Preoperative Maximum Research Articles

LOCL-14 FACTORS ASSOCIATED WITH TRACT SEEDING AFTER LASER INTERSTITIAL THERMAL THERAPY FOR INTRACRANIAL TUMORS

Abstract Laser interstitial thermal therapy (LITT) is a growing minimally-invasive approach for treatment of intracranial tumors. Stereotactic placement of the laser catheter within the target lesion carries a theoretical risk of tract seeding, which could lead to disease progression. A retrospective analysis of patients treated with LITT for biopsy-confirmed tumor from 2016-2020 was conducted to characterize the risk of post-LITT tract seeding. Forty-two patients met inclusion criteria, of whom 23 (54.7%) had primary brain tumors and 19 (45.3%) metastases. Thirty-three (78.6%) lesions were recurrent disease at the time of LITT. On follow-up MRI, 3 patients (7.1%) were identified to have had tumor seeding along the LITT tract resulting in progressing disease. There were no significant differences in tumor histology, pre-operative maximum lesion diameter, number of LITT trajectories, rounds of lasing, or post-LITT radiotherapy or surgery between patients with and without tract seeding. All patients with tract seeding were treated for periventricular lesions (<1cm). Patients with tract seeding were also more likely to have received LITT ablations administered from the superficial to deepest elements of the lesion (p=0.05). The median time to progression post-LITT for patients with tract seeding was significantly shorter than those without (1.1 vs 5.9 months, p=0.02). Additional analyses revealed trends towards longer median tract length (4.0 vs. 2.2 cm, p=0.23) and shorter overall survival (5.4 vs. 14.2 months, p=0.17) in the tract seeding cohort. In summary, tract seeding is an infrequent complication associated with both LITT and traditional biopsy. In LITT, tract seeding progression occurs significantly faster than at the treated site, which may be associated with a worse overall prognosis. Prophylactic stereotactic radiosurgery to the LITT tract could be of benefit, however this may pose further risk to patients given the low overall frequency. More frequent monitoring may be necessary lesions in periventricular or difficult to ablate regions, or with longer LITT tracts.

Surgical Management of Chiari Malformation Type I Associated with Syringomyelia: Outcome of Surgeries Based on the New Classification and Study of Cerebrospinal Fluid Dynamics.

Introduction: The mainstay of treatment of syringomyelia associated with Chiari malformation type I (CM-I) is the management of CM-I to normalize the cerebrospinal fluid (CSF) flow at the foramen magnum. CM-I is classified into three independent types. Surgical treatment was selected based on the mechanism of hindbrain ptosis in each CM-I type. Materials and Methods: Foramen magnum decompression (FMD: 213 cases), expansive suboccipital cranioplasty (ESCP: 87 cases), and craniocervical fixation (CCF: 30 cases) were performed. CSF flow dynamics were assessed pre- and post-surgery using cine phase contrast magnetic resonance imaging. During surgery, CSF flow dynamics were examined using color Doppler ultrasonography (CDU). Results: ESCP and FMD demonstrated high rates of improvement in neurological symptoms and signs (82.7%), whereas CCF demonstrated a high rate of improvement in neurological symptoms (89%). The pre-operative maximum flow velocity (cm/s) was significantly lower in patients than in controls and increased post-operatively. During surgery, CDU indicated that the volume of the major cistern was 8 mL, and the maximum flow velocity was >3 mL/s. Conclusions: An appropriate surgical treatment should be selected for CM-I to correct hindbrain ptosis. In addition, it is necessary to confirm the normalization of CSF flow at the foramen of Magendie.

Management of chronic subdural hematoma: A study from Jordan

ObjectivesChronic subdural hematoma (CSDH) is a common condition encountered in neurosurgical practice. Few studies have reported the characteristics of CSDH patients in the Middle Eastern population. We describe the clinical presentation, surgical management, radiological findings, and post-operative outcomes in our hospital. MethodsWe performed a retrospective cohort study in King Abdullah University Hospital, Northern Jordan, between 2009 and 2019. Data were extracted from patients’ medical records and analyzed in patients treated with burr hole drainage (BHD). Univariate analysis was performed to identify correlations with age, laterality, and recurrence. ResultsA total of 172 CSDH patients were identified, of whom 128 (74.4%) were treated surgically. The mean age of patients treated with BHD (n = 108) was 60.9 years with a male-to-female ratio of 2.38:1. Headache was the most common presenting symptom (64.81%) and was significant in patients aged 41–64 years (p = 0.004), whereas muscle weakness and unsteady gait were significant in patients ≥ 65 years (p = 0.004 and p = 0.033, respectively). A higher pre-operative maximum thickness was associated with bilateral presentation (p = 0.001), whereas a higher pre-operative midline shift was associated with unilateral presentation (p = 0.027). Regarding CSDH recurrence, only a preoperative midline shift was significant (p = 0.021). ConclusionClinical presentation was affected by age, as patients < 65 years commonly presented with headaches, whereas those ≥ 65 years presented with limb weakness, speech impairment, unsteady gait, and altered consciousness. BHD was the most utilized surgical option with low mortality and complication rates. Recurrence was only associated with a pre-operative midline shift.

Understanding the role of pelvic obliquity and leg length discrepancy in adult spinal deformity patients with coronal malalignment: unlocking the black box.

This study had 3 objectives: 1) to describe pelvic obliquity (PO) and leg-length discrepancy (LLD) and their relationship with coronal malalignment (CM); 2) to report rates of isolated PO and PO secondary to LLD; and 3) to assess the importance of preoperative PO and LLD in postoperative complications, readmission, reoperation, and patient-reported outcomes. Patients undergoing surgery (≥ 6-level fusions) for adult spinal deformity at a single institution were reviewed. Variables evaluated were as follows: 1) PO, angle between the horizontal plane and a line touching bilateral iliac crests; and 2) LLD, distance from the head to the tibial plafond. Coronal vertical axis (CVA) and sagittal vertical axis measurements were collected, both from C7. The cutoff for CM was CVA > 3 cm. The Oswestry Disability Index (ODI) was collected preoperatively and at 2 years. Of 242 patients undergoing surgery for adult spinal deformity, 90 (37.0%) had preoperative CM. Patients with preoperative CM had a higher PO (2.8° ± 3.2° vs 2.0° ± 1.7°, p = 0.013), a higher percentage of patients with PO > 3° (35.6% vs 23.5%, p = 0.044), and higher a percentage of patients with LLD > 1 cm (21.1% vs 9.8%, p = 0.014). Whereas preoperative PO was significantly positively correlated with CVA (r = 0.26, p < 0.001) and maximum Cobb angle (r = 0.30, p < 0.001), preoperative LLD was only significantly correlated with CVA (r = 0.14, p = 0.035). A total of 12.2% of patients with CM had significant PO and LLD, defined as follows: PO ≥ 3°; LLD ≥ 1 cm. Postoperatively, preoperative PO was significantly associated with both postoperative CM (OR 1.22, 95% CI 1.05-1.40, p = 0.008) and postoperative CVA (β = 0.14, 95% CI 0.06-0.22, p < 0.001). A higher preoperative PO was independently associated with postoperative complications after multivariate logistic regression (OR 1.24, 95% CI 1.05-1.45, p = 0.010); however, 2-year ODI scores were not. Preoperative LLD had no significant relationship with postoperative CM, CVA, ODI, or complications. A PO ≥ 3° or LLD ≥ 1 cm was seen in 44.1% of patients with preoperative CM and in 23.5% of patients with normal coronal alignment. Preoperative PO was significantly associated with preoperative CVA and maximum Cobb angle, whereas preoperative LLD was only associated with preoperative CVA. The direction of PO and LLD showed no consistent pattern with CVA. Preoperative PO was independently associated with complications but not with 2-year ODI scores.

Maximum standardised uptake value is prognostic in patients with early-stage squamous cell carcinoma of the tongue

The aims of this paper were to evaluate the relation between the preoperative primary tumour maximum standardised uptake value (SUVmax, tSUVmax) and clinicopathological features, including depth of invasion (DOI), recurrence factors, and survival outcomes, and to compare the prognostic value of tSUVmax with that of other factors associated with the recurrence of early-stage oral squamous cell carcinoma (OSCC) of the tongue. We retrospectively analysed data from 155 patients. All patients were treated and regularly monitored at the Changhua Christian Hospital (CCH). Only those who had undergone 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in the 14 days before surgery were included. A tSUVmax of >5.2 was found to be the sole strong predictor of a DOI of >4 mm. A tSUVmax of >7.6 was strongly associated with pT2 SCC of the tongue, more aggressive DOI, and perineural invasion. DOI and tSUVmax could be used to predict disease-free survival (DFS) for early-stage SCC of the tongue, and they showed stronger predictive power than the traditional American Joint Committee on Cancer (AJCC) T stage. Therefore tSUVmax could be a prognostic tool for DFS in AJCC early-stage SCC of the tongue.

Distal Aortic Failure Following the Frozen Elephant Trunk Procedure for Aortic Dissection.

BackgroundAim of this study was to report and to identify risk factors for distal aortic failure following aortic arch replacement via the frozen elephant trunk (FET) procedure.MethodsOne hundred eighty-six consecutive patients underwent the FET procedure for acute and chronic aortic dissection. Our cohort was divided into patients with and without distal aortic failure. Distal aortic failure was defined as: (I) distal aortic reintervention, (II) aortic diameter dilatation to ≥ 6 cm or > 5 mm growth within 6 months, (III) development of a distal stent-graft-induced new entry (dSINE) and/or (IV) aortic-related death. Preoperative, intraoperative, postoperative and aortic morphological data were analyzed.ResultsDistal aortic failure occurred in 88 (47.3%) patients. Forty-six (24.7%) required a distal reintervention, aortic diameter dilatation was observed in 9 (4.8%) patients, a dSINE occurred in 22 (11.8%) patients and 11 (6.4%) suffered an aortic-related death. We found no difference in the number of communications between true and false lumen (p = 0.25) but there were significantly more communications between Ishimaru zone 6–8 in the distal aortic failure group (p = 0.01). The volume of the thoracic descending aorta measured preoperatively and postoperatively within 36 months afterward was significantly larger in patients suffering distal aortic failure (p < 0.001; p = 0.011). Acute aortic dissection (SHR 2.111; p = 0.007), preoperative maximum descending aortic diameter (SHR 1.029; p = 0.018) and preoperative maximum aortic diameter at the level of the diaphragm (SHR 1.041; p = 0.012) were identified as risk factors for distal aortic failure.ConclusionThe incidence and risk of distal aortic failure following the FET procedure is high. Especially those patients with more acute and more extensive aortic dissections or larger preoperative descending aortic diameters carry a substantially higher risk of developing distal aortic failure. The prospective of the FET technique as a single-step treatment for aortic dissection seems low and follow-up in dedicated aortic centers is therefore paramount.

Late Rupture Following Endovascular Aneurysm Repair: Open or Endovascular Repair?

Late rupture following endovascular aneurysm repair (EVAR) carries significant morbidity and mortality. Traditionally treated with open surgery, there has been a growing tendency to perform repair using both simple and advanced endovascular techniques. We aimed to compare the short-term outcomes of patients with late rupture following EVAR treated with open surgery (OS) or endovascular repair (ER). A retrospective cohort study was performed using the Vascular Quality Initiative registry from January 2010 to July 2021. All patients with a prior EVAR who presented with a late rupture were included. A comparison was made of those undergoing OS or ER. Primary outcome was in-hospital mortality. Secondary outcomes included postoperative complications. A total of 264 patients (165 OS, 99 ER) underwent surgery for late rupture after EVAR. Mean age was 77.1 ± 8.0 years, and 212 patients (80.3%) were male. Comorbidities were similar between the groups, however preoperative creatinine was higher in those undergoing ER (1.8 ± 1.6 mg/dL vs 1.4 ± 0.7 mg/dL; P = .026). The preoperative mean maximum aortic diameter was 79.5 ± 23.8 mm. There was no difference in the lowest preoperative blood pressure before OS or ER (95.6 ± 29.7 mm Hg vs 93.0 ± 33.0 mm Hg; P = .526). Total procedure time (256.1 ± 124.4 minutes vs 183.9 ± 102.4 minutes; P < .0001), estimated blood loss (4230.5 ± 3759.9 mL vs 504.2 ± 841.9 mL; P < .0001), and packed red blood cell transfusion (6.6 ± 5.6 units vs 3.1 ± 3.3 units; P < .0001) were all significantly higher for open surgery. The time to extubation was significantly longer for those undergoing OS, with 7.5% being extubated in the OR and 60.6% requiring intubation for more than 24 hours, compared with 39.3% and 34.8%, respectively, of those undergoing ER (P < .0001). There was no difference in intensive care unit length of stay (9.1 ± 9.8 days vs 7.8 ± 11.9 days; P = .360) or total length of stay (15.0 ± 15.9 days vs 11.7 ± 12.5 days; P = .061) for those undergoing OS or ER. No significant difference was found in the in-hospital mortality between OS or ER (29.7% vs 30.3%; P = .917). Return to the OR (32.7% vs 17.4%; P = .007), congestive heart failure (8.0% vs 2.1%; P = .047), temporary dialysis (15.4% vs 1.0%; P = .001), and wound complications (10.5% vs 0.0%; P = .001) occurred more frequently in OS. Those undergoing ER had a higher incidence of postoperative stroke (6.2% vs 1.2%; P = .026), with those strokes being more likely to be major (P = .029). OS and ER for late rupture following EVAR have similar mortality. Those undergoing ER had lower morbidity; however, this approach was associated with a higher incidence of stroke.

Association of Nrf2 expression and mutation with Weiss and Helsinki scores in adrenocortical carcinoma.

Adrenocortical carcinoma (ACC) is a rare malignant tumor. Genetic abnormalities that may represent therapeutic targets and prognostic factors in ACC remain unclear. Besides being one of the main cellular defense mechanisms that regulates antioxidant pathways for detoxifying reactive oxygen species (ROS), the transcription factor nuclear factor erythroid 2–related factor 2 (Nrf2) promotes tumor proliferation by increasing metabolic activity. In surgical specimens from 12 cases of nonmetastatic ACCs and nine cases of benign adrenocortical adenoma (ACA), we investigated gene mutation and protein expressions for Nrf2 and the preoperative maximum standard glucose uptake (SUVmax) on [18F]fluorodeoxy‐glucose positron emission tomography. Three of five ACCs with a Weiss score of 7 to 9 were Nrf2 mutants; these ACCs had higher expression of Nrf2 and higher preoperative SUVmax. The other seven ACCs had a Weiss score of 3 to 6; these seven ACCs and all the ACAs were non‐Nrf2 gene mutants. Patients with a Weiss score of 7 to 9 and Nrf2 mutant ACC had shorter overall survival. Based on Helsinki scoring, three ACCs with a Helsinki score greater than 17 had Nrf2 mutants, higher expression of Nrf2, higher preoperative SUVmax, and shorter overall survival. Our findings indicate that Nrf2 activation and the associated increase in metabolism play roles in ACC, in particular in ACC with a Weiss score of 7 to 9 and a Helsinki score of greater than 17.

Transsphenoidal Surgery of Giant Pituitary Adenoma: Results and Experience of 239 Cases in A Single Center.

BackgroundTranssphenoidal surgery (TSS) is first-line treatment for giant pituitary adenomas (PAs). Although PA is a benign neuroendocrine tumor that originates from adenohypophysial cells, the surgical outcomes and prognosis of giant PAs differ significantly due to multiple factors such as tumor morphology, invasion site, pathological characteristics and so on. The aim of this study was to evaluate surgical outcomes of giant PAs in a single-center cohort.MethodsThe clinical features and outcomes of 239 patients with giant PA who underwent sphenoidal surgery at the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2015 to October 2021 were collected from medical records. The basic clinical information (age, gender, function etc.), surgical procedure, imaging features (maximum diameter, invasion characteristics, tumor shape etc.) and histopathological characteristics (pathological results, Ki-67, P53 etc.) were retrospectively reviewed. SPSS 25.0 and Stata 12.0 software were used for statistical analysis.ResultsA total of 239 patients with giant PAs underwent TSS, of which 168 surgeries (70.29%) were endoscopic endonasal transsphenoidal (EETS) and 71 (29.71%) were microscopic transsphenoidal (MTS). The mean preoperative maximum diameter in the cohort was 45.64 mm. Gross-total resection was achieved in 46 patients (19.25%), near-total in 56 (23.43%), subtotal in 68 (28.45%), and partial in 69 (28.87%) patients. The maximum tumor diameter and Knosp grade were the significant factors that limited the extent of the resection of giant PAs. A total of 193 patients (80.75%) experienced surgical complications, and the most common complications were postoperative diabetes insipidus (DI) (91, 38.08%), intracranial infection (36, 15.06%) and cerebrospinal fluid (CSF) leaks (37, 15.48%). In addition, there was a significant difference in the incidence of CSF leaks between the neuroendoscopy group and the microscopic group (P < 0.05).ConclusionThe management of giant PAs remains a therapeutic challenge due to their large size and postoperative complications. The maximum diameter and Knosp grade of giant PAs significantly limited the extent of resection, which warrants a reasonable surgical plan.

Treatment of advance keratoconus using donor bowman layer: the zaman technique of bowman layer transplantation (Type I &amp; Type II)

Commonly referred to as an ecstatic, non-inflammatory disease, Keratoconus, usually bilateral and asymmetric, is characterized by progressive steeping and thinning of the cornea. This results in irregular astigmatism which compromises vision [1,2]. Traditionally, early Keratoconus stages have been treated by prescribing a hard contact lens to obtain a regular anterior optical surface. This tendency was discontinued when contact lens intolerance in advanced stages required the use of penetrating keratoplasty (PKP) or deep anterior lamellar Keratoplasty (DALK). An alternative technique of corneal cross-linking was designed in 2003 as a treatment option for keratoconus. The cornea measured at least 400 um thickness after epithelium removal and pre-operative maximum keratometry (Kmax) measured 58D or less. As a result, no corneal transplantation was required or postponed [3].

Abstract 286: Prediction Of Adverse Events Following Stent Graft Repair Of Type B Aortic Dissection From Imaging Modalities

Objectives: The prophylactic treatment of uncomplicated TBAD with TEVAR is controversial. This warrants the identification of a high-risk category of dissections that may particularly benefit from surgical intervention. The analysis of radiographic features presents a promising modality of assessing this high-risk cohort. We test the ability of aortic size and shape metrics from the literature to predict patient suitability for TEVAR from pre-operative imaging. Methods: We collected a single institutional retrospective cohort of 36 patients with TBAD who received TEVAR and had pre-operative and follow-up CTA imaging. We tested 8 aortic size and shape metrics. We segmented each patient’s aorta and true lumen from the pre-operative scan. Tortuosity, mean diameter, centerline curvature, and eccentricity were measured from the centerline. True and false lumen volumes and max diameter were calculated. The question mark angle, as previously defined by Li et al., was also measured. Univariate and multivariate logistic regression analyses were performed. Results: In the univariate analysis, pre-operative false lumen volume (OR 26.2 95% CI 2.72 to 252, p = .005), mean diameter (OR 9.6 95% CI 2.19 to 42.3, p = .003), and maximum diameter (OR 9.0 95% CI 2.12 to 38.3, p = .003) were all significantly associated with post-TEVAR outcomes. Tortuosity index (OR 2.7, 95% CI 1.14 to 6.37, p = .024) was the only significant shape parameter. In multivariate analysis, we found that pre-operative maximum diameter (OR 10.0, 95% CI 1.50 to 67.0, p &lt; .018) is a significant predictor of TEVAR outcomes independent of shape parameters, all of which were not significant. Conclusions: False lumen volume and maximum diameter can predict the occurrence of reintervention and type I endoleak following TEVAR for uncomplicated TBAD. While size measures are effective in explaining aortic dissection behavior, current shape measures are not as effective and better methodologies must be developed.

Flattening of Central, Paracentral, and Peripheral Cones After Non-accelerated and Accelerated Epithelium-off CXL in Keratoconus: A Multicenter Study.

To assess the flattening of central, paracentral, and peripheral cones following non-accelerated (non-A-CXL) and accelerated (A-CXL) epithelium-off corneal cross-linking with 10 times higher intensity. In this multicenter study of 200 eyes (100 in each group), following 10 minutes of soak time with riboflavin 0.1%, continuous CXL was performed for 30 minutes (intensity: 3 mW/cm2, fluence: 5.4 J/cm2) in the non-A-CXL group and 3 minutes (intensity: 30 mW/cm2, fluence: 5.4 J/cm2) in the A-CXL group. Anterior and posterior cone flattening were compared at 12 months. Multiple regression analysis was performed to establish correlation of age, sex, cone location, and preoperative maximum keratometry (Kmax) values with postoperative flattening at 12 months. In the non-A-CXL and A-CXL groups, central cones were the steepest, followed by paracentral and peripheral cones. Both groups showed significant flattening in central (1.54 ± 1.94 and 1.09 ± 1.79 diopters [D]) and paracentral (0.62 ± 1.59 and 0.55 ± 0.98 D) cones only. In the non-A-CXL group, there was a positive correlation between postoperative flattening and preoperative Kmax values, whereas paracentral and peripheral cone locations were negatively related. In the A-CXL group, only paracentral location was negatively correlated to postoperative flattening and showed posterior cone steepening at 12 months. Although central cones were the steepest in both groups, there was no difference in postoperative flattening between the groups for all cone locations. In the non-A-CXL group, postoperative flattening was proportional to preoperative Kmax values in central cones and was less with paracentral and peripheral locations. With A-CXL, postoperative flattening was less only with paracentral location. In the A-CXL group, significant posterior cone steepening was noticed only in paracentral cones. [J Refract Surg. 2022;38(5):310-316.].

Arthrocentesis in Temporomandibular Joint disc Derangement Patients, with and without Hyaluronic Acid, A Clinical Trial

Objective: Our research looked at the effectiveness of arthrocentesis in the treatment of TMJ issues with and without the addition of hyaluronic acid. Study Design: Prospective study Place and Duration: Dental College, HITEC-IMS, Taxila Cantonment. December 2019- May 2022 Methods: In this study 60 patients of both genders who had temporomandibular Joint disc derangement disorders were presented. After obtaining informed written consent, the demographics of enrolled patients were analyzed, including age, sex, side, and type of effusion. In two groups, patients were split evenly. Group I received arthrocentesis alone with lavage and group II received arthrocentesis with hyaluronic acid. We used standard two needle arthrocentesis among all cases. Post treatment effectiveness among both groups were assessed and compared in terms of maximum mouth opening, reduction in pain score and complications. SPSS 24.0 version was used to analyzed completed data. Results: There were majority females in group I was 20 (66.7%) and in group II was 23 (76.7%). Mean age of the patients in group I was 34.6±11.44 years and had mean BMI 22.8±7.28 kg/m2 while in group II mean age was 32.11±14.34 years with mean BMI 21.5±8.41 kg/m2. Right side was the most common side among both groups found in 16 (53.3%) in group I and 17 (56.7%) in group II. In group I effusion in upper compartment found in 22 (73.3%) cases while in group II 24 (80%) cases had upper compartment. Pre-operative maximum mouth opening in group I was 30.4±9.45 mm and in group II MMO was 31.9±14.41. Post-operative we found increased in MMO in group I was 42.6±12.32 mm and in group II 44.7±11.29 mm but no any significantly difference was observed after 2 years of follow up 39.3±15.49 in group I and 41.13±6.51 mm in group II. Post-operative reduction in pain score was observed 1.8±5.1 in group I and 0.1±1.9 in group II by using VAS significantly with p value &lt;0.003. Conclusion: We concluded in this study that the arthrocentesis is an effective and safe method in the treatment of temporomandibular joint disc derangement in terms of increase in MMO and reduction in pain score while arthrocentesis with hyaluronic acid showed better results but difference was not significant. Keywords: Temporomandibular Joint disc, Arthrocentesis, MMO, Pain score

Return to Physical Activity following Flatfoot Reconstruction

Category:Hindfoot; Midfoot/Forefoot; SportsIntroduction/Purpose:Progressive collapsing foot deformity (PCFD) is a condition encompassing multiple interrelated, progressive bony and soft tissue deformities, often requiring surgical correction. Patients are often debilitated, with postoperative goals commonly cited as walking and low-impact activities without pain. However, some patients engage in sports and more rigorous activities. Surgeons may struggle to set expectations after surgery since few studies investigate returns to activity following flatfoot reconstruction and every patient is different. Existing studies are limited by small sample sizes, lack of data of activity-specific data, and cohorts confined to one or two of the many possible concomitant procedures in flatfoot reconstruction. This study aims to provide the first generalizable assessment of returns to sports and physical activity following reconstruction surgery in patients with flexible PCFD.Methods:Patients who underwent reconstructive surgery from February 2016-May 2019 for flexible-stage PCFD were identified by registry review and contacted with IRB approval. 70/119 patients (72/121 feet, 60%) were reached at mean 3.1 (range, 2.0 to 5.4) years post-operatively with mean age 43.5 (range, 18 to 59) years at surgery. Concomitant procedures were noted. Physical activity was evaluated with a previously published questionnaire that assessed participation in 15 sports and activities, allowed patients to list additional activities, and classified activities as high or low-impact. Patients specified postoperative number of sessions per week, session duration, return times to participation and maximal activity, relative pre/postoperative difficulty, and satisfaction with outcome regarding sports. Clinical outcomes were evaluated with Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Multivariable regressions assessed associations between PROMIS domain changes and survey responses and linear models measured association of sports participation with the most performed procedures, controlling for concomitant procedures.Results:Patients experienced significant improvements in all PROMIS domains except Depression and surpassed previously reported minimal clinically important differences for PCFD in Physical Function and Pain Interference scores. Patients reported participation in 21 specific sports and activities (Table 1). Compared to preoperatively, patients rated 16.7% (45/270) of activities as more difficult postoperatively, 33.3% (90/270) as equally difficult, and 50% (135/270) as less difficult. Median return times were 6-9 months for participation in activities and 13-18 months to reach maximum preoperative participation. Patients spent a median 7.6 (range, 0-29.8) hours/week engaged in physical activity. 3% of patients (2/72) were sedentary, 31% (22/72) were moderately active, 28% (20/72), were highly active and 36% (26/72) were extremely active. Improvements in Physical Function (P=.021), Pain Interference (P=.001), and Global Physical Health (P=.001) were associated with increased outcome satisfaction regarding physical activities. No associations were found between procedures performed and any PROMIS domains or return parameters.Conclusion:This is the largest and most comprehensive analysis of patient participation in sports and physical activities following flatfoot reconstruction. Results suggest that flatfoot reconstruction surgery generally results in good returns to physical activity in terms of return time, pre-postoperative difficulty changes, and satisfaction. Some patients reported increased difficulty or inability to return to their preoperative maximum level of participation, indicating that flatfoot reconstructions can lead to some athletic limitations. However, ninety percent of patients reported satisfaction with their surgical outcomes with respect to returns to physical activity, indicating that, for most patients, flatfoot reconstruction provides meaningful relief from debilitation.

Return to Physical Activity Following Flatfoot Reconstruction.

Progressive collapsing foot deformity (PCFD) is a debilitating condition encompassing several interrelated, progressive deformities requiring a combination of reconstructive procedures. Few studies investigate returns to activity following flatfoot reconstruction, and existing studies only examine 1 or 2 of the numerous procedures employed. This study aims to provide the first generalizable assessment of returns to sports and physical activity following reconstruction surgery in patients with flexible flatfoot deformity. Patients aged 18-60 years who underwent reconstructive surgery between February 16 and May 19 for symptomatic flexible-stage flatfoot deformity were identified by registry review. Eighty-two of 113 eligible patients (73%) were reached at a mean 2.9 years (range, 2.0-5.4) of follow-up with mean age at surgery of 48.9 years (range, 18-59). Returns to physical activity were evaluated with a sports-specific survey. Clinical outcomes were evaluated with Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Patients reported participation in 21 specific sports and activities. One-fourth (25.6%) of patients (21/82) reported increased difficulty with physical activities postoperatively, 15.9% reported equal difficulty, and 58.5% (48/82) reported decreased difficulty. Median return times were 9-12 months for participation and 12-18 months to reach maximum preoperative participation levels. Improvements in Physical Function (P= .001), Pain Interference (P < .001), Pain Intensity (P <.001), and Global Physical Health (P = .004) were associated with increased satisfaction with respect to sports and physical activities. This study investigated participation in specific sports and physical activities following flatfoot reconstruction. Our findings suggest mixed outcomes, where many patients reported life-changing improvements but many also experienced prolonged pain and difficulty after surgery. Some patients reported increased difficulty or inability to return to their preoperative maximum level of participation, indicating that flatfoot reconstructions can lead to athletic limitations. Although flatfoot reconstruction can be a powerful tool to increase patients' capacity to engage in physical activity, in our cohort many patients had reduced physical activity outcomes. Level IV, retrospective case series.

Predictors of Abdominal Aortic Aneurysm Shrinkage after Endovascular Repair.

Recent studies demonstrate that patients with a shrinking abdominal aortic aneurysm (AAA), one-year after endovascular repair (EVAR), have better long-term outcomes than patients with a stable AAA. It is not known what factors determine whether an AAA will shrink or not. In this study, a range of parameters was investigated to identify their use in differentiating patients that will develop a shrinking AAA from those with a stable AAA one-year after EVAR. Hundred-seventy-four patients (67 shrinking AAA, 107 stable AAA) who underwent elective, infrarenal EVAR were enrolled between 2011–2018. Long-term survival was significantly better in patients with a shrinking AAA, compared to those with a stable AAA (p = 0.038). Larger preoperative maximum AAA diameter was associated with an increased likelihood of developing AAA shrinkage one-year after EVAR—whereas older age and larger preoperative infrarenal β angle were associated with a reduced likelihood of AAA shrinkage. However, this multivariate logistic regression model was only able to correctly identify 66.7% of patients with AAA shrinkage from the total cohort. This is not sufficient for implementation in clinical care, and therefore future research is recommended to dive deeper into AAA anatomy, and explore potential predictors using artificial intelligence and radiomics.

Preoperative maximum phonation time as a predictor of pneumonia in patients undergoing esophagectomy

Esophagectomy is a highly invasive procedure, associated with several postoperative complications including pneumonia, anastomotic leakage, and sepsis, which may result in multiorgan failure. Pneumonia is considered a major predictor of poor long-term prognosis, so its prevention is important for patients undergoing surgery for esophageal cancer. The subjects of this study were 137 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January, 2012 and December, 2016. Patients who underwent R0 or R1 resection or esophagectomy with organ excision were included. Patients who underwent salvage surgery or resection of recurrent laryngeal nerve, and those with preoperative recurrent laryngeal nerve palsy, were excluded. We investigated the effect of the maximum phonation time on the development of postoperative pneumonia. Pneumonia developed more frequently in patients with a long operative time, clinically left recurrent nerve lymph node metastasis, and a short preoperative maximum phonation time (p = 0.074, 0.046, and 0.080, respectively). Pneumonia was also more common in men with an abnormal maximum phonation time (p = 0.010). The maximum phonation time is a significant predictor of postoperative pneumonia after esophagectomy in men.

Intraoperative hand strength as an indicator of consciousness during awake craniotomy: a prospective, observational study

Awake craniotomy enables mapping and monitoring of brain functions. For successful procedures, rapid awakening and the precise evaluation of consciousness are required. A prospective, observational study conducted to test whether intraoperative hand strength could be a sensitive indicator of consciousness during the awake phase of awake craniotomy. Twenty-three patients who underwent awake craniotomy were included. Subtle changes of the level of consciousness were assessed by the Japan Coma Scale (JCS). The associations of hand strength on the unaffected side with the predicted plasma concentration (Cp) of propofol, the bispectral index (BIS), and the JCS were analyzed. Hand strength relative to the preoperative maximum hand strength on the unaffected side showed significant correlations with the Cp of propofol (ρ = − 0.219, p = 0.007), the BIS (ρ = 0.259, p = 0.002), and the JCS (τ = − 0.508, p = 0.001). Receiver operating characteristic curve analysis for discriminating JCS 0–1 and JCS ≥ 2 demonstrated that the area under the curve was 0.76 for hand strength, 0.78 for Cp of propofol, and 0.66 for BIS. With a cutoff value of 75% for hand strength, the sensitivity was 0.76, and the specificity was 0.67. These data demonstrated that hand strength is a useful indicator for assessing the intraoperative level of consciousness during awake craniotomy.

Correlation of MRI and arthroscopic findings with clinical outcome in temporomandibular joint disorders: a retrospective cohort study

BackgroundArthroscopy is a minimally invasive diagnostic tool and treatment strategy in patients suffering from temporomandibular disorders (TMD) when conservative treatment fails. This study aimed to find specific variables on pre-operative MRI or during arthroscopy that could predict success of arthroscopic lysis and lavage.MethodsThis retrospective analysis compared pre-operative maximum interincisal opening (MIO), pain and main complaint (pain, limited MIO or joint sounds) with results at short-term and medium-term follow-up (ST and MT respectively). Different variables scored on MRI or arthroscopy were used to make a stepwise regression model, subsequently a combined analysis was conducted using variables from both MRI and arthroscopy.ResultsA total of 47 patients (50 joints) met the inclusion criteria. The main complaint improved by 62 and 53% at ST and MT respectively. The absolute or probable absence of a crumpled disc scored on MRI predicted success at ST and MT (p = 0.0112 and p = 0.0054), and remained significant at MT in the combined analysis (p = 0.0078). Arthroscopic findings of degenerative joint disease predicted success at ST (p = 0.0178), absolute or probable absence of discal reduction scored during arthroscopy significantly predicted success in the combined analysis at ST (p = 0.0474).ConclusionTo improve selection criteria for patients undergoing an arthroscopic lysis and lavage of the TMJ, future research might focus on variables visualized on MRI. Although more research is needed, disc shape and in particular the absolute or probable absence of a crumpled disc might be used as predictive variable for success.

Preoperative MRI to Improve Aesthetic Outcomes in Secondary Mastopexy Augmentation: A Step-by-Step Approach.

Secondary mastopexy augmentation is challenging because of compromised blood supply to the nipple areola complex (NAC). The operating surgeon often relies on clinical judgment and may perform a more conservative elevation of the NAC to minimize the risk of nipple necrosis. Despite this, the danger of necrosis persists. In our experience, MRI with contrast has enhanced preoperative planning in both cosmetic and reconstructive cases. The goals of this article are to describe our use of preoperative MRI in identifying the blood supply to the NAC, evaluating dermo glandular thickness, decreasing surgical complications, and improving outcomes in secondary mastopexy augmentation. A consecutive series of secondary mastopexy augmentation procedures performed in 2021 were reviewed. In each case, preoperative maximum intensity projection (MIP) and/or high-resolution T1-weighted contrast enhanced MRI imaging was reviewed to elucidate the blood supply to the NAC and quantify the dermo glandular thickness. The imaging was used to formulate the operative plan. Preoperative and postoperative photographs were compared. Eight cases were performed, four of which were selected to demonstrate our method using breast MRI with contrast in step-by-step approach. Patient satisfaction was high. The NAC survived in all cases. Surgeons can utilize preoperative breast MRI for strategic operative planning when performing secondary mastopexy augmentation. Visualization of the blood supply to the NAC and dermo glandular flap thickness are vitally important when performing a more aggressive lift of the breast.