Postoperative Clinical Assessment Research Articles

Simultaneous versus two stage surgical treatment of developmental dislocation of the hip with excessive femoral anteversion in children under the age of three years

Background: Delayed diagnosis and improper treated cases of developmental dysplasia of the hip (DDH) in the presence of excessive anteversion of femoral head may lead to undesirable consequences, including more extensive interventions with severe complications and functional disability. This study aimed to compare the clinical, radiological, and complication outcomes of simultaneously versus two-stage surgical procedures (open reduction and proximal femoral derotation osteotomy) in the treatment of DDH with excessive femoral anteversion among a sample of Iraqi children aged less than three years old. 
 Methods: A total of 26 DDH cases were treated in two groups (GI, GII) at Al-Wasity Teaching Hospital (Baghdad, Iraq) from January 2014 to March 2015. GI (15 hips) in 13 patients subjected to simultaneous open reduction (with/without salter osteotomy) and proximal femoral derotation osteotomy. GII (18 hips) in 13 patients operated in two stages procedure; open reduction (with/without salter osteotomy) followed by proximal femoral derotation osteotomy six weeks later. 
 Results: At the time of operation, the average age was 21.79±3.51months (range: 18-30). The mean follow-up period was 10.36 ±1.45 months (range, 8 -12). Statistically, the postoperative clinical, radiological, and complication findings were not significantly different between the two groups. However, in post-operative clinical assessment (McKay's criteria), the satisfying results (excellent and good) were 93% in GI and 88% in GII, respectively. Moreover, in radiological assessment (Severins classification), the satisfying results (excellent and good) were 94% in GI and 83% in GII, respectively. Two cases of re-dislocation and avascular necrosis (AVN) were reported in GII.
 Conclusion: When the clinical and radiological findings of one and two-stage open reduction and proximal femoral derotation osteotomy procedures are similar, the one-stage is more likely to overcome the two-stage in terms of minimizing the cost, length of stay and the risk of AVN of the femoral head.

Increased scapular spine fractures after reverse shoulder arthroplasty with a humeral onlay short stem: an analysis of 485 consecutive cases

Scapular stress fractures after reverse shoulder arthroplasty (RSA) are a potentially serious complication with modern lateralized and onlay implants. The aim of this study was to report the scapular spine stress fracture rate after RSA with an onlay, 145° humeral stem, analyzing potential fracture risk factors and clinical outcomes in a large cohort of patients. A consecutive series of 485 RSAs were implanted with the Aequalis Ascend Flex stem. Data collection included preoperative and postoperative clinical and radiographic assessment findings (rotator cuff Goutallier grade; Hamada, Walch, and Favard classifications; range of motion; Constant score) and perioperative data. Patients with a scapular spine fracture following RSA were matched with nonfracture control patients, and preoperative variables were tested to determine whether they were predictive of a scapular spine fracture. A scapular spine fracture following RSA occurred in 21 patients (4.3%), with a mean time to diagnosis of 8.6 months (range, 1-34 months). No preoperative factor was found to be a significant predictor of scapular spine fracture. Both groups showed significant improvements in active mobility measurements and Constant scores from preoperatively to final follow-up (P < .001). The control group scored significantly better than the scapular spine fracture group regarding the Constant score and forward flexion. Scapular spine fractures have shown an increased prevalence after onlay-design RSA. This series was not able to link any clear risk factors. Functional results are limited, regardless of the fracture management.

Postoperative motor deficits following elbow flexion reanimation by nerve transfer

We aimed to assess the rate and type of postoperative motor deficits that might be encountered following elbow flexion reanimation using ulnar- and/or median-based side-to-end nerve transfers in patients with brachial plexus injuries. All patients who underwent elbow flexion reanimation between November 2015 and October 2017 at our facility by nerve transfer based on partial harvests of the median and/or ulnar nerves were included. Postoperative clinical assessment was conducted the day after surgery to identify motor deficits in the territory of the harvested nerves. If a clinically noticeable deficit was present, the type and extent of the deficit were noted, and postoperative clinical evaluations were conducted monthly to determine its progression. After reviewing the charts of 27 consecutive patients, 4 patients were found to have a postoperative motor deficit (15%). In all four cases, the deficit was limited to the anterior interosseous nerve (AIN) territory in patients who underwent a double transfer (i.e., ulnar-to-biceps and median-to-brachialis). With clinical impairments of the flexor pollicis longus and/or the flexor digitorum profundus of the index and third fingers initially ranging from grade-0 to grade-3 strength, full recovery to preoperative strength levels occurred in all cases after a mean of 7 months’ follow-up. Transient motor deficits may be observed in the AIN territory following elbow flexion reanimation when a median-to-brachialis nerve transfer is associated with the original Oberlin procedure.

Revision surgery for leg length inequality after primary hip replacement.

We discuss the surgical results of revision surgery for patients with refractory symptomatic leg length inequality (LLI) after primary hip replacement. This is a retrospective review of 21 patients who underwent revision for LLI after primary total hip replacement. All of them were referred to a tertiary clinic between 2006 and 2015. Leg length was measured, to the nearest mm, using Woolson's validated X-ray technique which references to centre of femoral rotation, the acetabular teardrop and the midpoint of the lesser trochanter. The post-operative clinical assessment using a modified D'Aubigne and Postel scoring system investigated the pain, function, and satisfaction after surgery. The mean pre-revision LLI was 16.2 mm (8-30 mm). The mean post revision operation leg length inequality was 2.0 mm (12 mm short to 9 mm long). The mean post-operative D'Aubigne and Postel scores, achieved at a mean 12 months (6-30 months), were; pain 5.2 (3-6), function 4.6 (3-6) and satisfaction 4.4 (3-5). Following revision surgery 20 out of 21 (95%) patients were satisfied with the improvement in LLI. Revision surgery for LLI, while it may not resolve all of the pain that the patient presents with, it is a successful treatment for patients who do not respond to conservative management of their LLI.

Relatively High Complication and Revision Rates of the Mayo®Metaphysical Conservative Femoral Stem in Young Patients

The Mayo metaphysical conservative femoral stem (Zimmer, Warsaw, Indiana) is a wedge-shaped implant designed to transfer loads proximally, reduce femoral destruction, and enable the preservation of bone stock in the proximal femur. Thus, it is a potentially preferred prosthesis for active, non-elderly patients who may require additional future surgeries. This retrospective case study analyzed the outcomes of consecutive patients who underwent total hip replacements with this stem between May 2001 and February 2013. All patients underwent clinical assessment, radiological evaluation for the presence and development of radiolucent lines, and functional assessment (numerical analog scale, Harris hip score, and Short Form-12 questionnaire). Ninety-five hips (79 patients) were available for analysis. The patients' mean age was 43 years (range, 18-64 years), and the mean follow-up was 97 months (range, 26.9-166 months). The postoperative clinical assessments and functional assessments revealed significant improvements. Sixteen patients (20.3%) had 18 orthopedic complications, the most common of which were an intraoperative femoral fracture and implant dislocation requiring revision surgeries in 10 hips (10.5%). Radiological analysis revealed evidence of femoral remodeling in 64 (67.4%) implants, spot welds (neocortex) in 35 (36.8%), and osteolysis in 3 (3.2%). These results suggest that the conservative hip femoral implant has an unacceptable complication rate for non-elderly patients. [Orthopedics. 2018; 41(4):e516-e522.].

PHONOPHORESIS VERSUS ULTRASOUD THERAPY IN MYOFASCIAL PAIN DYSFUNCTION SYNDROME

Purpose: Myofascial pain dysfunction syndrome (MPDs) coupled by trigger points (TPs) has been conversed medically and dentally for over a century. Phonophoresis (PH) is a non-invasive transdermal drug delivery system that use ultrasound (US) to enhance the distribution of topically applied drugs which provide less chance of an overdose and permit both local and systemic treatment effects. The aim: of this study was to assess the outcome of phonophoresis with Extrauma and ultrasound therapies in the treatment of myofascial pain dysfunction syndrome. Patients and method: twenty cases with MPDs of TPs in the masseter muscle were selected and divided into two groups; study group (PH): comprised ten female patients that were treated with phonophoresis (PH) using Extrauma gel for 10 sessions over three weeks. Control group (US): comprised ten female patients that were treated with ultrasound (US) for 10 sessions over three weeks. Postoperative clinical assessment including visual analogue scale (VAS) and maximum mouth opening (MMO) were assessed. Results: Comparison of VAS between the two groups at immediate post-operative period showed that PH group recorded decrease and significant values and at six months post-operative period the two groups showed non-significant decrease in VAS. MMO showed non-significant increase values in both groups along the follow up periods. Conclusion: Extrauma phonophoresis in the masseter muscle trigger points considered an effective treatment option for myofascial pain dysfunction syndrome.

Findings of postoperative clinical assessment of swallowing in infants with congenital heart defect.

Describe the findings of postoperative clinical evaluation of swallowing in infants with congenital heart disease (CHD) in a reference hospital in southern Brazil. This is a cross-sectional study conducted postoperatively with infants with medical diagnosis of CHD aged 0-6 months in a Pediatric Intensive Care Unit. Exclusion criteria comprised infants with neurological and respiratory impairments, craniofacial malformation, structural alteration in the upper airways, and suspicion or diagnosis of genetic syndromes. Clinical evaluation was performed through partial application of the Assessment of Pediatric Dysphagia protocol. Regarding statistical analysis, the quantitative variables were described by median and interquartile range and the qualitative variables were described by absolute and relative frequencies. Non-parametric tests were used to evaluate the associations. Of the 31 infants in the sample, 23 (74.2%) were classified with some degree of dysphagia. Significant difference was observed in the clinical evaluation performed with bottle-feeding compared with breast-feeding; a larger number of swallowing disorders was also found in bottle-feeding. Statistically significant correlation was observed between duration of orotracheal intubation (OTI) >24 h and presence of dysphagia. Postoperative clinical evaluation enabled description of swallowing impairments in infants with CHD regardless of the type of feeding offered, as well as identification of presence of dysphagia in a large number of individuals in the sample and its association with duration of OTI >24 h.

Long-term humeral complications after Grammont-style reverse shoulder arthroplasty

Recent experiences with Grammont reverse shoulder arthroplasty (RSA) have revealed some problems related to the biomechanical changes of the shoulder and humeral stem complications. We analyzed humeral complications in a long-term follow-up of a large series of RSAs, searching for correlations between these and the initial etiology, the follow-up duration, and the clinical outcomes. Preoperative and postoperative clinical and radiologic assessments of 1035 RSAs with a minimum 5-year follow-up (implanted in 7 specialized shoulder centers between 1993 and 2010) were retrospectively collected. Postoperative humeral complications, managed conservatively or surgically, were radiographically documented. Overall, a 3.3% rate of postoperative humeral complications was found in our database. We identified 17 cases (1.6%) with postoperative humeral fractures, 15 cases (1.4%) with aseptic humeral loosening, and 3 cases (0.3%) with humeral stem disassembly. The humeral complications were more frequent in RSAs implanted for tumors, fracture sequelae, and revision for failed arthroplasty. Humeral complications after RSA are not rare, increase with longer follow-up, and have a negative impact on functional outcomes. Postoperative humeral fractures are more frequent in elderly patients, operated on through a superior approach, and after cemented stem implantation. In the absence of associated humeral loosening, conservative treatment should be preferred. Proximal humeral bone loss (due to revisions and tumors) is the most significant risk factor for humeral loosening. Implant unscrewing was initially related to a technological problem, which has been solved, and this complication has disappeared.

Brain tissue Aβ42 levels are linked to shunt response in idiopathic normal pressure hydrocephalus.

The authors conducted a study to test if the cortical brain tissue levels of soluble amyloid beta (Aβ) reflect the propensity of cortical Aβ aggregate formation and may be an additional factor predicting surgical outcome following idiopathic normal pressure hydrocephalus (iNPH) treatment. Highly selective ELISAs (enzyme-linked immunosorbent assays) were used to quantify soluble Aβ40, Aβ42, and neurotoxic Aβ oligomers/protofibrils, associated with Aβ aggregation, in cortical biopsy samples obtained in patients with iNPH (n = 20), sampled during ventriculoperitoneal (VP) shunt surgery. Patients underwent pre- and postoperative (3-month) clinical assessment with a modified iNPH scale. The preoperative CSF biomarkers and the levels of soluble and insoluble Aβ species in cortical biopsy samples were analyzed for their association with a favorable outcome following the VP shunt procedure, defined as a ≥ 5-point increase in the iNPH scale. The brain tissue levels of Aβ42 were negatively correlated with CSF Aβ42 (Spearman’s r = -0.53, p < 0.05). The Aβ40, Aβ42, and Aβ oligomer/protofibril levels in cortical biopsy samples were higher in patients with insoluble cortical Aβ aggregates (p < 0.05). The preoperative CSF Aβ42 levels were similar in patients responding (n = 11) and not responding (n = 9) to VP shunt treatment at 3 months postsurgery. In contrast, the presence of cortical Aβ aggregates and high brain tissue Aβ42 levels were associated with a poor outcome following VP shunt treatment (p < 0.05). Brain tissue measurements of soluble Aβ species are feasible. Since high Aβ42 levels in cortical biopsy samples obtained in patients with iNPH indicated a poor surgical outcome, tissue levels of Aβ species may be associated with the clinical response to shunt treatment.

Evolution of Technique in Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Single Institution Experience from 220 Procedures.

IntroductionEndoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA) has been a recent shift from the traditional microscopic technique. Although some literature demonstrated superiority of ETSS over the microscopic method and some evaluated mono- vs. binostril access within the ETSS, none had explored the potential influence of dedicated instrument, as this procedure had evolved, on patients’ outcomes when compared to traditional microscopic tools.ObjectiveTo investigate our own clinical and radiographic outcomes of ETSS for PA with its technical evolution over time as well as a significance of, having vs. lacking, the special endoscopic tools.MethodsIncluded patients underwent ETSS for PA performed by the first author (AH). Prospectively recorded patients’ data concerning pre-, intra- and postoperative clinical and radiographic assessments were subject to analysis. The three groups of differently evolving ETSS techniques, beginning with mononostril (MN) to binostril ETSS with standard microsurgical instruments (BN1) and, lastly, binostril ETSS with specially-designed endoscopic tools (BN2), were examined for their impact on the intra- and, short- and long-term, postoperative results. Also, the survival after ETSS for PA, as defined by the need for reintervention in each technical group, was appraised.ResultsFrom January 2006 to 2012, there were 47, 101 and 72 ETSS, from 183 patients, in the MN, BN1 and BN2 cohorts, respectively. Significant preoperative findings were greater proportion of patients with prior surgery (p=0.01) and tumors with parasellar extension (p=0.02) in the binostril (BN1&2) than the MN group. Substantially shorter operative time and less amount of blood loss were evident as our technique had evolved (p<0.001). Despite higher incidence, and more advanced grades, of cerebrospinal fluid leakage in the binostril groups (p < 0.001), the requirement for post-ETSS surgical repair was less than the mononostril cohort (p=0.04). At six-month follow-up (n=214), quantitative radiographic outcome analysis was markedly superior in BN2. Consequently, long-term result was better in this latest technical group. Important negative risk factors, from multivariate Cox regression analysis, were prior surgery, Knosp grade, and firm tumor while BN1, BN2 and percentages of anteroposterior dimension PA removal had positive effect on longer survival.ConclusionThe evolution of technique for ETSS for PA from MN to BN2 has shown its efficacy by improving intra- and postoperative outcomes in our study cohorts. Based on our results, not only that a neurosurgeon, wishing to start performing ETSS, should enroll in a formal fellowship training but he/she should also utilize advanced endoscopic tools, as we have proved its superior results in dealing with PA.

Outcome of curettage of peritrochanteric benign lesions in skeletally immature patients without internal fixation

Background Peritrochanteric benign lesions are common in skeletally immature patients, which might cause limping and bone destruction up to pathological fracture. Many techniques have been described for the treatment of such lesions; curettage is one of them, which may be combined with bone graft and internal fixation. Curettage without internal fixation is the principal technique used in this study. Patients and methods This study included 20 patients, with 12 males and eight females, and their mean age was 10.6 years (range, 4–15 years). The diagnosis was 12 cases of simple bone, three cases of aneurysmal bone cyst, two cases of fibrous dysplasia, two cases of nonossifying fibroma, and one case of osteoid osteoma. Treatment included curettage, either simple or extended by high-speed burr and phenol adjuvant, and only cast as external immobilization. Patients were placed in hip spica or antirotational cast for 6–8 weeks. The visual analog scale (VAS) and Harris hip score (HHS) were used for preoperative and postoperative clinical and functional assessments. Results The mean follow-up period was 30.5 months. Clinically, 17 patients had full recovery 3–6 months postoperatively with excellent results according to HHS for hip function and VAS for pain assessment. The VAS score decreased highly significantly, which denoted pain improvement after treatment. HHS increased highly significantly, which denoted improvement of functional activity after treatment. Three patients developed complications. Conclusion Curettage without internal fixation and its replacement by external immobilization by cast is effective, less morbid, and technically simple procedure for the treatment of peritrochanteric benign lesions in skeletally immature patients. Good satisfactory results in local tumor control and excellent long-term functional and radiological results with less emotional negative effects on the patient or his family have been recorded.

Innovative, intra-articular, prosthetic technique for cranial cruciate ligament reconstruction in dogs: a cadaveric study.

The purpose of this study was to describe and assess the feasibility of a new intra-articular approach in the treatment of cranial cruciate ligament deficiency in dogs using an artificial ligament and a new bone-anchor system. Twelve canine cadavers weighting 26 to 45 kg were used in this ex-vivo study. Special tibial and femoral screws, two helicoils, and a high resistance artificial fiber compose the implant. Surgery was performed using the cranio-lateral approach to the stifle joint. Helicoil and tibial screw, connected to the fiber, were inserted in the center of the tibial insertion area of the cranial cruciate ligament. The fiber was passed over-the-top, tensioned, and fixed to the femoral screw, previously inserted with the helicoil in the distal part of the femur. Surgery was completed in all the cases. Occasional problems found during the insertion of the helicoils and screws were resolved with simple procedures. Post-operative clinical assessment showed negative cranial drawer test, negative cranial tibial thrust, and normal range of motion. Radiographic evaluation showed an appropriate positioning of both tibial and femoral implants in all the cases. The results of the first surgical appraisal of this new technique are encouraging, although further studies are necessary to demonstrate the in vivo efficacy of this procedure.

Peri-operative Radiological Factors Predicting Outcome of Discogenic Cauda Equina Syndrome

Background Data: Acute cauda equina syndrome (CES) is a rare disorder considered as a neurosurgical emergency. It can be devastating in some circumstances. Outcome can be predicted by certain preoperative radiological and clinical items.Purpose: To evaluate and analyse the effect of radiological criteria either pre- or postoperative on the final outcome of acute cauda equina syndrome.Study Design: A prospective clinical case study on 27 patients who were presented by manifestations of CES from May 2014 to September 2017.Patients and Methods: Between May 2014 to May 2017 a total of 27 consecutive patients with discogenic acute cauda equina syndrome underwent decompressive surgery (laminectomy and discectomy) with a follow-up at 6 and 12 months postoperative. Preoperative and postoperative clinical assessments were done by using Visual Analogue Scale (VAS) for analysing pain and full neurological examination. Surgical outcome was assessed using Oswestry Disability Index (ODI) and Japanese Orthopedic Association (JOA) scale. Recovery rate (RR) was calculated in final follow up for each patient. In all cases, preoperative and at the last follow-up control a neuro-radiographic MRI assessment was done. Level of affection, size and direction of prolapsed disc, presence of lumbar canal stenosis, degree of decompression (laminectomy), and the presence of disc residual disc, were all thoroughly analyzed with evaluating the correlation with clinical outcome.Results: At final follow-up visit, we found that radiological factors had significant effect on the overall clinical outcome. L5-S1 disc level had the most favourable outcome when compared to other affected level. A statically significant correlation was found between degree of decompression and overall clinical improvement (P=0.001). Residual disc fragments had a direct relation to incomplete recovery from preoperative symptoms although statistically insignificant (P=0.93).Conclusion: Full and thorough study of the pre- and postoperative radiological findings of the patients presented with discogenic cauda equina syndrome has an important prognostic value that can give a prediction for the surgical outcome and the overall clinical improvement. The degree of decompression and presence of canal stenosis was the most important outcome predictor factors. (2017ESJ148)

Cryopreserved Amniotic Membrane Improves Clinical Outcomes Following Microdiscectomy.

Prospective, randomized controlled trial. To compare pain, physical/mental functional recovery and recurrent herniation for patients following lumbar microdiscectomy with and without the use of a cryopreserved amniotic tissue graft. Although microdiscectomy procedures are routinely successful for patients with lumbar radiculopathy due to herniated disc disease, residual low back pain, and recurrent herniation remain unsolved clinical problems. Following Investigated Review Board approval, 80 subjects were randomized in a 1:1 ratio to either receive cryopreserved amniotic (cAM) tissue or no tissue following elective lumbar microdiscectomy surgery. cAM grafts were applied to the annular defect at the conclusion of the procedure. Patients provided preoperative and postoperative clinical assessment data out to 24 months using the Oswestry Disability Index (ODI), Short Form-12 (SF-12) Health Survey, and Visual Analog Pain Scale for back and leg pain. Patients with symptomatic recurrent disc herniation were recorded. In total, 48 males and 32 females with an average age of 47.2 years were included. Mean ODI scores for subjects treated with cAM graft demonstrated statistically greater improvement at 6 weeks (14.49 vs. 21.82; P=0.05) and 24 months (6.62 vs. 14.40; P=0.02) compared with controls. Similarly, SF-12 Physical Component Scores demonstrated statistically greater gains in the cAM group at both the 6 weeks and 24 months. None of the subjects in the cAM graft group sustained a recurrent herniation at the same surgical level, whereas 3 patients in the control group sustained a recurrent herniation at the same surgical level, with 2 requiring fusion to manage persistent pain. The data demonstrate statistically superior clinical outcomes following lumbar microdiscectomy as measured by ODI and SF-12 (physical composite scale) and a lower rate of recurrent herniation with the use of a cAM tissue graft compared with traditional microdiscectomy.

Closure of fistula of the hard palate with two layers of mucoperiosteum

ObjectiveOronasal fistula represents a functional problem, as it may result in nasal regurgitation of food and fluids and it also leads to hypernasal speech. Many methods have been proposed for its closure with a high recurrence rate. The aim of this study was to assess the efficacy of closure of hard palate fistula by two layers of mucoperiosteal flaps. MethodsEighteen patients with fistula of the hard palate were included. The fistula was repaired by two layers of mucoperiosteal flaps; the first layer was created from the mucoperiosteum surrounding the fistula as bilateral hinge flaps and the second layer was formed of a rotational flap based on the greater palatine artery. Pre- and postoperative clinical assessment was performed. ResultsThe etiology of fistulas was previous cleft palate repair in 13 patients, previous nasal septal surgery in 3 patients, and untreated sharp accidental trauma to the palate in 2 patients. All patients presented with nasal regurgitation and hypernasal speech. Complete closure of all fistulas was achieved at first attempt, with no recurrence through the follow up period. ConclusionsClosure of oronasal fistula by two layers of mucoperiosteal flaps is an effective method and it has neither complications nor recurrence.

Mid-Term Clinical, Functional, and Radiographic Outcomes of 105 Gender-Specific Patellofemoral Arthroplasties, With or Without the Association of Medial Unicompartmental Knee Arthroplasty

BackgroundThe purpose of this study is to evaluate clinical and radiographic outcomes after gender-specific patellofemoral arthroplasty (PFA) either isolated or combined with unicompartmental knee arthroplasty (UKA). MethodsA total of 105 PFAs in 85 patients were reviewed: 64 knees had isolated patellofemoral osteoarthritis and received an isolated PFA, and 41 knees with bicompartmental osteoarthritis were treated with medial UKA and PFA. Preoperative and postoperative clinical and functional assessment included knee range of motion, Knee Society Score, University of California Los Angeles Activity Score, Tegner Activity Level Scale, and visual analogue scale pain. Preoperative and postoperative radiographs were evaluated for patellofemoral and tibiofemoral compartment osteoarthritis, trochlear dysplasia, changes in patellar height, and signs of osteolysis. ResultsAt a mean follow-up of 5.5 ± 1.6 years, both groups showed improvement in knee joint range of motion (P < .001), clinical and functional Knee Society Score (P < .001), University of California Los Angeles Activity Score (P < .001 in the PFA group and P = .004 in the UKA + PFA group), and visual analogue scale pain (P < .001). There were no statistically significant postoperative differences between the 2 groups. No signs of osteolysis or subsidence were recorded. Survivorship of these 105 implants was 95.2%. ConclusionExcellent clinical and radiographic outcomes were achieved after PFA with a gender-specific implant both as isolated replacement and when combined with medial UKA. Bicompartmental replacement with small implants can be considered in patients with bicompartmental osteoarthritis and intact anterior cruciate ligament.

The subchondral bone healing after fixation of an osteochondral talar defect is superior in comparison with microfracture

PurposeArthroscopic bone marrow stimulation (BMS) has been considered the primary surgical treatment for osteochondral defects (OCDs) of the talus. However, fixation has been considered as a good alternative. Recently, a new arthroscopic fixation technique was described: the lift, drill, fill and fix procedure (LDFF). The purpose of this study was to evaluate the clinical and radiological results between arthroscopic LDFF and arthroscopic BMS in primary fixable talar OCDs at 1-year follow-up.MethodsIn a prospective comparative study, 14 patients were treated with arthroscopic BMS and 14 patients with arthroscopic LDFF. Pre- and postoperative clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) score and the numeric rating scales (NRSs) of pain at rest and running. Additionally, the level of the subchondral plate (flush or depressed) was analysed on the 1 year postoperative computed tomography scans.ResultsNo significant differences in the AOFAS and NRS pain at rest and running were found between both groups at 1-year follow-up. After LDFF the level of the subchondral bone plate was flush in 10 patients and after BMS in three patients (p = 0.02).ConclusionNo clinical differences were found between arthroscopic LDFF and arthroscopic BMS in the treatment of talar OCDs at 1-year follow-up. However, the subchondral bone plate restores significantly superior after arthroscopic LDFF compared to arthroscopic BMS. It may therefore give less progression of ankle osteoarthritis in the future with a thus potential better long-term outcome.Level of evidenceIII.

Conventional two plate fixation versus L-shaped plates in management of mandibular angle fracture: A comparative retrospective study

Purpose: In mandibular angle fractures, various treatment modalities have been used to rigidly fix the fractured segments aiming to achieve healing through stability and bone formation. In this study, a comparison between two fixation techniques was implied; one L-shaped plate versus two horizontal plates superiorly and inferiorly placed respectively, in an attempt to assess their different effect on healing and complications.Materials and methods: Sixteen patients suffering from displaced angle fractures were included in this study with a mean age of 42 years. The selected patients were divided into two equal groups; Group A employed the fixation of the fractured segments using one L-shaped plate and Group B used the conventional treatment method of utilizing two horizontal plates to fix the fragments in their normal position with subsequent immediate postoperative mandibular function. All the patients were followed-up at minimum period of evaluation of six months. Postoperative complications were recorded if present which included fragment mobility, changed occlusion, dehiscence, infection and/or parasthesia. Postoperative clinical assessment through pain evaluation via visual analogue scale (VAS; scale 0-10) and maximal non-assisted inter-incisal mouth-opening (MIO) measured in mm was performed. Plain radiographic views were performed for inter-fragment alignment assessment. Clinical readings were recorded immediately postoperative and on months 1 and 3. The collected clinical and radiographic findings were tabulated and statistically analyzed. Results: The healing in all cases was uneventful and all patients showed clinical success with no sign of fragments mobility. All the data were analyzed by Mann Whitney U test to compare between the tested groups. Friedman test used to compare between follow up periods followed by Wilcoxon signedrank test for pair wise comparison. The clinical examination and the radiographic assessment revealed no statistically significant difference between the readings of both groups. Regarding the postoperative complications, better initial results came in favor of group A patients, however, with no difference between both groups at the end of the follow up period. Conclusion: Despite of the displacement of the segments in mandibular angle fractures, this study stated that no significant benefit in MAF healing was seen when different plating techniques were used, under the condition of utilizing more than one plane in plate fixation. However, the one-plate L-shaped fixation technique presented fewer postoperative complications.

Bilateral bidirectional Glenn: outcome of off-pump technique.

Off-pump bilateral bidirectional Glenn (b-BDG) poses a surgical challenge and may add complexity to the postoperative outcome especially regarding uniformity of the anastomosis and central pulmonary artery growth. Herein, we report early- and mid-term outcomes after off-pump b-BDG without using superior vena cava decompression techniques. Ninety-seven consecutive patients, between 2009 and 2014, were included in this prospective study. All patients had complete pre- and postoperative clinical and detailed neurological assessments. Diagnosis and follow-up were done by echocardiography and cardiac catheterization for assessment of pulmonary artery anatomically and haemodynamically. Median follow-up period was 3.5 years. Perioperative variables, clinical outcome, morbidity, mortality and follow-up data were recorded. Hypoplastic right ventricle was present in 52 cases (53.6%) and hypoplastic left ventricle was present in 45 cases (46.4%). Mean superior vena cava pressure on clamping was 21.49 ± 3.04 mmHg. Mean total clamping time was 23.11 ± 3.44 min. Mean oxygen saturation increased from preoperative 69.22 ± 6.01% to 83.66 ± 3.97% after b-BDG construction (P-value ≤ 0.0001). The Nakata index increased from 288.47 ± 28.66 mm2/m2 to 303.64 ± 26.85mm2/m2 on follow-up (P-value ≤ 0.05). In-hospital mortality was 4 patients (4.1%) due to low-cardiac output. There were chylothorax in 9 patients (9.3%) and convulsions in 4 patients (4.1%) who were treated conservatively. Off-pump b-BDG can be conducted safely, with a uniform anastomosis that allows a good central pulmonary artery growth for subsequent Fontan completion. Moreover, avoiding the use of cardiopulmonary bypass is more economic and less hazardous.

Guided Modern Endodontic Surgery: A Novel Approach for Guided Osteotomy and Root Resection

IntroductionContinuous improvements in techniques, instruments, and materials have established modern endodontic microsurgery as a state-of-the-art treatment method. The purpose of this approach was to introduce a new surgical endodontic technique by using a three-dimensional printed template for guided osteotomy and root resection. MethodsA 38-year-old patient was diagnosed with periapical lesions of teeth #3 and #4 and extruded gutta-percha material. Three-dimensional radiographic and optical scan files were imported into surgical planning software designed for guided implant surgery. Within the adapted software program the periapical lesions and the extruded gutta-percha were visualized and marked. With the aid of virtually positioned surgical pins and piezoelectric instruments, the osteotomy size, the apical resection level, and the bevel angle were defined before treatment. Three-dimensional surgical templates for each tooth were designed within the software program for a guided treatment approach. ResultsThis approach comprised the treatment of periapical lesions of teeth #3 and #4 with root-end fillings and the detection and complete removal of the extruded gutta-percha material without perforation of sinus membrane. There were no postoperative complications, and clinical and radiologic assessments verified complete healing of the teeth. ConclusionsThe guided microsurgical endodontic treatment presented appears to be a viable technique that allows for predefined osteotomies and root resections.