Permanent Complications Research Articles

Insulo-opercular stereoelectroencephalography exploration in children and young adults: Indications, techniques, and safety.

Sampling the insulo-opercular region with invasive recordings is crucial given the importance of this region in epileptic networks and a variety of electroclinical presentations. However, implantation of the insulo-opercular region via stereoelectroencephalography (sEEG) is considered technically challenging given complex vascular and gray matter relationships in this region. We investigated the safety of insulo-opercular sEEG exploration in children and young adults using standard sEEG approaches: (1) orthogonal insulo-opercular (including the pseudo-orthogonal insulo-opercular approach) and (2) medial-lateral insular oblique approach. We performed a retrospective cohort study of 30 consecutive patients who underwent 33 sEEG implantations. All patients had drug-resistant focal epilepsy, were between the ages of 4 and 21, and were operated at one institution between January 2019 and March 2021. Medical records and neuroimaging were reviewed. Hemorrhage, infection, and other complications were considered as outcome variables. A total of 519 electrodes were placed. Eighty-one were placed orthogonally into the temporal operculum, 53 orthogonally into the frontal operculum, and 19 obliquely into the insula. sEEG electrodes localized seizure onset to the insulo-opercular region in eight patients, leading to a resection three times, an ablation four times, and one peri-insular hemispherectomy. Of the 519 electrodes placed, none of them exhibited hemorrhage or serious complications. Of the 153 electrodes placed into the insula, none had any permanent deficits or complications and one had minor bleeding due to the electrode breaking. These results demonstrate that the orthogonal (including pseudo-orthogonal) and medial approaches to sampling the insula are safe.

Acute transverse myelitis after spinal anesthesia: Should anesthesia be condemned?

Spinal anesthesia is widely used during surgical procedures. It is generally safe and the frequency of severe, permanent neurological complications associated with it has been reported to be extremely low. We report a patient, who developed paraplegia following spinal anesthesia. A 23-year-old lady developed acute transverse myelitis (ATM) with a rapid progression of acute motor sensory spastic paraplegia and autonomic dysfunction 24 hours after delivery of her first child by caesarean section. Spinal magnetic resonance imaging revealed myelitis at D9-12. She was given 1 gram methyl prednisolone daily for 5 days followed by oral prednisolone 1mg/kg/day which was tapered off in next 3 months. The neurological recovery was fairly good and the patient returned to full time work in 6 months. Since spinal anesthesia had been used in our case, a causal relationship can be assumed. This case emphasizes the danger of attributing all cases of transverse myelitis which have a close temporal relationship to spinal or epidural anesthesia, to the anesthetic technique itself.

Transradial versus transfemoral access for embolization of intracranial aneurysms with the Woven EndoBridge device: a propensity score-matched study.

Transradial access (TRA) is commonly utilized in neurointerventional procedures. This study compared the technical and clinical outcomes of the use of TRA versus those of transfemoral access (TFA) for intracranial aneurysm embolization with the Woven EndoBridge (WEB) device. This is a secondary analysis of the Worldwide WEB Consortium, which comprises multicenter data related to adult patients with intracranial aneurysms who were managed with the WEB device. These aneurysms were categorized into two groups: those who were treated with TRA or TFA. Patient and aneurysm characteristics and technical and clinical outcomes were compared between groups. Propensity score matching (PSM) was used to match groups according to the following baseline characteristics: age, sex, subarachnoid hemorrhage, aneurysm location, bifurcation aneurysm, aneurysm with incorporated branch, neck width, aspect ratio, dome width, and elapsed time since the last follow-up imaging evaluation. This study included 682 intracranial aneurysms (median [interquartile range] age 61.3 [53.0-68.0] years), of which 561 were treated with TFA and 121 with TRA. PSM resulted in 65 matched pairs. After PSM, both groups had similar characteristics, angiographic and functional outcomes, and rates of retreatment, thromboembolic and hemorrhagic complications, and death. TFA was associated with longer procedure length (median 96.5 minutes vs 72.0 minutes, p = 0.006) and fluoroscopy time (28.2 minutes vs 24.8 minutes, p = 0.037) as compared with TRA. On the other hand, deployment issues were more common in those treated with TRA, but none resulted in permanent complications. TRA has comparable outcomes, with shorter procedure and fluoroscopy time, to TFA for aneurysm embolization with the WEB device.

Bilateral pallidotomy for acquired or heredodegenerative generalized dystonia in children.

Dystonias are relatively rare disorders characterized by sustained or intermittent muscle contractions causing abnormal movements or postures. Generalized dystonia is a therapeutic challenge because medications are unable to control dystonia adequately in most patients. These patients may be candidates for surgical therapy. The commonly used surgical procedures in these patients are pallidotomy and deep brain stimulation. Limited studies are available on the role of pallidotomy in children with acquired/heredodegenerative generalized dystonia. The objective of this study was to describe the authors' experience with bilateral pallidotomy in this group of patients. The authors retrospectively reviewed all pediatric patients (less than 18 years of age) with acquired/heredodegenerative generalized dystonia who underwent bilateral simultaneous pallidotomy at their center between January 2014 and January 2021. Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) scores before and after surgery were recorded. Complications arising after the procedure were recorded as well. Ten patients (8 male and 2 female) with a mean (range) age of 11.1 (5-17) years were included in this study. The mean duration between disease onset and surgical intervention was 3.9 years. Two patients presented in status dystonicus. The mean ± SD (range) preoperative BFMDRS score of the patients without status dystonicus (n = 8) was 80 ± 18.9 (59.5-108). The mean ± SD BFMDRS score at the time of discharge from the hospital after surgery was 58.8 ± 37.9. Three patients had more than 20% change in BFMDRS score at the time of discharge from the hospital. The mean improvement was 25.5% at the end of 1 year. Of 5 surviving patients in the non-status dystonicus group, 3 patients had more than 40% change in BFMDRS score while the other 2 patients developed recurrence at the last follow-up (4.5 years). Status dystonicus abated after bilateral pallidotomy in both patients. Permanent bulbar complications were seen in 2 patients. Bilateral pallidotomy may result in clinically significant improvement in children with acquired/heredodegenerative generalized dystonia, although the benefits should be closely weighed against the risk of irreversible bulbar dysfunction. It is a viable option for children in resource-limited settings.

An update on epidural steroid injections: is there still a role for particulate corticosteroids?

Epidural steroid injections (ESIs) play an important role in the multifaceted management of neck and back pain. Corticosteroid preparations used in ESIs may be considered "particulate" or "non-particulate" based on whether they form a crystalline suspension or a soluble clear solution, respectively. In the past two decades, there have been reports of rare but severe and permanent neurological complications as a result of ESI. These complications have principally occurred with particulate corticosteroid preparations when using a transforaminal injection technique at cervical or thoracic levels, and only rarely in the lumbosacral spine. As a result, some published clinical guidelines and recommendations have advised against the use of particulate corticosteroids for transforaminal ESI, and the FDA introduced a warning label for injectable corticosteroids regarding the risk of serious neurological adverse events. There is growing evidence that the efficacy of non-particulate corticosteroids for pain relief and functional improvement after ESI is non-inferior to particulate agents, and that non-particulate injections almost never result in permanent neurological injury. Despite this, particulate corticosteroids continue to be routinely used for transforaminal epidural injections. More consistent clinical guidelines and societal recommendations are required alongside increased awareness of the comparative efficacy of non-particulate agents among specialists who perform ESIs. The current role for particulate corticosteroids in ESIs should be limited to caudal and interlaminar approaches, or transforaminal injections in the lumbar spine only if initial non-particulate ESI resulted in a significant but short-lived improvement.

Intraoperative neurophysiologic monitoring alteration during en bloc laminectomy surgery for thoracic ossification of ligamentum flavum.

BackgroundThere is real risk during en bloc resection for the treatment of thoracic ossification of ligamentum flavum (TOLF). Intraoperative neurophysiologic monitoring (IONM) has been applied to monitor neurologic functional integration of the spinal cord during surgery. However, the IONM outcome and its relationship with clinical results still needs to be investigated. The purpose of this study is to evaluate the effectiveness and usefulness of IONM in en bloc laminectomy for TOLF.MethodsData from a total of 68 patients with TOLF who received en bloc resection was collected for this retrospective study. IONM of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) were analyzed in different patterns of signal alerts, i.e. alert in either MEPs or SSEPs, alert in both MEPs and SSEPs, permanent alert, or recovery during surgery. Postoperative motor and sensory neurological function was evaluated in each patient immediately after surgery and at 12-month follow-up after surgery. The relationship of IONM outcomes and postoperative neurologic function were observed.ResultsFifty of 68 patients did not present significant changes over alert criteria of IONM, neither SSEPs nor MEPs. Those 50 patients without IONM alerts did not show post-operative neurologic deterioration. Four patients presented alert of IONM in a single modality, while 2 patients showed only SSEP alert and 2 patients showed only MEP alert. Fourteen patients showed alerts in both SSEP and MEP, while 8 patients showed one or both signals return to normal during surgery and other 6 showed permanent abnormal electrophysiologic signals to the end of surgery. In the follow-up neurologic test, 3 patients presented transient neurologic complications from among 8 patients with both SSEP and MEP alerts and recovery during surgery. Six patients without recovery of IONM showed permanent neurologic complications after surgery.ConclusionsResults of this study prove the effectiveness and usefulness of IONM in in en bloc laminectomy surgery for TOLF. The patterns of IONM changes correlated with postoperative neurologic functions. Special attention must be paid to the rapid loss of IONM without recovery during spinal decompression.

P02 ThinkJIA: A campaign to raise awareness that children and young people get arthritis, enabling families and frontline health professionals to recognise symptoms and refer to specialist services

Introduction/BackgroundAwareness that Children and Young People (CYP) may develop arthritis (Juvenile Idiopathic Arthritis, JIA) is low within the general population and amongst non-rheumatology frontline health professionals. This can lead to delays in diagnosis and reduced access to treatment, with consequential risk of joint damage and permanent eye complications through undiagnosed JIA-associated uveitis. The aim of this work was to develop a campaign to enable frontline health professionals and families to be aware that CYP can develop arthritis, to know the main signs and symptoms, and to pursue early referral to speciality services.Description/MethodAn awareness-raising campaign was developed by UK charity Juvenile Arthritis Research working with parents of CYP with JIA, adults with JIA, teachers, campaigners, paediatric rheumatologists, ophthalmologists, and other interested lay and professional individuals. The campaign, called #ThinkJIA, includes postcards with key messages and a supporting website, www.thinkjia.orgResources are aimed at both the general population, to help improve recognition of the signs and symptoms and encourage early attendance at primary care health services; and at non-rheumatology frontline health professionals to support recognition of JIA symptoms and the need for prompt referral. Whilst the key messaging is common to both audiences, the language used differs to reflect the lay and medical professional expectations.Once draft campaign resources were developed, they were shared with clinical professionals and tested by parents and school teachers.Discussion/ResultsOf the pilot group of parents and teachers receiving draft resources, 100% of parents and 68% of teachers agreed that they would feel confident in seeking medical attention if their child, or a child in their school, started showing signs of JIA. Following feedback from recipients in the pilot group resources have been updated with clearer imagery. These are also supported by posters for use in health clinics and general circulation.Key learning points/ConclusionThe development of the #ThinkJIA awareness-raising resources has helped ensure frontline health professionals and the general population can have access to information about JIA. This can help facilitate early referral and improved access to treatment. The broad rollout of awareness resources is essential to appropriately support CYP with JIA and ensure they receive the treatment they require promptly.AcknowledgementsThanks to Prof Helen Foster for her vital role in the initial development of these resources, and to all those involved in the development and pilot testing.

Tibial Lengthening along Submuscular Plate with Simultaneous Acute Tibial Deformity Correction by High-Energy Osteotomy: A Comparative Study.

Submuscular plating and osteotomy using power saw have shown the benefits in certain situations of limb lengthening. However, no previous studies combining both procedures have been conducted for acute tibial deformity correction and limb lengthening. Nineteen cases were enrolled in this study. Ten patients received tibial lengthening with acute knee angular deformity correction using high-energy osteotomy (Group 1), and nine patients received tibial lengthening only with osteotomy using multiple drills and osteotome (Group 2). Radiographic parameters retrieved before and after the operation included leg-length discrepancy, tibial length, length gained, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), and mechanical axis deviation (MAD). There were significant differences between groups in terms of external fixator index (EFI) (p = 0.013) and healing index (HI) (p = 0.014), but no significance in the length gained (p = 0.356). The latest postoperative mLDFA (p = 0.315), MPTA (p = 0.497), and MAD (p = 0.211) of Group 1 were not distinguishable from Group 2. The functional outcomes were excellent, and there were no permanent complications. Despite showing a longer healing time, this alternative lengthening procedure which combines fixator-assisted plate lengthening in the tibia with simultaneous surgical intervention of acute tibial deformity correction using an oscillating saw is appropriate for patients with leg-length discrepancy and angular deformity of the tibia.

Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Incision: A Systematic Review and Meta-Analysis.

Background Supraorbital eyebrow craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor and vascular pathologies. The purpose of this study was to investigate how patient cosmetic outcomes are affected by technique variations of this approach. Methods PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to PRISMA guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used, and the primary end points were patient satisfaction and percentage of permanent cosmetic complications. Results A total of 2,629 manuscripts were identified. Of those, 124 studies (8,241 surgical cases) met the inclusion criteria. Overall, 93.04 ± 11.93% of patients reported favorable cosmetic outcome following supraorbital craniotomy, and mean number of cases with permanent cosmetic complications was 6.62 ± 12.53%. We found that vascular cases are associated with more favorable cosmetic outcomes than tumor cases ( p = 0.0001). Addition of orbital osteotomy or use of a drain is associated with adverse cosmetic outcomes ( p = 0.001 and p = 0.0001, respectively). The location of incision, size of craniotomy, utilization of an endoscope, method of cranial reconstruction, skin closure, use of antibiotics, and addition of pressure dressing did not significantly impact cosmetic outcomes ( p > 0.05 for all). Conclusions Supraorbital craniotomy is a minimally invasive technique associated with generally high favorable cosmetic outcomes. While certain techniques used in supraorbital keyhole approach do not pose significant cosmetic risks, utilization of an orbital osteotomy and the addition of a drain correlate with unfavorable cosmetic outcomes.

Observation versus intervention for Borden type I intracranial dural arteriovenous fistula: A pooled analysis of 469 patients.

While it is thought that Borden Type I intracranial dural arteriovenous fistula (dAVF) have a benign clinical course, their management remains controversial. A comparative meta-analysis was completed to evaluate the outcomes of intervention verses observation of Borden Type I intracranial dAVF. Outcome measures included: grade progression, worsening symptoms, death due to dAVF, permanent complications other than death, functional independence (mRS 0-2), and rate of death combined with permanent complication, were evaluated. Risk differences (RD) were determined using a random effects model. Three comparative studies combined with the authors' institutional experience resulted in a total of 469 patients, with 279 patients who underwent intervention and 190 who were observed. There was no significant difference in dAVF grade progression between the intervention and observation arms, 1.8% vs. 0.7%, respectively (RD: 0.01, 95% CI: -0.02 to 0.04, P = 0.49), or in symptom progression occurring in 31/279 (11.1%) intervention patients and 11/190 (5.8%) observation patients (RD: 0.03, CI: -0.02 to 0.09, P = 0.28). There was also no significant difference in functional independence on follow up. However, there was a significantly higher risk of dAVF related death, permanent complication from either intervention or dAVF related ICH or stroke in the intervention group (11/279, 3.9%) compared to the observation group (0/190, 0%) (RD: 0.04, CI: 0.1 to 0.06, P = 0.007). Intervention of Borden Type I dAVF results in a higher risk of death or permanent complication, which should be strongly considered when deciding on management of these lesions.

Impact of balloon predilatation in patients with reduced versus preserved ejection fraction during transcatheter aortic valve implantation

Although there is a trend toward direct transcatheter aortic valve implantation (TAVI), still balloon predilatation is necessary in some cases, especially in patients with severe calcification. However, predilatation including rapid ventricular pacing may have adverse outcomes, especially in patients with reduced ejection factor (EF). To evaluate the impact of predilatation on in-hospital outcomes in patients with reduced versus preserved EF underwent TAVI. This was a prospective observational study including 110 patients (72 patients with preserved EF (≥50%) and 38 patients with reduced EF (<50%)) who underwent TAVI. The two groups were compared regarding in-hospital outcomes. Predilatation was done routinely in all 110 patients. The mean age was significantly higher in patients with preserved EF (82.76 ± 5.74 vs. 80.13 ± 6.51 years; p = 0.03). The majority (51.4%) of patients with preserved EF were females but the majority (73.7%) of those with reduced EF were males (P < 0.001). Predilatation showed no statistical difference regarding in-hospital mortality (2.6% vs. 1.4%; p = 0.29), hemodynamic instability (5.3% vs. 0.0%; p = 0.11), stroke (0% vs. 1.4%; p = 0.67), conduction defects (13.2% vs. 19.4%; p = 0.29), permanent pacemaker implantation (7.9% vs. 5.5%; p = 0.45), paravalvular leakage (5.3% vs. 2.8%; p = 0.42), vascular complications (7.9% vs. 11.1%; p = 0.43), and acute kidney injury (7.9% vs. 7%; p = 0.4) in patients with reduced versus preserved EF, respectively. When balloon predilatation is inevitable during TAVI it is safe in patients with reduced as well as preserved EF with no added risk of hemodynamic instability or other outcomes.

Endophthalmitis and COVID-19: A Narrative Literature Review

Endophthalmitis is a severe form of intraocular inflammation which is caused by bacteria or fungi. It is a medical emergency with an imminent threat to vision and permanent structural and functional complications. The condition affects the anterior and posterior segments of the eye. It may be either exogenous – following penetrating trauma or intraocular surgery, or endogenous, in which the pathogens enter the eye hematogenous. The diagnosis is based on the clinical picture and on specialized testing – aqueous and/or vitreous cultures, with or without additional PCR for panbacterial and panfungal primers. If endogenous endophthalmitis is suspected, blood and urine cultures may also be performed. The most common bacterial pathogens in acute postoperative endophthalmitis belong to the Staphylococcus and Streptococcus groups. Endogenous endophthalmitis is most frequently fungal and caused by Candida. The incidence of post-traumatic endophthalmitis ranges from 0.9 to 17% and of postoperative - from 0.016 to 5.7%, depending on the surgical procedure and the geographic location. Endogenous endophthalmitis has been observed in up to 8% of all cases. Therapy is urgent and may include intravitreal medications or pars plana vitrectomy (PPV), according to the Endophthalmitis Vitrectomy Study criteria. The combination of COVID-19-associated severe pneumonia, systemic corticosteroid therapy, and diabetes appear to be risk factors for endogenous endophthalmitis. The ethology has mostly been linked to fungal infections, especially Candida, as in the pre-COVID-19 era. There has been a tendency to perform PPV with intravitreal medications as the primary procedure, but the results have been mixed.

Morbidity Associated With Surgical Removal of Substernal Thyroid Goiters.

Surgical excision of substernal thyroid goiters (STG) can be challenging while minimizing postoperative morbidity. Postoperative complication rates associated with transcervical and transthoracic approaches (i.e., partial or total sternotomy) for STG compared to multinodular goiters (MNG) limited to the neck (i.e., non-substernal) remains unclear. This study examines postoperative morbidity related to surgical approaches in the removal of STG and MNG. A retrospective review of prospectively collected data of 988 patients with STG and non-substernal MNG from a single institution between 2010 and 2021 was performed. Patients were stratified by STG and conventional non-substernal MNG limited to the neck excised by transcervical and transthoracic approach. Postoperative complications including neck hematoma requiring return to the operating room, permanent recurrent laryngeal nerve injury and hypocalcemia, and transient or temporary recurrent laryngeal nerve injury and hypocalcemia were identified. Demographics including age, sex, and race, among others, were analyzed. Of the 988 cases, there were 887 (90%) MNG and 101 (10%) STG. Of the STG cohort, 11 (11%) required a partial sternotomy and 4 (4%) required a total sternotomy. Permanent complication rates for non-substernal MNG and STG patients were 1.5% and 0.9%, respectively. Only transient or temporary hypocalcemia rates were statistically different between the STG and MNG cohorts (9.9% versus 3.8%, P<0.001). Regardless of transcervical or transthoracic approach, postoperative complications associated with the surgical removal of STG are low in the hands of experienced, high-volume thyroid surgeons.

Active surveillance of highly suspicious thyroid nodules cohort in China shows a worse psychological status in younger patients.

BackgroundActive surveillance has been considered a safe alternative to surgery for low-risk papillary thyroid microcarcinoma. This study aimed to assess the oncological outcomes and psychological status of active surveillance of highly suspicious thyroid nodules ≤10 mm in China.MethodsThis prospective single-center cohort study enrolled 336 patients with highly suspicious thyroid nodules for active surveillance to assess oncological outcomes and psychological status. The psychological status of patients was assessed by two different questionnaires and compared among different patient groups.ResultsDuring a median follow-up period of 28.5 months, eight patients underwent delayed surgery for tumor enlargement and one for lymph node metastases. The cumulative incidence of disease progression at 5 and 10 years was 6.0% and 12.8%, respectively. Patients who underwent delayed surgery had no permanent complications, and no patient had distant metastasis or death. Patients ≤30 years old had a higher baseline anxiety score (4.9 vs. 3.8, p=0.024), a higher proportion of baseline anxiety score, i.e., ≥8 points (24.0% vs. 12.6%, p=0.033), and a worse baseline emotional function (62.7 vs. 70.7, p=0.013) than patients >30. During AS, patients ≤30 years of age had higher overall anxiety levels (p=0.005) and a worse overall emotional function (p=0.001).ConclusionsActive surveillance in Chinese patients with highly suspicious subcentimetre thyroid nodules has good oncological outcomes and can be used as a safe alternative to surgery. Younger patients (≤30) show a worse psychological status; therefore, more attention should be paid to younger patients.

Clinical Results Evaluation of Patients With Submental Mass Through Endoscopy-Assisted Transoral Surgery.

Surgical resection through extraoral approach is the first choice for submental mass but leaves a visible scar. This study introduces an endoscopy-assisted transoral approach to resect submental mass and evaluates the clinical results. From September 2018 to December 2019, 5 patients with submental mass underwent surgical resection through endoscopy-assisted transoral approach. The swallowing, speech, and appearance domains of the University of Washington Quality of Life questionnaire were assessed preoperatively and at 3 months postoperatively. Each mass was completely removed without rupture. No patient developed any permanent postoperative complications. The function and aesthetic outcomes were excellent without recurrence. Endoscopy-assisted transoral approach for resection of submental mass is a reliable technique that achieves excellent postoperative aesthetics and functional results.

Sex differences in rates of permanent pacemaker implantation and in-hospital complications: A statewide cohort study of over 7 million persons from 2009–2018

Whether a bias exists in the implantation of permanent pacemakers (PPI) and complications according to sex and age in the Australian population is unclear. Population rate of PPI and its complications differed between men and women. We examined the prevalence of PPI from January-2009 to December-2018 from datasets held by the New South Wales (NSW) Centre-for-Health-Record-Linkage, including patient's characteristics and in-hospital complications. All analysis was stratified by sex and age by decade. A total of 28,714 admissions involved PPI (40% women). The mean PPI rate (±standard-deviation) and median age (interquartile range) was 2,871±242 per-annum and 80yrs (73-86yrs), respectively. At the same time-period, the mean NSW population size was 7,487,393±315,505 persons (50% women; n = 3,773,756±334,912). The mean annual age-adjusted rate of PPI was 125.5±11.6 per-100,000-men, compared to 63.4±14.3 per-100,000-women (P<0.01). The mean annual rate of PPI increased from 2009-2017 by 0.9±3.3% in men, compared to 0.4±4.4% in women (P<0.01) suggesting a widening disparity. Total non-fatal in-hospital complications was higher in women compared to men (8.2% vs 6.6%, P<0.01), and this persisted throughout study period even after adjusting for multiple covariates. Overall, in-hospital mortality was low (0.73%) and similar between sexes. In a statewide Australian population exceeding 7 million, PPI rates were consistently nearly two-fold higher for men compared to women over 10-years, with an apparently widening disparity, that was not explained by age. Overall complication rates were higher in women. Future studies should examine the aetiology behind this disparity in PPI rates, as well as its complications.

Pediatric medial humeral epicondyle fracture in children: Are biodegradable pins with tension band absorbable sutures efficient?

Medial humeral epicondyle fractures account for 10% to 20% of elbow injuries in children. We hypothesized that in the fixation of medial humeral epicondyle fractures, safety and efficiency of bioabsorbable poly(l-lactide-co-glycolic acid) implant are comparable to traditional metallic and other novel approaches.A retrospective cohort study was performed between 2016 and 2019, analyzing 24 children who had medial humeral epicondyle fractures. Every fracture was stabilized with biodegradable poly(l-lactide-co-glycolic acid) implants (Bioretec® ActivaPin®) and tension band polydioxanone sutures. Indications for surgery included closed fractures with >1 cm dislocation and incarcerated fractures. Postoperatively, the degree of anatomic reduction and the presence or absence of nonunion or fragmentation were confirmed with X-rays. In this clinical study, we evaluated the operation time, age, and gender distribution.The mean age at the time of injury was 12.3 (8–16 years). In the fourth week, every patient’s X-ray showed callus formation, and the range of motion of the elbow after 6 months of the operation was almost complete in all children. Transient ulnar nerve palsy was developed in 1 patient, which was spontaneously resolved in the fourth postoperative month. No other complications were observed during the average follow-up period of 34 months (16–60 months).Bioabsorbable pins with absorbable sutures are a good alternative treatment of medial epicondyle humeral fracture. No permanent complications were noted while using this technique. We suggest this method because it does not require a secondary (metal removal) operation.

Standardized reporting of complications of epilepsy surgery and invasive monitoring: A single-center retrospective study

ObjectiveMonitoring adverse effects related to epilepsy surgery is essential for quality control and for counseling patients prior to the procedure. The aim of this study was to analyze the rates of complications related to epilepsy surgery following invasive monitoring and to classify them according to the recently proposed protocol by the E-pilepsy consortium. MethodsThis is a retrospective study of collected data extracted from our routinely updated epilepsy surgery database which consisted of 173 surgical procedures: 89 surgeries for insertion of subdural grids, strips, and/or depth electrodes, and 84 resective surgeries. According to the protocol, complications were defined as unexpected postoperative adverse events and were stratified into transient (lasting less than 6 months) and permanent deficits (lasting 6 months or longer). In addition, we reported patients with postoperative psychiatric disturbances and calculated the rates of transient and permanent postoperative sequelae which were defined as expected postoperative deficits deemed inherent to the surgical procedure. ResultsSix potentially life-threatening complications requiring acceleration of the planned resective surgery occurred during invasive monitoring. Following resective surgery, 12 transient sequelae (8 motor deficits, three language deficits, and one transient dyscalculia) and 10 permanent sequelae (5 mild memory disturbances, four visual field cuts, and one contralateral dysesthesia) occurred. In addition, 7 patients experienced transient motor complications. Four permanent postoperative neurological complications (4.8%) occurred: motor deficits in three patients and a partial peripheral facial palsy in one. Finally, five patients developed de novo psychiatric disturbances (transient in four and permanent in one). ConclusionsThis is the first study to classify complications of epilepsy surgery according to the E-pilepsy consortium protocol. Our findings demonstrate that epilepsy surgery following invasive monitoring is safe and associated with low morbidity when performed in specialized centers. Monitoring these complications according to a unified definition and using a multidimensional protocol will allow for a direct comparison across epilepsy surgery centers, will provide the epileptologists and surgeons with objective percentages to share with their patients and will help in identifying risk factors and improving the safety of epilepsy surgery.

MRI-guided DBS of STN under general anesthesia for Parkinson's disease: results and microlesion effect analysis.

The efficacy of the subthalamic nucleus (STN) stimulation for Parkinson's disease has been widely established. The microlesion effect (MLE) due to deep brain stimulation (DBS) electrode implantation has been reputed to be a good predictor for long-term efficacy of the procedure but its analysis in asleep implantation is still unclear. We thus analyzed MLE rate in our strategy of targeting the STN on MRI under general anesthesia and its correlation with our long-term results. We retrospectively analyzed 32 consecutive parkinsonian patients implanted with a DBS targeting the STN bilaterally under general anesthesia between October 2013 and December 2020. Targeting was performed after head frame and localizer placement using a stereotactic peroperative robotic 3D fluoroscopy (Artis Zeego, Siemens) fused with preoperative CT and MRI data. We collected intraoperative data, postoperative occurrence of MLE, modification of Unified Parkinson Disease Rating Scale item III (UPDRS III) postoperatively and at subsequent visit, as well as reduction of medication. The mean operative time was 223min. No permanent complication occurred. MLE was observed in 90.7%. The mean follow-up time was 17months. The UPDRS III for the off medication/on stimulation condition improved by 64.8% from baseline. The mean dose reduction of Prolopa after the surgical procedure was 31.3%. Direct targeting of STN under general anesthesia based on preoperative CT and MRI data fused with a preoperative 3D fluoroscopy is safe. It allows for a high rate of postoperative MLE (90.7%) and results in prolonged clinical improvement.

Outcome of surgical treatment for neglected congenital muscular torticollis: A series of 28 adolescent patients

Background: Congenital muscular torticollis (CMT) is a common musculoskeletal anomaly that can be excellently managed at birth with conservative physiotherapy; as a result, literature on neglected cases of CMT in older patients is sparse, and there is controversy regarding the ideal surgical approach. This report aims to provide the outcome of 28 adolescent patients with neglected CMT who underwent unipolar release at the distal sternocleidomastoid muscle (SCM).Methods: Twenty-eight adolescent patients with untreated CMT presented to our department between 2016 and 2019 and underwent unipolar release at the distal end of their SCM. All patients had no other anomaly based on clinical examination and radiological investigations. At the time of surgery, the mean age of patients was 15.8 years (range 13–18 years). There were 10 male and 18 female patients with the right side affected in 20 cases. All patients were followed up for 2 years. Patients were evaluated using an adapted version of the modified Lee’s scoring system to assess cosmesis and the cervical-mandibular angle (CMA) to assess radiological change.Results: The adapted modified Lee’s scoring system indicated 17 patients (60.7%) had an excellent outcome, 6 patients (21.4%) had a good outcome, and 5 patients (17.9%) had a fair outcome. In particular, scarring was fine in 23 patients (82.1%) and only slight in the remaining. Independent to the categorical outcome, all patients subjectively reported high satisfaction with their cosmesis. The preoperative mean CMA was 19.6° (range, 8.5–31.5°), which was reduced to a mean of CMA of 14.0° (range, 3–28°) after surgery (P < 0.05). No patient developed any permanent complication or required surgery for recurrence. No serious postoperative complications such as infection or hematoma were observed.Conclusion: In uncomplicated cases of neglected CMT in adolescent patients, unipolar tenotomy of the distal SCM is a safe and reliable technique with good clinical outcomes.