present in a retrospective cohort of skeletally immature patients with coronally angulated distal radius fractures.&#x0D; Methods: A retrospective chart review was performed to identify skeletally immature patients treated for an angulated distal radius fracture at a single institution by either a pediatric orthopaedic surgeon or an orthopaedic trauma surgeon from 2006-2018. Coronal angulation was measured at every visit where radiographs were available from time of injury to the final follow-up visit to determine the rate of remodeling.&#x0D; Results: 36 patients with distal radius fractures with a mean age of 7.93 years (range 4 to 12 years) at time of injury were identified. The mean rate of remodeling from maximum angulation to final follow-up was 2.30°per month in the coronal plane. The median peak angulation in the coronal plane was 17°(range 12.4°to 30.4°). At final follow- up, the median coronal angulation was 3.35°(range 0.24°to 14.0°). At the 95% confidence level, remodeling rates ranged from 2.00°per month to 2.59°per month. The mean follow-up period was 6.4 months from the time of maximum angulation to the final visit. The median time from cast removal to final follow-up was 26.36 weeks and ranged from 10 weeks to 34.86 weeks.&#x0D; Conclusion: Distal radius fractures have a large capacity to remodel in the coronal plane in the pediatric population. This remodeling occurs in a predictable and reliable fashion. These injuries should be expected to remodel at a rate of 2°per month. Repeat manipulation is not indicated in patients where the maximum coronal angulation is less than 24°, which provides a conservative estimate of the amount of remodeling that can be expected to occur in the first year following fracture.&#x0D; Significance: These findings provide a standard for acceptable coronal plane angulation, which should reduce treatment variability among orthopaedic surgeons and limit the number of surgical interventions that likely are not necessary given the distal radius’ ability to remodel.

Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery

Excessive bleeding is a common complication of cardiac surgery. An important cause of bleeding is acquired hypofibrinogenemia (fibrinogen level <1.5-2.0 g/L), for which guidelines recommend fibrinogen replacement with cryoprecipitate or fibrinogen concentrate. The 2 products have important differences, but comparative clinical data are lacking. To determine if fibrinogen concentrate is noninferior to cryoprecipitate for treatment of bleeding related to hypofibrinogenemia after cardiac surgery. Randomized clinical trial at 11 Canadian hospitals enrolling adult patients experiencing clinically significant bleeding and hypofibrinogenemia after cardiac surgery (from February 10, 2017, to November 1, 2018). Final 28-day follow-up visit was completed on November 28, 2018. Fibrinogen concentrate (4 g; n = 415) or cryoprecipitate (10 units; n = 412) for each ordered dose within 24 hours after cardiopulmonary bypass. Primary outcome was blood components (red blood cells, platelets, plasma) administered during 24 hours post bypass. A 2-sample, 1-sided test for the ratio of the mean number of units was conducted to evaluate noninferiority (threshold for noninferiority ratio, <1.2). Of 827 randomized patients, 735 (372 fibrinogen concentrate, 363 cryoprecipitate) were treated and included in the primary analysis (median age, 64 [interquartile range, 53-72] years; 30% women; 72% underwent complex operations; 95% moderate to severe bleeding; and pretreatment fibrinogen level, 1.6 [interquartile range, 1.3-1.9] g/L). The trial met the a priori stopping criterion for noninferiority at the interim analysis after 827 of planned 1200 patients were randomized. Mean 24-hour postbypass allogeneic transfusions were 16.3 (95% CI, 14.9 to 17.8) units in the fibrinogen concentrate group and 17.0 (95% CI, 15.6 to 18.6) units in the cryoprecipitate group (ratio, 0.96 [1-sided 97.5% CI, -∞ to 1.09; P < .001 for noninferiority] [2-sided 95% CI, 0.84 to 1.09; P = .50 for superiority]). Thromboembolic events occurred in 26 patients (7.0%) in the fibrinogen concentrate group and 35 patients (9.6%) in the cryoprecipitate group. In patients undergoing cardiac surgery who develop clinically significant bleeding and hypofibrinogenemia after cardiopulmonary bypass, fibrinogen concentrate is noninferior to cryoprecipitate with regard to number of blood components transfused in a 24-hour period post bypass. Use of fibrinogen concentrate may be considered for management of bleeding in patients with acquired hypofibrinogenemia in cardiac surgery. ClinicalTrials.gov Identifier: NCT03037424.

Reconstruction of complex hand defects using trapezoidal osteocutaneous free fibular flap.

Traumatic defects of multiple metacarpal bones can be addressed using conventional or vascularized bone grafts. When associated with extensive skin and tendon loss, the treatment becomes more challenging. The aim of the study was to describe the results of using free osteocutaneous fibular flap placed in a new fashion for the reconstruction of complex hand defects. Six patients with complex hand defects underwent reconstruction using free osteocutaneous fibular flap placed in trapezoidal fashion with two-stage tendon reconstruction using fascia lata graft. The mean age at the time of injury was 34.7 years (range: 14-54 years). The injury was caused by motor vehicle accident in four patients, machine injury in one patient, and falling from height in one patient. All patients had extensive three or four metacarpal bones defects, segmental loss of tendons, and large skin defect ranging from 6 × 10 cm to 10 × 15 cm. The fibular graft was divided into three segments and positioned in a trapezoidal fashion with the middle bone segment placed transversely to support the bases of the proximal phalanges while the first and third bone segments were placed obliquely along the metacarpal axis converging toward the remaining metacarpal bases and/or carpal bones. At final follow-up visit, the finger range of motion was assessed using the total active motion (TAM) scoring system. Functional outcome was evaluated by the disabilities of the arm, shoulder and hand (DASH) score. Active range of motion (AROM) of the pseudo-metacarpophalangeal (MP) joint was measured. The handgrip strength was measured using Jamar hydraulic dynamometer. The mean length of the harvested fibular graft was 18 cm (range: 17-19). The mean size of the skin paddle was 7.5 × 13.1 cm (range: 6 × 10 cm to 10 × 15 cm). Fibular flaps survived in all patients. The mean follow-up period was 30.8 months (range: 24-40 months). The mean time to achieve bone healing was 3.8 months (range: 3-5 months). The mean TAM was 185° (range: 165-204°) and TAM percentage was described as excellent in two patients and good in four patients. The mean AROM at the pseudo-MP joint was 53.8° (range: 42-70°). The mean injured handgrip strength was 27.3 kg (range: 23-31 kg) and the mean grip strength ratio was 74.8% (range: 69-80%). The mean DASH score was 19.6 (range: 11.67-26.67). Pin tract infection, partial skin paddle necrosis, and wound infection were reported. The fibular osteocutaneous flap arranged in trapezoidal fashion is a viable choice for the reconstruction of complex hand defects, particularly when the metacarpophalangeal joints are not preserved.

Maintenance of Correction of the First Tarsometatarsal Joint Arthodesis Procedure with a First Metatarsal to Second Metatarsal Screw Technique: A Preliminary Report

Category:BunionIntroduction/Purpose:Fusion of the first tarsometatarsal joint is common for the treatment of moderate to severe hallux abductovalgus deformity. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the deformity remains a concern. The addition of a screw from the 1st metatarsal base to the 2nd metatarsal base allows for increased stability and can help create a “spot weld” between the metatarsal bases to prevent loss of deformity correction. The additional screw construct is termed the intermetatarsal screw in this study. The purpose of the current study is to determine the long-term maintenance of angular correction of the 1st and 2nd intermetatarsal angle, hallux abductus angle, and tibial sesamoid position after undergoing a 1st tarsometatarsal joint arthrodesis with the addition of the intermetatarsal screw.Methods:A retrospective, single-center chart and radiographic review was performed of 17 consecutive patients who underwent primary hallux abductovalgus correction with a 1st tarsometatarsal joint arthrodesis using the intermetatarsal screw fixation by the senior author. The study period was from January 1, 2017 to May 14, 2018. Three observers independently reviewed radiographic data including preoperative weight bearing, 1st weight bearing, and final weight bearing plain film radiographs.Preoperative films were used if they were within 3 months of the surgery and the radiographic time line for the post-operative intervals were at 12 ± 2 weeks, 18 ± 4 weeks, 26 ± 4 weeks, 52 ± 12 weeks, and the final follow-up visit. Radiographic data evaluated were initial improvement and long-term maintenance of intermetatarsal angle, hallux abductus angle, and tibial sesamoid position.Results:17 consecutive patients were identified for review that met inclusion criterea. Mean follow up time was 8.12 months (SD ± 3.68). Bony union was achieved in all patients. There was 1 symptomatic recurrent bunion, 1 case of symptomatic hardware, and 1 case of transient neuritis. Average preoperative IMA was 16.05º (±2.34), HAA was 33.05º (±6.24), and tibial sesamoid position was 5.77 (±0.9). Average IMA improvement was 8.38º (±2.21), HAA improvement was 17.25º (±8.21), and TSP improvement was 3.29 (±1.36) positions. Average loss of IMA was 1.03º (±1.24), HAA was 4.14º (±5.34), and tibial sesamoid position was 0.65 (±0.86) positions. Wilcoxon signed rank test showed statistical significance in all radiographic parameters; both in initial improvements and loss of correction (p<0.005).Conclusion:The current study shows the addition of an intermetatarsal screw for 1st tarsometatarsal joint arthrodesis has good union rates, a low complication rate, and maintains correction. Further clinical and comparative studies with a larger patient cohort may yield additional useful information.

No Progression to MTPJ Arthrodesis with Youngswick Osteotomy for Hallux Rigidus Stage II and III

Category:Midfoot/ForefootIntroduction/Purpose:Hallux rigidus treatment by the means of decompressive osteotomy would theoretically be able to alleviate pain and improve function. The Youngswick osteotomy is a procedure conceived for relatively long first metatarsals, a characteristic that has been associated with the pathogenesis of hallux rigidus. Nevertheless, studies of this procedure that assessed the overall results and further need of a first metatarsal arthrodesis over the years are lacking.After using the Youngswick first metatarsal decompressive osteotomy for many years, we decided to review a retrospective series of patients. The purpose of this study was to evaluate the need for first metatarsophalangeal joint arthrodesis or any other secondary procedures in the long term follow up in patients with stage II and III hallux rigidus.Methods:A retrospective review of 61 consecutive patients (61 feet) who had undergone decompressive osteotomy by the same surgical team during a period of 156 months was performed.The candidates for inclusion into the present study underwent a clinical evaluation preoperatively, and the clinical data recorded in the patients’ medical records were reviewed retrospectively. All clinical measurements were taken at the initial preoperative examination and at the final follow-up visit. Patients underwent Youngswick first metatarsal osteotomy as described in previous publication.The clinical examination included the the Foot and Ankle Outcome Score (FAOS), total range of motion of the first MTPJ. Radiographic examinations (AP and lateral weightbearing) were performed preoperatively, immediately postoperatively, and at each patient’s last follow-up visit by another member who was unaware of the clinical results. The need of any secondary procedure of the first metatarsal or subsequent need of first MTPJ arthrodesis was also recorded.Results:Decompressive osteotomy was performed in 61 patients, including 41 right feet and 20 left feet, with no bilateral procedures. The patient population consisted of 45 females (78%), with an average age of 53.8 years (range 29 to 72) years. The mean follow-up time was 54.8 months (range 12 to 150). 74% (45 patients) were classified as grade II and 16 patients (26%) as grade III. All patients who underwent this procedure had improvement their visual analog scale foot and ankle score, with all achieving postoperative scores >75 points.Evaluation at the last follow-up visit showed that 91% of patients would recommend the same procedure to a family member. In our group of patients there were no further needs of first MTPJ arthrodesis.Conclusion:We found significant visual analog scale foot and ankle score, providing evidence that good outcomes and high levels of patient satisfaction can be achieved, and that this results would maintain over time. Secondary procedures mainly hardware removal were somewhat usual, however no first MTPJ arthrodesis was needed in the medium term.

Maintenance of Correction of First Tarsometatarsal Joint Arthrodesis Using the First Metatarsal to Intermediate Cuneiform Cross Screw Technique: A Retrospective Review

Category:BunionIntroduction/Purpose:The Lapidus procedure is common for the treatment of moderate to severe hallux abductovalgus deformity. Standard fixation consists of a combination of crossing screws and plates. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the deformity remains a concern. A recently described construct adds an additional point of fixation from the plantar medial first metatarsal to the intermediate cuneiform. This construct is termed the cross screw intermediate cuneiform construct. The purpose of this study is to determine the long-term angular maintained correction of the 1st and 2nd intermetatarsal angle, hallux abductus angle, and tibial sesamoid position after undergoing a 1st tarsometatarsal joint arthrodesis utilizing the cross screw intermediate cuneiform construct to correct and maintain the hallux abductovalgus deformity.Methods:A retrospective, single-center chart and radiographic review was performed of all patients with HAV treated with a 1st tarsometatarsal joint arthrodesis with cross screw intermediate cuneiform construct fixation by the senior author. The study period was from June 1st, 2016 to June 1st, 2017. Patients who underwent 1st tarsometatarsal joint arthrodesis for a primary diagnosis of HAV were studied. Three observers independently reviewed radiographic data including preoperative weight bearing, 1st weight bearing, and final weight bearing plain films radiographs. Preoperative films were used if they were within 3 months of the surgery, and the radiographic time line for the post-operative intervals were at 12 ± 2 weeks, 18 ± 4 weeks, 26 ± 4 weeks, 52 ± 12 weeks, and the final follow-up visit. Radiographic data evaluated were initial improvement and long-term maintenance of intermetatarsal ankle, hallux abductus angle, and tibial sesamoid position.Results:Forty-five patients met inclusion criteria and were included in the study. Mean follow-up time was 9.76 months (SD ± 7.62). Bony union was achieved in 43 of 45 patients (95.6%). Two patients required revision bunionectomy as result of recurrence (4.4%). Other complications included symptomatic hardware in 2 patients requiring hardware removal and neuritis in 2 patients. Average preoperative IMA was 15.95º (±2.55), HAA was 31.14º (±6.19), and tibial sesamoid position was 4.36 (±1.07). Final average improvement of IMA was 6.26º (±2.9), HAA was 13.89º (±7.02), and tibial sesamoid position was 2.07 (±1.34) positions. Average loss of IMA correction was 1.70º (±1.64), HAA was 2.45º (±4.6), and tibial sesamoid position was 0.8 (±0.82) positions. Wilcoxon signed rank test showed statistical significance in all radiographic parameters both in initial improvements and loss of correction (p<0.005).Conclusion:The current study shows the cross screw intermediate cuneiform construct for 1st tarsometatarsal joint arthrodesis has good union rates, a low complication rate, and maintains correction. Further clinical and comparative studies may yield additional useful information.

Visual function after bilateral implantation of multifocal versus monofocal IOLs in children below 5 years of age

Background: Since pediatric ophthalmologists still prefer to implant monofocal IOL and experience with multifocal IOL implantation in children is limited. Therefore, the aim of the study was to evaluate visual results after bilateral implantation of multifocal versus monofocal IOLs in children aged 1–5 years with congenital cataract. Methods: Children between 1 and 5 years of age with bilateral cataract who underwent cataract removal implantation of an multifocal IOL – Lentis Mplusx , Oculentis GmbH, Germany (55 children – group A) or monofocal IOL – C-flex Aspheric Monofocal, Rayner Intraocular Lenses Limited, UK (55 children – group B). The distance corrected visual acuity, distance corrected near visual acuity, binocular function using the Worth 4-dot test, stereopsis using the TNO test were evaluated. Results: At the final follow-up visit after 12 months, the mean best corrected distant visual acuity was not significantly different between groups A and B but the best corrected near visual acuity, binocular vision and stereopsis were significantly better in patients from group A as compared to group B. Conclusion: Implantation of a multifocal IOL in children aged 1–5 years with bilateral cataract provides a better level of near vision and considerably improves the development of stereopsis in comparison with children after monofocal IOL implantation.

Oral Lefamulin vs Moxifloxacin for Early Clinical Response Among Adults With Community-Acquired Bacterial Pneumonia

New antibacterials are needed to treat community-acquired bacterial pneumonia (CABP) because of growing antibacterial resistance and safety concerns with standard care. To evaluate the efficacy and adverse events of a 5-day oral lefamulin regimen in patients with CABP. A phase 3, noninferiority randomized clinical trial conducted at 99 sites in 19 countries that included adults aged 18 years or older with a Pneumonia Outcomes Research Team (PORT) risk class of II, III, or IV; radiographically documented pneumonia; acute illness; 3 or more CABP symptoms; and 2 or more vital sign abnormalities. The first patient visit was on August 30, 2016, and patients were followed up for 30 days; the final follow-up visit was on January 2, 2018. Patients were randomized 1:1 to receive oral lefamulin (600 mg every 12 hours for 5 days; n = 370) or moxifloxacin (400 mg every 24 hours for 7 days; n = 368). The US Food and Drug Administration (FDA) primary end point was early clinical response at 96 hours (within a 24-hour window) after the first dose of either study drug in the intent-to-treat (ITT) population (all randomized patients). Responders were defined as alive, showing improvement in 2 or more of the 4 CABP symptoms, having no worsening of any CABP symptoms, and not receiving any nonstudy antibacterial drug for current CABP episode. The European Medicines Agency coprimary end points (FDA secondary end points) were investigator assessment of clinical response at test of cure (5-10 days after last dose) in the modified ITT population and in the clinically evaluable population. The noninferiority margin was 10% for early clinical response and investigator assessment of clinical response. Among 738 randomized patients (mean age, 57.5 years; 351 women [47.6%]; 360 had a PORT risk class of III or IV [48.8%]), 707 (95.8%) completed the trial. Early clinical response rates were 90.8% with lefamulin and 90.8% with moxifloxacin (difference, 0.1% [1-sided 97.5% CI, -4.4% to ∞]). Rates of investigator assessment of clinical response success were 87.5% with lefamulin and 89.1% with moxifloxacin in the modified ITT population (difference, -1.6% [1-sided 97.5% CI, -6.3% to ∞]) and 89.7% and 93.6%, respectively, in the clinically evaluable population (difference, -3.9% [1-sided 97.5% CI, -8.2% to ∞]) at test of cure. The most frequently reported treatment-emergent adverse events were gastrointestinal (diarrhea: 45/368 [12.2%] in lefamulin group and 4/368 [1.1%] in moxifloxacin group; nausea: 19/368 [5.2%] in lefamulin group and 7/368 [1.9%] in moxifloxacin group). Among patients with CABP, 5-day oral lefamulin was noninferior to 7-day oral moxifloxacin with respect to early clinical response at 96 hours after first dose. ClinicalTrials.gov Identifier: NCT02813694; European Clinical Trials Identifier: 2015-004782-92.

Long-Term Outcomes of Treat and Extend Regimen of Anti-Vascular Endothelial Growth Factor in Neovascular Age-Related Macular Degeneration

This retrospective cross-sectional cohort study describes the long-term visual and anatomic outcomes of anti-vascular endothelial growth factor (VEGF) treatment using a treat and extend (TAE) regimen. The cohort consisted of 224 treatment-naïve eyes with age related macular degeneration (NV-AMD) from 202 patients that were treated with anti-VEGF agents bevacizumab, ranibizumab, and aflibercept using a TAE regimen by four physician investigators in a large urban referral center from 2008-2015. Subjects were evaluated for visual acuity, injection frequency and optical coherence tomography (OCT). Over a seven-year follow-up period (mean 3.4 years), an average 20.2 ± 14.7 injections were administered per patient. Visual acuity was 0.70 logMAR (20/100 Snellen) at the first visit and 0.67 logMAR (20/93 Snellen) at the final visit, with 74% of eyes maintaining or gaining more than 2 lines of vision. Longterm, 45.1% of eyes achieved 20/50 or better, while 27.1% were 20/200 or worse. 61.2% received monotherapy with no difference in visual acuity outcomes or injection frequency between the agent used. OCT analysis showed decreased fluid from initial to final follow-up visit: 70.1% to 15.6% with sub-retinal fluid (SRF) and 47.3% to 18.8% with intraretinal fluid (IRF) with no difference between the agent used. This study demonstrates that most patients (74%) improve or maintain visual acuity gains long-term using a TAE model with a significant portion (45.1%) achieving 20/50 or better with sustained treatment.

Prevalence of anterior knee pain after patellar retention total knee arthroplasty: Comparison of patients with rheumatoid arthritis versus primary osteoarthritis

ObjectiveThe aim of this study was to investigate whether there is an increased risk of anterior knee pain (AKP) after total knee arthroplasty (TKA) without patellar resurfacing in patients with rheumatoid arthritis (RA) versus primary osteoarthritis (OA). MethodsThis study was a retrospective review of 388 patients (577 knees) who underwent TKA without patellar resurfacing between 2003 and 2011, with a minimum of 5 years of follow-up. Patients were divided into two groups: Group OA (273 knees of 206 patients; 83 males, 123 females; mean age: 64.4 (47–87) years) and Group RA (304 knees of 182 patients; 92 males, 90 females; mean age: 50.7 (21–72) years). In the clinical evaluation, the knee range of motion (ROM) and several outcome measures such as The Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and International Knee Documentation Committee (IKDC) scores were used preoperatively and at the final follow-up visit. The quality of life was measured using Short Form (SF)-36 MCS and PCS scores. The primary outcome was the frequency and severity of patient-reported AKP. The AKP Scale was used to determine the severity of AKP. ResultsThe IKDC raised from 21.62 (range, 13–29.9) preoperatively to 85.1 (range, 80–88) for group OA and from 21.8 (range, 13–29.9) to 85.2 (range, 81–88) for group RA (p < 0.001). The mean KSS improved from 28.35 (range, 22–38) preoperatively to 90.04 (range, 88–95) for group OA and from 21.9 (range, 18–35) preoperatively to 89.7 (range, 86–95) for group RA. The mean WOMAC increased from 20.61 (range, 17.4–24.2) preoperatively to 95.7 (range, 90.9–97.7) for group OA (p < 0.001) and from 20.2 (range, 16.7–24.2) preoperatively to 95.8 (range, 90.9–98.5) for group RA (p < 0.001). The mean ROM improved from 80.14° (range, 55°–130°) preoperatively to 113.17° (range, 95°–140°) in group OA (P = 0.003) and from 73.4° (range, 10°–130°) to 112.8° (range 90°–140°) in group RA (P = 0.003) postoperatively. The frequency of AKP was 8% in Group OA and 7% in Group RA (p = 0.27). For patients with AKP, the mean AKP Scale was 92.74 (range, 84–98) in Group OA and 93.39 (range, 82–98) in Group RA (p = 0.3). ConclusionAfter TKA without resurfacing the patella, patients with RA were determined to have a similar risk for AKP as those with OA. Level of evidenceLevel III, Therapeutic Study.

Treatment of finger phalangeal fractures using the Ichi-Fixator system: A prospective study of 12 cases

External fixators are an effective treatment option for comminuted or unstable phalangeal fractures. We developed a new linked-wire type of external fixator (the Ichi-Fixator) for finger phalangeal fractures, which enables fine adjustment of the fixation under fluoroscopy guidance either in a static way or with distraction through small screws inside the fixator. This technique was designed to improve on the stability and rigidity of conventional percutaneous Kirchner wire fixation. We assessed the effectiveness of the fixator through 12 cases of open or percutaneous fixation in comminuted or unstable phalangeal fractures. All patients were examined for postoperative complications, functional recovery, pain on visual analog scale (VAS), and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score at the final follow-up visit. Patients could perform all routine activities with normal grip strength and a full range of hand motion without pain after treatment. This treatment, which reduces the postoperative discomfort and may allow an immediate return to work, will clearly boost patient satisfaction. Linked-wire type external fixation enhances the security of fixation, facilitates postoperative mobilization, and may allow an immediate return to work.

Long-term Clinical Outcomes of Ahmed and Baerveldt Drainage Device Surgery for Pediatric Glaucoma Following Cataract Surgery.

In this retrospective case series, both Baerveldt and Ahmed glaucoma drainage devices resulted in good long-term outcomes in eyes with pediatric glaucoma following cataract surgery (GFCS). The aim of this study was to describe the long-term safety and efficacy of primary glaucoma drainage device surgery in patients with pediatric GFCS. We retrospectively identified 28 eyes of 28 patients with GFCS that underwent tube shunt surgery with the Ahmed Glaucoma Valve or Baerveldt Glaucoma Implant. The primary outcome measure was a surgical failure, defined as intraocular pressure (IOP) >21 mm Hg or not reduced by 20% below baseline on 2 consecutive follow-up visits after 3 months, IOP <5 mm Hg on 2 consecutive follow-up visits after 3 months, and reoperation for glaucoma. The mean duration between cataract removal and the diagnosis of glaucoma was 3.6±1.5 years. Kaplan-Meier survival curves indicated a mean time to failure of 41.9±2.1 months after drainage device surgery. The cumulative probability of failure at 1, 2, 3, and 4 years was 3.6%, 19%, 28%, and 28%. IOP was significantly decreased from 29.3±4.1 mm Hg preoperatively to 17.6±1.6 mm Hg at the final follow-up visit (P<0.001). The number of glaucoma medications at baseline was 3.1±0.6, which decreased to 2.1±0.7 at the final visit (P=0.001). Glaucoma drainage device surgery results in good long-term outcomes in patients with GFCS.

Long-Term Effect of a Treatment Protocol for Acute Ocular Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

To describe the long-term effect of a treatment protocol for ocular involvement in acute Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), including focused ocular examination and pathology-appropriate use of lubrication, topical corticosteroids, topical antibiotics, and amniotic membrane transplantation (AMT). Retrospective, comparative case series. A total of 48 patients (96 eyes) were included in this study. Nine of 48 patients (18 eyes) had acute SJS/TEN from 2000 to 2007 and did not receive protocol care (Group I). Thirty-nine of 48 patients (78 eyes) had acute SJS/TEN from 2008 to 2017 and received protocol care (Group II). The main outcome measures were best-corrected visual acuity (BCVA) at final follow-up visit and incidence of complications in the chronic phase. No eyes in Group I received AMT for SJS/TEN, compared to 87% of qualifying eyes in Group II (P < .0001) There was a significant difference in the proportion of eyes with BCVA ≥20/40 at last follow-up between Group I and Group II (33% vs 92%, P<.001). The proportion of eyes with vision-threatening complications in the chronic phase was significantly higher in Group I versus Group II (67% vs 17%, P= .002), with most complications occurring in the first 2 years after disease onset in both groups. A specific protocol for acute ocular care in SJS/TEN, including aggressive use of AMT, was highly successful in reducing corneal blindness and severe vision-threatening complications of the disorder.

Retinoschisis: A Predictive Factor in Vitrectomy for Lamellar Macular Holes in Highly Myopic Eyes

Purpose: To evaluate the effect of pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling for lamellar macular hole (LMH) with or without macular retinoschisis in highly myopic eyes. Methods: In this retrospective, consecutive case-control study, 21 highly myopic patients (22 eyes) with LMH were divided into two groups based on preoperative optical coherence tomography (OCT): the “flat group” had no macular retinoschisis (n = 10), and the “retinoschisis group” had macular retinoschisis (n = 12). The average follow-up time was 17.2 ± 12.6 months. Outcomes were based on 6-month postoperative best-corrected visual acuity (BCVA), integrity of the ellipsoid zone (EZ), external limiting membrane (ELM), and residual foveal thickness (RFT). Results: The appearance of the macula on OCT was normalized in 19 eyes (86.3%) at the final follow-up visit. Compared to the flat group, the retinoschisis group presented a significantly higher incidence of epiretinal membrane (p = 0.046) and lower refractive error (p = 0.033), shorter axial length (p = 0.0009), better integrity of ELM and EZ (p = 0.005 and p = 0.005, respectively), and better preoperative and postoperative BCVAs (p = 0.015). Conclusions: PPV is an effective method to achieve a high anatomical success, improve postoperative vision, and prevent foveal thinning in highly myopic eyes with LMH. In these eyes, the presence of retinoschisis strongly indicates the need for vitrectomy.

Safety and efficacy of microwave ablation for benign thyroid nodules and papillary thyroid microcarcinomas: A systematic review and meta-analysis

PurposeTo summarize the published literature on microwave ablation (MWA) for the treatment of benign thyroid nodules and papillary thyroid microcarcinomas, and to evaluate the effectiveness and safety of MWA as a novel treatment strategy. MethodsTwo independent authors carried out the literature search using four databases, including PubMed, Embase, Cochrane, and Web of Science. The meta-analysis included prospective and retrospective data that compared pre-treatment values to post-treatment outcomes. ResultsFrom the 33 original articles, seven studies met the inclusion criteria for this meta-analysis. Of these, five were retrospective studies, two were prospective trials, one was controlled study, and one was a multi-center study. The results showed significant improvements in nodule volume, clinical symptom scores, and beauty scores between the baseline and final follow-up visits. In all of the studies, the most common adverse effects were hematomas, unbearable pain, and transient or permanent voice change in 3.8%, 2.2%, and 4.6% of patients, respectively. None of these incidents resulted in hospitalization or death. ConclusionsMWA is effective and safe for the treatment of benign thyroid nodules and papillary thyroid microcarcinomas. However, future studies should compare the efficacy of MWA, RFA, and surgical intervention.

Lateral column lengthening augmented by medial split tibialis posterior tendon advancement for the treatment of symptomatic flexible flatfeet

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Management of Idiopathic flexible pes planus (IFPP) is debatable. Surgery is rarely indicated for flexible flatfoot. The goal of the surgery should be always to treat symptomatic patients and not to alter the shape of the foot. There are numerous options for surgical treatment in children and adolescents including subtalar arthroereisis or osteotomy with or without soft tissue procedures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Between June 2013 to December 2017, twenty eight feet in sixteen patients (9 boys, 7 girls) were included in this study. Twelve cases were operated bilaterally, three in the right foot and one in the left side. The mean age of the patients was 8.36±1.704 years (6-12 years). Calcaneal lengthening osteotomy was done with an oscillating saw about 1.5 cm proximal to the calcaneocuboid joint. Usually, 8-10 mm autologous bone graft from iliac crest was sufficient and fixed by K wires. Half of the tibialis posterior tendon after splitting with a periosteal flap from the navicular was then advanced distally until clinical restoration of the medial arch was then performed.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Radiographic analysis revealed significant improvements in talo-first metatarsal, calcaneal pitch, talocalcaneal angles in lateral radiographs, and talo-first metatarsal and talonavicular coverage angles in AP radiographs. All patients were evaluated at final follow-up visits. Preoperative mean AOFAS score increased significantly from 64.04±8.867 (range: 50 to75) to 94.11±3.765 (90-100).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; It is concluded that Evans calcaneal lengthening osteotomy augmented by spilt tibialis posterior tendon advancement is an excellent procedure in the management of IFPP.&lt;/p&gt;

Effect of Using a Simulation Device for Ostomy Self-care Teaching in Iran: A Pilot, Randomized Clinical Trial

The aim of this pilot study was to determine the effects of simulation in ostomy self-care training on self-efficacy and adjustment. A randomized clinical trial was conducted among patients at 2 public medical center surgical units in eastern Iran from April 2015 to December 2015 using consecutive sampling. Patients who spoke Persian, were 18 to 65 years of age, had a temporary or permanent intestinal stoma, and did not have comorbidities that might interfere with self-care teaching were invited to participate and randomly allocated to the simulation (SG) or the control group (CG). Both groups were provided 4 training sessions; the first and fourth session was the same for each group, but in sessions 2 and 3, the SG group used a wearable stoma simulator, whereas the CG group used the demonstration-return method. Demographic and stoma variables were collected, and the Stoma Self-Efficacy Scale (SSES) and Ostomy Adjustment Inventory-23 (OAI-23) were administered at baseline (following surgery), after 4 instructional sessions, and 45 days following the last education session. Descriptive statistics and chi-squared, Fisher's exact, Mann-Whitney U, repeated measure, and least significant difference tests were used to analyze the data. Of the 53 patients enrolled, 46 (23 in each group) completed the study. Mean age for SG and CG patients was 45.91 ± 10.40 and 53.78 ± 9.15, respectively (P = .009). The majority of patients were female (SG: 11 [47.8%]; CG: 14 [60.9%]), married (SG: 20 [87.0%]; CG: 19 [82.6%]), and had a diagnosis of cancer (SG: 20 [87.0%]; CG: 21 [91.3%]). The mean SSES score for stoma self-efficacy was 103.82 ± 15.81 in the SG and 89.91 ± 13.41 in the CG after the fourth session. Results indicated an improvement in self-efficacy in both groups from baseline to final follow-up visit (P <.0001). SSES in the SG was significantly different from baseline to final follow-up visit during the study (F = 3.183, P = .008). Mean OAI-23 scores were 51.04 ± 13.37 in the SG and 50.82 ± 13.84 in the CG at baseline and after the intervention (fourth session) were 60.56 ± 16.41 in the SG and 53.95 ± 13.22 in the CG group. The repeated measure test results indicated significant increases in adjustment scores from baseline to final follow-up visit in both groups (P = .000). The results of this pilot study suggest that using simulation to teach ostomy self-care improves self-efficacy after 3 and 9 weeks. Further randomized controlled trials that expand the sample size and demographic should be conducted.

A unidirectional porous beta-tricalcium phosphate material (Affinos®) for reconstruction of bony defects after excision of fibular bone for spinal surgery graft

The aim of this study was to elucidate the bone regeneration-inducing capability of Affinos®, a newly developed, high-porosity unidirectional porous β-TCP artificial bone. We compared the ability of Affinos® and OSferion®, a commercially available β-TCP product, to induce bone regeneration following implantation into bony defects left after fibula harvesting for spinal fusion surgery.Study subjects underwent surgery to harvest non-vascularized fibula grafts for spinal fusion surgery and were implanted with either Affinos® (19 patients) or OSferion® (15 patients, control group) at the defect site. The minimal and mean follow up periods were 6 and 11 months after surgery, respectively. X-rays of the lower leg taken 1–2 weeks after surgery and at the final follow-up visit were used to evaluate fibular-β-TCP continuity and fibula defect filling ratio.There was no significant difference in radiographic continuity in the fibula between the two groups. The fibula defect filling ratio for the Affinos® group decreased from 0.94 ± 0.17 at 1–2 weeks to 0.77 ± 0.14 at 10 months. For the OSferion® control group, the fibula defect filling ratio decreased from 0.94 ± 0.14 at 1–2 weeks to 0.52 ± 0.27 at final follow-up. The Affinos® group showed a significantly higher fibula defect filling ratio compared to that for the OSferion® group (p = 0.003).These results indicate that Affinos® has slow absorption rates and significant defect filling activity compared with OSferion®. Thus, Affinos® could be a suitable substitute to fill bony defects induced by fibula harvesting for spinal reconstruction surgery.

Intravitreal injection of C3F8 in the treatment of vitreomacular traction syndrome

Objective To evaluate the efficacy of single intravitreal injection of C3F8 in treating vitremacular traction (VMT) syndrome. Methods A retrospective case series of 38 eyes of 36 patients affected with VMT syndrome in Department of Ophthalmology, Central Theater Command General Hospital from March 2016 to June 2017 were enrolled in this study. There were 16 males (16 eyes) and 20 females (22 eyes), with the mean age of 64.11±9.49 years and the mean courses of 151.55±127.87 days. All the patients received an intravitreal injection of 0.3 ml of 100% C3F8 within one week. The BCVA examination was performed using the international standard visual acuity chart, which was converted into logMAR visual acuity. The severity of metamorphopsia was detected using M-charts. The extent of vitreomacular adhesion (VMA), central macular thickness (CMT) and the status of ellipsoid zone (EZ) were assessed with spectral-domain OCT at baseline and each month after treatment. The average BCVA was 0.58±0.22. The mean horizontal metamorphopsia (MH) and vertical metamorphopsia (MV) were 0.34±0.30 and 0.50±0.42, respectively. The mean CMT was 415.15±89.59 μm. The mean horizontal VMA was 1168.68±400.61 μm (30 eyes with VMA≤1500 μm and 8 eyes with VMA>1500 μm). The mean vertical VMA was 976.89±295.92 μm. There were 22 eyes with integrity EZ and 16 eyes without integrity EZ, 33 eyes with crystalline lens and 5 eyes with IOL. The mean follow-up time was 10.7 months. The differences in BCVA, MH, MV, CMT, the integrity of EZ before and after treatment were analyzed. The VMT release rates were assessed. The Spearman rank correlation analysis was performed to investigate the relationship of VMT release rates with the data at baseline. Results Vitreomacular traction release occurred in 29 of 38 eyes by the final follow-up visit, the VMT release rate was 76.3%. VMT release occurred and the average time of VMT release occurred was 2.2 weeks. VMT persisted in 7 eyes, in the rest two eyes, one eye developed a retinal detachment and another eye formed macular hole, both eyes responded to vitrectomy. At 6 months after treatment, the average logMAR BCVA was 0.43±0.23, the mean MH and MV were 0.25±0.23 and 0.24±0.23, the mean CMT was 310.61±63.10 μm. Among 16 eyes without integrity EZ before treatment, there were 9 eyes with integrity EZ at 6 months after treatment. There were 16 eyes with integrity EZ and 9 Compared with baseline, the mean BCVA at 6 months after treatment was significantly increased (F=3.779, P=0.037), but the MV (F=4.958, P =0.003) and CMT (F=13.419, P<0.001) were significantly decreased, the integrity of EZ was improved significantly (χ2=5.050, P=0.025). The VMT release correlated inversely with the extent of horizontal VMA, BCVA, and CMT at baseline (r=-0.514, -0.348, -0.429; P=0.009, 0.001, 0.038). Conclusion Intravitreal injection of C3F8 can induce a posterior vitreous detachment and release vitreomacular traction, it is an efficient and safe treatment for VMT syndrome. It can improve the visual acuity, metamorphopsia and foveal morphology in patients with VMT syndrome. Key words: Noble gases/therapeutic use; Treatment outcome; Vitreomacular traction syndrome