Initial Surgery Research Articles

Factors Influencing Recurrence Rates and Surgical Outcomes in Lumbar Microdiscectomy: A Retrospective Study of 130 Patients in Turkey.

BACKGROUND Lumbar disc herniation surgery, specifically lumbar microdiscectomy, shows recurrence in 3-24% of patients, necessitating potential re-operations. This study focuses on the outcomes and recurrence causes in 130 cases of lumbar disc herniations. These cases were managed by a single surgeon at a single center, offering a unique perspective on a common issue in neurosurgery. MATERIAL AND METHODS The study involved 130 patients treated for lumbar disc herniations. Analysis considered various factors: age, sex, symptoms, surgical level, complications, pre- and postoperative pain levels, and quality of life indices. RESULTS Of the 130 cases analyzed, all underwent initial surgery by the same surgeon or sought treatment from this surgeon after recurrence. Inclusion criteria were based on radiologic and clinical indications for re-operation. The demographic split was 76 males (56.4%) and 54 females (43.6%). A notable finding was a higher recurrence rate in males and patients under 45 years, although the sex difference was not statistically significant. The average age was 47.5 years. Significant changes were noted in the Oswestry Disability Index (ODI) levels during follow-ups (P<0.001). CONCLUSIONS This study underscores the effectiveness of lumbar microsurgery in treating recurrent lumbar disc herniations. Techniques such as medial facet utilization and laminectomy border expansion show promise. However, determining instability rates requires long-term patient follow-up. Our findings contribute valuable insights into surgical approaches and patient outcomes in recurrent lumbar disc herniation cases.

NIMG-30. DEEP LEARNING SEGMENTATION OF INFILTRATIVE AND ENHANCING CELLULAR TUMOR IN POST-TREATMENT GLIOBLASTOMA PATIENTS WITH MULTI-SHELL DIFFUSION MRI

Abstract Multimodal MRI is used for the evaluation of tumor burden in glioblastoma (GBM) patients after surgical resection, radiation, and chemotherapy. However, it can be challenging to identify non-enhancing infiltrative tumor and differentiate recurrent enhancing tumor from post-treatment changes. Restriction spectrum imaging (RSI), an advanced multishell diffusion technique, has shown promise in distinguishing cellular tumor from edema and enhancing post-treatment changes including pseudoprogression and radiation necrosis. We developed a convolutional network (nnUNet) that incorporates traditional multimodal MRI with DSC perfusion and RSI to detect and quantify enhancing and nonenhancing cellular tumor in post-treatment glioblastoma patients. This cellular tumor segmentation network was evaluated in a cohort of 186 post-treatment GBM patients (55.5 +/- 13.7 years, 158 male) with 243 timepoints using 5-fold cross validation. Cellular tumor volumes were then used to predict overall survival (OS) and progression free survival (PFS) in 94 patients with imaging within 3 months of initial surgery. Accuracy for segmenting cellular tumor as measured by the Dice-similarity coefficient was 0.77 (IQR 0.55-0.87) and the AUC of the ROC curve for detecting residual/recurrent tumor compared to post-treatment changes was 0.86. The predicted cellular tumor volumes were an independent hazard over age, sex, GTR status and conventional enhancing residual tumor for both OS (p=0.0003) and PFS (p=0.0004). The tumor segmentation network was validated in an external dataset of 22 GBM patients (55 timepoints) with a median Dice of 0.73 and AUC of 0.91. Survival prediction was validated in a different external dataset of 70 post-treatment GBM patients, with cellular tumor volumes being an independent predictor of OS (p=0.03). In conclusion, deep learning models incorporating advanced imaging can accurately segment enhancing and nonenhancing cellular tumor, which can help distinguish recurrent/residual tumor from post-treatment changes and predict OS and PFS.

POSTERIOR CRUCIATE LIGAMENT INJURIES MANAGED WITH INTERNAL BRACING

Poor availability of allografts in South Africa has led to an increased use of synthetic augmentation to stabilize knee joints in the treatment of knee dislocations. This study aims to evaluate multiligament knee injuries treated with a posterior cruciate ligament internal brace.The study included patients with knee dislocations who were treated with a PCL internal brace. The internal brace involved the insertion of a synthetic suture tape, which was drilled into the femoral and tibial footprint. Chronic injuries were excluded. Patient-reported outcome scores (PROMs), range of motion, stress X-Rays, and MRI scans were reviewed to assess outcomes. Acceptable outcomes were defined as a Lysholm score of 84 or more, with grade II laxity in no more than one ligament and a range of motion from full extension to 90° or more.The study included eight patients, with a median age of 42, of which five were female. None of the patients had knee flexion less than 90° or an extension deficit of more than 20°. PROMs indicated acceptable outcomes (EQ5D, Tegner Lysholm). Stress radiographs showed less than 7mm (Grade I) of posterior translation laxity in all patients. Four patients underwent MRI scans 1–2 years after the initial surgery, which revealed healing of the PCL in all patients. However, increased signal in a continuous ligament suggested only partial healing in two patients. Tunnel widening of 200% and 250% was noted around the tibial and femoral PCL footprints, respectively.All patients demonstrated stable knees and acceptable PROMs. Tunnel widening was observed in all patients who had MRI scans. Factors such as suspensory fixation, anisometric tunnel position, and the absence of PCL tear repair may have contributed to the tunnel widening.

The Effectiveness of Autogenous Dentin Graft as a Biomaterial in Optimizing the Esthetic Outcomes of Immediate Dental Implants: A Prospective Clinical Study

Background: Immediate implant placement in the maxillary anterior region was challenging, especially with the jumping gap and limited primary implant stability. Objective: To assess the autogenous dentin graft biomaterial's ability to improve the esthetic outcomes of an immediately inserted implant. Methods: Twenty patients with non-restorable retained roots in the maxillary non-molar region surrounded by natural sound teeth were included in this study after a complete clinical and radiological examination, including patient health and clinical fitness for the immediate dental implant procedure. A single dental implant was inserted for each patient, and the resulting jump distance was filled with the mineralized dentin graft and covered by gel foam with the figure of eight suturing. The Pink Esthetic Score index of the implant-supported prostheses was evaluated six months after the initial surgery. Results: Twenty eligible patients were included in this study. The assessment of the clinical measurements of the alveolar ridge width and gingival biotype before surgical intervention and after 6 months showed no significant differences between them. The mean Pink Esthetic Score (PES) was 7.75. Only two patients achieved a total esthetic score of 10; another three patients had a score of 8, four with a score of 7, and the rest with a score of 6. Conclusion: An autogenous dentine graft effectively achieves acceptable esthetic results with an isolated immediate dental implant inserted in the anterior maxillary area.

Detecting recurrent disease and surgical outcomes in patients with locally advanced tongue cancer after multimodal treatment using ¹⁸F-FDG-PET/CT

The purpose of this study was to evaluate the utility of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FPCT) parameters for detecting recurrent disease and the outcomes of salvage surgery in patients with locally advanced oral tongue squamous cell carcinoma (TSCC) after multimodal treatment. In total, 69 patients with locally advanced TSCC were treated with multimodal therapy. All patients underwent whole-body FPCT scans 4–10 months after the initial surgery. The analysis included FPCT parameters, such as maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Histological examination was used as the reference standard. Patients with recurrent TSCC underwent salvage surgery or surgery plus systemic treatment. This study included 69 patients: 36 in the recurrent TSCC group and 33 in the non-recurrent TSCC group. The SUVmax, MTV, and TLG in the recurrent TSCC group were 11.3 ± 3.6, 28.3 ± 15.6 cm3, and 113.2 ± 46.8 g, respectively; these values were 5.9 ± 3.6, 5.1 ± 2.2 cm3, and 13.4 ± 4.8 g, in the non-recurrent TSCC group respectively. The two groups had significant differences in terms of SUVmax, MTV, and TLG. In the recurrent TSCC group, 91.6 % of patients presented with local, locoregional, and regional disease and underwent salvage surgery plus systemic therapy, whereas 8.4 % had locoregional recurrence with distant metastases alone and underwent surgery plus systemic therapy. The patients were followed up for 12–60 months; 19 and 20 patients in the recurrent and non-recurrent TSCC groups showed no evidence of disease, whereas 11 and 8 were alive with the disease. Local recurrence or distant metastases led to the deaths of six patients in the recurrent TSCC group and five in the non-recurrent TSCC group. No significant differences in survival were observed between the two groups. FPCT parameters can detect the recurrence of locally advanced TSCC after multimodal treatment. Early salvage surgery can improve the treatment outcomes for recurrent TSCC.

Machine learning-based prediction models for parathyroid carcinoma using pre-surgery cognitive function and clinical features

Patients with parathyroid carcinoma (PC) are often diagnosed postoperatively, due to incomplete resection during the initial surgery, resulting in poor outcomes. The aim of our study was to investigate the pre-surgery indicators of PC and try to develop a predictive model for PC utilizing machine learning. Evaluation of pre-surgery neuropsychological function and confirmation of pathology were carried out in 133 patients with primary hyperparathyroidism in Beijing Chaoyang Hospital from December 2019 to January 2023. Patients were randomly divided into a training cohort (n = 93) and a validating cohort (n = 40). Analysis of the clinical dataset, two machine learning including the extreme gradient boosting (XGBoost) and the least absolute shrinkage and selection operator (LASSO) regression were utilized to develop the prediction model for PC. Logistic regression analysis was also conducted for comparison. Significant differences in elevated parathyroid hormone and decreased serum phosphorus in PC compared to (BP). The lower score of MMSE and MOCA was observed in PC and a cutoff of MMSE < 24 was the optimal threshold to stratify PC from BP (area under the curve AUC 0.699 vs 0.625). The predicted probability of PC by machine learning was similar to the observed probability in the test set, whereas the logistic model tended to overpredict the possibility of PC. The XGBoost model attained a higher AUC than the logistic algorithms and LASSO models. (0.835 vs 0.683 vs 0.607). Preoperative cognitive function may be a probable predictor for PC. The cognitive function-based prediction model based on the XGBoost algorithm outperformed LASSO and logistic regression, providing valuable preoperative assistance to surgeons in clinical decision-making for patients suspected PC.

Arthroscopic pullout repair versus suture anchor repair for medial meniscus posterior root tear combined with high tibial osteotomy

BackgroundThe aim of this study was to compare the outcomes of pullout repair with a metal button and suture anchor repair for medial meniscus posterior root tears in patients undergoing high tibial osteotomy with varus alignment. MethodsPatients who underwent arthroscopic pullout repair (P group) and suture anchor repair (SA group) in combination with open-wedge high tibial osteotomy between 2018 and 2021 were retrospectively examined. Patients who received second-look arthroscopy at 1 year and at least 2 years of follow up were included. Structural healing (complete/partial or failed healing) and chondral lesions at the initial surgery and the second-look arthroscopy, radiographic parameters around the knee, Lysholm score, and Tegner activity scale (before and 2 years after surgery) were compared. ResultsA total of 88 patients (68 women/20 men, mean age 61.1 ± 7.9 years old) were included in the analysis. Of these, 51 patients underwent pullout repair, while the other 37 underwent suture anchor repair. The SA group showed a significantly higher rate of complete healing (64.9%) than the P group (21.6%, P < 0.001). The Lysholm score significantly improved after surgery in both treatment groups. At the final follow up, the SA group had a significantly higher Lysholm score (89.6 ± 10.7) than the P group (80.9 ± 17.4, P = 0.011). ConclusionArthroscopic suture anchor repair had superior healing status and Lysholm Score in comparison with pullout repair with a metal button, as it achieved better tension adjustment. This result is meaningful particularly when medial meniscus root repair and high tibial osteotomy are performed simultaneously.

Stereo-EEG-guided network modulation for psychiatric disorders: Surgical considerations

BackgroundDeep brain stimulation (DBS) and other neuromodulatory techniques are being increasingly utilized to treat refractory neurologic and psychiatric disorders. Objective/Hypothesis: To better understand the circuit-level pathophysiology of treatment-resistant depression (TRD) and treat the network-level dysfunction inherent to this challenging disorder, we adopted an approach of inpatient intracranial monitoring borrowed from the epilepsy surgery field. MethodsWe implanted 3 patients with 4 DBS leads (bilateral pair in both the ventral capsule/ventral striatum and subcallosal cingulate) and 10 stereo-electroencephalography (sEEG) electrodes targeting depression-relevant network regions. For surgical planning, we used an interactive, holographic visualization platform to appreciate the 3D anatomy and connectivity. In the initial surgery, we placed the DBS leads and sEEG electrodes using robotic stereotaxy. Subjects were then admitted to an inpatient monitoring unit for depression-specific neurophysiological assessments. Following these investigations, subjects returned to the OR to remove the sEEG electrodes and internalize the DBS leads to implanted pulse generators. ResultsIntraoperative testing revealed positive valence responses in all 3 subjects that helped verify targeting. Given the importance of the network-based hypotheses we were testing, we required accurate adherence to the surgical plan (to engage DBS and sEEG targets) and stability of DBS lead rotational position (to ensure that stimulation field estimates of the directional leads used during inpatient monitoring were relevant chronically), both of which we confirmed (mean radial error 1.2±0.9 mm; mean rotation 3.6±2.6°). ConclusionThis novel hybrid sEEG-DBS approach allows detailed study of the neurophysiological substrates of complex neuropsychiatric disorders.

Early small bowel obstruction as a complication of abdominal drain in colon cancer surgery: a case report and literature review

Introduction: Early postoperative small bowel obstruction (EPSBO) is an obstruction that occurs within 4 weeks after the initial surgery. Routine prophylactic abdominal drainage does not provide any benefit in colon cancer surgery. The cause of EPSBO due to the abdominal drainage tube is infrequent. Case presentation: A 72-year-old male patient was diagnosed with sigmoid carcinoma and underwent laparoscopic left colectomy. A surgical drain was placed in the pouch of Douglas through the incision of the right iliac fossa trocar site. On the fourth day, he began to flatus, and the abdominal pain decreased. However, on the ninth day after surgery, the patient had more abdominal pain, could not pass gas and defecate, and the abdomen was more distended. An abdominal computed tomography (CT) scan showed a dilated loop of the small intestine above the transition site with a drainage sonde and no dilation of the loop below the sonde. The patient was indicated to remove the sonde. He could pass gas and defecate the next day again and was relieved of the abdominal distention. Discussion: Once an EPSBO is considered, it is essential to think of the bowel obstruction caused by the drainage tube in the case of abdominal drainage. It is necessary to have a contrast CT scan to examine. Conclusion: EPSBO due to intra-abdominal drainage is a rare condition that presents a challenge in diagnosis and treatment. Diagnosis usually begins on the fourth postoperative day, mainly in operations in the lower transverse mesentery, including drainage placement after laparoscopic surgery.

Using a disparities dashboard to identify racial/ethnic differences in breast cancer treatment: Implications for improving cancer care delivery.

161 Background: Delays in the initiation of breast cancer treatment (e.g., surgery, chemotherapy, adjuvant endocrine therapy) contributes to breast cancer survival disparities. Yet, the use of a cancer dashboard to assess and inform real time assessments of the timing of surgery and systemic treatment by race/ethnicity is unclear. The purpose of this study is to investigate whether a cancer disparities dashboard can be used to assess racial/ethnic differences in the initiation of first line of treatment and timeliness of breast cancer surgery. Methods: A disparities dashboard was built using data from the tumor registry and the electronic medical record’s Data Warehouse. Key fields assessing patient race/ethnicity, cancer stage, receptor status, surgery type, treatments received and dates of surgery. This retrospective analysis included women diagnosed with a new primary breast cancer who underwent definitive surgery at Mount Sinai Hospital (2010-2020). We defined delays as &gt;8 weeks to treatment initiation, and delay to breast surgery as &gt; 6 weeks from diagnosis. Chi-square and t tests were used to assess independent variables (e.g., stage, age) by race/ethnicity. Patient-level multivariable logistic regression was used to evaluate the association between race/ethnicity and delays to initiation of first treatment and surgical delays. Results: Of 8,403 women identified (46.5% non-Hispanic White, 17.7% Black, 16.9% Hispanic), 64.5% had stage I cancer, 80.8% had estrogen receptor cancer. 18.5% of the sample had delays to initial treatment and 42.6% experienced delays to surgery. After adjusting for stage, age and receptor status Black patients compared to non-Hispanic White patients had the greatest likelihood of delayed initial treatment (OR: 3.03; 95% CI:2.6-3.5) or surgery delays (OR:2.45; 95% CI:2.1-2.8). With regards to clinical/sociodemographic factors younger patients (22-39 vs. 40-64; p&lt;0.001), mastectomy surgery type (; p=0.031), higher stage (stage 3 vs.1; p&lt;0.0001), HER2 and TNBC receptor status (vs. ER; p&lt;0.0001),) were more likely to experience surgery delays. Conclusions: Breast cancer treatment delays were more common among minoritized patients compared to White counterparts. A Disparities Dashboard can be used to assess differences in care. These data can be used to inform quality initiatives to improve cancer care delivery for at-risk patient populations who experience worse cancer outcomes.

Efficacy and safety of purified starch for adhesion prevention in colorectal surgery

BackgroundAdhesions within the abdominal cavity develop in as many as 90 % of individuals following abdominal surgery. However, the true adhesive condition of patients can only be ascertained during the second surgery. MethodsWe conducted a prospective, non-randomized study to assess the anti-adhesion properties of purified starch in patients who had undergone colorectal surgery in the past and then needed a subsequent surgical intervention. Adhesion scores have been prospectively recorded in operation notes since January 2020 when patients underwent a second surgery. Patients who had received purified starch during their initial surgery constituted the purified starch group, while those who had not received anti-adhesion medical materials were the control group. The main objectives of the study were to evaluate the extent and severity of adhesions as primary outcomes, while secondary outcomes included measuring blood loss, operation time, and postoperative complications. ResultsWe analyzed the data of 101 patients, with 61 in the purified starch group and 40 in the control group. In multivariate analysis, adhesion severity (Odds ratio, 0.20, 95 % confidence interval 0.08–0.54, P < 0.01) and adhesion area scores (Odds ratio, 0.13, 95 % confidence interval 0.04–0.45, P < 0.01) were significantly lower in the purified starch group than in the control group. There was no significant difference in operation times, blood loss, and postoperative complications between the two groups. ConclusionPurified starch is a safe and effective anti-adhesion material that can significantly reduce the severity and extent of adhesion after colorectal surgery.

An Intravertebral Pseudoaneurysm Formed after Infective Spondylitis

The surgical treatment of spondylitis involves potential risks, especially when dealing with infected tissues that may be fragile and susceptible to injury from surgical trauma and inflammation. In cases where spondylitis is not controlled even after the initial surgery, unexpected situations can arise if an unusual change in infected tissues around the spine is misinterpreted. The present case involves a 62-year-old who underwent laminectomy, debridement, and stabilization from T12 to L2 due to medically intractable spondylitis caused by methicillin-resistant Staphylococcus aureus. No major bleeding or vascular injury occurred during surgery. However, despite some improvement in pain and weakness, inflammation markers remained elevated and back pain recurred. A computed tomography (CT) scan taken 15 days after surgery showed a round-enhancing lesion inside the L1 vertebra. Although the primary imaging diagnosis suggested a loculated abscess, a round-enhancing lesion raised suspicion of an unusual pseudoaneurysm. A CT angiography confirmed a pseudoaneurysm from the L1 segmental artery, successfully treated with endovascular embolization. After embolization, the patient’s back pain improved, and inflammation markers further decreased with oral antibiotics. This case highlights the possibility of a pseudoaneurysm occurring in cases of spondylitis, emphasizing the importance of considering this entity in the differential diagnosis to ensure proper treatment.

Tumor Characteristics of Bilateral Breast Cancer Compared with Unilateral Breast Cancer.

Bilateral breast cancer (BC) has an incidence of 1 to 3 %. This study aimed to describe the clinicopathologic characteristics and management of bilateral BC, estimate disease-free survival (DFS), and compare DFS with unilateral BC. A retrospective analysis was performed for patients who hadbilateral invasive BC or unilateral invasive BC and contralateral ductal carcinoma in situ (DCIS) treated at Mayo Clinic Rochester from 2008 to 2022. A 4:1 matched cohort of patients with unilateral invasive BC was used for comparison. The groups were compared using Wilcoxon rank-sum or chi-square tests. Disease-free survival was analyzed using the Kaplan-Meier method and log-rank test, with Cox proportional hazards regression used for multivariable analysis. The study identified 278 cases of bilateral breast cancer (177 cases of bilateral invasive cancer and 101 cases of unilateral invasive cancer with contralateral DCIS), representing 4.1 % of invasive BCs. Biologic subtype was concordant between sides in 79.8 % of the patients. Initial surgery was bilateral mastectomy for 76.6 %, bilateral lumpectomy for 20.5 %, and unilateral mastectomy with unilateral lumpectomy for 2.9 % of the patients. Pathogenic variants in breast cancer predisposition genes were present in 21.7 % of those tested. The patients who had bilateral BC presented with a higher cT category than the patients who had unilateral BC (p = 0.02), and a higher proportion presented with ILC (17.3 % vs 10.9 %; p = 0.004), estrogen receptor-positive (ER+) disease (89.2 % vs 84.2 %; p = 0.04), multicentric/multifocal disease (37.1 % vs 24.3 %; p < 0.001), breast cancer pathogenic variant (21.7 % vs 12.4 %; p = 0.02), and palpable presentation (48.2 % vs 40.8 %; p = 0.03). The patients with bilateral BC showed DFS similar to that for the unilateral BC cohort (p = 0.71). Bilateral BCs most commonly are biologically concordant between sides. Bilateral BC presented more commonly with larger tumors, lobular histology, ER+ status, multicentricity or multifocality, pathogenic variant, and palpable disease. Bilateral BC is not associated with worse DFS than unilateral BC.

Clear cell carcinoma arising in an ovarian remnant 19 years after oophoerctomy: case report

BackgroundOvarian remnant syndrome (ORS) is a rare complication that occurs after oophorectomy, characterized by residual ovarian tissue causing pelvic pain, masses, and various symptoms. The clinical manifestations of ORS are nonspecific, and its diagnosis relies on histological examination. Since ORS typically represents a benign ovarian lesion, there have been few reported cases of malignant transformation. In this report, we presented a unique case of ovarian clear cell carcinoma (OCCC) arising from an ovarian remnant following salpingo-oophorectomy.Case presentationOur patient was a 47-year-old female initially diagnosed with uterine myoma. She had previously undergone cesarean section and unilateral salpingo-oophorectomy. Transvaginal ultrasound and computed tomography (CT) scans revealed a soft tissue mass adjacent to the right lateral wall of the myometrium. The patient opted for transabdominal hysterectomy, left adnexal resection, laparoscopic omentectomy, appendectomy, and pelvic and abdominal lymphadenectomy. The final pathology results confirmed the diagnosis of OCCC, consistent with ORS. The patient subsequently received six cycles of intravenous chemotherapy using the carboplatin/paclitaxel (TC) regimen (paclitaxel liposomes 175 mg/m², carboplatin AUC 5). After 3 years of follow-up, the patient’s condition remained normal.ConclusionORS can significantly impact patients’ quality of life and pose challenges for clinicians. Complete excision of ovarian tissue during the initial surgery is crucial in preventing ORS recurrence and potential malignant transformation of ovarian remnants.

Proteometabolomics of initial and recurrent glioblastoma highlights an increased immune cell signature with altered lipid metabolism.

There is an urgent need to better understand the mechanisms associated with the development, progression, and onset of recurrence after initial surgery in glioblastoma (GBM). The use of integrative phenotype-focused -omics technologies such as proteomics and lipidomics provides an unbiased approach to explore the molecular evolution of the tumor and its associated environment. We assembled a cohort of patient-matched initial (iGBM) and recurrent (rGBM) specimens of resected GBM. Proteome and metabolome composition were determined by mass spectrometry-based techniques. We performed neutrophil-GBM cell coculture experiments to evaluate the behavior of rGBM-enriched proteins in the tumor microenvironment. ELISA-based quantitation of candidate proteins was performed to test the association of their plasma concentrations in iGBM with the onset of recurrence. Proteomic profiles reflect increased immune cell infiltration and extracellular matrix reorganization in rGBM. ASAH1, SYMN, and GPNMB were highly enriched proteins in rGBM. Lipidomics indicates the downregulation of ceramides in rGBM. Cell analyses suggest a role for ASAH1 in neutrophils and its localization in extracellular traps. Plasma concentrations of ASAH1 and SYNM show an association with time to recurrence. We describe the potential importance of ASAH1 in tumor progression and development of rGBM via metabolic rearrangement and showcase the feedback from the tumor microenvironment to plasma proteome profiles. We report the potential of ASAH1 and SYNM as plasma markers of rGBM progression. The published datasets can be considered as a resource for further functional and biomarker studies involving additional -omics technologies.

Combination of flexible intramedullary nailing and Ilizarov frame for salvage of femur and humerus nonunion in a girl with osteogenesis imperfecta

Background Fixation of pathological long bones with telescopic intramedullary rods is well known to be a technically challenging procedure even in specialist centres, with a high complication rate due to rod migration, hardware failure, nonunion or malunion. However there is very little guidance in the literature regarding salvage treatment options when failure occurs.Aim We demonstrate a surgical technique that can be used for salvage treatment of both femoral and humeral complex nonunions following Fassier-Duval (FD) rodding in a child with osteogenesis imperfecta (OI).Case description A 13 year-old girl with OI type VIII presented sequentially with nonunion and deformity of the femur then the humerus following previous FD rods in those segments. The femur was also complicated with metallosis between the steel rod and an overlying titanium plate. Both segments were treated with pseudarthrosis debridement, removal of metalwork and stabilisation with hydroxyapatite (HA)-coated flexible intramedullary nails, with temporary Ilizarov frame to provide enough longitudinal and rotational stability to allow immediate weight-bearing. The femur Ilizarov frame was removed after 64 days, and the femur remained straight and fully healed at 2.5 years. The frame time for the humerus was 40 days, complete union was achieved and upper limb function restored and maintained at 9 months.Discussion The transphyseal telescopic rod is the traditional implant of choice in terms of treating fractures and stabilising osteotomies for deformity in OI. However, it does not provide enough torsional or longitudinal stability by itself to allow early weight-bearing which is detrimental to bone healing in this vulnerable patient group. The incidence of delayed union or nonunion at osteotomy site in telescopic rod application is not negligible: up to 14.5-51.5 %. Although the technique we have shown in this case may not be applied to all complex OI patients, we believe that the combination of flexible intramedullary nails and Ilizarov frame provides a favourable environment for bone healing in complex or revision cases. As a secondary learning point the initial revision surgery to the left femur demonstrated the perils of using a steel rod and a titanium plate in a biologically active environment which in this case lead to metallosis and lysis.Conclusion We found the technique of HA-coated flexible intramedullary nails combined with the Ilizarov frame effective in the salvage of failed telescopic rods in both femur and humerus and feel this technique can be used as a salvage option in similar cases worldwide. This case also demonstrates the perils of using different metals in combined internal fixation.

Surgical and visual outcomes after vitreoretinal surgery for complex retinal capillary hemangioblastoma.

We evaluated the anatomical and functional outcomes after vitreoretinal surgery for complex retinal capillary hemangioblastoma (RCH). This was a retrospective case series of 15 patients (16 eyes) with tractional or combined retinal detachment (RD) managed with pars plana vitrectomy and tumor endoresection (ER) with/without feeder vessel ligation. The mean age at the time of surgery was 30 years (range, 14-46 years). The most common tumor locations were inferotemporal (six eyes) and temporal (six eyes) quadrants. Indications for surgery included exudative RD with fibrovascular proliferation (eight eyes), combined RD (five eyes), vitreous hemorrhage (four eyes), and rhegmatogenous RD (two eyes). Tumor destruction was performed with laser and/or cryotherapy in nine eyes (57%) and ER in seven eyes (43%). Feeder vessel was ligated and cauterized in 10 (63%) and six eyes (37%), respectively. Anatomical success after initial surgery was 50% (eight eyes), which improved to 88% (14 eyes) after they underwent a repeat procedure for recurrent RD (eight eyes). At the last visit, visual acuity improved in seven eyes (44%), was stable in four eyes (25%), and worsened in five eyes (31%) with a mean follow-up of 29 months (6-79 months). Comparison between the ER group and the laser/cryotherapy group revealed no significant difference in final retinal reattachment rate (89% vs. 86%, P > 0.05), with better visual outcomes in laser/cryotherapy group (57% vs. 78%, P < 0.05). Pars plana vitrectomy with/without tumor endoresection can be a safe and effective treatment option for complex RCHs, achieving good tumor control and anatomical success with limited functional success.

Characteristics and outcomes for 61 cats that underwent either surgery or stereotactic radiotherapy as treatment for intracranial meningioma (2005-2017).

To report clinical features and outcomes of cats undergoing either stereotactic radiotherapy (SRT) or surgical excision for the treatment of intracranial meningioma. 61 client-owned cats. Medical records were retrospectively reviewed of cats with intracranial meningiomas that were treated with surgical removal and/or SRT between 2005 and 2017. Signalment, clinical signs, duration of clinical signs, diagnostic imaging reports, histopathology reports, treatment protocol, complications, recurrence or progression, and survival time were obtained from the medical record and through follow-up phone calls. Of the 61 patients, 46 had surgery, 14 had SRT, and 1 had surgery followed by SRT for initial treatment. Significantly more cats that underwent surgery had peritreatment complications compared to the SRT group (P < .0001). Cats that received surgery initially had a significantly longer median survival time (MST) of 1,345 days compared to the MST of 339 days for the SRT cats (P = .002). Fourteen (30%) cats in the surgery group and 4 cats in the SRT group (28%) had MRI- or CT-confirmed tumor regrowth or new tumor growth (P = 1.00). Five cases that had SRT for subsequent recurrence had an MST of 700 days (range, 335 to 1,460 days) after the last treatment. SRT proved to be a safe, alternative treatment option for feline patients with intracranial meningiomas; however, the survival times with surgery alone were significantly longer. SRT for the treatment of recurrence following initial surgery may show promising results.

Combining Perfluorobutylpentane (F4H5) with Glaucoma Drainage Device Implantation for Silicone Oil-Induced Glaucoma: A Pilot Study.

Our aim was to perform a perfluorobutylpentane (F4H5) washout in conjunction with glaucoma drainage device (GDD) placement in patients with silicone oil (SO)-induced glaucoma. In this report we present our preliminary results concerning the effectiveness in clearing the SO and the safety of the procedure. Eight patients who previously underwent pars plana vitrectomy with SO tamponade due to retinal detachment were selected. Removal of SO was performed on average 10 months after initial surgery. All patients developed glaucoma with evidence of SO remnants in the anterior chamber (AC) and angle. Removal of the remaining SO with F4H5 washout was performed in all cases with concomitant insertion of a GDD to treat the refractory glaucoma. Intraocular pressure (IOP), SO remnants, endothelial cell count, and need for glaucoma medications were evaluated up to 12 months after the surgical procedure. All patients had uneventful surgery with no major complications 12 months postoperatively. A marked reduction of SO remnants in the AC and angle was observed in all cases after surgery. There was a 60.9% decrease in mean IOP 12 months postoperatively (p<0.05) and the need for glaucoma medication was lower in all patients (mean topical medicines: 4 preoperatively vs. 0.75±0.89 postoperatively; p<0.05). Endothelial cell density showed no significant change (mean 2012±129 cells/mm2 preoperatively vs. 1985±134 cells/mm2 postoperatively; p>0.05), and there were no signs of corneal edema. F4H5 is an effective emulsifier for removing SO remnants and may be safely used in conjunction with GDD placement in order to control IOP in eyes with silicone oil-induced glaucoma.

Serial RV wall stress measurements: association with right ventricular function in repaired Tetralogy of Fallot patients

BackgroundOptimal timing of pulmonary valve replacement (PVR) in Tetralogy of Fallot (TOF) patients remains challenging. Ventricular wall stress is considered to be an early marker of right ventricular (RV) dysfunction.ObjectivesTo investigate the association of RV wall stresses and their change over time with functional parameters in TOF patients.MethodsTen TOF patients after surgical repair with moderate/severe pulmonary regurgitation were included. At two timepoints (median follow-up time 7.2 years), patient-specific computational biventricular models for wall stress assessment were created using CMR short-axis cine images and echocardiography-based RV pressures. RV ejection fraction (RVEF), NT-proBNP and cardiopulmonary exercise tests were used as outcome measures reflecting RV function. Associations between regional RV diastolic wall stress and RV function were investigated using linear mixed models.ResultsIncreased wall stress correlated with lower RV mass (rrm = −0.70, p = 0.017) and lower RV mass-to-volume (rrm = −0.80, p = 0.003) using repeated measures. Wall stress decreased significantly over time, especially in patients with a stable RVEF (p &amp;lt; 0.001). Higher wall stress was independently associated with lower RVEF, adjusted for left ventricular ejection fraction, RV end-diastolic volume and time since initial surgery (decrease of 1.27% RVEF per kPa increase in wall stress, p = 0.029) using repeated measurements. No association was found between wall stress, NT-proBNP, and exercise capacity.ConclusionsUsing a computational method to calculate wall stress locally in geometrically complex ventricles, we demonstrated that lower wall stress might be important to maintain ventricular function. RV wall stress assessment can be used in serial follow-up, and is potentially an early marker of impending RV dysfunction.