Good Clinical Outcome Research Articles

Orthogonal plating for complex olecranon fractures: retrospective case series with patient-reported outcomes.

Treatment for complex olecranon fractures with metaphyseal comminution can be challenging. To improve reduction maneuvers and augment stability, we apply a small medial and/or lateral locking compression plate (LCP) prior to placing a posterior contoured 3.5mm-2.7mm LCP. The aim is to describe our technique and outcomes of this "orthogonal" plating technique. 26 patients were treated with orthogonal plating. Clinical outcome variables were available for all patients at a median of 27 months (IQR 6-54), and patient-reported outcomes (Q-DASH and MEPS) for 23 patients at 38 months (IQR 18-71). All fractures healed at a median of 2.0 months (IQR 1.5-3.8). The median elbow flexion was 120°, extension-deficit 15°, pronation 88°, and supination 85°. The median Q-DASH was 9 (IQR 0-22) and the median MEPS was 90 (IQR 80-100). Hardware was electively removed in seven patients. One patient had a late superficial infection that resolved with hardware removal and antibiotics, and one patient had two consecutive re-fractures after two hardware removals; and healed after the second revision surgery. Orthogonal plating with a posterior LCP and a small medial and/or lateral LCP is a safe technique that leads to excellent healing rates, and good clinical and patient-reported outcomes.

Biportal Endoscopic Transforaminal Lumbar Interbody Fusion with Percutaneous Instrumentation: A Technical Note

Endoscopic spine surgery (ESS) has gained popularity in recent years due to its effectiveness and minimal invasiveness. In addition to decompression surgery, ESS has been used in lumbar fusion surgery to minimize tissue trauma and improve the fusion rate due to its ability to facilitate better endplate preparation under an endoscope. Biportal endoscopic transforaminal lumbar interbody fusion (BETLIF) has recently been proven to be a safe and efficient method with good clinical outcomes. We have adopted BETLIF to treat patients since 2021 and have experienced satisfactory results. In this article, we introduce our surgical steps and techniques for BETLIF with percutaneous instrumentation.

Closed-loop obstruction due to internal hernia: An atypical clinical presentation of acute abdomen - A case report

Abstract Internal hernia is the protrusion of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. They can be congenital or acquired after abdominal surgery. We report a case of a 58-year-old woman who presented with complaints of abdominal pain and nonbilious vomiting for 2 days. She underwent an abdominal hysterectomy 15 years ago. After baseline blood investigations and imaging, a diagnosis of subacute intestinal obstruction was made. As she clinically worsened over 24 h, CT imaging was done, which suggested acute small bowel obstruction secondary to adhesions. Surgery revealed herniation with incarceration of distal ileal loops through a defect in the sigmoid mesocolon. Bowel resection was done, and the defect was closed. The clinical presentation of internal hernias, especially transmesosigmoid hernia, is nonspecific, and they rapidly progress to bowel ischemia. Early intervention and surgical correction are prudent for good clinical outcomes.

P-734 Low cost antagonist protocol in ivf-icsi cycles using oral ovulation induction agents in developing countries

Abstract Study question The study aimed at comparing the cost-effectiveness of a low cost antagonist protocol using oral-ovulation-induction agents with a standard long GnRH-Agonist protocol in IVF-ICSI cycles. Summary answer Low cost antagonist protocol using oral-ovulation-induction agents comparing with a standard long GnRH-Agonist protocol in IVF-ICSI cycles is cost-effectiveness in developing countries. What is known already IVF-ICSI had always been proved to be costly treatment. The additional expenditure is mainly due to use of high dose of gonadotrophins in order to get more number of eggs. To cut down the cost,low dose or mild stimulation protocol have been popularized all over the world in last few years. Use of aromatase inhibitors along with low doses of gonadotrophins have been an effective means of mild stimulation protocols for IVF cycles. Oral ovulogens, reduces the total dose of gonadotrophin required for inducing follicular maturation. We evaluated if incorporation of letrozole could be an effective alternative for low-cost IVF. Study design, size, duration A total of 304 patients under 40 years of age were studied between 2018 to 2022 Subsequently, they were randomly divided into two groups. The agonist group underwent standard long GnRH analogue protocol. The antagonist group received oral ovulation inducing drugs (CC/Letrozole) and 0.25mg antagonist injections upto the day of hCG injection, using a flexible start approach. Participants/materials, setting, methods A total of 304 patients under 40 years of age were studied between 2018 to 2022. All patients received low-dose OCP before starting treatment. Subsequently, they were randomly divided into two groups. The agonist-group underwent standard long GnRH analogue protocol. The antagonist group received oral ovulation inducing drugs (CC/Letrozole) and 0.25mg antagonist injections upto the day of hCG injection, using a flexible start approach. Follicular development was monitored by vaginal ultrasound and serum estradiol levels. Main results and the role of chance There was a significant difference in the gonadotropin usage between the two groups. As a result, the cost of the CC/Letrozole-gonadotropin-antagonist cycle was significantly lower than the long GnRH agonist-gonadotropin protocol. Though the mean number of oocytes retrieved was higher in the long protocol group, yet the clinical pregnancy rate per transfer was the same in both groups. While comparing for the primary outcomes pregnancy rate and miscarriage rate were comparable between two groups. It is of particular importance to note that despite 60%reduction of total dose of rFSH in the Let-rFSH group,which entailed significant reduction of the cost of treatment, the outcomes in all major aspects including pregnancy rate were comparable between the groups. However, numbers of matured follicles, retrieved oocytes and transferable embryos were not statistically different between study and control group in this study. This prospective study, designed to evaluate the efficacy of oral-ovulogens -FSH as a low-cost IVF protocol, involved an average number of patients; however, the results have been encouraging. We have been successful in reaching our objective to modify an expensive conventional down regulated IVF protocol into one in which the cost was reduced to a larger extent, without compromising the rate of success in developing countries. Limitations, reasons for caution Since last Cochrane review, GnRH-antagonist protocol was proved to be a short and simple protocol with good clinical outcome with significant reduction in incidence of severe OHSS and amount of gonadotrophins requirement. Although, we need more RCTs to come to a conclusion on regular use of such combined protocol. Wider implications of the findings Usage of GnRH-antagonist in combination with Oral-Ovulogens offers the advantage of a low-cost economical stimulation in IVF, as compared to an agonist-protocol, with similar pregnancy-rate in developing countries. It not only offers a cost-saving stimulation-protocol but also reduces side effects like OHSS and multiple pregnancies yet maintain a descent success-rate. Trial registration number not applicable

Case Series of Endoscopic Transoral Excision of Huge Parapharyngeal Tumors: Pushing the Boundaries.

Endoscopic transoral excision of parapharyngeal space (PPS) tumors is often condemned for its many limitations. We revisit this approach and aim to introduce some updated perspectives following the advancement of endoscopic instrumentation, robotic transoral surgery, and radical tonsillectomy. We illustrate the techniques that were deployed for six patients with huge benign PPS tumors originating from the pre-styloid compartment at our center. Only patients who had a tumor size of five cm or larger were included in this study. We summarized our patients' outcomes, the important considerations, and the advantages and disadvantages of this approach. With accurate selection and surgical strategy, all our patients had good clinical outcomes. We demonstrated that even larger tumors can be safely removed endoscopically. Surely, this approach will gain traction, and better-designed studies should be conducted in the future to assess its credibility.

Short-Term Results after Reversed Total Shoulder Arthroplasty

Abstract Purpose Massive rotator cuff tear, with or without arthritis and proximal humerus fracture non-union or malunion, lead to the loss of center of rotation of shoulder, while anatomical total shoulder arthroplasty does not provide a stable center of rotation, Therefor reversed total shoulder arthroplasty (RTSA) is the suitable method for these indications, as well as in elderly patients with primary glenohumeralosteoarthritis because anatomical total shoulder arthroplasty has the risk of failure either due to loosening of glenoid component or cuff tear. This study aimed to determine the short-term results after RTSA in patients a with massive cuff tear, acute proximal humerus fracture, proximal humerus fracture malunion or non- union, and primary glenohumeralosteoarthritis. Methods This one arm clinical trial (interventional study) conducted in Ain Shams University Hospitals included 16 patients who underwent RTSA. Short-term outcomes included constant score, American Shoulder and Elbow Surgeon (ASES) score, and range of motion (ROM). Patients with rotator cuff arthropathy, massive irreparable cuff tear with or without glenohumeralarthritis, elderly patients with acute complex proximal humerus fracture, malunited or nonunited proximal humerus fracture, and patients with glenohumeralosteoarthritis were included. Patients who were aged <50 years were excluded, as well as patients with axillary nerve injury or deltoid muscle dysfunction. Results This study included 16 patients, including 8 males and 8 females. The mean age was 64.19 years and the duration of follow up-was 1 year postoperatively. Seven Patients with massive irreparable cuff tear were included, of them, 1 had associated anterior shoulder instability and recurrent anterior dislocation, 3 had a four-part proximal humerus fracture, 2 had fracture dislocation, 2 had proximal humerus fracture non –union, 1had neglected dislocation, and 2 had glenohumeralosteoarthritis. Outcomes were followed using constant and ASES scoring systems, and ROM. The global postoperative gain was statistically significant (p < 0.001). Complication in the form of dislocation occurred in one case that had RTSA after fracture non-union. Conclusion Good clinical and functional outcomes were achieved after RTSA, not only for classic massive cuff tear indication, but for other disorders, such as acute proximal humerus fracture, fracture non-union, and primary glenohumeralosteoarthritis. However, the outcomes after irreparable cuff tear were the best among all indications, while fracture non-union had the least improvement in clinical outcomes. Improvements in prosthesis design, surgeon’s experience, and clinical results are necessary to optimize this treatment for many shoulder conditions.

Intrajejunal levodopa in Parkinson's disease: Optimization of PEG application

The various forms of Percutaneous Endoscopic Gastrostomy (PEG) are highly relevant in neurology, as pump-administered intrajejunal levodopa application is one of the indispensable forms of therapy in advanced Parkinson's disease. Optimal PEG placement and follow-up are therefore significant for the success of the therapy. However, the standard intrajejunal administration of levodopa gel via a JET-PEG, i. e. a PEG with an internal catheter inserted into the jejunum, is not without problems for various reasons. In particular, the considerable cumulative complication rates demand a reconsideration of the situation. The very limited absorption area of the drug in the region of the flexura duodenojejunalis must also be taken into account. Causes of complications are predominantly a non-optimal application technique of PEG and internal catheter as well as the frequent lack of an adequate follow-up. In this paper, the details of a modified and optimized application technique compared to the conventional techniques are presented. These new methods have proved their usefulness in clinical applications for years, and additionally a new application form, the Hybrid-PEG, is presented. However, many of the details derived from anatomical/physiological, surgical and endoscopic aspects must be strictly observed during the application in order to reduce or avoid minor and major complications. In particular, problems are caused by local infections in the area of the insertion point of the PEG including peritonitis, leaks and buried bumper syndrome (BBS). The relatively frequent dislocations of the internal catheter also prove to be particularly troublesome. These can ultimately be avoided by clip fixation of the catheter tip down in the jejunum. In particular, the use of the newly developed Hybrid-PEG, a combination of endoscopically controlled gastropexy with three sutures and subsequent central thread-pull-through of the PEG tube, can significantly reduce the complication rate and thus achieve a decisive improvement for patients. The aspects discussed here are highly relevant for all those involved in the therapy of advanced Parkinson's disease. Trustful interdisciplinary collaboration between neurology and endoscopy/surgery/gastroenterology is a prerequisite for good clinical outcomes.

Autologous bone grafting in combination with autologous chondrocyte implantation yields favourable outcomes in the treatment of osteochondral defects of the knee: A systematic literature review.

This study addresses the gap in the current literature by evaluating the combined treatment of autologous bone grafting and autologous chondrocyte implantation (ABCI) for osteochondral defects of the knee. It aims to evaluate clinical outcomes against methodological quality and to summarize histological results and surgical techniques. A thorough search was conducted across Pubmed, Cochrane and Embase databases. Studies reporting clinical outcomes of ABCI for osteochondral defects of the knee were included. Patient-reported outcome measures (PROMs), failure rates, methodological quality and potential conflicts of interest were evaluated. Histological results and surgical techniques were summarized. Eighteen studies with 344 analyzed patients met the eligibility criteria for inclusion. All studies showed a significant improvement (p < 0.05) across different PROMs (subjective International Knee Documentation Committee score, Cincinnati Knee Rating System, Visual Analogue Scale, Lysholm Score, Tegner Activity Scale, Knee injury and Osteoarthritis Outcome Score and Knee Society Score) compared to the preoperative status. Failure rates ranged from 0% to 17.6%, with a mean follow-up of 73.2 months (range: 9.0-143.6 months). Methodological quality was low to medium, including only one comparative study. Six studies reviewed reported a potential conflict of interest. The histological assessment showed effective bonding between autologous chondrocytesand bone graft. A large degree of variability was observed in the operative technique used. The current literature suggests that ABCI yields good clinical outcomes at mid- to long-term follow-up with favourable histological results for osteochondral defects of the knee. However, future research should focus on high-quality comparative studies to better guide treatment choices. Introducing ABCI as the standard abbreviation may enhance clarity in future research. Level IV.

Repeat ablation of atrial fibrillation using electrogram dispersion to identify additional areas of mechanistic significance

Electrogram dispersion identifies putative atrial fibrillation (AF) drivers in first time ablation procedures, with high acute termination rates and long-term outcomes akin to extensive ablation approaches. Its use in a population that had undergone repeat ablation is unknown, particularly where the pulmonary veins are already isolated. This purpose of this study was to assess electrogram dispersion mapping during repeat ablation procedures for persistent AF. One hundred sixty-seven patients from the United Kingdom and Denmark, all with persistent AF recurrence after prior ablation procedure(s), were mapped using a five splined catheter for electrogram dispersion before ablation. Areas were manually tagged on biatrial electroanatomic maps and ablated once pulmonary vein isolation was confirmed or reisolated if required. All patients had 12-month continuous monitoring, with most of the cohort having follow-up beyond 24 months. Of the 167 patients [53 (32%) female; mean age 66 ± 8 years; mean left atrial (LA) diameter 4.8 cm; mean ejection fraction 53%], 108 had pulmonary veins already isolated. Dispersion sites occurred in both atria (3.2 LA, 1.4 right atrium). Acute termination to sinus rhythm occurred in 71 (42%) of the cohort patients, with a further 73 (44%) terminating to atrial tachycardia/flutter. At 12-month follow-up, 95% of patients were free of AF, with 74% overall freedom from all atrial arrhythmias. Heart failure and severely enlarged LA predicted recurrence, and termination to sinus improved freedom from all atrial arrhythmias. Dispersion mapping is a promising approach at repeat ablation procedures for persistent AF, with high acute termination rates and good clinical outcomes. Further prospective randomized trials are needed to evaluate this approach in a population that had undergone repeat ablation.

A preliminary study of contrast-enhanced ultrasound guided capsule-preserving hydrodilatation in shoulder adhesive capsulitis.

Capsule-preserving hydrodilatation is a common treatment for adhesive capsulitis (AC), and ultrasound (US) has recently become the most popular adjuvant tool for image-guided glenohumeral joint injection. However, traditional US is hardly adequate to assess extracapsular fluid leakage, which may decide the treatment outcomes. In this study, we explored the value of contrast-enhanced ultrasound (CEUS) guided capsule-preserving hydrodilatation with steroids and ultrasonic contrast agents for treatment of AC. A total of 40 consecutive patients with AC were prospectively enrolled and received CEUS-guided capsule-preserving hydrodilatation. The number of injection attempts, injection volume, and fluid leakage were recorded, and the correlations with clinical features were analyzed by Pearson or Spearman correlation coefficients. Outcome measures including visual analog scale (VAS) score, passive range of motion (ROM), and shoulder pain and disability index (SPADI) score were evaluated at baseline and 4 weeks after treatment. Comparisons between patients with good and poor clinical outcomes were performed with independent t-test, Mann-Whitney U test, and chi-square test. Logistic regression was used to identify predictors of good clinical outcomes. A P value <0.05 defined significance. Access to the glenohumeral joint was successful in 87.5% patients on the first attempt. The infused fluid volume was 21.0±3.40 mL. Longer symptom duration (r=-0.676, P<0.001), greater SPADI (r=-0.148, P=0.007), and decreased ROM in abduction (r=0.38, P=0.016) were associated with a decreased volume of infused fluid. CEUS detected massive fluid leakage in 5 (12.5%) patients, with 4 capsule ruptures confirmed by magnetic resonance imaging (MRI). Longer symptom duration (r=0.485, P=0.001), decreased ROM in the direction of abduction (r=-0.33, P=0.037), and external rotation (r=-0.34, P=0.032) were correlated with an increased incidence of massive fluid leakage. Moreover, patients with good outcomes had significantly shorter symptom duration (5.7±2.09 vs. 11.2±3.89 months, P=0.002) and greater initial VAS score (6.9±1.04 vs. 6.3±0.50, P=0.022) than those with poor outcomes. Absence of massive fluid leakage was an independent predictor of clinical good outcomes at 4 weeks after treatment [odd ratio (OR) =0.05, 95% confidential interval (CI): 0.003-0.882, P=0.041]. CEUS-guided capsule-preserving hydrodilatation allows real-time visualization of capsule dilatation, accurate detection of extracapsular fluid leakage, and identification of risks for capsule rupture. It provides an effective treatment for AC, and is useful to predict patients' clinical outcomes.

Cryoablation of atrial fibrillation in "very severe" obese patients (BMI ≥ 40): Indications, feasibility, procedural safety and efficacy, and clinical outcome (the ICE-Obese Extreme).

Management of atrial fibrillation (AF) in very severe obese patients is challenging. Cryoballoon ablation (CBA) represents an effective rhythm control strategy. However, data in this patient group were limited. Highly symptomatic AF patients with body mass index (BMI) ≥ 40 kg/m2 who had failed antiarrhythmic drug therapy and electrocardioversion and failure to achieve targeted body-weight-reduction underwent CBA. Data of 72 very severe obese AF patients (Group A) and 129 AF patients with normal BMI (Group B, BMI < 25 kg/m2) were consecutively collected. Group A had significantly younger age (60.6 ± 10.4 vs. 69.2 ± 11.2 years), higher BMI (44.3 ± 4.3 vs. 22.5 ± 1.6 kg/m2). Procedural pulmonary vein isolation (PVI) was successful in all patients (2 touch-up ablation in Group A). Compared to Group B, Group A had similar procedural (61.3 ± 22.6 vs. 57.5 ± 19 min), similar fluoroscopy time (10.1 ± 5.5 vs. 9.2 ± 4.8 min) but significantly higher radiation dose (2852 ± 2095 vs. 884 ± 732 µGym2). We observed similar rates of real-time-isolation (78.6% vs. 78.5%), single-shot-isolation (86.5% vs. 88.8%), but significantly longer time-to-sustained-isolation (53.5 ± 33 vs. 43.2 ± 25 s). There was significantly higher rate of puncture-site-complication (6.9% vs. 1.6%) in Group A. One-year clinical success in paroxysmal AF was (Group A: 69.4% vs. Group B: 80.2%; p < .001), in persistent AF was (Group A: 58.1% vs. Group B: 62.8%; p = .889). In Re-Do procedures Group A had a numerically lower PVI durability (75.0% vs. 83.6%, p = .089). For very severe obese AF patients, CBA appears feasible, leads to relatively good clinical outcome.

Functional Outcomes and a Review of Management Options for Revision Shoulder Arthroplasty.

Increase in the number of primary shoulder arthroplasty has led to an increase in the number of revisions which presents many complex challenges and often has inferior outcomes. Data was collected retrospectively, and patients were classified using Dines classification. Comprehensive case reviews were done to identify preoperative and intra-operative challenges. The primary outcome measure was Oxford shoulder score (OSS). The secondary measures were range of motion (ROM) and patient satisfaction (very satisfied, satisfied, not satisfied or worse). A total of 32 patients were identified with a mean age of 67.64 years and the most common cause of revision was a combination of bone and soft tissue failure (39.3%). All patients (n=8) with hemiarthroplasty had rotator cuff deficiency while patients with resurfacing had both rotator cuff failure and bony erosion. Four patients needed a proximal humeral osteotomy and six patients needed allograft reconstruction of the glenoid for bone loss. Twenty-one shoulders were revised to reverse total shoulder arthroplasty (TSA), 2 to anatomical TSA and 5 were left with cement spacer in situ. Mean duration of follow-up was 41.6 months. Mean OSS at the last follow-up was 26.88 with statistically significant improvement in ROM. There was no statistical difference in clinical outcomes (p>0.05) based on the type of primary prosthesis or cause of revision. A total of 70% patients were pain free. Patients with infection had inferior outcomes with a mean OSS of 17. Management of patients with failed shoulder arthroplasty is often challenging but has good clinical outcome except in infections.

Good clinical outcomes and low recurrence rate in patients undergoing arthroscopic revision Latarjet for failed arthroscopic Bankart repair

BackgroundThe role of arthroscopic Latarjet stabilization after failed arthroscopic Bankart repair has yet to be definitively established and merits further investigation. ObjectiveTo assess clinical and radiological outcomes after arthroscopic Latarjet stabilization as a revision procedure for failed Bankart repair, as well as the return to athletic activity and complication rates. MethodsBetween 2009 and 2020, patients with a previous failed arthroscopic Bankart repair who were treated with an arthroscopic Latarjet were retrospectively evaluated. Clinical outcomes at a minimum of 24 months postoperatively included Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome score (CS), and Single Assessment Numeric Evaluation (SANE). Dislocations, subluxations, complications, pre and postoperative level of activity and degree of osteoarthritis were also assessed. ResultsA total of 77 patients, mean age at revision surgery 31.2 ± 9.1 and with either one (n = 59), two (n = 13), or three (n = 4) arthroscopic previous stabilizations underwent revision surgery using arthroscopic Latarjet procedure were studied. Postoperatively, the mean ROWE and CS scores increased from 41.8 ± 16 to 90.7 ± 14.3 (p<0.001) and from 50.5 ± 13.8 to 90.5 ± 10.3 (p<0.001), respectively. WOSI decreased from 1247 ± 367.6 to 548.9 ± 363 at the final follow-up (p<0.001). After a mean follow-up of 39.6 ± 23.1 months, 64 shoulders (83.1%) were subjectively graded as good to excellent using SANE score. Grade 1, 2, and 3 osteoarthritis, according to Ogawa et al were found in 18 (23.4%), 6 (7.8%), and 3 (3.9%) shoulders, respectively. Six dislocations after revision surgery were reported (7.8%). In four failed cases an Eden-Hybinette procedure was conducted and in remaining two patients an arthroscopic extraarticular anterior capsular reinforcement was performed. Significantly decreased level of athletic activity was observed postoperatively (p= 0.01). ConclusionsArthroscopic Latarjet for revision of failed arthroscopic Bankart repair provides satisfactory patient-reported subjective outcomes with low rate of recurrences and complications. However, decreased level of athletic activity is expected.

Single bundle hamstrings autograft preparation techniques for anterior cruciate ligament reconstruction: current concepts.

Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures, and huge variation exists in the surgical technique. Single bundle hamstrings autograft reconstruction is a common method and has good clinical outcomes. A criticism of the hamstrings autograft is a small graft diameter, often less than 8-mm, which has been associated with increased re-rupture rates. Several graft preparation techniques for single bundle hamstrings autograft exist. Perioperative decisions include the number of tendons utilized, number of graft strands, graft configuration, and femoral and tibial fixation methods. Awareness of the minimum tendon and graft length required to produce each graft variation is necessary to avoid common pitfalls. However, intraoperative graft modification is possible to maximize graft diameter, and obtain proper fixation. The objective of this current concepts review is to describe the indications, surgical anatomy, technique, intraoperative tips, clinical outcomes, and complications for single bundle hamstrings autograft preparation techniques in ACLR.

Short-Term Results after Reverse Total Shoulder Arthroplasty

Abstract Background: The loss of the shoulder’s center of rotation is caused by massive rotator cuff tears, which can occur with or without arthritis and proximal humerus fractures that are nonunion or malunion. Because anatomical total shoulder arthroplasty cannot provide a stable center of rotation, reverse total shoulder arthroplasty (RTSA) is the appropriate procedure for these indications and in older patients who have primary glenohumeral osteoarthritis. Anatomical total shoulder arthroplasty carries a risk of failure because of the loosening of the glenoid component or cuff tear. The purpose of this study was to determine the short-term outcomes following RTSA in patients who had primary glenohumeral osteoarthritis, acute proximal humerus fractures, malunited or nonunited proximal humerus fractures, and massive cuff tears. Materials and Methods: This single-arm clinical trial (interventional study) was done in Ain Shams University Hospitals; 16 patients were included who underwent RTSA. Constant score, American Shoulder and Elbow Surgeon score, Visual Analog Scale score, and range of motion (ROM) were the short-term outcomes. Patients with cuff tear arthropathy, irreparable cuff tear with or without glenohumeral arthritis, elderly patients with unreconstructable proximal humerus fracture, proximal humerus fracture malunion or nonunion, and patients with glenohumeral osteoarthritis were included. Patients under the age of 50, as well as those with deltoid muscle dysfunction or injuries to the axillary nerve, were excluded. Results: There were 16 patients in this study, 8 of whom were male and 8 of whom were female. The follow-up period lasted 2 years following surgery, with a mean age of 64.19 years. The study included 7 patients with irreparable cuff tears one of them had associated anterior shoulder instability and recurrent anterior shoulder dislocation. One patient had a neglected shoulder dislocation, two patients had proximal humerus fracture dislocation, two patients had a nonunited proximal humerus fracture, three patients had unreconstructable proximal humerus fracture, and two had glenohumeral osteoarthritis. Conclusion: Not only did RTSA provide good clinical and functional outcomes for the standard indication of a massive cuff tear, but it also proved beneficial for other disorders such as primary glenohumeral osteoarthritis, nonunited fracture, and acute proximal humerus fracture. Among all indications, irreparable cuff tears yielded the highest results; nonunited fractures displayed the least improvement regarding clinical outcomes. Enhancements in the design of prostheses, the expertise of surgeons, and clinical outcomes are crucial to maximize their effectiveness in treating various shoulder disorders.

First-Ray Distal Metatarsal and Proximal Phalangeal Osteotomies Without Soft Tissue Procedure for Severe Hallux Valgus: A Case Series.

This case series reported the outcomes of severe hallux valgus treated with first-ray distal metatarsal and proximal phalangeal osteotomies without soft tissue procedure. The medical records of patients who underwent this surgery from February 2018 to December 2021 were reviewed, including patients with a hallux valgus angle (HVA) ≥40 degrees who were followed up for >2 years. The analyzed data included age, sex, height, weight, and body mass index at the surgery, HVA and intermetatarsal angle (IMA) on the weighted anteroposterior radiograph of the affected foot, the Japanese Society for the Surgery of the Foot score, visual analog scale (VAS) score, and passive plantarflexion and dorsiflexion angles of the first metatarsophalangeal joint 1 month before surgery and at final follow-up. The study group included 35 feet in 29 patients (26 females) with a mean age of 67 ± 10.6 years and mean follow-up of 3.5 ± 0.8 years. Average preoperative and final follow-up measures were HVA, 46.8 to 7.7 degrees; IMA, 18.8 to 9.5 degrees; and VAS score, 61.5 ± 29.6 to 2.7 ± 4.6. Range of motion decreased on average: dorsiflexion, 83.6 ± 14.7 to 71.3 ± 12.0 degrees; and plantarflexion, 63.0 ± 14.7 to 53.0 ± 11.8. All changes were statistically significant (P < .001). This surgery achieved good correction and clinical outcomes for severe hallux valgus, but the postoperative range of motion decreased.Level of Evidence: Level IV, case series.

Good mid- to long-term outcomes after meniscus bucket-handle tear repair: A comparative analysis with and without anterior cruciate ligament reconstruction.

To evaluate mid- to long-term clinical outcomes after arthroscopic bucket-handle meniscal tear (BHMT) repair and to assess the impact of concurrent anterior cruciate ligament reconstruction (ACLR). A comparative retrospective case series with blinded outcome assessment was conducted. All consecutive patients treated with arthroscopic BHMT repair with or without concurrent ACLR between 2001 and 2021 were eligible for inclusion. Fifty-five patients with an average follow-up of 7.3 ± 3.4 years were included in the analysis. Outcome measures comprised post-operative IKDC Subjective Knee Form, Lysholm Score, Tegner Activity Scale, KOOS, and visual analogue scale (VAS) for satisfaction. Additionally, failure and reoperation rates were assessed. The failure rate was 9%. Medial BHMT repair showed superior post-operative IKDC scores compared to lateral meniscus repair (p = 0.038). Concurrent ACLR did not demonstrate any impact on post-operative KOOS, IKDC, Tegner or patient satisfaction. The mean IKDC score at final follow-up across both groups was 80.4 ± 17.8. The mean Lysholm score was 86.9 ± 16.7. Mean KOOS scores were (i) symptoms: 83.6 ± 18.3, (ii) pain: 90.2 ± 14.4, (iii) activities of daily living: 93.6 ± 15.1, (iv) sports: 78.3 ± 26.0 and (v) quality of life: 70.5 ± 24.5. Mean patient satisfaction (VAS) was 7.9 ± 2.5. The mean Tegner score was 4.9 ± 1.9. A consistent positive correlation between the number of sutures used and post-operative outcome measures was observed but did not reach statistical significance for most items. Arthroscopic BHMT repair achieved good clinical outcomes and an acceptable failure rate of 9% at a mean follow-up of 7 years, supporting the clinical value of meniscal repair, including large BHMTs. Concurrent ACLR showed no impact on clinical outcomes. Level IV (retrospective case series).

Super-Speciality in India: A Boon or Bane?

In the past few decades, super-specialization has gained popularity in many medical disciplines. It provides professionals with a sturdy platform for advanced research and helps to deliver focused and extensive care in the fields of trauma and critical care, which can translate into good clinical outcomes for patients. Although this drift may bring about novel research opportunities, it may limit the number of doctors attending to the basic healthcare needs of the population. India is still struggling to provide primary healthcare services to its population. Super-specialization is a highly technology-driven industry, the costs of which our public health system cannot endure in the present settings. The current demand in India, where basic priorities are yet to be met, is to increase health awareness, provide basic healthcare facilities, and generate interest among medical professionals in providing general health services, especially in rural areas.

Effect of L-PRF and autogenous bone grafts for immediate implant placement in post tooth extract socket.

The clinical outcomes of bone augmentation substances in immediate dental implant (IDI) placement are of interest to dentists. Hence, we evaluated and compared the effectiveness of L-PRF and autogenous bone grafts in immediate implant placement in tooth extract socket. Hence, assessment of periimplantis pocket depth, assessment of tissue biotype, implant stability and marginal bone loss at one month, three months, and six months follow up was completed. The tissue biotype values at one month, 3 month and 6 month follow up revealed that tissue biotype increased in each category as the time increased in all categories. We found that all three techniques were found to have good clinical outcomes regarding immediate implant placement in fresh tooth extraction socket, however the outcomes were better in the case L-PRF.

When microsurgery becomes the only lifesaving resource: An institutional experience treating patients from low-income backgrounds affected by posterior circulation brain aneurysms

Background and objectiveAneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern era, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of the clinical setting in the treatment decision. MethodsThe authors conducted a retrospective review of the health records of patients who received microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed. ResultsSurgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (69%), followed by the PCA (15%) and PICA (15%). Among neurological complications, 25% of patients developed oculomotor nerve palsy. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale scores of 0–2). ConclusionThe present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not easily accessible. Importantly, this clinical setting pressure could exhort trainees to strive for microsurgical mastery and gain a competitive advantage.