Need For Additional Surgery Research Articles

Outcomes of Volume Replacement Oncoplastic Breast-Conserving Surgery Using Chest Wall Perforator Flaps: Comparison with Volume Displacement Oncoplastic Surgery and Total Breast Reconstruction.

Volume replacement oncoplastic breast-conserving surgery (VR-OBCS) uses islanded or pedicled chest wall fasciocutaneous perforator flaps from outside of the breast footprint to replace the volume that has been excised during lumpectomy, extending the options for breast conservation to patients who may otherwise require mastectomy. This study compares outcomes for VR-OBCS with both standard volume displacement oncoplastic breast-conserving surgery (VD-OBCS) and mastectomy with immediate total breast reconstruction (TBR). A retrospective cohort study was conducted; demographic data, clinicopathologic factors, surgical details, and postoperative events were collected until patients had completed their reconstructions. Variables were compared using the t test and analysis of variance test, or chi-square analysis and Fisher's exact test, as appropriate. Ninety-seven consecutive patients (109 immediate breast reconstruction procedures) were included: 43 percent underwent standard VD-OBCS procedures, 35 percent underwent mastectomy with immediate TBR, and VR-OBCS techniques were used in 22 percent, of which only one patient required a delayed procedure for symmetry. Mean whole tumor size was similar in the VR-OBCS and TBR groups and was significantly higher than for the VD-OBCS group (p < 0.05). Overall rate of complications affecting the breast area (p < 0.001), need for additional surgery to either breast (p < 0.001), and time to reconstruction completion (p < 0.001) were significantly higher in the TBR group. VR-OBCS extends the options for breast conservation to many patients that would otherwise require mastectomy. The complication rate is lower, fewer procedures are necessary, and less time is required to complete the reconstruction when compared with mastectomy and immediate TBR. Therapeutic, III.

One-week intubation in external dacryocystorhinostomy– a report on long-term outcome

ABSTRACT Purpose The role of silicone stent intubation in dacryocystorhinostomy (DCR) is not clear, and conclusions presented in the literature are contradictory both regarding if intubation should be recommended and if so, the appropriate duration of intubation. This paper reports on the long-term outcome of a comparatively short duration of silicone stent intubation, one week, and discusses the possibility of an optimal duration of intubation where the benefit of the silicone stent is utilized but with minimal risk of complications. Methods A total of 70 cases of DCR were followed in 67 patients for four years in a descriptive case series of uncomplicated external DCR with one-week silicone stent intubation. Pre- and perioperative findings, complications, and the need for additional surgery were recorded. At end of follow-up, a questionnaire was sent to the patients asking them to grade the frequency of epiphoric problems. If graded often/constant, a follow-up visit was offered. Results One patient received additional surgery during follow-up due to persistent epiphora caused by synechiae between the middle turbinate and lateral nasal wall. The response rate to the questionnaire was 88%, with 93% of the respondents reporting epiphora never/seldom. Four patients reported persistent problems: one declined further examination, the tear duct was anatomically patent in two, and one was referred to the ENT department due to inflamed nasal mucosa and extensive adhesions. The long-term functional or anatomical success rate was 97%. Conclusions This study shows that a high long-term success rate for uncomplicated DCR is possible with only one-week silicone stent intubation.

Optimization of Pediatric Bowel Management Using an Antegrade Enema Troubleshooting Algorithm

BackgroundA successful flush is the ability to flush through the appendicostomy or cecostomy channel, empty the flush through the colon, and achieve fecal cleanliness. We evaluated our experience with patients who were having flush difficulties based on a designed algorithm. MethodsEight patients with flush difficulties were initially evaluated. Based on the need for additional surgery versus changes in bowel management therapy (BMT), we developed an algorithm to guide future management. The algorithm divided flush issues into before, during, and after flushing. Children aged <20 y who presented with flush issues from September 2018 to August 2019 were evaluated to determine our algorithm's efficacy. Specific outcomes analyzed included changes in BMT versus need for additional surgery. ResultsAfter algorithm creation, 29 patients were evaluated for flush issues. The median age was 8.4 y (interquartile range: 6, 14); 66% (n = 19) were men. Underlying diagnoses included anorectal malformations (n = 17), functional constipation (n = 7), Hirschsprung's disease (n = 2), spina bifida (n = 2), and prune belly (n = 1). A total of 35 flush issues/complaints were noted: 29% before the flush, 9% during the flush, and 63% after the flush. Eighty percent of issues before the flush required surgical intervention, wherease 92% of issues during or after the flush were managed with changes in BMT. ConclusionsMost flush issues respond to changes in BMT. This algorithm can help delineate which types of flush issues would benefit from surgical intervention and what problems might be present if patients are not responding to changes in their flush regimen.

Clinical Characteristics and Distribution of Thumb Polydactyly in South China: A Retrospective Analysis of 483 Hands

This study was intended to characterize the epidemiological features of thumb polydactyly (TP) in South China. Clinical records were retrieved from 1 central hospital in South China to identify the patients with a definite diagnosis of TP from January 2004 to January 2017. The cases were classified by their x-ray appearance. The data collected included sex, age at first operation, reoperation, family history, unilateral/bilateral polydactyly, right/left hand involvement in unilateral cases, classification of polydactyly, and the presence of associated congenital anomalies. A total of 428 patients with a definite diagnosis of TP were identified (278 males and 150 females) involving 483 cases, 373 unilateral and 55 bilateral. A syndrome or associated congenital anomaly was found in 26 (18 unilateral and 8 bilateral cases). A dominant thumb, larger and more developed, was observed in 448 hands (93%), and was the ulnar thumb in 433. Owing to postoperative complications, 31 thumbs (6.4%) underwent reoperation. The average interval from initial surgery to reoperation was 4.8 years. Thumb polydactyly had a male predominance in this Chinese cohort, mostly occurring on the right hand with an ulnar dominant thumb. Bilateral cases had a higher incidence of associated anomaly and positive family history than unilateral cases. The need for additional surgery for TP might occur as late as 4.8 years after primary surgery. Therapeutic IV.

Reconstruction of finger joints using autologous rib perichondrium \u2013 an observational study at a single Centre with a median follow-up of 37\u2009years

BackgroundGratifying long-term results are difficult to achieve when reconstructing osteoarthritic finger joints. Implant surgery is the most commonly used method to restore function and dexterity. However, all types of implant have disadvantages and may be a less favorable option in some cases, especially in young patients with a long expected lifetime and high demands on manual load. Implant related complications as loosening, instability, subsidence and stiffness are the main concerns. In this context, joint reconstruction using rib perichondrium might be a reasonable alternative in selected cases. The aim of the study was to evaluate the long-term results of finger joint reconstruction using rib perichondrial transplantation.MethodsThe study group (n = 11) consisted of eight individuals reconstructed in the proximal interphalangeal (PIP) joints and three reconstructed in the metacarpophalangeal (MCP) joints during 1974–1981. All patients were evaluated at clinical visits (median: 37 years after perichondrial transplantation, range: 34–41 years) using radiographs, disability in arm-shoulder-hand (DASH) score, Visual Analog Scale (VAS), range-of-motion (ROM) and manual strength (JAMAR).ResultsNone of the 11 patients had undergone additional surgery. All of the PIP-joints (n = 8) were almost pain-free at activity (VAS 0,6) (range 0–4), had an average range-of-motion of 41 degrees (range 5–80) and a mean DASH-score of 8,3 (range 1–51). The mean strength was 41 kg compared to 44 kg in the contralateral hand (93%). The three MCP joints were almost pain-free at activity (VAS 0,7), (range 0–1). The ROM was on average 80 degrees (range 70–90) and the mean DASH-score was 2 (range 1–3). The mean strength was 43 kg compared to 53 kg in the contralateral hand (81%).ConclusionsPerichondrium transplants restored injured PIP and MCP joints that remained essentially pain-free and mostly well-functioning without need for additional surgeries up to 41 years after the procedure. Additional studies are needed to evaluate long-term results in comparison to modern implants and to better describe the factors that determine the outcome of these procedures.Level of evidenceLevel IV, Therapeutic Study.

Is Labral Size Predictive of Failure With Repair in Hip Arthroscopy?

To assess whether labral size is predictive of labral repair failure or shows an association with patient outcomes after hip arthroscopy. We performed a retrospective chart review of patients who underwent arthroscopic hip labral repair. Labral size was measured in 4 quadrants with an arthroscopic probe. The average size across torn labral segments was assessed for failure as determined by the change in patient-reported outcomes, the rate at which subjects achieved the minimal clinically important difference and patient acceptable symptomatic state, and the need for additional surgery. Outcomes were evaluated for any continuous correlation as well as significant differences between the middle 50% of labral sizes and classes of labral sizes derived from upper and lower quartile and decile ranges. Included hips were those from patients aged between 18 and 55 years with 2-year postoperative follow-up and lateral center-edge angles between 25° and 40°. The study included 571 hips. Labral width did not show a significant difference between hips requiring revision and those not requiring revision (P= .4054). No significant correlation was found between labral width and the change in the International Hip Outcome Tool 12 score (R2= 0.05780), modified Harris Hip Score (R2=0.19826), or Nonarthritic Hip Score (R2= 0.23543) from preoperatively to 2 years postoperatively. Hips with labral sizes in the upper decile of our cohort showed significantly decreased improvement in the International Hip Outcome Tool 12 score (P= .0287) and Nonarthritic Hip Score (P= .0490) compared with the middle 50% of labral sizes. No statistically significant difference was found in the rate at which the groups achieved the minimal clinically important difference or patient acceptable symptomatic state. Hypertrophic labra in the largest 10th percentile showed lower postoperative outcome scores. However, no detectable clinical benefit was found in terms of patient-perceived clinical difference or acceptable symptomatic state. For most patients, labral size does not appear to significantly alter patient outcomes or the need for arthroplasty. Level IV, retrospective case series.

Complications of Wise-Pattern Compared With Vertical Scar Mastopexy/Breast Reduction in Oncoplastic Breast-Conserving Surgery.

Oncoplastic breast-conserving surgery (OBCS) is most commonly performed using established or modified mastopexy/breast reduction techniques. Although the comparative complication profiles of Wise-pattern mastopexy/breast reduction techniques compared with vertical scar techniques are well understood, outcomes in the setting of OBCS are unknown. A retrospective study was conducted of all patients that underwent OBCS using mastopexy/breast reduction techniques at a single center over a 6-year period. Patients who underwent Wise-pattern techniques were compared with those who underwent vertical scar techniques. Demographic, treatment, and outcomes data were collected. Descriptive statistics were used, and multivariate analysis was performed to evaluate the relationship between these multiple variables and complications. Of 413 eligible patients, 278 patients (67.3%) received a Wise-pattern technique and 135 (32.7%) underwent a vertical scar technique. The overall complication rate was significantly higher in the Wise-pattern than in the vertical scar group (30.6% vs 18.5%, respectively; P = 0.012), as was the major complication rate (11.9% vs 4.4%; P = 0.011) including need for additional surgery for complications (6.8% vs 1.5%; P = 0.029). Complications resulted in a delay to any adjuvant therapy in 20 patients (4.8%); however, the difference between the groups was not significant (6.1% for Wise pattern vs 2.2% for vertical scar; P = 0.098). In a multivariable logistic model, use of a Wise-pattern technique (odds ratio, 0.37 [95% confidence interval, 0.14-0.99]; P = 0.049) was a significant predictor of major complications. The Wise-pattern mastopexy/breast reduction OBCS technique was associated with a significantly higher complication and major complication rate than vertical scar techniques. The findings should be considered during choice of surgical technique in oncoplastic breast conservation.

MP22-02 THE EFFECT OF SMALLER RESIDUAL STONES AFTER MINIMAL INVASIVE ENDOUROLOGY PROCEDURES FOR RENAL STONES

INTRODUCTION AND OBJECTIVE: The new era in urology with the advent of minimally invasive surgical techniques has helped in reduction of morbidity associated with surgical treatment of renal stones. Nevertheless, there is lack of agreement as to what has to be done to residual stones, as it has been known that these fragments might have the potential to cause complications after these elective procedures.The objective of our study was to evaluate the natural course followed by residual stones after percutaneous nephrolithotomy (PCNL) or flexible ureterorenoscopy (F-URS) procedures for treatment of kidney calculi. METHODS: Total of 373 patients were submitted to prospective follow-up after elective endoscopic procedures such as PCNL and URS for treatment of kidney stones. The presence and features of residual fragments was followed on radiologic scans and the frequency of revisiting hospital for complications or the necessity of additional procedures were sorted out. RESULTS: The overall stone-free rate was 76.3% in F-URS and 67.7% in PCNL. The natural history of 257 patients having residual stone fragments was followed. There was spontaneous passage of these fragments in 13.4% (34) of cases. While 18.2% (47 patients) developed pain or colicky symptoms, 10.5% (26 patients) had complications such as readmission for pain, fever and Urinary tract infection. Total of the 257 patients followed, 16.7% (43 subjects) needed a next surgical procedure. The residual stones larger than 4mm had more complications (p<0.003), more recurrence of pain symptoms (p=0.04) and need for additional surgeries (p<0.002) as compared to the stones of smaller than 4mm in size. Number of the residual fragments even less than 4 mm were more prone to the complications. Size and number of the residual fragments and the multi-calicial distribution were strong predictors of the development of new symptoms and the need of surgical re-intervention. (p=0.04). CONCLUSIONS: Residual stones are frequently seen in endourological procedures for renal stones treatment and might cause morbidity and complications.Number of stone fragements and poles involved have role in these complications. More multicenter prospective studies are needed in this regard. Source of Funding: None

Natural History of 321 Flatfoot Reconstructions in Adult Acquired Flatfoot Deformity Over a 14-Year Period.

The purpose of this study was to report the natural history, demographics, and mechanisms of requirement for additional surgery in patients undergoing flatfoot reconstruction for adult acquired flatfoot. A total of 321 consecutive patients undergoing flatfoot reconstruction over a 14-year period were included (2002-2016). All procedures were performed by a senior orthopaedic foot and ankle surgeon at our institution. Demographic data, operative reports, clinic notes, and radiographs were available for review. Statistical analysis included calculation of relative risk (RR) ratios. The majority of patients were female (83.2%,) and most patients were overweight with a body mass index greater than 25 kg/m2 (56.4%). Patient comorbidities included diabetes (13.7%) and rheumatoid arthritis (3.7%). Additional surgery was required for 54 patients (16.8%). The most common reasons for additional surgery were the following: painful calcaneal hardware (57.4%), conversion to triple arthrodesis (16.7%), and wound healing complications (9.1%). An increased risk of need for additional surgery was associated with female gender (RR = 3.4; P = .0005), smoking status (RR = 1.9; P = .0081), and age (<60 years of age; RR = 1.8; P = .042). Although retrospective, the results provide insight into the natural history of this procedure. Clinicians may use these data to appropriately counsel patients who are at increased risk of requirement for additional surgery, such as smokers, women, and patients <60 years old, regarding treatment options.Levels of Evidence: Level IV.

Long-term outcome of surgical excision for treatment of cervicofacial granulomatous lymphadenitis in children.

PurposeGranulomatous inflammation is a common cause of subacute cervicofacial lymphadenitis in children. Nontuberculous mycobacterial (NTM) infections and cat-scratch disease (CSD) are the most frequent causes. Optimal treatment, which may include surgery, antibiotic treatment or wait-and-see approach, is debatable. The goal of this study was to compare the short- and long-term outcome of various surgical procedures.MethodsCase series with a chart review of all children treated by surgical excision of granulomatous lymph nodes in the cervicofacial area from 2000 to 2016 at two tertiary care centers.ResultsForty patients were included in this study. The median age at first symptoms was 3.7 years (13 months–14 years). Mean follow-up was 5.8 years (6 months–15.3 years). 25 patients fit with diagnosis of NTM infection, 6 with CSD while diagnosis remained uncertain in 9 patients. The primary surgical procedure consisted of total excision (n = 27), incision/drainage (n = 9) or incomplete excision (n = 4). None of the patients treated by primary complete excision needed further intervention contrary to the group of patients with incomplete surgical procedures where additional surgical management was required in 54%. At follow-up, all patients were healthy without evidence of recurrence.ConclusionWe advocate early surgical intervention with complete excision to reach quick resolution and reduce the need for additional surgery. The long-term outcome was favorable.

Reconstruction of the Orbit and Anophthalmic Socket Using the Dermis Fat Graft: A Major Review.

To perform a comprehensive review of dermis fat graft (DFG) in socket reconstruction and illustrate the technical nuances and outcomes using a retrospective case review. A literature search of 143 texts was reviewed. A retrospective case series of 34 patients following primary or secondary DFG after enucleation at a single institution (2009-2019) was performed. Clinical outcomes were statistically analyzed. Variables investigated included age, sex, race, surgical indication, muscle reattachment, complications, motility, eyelid position, prosthesis fit, and need for additional surgery. The history of DFG, use in socket reconstruction, primary and secondary indications, and surgical techniques are described. Thirty-two adults and 2 pediatric cases of DFG were reviewed; 18.75% indications were primary and 81.25% were secondary. Good eyelid position was observed in 83.3% of patients with primary DFG versus 37.5% with secondary DFG (p = 0.07). Postoperative complications occurred in 58.8% of patients, were typically mild, and resolved with minimal or no intervention. No statistically significant differences were found between occurrence of any particular complication in primary versus secondary DFG placement (p = 0.36) or between primary and secondary DFG placement and the need for additional surgery (p = 1.0). Among the 67.7% patients who had implant exposure or extrusion as an indication for DFG, 39.1% required additional surgery within 2 years. Advanced age was not associated with higher complication rates (p = 0.12). DFG is an excellent option for socket reconstruction, particularly in cases involving pediatric patients, complicated orbits, history of multiple previous surgeries, and inflamed, contracted, or scarred sockets.

Clinical Presentation and Outcomes Associated With Fabellectomy in the Setting of Fabella Syndrome.

Background:Clinical outcomes pertaining to isolated lateral fabellectomy in the setting of fabella syndrome are limited to small case reports at this time.Purpose:To assess the most common presenting symptoms, clinical outcomes, and satisfaction after fabella excision in the setting of fabella syndrome.Study Design:Case series; Level of evidence, 4.Methods:Consecutive patients with a minimum of 21-month follow-up after isolated fabellectomy for fabella syndrome were reviewed retrospectively. Clinical outcome scores of the following domains were collected: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and Lysholm knee survey, along with a simple numeric patient satisfaction score (range, 1-10; 10 = “very satisfied”). Statistical analysis was performed using paired t tests for all clinical outcome data.Results:A total of 11 isolated fabella excisions were included in 10 patients with isolated lateral-sided knee pain in the setting of fabella syndrome (8 males, 2 females), with a mean age of 36.9 years (range, 23-58 years) and a mean follow-up of 2.4 years (range, 21-47 months). A total of 8 patients (80%) were able to return to full desired activities, including sports. Only 5 of 11 (45%) excisions had concomitant lateral femoral condyle cartilage pathology. There were significant improvements across multiple WOMAC domains, and the WOMAC total score improved from 28.5 ± 17.6 preoperatively to 11.6 ± 10.2 postoperatively (P < .05). Lysholm scores significantly improved from 66.6 ± 23.1 preoperatively to 80.2 ± 13.9 postoperatively (P = .044). Overall patient-reported satisfaction was 8.8 ± 1.6.Conclusion:Fabella excision in the setting of fabella syndrome demonstrated improvements in clinical outcome scores, high rate of returning to preinjury level of activities, and low risk of complications or need for additional surgical procedures.

Neurogenic bladder: management of the severely impaired patient with complete urethral destruction: ileovesicostomy, suprapubic tube drainage or urinary diversion-is one treatment modality better than another?

Management of the severely impaired patient (pt) with a neurogenic bladder (NGB) and complete urethral destruction employs three therapeutic options; bladder neck closure (BNC) with ileovesicostomy, BNC with suprapubic tube (SPT) placement or in pts with an end-stage bladder, cystectomy with enteric conduit diversion. This paper was performed to test the hypothesis that pts managed with an ileovesicostomy would have the best long-term prognosis. Patients with a NGB and complete urethral destruction managed between 1986-2018 were reviewed. Three treatment populations were assessed, pts treated with BNC with ileovesicostomy, BNC with SPT placement or cystectomy with enteric conduit diversion. A minimal follow-up interval of 2 years was necessary to be entered into the study. The number of uroseptic episodes, development of urolithiasis, the onset of new renal scars, ≥ stage 3 chronic renal failure, or need for additional surgery were recorded. Statistical evaluations used either chi-squared contingency table analysis, Fisher's exact 2-tailed tests, or Kaplan-Meier curve analysis where indicated. P values of <0.05 were considered significant. Ten pts were managed by cystectomy, and enteric conduit, 17 by BNC and ileovesicostomy and 21 by BNC and SPT placement, median follow up of 8 yrs (range, 2-30 yrs). No significant differences between the three groups regarding the development of urolithiasis (30%, 3/10 pts; 53%, 9/17 pts; 52%, 11/21 pts; respectively), new onset of renal scarring (30%, 6/20 kidneys; 41%, 14/34 kidneys; 45%, 19/42 kidneys; respectively) or stage 3 chronic renal failure (40%, 4/10 pts; 47%, 8/17 pts; 24%, 5/21 pts; respectively. However, the number of hospitalizations for uroseptic episodes significantly increased in patients managed with an ileal conduit (60%, 6/10 pts) and ileovesicostomy (82%; 14/17 pts) compared to those maintained with a SPT (29%, 6/21 pts) P=0.025 and 0.006, respectively. When evaluating the need for delayed surgical intervention due to either urolithiasis or other complications, a total of 50% (5/10 pts) of the patients managed by an ileal conduit, 88% (15/17 pts) of the ileovesicostomy and 52% (11/21 pts) of the patients with a SPT required additional operations. In essence, significantly more pts undergoing BNC and ileovesicostomy required delayed surgical interventions for complications arising from the surgery compared to patients managed with either a cystectomy and ileal conduit (P=0.0285) or BNC and SPT placement (P=0.0180). In severely impaired pts with a NGB and urinary outlet destruction, BNC and ileovesicostomy are associated with a significantly increased incidence of urosepsis and late surgical complications that required operative intervention compared to alternative treatments. This finding has resulted in the abandonment of the ileovesicostomy from our surgical armamentarium.

Surgical Outcomes of Nontraumatic Pediatric Cataracts

Purpose: To evaluate post-surgical complications in patients who were operated for nontraumatic pediatric cataracts in our clinic. Methods: Medical records of 62 patients (101 eyes) that underwent cataract surgery younger than 15 years of age, without history of ocular trauma and with a minimum follow-up period of 6 months, were reviewed retrospectively. Results: The most common initial complaint was leukocoria. Thirty-nine patients (62.9%) had bilateral cataracts and 23 patients (37.1%) had unilateral cataracts. The most common type was posterior polar cataract (22%) in patients with unilateral cataracts, and total cataract (33%) in patients with bilateral cataracts. The overall prevalence of postoperative complications was 58%, visual axis opacification (VAO) being the most common one (39%). The incidence of VAO was significantly higher in eyes with intact posterior capsules. Secondary glaucoma occurred in 12 (12%) eyes. Thirty-one (50%) patients were orthophoria, 17 (27%) patients had esotropia, and 14 (23%) patients had exotropia. Additional surgery for all of these complications was performed in 53 (53%) eyes. Conclusions: Despite appropriate surgical treatment of nontraumatic pediatric cataracts, post-surgical complications including VAO, glaucoma, or strabismus remain an important cause of morbidity in these patients. Posterior capsulotomy and anterior vitrectomy must be performed in all children below 6 years to reduce the need for additional surgery for VAO.

Development of Core Outcome Sets for Patients Undergoing Major Lower Limb Amputation for Complications of Peripheral Vascular Disease

Introduction: Despite advances in techniques for revascularisation, around 5000 patients each year undergo major lower limb amputation (MLLA) in the UK alone. Despite this, the evidence for optimal management of these patients is weak. Core Outcome Sets attempt to capture consensus on the most important outcomes for a patient cohort to improve the efficiency of future research. The aim of this work was to establish consensus on Core Outcomes Sets for studies involving patients undergoing MLLA. Methods: A list of outcomes was developed by systematic review to establish previously reported outcomes; and supplemented by focus groups involving healthcare professionals, patients and carers to identify additional areas which have not previously received research attention. Topics from these were then taken forward to a three-round Delphi consensus process, where outcomes were rated on a Likert scale from 1 (unimportant) to 9 (critical). Outcomes were rated for both short-term studies, with primary outcomes in the region of 30 days, and medium-term studies, with primary outcomes measured between a few months and 2 years following surgery. Results of the Delphi survey were then discussed at a face-to-face meeting of stakeholders, and recommendations made for Core Outcome Sets. Results: The systematic review revealed 444 distinct outcomes from 440 included studies involving a total of 442885 patients. Of these, 281 outcomes were reported by only a single study. These were reduced to a set of 44 broad themes to carry forward to the consensus survey. Focus groups revealed a further six themes which were felt to be important by participants, but which had not previously been reported in the research literature. The consensus survey received responses from 123 participants in round 1, and 91 individuals completed all three rounds. In the final round, stump wound infection and wound healing were rated as 'core' for both short-term and medium-term studies. Mortality; cause of death; effectiveness of analgesia; need for re-admission; need for additional operations; perioperative complications; and effective communication between patients, carers and healthcare professionals were rated as 'core' for short-term studies. Pain in the residual limb/stump/phantom; supply of a prosthetic limb; prosthetic limb use, comfort and fitting; level of independent mobility; participation in work and social activities; independent living; and quality of life were rated as 'core' for medium-term studies. The face-to-face stakeholder meeting ratified inclusion of all outcomes from the Delphi and suggested that deterioration of the other leg and psychological morbidity should also be reported for both short- and medium-term studies; length of hospital stay should also be reported for short-term studies, and that mortality should also be reported for medium-term studies. Conclusion: Studies concerning patients undergoing MLLA have historically been highly in-efficient, with huge numbers of different outcomes reported and little overlap between studies. We have established consensus on 9 core outcomes for short- and medium-term studies. Three additional outcomes were proposed at a face-to-face stakeholder meeting for each time period. We recommend that all future studies involving patients undergoing MLLA should report these outcome sets. Disclosure: Nothing to disclose

Medical Malpractice Litigation in Non-Mesh-Related Pelvic Organ Prolapse Surgery: An Analysis of 91 Cases.

Malpractice litigations have significant implications for patients and physicians. Studies have investigated mesh litigations in female pelvic reconstructive surgery, but none on nonmesh pelvic organ prolapse (POP) surgery. Our purpose is to determine the reasons for and outcomes of medical malpractice after nonmesh POP surgery. Westlaw (Thompson Reuters, New York, New York) is a legal research database of US court records. We identified completed POP litigations from 1987 to 2018 using the following: "pelvic organ prolapse," "enterocele," "rectocele," "cystocele," "uterine prolapse," and "vaginal wall prolapse." Mesh-related cases were excluded. Outcomes included reasons for litigation, verdict, injury, and payments. Statistical analysis was performed with nonparametric tests and χ2 independence test. Ninety-one litigations were included. The median plaintiff age was 53 years (range, 36-85 years). The leading allegation was negligence of surgery (n = 59; 65%). The jury sided with the defendant physician in 67% of cases (n = 61). There was no association between case verdict and patient age (P = 0.781), geographic region (P = 0.824), or allegation (P = 0.904). The primary complications were urinary tract injury (n = 24; 26%), need for additional surgery (n = 22; 24%), and new postoperative urinary symptoms (n = 22; 24%). The median payout was $280,000 (interquartile range, $137,250-$1,300,000), with no difference between plaintiff awards or settlements (P = 0.659). The leading allegation of malpractice litigations for nonmesh POP surgery is negligence of surgery, whereas the most common complication was urinary tract injury. A verdict in favor of the physician defendant was the most likely outcome. Plaintiff awards and settlements were not statistically different with no variation by region or time.

Extendable Endoprostheses in Skeletally Immature Patients: A Study of 124 Children Surviving More Than 10 Years After Resection of Bone Sarcomas.

Extendable endoprostheses are used to reconstruct segmental defects following resection of bone sarcomas in skeletally immature patients. However, there remains a paucity of studies with regard to long-term outcomes. We retrospectively reviewed 124 skeletally immature children who underwent an extendable endoprosthetic replacement and survived more than 10 years after the surgical procedures. Anatomical sites included the distal part of the femur (n = 66), the proximal part of the femur (n = 13), the proximal part of the tibia (n = 29), and the proximal part of the humerus (n = 16). Complications and implant survival were classified according to the modified Henderson criteria. The mean follow-up was 24 years (range, 10 to 36 years). The mean age at the time of the extendable endoprosthetic replacement was 9 years (range, 2 to 16 years). All patients had reached skeletal maturity at the last follow-up. The 10-year endoprosthetic failure-free survival rate was 28%. A total of 243 complications occurred in 90% of patients; these complications were most frequently related to soft-tissue problems (27% of complications). The incidence of and cumulative survival with respect to each failure mode varied between anatomical sites. Soft-tissue failures occurred most frequently in the proximal part of the femur (77%; p = 0.003), and the distal part of the femur was the most frequent site of aseptic loosening (52%; p = 0.014) and structural failure (55%; p = 0.001). Excluding lengthening procedures, 105 patients (85%) underwent an additional surgical procedure, with a mean of 2.7 surgical procedures per patient (range, 0 to 7 surgical procedures per patient). The mean limb-length discrepancy at the final follow-up was 1 cm (range, 0 to 9 cm). Limb salvage was achieved in 113 patients (91%). The mean Musculoskeletal Tumor Society functional score (the percentage of a total score of 30 points) was 82% (range, 40% to 100%) in 115 patients with available data at the last follow-up. Extendable endoprostheses are associated with a high complication rate and a need for additional surgical procedures over time. Despite this, successful limb salvage with reasonable function and small limb-length discrepancy is achievable in the long term. Our study provides benchmark data for individual anatomical sites for further improvements of outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

3D Printed Neural Regeneration Devices.

Neural regeneration devices interface with the nervous system and can provide flexibility in material choice, implantation without the need for additional surgeries, and the ability to serve as guides augmented with physical, biological (e.g., cellular), and biochemical functionalities. Given the complexity and challenges associated with neural regeneration, a 3D printing approach to the design and manufacturing of neural devices could provide next-generation opportunities for advanced neural regeneration via the production of anatomically accurate geometries, spatial distributions of cellular components, and incorporation of therapeutic biomolecules. A 3D printing-based approach offers compatibility with 3D scanning, computer modeling, choice of input material, and increasing control over hierarchical integration. Therefore, a 3D printed implantable platform could ultimately be used to prepare novel biomimetic scaffolds and model complex tissue architectures for clinical implants in order to treat neurological diseases and injuries. Further, the flexibility and specificity offered by 3D printed in vitro platforms have the potential to be a significant foundational breakthrough with broad research implications in cell signaling and drug screening for personalized healthcare. This progress report examines recent advances in 3D printing strategies for neural regeneration as well as insight into how these approaches can be improved in future studies.

3D printing-based Ganz approach for treatment of femoral head fractures: a prospective analysis

BackgroundFemoral head fractures are uncommon injuries. Open reduction and internal fixation (ORIF) of femoral head fracture is the preferred treatment for most patients. There are several surgical approaches and treatments for this difficult fracture. However, the optimal surgical approach for the treatment of femoral head fracture remains controversial. Meanwhile, the operation is difficult and the complications are numerous. We prospectively reviewed patients with femoral head fractures managed surgically through the 3D printing-based Ganz approach to define a better approach with the least morbidity.Patients and methodsBetween 2012 and 2017, a total of 17 patients were included in this study. An exact 1:1 3D printing model of the injured hip side was fabricated for each patient and simulated surgery was finished preoperative. The surgical approach was performed as described by Ganz. Functional assessment was performed using the modified Merle d’Aubigne scores. The reduction of the fracture was evaluated according to Matta’s criteria. The incidence of complications, such as heterotopic ossification (HO) and avascular necrosis (AVN), and the need for additional surgery were also documented.ResultsTwelve of 17 patients (four females and eight males) were available for 2 years follow-up. The mean follow-up was 35 months (25–48 months). Average age for the 12 patients was 39.9 ± 12.2 years. According to the Pipkin classification, four patients were type I fracture, three patients were type II fracture, and five patients were type IV fracture. The mean operative time was 124.2 ± 22.1 min, and the estimated blood loss was 437.5 ± 113.1 ml. According to Merle d’ Aubigne scores, excellent results were achieved in six of the 12 patients; four good and two poor results occurred in the rest of the patients. On the radiograph evaluation, fracture reduction was defined as anatomical in eight patients, and imperfect in four. Most patients had good outcomes and satisfactory hip function at last follow-up. Almost all great trochanteric osteectomy healed uneventfully. One patient developed symptomatic AVN of the femoral head and underwent THA at 3 years. After THA, she regained a good hip function with the ability to return to work and almost no reduction in sports activities. Heterotopic ossification was found in four cases (type I-1, type II-2, and type III-1).ConclusionsThe 3D printing-based Ganz approach provides a safe and reliable approach and satisfactory results of treatment in femoral head fractures. Using 3D printed model for the fracture of the femoral head, the fracture can be viewed in every direction to provide an accurate description of fracture characteristics, which contributes to make a reasonable surgical plan for patients. In addition, the 3D printing-based Ganz approach can obtain excellent surgical exposure and protection of the femoral head blood supply, reduce the operation time and intraoperative blood loss, make the precise osteotomy, anatomically fix the intra-articular fragments, and effectively reduce postoperative complications.Trial registrationWe register our research at http://www.researchregistry.com. The Unique Identifying Number (UIN) from the Research Registry of the study is researchregistry4847.

Urinary tract injuries during treatment of patients with morbidly adherent placenta

Introduction Urinary tract injuries (UTI) are a frequent complication of morbidly adherent placenta (MAP) management. In this study, we aim to characterize the type of UTI that occurs and to define if their incidence varies after establishing a fixed interdisciplinary group for the protocolized management of patients with MAP. Methodology All patients with confirmed MAP attended between 2011 and 2019 in our institution, were included. We analyzed the effect of a change in the surgical protocol including rigid ureteral catheters, vesicouterine dissection before hysterotomy and interdisciplinary planning, in the bladder or ureteral injuries incidence. Results The study included 65 women. UTI was identified in 27.7% of patients and was associated with a greater volume of blood loss, transfusion requirement, hospital stay, and the need for additional surgeries. There was a high frequency of UTI in patients without protocolized management. The use of rigid ureteral catheters and retrovesical dissection before hysterotomy were associated with a less ureteral injury. Conclusions Developing expertise among the members of the surgical team is essential to improve results. Using rigid ureteral catheters, performing retrovesical dissection before hysterotomy, and performing less extensive surgeries in selected patients are associated with a low frequency of ureteral injuries.