Mean Number Of Surgeries Research Articles

Laryngeal sequelae secondary to surgical treatment for recurrent respiratory papillomatosis in children

Objectiveto describe the frequency and predictive factors associated with laryngeal scarring caused by surgical treatment of recurrent respiratory papillomatosis (RRP) in children. IntroductionRRP is an important cause of hoarseness and respiratory obstruction in children. The current standard of care for RRP is the systematic and repetitive surgical interventions. The repetitive surgeries may increase the risk of sequelae. A larger number of surgeries, the surgical technique used, and disease severity are related to an increased risk of scarring. Material and methodsA retrospective, descriptive review of the medical charts of patients with RRP younger than 18 years was conducted. Between 2014 and 2017, 79 patients were identified; five patients were excluded. Demographic and clinical data were recorded and analyzed. The patients were divided into two groups, one with and the other without surgical sequelae, for comparison to identify sequela-associated factors. Results75 patients, 40 (53.3%) male, were analyzed. Age at symptom onset ranged from 2 months to 13 years. Median age at the time of diagnosis was 42 months. Overall, 44% presented with disseminated disease. A median of nine (range, 1 to 86) surgeries were performed in each patient with a median of two (range, 0.6 to 10) of the average number of surgeries per year per patient. 29 patients (38.7%) had laryngeal sequelae. When comparing the patients with and without sequelae, statistically significant differences were found in the variables of dissemination during the course of the disease, overall number of surgeries and mean number of surgeries per year, history and number of previous surgeries at an outside institution, urgent surgeries, and CO2 laser use. Patients who underwent more than 10 surgeries or who had a history of previous surgeries at an outside institution had a higher frequency of laryngeal scarring in multivariate analysis. ConclusionScarring secondary to surgical treatment for RRP is common. Surgery-related variables seem to be predisposing factors. A greater number of surgeries and surgeries performed at less specialized centers are strongly related to this complication. Future studies with a larger sample size are necessary to determine whether other factors are involved.

The effects of reoperation on surgical outcomes following surgery for major abdominal emergencies. A retrospective cohort study.

The objective of this study was to analyze outcomes and determine independent predictors of subsequent reoperation following emergency laparotomy (EL). Patients undergoing EL (n=854) from 2012 to 2018at our institution were retrospectively assessed. Postoperative complications, in-hospital mortality and predictive factors were assessed. Among the studied patients, 307 (35.9) required subsequent reoperation, and 547 (64.1%) did not. The mean number of surgeries was 2.02±1.54, with a median of 2 (range 1-10). Viscus organ perforation had the highest reoperation rate (25.6%), followed by hemorrhage (16.1%), anastomotic leakage (15.4%), mesenteric ischemia (14.9%), and bowel obstruction (11.9%). The incidence of postoperative complications was higher in reoperated patients (100%) than in non-reoperated patients (58.9%). There were 305 deaths, with an overall in-hospital mortality rate of 35.7%; 175 (57%) occurred in the reoperated group, and 130 (23.8%) occurred in the non-reoperated group. In multivariate regression (N=854), an American Society of Anesthesiologists (ASA) class of 3 or above (OR, 4.27; 95% CI, 2.54-7.18), coexisting liver cirrhosis of Child grade B or above (OR, 2.50; 95% CI, 1.46-4.29), coexisting cardiac arrhythmia (OR, 1.59; 95% CI, 1.10-2.30), and steroid use (OR, 1.95; 95% CI, 1.01-3.77) strongly predicted reoperation. Our data showed notably high mortality due to subsequent reoperation, and there was a steady increase in mortality as the number of reoperations increased. A high ASA class, liver cirrhosis, cardiac arrhythmia and steroid use were independently associated with the risk of subsequent reoperation.

Induced membrane technique for clavicle reconstruction in paediatric patients: Report of four cases

BackgroundClavicular reconstruction in paediatric patients is a rarely performed procedure that often raises complex technical challenges and produces unreliable outcomes. The induced membrane technique is an innovative two-stage procedure involving cement spacer placement into the defect to induce the development of a membrane, followed by the implantation of a cortical-cancellous bone graft. The primary objective of this study was to assess the medium- and long-term clinical and radiographic outcomes of clavicular reconstruction using the induced membrane technique in children and to highlight the advantages and drawbacks of this technique. The secondary objectives were to evaluate the fixation and the outcomes according to age and to the underlying diagnosis. HypothesisClavicular reconstruction using the induced membrane technique produces good outcomes in paediatric patients. Patients and methodsThe induced membrane technique was used for clavicular reconstruction in 4 children with a mean age of 9.7 years (range, 7.4–12.3 years). The diagnosis was congenital pseudarthrosis of the clavicle in 3 patients and aneurysmal bone cyst in 1 patient. Shoulder pain and mobility were assessed at last follow-up. Radiological bone healing was evaluated using the total radiographic union score (RUS, range, 0–10). Complications and number of procedures per patient were recorded. ResultsMean follow-up was 3.9 years (range, 1–8.4 years). None of the patients had pain or motion range limitation. After 6 months, the clavicle was healed with a RUS of 10 in all patients. The mean number of surgical procedures per patient was 3.75 (range, 3–5). Two patients required revision surgery for distal pin migration and another for a subcutaneous abscess under the pin. DiscussionWhen used for clavicular reconstruction, the induced membrane technique is effective and associated with a low complication rate. The induced membrane technique therefore deserves to be viewed as an alternative to other methods. Level of evidenceIV, retrospective observational study.

Total femur replacement in non-oncologic indications: Functional and radiological outcomes from a French survey with a mean 6 years’ follow-up

IntroductionThere are few published studies on total femur replacement (TFR) because its indications are rare. Other than malignant diseases, the indications extend to revisions and interprosthetic femur fractures; however, the outcomes of these indications have not been well defined. The aim of this retrospective survey was to analyze the complication rate and functional outcomes of these newer indications. HypothesisThe morbidity and outcomes after TFR are comparable to those reported in the literature for non-cancer indications. Material and methodsBetween 1997 and 2016, 29 TFR procedures were done at 6 French teaching hospitals in 15 women and 14 men, average age 68±14 years [32–85]. The primary indication was degenerative joint disease in the hip and/or knee in 16 cases, mechanical failure of the implant used after tumor resection in 11 cases and femur fracture in 2 cases. The mean number of surgical procedures before TFR was 3.6 (maximum 5) at the hip and 4.5 (maximum 10) at the knee. Six different models were implanted consisting of a rotational hinge knee (except in one case); 20 patients received a dual mobility system and 9 a standard hip replacement bearing. The femoral shaft was partially conserved 21/29 times and the trochanter 25/29 times. ResultsFive patients suffered a general complication and 12 suffered a local complication (including 4 hematomas and 2 hip dislocations). Eight patients (28.6%) suffered a surgical site infection, although three had a prior infection. Among the 12 patients with a history of infection or progressive infection before the TFR, 9 healed and 3 had the infection continue. At a minimum follow-up of 2 years and mean of 6 years, 23 TFR implants were still in place and not infected; the other 6 had been removed or were infected, including one patient who underwent disarticulation. The median survival of the non-infected TFR was 15 years. At 10 years, 70% of TFR implants were still in place and non-infected.Walking was possible with or without a cane in 15 patients (51.7%), with two canes or a walker in 12 patients (41.3%) and impossible in 2 patients. Active knee flexion averaged 79.4°±30.3° [0°–120°]; 17 patients (62.9%) had 90° or more flexion; two patients (7.4%) had no flexion. The extension deficit averaged 3.7°±7°[−20° to 10°] and 20 patients had no flexion deformity. The leg length difference averaged 1.3cm±2.3 [0–10]; 19 patients (67.8%) had no difference in leg length. DiscussionOur starting hypothesis was confirmed for the complication rate and clinical outcomes. The benefits of dual mobility cups are emphasized. While the indications for TFR are rare, they will likely increase in the coming years.Level of evidence: IV, Retrospective cohort study…

Epidemiology, Management, and Outcomes of Large and Small Native Joint Septic Arthritis in Adults.

Native joint septic arthritis (NJSA) is poorly studied. We describe the epidemiology, treatment, and outcomes of large joint NJSA (LNJSA) and small joint NJSA (SNJSA) in adults at Middlemore Hospital, Auckland, New Zealand. This was a coding-based retrospective study of patients ≥16 years old admitted between 2009 and 2014. Prosthetic joint infections were excluded. Five hundred forty-three NJSA episodes were included (302 LNJSA, 250 SNJSA). Only 40% had positive synovial fluid culture. Compared to SNJSA, LNJSA has higher incidence (13 vs 8/100 000 person-years [PY]), occurs in older, more comorbid patients, and is associated with greater rates of treatment failure (23% vs 12%) and mortality, despite longer antibiotic treatment. Total incidence is higher than previously reported (21/100 000 PY), with marked interethnic variation. Incidence rises with age (LNJSA only) and socioeconomic deprivation (LNJSA and SNJSA). Tobacco smokers and males are overrepresented. The most commonly involved joints were knee (21%) and hand interphalangeal (20%). Staphylococcus aureus was the most common pathogen (53%). Mean antibiotic duration was 25 days for SNJSA and 40 days for LNJSA, and the mean number of surgical procedures was 1.5 and 1.6, respectively. Treatment failure was independently associated with LNJSA, age, intra-articular nonarthroplasty prosthesis, and number of surgical procedures. This is the largest contemporary series of adult NJSA. SNJSA has better outcomes than LNJSA and may be able to be safely treated with shorter antimicrobial courses. Incidence is high, with significant ethnic and socioeconomic variation. Microbiological NJSA case ascertainment underestimates case numbers as it frequently excludes SNJSA.

Sympathetic Ophthalmia after Vitreoretinal Surgeries: Incidence, Clinical Presentations and Outcomes of a Rare Disease

Aim: To evaluate clinical presentation, course and outcomes in patients without a history of penetrating ocular trauma who developed Sympathetic Ophthalmia (SO) following vitreoretinal surgeriesMethods: Retrospective review of clinical records of all patients diagnosed and treated as S.O was done . All cases without a previous history of trauma were included and were analyzed with respect to clinical presentations, anatomic and visual outcomes.Results: 175 cases of sympathetic ophthalmia were diagnosed and treated till June 2017. 16 of these cases had undergone a pars plana vitrecomy (PPV) in the past and had no history of prior ocular trauma. SO after vitreoetinal surgeries accounted for 9.14 percent of all cases of SO .In the same duration, till 2017,a total 41365 PPV were done. Thus 0.038 percent of PPV cases developed a SO . 10 patients were males and 6 were females. The median age at presentation was 45.7 years. The time interval from surgery to diagnosis of sympathetic ophthalmia ranged from 22 days to 4 years after undergoing a surgery. The mean visual acuity in the sympathizing eye was 1.26 logMAR (snellens equivalent of 20/320) which improved to 0.62 logMAR(snellens equivalent of 20/80) after treatment. The most common anterior segment finding was non granulomatous anterior uveitis, seen in 8 cases (50%) while neurosensory detachments were the most common posterior segment presentation (10 cases, 62.5%).12 patients had undergone more than 1 surgery (mean number of surgeries was 1.88). 10 patients had undergone a sutureless PPV (6 cases of 23 gauge and 4 cases of 25 gauge vitrectomy) while 4 patients had undergone a 20 gauge vitrectomy where all sclerotomies were sutured after surgery All patients were treated with systemic steroids and immunosuppresants and 15 out of 16 patients showed significant improvement in the final visual acuity in the sympathizing eyeConclusions: Sympathetic ophthalmia after vitreoretinal surgeries is a rare but potentially sight threatening disease occurring in 0.038 percent of all cases of Pars Plana Vitrectomy. Presence of inflammation in the fellow eye after a vitreoretinal surgery in the other eye should alert the surgeon to possibility of sympathetic ophthalmia

The Prognostic Roles of the Ki-67 Proliferation Index, P53 Expression, Mitotic Index, and Radiological Tumor Invasion in Pituitary Adenomas.

The fourth edition of the World Health Organization (WHO) classification of pituitary tumors recommended evaluation of tumor proliferation and invasion to identify aggressiveness. We aimed to assess the prognostic roles of the Ki-67 proliferation index, mitotic index, P53 expression, and cavernous sinus invasion in pituitary adenomas (PAs). Among the 601 patients who underwent transnasal/transsphenoidal adenomectomy from 2001 to 2016, 101 patients (16.8%) who had tumors with a high (≥ 3%) Ki-67 index (group A) and a control group consisting of 43 patients with a low (< 3%) Ki 67 index who were matched for age, gender, and tumor type were included. Mitotic index and P53 expressions were evaluated. Patient characteristics, histopathology reports, pre/postoperative magnetic resonance imaging (MRI), and follow-up data were assessed retrospectively. The frequency of macroadenomas and mean tumor size were greater in group A when compared to group B (67.4 vs. 94.1%, p< 0.01 and 25 ± 10.6 vs. 18 ± 11 mm, p< 0.01, respectively). Invasion to cavernous sinus was found in 53 (36.8%) patients and was more frequent in group A (p<0.01). The mean number of surgery was higher in group A than group B (p< 0.05). The mean follow-up period was 46.6 ± 34months. The postoperative MRIs and follow-up data for at least 24 months were available in 117 patients. Recurrence risk was higher in group A than group B (p = 0.03). Tumors with high Ki-67 proliferation index were grouped as 3-5, 6-10, 11-15, and > 15%. The risk of recurrence was not different between groups of high Ki-67 index. The optimal cutoff point of the Ki-67 proliferation index that predicted recurrence was 2.5% with 84.6% sensitivity and 47.4% specificity. The cavernous sinus invasion on MRI was associated with recurrence (p = 0.03). Tumor size and recurrence risk were not associated with P53 expression. High P53 expression was related with cavernous sinus invasion (p = 0.03). The mitotic index was not associated with recurrence risk and tumor invasion. Recurrence risk was higher in tumors with ≥ 2 histopathological atypia criteria (p = 0.01). High Ki-67 index with a 2.5% cutoff point and cavernous sinus invasion on MRI are reliable markers for predicting recurrence in PAs. Recurrence risk is also higher in tumors with two histopathological aggressiveness criteria. Strict follow-up and more aggressive treatment approaches may be necessary for invasive-proliferative PAs.

Child injuries in the Syrian Civil War

Objective: During wars, many soldiers and civilians either get injured or die. In civil wars, older people, women, and children are more vulnerable to injuries and traumas. The aim of this study is to reveal the demographic features and variety as well as the characteristicsof the injuries in children who were impacted from the Syrian civil war and underwent surgeries in the plastic, reconstructive and aesthetic surgery department. Patients and Methods: This is a retrospective study which initially included 121 children aged 0–18 years out of a total of 402 Syrian patients treated in the plastic, reconstructive and aesthetic surgery department between December 2011 and December 2016. Results: Of 83 children with war injuries treated in our clinic, 42% were female and 58% were male. Forty-one percent of the injuries were located in the head-neck region. 43.4% of the injuries were due to burns. Thirty-six percent of the injuries were located on the extremities. All the patients underwent a total of 242 surgeries. The mean number of surgeries per child was 2.9. The mean time of hospitalization was 17.12% days. Conclusion: The results of the study show that children are impacted just as much or more thanadults in the Syrian civil war and had more severe injuries than those effected by similar wars and terrorist attacks.

Outcome of subtrochanteric femur resection in patients with spinal cord injuries.

To analyse the clinical outcome of subtrochanteric femur resection in patients with infected hip joints caused by pressure ulcers (PUs) in patients following spinal cord injury (SCI). A retrospective cohort study, carried out between January 2004 and December 2015. Only patients receiving a subtrochanteric femur resection were included. SCI patients were treated for a hip joint infection caused by a PU. Primary outcome measures were to work out the revision rates and the rate of heterotopic ossification occurrence. At the time of admission, 37 out of the 56 participating patients (66.1%) showed a category IV PU with the ischium being most commonly affected (n=25, 44.6%). The subtrochanteric femur resection was combined either with a direct wound closure (n=29; 51.8%) or a myocutaneous flap (n=27; 48.2%). The mean number of surgeries was 2.6 (1-4; SD=1.6) and 21 patients were successfully treated by a single surgery. Of the patients, 28 had wound healing disorders (50%) and required a revision surgery, and 24 (42.9%) developed a postoperative heterotopic ossification. Hip joint infection caused by PUs can be treated with subtrochanteric femur resection. However, the number of postoperative complications is still high

Amputation Outcomes in Congenital Pseudarthrosis of the Tibia.

Successful radiographic union in the treatment of congenital pseudarthrosis of the tibia (CPT) may be complicated by persistent pain, recurrent fracture, and poor function necessitating further intervention, including amputation. The long-term functional, radiographic, and clinical outcomes of patients who have undergone amputation as treatment for CPT are unknown. A retrospective study of patients with a diagnosis of CPT secondary to neurofibromatosis and eventual treatment with amputation were included. Clinical and radiographic data, including initial Crawford classification, type of amputation, subsequent operative procedures, and evidence of radiographic healing were collected. A total of 17 patients with a mean age of 4.5 years (range, 0.7 to 9.2 y) at the time of amputation met inclusion criteria. Clinical follow-up averaged 11.1 years (range, 2.1 to 18.4 y), with radiographic follow-up averaging 9.1 years (range, 2.1 to 16.4 y). The mean number of surgeries before amputation was 2.2 procedures. Four patients underwent amputation as the primary procedure (3 Boyd, 1 below knee amputation (BKA)). At the time of amputation, a Boyd amputation was performed in 13 patients with stabilization of the pseudoarthrosis achieved with retrograde Rush rodding of the tibia and local autograft. A transtibial amputation (BKA) was performed in 4.After the Boyd procedure, 4 of the 13 patients (31%) demonstrated persistent nonunion of the pseudoarthrosis and required secondary procedures to gain union. At the most recent follow-up, 12 of 13 patients demonstrated successful radiographic healing of the pseudoarthrosis. Two patients, one for persistent pain and the other for refracture, were later converted to a BKA during the late teen years. All patients functioned well with the use of prosthetic devices. Union of the pseudoarthrosis occurred in >90% of cases following amputation. However, secondary procedures were required in 13 of the 17 patients (76%). Early amputation in the treatment of CPT provides a stable extremity and potential for a high level of function with the use of an adequate prosthesis. Level IV-case series.

353 Improving Outcomes in Fournier’s Gangrene Using Skin and Soft Tissue Sparing Flap Preservation Surgery: An Alternative Approach to Wide Radical Debridement

Fournier’s Gangrene remains a formidable disease that initially requires a high degree of suspicion followed by early diagnosis, prompt surgical intervention and targeted antibiotic therapy. Surgical management is wide radical excision which often includes an “everything including the kitchen sink” philosophy as a means of sepsis damage control. This in turn often leaves survivors with large morbid wounds requiring complex soft tissue coverage and prolonged hospitalizations. We report a nine-year retrospective case series review of Fournier’s Gangrene (FG) treated in our burn and wound center in which large skin and soft tissue sparing flap preservation was achieved. This series illustrates an approach to skin and soft tissue sparing surgery in 15 consecutive cases of FG since 2008. All patients underwent simultaneous serial debridement, partial complex wound closure and negative pressure wound therapy (NPWT) of spared skin and soft tissue flaps. The mean number of surgeries was 5.53. The average number of days from initial consult to wound closure was 25.4 days. Ninety-three percent required no surgical fecal diversion. Delayed primary closure (DPC) was achieved in 100% of the patients using this reproducible technique. Less than 1.5 percent (1.3%) required split thickness skin grafting as part of wound closure. There were no mortalities in this group of patients. Our average ICU and hospital length of stay (LOS) was 2.67 and 18.40 days respectively. Greater than fifty percent (53.3%) were partially managed as an outpatient during wound closure. Their mean number of outpatient management days was 9.47 during DPC. We report a series of 15 consecutive patients with Fournier’s in whom large skin and soft flap preservation was safely achieved. Thinking outside the box all patients underwent a specific alternative technique of concurrent debridement, DPC and NPWT; ultimately achieving faster times to closure, decreased total number of operations, decreased ICU LOS, decreased hospital LOS and better cosmetic and functional outcomes without compromising safe NSTI surgical management. Presents an alternative approach to skin and soft tissue management of necrotizing soft tissue infections during a time where there is pressure to get safe, effective and efficient outcomes in a timely manner.

MP75-11 FUNCTIONAL OUTCOMES OF ADJUSTABLE CONTINENCE THERAPY BALLOONS IN WOMEN : A MULTICENTRIC RETROSPECTIVE STUDY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy III1 Apr 2018MP75-11 FUNCTIONAL OUTCOMES OF ADJUSTABLE CONTINENCE THERAPY BALLOONS IN WOMEN : A MULTICENTRIC RETROSPECTIVE STUDY Claire Sanson, Pauline Guiffart, Benoît Peyronnet, Xavier Gamé, and Xavier Biardeau Claire SansonClaire Sanson More articles by this author , Pauline GuiffartPauline Guiffart More articles by this author , Benoît PeyronnetBenoît Peyronnet More articles by this author , Xavier GaméXavier Gamé More articles by this author , and Xavier BiardeauXavier Biardeau More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2103AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To assess efficacy and safety of the adjustable continence therapy device (ACT) in the treatment of female pure stress (SUI) or mixed urinary incontinence (MUI). METHODS This is a multicentric retrospective study. All women undergoing ACT device placement between 2008 and 2016 to treat SUI or MUI within one the 3 participating centers were considered eligible. The last consultation marked the end of the follow-up period. Regarding efficacy, the improvement in urinary incontinence was subjectively assessed by the woman herself using a numbered rating scale (NRS) from 0 to 10. Success was defined by a NRS > 8, while improvement was defined by a NRS between 0 and 8, and failure by a NRS = 0, at the end of the follow-up period. The continence was also assessed using the PGI-I (Patient's Global Impression of Improvement). Regarding safety, per- and post-operative complications were retrieved. Early complications (<30 days) were reported according to the Clavien-Dindo classification. RESULTS Eighty-eight women with a mean age of 68 yo (20-90) were included. Among them, 25.0% had an underlying neurologic disease, 10.2% had a history of pelvic radiation therapy, and 79.5% had already undergone previous surgery for urinary incontinence (mean number of surgery was 1.5). 51.1% presented with SUI. After a mean follow-up period of 21.0 months (1-76), 25 patients (28.4%) achieved success, 28 patients (31.8%) showed improvement, and 35 patients (39.8%) were considered in failure. Considering all included women, PGI-I was quoted as 1, 2, 3 and 4 by 12 (13.6%), 17 (19.3%), 24 (27.3%) and 33 (37.5%) of them, respectively. Only two patients reported a PGI-I > 4. Mean volume per balloon was 3.5ml, with a mean of 3.3 balloon inflations. Among the 88 procedures, 6 per-operative complications (6.8%) were noted (vesical or vaginal injury), while 16 early post-operative complications (18.2%) were reported (all grade I or II, to the Clavien-Dindo classification). Late complications (infection, erosion or balloon migration) occurred in 18 patients (20.5%) and explantation was finally required in 29 patients (33.0%) (complication or failure). All complications resolved without any sequelae. CONCLUSIONS The ACT device implantation showed a limited efficacy, with a success or improvement rate of 60.2%. However, it was counterbalanced by an interesting safety profile, with no severe complication. These results should be interpreted with caution considering the high previous urinary incontinence surgery rate as well as the high neurogenic urinary incontinence among the studied population. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1012-e1013 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Claire Sanson More articles by this author Pauline Guiffart More articles by this author Benoît Peyronnet More articles by this author Xavier Gamé More articles by this author Xavier Biardeau More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A Novel Mohs Precision Tool.

Effective treatment by Mohs micrographic surgery requires preparation of high-quality slides. To examine a novel tissue alignment device designed to address variability in tissue processing because of excessive sample trimming. A device was designed to account for angular errors and unparalleled tissue embedding. A retrospective chart review was performed both with and without the use of the device over the course of a 4-year period (2012-2015). Between January 1, 2012, and June 10, 2014, before device implementation, mean number of stages per case was 1.65 (n = 3,680) and mean number of surgeries per day was 6.34 (n = 640). Between June 11, 2014, and October 02, 2015, with device implemented, the average number of stages per case between decreased to 1.58 (n = 2,562) and the number of daily surgeries increased to 7.05 (n = 358). This represents a significant decrease in number of stages per case by 0.07 stages (95% CI: -0.01 to -0.13, p = .02), as well as an increase in the number of cases per day by 0.71 cases (95% CI: 0.12-1.3, p < .01). Slide preparation using the novel alignment device may result in less tissue waste and more cases being performed daily.

Assessment of Orthodontic Burden of Care in Patients With Unilateral Complete Cleft Lip and Palate.

To assess the orthodontic burden of care of patients from a Brazilian rehabilitation center (Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo [HRAC-USP]). Retrospective. Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo. One hundred files of unilateral complete cleft lip and palate patients who had consecutively finished orthodontic rehabilitation at HRAC-USP were evaluated from January 2011 to January 2013. The duration of orthodontic treatment, number of visits, kilometers traveled, number of appliances and surgical procedures performed were recorded. The sample was divided into 2 subgroups according to severity the interarch relation (Goslon Yardstick score) at the beginning of orthodontic treatment. Mann-Whitney test was applied for intergroup comparison ( P < .05). For the total sample (n = 100), the mean time of orthodontic treatment was 140.2 months, the mean number of orthodontic appointments was 61.8, the mean number of appliances was 10, the mean number of surgical procedures was 6.2, and the mean distance traveled to attend the center for orthodontic appointments was 38,978.5 km. The subgroup with the most severe malocclusion (Goslon yardsticks scores 4 and 5) showed a longer orthodontic treatment length, greater number of surgical procedures, and longer distance traveled than those presenting Goslon yardstick scores 1, 2, and 3. Patients with greater severity of the initial malocclusion experienced a higher burden of care than patients with less severity of the initial malocclusion. To reduce the burden of care, research and efforts should focus on minimizing maxillary growth deficiency related to primary surgery.

Pediatric Lower Extremity Lawn Mower Injuries and Reconstruction: Retrospective 10-Year Review at a Level 1 Trauma Center.

From 2004 to 2013, there were 9341 lawn mower injuries in children under 20 years old. The incidence of lawn mower injuries in children has not decreased since 1990 despite implementation of various different prevention strategies. In this report, the authors review the results of pediatric lawn mower-related lower-extremity injuries treated at a tertiary care referral center as well as review the overall literature. A retrospective review was performed at a level 1 trauma center over a 10-year period (2005-2015). Patients younger than 18 years who presented to the emergency room with lower extremity lawn mower injuries were included. Of the 27 patients with lower-extremity lawn mower injuries during this period, the mean age at injury was 5.5 years and Injury Severity Score was 7.2. Most (85%) patients were boys and the predominant type of mower causing injury was a riding lawn mower (96%). Injury occurred in patients who were bystanders in 78%, passengers in 11%, and operators in 11%. Mean length of stay was 12.2 days, and mean time to reconstruction was 7.9 days. Mean number of surgical procedures per patient was 4.1. Amputations occurred in 15 (56%) cases with the most common level of amputation being distal to the metatarsophalangeal joint (67%). Reconstructive procedures ranged from direct closure (41%) to free tissue transfer (7%). Major complications included infection (7%), wound dehiscence (11%), and delayed wound healing (15%). Mean follow up was 23.6 months and 100% of the patients were ambulatory after injury. The subgroup of patients with the most severe injuries, highest number of amputations, and need for overall surgical procedures were patients aged 2 to 5 years. A review of the literature also showed consistent findings. This study demonstrates the danger and morbidity that lawn mowers present to the pediatric population, particularly children aged 2 to 5 years. Every rung of the so-called reconstructive ladder is used in caring for these children. Increased public awareness is insufficient to decrease the incidence of these injuries. These products should have additional warning labels and meet updated changes to the design of lawn mowers to prevent these mutilating injuries successfully.

Initial experience with negative-pressure wound therapy with instillation in complex wounds.

to report the initial experience with Negative-Pressure Wound Therapy with instillation in infected or contaminated complex wounds. the negative-pressure wound therapy with instillation used was V.A.C. Ulta with Veraflo instillation (Kinetic Concepts, Inc). The mode of operation was continuous with negative pressure set at 125 mmHg for two hours and instillation between the pauses. The instillation time was 20 minutes (contact time of the topical agent with the wound) and the instilled substance was 0.9% normal saline. After adequate preparation of the wound, it was covered with graft or flap. ten patients with complex or contaminated wounds were operated on. The mean number of NPWTi changes was 1.4, the mean number of surgeries was 2.4, the interval until complete wound coverage was 6.3 days, and the interval up to the time of discharge was 11.4 days. the comparison of the negative-pressure wound therapy with instillation with two previous studies (historical control) evidenced a shorter hospitalization time, favoring TPNi. This study had an initial character, making it necessary to conduct a randomized and controlled trial to confirm the efficacy of this therapy and verify its cost-effectiveness.

Comparison of four measures in reducing length of stay in burns: An Asian centre’s evolved multimodal burns protocol

IntroductionMultidisciplinary burns care is constantly evolving to improve outcomes given the numerous modalities available. We examine the use of Biobrane, micrografting, early renal replacement therapy and a strict target time of surgery within 24h of burns on improving outcomes of length of stay, duration of surgery, mean number of surgeries and number of positive tissue cultures in a tertiary burns centre. MethodsA post-implementation prospective cohort of inpatient burns patients from 2014 to 2015 (n=137) was compared against a similar pre-implementation cohort from 2013 to 2014 (n=93) using REDCAP, an electronic database. ResultsThere was no statistically significant difference for comorbidities, age and percentage (%) TBSA between the new protocol and control groups. The protocol group had shorter mean time to surgery (23.5–38.5h) (p<0.002), 0.63 fewer operative sessions, shorter mean length of stay (11.8–16.8 days) (p<0.04), less positive tissue cultures (0.59–1.28) (p<0.03). Discussion/ConclusionThe 4 measures of the new burns protocol improved burns care and validated the collective effort of a multi-disciplinary, multipronged burns management supported by surgeons, anesthetists, renal physicians, emergency physicians, nurses, and allied healthcare providers. Biobrane, single stage onlay micrograft/allograft, early CRRT and surgery within 24h were successfully introduced. These are useful adjuncts in the armamentarium to be considered for any burns centre.

Vascularised fibula or induced membrane to treat congenital pseudarthrosis of the Tibia: A multicentre study of 18 patients with a mean 9.5-year follow-up

BackgroundThe objective of this study was to compare outcomes of two surgical techniques used to treat congenital pseudarthrosis of the tibia (CPT), the induced membrane technique (IM) and the transfer of the contralateral vascularised fibula (VF). HypothesisThe IM technique produces similar outcomes to those of VF grafting in terms of healing and function, while being simpler and having a lower complication rate. Material and methodThis retrospective multicentre study included 18 patients with a mean age of 2.8 years at surgery. Among them, 11 had neurofibromatosis type 1 (NF1). The IM technique was used in 10 patients and VF grafting in 8 patients. Mean follow-up was 9.5 years (range: 5–15 years). ResultsThe two groups showed no significant differences for healing or the occurrence of complications such as limb length discrepancy and residual malalignment. Two patients required amputation, one in each group. The mean number of surgical procedures per patient was 4.7 in the IM group and 5 in the VF group. DiscussionOutcomes are similar with the two techniques. Although VF grafting theoretically involves a single stage, the mean number of surgical procedures was not lower than after the IM technique. The IM technique was associated with lower risks of complications and residual donor site abnormalities. Regardless of the reconstruction technique, the quality of the initial bone resection and internal fixation, particularly regarding alignment, is of the utmost importance. Level of evidenceIV, comparative retrospective study.

Multidimensional vocal assessment after laser treatment for recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis (RRP) is a benign epithelial tumor that exhibits a high frequency of recurrence. This study assesses the vocal function after laser treatment for RRP, particularly in relation to the frequency of surgery. Retrospective study. Thirty RRP patients who underwent laser surgery that controlled the tumor were included. Preoperative and postoperative Grade, Roughness, Breathiness, Asthenia, and Strain Scale, videostroboscopic findings, aerodynamic and acoustic parameters, and self-assessment questionnaires were measured and compared with an age- and sex-matched control group. Subsequently, to evaluate the association between postoperative voice quality and the number of surgeries, the patients were divided into three groups (group 1: single surgery, group 2: 2-5 surgeries, group3: >6 surgeries), and comparative multidimensional vocal assessments were performed. The mean number of surgeries was 3.4 (range, 1-8). Although all patients exhibited poorer vocal function than the control group preoperatively, they showed improvement in postoperative subjective and objective parameters. However, four patients who underwent one surgery with relatively aggressive ablation exhibited vocal cord scarring and deteriorated objective parameters. All remaining patients showed voice quality that was on par with the control group. Subgroup analysis proved no association between post-therapeutic voice quality and the patient characteristics, including preoperative staging and the number of surgical treatments performed. RRP patients can achieve a close to normal voice with high satisfaction even after recurrent surgical treatment when ablation of a subepithelial lesion using sufficient laser energy is adequate. 3b Laryngoscope, 127:679-684, 2017.

Limb Preserving Surgical Treatment of Osteomyelitis in the Foot

Category: Other Introduction/Purpose: Osteomyelitis of the foot and ankle is a challenging problem. In the literature the outcome of limb preserving surgical treatment is characterized by a high percentage of osteomyelitis recurrence and revision surgery. The aim of this study was to evaluate the outcome of limb preserving surgery of osteomyelitis in the foot. Methods: From 2013 to 2015 42 patients with a mean age of 66 years underwent surgical treatment of osteomyelitis in the foot. Patients who were treated with amputations were excluded from the study. In all patients initial surgery with debridement, bone resection, bone biopsy, jet lavage and gentamycin inlay was performed. Depending on the clinical findings revision surgery and finally resection arthroplasty or arthrodesis followed. All patients had an antibiotic treatment for 6 weeks. The location of the osteomyelitis, the applied surgical procedure, the number of surgical procedures, the number of postoperative complications, the recurrence rate of osteomyelitis, the recurrence rate of foot ulceration and the histological findings were documented. Results: Forty-two patients (28 diabetics) were included in the study. The mean follow up was 19.7 months. The location of osteomyelitis showed the following distribution: minor toes (24%), great toe (19%), metatarsals (33%), midfoot (13%), hindfoot (11%). Twenty-six patients showed a foot ulceration. Bone biopsy confirmed chronic osteomyelitis in 28, acute osteomyelitis in 7 patients. After control of wound infection surgery consisted of a resection arthroplasty in 14 patients, an arthrodesis in 12 patients. The mean number of surgical procedures was 3. The complication rate was 14.2%. Osteomyelitis recurrence was found in 4 patients. Patients treated with a resection arthroplasty showed no ulcer recurrence however in 50% of the patients who had been treated with a MTP1 or IP 1 arthrodesis a recurrent ulcer was seen( p &lt; 0.05). Conclusion: Limb preserving surgical treatment of osteomyelitis in the foot shows a high complication rate. Resection arthroplasty of the forefoot in comparison to arthrodesis provides significantly better results with less ulcer recurrence.