Fixation Procedures Research Articles

Trends and Risk Factors for Surgical Site Infection after Treatment of the Ankle Fracture: National Cohort Study.

Surgical site infection (SSI) is a major complication after the surgical treatment of ankle fractures that can result in catastrophic consequences. This study aimed to determine the incidence of SSI in several cohorts from national insurance databases over the past 12 years and identify its predictors. The claimed data for patients (n = 1,449,692) with ankle fractures between 2007 and 2019 were investigated, and a total of 41,071 patients were included in the final analysis. The covariates included were age, sex, season, fracture type (closed vs. open), type of surgical fixation procedure, and comorbidities of each patient. All subjects were divided into two groups according to the SSI after the surgical fixation of the ankle fracture (no infection group vs. infection group). The number of SSIs after the surgical treatment of ankle fractures was 874 (2.13%). Open fractures [odds ratio, (OR) = 4.220] showed the highest risk for SSI, followed by the male sex (OR = 1.841), an increasing number of comorbidities (3-5, OR = 1.484; ≥6, OR = 1.730), a history of dementia (OR = 1.720) or of myocardial infarction (OR = 1.628), and increasing age (OR = 1.010). The summer season (OR = 1.349) showed the highest risk among the four seasons for SSI after ankle fracture surgery.

Use of the iliac-outlet and iliac-inlet combined views in percutaneous posterior column retrograde screw fixation

Posterior column fractures are common acetabular injuries. Although displaced fractures require open reduction and fixation, undisplaced patterns may benefit from percutaneous screw fixation. The combination of iliac oblique with inlet and outlet views offers an intuitive and panoramic rendering of the bony corridor into the posterior column; lateral cross table view completes the sequence of fluoroscopic projections. Herein we describe the use of outlet/inlet iliac views and a detailed procedure for percutaneous retrograde posterior column screw fixation.

Benefits of Erector Spinae Block in lumbar Vertebral Surgical Fixation Procedures; Beyond the Perioperative Analgesic Outcomes

Benefits of Erector Spinae Block in lumbar Vertebral Surgical Fixation Procedures; Beyond the Perioperative Analgesic Outcomes

Short and Middle Functional Outcome in the Static vs. Dynamic Fixation of Syndesmotic Injuries in Ankle Fractures: A Retrospective Case Series Study.

Syndesmotic injuries are common lesions associated with ankle fractures. Static and dynamic fixation are frequently used in syndesmotic injury-associated ankle fractures. The purpose of this study is to compare short- and mid-term quality of life, clinical outcomes, and gait after static stabilization with a trans-syndesmotic screw or dynamic stabilization with a suture button device. Here, 230 patients were enrolled in a retrospective observational study. They were divided in two groups according to the fixation procedure (Arthrex TightRope®, Munich, Germany) synthesis vs. osteosynthesis with a 3.5 mm trans-syndesmotic tricortical screw). They then underwent clinical assessment using the American Foot and Ankle Score (AOFAS) at 1, 2, 6, 12, and 24 months after surgery. Quality of life was assessed according to the EuroQol-5 Dimension (EQ-5D) at 2 and 24 months after surgery in the follow-up; gait analysis was performed 2 and 24 months postoperatively. Significant differences were found at a two-month follow-up according to the AOFAS (p = 0.0001) and EQ-5D (p = 0.0208) scores. No differences were noted in the other follow-ups (p > 0.05) or gait analysis. The dynamic and static fixation of syndesmotic injuries in ankle fracture are both efficacious and valid procedures for avoiding ankle instability. The suture button device was comparable to the screw fixation according to functional outcomes and gait analysis.

Effects of electroacupuncture at "Siguan" points on the expression of colonic 5-hydroxytryptamine and fecal short-chain fatty acids in rats with post-stroke depression

To observe the effects of electroacupuncture at "Siguan" points on behavior, colonic 5-hydroxytryptamine (5-HT) and fecal short-chain fatty acids (SCFAs) in rats with post-stroke depression (PSD), and explore the effect mechanism of electroacupuncture at Siguan points on PSD. Fifty SD rats were randomly divided into a sham-operation group, a stroke group, a PSD group, a drug group and an electroacupuncture group, with 10 rats in each one. The stroke model was established by middle cerebral artery occlusion (MCAO) method in the stroke group; except for the sham-operation group, the rats in the other groups were intervened with MCAO combined with solitary and chronic unpredictable mild stress (CUMS) to establish PSD model. In the electroacupuncture group, electroacupuncture was delivered at "Hegu" (LI 4) and "Taichong" (LR 3), with disperse-dense wave, 2 Hz/10 Hz in frequency, for 30 min in each intervention, once daily, for consecutive 21 days. Simultaneously, distilled water (0.01 L•kg-1•d-1) was administrated intragastrically. Fluoxetine solution (2.33 mg•kg-1•d-1) was given by gavage , once a day and for 21 days in the drug group. The same procedure of fixation and gavage with distilled water were adopted in the sham-operation group, the stroke group and the PSD group. Separately, before stroke modeling, after PSD modeling and after 21-day intervention, the consumption of sugar water and the scores of horizontal movement and vertical movement in open-field test were observed. After 21-day intervention, the content of colonic 5-HT was detected by immunohistochemical method, and that of fecal SCFAs was determined by gas chromatography mass spectrometry. After PSD modeling, compared with the stroke group, the sugar water consumption, the horizontal movement scores and vertical movement scores of the open-field test were all reduced in the PSD group, the drug group and the electroacupuncture group (P<0.05). After 21-day intervention, the sugar water consumption and the scores of horizontal movement and vertical movement of the open-field test were increased in the drug group and the electroacupuncture group (P<0.05) when compared with the PSD group; and the horizontal movement score in the electroacupuncture group was lower than that of the drug group (P<0.05). Compared with the sham-operation group, the contents of total fecal SCFAs and acetic acid were lower in the stroke group (P<0.05), and the contents of colonic 5-HT and total fecal SCFAs, acetic acid, propionic acid and butyric acid were reduced in the PSD group (P<0.05). In comparison with the PSD group, the contents of colonic 5-HT and total fecal SCFAs, acetic acid and propionic acid were increased in the drug group and the electroacupuncture group (P<0.05); and the content of colonic 5-HT in the electroacupuncture group was lower than that of the drug group (P<0.05). The level of colonic 5-HT was positively correlated with the contents of total fecal SCFAs and propionic acid (r=0.424, P=0.005; r=0.427, P=0.004). Electroacupuncture at "Siguan" points can relieve the depression-like behavior of PSD rats, and its underlying mechanism may be related to the regulation of fecal SCFAs, which affects the release of colonic 5-HT.

Effects of electroacupuncture at "Siguan" points on the expression of colonic 5-hydroxytryptamine and fecal short-chain fatty acids in rats with post-stroke depression

To observe the effects of electroacupuncture at "Siguan" points on behavior, colonic 5-hydroxytryptamine (5-HT) and fecal short-chain fatty acids (SCFAs) in rats with post-stroke depression (PSD), and explore the effect mechanism of electroacupuncture at Siguan points on PSD.Fifty SD rats were randomly divided into a sham-operation group, a stroke group, a PSD group, a drug group and an electroacupuncture group, with 10 rats in each one. The stroke model was established by middle cerebral artery occlusion (MCAO) method in the stroke group; except for the sham-operation group, the rats in the other groups were intervened with MCAO combined with solitary and chronic unpredictable mild stress (CUMS) to establish PSD model. In the electroacupuncture group, electroacupuncture was delivered at "Hegu" (LI 4) and "Taichong" (LR 3), with disperse-dense wave, 2 Hz/10 Hz in frequency, for 30 min in each intervention, once daily, for consecutive 21 days. Simultaneously, distilled water (0.01 L•kg-1•d-1) was administrated intragastrically. Fluoxetine solution (2.33 mg•kg-1•d-1) was given by gavage , once a day and for 21 days in the drug group. The same procedure of fixation and gavage with distilled water were adopted in the sham-operation group, the stroke group and the PSD group. Separately, before stroke modeling, after PSD modeling and after 21-day intervention, the consumption of sugar water and the scores of horizontal movement and vertical movement in open-field test were observed. After 21-day intervention, the content of colonic 5-HT was detected by immunohistochemical method, and that of fecal SCFAs was determined by gas chromatography mass spectrometry.After PSD modeling, compared with the stroke group, the sugar water consumption, the horizontal movement scores and vertical movement scores of the open-field test were all reduced in the PSD group, the drug group and the electroacupuncture group (P<0.05). After 21-day intervention, the sugar water consumption and the scores of horizontal movement and vertical movement of the open-field test were increased in the drug group and the electroacupuncture group (P<0.05) when compared with the PSD group; and the horizontal movement score in the electroacupuncture group was lower than that of the drug group (P<0.05). Compared with the sham-operation group, the contents of total fecal SCFAs and acetic acid were lower in the stroke group (P<0.05), and the contents of colonic 5-HT and total fecal SCFAs, acetic acid, propionic acid and butyric acid were reduced in the PSD group (P<0.05). In comparison with the PSD group, the contents of colonic 5-HT and total fecal SCFAs, acetic acid and propionic acid were increased in the drug group and the electroacupuncture group (P<0.05); and the content of colonic 5-HT in the electroacupuncture group was lower than that of the drug group (P<0.05). The level of colonic 5-HT was positively correlated with the contents of total fecal SCFAs and propionic acid (r=0.424, P=0.005; r=0.427, P=0.004).Electroacupuncture at "Siguan" points can relieve the depression-like behavior of PSD rats, and its underlying mechanism may be related to the regulation of fecal SCFAs, which affects the release of colonic 5-HT.目的：观察电针“四关”穴对卒中后抑郁（PSD）大鼠行为学、结肠5-羟色胺（5-HT）、粪便短链脂肪酸（SCFAs）的影响，探讨电针四关穴治疗PSD的作用机制。方法：将50只SD大鼠随机分为假手术组、卒中组、PSD组、药物组和电针组，每组10只。除假手术组外，其余各组采用大脑中动脉栓塞（MCAO）法制备卒中模型；除假手术组和卒中组外，其余组大鼠采用MCAO结合孤养和慢性不可预知性温和应激（CUMS）法制备PSD模型。电针组予电针“合谷”“太冲”干预，疏密波，频率2 Hz/10 Hz，每次30 min，每日1次，持续21 d，同时予蒸馏水（0.01 L•kg-1•d-1）灌胃；药物组予氟西汀溶液（2.33 mg•kg-1•d-1）灌胃，每日1次，持续21 d；假手术组、卒中组、PSD组予同等固定束缚、蒸馏水灌胃。分别于卒中造模前、PSD造模后、干预21 d后观察大鼠糖水消耗量及敞箱实验水平运动得分、垂直运动得分；干预21 d后，采用免疫组化法检测结肠5-HT水平，气相质谱法测定粪便短链脂肪酸含量。结果：PSD造模后，与卒中组比较，PSD组、药物组、电针组大鼠糖水消耗量及敞箱实验水平运动得分、垂直运动得分均降低（P<0.05）。干预21 d后，与PSD组比较，药物组、电针组糖水消耗量及敞箱实验水平运动得分、垂直运动得分均升高（P<0.05）；电针组水平运动得分低于药物组（P<0.05）。与假手术组比较，卒中组粪便总短链脂肪酸及乙酸含量均降低（P<0.05），PSD组结肠5-HT水平及粪便总短链脂肪酸、乙酸、丙酸、丁酸含量均降低（P<0.05）；与PSD组比较，药物组和电针组结肠5-HT水平及粪便总短链脂肪酸、乙酸、丙酸含量均升高（P<0.05）；电针组结肠5-HT水平低于药物组（P<0.05）。结肠5-HT水平与粪便总短链脂肪酸、丙酸含量存在正相关关系（r=0.424，P=0.005；r=0.427，P=0.004）。结论：电针“四关”穴可改善PSD大鼠抑郁样行为，可能与调控粪便短链脂肪酸含量，从而影响结肠5-HT释放有关。.

Concomitant valgus hip osteotomy in operative fixation of displaced proximal femoral neck fractures.

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs). In the first series, 98 hip fixation procedures were performed using CCS. After fluoroscopic reduction of the fracture, three CCSs were placed. In the second series, 105 VOOF procedures were performed using a closing wedge intertrochanteric osteotomy with a compression lag screw and lateral femoral plate. The alignment goal was to create a modified Pauwel's fracture angle of 30°. After fluoroscopic reduction of fracture, lag screw was placed to achieve the calculated correction angle, followed by inter-trochanteric osteotomy and placement of barrel plate. Patients were followed for a minimum of two years. Mean follow-up was 4.6 years (4.1 to 5.0) in the CCS group and 5.5 years (5.25 to 5.75) in the VOOF group. The mean Harris Hip Score at two-year follow-up was 83.85 in the CCS group versus 88.00 in the VOOF group (p < 0.001). At the latest follow-up, all-cause failure rate was 29.1% in the CCS group and 11.7% in the VOOF group (p = 0.003). The total cost of the VOOF technique was 7.2% of a THA, and total cost of the CCS technique was 6.3% of a THA. The VOOF technique decreased all-cause failure rate compared to CCS. The total cost of VOOF was 13.5% greater than CCS, but 92.8% less than a THA. Increased cost of VOOF was considered acceptable to all patients in this series. VOOF technique provides a reasonable alternative to THA in patients who cannot afford a THA procedure.

Airway Management of Thyroid Malignancy with Cervical Spine Metastasis for a Two-Stage Dual Procedure; Discretion Dictates Never Burn Your Bridges

Thyroid swellings are a known cause of airway obstruction and potentially difficult intubation due to compression and deviation of the trachea. We encountered a unique challenging case of a malignant retrosternal goitre compressing the trachea, with cervical spine metastasis causing paresthesia and weakness in all four limbs, for a two-stage dual procedure, embolisation and excision of thyroid, and embolisation and fixation of the cervical spine.

The Outcome of Orthopedics Treatment of Lombok Earthquake Victim 2018: A Cohort of One-Year Follow-Up Study-Lesson Learned After Lombok Earthquake.

There was a magnitude 7 on the Richter scale earthquake on Lombok Island in 2018, causing more than 500 deaths. In the event of earthquakes, there is often an imbalance between overcrowding in hospitals and inadequate resources. The initial management of earthquake victims with musculoskeletal injuries is controversial, arguing over whether to utilize debridement, external or internal fixation, or conservative or operative treatment in an acute onset disaster situation. This study aims to determine the outcome of initial management after the 2018 Lombok earthquake, between immediate open-reduction and internal fixation (ORIF) and Non-ORIF procedures after one year follow-up. This is a cohort study to evaluate radiological and clinical outcomes one year after orthopedic treatment in the Lombok earthquake 2018. The subjects were recruited from eight public health center and one hospital in Lombok in September 2019. We evaluate radiological outcomes (non/malunion and union) and clinical outcomes (infection and SF-36 score). Based on 73 subjects, the ORIF group has a higher union rate than the non-ORIF group (31.1% vs. 68.9%; p = 0.021). Incidence of infection only appeared in the ORIF group (23.5%). Clinical outcome as measured by SF36 showed the ORIF group had a lower mean of general health (p = 0.042) and health change (p = 0.039) clinical outcomes than the non-ORIF group. The most affected public group is the productive age with significant impact on social-economy. ORIF procedure is a major risk factor of infection in initial treatment after earthquake. Therefore, definitive operation with internal fixation is not recommended in the initial phase of a disaster. Damage Control Orthopedic (DCO) surgery protocol is the treatment of choice in acute disaster setting. The ORIF group had better radiological outcomes than the non-ORIF group. However the ORIF group had higher cases of infection and lower SF-36 than the non-ORIF group. Definitive treatment in acute onset disaster setting should be prevented.

Risk factors affecting the outcome of management of intertrochanteric fractures with dynamic hip screw in elderly patients: a retrospective, observational study

Background: Among the different fixation procedures for intertrochanteric fractures, dynamic hip screw fixation is the most used therapy. Present study evaluated the risk factors affecting the outcome of intertrochanteric fractures managed by dynamic hip screw fixation. Methods: This was an observational retrospective study conducted between March 2021 and February 2022. Patients with intertrochanteric fractures aged &gt;60 years presenting within a week after incurring the fractures were enrolled. Evan’s and AO/OTA classification were used to categorize patients. “Failed” surgery was considered based on one of the following radiographic criteria. Functional outcomes were assessed at 6-months by Harris hip score (HHS). Results: 40 patients were enrolled, majority being females (n=22, 55%) with mean age of 67.79±4.76 years. Commonest mode of injury was fall while standing (n=32, 80%). Based on Evans classification, majority cases were stable fractures (n=25, 62.5%). By the AO/OTA classification, majority patients were under A2 class (n=22, 55%). The 30 cases (75%) had outstanding to good outcomes based on HHS assessment. 8 patients (20%) had “failed” surgical outcomes of which commonest presentations were &gt;20 mm lag screw pull-out (n=4, 10%) and mal union (n=2, 5%). Mean age, and number of obese patients were found to be significantly greater in the “failed fracture” subgroup, versus “united fracture” subgroup (p&lt;0.05). Significantly greater number of cases in “failed fracture” subgroup belonged to Evans’ class IV or V, and to A3 class of AO/OTA classification (p&lt;0.05). Conclusions: Patient factors like greater age, obesity and intertrochanteric unstable fractures as indicated by Evans’ and AO/OTA classification were risk factors affecting the outcome of intertrochanteric fractures, managed with dynamic hip screw.

Abstract 2116: Phosphorylated extracellular signal-regulated kinase (pERK) activation in T effector cells as a target engagement biomarker for the DGKζ inhibitor BAY2965501 in clinical trials

Abstract Introduction: BAY2965501 is a small molecule that is a potent selective inhibitor of diacylglycerol kinases zeta (DGKζ). DGK are a family of enzymes that catalyzes the phosphorylation of the membrane lipid sn-1,2 diacylglycerol (DAG) to form phosphatidic acid. In T-cells, DGKζ is considered to play a key role in T-cell receptor (TCR) signaling. One of the signaling pathways controls T-cell proliferation and activation in response to antigen receptor engagement is controlled by extracellular-regulated kinase ERK1 and ERK2 (ERK1/2). The RASGRP/ERK pathway plays a crucial part the polarization of microtubule-organizing center in the cytotoxic T-cells, which is required to deliver granzyme to the targeted cells. Restoring T-cell cellular DAG level and activation of ERK1/2 in anergic T-cells via DGK inhibition has been considered a viable mechanism to assist T-cell mediate tumor cell kill. BAY2965501 showed that pERK could be activated in preclinical models. Phosphorylation of ERK (pERK) inhibition in tumor cells and its difficulty in clinical implementation has been largely acknowledged in oncology community. Circulating T-cell pERK changes as a target engagement biomarker may provide a plausible solution in clinical trial. Here, we report a development of a fit-for-purpose pERK+CD8+ assay. Method: Feasibilities to detect BAY2965501 induced pERK activation was tested to minimize the expected clinical hurdles by using various conditions such as various blood collection tubes (BCT), CD3/CD28 concentrations, and incubation times were evaluated. Whole blood was stimulated with BAY2965501 followed by activation with anti-CD3/anti-CD28 cocktail with subsequent lysis and fixation procedure including freezing. Samples were then stained with antibodies against T-cell cell-surface markers and anti-pERK antibody followed by analyzing on a flow cytometer. Results: A pERK+CD8+ cell frequency increase was successfully observed after stimulation with BAY2965501 at different concentrations (e.g., 12.89% spiked vs. 30.42% non-spiked). A peak of pERK+CD8+ cell frequency was observed with incubation of anti-CD3/CD28 at 15 min compared to 5 min or 30 min. Titration of anti-CD3/anti-CD28 cocktail resulted in saturation observed at a concentration of 2 µg/mL (range 1-4 µg/ml). Three collection tubes were tested; 1) Sodium heparin (SoHep); 2) Citrate and 3) TruCulture. SoHep showed the highest pERK+ CD8+ cell frequency (8.29%) compared to Citrate BCT or TruCulture. Activated and stimulated samples are stable at -80°C for at least 6 days (D0 30.42% vs D6-80°C 29.52%) although samples are not stable at ambient or cooled conditions (D0 12.38% vs D1RT 3.02% vs D14°C 7.66%). Conclusion: These findings support implementing the pERK+CD8+ assay in T cells as a target engagement biomarker during early phase clinical trials. Citation Format: Nicole Schubert, Dennis Kirchhoff, Joumana Zeidan, Joanie Duchesne, Philip Boulais, Yuko Ishii. Phosphorylated extracellular signal-regulated kinase (pERK) activation in T effector cells as a target engagement biomarker for the DGKζ inhibitor BAY2965501 in clinical trials [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2116.

The Routine Use of Running Subcuticular Closures in Orthopaedic Trauma Patients Does Not Increase Wound Complications.

To investigate if the routine use of running subcuticular closures (RSC) in orthopaedic trauma patients increases the rate of wound complications and reoperations. Retrospective comparative study. Urban level 1 trauma centerPatients/Participants: 266 patients undergoing orthopaedic trauma procedures between June 2020 and March 2022. Adoption of a RSC protocol where any incision/wound that could be approximated with interrupted subcuticular 2-0 monofilament sutures was instead closed with a running subcuticular 3-0 monofilament suture. Wound complications and subsequent reoperations. With adoption of the RSC protocol, 91.0% of all orthopaedic trauma procedures were closed with RSC compared to 7.5% of the historical control group. There were no observed differences in the rate of wound complications (proportional difference (PD) 6.0%, confidence interval (CI) -2.3 to 14.1%; p=0.15) or reoperations (PD 5.2%, CI -1.9 to 12.2%; p=0.14) between the RSC and the control group. Wound complications were not associated with RSC on univariate analysis (PD 7.2%, CI -10.0 to 24.0%; p=0.41). On multivariate analysis, an ASA>2 (odds ratio (OR) 2.4, CI 1.0 to 5.7; p=0.03), lower extremity injuries (OR 4.9, CI 1.3 to 17.8; p=0.01), and open reduction internal fixation procedures (OR 2.8, CI 1.1 to 7.2; p=0.02) were found to be independently associated with wound complications. RSC for orthopaedic trauma procedures was not associated with increased wound complications when compared to a historical cohort.

Association of Hip Fracture With the Use of Walking Assistance Devices Post-surgery: A Retrospective Study Comparing Intertrochanteric and Subtrochanteric Hip Fractures.

Background Hip fractures, including intertrochanteric and subtrochanteric fractures, are among the most common types of fractures. The dynamic hip screw (DHS) and the cephalomedullary hip nail (CHN) are the two main techniques used for the fixation of these types of fractures. This study aims to explore the association of the fracture type with the use of walking assistance devices post-surgery, regardless of the fixation technique. Methodology This study is a retrospective study based on the review of de-identified patient data from the American College of Surgeons National Surgical Quality Improvement Program database. Patients aged 65 years old or above who underwent fixation procedures for intertrochanteric or subtrochanteric fractures using CHN or DHS techniques were included in this study. Results A total of 8,881 patients were included and divided into the following two groups: 876 (9.9%) patients treated for subtrochanteric fracture, and 8,005 (90.1%) patients treated for intertrochanteric fracture. No statistical significance was detected in the use of mobility aid postoperatively between the two groups. When compared to CHN, DHS was noted to be the most employed fixation technique among patients with intertrochanteric fractures. One main finding was that patients who underwent surgery using DHS for intertrochanteric fractures were more likely to use walking assistance devices postoperatively compared to those with subtrochanteric fractures treated with the same fixation technique. Conclusions Findings suggest that the use of walking assistance devices post-surgery is independent of the type of fracture and potentially dependent on the fixation technique employed. Future studies focused on the difference in the use of walking assistance devices based on fixation techniques for patients with distinctive sub-types of trochanteric fractures are highly encouraged.

Sacrospinous fixation: Review of relevant anatomy and surgical technique.

Apical support is an important component of pelvic floor reconstruction for pelvic organ prolapse. Sacrospinous ligament fixation is a recognized procedure for apical support. Complications from sacrospinous ligament fixation include pain (buttock and leg) and bleeding. There is some debate as to the optimal location for placement of the sacrospinous fixation sutures. This review summarizes the neuroanatomy of the coccygeus sacrospinous ligament as it pertains to the sacrospinous ligament fixation procedure. An appreciation of the neuroanatomy will lead to a better understanding of methods to reduce operative complications and improve suture placement. This paper also describes a technique for the sacrospinous fixation procedure to better assist clinicians in dissecting the connective tissue off the ligament. Removing or clearing the connective tissue off the ligament will allow critical landmarks to be easily palpated and hence a more accurate placement of sutures. This in turn may reduce the risk of perioperative complications.

The localization of molecularly distinct microglia populations to Alzheimer's disease pathologies using QUIVER

New histological techniques are needed to examine protein distribution in human tissues, which can reveal cell shape and disease pathology connections. Spatial proteomics has changed the study of tumor microenvironments by identifying spatial relationships of immunomodulatory cells and proteins and contributing to the discovery of new cancer immunotherapy biomarkers. However, the fast-expanding toolkit of spatial proteomic approaches has yet to be systematically applied to investigate pathological alterations in the aging human brain in health and disease states. Moreover, post-mortem human brain tissue presents distinct technical problems due to fixation procedures and autofluorescence, which limit fluorescence methodologies. This study sought to develop a multiplex immunohistochemistry approach (visualizing the immunostain with brightfield microscopy). Quantitative multiplex Immunohistochemistry with Visual colorimetric staining to Enhance Regional protein localization (QUIVER) was developed to address these technical challenges. Using QUIVER, a ten-channel pseudo-fluorescent image was generated using chromogen removal and digital microscopy to identify unique molecular microglia phenotypes. Next, the study asked if the tissue environment, specifically the amyloid plaques and neurofibrillary tangles characteristic of Alzheimer's disease, has any bearing on microglia's cellular and molecular phenotypes. QUIVER allowed the visualization of five molecular microglia/macrophage phenotypes using digital pathology tools. The recognizable reactive and homeostatic microglia/macrophage phenotypes demonstrated spatial polarization towards and away from amyloid plaques, respectively. Yet, microglia morphology appearance did not always correspond to molecular phenotype. This research not only sheds light on the biology of microglia but also offers QUIVER, a new tool for examining pathological alterations in the brains of the elderly.

The "Tube Submarine Technique": a safe and easy technique to place an external drainage tube during hepaticojejunostomy in minimally invasive surgery.

Pancreaticoduodenectomy (PD) is a standard procedure for various pancreatic head lesions. Recently, minimally invasive surgery (MIS), including laparoscopic PD (LPD) or robotic PD (RPD), has been widely performed. The hepaticojejunostomy (HJ) technique in MIS is more difficult than that in open procedures, and the placement of an external drainage tube (EDT) is not common in MIS owing to its complicated procedure. Here, we demonstrate the "Tube Submarine Technique" (TST) to facilitate EDT placement without hampering the anastomotic maneuver in MIS. After resection of the MIS-PD, the jejunal stump was extracted from the umbilical incision, and a small jejunostomy was performed. A retrograde insertion of the EDT was carried out from this hole towards the jejunal stump. A 4-0 suture was applied through the tip and neighboring side hole, and ligated with a margin of approximately 1-2cm without needle release. The needle was passed through the anterior jejunal limb wall from the inside to the outside, and the tube was placed into the jejunal limb like a submarine and fixed to the anterior inside wall. After posterior wall suturing during HJ in MIS, the tube-fixing suture was cut immediately below the knot, the tube-like surface of the submarine was pulled up from the jejunal hole and inserted into the bile duct. The procedure of tube fixation inside the jejunal limb and tube surfacing was safe and easy with no complications. The TST can significantly help in the placement of an EDT in MIS.

The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse.

Historically, the sacrospinous ligament (SSL) has been used to treat POP in order to restore the apical compartment through a posterior or an anterior vaginal approach. The SSL is located in a complex anatomical region, rich in neurovascular structures that must be avoided to reduce complications such as acute hemorrhage or chronic pelvic pain. The aim of this three-dimensional (3D) video describing the SSL anatomy is to show the anatomical concerns related to the dissection and the suture of this ligament. We conducted a research of anatomical articles about vascular and nerve structures located in the SSL region, in order to increase the anatomical knowledge and show the best placement of sutures to reduce complications related to SSL suspension procedures. We showed the medial part of the SSL to be most suitable for the placement of the suture during SSL fixation procedures, in order to avoid nerve and vessel injuries. However, nerves to the coccygeus and levator ani muscle can course on the medial part of the SSL, the portion of the SSL where we recommended to pass the suture. Knowledge of the SSL anatomy is crucial and during surgical training it is clearly indicated to stay far away (almost 2 cm) from the ischial spine to avoid nerve and vascular injuries.

Mapping the primate thalamus: systematic approach to analyze the distribution of subcortical neuromodulatory afferents

Neuromodulatory afferents to thalamic nuclei are key for information transmission and thus play critical roles in sensory, motor, and limbic processes. Over the course of the last decades, diverse attempts have been made to map and describe subcortical neuromodulatory afferents to the primate thalamus, including axons using acetylcholine, serotonin, dopamine, noradrenaline, adrenaline, and histamine. Our group has been actively involved in this endeavor. The published descriptions on neuromodulatory afferents to the primate thalamus have been made in different laboratories and are not fully comparable due to methodological divergences (for example, fixation procedures, planes of cutting, techniques used to detect the afferents, different criteria for identification of thalamic nuclei…). Such variation affects the results obtained. Therefore, systematic methodological and analytical approaches are much needed. The present article proposes reproducible methodological and terminological frameworks for primate thalamic mapping. We suggest the use of standard stereotaxic planes to produce and present maps of the primate thalamus, as well as the use of the Anglo-American school terminology (vs. the German school terminology) for identification of thalamic nuclei. Finally, a public repository of the data collected under agreed-on frameworks would be a useful tool for looking up and comparing data on the structure and connections of primate thalamic nuclei. Important and agreed-on efforts are required to create, manage, and fund a unified and homogeneous resource of data on the primate thalamus. Likewise, a firm commitment of the institutions to preserve experimental brain material is much needed because neuroscience work with non-human primates is becoming increasingly rare, making earlier material still more valuable.

SIMPLE REFIXATION OF A DISLOCATED HAPTIC OF FLANGED INTRAOCULAR LENS USING A 25-GAUGE NEEDLE.

To report the development of a novel, simple-to-use technique for the salvage of a haptic of dislocated flanged intraocular lens during a retinal detachment surgery. A 25-gauge regular-wall needle was prepared and threaded by the dislocated flanged haptic before the flanged haptic was heated and enlarged by low-temperature cautery. The dislocated flanged haptic was probably the result of too small of a diameter of the previously flanged haptic and was triggered by scleral indentation. The rescue technique required only a 25-gauge regular-wall needle to conduct the conventional procedure of flanged haptic intraocular lens fixation before being enlarged by low-temperature cautery. The intraocular lens remained centered and stable at a 3-month postoperative follow-up examination. The application of a 25-gauge needle in the salvage of a haptic of dislocated flanged intraocular lens is simple and effective without the need for trimming the flanged tip.

HA-COATED SCREW VERSUS TITANIUM TRIANGULAR DOWEL FOR SACROILIAC JOINT FUSION: RESULTS FROM A PROSPECTIVE OUTCOME STUDY

BackgroundProspective study to compare patient reported outcome measures (PROM) for sacroiliac joint (SIJ) fusion using HA-coated screw (HACS) vs triangular titanium dowel (TTD). First study of its kind in English literature.Methods40 patients underwent percutaneous SIJ stabilisation using HACS and TTD was used in 70 patients. Patients were followed up closely and outcome scores were collected prospectively. PROMs were collected preoperatively and 12 months after surgery. Short Form (SF)-36, Oswestry Disability Index, EuroQol-5D-5L and Majeed Pelvic Scores were collected. Shapiro-wilk test was used to determine normality of data. Mann-whitney U test was used to compared non-parametric data and Independent sample T test for parametric data.Results33 patients in HACS group and 61 in TTD group completed follow-up. There was no significant difference in all preoperative PROMs in both groups hence the data was considered comparable. All postoperative PROMs were significantly higher in the TTD group. In the HACS group, 21 patients (63%) had lysis around the screw and a sub-group analysis showed that improvement in PROMs was significantly less in patients with lysis around the screw. 4 patients with lysis around the screw were offered revision due to ongoing pain. Revision was successful in only 1 patient. In TTD group only 5 patients (8.2 %) patients had radiological evidence of lysis. Relative risk of developing lysis was 6.7 times higher in HACS group.ConclusionPercutaneous SIJ fixation procedure has been shown to have good clinical outcomes and TTD leads to significantly better patient reported outcomes compared to HACS. There is a 6.7 time higher risk of lysis with use of HACS and lysis is a risk factor for poor outcomes.