Intraoperative Assessment Research Articles

Assessment of Cup Placement Impact on Functional Outcomes in Total Hip Replacement: A Retrospective Analysis of 20 Patients

Introduction:Total hip replacement surgery is gaining popularity as a treatment for hip disorders, replacing alternative treatments like excisional arthroplasty, osteotomy, arthrodesis, and hemiarthroplasty. This research aims to evaluate the effect of the acetabular cup on functional outcomes, particularly in younger patients with hip arthritis and femur neck fractures.Materials And Methods:This study aimed to evaluate the placement of the acetabular cup and its association with functional outcomes in total hip replacement (THR). 20 patients were randomly selected from the MRD department and underwent pelvic CT scans postoperatively. Functional results have been analyzed using the Harris Hip Score. The acceptable cup version range was 15 ± 10 degrees, and patients outside this range were closely examined for rotational movements. Results: A study of 20 patients with a neck or femur fracture found that 11 patients had a right knee injury, while 9 had a left knee injury. After a year postoperatively, 18 patients reported no pain, while 2 had mild pain. Functional assessment depicted better outcomes in 17 patients, good outcomes in 2 patients, and fair outcomes in 1 patient. Radiological analysis revealed a mean cup version of 17.77 degrees, with complications including one dislocation and three limb length discrepancies. None of the patients developed an infection.Conclusion:The study found that 90% of patients had excellent functional outcomes, with only 10% exhibiting excessive anteversion. CT scan-based measurements of cup placement provided reliable predictions, consistent with intraoperative assessment of cup positioning.

Indocyanine green fluorescence in the evaluation of post-resection pancreatic remnant perfusion after a pancreaticoduodenectomy: a clinical study protocol

BackgroundPancreaticoduodenectomy is associated with an incidence of postoperative complications of approximately 41%. One of the most severe complications is a postoperative pancreatic fistula. The exact cause of postoperative fistula development is still unknown, but it appears to be multifactorial. Proper perfusion of pancreatic remnant is essential for the healing of pancreaticojejunostomy. To date, there is no method to reliably evaluate the vascular supply of the remnant. One of the methods for the assessment of organ perfusion is the indocyanine green fluorescence. This study aims to determine if indocyanine green fluorescence is a reliable method to measure the perfusion of the post-resection pancreatic remnant. The secondary outcome is to determine if intraoperative evaluation of the vascular supply of the post-resection remnant may predict the increased risk of postoperative pancreatic fistula development.MethodsThis study is designed as a prospective, observational study. All consecutive patients undergoing open or robotic pancreaticoduodenectomies at our department during the 1st May 2024-31st December 2026 period will be enrolled. The exclusion criteria are an allergy to indocyanine green and refusal by the patient. The adequacy of the vascular supply of the post-resection pancreatic remnant will be intraoperatively evaluated using a fluorescence detector. Patients will be divided into two groups: Those with high risk of pancreatic fistula development and those with low risk. The incidence of pancreatic fistulas in both groups is to be compared. Postoperative data including morbidity, mortality, hospital stay, intensive care unit stay and postoperative fistula development will be collected.DiscussionIf an intraoperative assessment of the perfusion of post-resection pancreatic remnant using indocyanine green is proven to be a suitable method to estimate the increased risk of the pancreatic fistula, the list of the existing known risk factors could be expanded. In the most high-risk patients the modification of the surgical procedure could be considered.Trial registrationNumber: NCT06198400 ClinicalTrials.Gov. Date 08.01.2024.

The infraacetabular screw - anatomy, radiology, biomechanics and clinics.

Acetabular fracture surgery follows the primary aim of anatomic reduction and rigid stable fixation of the fracture. Infraacetabular screws (IAS) allow for an increased stability of the acetabular fixation by closing the periacetabular fixation frame without requiring an additional posterior approach. The osseous screw corridor for infraacetabular screws use the transition zone between the acetabular ring and the obturator ring. The infraacetabular screw corridor (IAC) shows a double-cone shape with an isthmus located near the acetabular fovea. The iliopectineal eminence (IE) is mainly used as a clinical landmark for the intraoperative assessment of the entry point of IAS. The inlet view, the combined obturator oblique outlet view and a 1/3 iliac oblique outlet view may be used for the intraoperative radiological assessment for both the entry point and the screw trajectory of IAS. Several biomechanical studies have shown that IAS increase the stiffness of the internal fixation. Scientific proof for an improved clinical outcome is still missing.

Indocyanine Green for Assessment of Ureteral Vascularity Can Reduce the Rate of Ureteral Complications in Patients Undergoing Extended Hysterectomy.

Objectives: This study aimed to evaluate the effectiveness of using indocyanine green (ICG) for assessing ureteral vascularity to reduce ureteral complications in patients undergoing extended hysterectomy for deep endometriosis or oncological indications. Methods: A retrospective-prospective cohort study was conducted at the Centre of Gynecology in Opole, Poland, involving 555 patients who underwent hysterectomy from 2020 to 2023. Patients were categorized based on the Querleu-Morrow classification. ICG was used intraoperatively for vascular assessment in patients with deep endometriosis undergoing wide ureter dissection typical of Type C hysterectomy. Results: Ureteral complications occurred in 12 (2.2%) patients, with a significantly lower complication rate in those who underwent ICG testing (1.7%) compared to those who did not (22.7%, p = 0.001). Prophylactic double-J stenting further reduced the risk of complications. Conclusions: The use of ICG for intraoperative assessment of ureteral vascularity significantly reduces the risk of ureteral complications in complex hysterectomies. Further studies are needed to confirm these findings.

Commentator Discussion: A novel, multimodal, intraoperative cognitive workload assessment of cardiac surgery team members

Commentator Discussion: A novel, multimodal, intraoperative cognitive workload assessment of cardiac surgery team members

A new method of intraoperative assessment of the dynamics of cortical blood flow using imaging photoplethysmography

Background. Intraoperative assessment of changes in cerebral blood flow is an important component of objective quality control of surgical treatment of cerebral artery aneurysms. Various techniques have been tried to solve this task, but they all have their drawbacks, which forces us to look for new ways of blood flow monitoring. We propose to use the technology of imaging photoplethysmography (IPPG) – a technically simple, contactless, safe and cheap optical method for assessing the perfusion of biological tissues.Aim. To demonstrate the possibility of using IPPG to assess the dynamics of cerebral blood flow parameters during aneurysm clipping surgery, as well as to identify early changes in blood supply to the cerebral cortex.Materials and methods. The study was carried out during six surgeries of clipping aneurysms of the anterior part of the Willis’s circle, both in the acute stage of rupture (n = 1) and in a planned manner (n = 5). The IPPG system, which is an LED illuminator in a single unit with a digital video camera, was located on a tripod 25 cm from the intervention zone. During each operation, two one-minute recordings of the illuminated surface of the cerebral cortex were performed: after dissection of the dura mater and before its suturing at the end of the main stage of the intervention. To improve the measurement accuracy, video frames of the studied area were recorded synchronously with the registration of an electrocardiogram. After recording, two IPPG parameters were calculated and compared: the amplitude of the pulsatile component and the pulse wave transit time. Thereafter, the obtained data were compared with the results of computed tomography. Statistical analysis was performed using pairwise comparison tests in the GraphPad Prism software package.Results. Clipping of cerebral vessel aneurysms are accompanied by significant changes in the parameters of cerebral blood flow. Analysis of the data for all patients revealed significant differences in IPPG parameters before and after surgery, namely, statistically significant increase in amplitude of the pulsatile component (n = 3) and decrease in pulse wave transit time (n = 5). The absence of significant changes in both parameters was found only in one patient who had mechanical damage in the cortex in the region of video recording.Conclusion. The IPPG system is capable to quantify changes in blood supply to the cortex during surgical treatment of cerebral artery aneurysms and to identify areas with either increased or decreased blood supply. In-depth studies are required to obtain additional markers of the postoperative state of cerebral blood flow.

Lymph node evaluation and nodal metastasis prediction in epithelial ovarian cancers: A retrospective study.

To identify consensus regarding lymph node (LN) evaluation in epithelial ovarian cancer (EOC). The objective of the present study was to evaluate surgico-pathological findings, LN involvement, and the prediction of LN metastasis via preoperative imaging and intraoperative assessment in women with EOC. Women with EOC who underwent cytoreductive surgery (CRS) between Jan 2019 to June 2022 were included. The distribution of histology, stage, and LN metastasis was studied. The predictive value of serum cancer antigen (CA)-125, instead of and radiologically and surgically enlarged LNs with final LN histopathology was studied. A total of 96 women with EOCs underwent CRS. Fifty women (52%) underwent primary CRS and 46 women (48%) underwent interval CRS. Seventy-five women (78.13%) with EOC underwent pelvic and/or para-aortic lymphadenectomy, out of which 23 (30.67%) were histologically positive. High-grade serous carcinoma was the commonest (n=55, 73.33%) histology. The majority of women, 56 (74.67%) were stage III or IV at presentation. Complete cytoreduction was achieved in 59 (78.66%) patients. The receiver operating characteristics curve showed a cutoff for CA-125 of 1360 U/mL (area under the curve 0.702, p=0.002) for LN metastases. Both radiologically and surgically enlarged LNs significantly predicted LN metastasis on histopathology (p=0.02 and 0.006 respectively). The combined sensitivity, specificity, positive predictive value and negative predictive value of both contrast enhanced computed tomography (CECT) and surgically enlarged LNs were 78.26%, 57.69%, 45%, and 85.71%, respectively. Serous histology, high-grade tumors, highCA-125 levels, and suspicious LNs on CECT or during surgery were significantly associated with LN metastasis. However, considering the false-negative rate of 21.74%, the combination of radiologically and surgically enlarged LNs cannot be used as the sole surrogate marker for lymphadenectomy.

Functional preoperative assessment of coronal knee laxity better predicts postoperative patient outcomes than intraoperative surgeon-defined laxity in total knee arthroplasty.

Intraoperative laxity assessments in total knee arthroplasty (TKA) are subjective, with few studies comparing against standardised preoperative and postoperative assessments. This study compares coronal knee laxity in TKA patients awake and anaesthetised, preprosthesis and postprosthesis implantation, evaluating relationships to patient-reported outcome measures. A retrospective analysis of 49 TKA joints included preoperative and postoperative computed tomography scans, stress radiographsand knee injury and osteoarthritis outcome score (KOOS) questionnaire results preoperatively and 12 months postoperatively. The imaging was used to assess functional laxity (FL) in awake patients, whereas computer navigation measured intraoperative surgical laxity (SL) preimplantation and postimplantation, with patients anaesthetised. Varus and valgus stress states and their difference, joint laxity, were measured. SL was greater than FL in both preimplantation [8.1° (interquartile range, IQR2.0°) and 3.8° (IQR 2.9°), respectively] and postimplantation [3.5° (IQR 2.3°) and 2.5° (IQR 2.7°), respectively]. Preimplantation, SL was more likely than FL to categorise knees as correctable to ±3° of the mechanical axis. Preoperative FL correlated with KOOS Symptoms (r = 0.33, p = .02) and quality of life (QOL) (r = 0.38, p = .01), whereas reducing medial laxity with TKA enhanced postoperative QOL outcomes (p = .02). Functional coronal knee laxity assessment of awake patients is generally lower than intraoperative surgical assessments of anaesthetised patients. Preoperative SL may result in overcorrection of coronal TKA alignment, whereas preoperative FL better predicts postoperative patient outcomes and reflects the patients' native and tolerable knee laxity. Preoperative FL assessment can be used to guide surgical planning. Level II.

Optimizing the patellofemoral compartment in total knee arthroplasty: Is it time for dynamic assessment?

Despite improvements in implant design, surgical techniques and assistive technologies for total knee arthroplasty (TKA), anterior knee pain (AKP) remains frequently reported, even by satisfied patients. This persistent problem calls for better understanding and management of the patellofemoral or anterior compartment during surgery, just as the techniques and strategies deployed to optimize the flexion and extension spaces through personalized alignment, bone cuts and ligament balancing. Assistive technologies such as navigation and robotics provide new tools to manage this 'third space' through precise pre-operative planning and dynamic intra-operative assessment. Such endeavors must start with clear definitions of the 'third space', how it should be measured, what constitutes its 'safe zone', and how it affects outcomes. There are yet no established methods to evaluate the patellofemoral compartment, and no clear thresholds to define over- or under-stuffing. Static assessment using lateral radiographs provides a limited understanding and depends considerably on flexion angle, while dynamic evaluation at multiple flexion angles or using intra-operative computer or robotic-assistance enables a broader perspective and solutions to manage patellar tracking and anterior offset. Future studies should investigate the impact of variations in anterior offset in TKA, define its safe zone, and understand the effects of of thresholds for over- or under-stuffing. Experimental methods such as in-vivo motion analysis and force sensors could elucidate the influence of anterior offset on flexion and extension biomechanics.

SHIELD Study: Reoperation Rate in Breast-Conserving Surgery using Confocal Histolog Scanner for Intraoperative Margin Assessment – Interim Results

SHIELD Study: Reoperation Rate in Breast-Conserving Surgery using Confocal Histolog Scanner for Intraoperative Margin Assessment – Interim Results

807. A REVISED APPROACH TO THE ESOPHAGOGASTRIC JUNCTION: A MODIFIED SIEWERT CLASSIFICATION

Abstract Background Esophagogastric junction (EGJ) adenocarcinomas are challenging due to their anatomical and histopathological features and treated either as part of the esophagus or stomach cancers. Siewert (S) and Nishi classifications rely on the tumor’s epicenter to guide treatment decisions, which can lead to diagnostic and therapeutic inconsistencies. Moreover, recent studies helped define the optimal extent of lymphadenectomy for EGJ cancers. Here we present our standardized approach to EGJ cancers that integrates these insights, providing a framework to guide clinical decision-making. Methods Our modified classification relies on tumor extent rather than the epicentre, based on endoscopic measurement of the proximal and the distal limits, and the exact location of the EGJ. This approach classifies tumors based on their extent which results into six categories: SI, SI/II, SII, SII/III, SIII, and SI/II/III. Lower esophageal tumors whose distal limit lies between + 1cm and -2cm are classified as I/II. Cardia tumors whose proximal limit falls between those boundaries are II/III. Tumors that span more cephalad than + 1cm and more distally than – 2cm, are I/II/III. For Siewert I, I/II and II tumors, surgical management depends on the extent of esophageal involvement, mainly dictated by the probability of mediastinal basement nodal involvement, as defined by Kurokawa et al (2019). Additionally, a 3-field lymphadenectomy is performed when there is involvement of the cervical or recurrent laryngeal nerve lymph node stations. Results In SI, SI/II, and SI/II/III, with esophageal involvement exceeding 4 cm we favor a transthoracic esophagectomy (TTE) with total thoracic lymphadenectomy. If the involvement is between 1-4 cm, a transhiatal esophagectomy (THE) with lower mediastinal lymphadenectomy is performed. In SII, THE is done for 0-1 cm of involvement; absence of esophageal involvement permits a transhiatal extended total gastrectomy (eTG) with abdominal D2 lymphadenectomy and intra-operative margin status assessment via frozen sections. In SI/II/III and esophageal involvement of more than 4 cm, TTE is required; for esophageal involvement of 1-4 cm, we perform a THE and total gastrectomy with abdominal D2 lymphadenectomy based on distal margin findings. Conclusion This proposed modification to the classification of EGJ adenocarcinomas introduces a comprehensive framework that is tailored to the extent of tumor involvement. By addressing the limitations of existing systems and incorporating current insights, this updated classification aims to improve patient categorization and standardize treatment protocols, potentially leading to enhanced clinical outcomes.

Extended segmentectomy for intersegmental lesions with intraoperative surgical margin assessment by radiofrequency identification markers

ObjectiveWe developed a technique to determine deep surgical margins using radiofrequency identification markers. This study assessed the feasibility of this technique during extended segmentectomy of intersegmental lesions. MethodsA single-center, prospective, single-arm study was performed from 2020 to 2023. Small pulmonary lesions suspicious for malignancy locating the virtual intersegmental plane based on 3-dimensional imagery were included. Markers were placed in the vicinity of the lesions using electromagnetic navigation bronchoscopy. In addition to indocyanine green injection, surgeons used wireless signal strength to determine the best resection line without lung palpation to obtain surgical margins of 10 mm or the same size as the tumor. ResultsWe analyzed 75 lesions in 75 patients. Median lesion size and depth from the pleura were 12.0 mm and 23.6 mm, respectively. Three-dimensional imagery identified lesions at a median distance of 7.0 mm from the virtual intersegmental plane. The median marker-lesion and marker-virtual intersegmental plane distances were 5.8 mm and 4.9 mm, respectively. Complex segmentectomy was performed in 64 of 75 patients (85.3%). The indocyanine green and preoperative simulated intersegmental lines agreed in 92.0% (69/75). In 6 cases (8.0%), the resection line was determined using radiofrequency identification markers to obtain adequate margins because the indocyanine green undyed area was smaller than the preoperatively simulated one. In 1 patient, planned segmentectomy was converted to lobectomy because of a misplaced radiofrequency identification marker (1.3%). The successful tumor resection rate was 98.7%. The median surgical margin was 16.0 mm. ConclusionsUse of radiofrequency identification markers enabled precise extended segmentectomy with adequate surgical margins.

400. MODIFICATION OF THE LESSER CURVATURE INCISION ENHANCES GASTRIC CONDUIT BLOOD FLOW AND DECREASE ANASTOMOTIC LEAKAGE RISK AFTER ESOPHAGECTOMY

Abstract Background We conducted this study to investigate the effectiveness of a modified incision line on the lesser curvature for gastric conduit formation during esophagectomy in enhancing the perfusion of the gastric conduit, as determined by indocyanine green (ICG) fluorescence imaging, and reducing the incidence of anastomotic leakage. Methods A total of 272 patients who underwent esophagectomy at our institution between June 2014 and August 2022 were enrolled in the study. The patients were divided into two groups in accordance with the type of cutline on the lesser curvature: the Conventional group, consisting of patients operated on until 2018 (Conventional group; n = 141), in which the traditional cutline (5.0 cm from the pylorus in routine) was adopted, and the Current group, consisting of patients operated on from 2019 until date (Current group; n = 131), in which a modified cutline on the lesser curvature was adopted, that allowed preservation of the entire right gastric artery was adopted (hereinafter, modified cutline) was adopted. Gastric conduit perfusion during the surgery was assessed by intraoperative ICG fluorescence imaging, and the clinical outcomes after esophagectomy were also evaluated. Results All patients underwent esophagectomy with regional lymph node dissection and gastric conduit reconstruction via the retrosternal route. The distance from the pylorus to the cutline was significantly longer in the Current group as compared with the Conv group (median: 9.0 cm vs. 5.0 cm, p < 0.001). The blood flow speed in the gastric conduit wall assessed by ICG fluorescence imaging was significantly higher in the Current group than that in the Conventional group (median: 2.81 cm/sec vs. 2.54 cm/sec, p = 0.001). Furthermore, the incidence of anastomotic leakage was significantly lower (p = 0.024) and the hospital stay significantly shorter (p < 0.001) in the Current group as compared with the Conventional group. Logistic regression analysis using the data of the entire cohort identified the blood flow velocity in the gastric conduit wall as the only variable that was significantly (negatively) associated with anastomotic leakage. Conclusions ICG fluorescence imaging is a feasible, reliable method for intraoperative assessment of gastric conduit perfusion. Use of the modified lesser curvature cutline could enhance gastric conduit perfusion, promote blood circulation around the anastomosis and ultimately reduce the risk of anastomotic leakage after esophagectomy.

Treatment strategies for revision surgery of artificial urinary sphincter: A review.

Artificial urinary sphincters (AUS) are an effective treatment for male stress urinary incontinence (SUI). However, infection, erosion, mechanical failure, atrophy, and balloon deterioration cause device malfunction in approximately half of patients by 10 years after implantation. Many patients desire to regain urinary continence and require revision surgery (RS), including device removal and simultaneous or delayed implantation. Patients for whom RS is considered should be examined physically and by interview for signs of infection. Urethral erosion should be assessed using cystoscopy. If there is infection or erosion, all devices should be removed first, and a new device should be implanted several months later. During the RS, after strong adhesion around the urethra, transcorporal cuff implantation is a safe choice. Device removal and simultaneous implantation can be performed in the absence of infection or erosion. If a long time has passed since device implantation, the entire device should be replaced due to device aging and deterioration; however, if the time is short, only the defective component need be replaced. Intraoperative assessment of urethral health is necessary for device removal and implantation. If the urethra is healthy, a new cuff can be placed in the same position as the old cuff was removed from; however, if the urethra is unhealthy, the cuff can be implanted in a more proximal/distal position, or a transcorporal cuff implant may be chosen. This article reviews the literature on diagnostic and treatment strategies for recurrent SUI in male patients with AUS and proposes a flowchart for AUS revision.

Insular Gliomas. Experience in a Latin American Center and Assessment of Variables Related to Surgical Management and Prognosis

To describe our experience in the resection of gliomas involving the insula and analyze the variables implicated in the management and prognosis of these tumors. This retrospective, single-center, analytic study included a cohort of 83 patients who underwent surgery for insular gliomas by the same surgeon in a third-level Argentine center, in the period between 2010 and 2023. We analyzed the population's demographic, clinical, and radiologic features and surgical variables associated with postoperative results and prognosis using multivariate regression analysis. A total of 53 patients (54% men) were included, with a mean follow-up of 40.7 months. The mean age at surgery was 41 years (range, 21-73) and 66.1% corresponded to low-grade gliomas (LGGs). Seizures were the initial symptom in most cases. There was evidence of tumor extension over the insula to the temporal or/and frontal lobe in 64.2% of patients. An extent of resection >90% was achieved in 62.3% of cases (27% of gross total resection), with an average resected volume of 89.4%. Awake craniotomy was indicated in 47% of patients and intraoperative magnetic resonance imaging was performed in 24%. Recurrence was observed in 44% of patients, with a mean progression-free survival of 31 months (42 months in LGG and 10 months in high-grade glioma [HGG]). Nine patients underwent reoperation. By the time of 2 years, survival was 100% for LGG and 46% for HGG, whereas 4-year overall survival was 92% for patients with LGG and 15.4% for those with HGG. Surgery for insular gliomas is a complex task that needs to be managed with adequate preoperative and intraoperative assessment to achieve maximum safe resection with low morbidity for better functional and oncologic outcomes. Adequate anatomic understanding, radiologic analysis, awake craniotomy, and cortical and subcortical mapping are paramount to pursue this aim.

Characterizing narrative feedback and predictors of feedback content on an entrustable professional activity (EPA) assessment tool

PurposeAlthough EPA assessment tools generally allow for narrative feedback, limited data exist defining characteristics and predictors of such feedback. We explored narrative feedback characteristics and their associations with entrustment, case-specific variables, and faculty/trainee characteristics.MethodsOur general surgery residency piloted an intraoperative Entrustable Professional Activities (EPA) assessment tool in 2022. The tool included an entrustment score, four sub-scores, and narrative feedback. Given strong intercorrelations (r = 0.45–0.69) and high reliability (α = 0.84) between sub-scores, we summed the four sub-scores into a composite score. We coded narrative feedback for valence (reinforcing vs constructive), specificity (specific vs general), appreciation (recognizing or rewarding trainee), coaching (offering a better way to do something), and evaluation (assessing against set of standards). Multivariable regression analyzed associations between feedback characteristics and entrustment score, composite score, PGY level, case difficulty, trainee/faculty gender, gender matching, faculty years in practice, faculty case volume with trainees, faculty evaluation score, and trainees’ under-represented in medicine (URiM) status.ResultsForty-six faculty completed 325 intraoperative EPA assessments for 44 trainees. Narrative feedback had high valence (82%) and specificity (80%). Comments frequently contained appreciation (89%); coaching (51%) and evaluation (38%) were less common. We found that faculty gender, trainee gender, and gender match predicted feedback characteristics. Generally, entrustment level, composite score, and PGY level correlated with feedback types (Table).ConclusionEntrustment and performance relate to the type of feedback received. Gender and gender match resulted in different types of feedback. Evaluative feedback was the least prevalent and warrants further exploration since evaluation is critical for learning.

The use of ultrasound to predict flexor tendinopathy after anterior locking plating of the distal radius.

This study compares ultrasound to clinical and radiographic measurements for assessing tendon pathology associated with distal radial anterior locking plates. A total of 46 patients undergoing removal of a distal radial plate had a preoperative clinical examination, radiographs and ultrasound evaluation to detect evidence of tendon irritation. Gross changes to the tendon were assessed during plate removal. In total, 32 patients demonstrated clinical abnormality. Soong 2 position was noted in 13 patients. Ultrasound revealed tenosynovitis in nine patients, tendon fibrillation or thickening in four patients and a single case of partial discontinuity. Intraoperative assessment revealed tenosynovitis in 28 patients and tendon fibre discontinuity in eight patients. Ultrasound findings were not predictive of intraoperative tenosynovitis and discontinuity. A relationship was noted between higher Soong grade, especially grade 2, and intraoperative presence of tenosynovitis, as well as Soong grade and amount of soft-tissue coverage. This study negates our hypothesis that ultrasound is useful for identifying tendinopathy after distal radial anterior plate fixation.Level of evidence: II.

Diagnosis of spine pseudoarthrosis based on the biomechanical properties of bone

BACKGROUND CONTEXTFailure to fuse following anterior cervical discectomy and fusion (ACDF) may result in symptomatic pseudoarthrosis. Traditional diagnosis involves computerized tomography to detect bridging bone and/or flexion-extension radiographs to assess whether segmental motion is above specific thresholds; however, there are currently no well-validated diagnostic tests. We propose a biomechanically rational approach to achieve a reliable diagnostic test for pseudoarthrosis. PURPOSEDevelop and test a biomechanically based approach to the diagnosis of pseudoarthrosis. STUDY DESIGNLiterature review, development of theory, re-analysis of a previously published study with surgical exploration as the gold-standard, and retrospective analysis of pooled studies to understand time to fusion. METHODSFully automated methods were used to measure disc space strains (change in disc space height divided by initial height). Measurement error combined with the reported failure strain of trabecular bone led to a proposed strain threshold for diagnosis of pseudoarthrosis following ACDF. We reanalyzed previously reported flexion-extension radiographs for asymptomatic volunteers to assess whether flexion-extension radiographs, in the absence of fusion surgery, can be expected to provide sufficient stress on motion segments to allow for reliable strain-based fusion assessment. The sensitivity and specificity of strain- and rotation-based pseudoarthrosis diagnosis were assessed by reanalysis of previously reported post-ACDF flexion-extension radiographs, where intraoperative fusion assessments were also available. Finally, we assessed changes in strain over time using 9,869 flexion-extension radiographs obtained 6 weeks to 84 months post-ACDF surgery from 1,369 patients. RESULTSThe estimated error in automated measurement of disc space strain from radiographs was approximately 3%, and the reported failure strain of bridging bone was less than 2.5%. On that basis, we propose a 5% strain threshold for pseudoarthrosis diagnosis. Reanalysis of a study in which intraoperative fusion assessments were available revealed 67% sensitivity and 82% specificity for strain-based diagnosis of pseudoarthrosis, which was comparable to rotation-based diagnosis. Analysis of post-ACDF flexion-extension radiographs revealed rapid strain reduction for up to 24 months, followed by a slower decrease for up to 84 months. When rotation is less than 2 degrees, the strain-based diagnosis differed from the rotation-based diagnosis in approximately 14% of the cases. CONCLUSIONSWe propose steps for standardizing diagnosis of pseudoarthrosis based on the failure strain of bone, measurement error, and retrospective data. These steps include obtaining high-quality flexion-extension studies, the application of proposed diagnostic thresholds, and the use of image stabilization for conclusive diagnosis, when motion is near thresholds. The necessity for an accurate diagnosis with minimal radiation exposure underscores the need for further optimization and standardization in diagnosing pseudoarthrosis following ACDF surgery. CLINICAL SIGNIFICANCEIn a symptomatic postspine fusion patient, it is important to diagnose or rule-out pseudoarthrosis. There are currently no well-validated diagnostic tests for this condition. Incorporating strain-based intervertebral motion analysis into the diagnosis could lead to a standardized and validated test for detecting spine pseudoarthrosis.

Transcranial motor-evoked potentials disappear with pons transection.

Motor-evoked potential (MEP) monitoring by transcranial electrical stimulation (TES) is important for intraoperative motor function assessment in neurosurgery; however, false-negative results sometimes occur, and these findings should be interpreted with caution. Herein, we report an interesting MEP change resulting from a pons transection. The patient was a boy aged 5years and 2months. He underwent multiple craniotomies for cerebellar anaplastic ependymoma and was already paralyzed in the right upper and lower limbs. Therefore, we decided to remove the recurrent lesion from the left anterior pons. MEPs were recorded on both the right and left sides after the start of surgery but disappeared 1h 30min after the start of surgery in the TES on the operative side, even when the stimulation intensity was increased. The contralateral TES consistently recorded stable MEPs throughout the surgery. The tumor was completely resected on imaging. Immediately postoperatively, the patient experienced flaccid paralysis on the right side of the body, which recovered to preoperative levels over time. A transcranial MEP cannot be derived if the corticospinal tract is transected at the pons. Transcranial MEP findings may accurately reflect the corticospinal tract function if the injury is caudal to the pons.

Surgical approach for a refractory enterocutaneous fistula by combining laparoscopic surgery and a planned open conversion: a case report

BackgroundAn enterocutaneous fistula (ECF) is defined as an abnormal communication between the gastrointestinal tract and skin. ECFs are rarely encountered in clinical practice, yet are frequently difficult to treat. Few reports exist regarding the surgical techniques for the treatment of an ECF. Therefore, we report a case of refractory ECF with concomitant severe adhesions, in which we performed combined laparoscopic adhesiolysis and planned open conversion.Case presentationA 57-year-old female patient underwent a laparotomy for an ovarian cyst in her 20s. At 46 years, adhesiolysis without bowel resection was performed for adhesive small bowel obstruction (SBO). However, her symptoms did not improve. Eighteen days postoperatively, she underwent a reoperation and jejunostomy. An ECF developed post-reoperation; therefore, stoma closure and radical surgery for the ECF were planned. Due to the severe adhesions, only stoma closure was performed, based on intraoperative assessments. The patient was subsequently referred to our hospital. First, skin care around the fistula was provided during an outpatient visit. Appropriate sizing of the stoma pouch was performed, to improve erosions and ulcers. Thereafter, debridement of the perifistula skin and simple closure of the ECF outlet were attempted; however, the ECF recurred shortly thereafter. After 8 years of regular skin care, with the ECF remaining stable, however, manifesting as symptomatic SBO, she underwent laparoscopic adhesiolysis. This procedure was initiated in the epigastric region, where relatively fewer adhesions were anticipated. Post-open conversion, partial resection of the small intestine at four locations, including the fistula site, was performed. Postoperatively, jejunal edema and peristaltic dysfunction, due to narrowing of the superior mesenteric artery occurred. Regular drainage by percutaneous endoscopic gastrostomy was required. However, she improved and was discharged 3 months post-operatively. Three years post-operatively, the ECF and SBO did not recur.ConclusionsWe reported a case of refractory ECF in which we were able to safely perform surgery, by combining laparoscopic adhesiolysis and a planned open conversion. Therefore, the surgical approach used in this case may be an option for securing a safe surgical field, while avoiding collateral damage.