Previous Failed Surgery Research Articles

Empty nose syndrome: new insights from a CFD approach.

Empty Nose Syndrome (ENS) is a debilitating condition which usually arises after aggressive turbinate reduction. However, objective tests to help in the diagnosis of this condition are lacking. Accurate diagnosis of ENS patients is critical for effective diagnosis and treatment. The article's objectives are to utilize computational fluid dynamics (CFD) to analyze nasal airflow resistance and symmetry in suspected ENS patients, classify them into distinct groups based on CFD data, and demonstrate the potential of CFD analysis in refining ENS diagnosis and guiding individualized treatment strategies. This study involved 48 patients diagnosed of ENS. However, we only considered those patients with documented prior turbinate surgery (eventually plus septal surgery), CT scan with signs of prior surgery, and a history of ENS with symptoms included in the ENS Q6. We employed computational fluid dynamics (CFD) to analyze nasal airflow resistance and symmetry. Patients were classified into three groups based on their CFD data: low resistance and normal symmetry, evident asymmetry, and normal CFD parameters. Half of patients (24 out of 48) were found in the low resistance and normal symmetry group, indicating 'typical' ENS. A smaller group (8) exhibited evident asymmetry, suggesting unilateral ENS or failure of previous surgery. Finally, 16 patients whose CFD parameters are inside the normal range of flow and resistance were classified in the normal breathing group. Our findings highlight the value of CFD analysis in classifying ENS patients based on airflow characteristics, as CFD analysis seems helpful in refining the diagnosis of ENS. This classification system can potentially aid in tailoring individual treatment strategies and improving patient outcomes. Further research is necessary to validate these results and explore the clinical implications of different ENS subgroups. Level 4 [1].

Retinal redetachment after silicone oil removal: a risk factor analysis

PurposeTo report the rate of retinal redetachment after silicone oil removal following rhegmatogenous retinal detachment surgery and to determine potential risk factors.MethodsRetrospective observational case series of 161 eyes who underwent rhegmatogenous retinal detachment surgery and subsequent silicone oil removal. Pre- and intraoperative risk factors were evaluated using univariate and multivariate logistic regression. We also evaluated the effect of tamponade duration on anatomical outcomes.ResultsThe median tamponade duration was 5.9 [4.3;7.6] months. Seventeen (10.6%) eyes underwent silicone oil removal within 3 months of surgery, with a median delay of 2.3 [2.0;2.8] months. The rate of retinal detachment after silicone oil removal was 14.9%. A history of previous unsuccessful surgery was the only significant risk factor for retinal redetachment after silicone oil removal (OR 4.8, 95%CI [1.5;19.0], p = 0.02). The use of 360° laser retinopexy and concomitant air or gas tamponade during silicone oil removal were not found to affect the redetachment rate. Eyes with silicone oil tamponade ≤ 3 months showed an increased, albeit not significant, risk of developing recurrent rhegmatogenous retinal detachment after silicone oil removal (35.3% versus 12.5%, p = 0.06).ConclusionA retinal redetachment occurred in 14.9% of eyes undergoing silicone oil removal following rhegmatogenous retinal detachment surgery. Previous failed surgery was associated with a 4.8-fold increased risk of developing recurrent rhegmatogenous retinal detachment after silicone oil removal. Eyes with silicone oil tamponade ≤ 3 months tended to have a higher redetachment rate.Trial registration numberID NCT05647928 (12th April 2022)

Eighteen years of experience in laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency

Introduction and objectives: Artificial urinary sphincter (AUS) is a treatment option for women with stress urinary incontinence (SUI) after failure of previous surgery or as a primary procedure in severe intrinsic sphincter deficiency (ISD). The aim of the study was to assess the long-term efficacy and risk factors for surgical revision and definitive explantation of AUS laparoscopic implantation in female patients.Methods: A retrospective review of all women submitted to AUS implantation between April 2005 and March 2023 was conducted. The AUS was implanted via transperitoneal laparoscopic approach, by two experienced surgeons. The primary endpoint was postoperative continence. Continence was defined as no leakage and no pad usage or leakage and/or pad usage with no impact on social life and failure as leakage and/or pad usage impacting social life. As secondary outcomes, clinical predictive factors for AUS revision and definitive explantation were evaluated.Results: In the last 18 years, females with a mean age of 68±12 years-old were submitted to laparoscopic implantation of AUS. Early overall complication rate was 16%, but only one case was Clavien-Dindo ≥3. After a median follow-up of 67 months, 22.2% of the patients needed a device revision, the majority due to mechanical device dysfunction. AUS definitive explantation was performed in 16%, mainly due to urethral/vaginal erosion (9.9%) and infection (6.2%). Patients with age ≥70 years and follow-up ≥10 years significantly predisposed for device revision. At the time of the last follow-up, 72% of the patients were keeping the urinary continency.Conclusions: Laparoscopic AUS implantation in females is an effective treatment for SUI due to ISD. Meanwhile, adequate patient selection, multidisciplinary evaluation and careful expectation management are essential to achieving good results, concerning their significant complication rate.

[Translated article] Better results in consolidation of hallux metatarsophalangeal arthrodesis with dorsal plate and interfragmentary compression screw

Background and aimsThe first metatarsophalangeal joint arthrodesis is indicated for the treatment of various pathologies as a technique to reduce pain and improve the support of the first radius. Numerous surgical techniques and fixation methods have been described, with the combination of a dorsal plate and an interfragmentary screw being the one that has shown to be the most stable construct in biomechanical studies. Our aim is to analyze the radiological results after metatarsophalangeal arthrodesis of the hallux using a dorsal plate associated or not with an interfragmentary screw. The differences in terms of consolidation rates and complications in patients diagnosed with hallux rigidus, hallux valgus, hallux varus and failure of previous surgeries were evaluated. Materials and methodsA retrospective cohort study of 55 patients with a mean age of 65.10 years in whom a dorsal plate was used was performed. Patients were divided into two groups depending on whether or not an interfragmentary screw was used. The minimum follow-up was 6 months after surgery. The assessment of the pre and postoperative radiological results was based on the variation of the hallux angle, the intermetatarsal angle and the dorsal metatarsophalangeal angle of the hallux, as well as the cases of nonunion identified in each study group. ResultsThe radiological results, statistically significant differences (p<0.05) were only found in the dorsal metatarsophalangeal angle between both study groups. No statistically significant differences were found regarding the radiological evaluation of the pre and postoperative hallux angle and intermetatarsal angle. An equal decrease of each angles was observed in both study groups. Regarding the consolidation rate, statistically significant differences (p<0.05) were found between group A, which associated an interfragmentary screw, presenting a consolidation rate of 92%, and group B, which did not associate an interfragmentary screw, and that presented a union rate of 63%. ConclusionHallux metatarsophalangeal arthrodesis of the hallux with a dorsal plate and interfragmentary screw show best results regarding consolidation rate and complications compared to those cases in which an interfragmentary screw was not used.

Mejores resultados en la consolidación de la artrodesis metatarsofalángica del hallux con placa dorsal y tornillo de compresión interfragmentario

Introduction and aimsThe first metatarsophalangeal joint arthrodesis is indicated for the treatment of various pathologies as a technique to reduce pain and improve the support of the first radius. Numerous surgical techniques and fixation methods have been described, with the combination of a dorsal plate and an interfragmentary screw being the one that has shown to be the most stable construct in biomechanical studies. Our aim is to analyze the radiological results after metatarsophalangeal arthrodesis of the hallux using a dorsal plate associated or not with an interfragmentary screw. The differences in terms of consolidation rates and complications in patients diagnosed with hallux rigidus, hallux valgus, hallux varus and failure of previous surgeries were evaluated. Material and methodsA retrospective cohort study of 55 patients with a mean age of 65.10 years in whom a dorsal plate was used was performed. Patients were divided into 2 groups depending on whether or not an interfragmentary screw was used. The minimum follow-up was 6 months after surgery. The assessment of the pre and postoperative radiological results was based on the variation of the hallux angle, the intermetatarsal angle and the dorsal metatarsophalangeal angle of the hallux, as well as the cases of nonunion identified in each study group. ResultsThe radiological results, statistically significant differences (p<0.05) were only found in the dorsal metatarsophalangeal angle between both study groups. No statistically significant differences were found regarding the radiological evaluation of the pre and postoperative hallux angle and intermetatarsal angle. An equal decrease of each angles was observed in both study groups. Regarding the consolidation rate, statistically significant differences (p<0.05) were found between group A, which associated an interfragmentary screw, presenting a consolidation rate of 92%, and group B, which did not associate an interfragmentary screw, and that presented a union rate of 63%. ConclusionsHallux metatarsophalangeal arthrodesis of the hallux with a dorsal plate and interfragmentary screw show best results regarding consolidation rate and complications compared to those cases in which an interfragmentary screw was not used.

Causes of Failure of Canal Wall down Mastoidectomy.

To identify the causes of failure of the canal wall down mastoidectomy and evaluate the causes for discharging mastoid cavity and to address the causes of failure of previous surgery to minimize the Revision surgery. This was a prospective and retrospective observational study conducted at a tertiary care hospital from May 2019 to December 2021. Total 20 Patients (11 male & 9 female) with age group (0-60 years) who previously underwent canal wall down mastoidectomy and presented with complaints of persistent ear discharge were included. All patients underwent otoscopic, oto-endoscopic and microscopic examination. Out of 20 cases,13 cases had residual/recurrent cholesteatoma, 11 cases had narrow meatoplasty and 9 cases had high facial ridge.Other causes for failure are graft defect, incomplete removal of anterior and posterior buttress. Recurrent/residual cholesteatoma and Narrow meatoplasty are most common cause for failure of previous surgery. Persistent granulation at un-exenterated area was the most common cause for suppuration. Regular follow up and cleaning of the debris from cavity enhances the epithelialization and healing of the cavity.

Efficacy and safety of the PreserFlo implant with mitomycin C in childhood glaucoma after previous failed glaucoma surgeries.

This study aims to evaluate the efficacy and safety of the PreserFlo MicroShunt (Santen, Osaka, Japan) in lowering intraocular pressure (IOP) in childhood glaucoma patients with previous failed glaucoma surgeries. This is a prospective case review of consecutive PreserFlo procedures performed in childhood glaucoma patients after failed surgeries. Age, sex, diagnosis, and previous glaucoma surgeries, as well as visual acuity, IOP, and treatment in the preoperative visit and all follow-up visits were collected. Outcome measures included IOP reduction from baseline, mean IOP change from baseline at month 6, medication use at 6months, complications, adverse events, and need for further procedures. Fourteen patients were included, 8 (57%) males and 6 (43%) females; the mean age was 27.5 ± 13.5years. Nine patients (64%) had at least two trabeculectomies, and 6 patients (43%) had at least one trabeculectomy and a glaucoma drainage implant. The mean IOP change from baseline was 11.3 ± 4.9mmHg at 12months. At 12months, 12 patients (86%) presented ≥ 20% IOP lowering from baseline, and 11 patients (79%) presented ≥ 30%. The mean medication count decreased from 3.9 ± 0.7 (baseline) to 0.7 ± 1.3 (12months). No intraoperative complications were reported. No adverse events were noted. No secondary filtration surgery was required, although bleb needling was required in one case, 1month after the surgery. PreserFlo with MMC can be used successfully to treat uncontrolled IOP in childhood glaucoma cases with previous failed surgeries. Larger studies with longer follow-up are needed to further explore the role of the device in resistant childhood glaucoma cases.

Megaprosthesis in articular fractures of the lower limbs in fragile patients: a proposal for the therapeutic algorithm.

The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to identify the patients suitable to megaprosthetic implants in the treatment of lower limbs fractures, as well as periprosthetic fractures. From January 1st, 2015, to December 31st, 2021, all patients affected by femoral fractures with severe bone loss or previous surgery failure were retrospectively reviewed. ADL, IADL, SF-12 values pre- and post-operative were recorded. Hemoglobin value, NLR, PLR were recorded pre- and peri-operatively for all patients. Complications were recorded. All patients underwent a radiological follow-up. Significance was set at p ≤ 0.05. 23 patients were considered eligible, 10 males and 13 females; the mean age was 72.87 years old (± 12.33), while the mean BMI was 27.2 points (± 5.2). The mean follow-up was 2 years (± 1.4). The mean preoperative ADL and IADL scores were correlated with a positive independence of the patient, while the mean postoperative scores corresponded to a moderate-low independence. Also the mean Mental and Physical SF12 scores saw a decrease in values. NLR values were higher in the first group of patients with complications. A careful multiparametric and multidisciplinary patient selection is required to identify the suitable patient to this treatment.

Flap to Mastectomy Mass: Are Higher Ratios Associated with Greater Breast Reconstruction Satisfaction?

Autologous breast reconstruction is associated with superior patient-reported outcomes compared with prosthetic techniques, but little is known about the relationship between autologous flap mass and patient satisfaction. We hypothesized that a higher differential mass (ratio of flap mass to mastectomy mass) would be associated with greater satisfaction with reconstruction. In this retrospective study, patients who underwent autologous breast reconstruction between 2015 and 2020 with a deep inferior epigastric perforator (DIEP) flap completed the BREAST-Q survey. Multivariate linear regression models were used to examine the relationship between differential mass and patient satisfaction. Models controlled for body mass index (BMI), age at surgery, reconstruction size preference, number of surgeries, previous surgery failure, whether the patient underwent radiation therapy, and whether reconstruction was unilateral or bilateral. Overall, 45 patients (70 breasts) completed the BREAST-Q survey. Mean age at reconstruction was 52.2 years and mean time to survey completion following surgery was 21.1 months. Most patients (59.4%) desired a smaller breast after reconstruction. The mean differential mass was +26.3% (flap mass greater than mastectomy mass). Differential mass was positively associated with all satisfaction measures with results being significant for satisfaction with breasts scores (p=0.032). In this preliminary study, a higher ratio of autologous flap mass to mastectomy mass was associated with overall higher patient-reported satisfaction. A 1:1 flap to mastectomy mass ratio may not adequately reapproximate desired breast size or shape. Larger autologous flap mass may be favorable for long-term patient satisfaction, and future studies should investigate the relationship between differential mass and breast esthetics.

Management of chronic dacryocystitis cases after failed external dacryocystorhinostomy using endoscopic technique with a novel lacrimal ostium stent.

To demonstrate the outcomes of endoscopic endonasal dacryocystorhinostomy (En-DCR) with an novel lacrimal ostium stent (LOS) which was performed in patients with recurrent epiphora after failed external dacryocystorhinostomy (Ex-DCR) and analyze the causes of failed Ex-DCR. From September 2015 and December 2017, the clinic data of 29 cases suffered from recurrent epiphora after failed Ex-DCR was reviewed. The LOS were implanted into the ostium at the end of the revisional surgery. The causes of failed Ex-DCR were analyzed before revisional surgeries. Outcome of revisional surgeries with the new device were evaluated as well. The major causes of failure of the external approach were synechiae formation in the nasal ostium (29/29), followed by inadequate removal of the bony wall (21/29), nasal synechiae formation between lateral wall of nose and middle turbinate (11/29), and the bone opening was not in good location (7/29). The rate of success after revisional surgery was 82.76%. Re-obstruction of the ostiums were found in 5 failed cases. Endoscopic approach with a novel LOS may be an effective procedure to manage recurrent epiphora after previous failed Ex-DCR surgery. Synechiae formation in the nasal ostium and inadequate removal of the bony wall were the major causes of failure of Ex-DCR.

The Outcomes of XEN Gel Stent Implantation: A Systematic Review and Meta-Analysis

PurposeXEN gel stents are used for the treatment of open-angle glaucoma (OAG), including primary and secondary glaucoma that are uncontrolled by previous medical therapy and cases with previous failed surgery. Our aim was to systematically review of the clinical data of currently published ab-interno XEN gel stents with an emphasis on intraocular pressure (IOP), antiglaucoma medication outcomes, and safety profiles.MethodsWe analyzed all of the publications (MEDLINE, EMBASE, Cochrane Library) on the ab-interno XEN gel stent to evaluate the reduction in IOP and antiglaucoma medications following the procedure. The primary outcomes measured for the meta-analysis were reduction in IOP and anti-glaucoma medications. The secondary outcome were adverse events. For each study, we used a random effects analysis model to calculate the mean difference and 95% confidence intervals for the continuous results (reduction in IOP and antiglaucoma medications) using the inverse variance statistical method.ResultsFive hundred twenty-seven articles were checked and 56 studies were found to be relevant with a total of 4,410 eyes. There was a significant reduction in IOP as well as in the number of medications required in patients treated with ab-interno XEN implant either alone or combined with cataract surgery. This new treatment for various types of glaucoma reduced the IOP by 35% to a final average close to 15 mmHg. This reduction was accompanied by a decrease in the number of antiglaucoma medications in all the studies, approximately 2 classes of medication at the price of more needlings. The overall complete success rate was 21.0–70.8% after 2 years using strict criteria originally designed to record success rate in filtration surgery. The incidence of complications vision-threatening was low at <1%.ConclusionsXEN gel stent was effective and safe for primary and secondary OAG. Further studies should be performed to investigate the impact of ethnicity on the success and failure rate after XEN implantation.

The frequency and Risk Factors of Re-amputation in Diabetic Foot Disease at a tertiary care hospital.

Introduction: The prevalence of diabetes in Pakistan is 11.7% and the preva-lence of diabetic foot in Pakistan is 13.9% with amputation rate of as high as 48%. Re-amputation carries significant morbidity in form of economic im-pact. Like most re-operations, it reflects failure of previous surgery and thus translates into wastage of resources.Objective: To determine the frequency and associated risk factors of re-amputation, in patients who undergo amputation secondary to diabetic foot syndrome in our population.Methodology: This study was conducted at the Department of Surgery De-partment of Surgery, and Diabetic Clinic Ruth Pfau Civil Hospital Karachi, from August 2020 to July 2021, after approval of ethical review board. We enrolled a total of 125 patients in our study. Data was entered and analyzed using SPSS version 22.0. Mean ±SD/ Median (IQR) was computed for age, HbA1C, duration of diabetes, duration of symptoms leading to amputation, ulcer size, ankle-brachial index and duration of re-amputation. Frequency and percentage were computed for all the categorical variables like gender, co-morbid, type of diabetes, diabetic neuropathy, morphology of diabetic foot ulcer, indication of amputation, peripheral arterial disease, level of am-putation, indication of re-amputation, and level of re-amputation.Result: Among enrolled 125 patients, 85 patients (68%) were male and 40 patients (32%) were females. Mean age was 48.75 ±9.702years. Mean dura-tion of diabetes was 11.12 ±6.64 years and mean HbA1C was 8.246 ±1.1357. During study period 61(48.8%) patients required re-amputation. Mean ABPI in patient requiring re amputation is 0.790 ±0.2501(p=0.000).Conclusion: Patients at risk of re-amputation may be identify by focusing upon good evaluation that includes assessing additional risk factors and deciding initial level of amputation. It is important to have enhance in-formed consent in avoiding the morbidity of additional surgery.Key words: Diabetic foot disease. Amputation, Re amputation.

The value of megaprostheses in non-oncological fractures in elderly patients: A short-term results

IntroductionThe management of both hip and distal femur fractures as well as periprosthetic fractures can be challenging for orthopaedic surgeons. The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to evaluate the effectiveness of megaprosthetic implants for treating hip and distal femur fractures as well as periprosthetic fractures in elderly. Material and MethodsFrom January 1st 2015 to December 31st 2019, patients treated for proximal or distal femoral fractures with severe bone loss or failure of previous surgery were retrospectively reviewed. Patients were divided into two group based on diagnosis: proximal femur fractures (group A) and distal femur fractures (group B). Subsequently, patients underwent hip (group A) or knee (group B) megaprosthesis. Self-assessed questionnaires were administered to all patients pre and postoperatively. Primary outcome was the Activity Daily Living. Secondary outcomes were: Instrumental Activity Daily Living, Short Form-12, Oxford knee or hip score, complications. Charlson score, Harris classification for hip or Anderson Orthopaedic Research Institute score and complication were recorded. All patients underwent a radiological follow up to rule out implant loosening and mobilization. Pre and postoperative functional score comparisons in each group were undertaken. Significance was set p ≤ 0.05. ResultsTwelve patients were finally included in the study. There were 6 male and 6 females, the mean age was 72,9 years old (± 7,4); the mean BMI was 29,8 points (± 4.5). The mean follow-up was 2.9 years (± 1.4). No differences could be found between pre and postoperative evaluation in each group. No aseptic loosening, dislocation, mobilization or radiolucency were recorded during the follow-up. In group A, two surgical site infections (2/6 patients) and one pneumonia (1/6 patients) were recorded. In group B, two surgical site infections occurred (2/6 patients). All patients were treated by antimicrobial oral therapy with complete regression. ConclusionThe use of hip and knee megaprosthetic implants in traumatology is a safe and viable option in elderly patients.

In-growing toe nail results of segmental matrix excision

IntroductionIn-growing toenails commonly affect young men hampering the quality of life. There are many methods to treat in-growing toe nail but most of them have high recurrence rates and poor patient satisfaction. We describe our results of segmental matrix excision for correction of ingrowing toe nails. Material and methodsIt is a retrospective study over a period of 2 years. Patients with symptomatic in-growing toe nails with stage II and III were operated by technique of segmental matrix excision. All patients were available for follow-up at ∼1 year. Results90 patients, 59 males and 31females with ingrowing nail of great toe (108 toes and 120 surgical sites) that underwent correction of by segmental matrix excision. Patient’s age ranged from 19 to 59 years. There was involvement of right great toe in 42 patients, left great toe in 30 patients and bilateral toes in 18 patients. 12 great toes were affected on both sides (74 lateral sides and 46 medial sides of toes). 15/90 (16.6%) patients had history of previous failed surgery by nail plate avulsion. Complications include bleeding (n = 1), infection (n = 2). On average follow up of ∼1 year, there was only 1 recurrence. There was no loss of cutaneous innervation or osteomyelitis. All patients went back to their normal activity on 10th day. ConclusionSegmental matrix excision should be considered as the treatment of choice for ingrowing toe nail because of high cure rate, less pain, low risk of postoperative infection, and results in good cosmetic result.

Gonioscopy-assisted transluminal trabeculotomy as an option after failed trabeculectomy.

To evaluate the safety and efficacy profile of gonioscopy-assisted transluminal trabeculotomy (GATT) in patients with open-angle glaucoma with a history of previous failed trabeculectomy surgery. This case-series study included 26 eyes of 26 consecutive patients with a mean age of 64.1 ± 4.5 (56-78) years who underwent GATT using the 5/0 prolene suture to treat medically uncontrolled moderate to advanced glaucoma despite the previous trabeculectomy surgery. At baseline and each visit, Snellen best-corrected visual acuity (BCVA), IOP values, cup-to-disc (C/D) ratio, retinal nerve-fiber layer thickness and mean deviation values in visual field test were recorded. Need for medication or further glaucoma surgery were noted. Surgical success was defined as final IOP ≤ 15mmHg and ≥ 20% IOP reduction from baseline without any further glaucoma surgery. Twelve (46.2%) patients with primary open angle glaucoma (POAG) and fourteen (53.8%) patients with pseudoexfoliative glaucoma (PEXG) underwent GATT. Average baseline IOP was 25.3 ± 5.4 (16-45)mmHg. Mean follow-up time was 17.8 ± 4.1 (12-26) months. Mean baseline BCVA was 0.47 ± 0.25. Surgical success was achieved in 16 of 26 (61.5%). In ten of patients, medically uncontrolled glaucoma persisted after GATT surgery and they underwent further glaucoma surgery. PEXG patients showed a higher IOP reduction than POAG patients did at last follow-up (45.6% vs 34.8%). The present study revealed that GATT was an effective procedure as a second IOP-lowering surgery in PEXG patients having previous failed trabeculectomy. However, in POAG patients having previous failed trabeculectomy, GATT seems to have a limited efficacy.

Vagus nerve stimulation in pediatric patients with failed epilepsy surgery.

Adequate control of pharmacoresistant epilepsy continues to be a challenge. Multiple studies have reported the benefits of epilepsy surgery and vagus nerve stimulation for children with pharmacoresistant epilepsy. Little is known about the role of vagus nerve stimulation for children with failed epilepsy surgeries. The aim of this study was to examine the effects of vagus nerve stimulation on seizure frequency reduction for children with failed epilepsy surgeries. We retrospectively reviewed 85 children with pharmacoresistant epilepsy who underwent vagus nerve stimulation. Six of these patients underwent epilepsy surgery before vagus nerve stimulation (group I) and 79 patients received only vagus nerve stimulation (group II). We recorded seizure frequency at 3, 12, 24 and 36months after vagus nerve stimulator implantation. Both groups had reduced seizure frequencies at the 3-, 12-, 24- and 36-month follow-up (p = 0.044 for group I trends and 0.008 for group II trends). Vagus nerve stimulator implantations significantly improve seizure frequency for children with or without previous epilepsy surgery at 3, 12, 24 and 36months. These findings suggest that vagus nerve stimulation should be considered an alternative therapy for pediatric patients with previous failed surgeries.

Contemporary management of refractory pediatric glaucoma

The management of pediatric glaucoma poses a unique challenge in terms of maintaining lifelong vision and combating an aggressive scarring response from surgery. Contemporary literature regarding the surgical management of children with pediatric glaucoma who fail, or are at a high risk of failure, from conventional surgery is limited. The aim of this review is to highlight recent developments in relation to the current opinion regarding the management of children with refractory pediatric glaucoma. Some studies have reported impressive success rates with circumferential trabeculotomy, even in eyes with previous failed surgery. Early results of deep sclerectomy in populations which may not respond well to conventional angle surgery are encouraging but data is limited for the pediatric age group. In compliant patients in whom multiple postoperative examinations under anesthesia are possible, trabeculectomy remains an effective procedure. Multiple recent studies have demonstrated that glaucoma drainage device (GDD) surgery is associated with 5-year success rates of over 70% in primary childhood glaucomas. Glaucoma drainage device surgery is likely to remain a mainstay of surgical management for refractory glaucoma in older children. More prospective data are needed on the success of circumferential trabeculotomy, deep sclerectomy and micropulse laser in pediatric eyes with previous failed surgery. VIDEO ABSTRACT: http://links.lww.com/COOP/A34.

Mean Change in Refractive Status After Levator Muscle Resection in Patients of Simple Congenital Ptosis

Purpose: To determine the mean change in refractive status after Levator muscle resection in patients of simple congenital ptosis.&#x0D; Study Design: Quasi Experimental study.&#x0D; Place and Duration of Study: This study was carried out at Institute of Ophthalmology, King Edward Medical University, Mayo Hospital Lahore, from 2014 to 2015.&#x0D; Material &amp; Methods: Fifty patients were selected under the age of 12 years with no sex predilection presenting with simple congenital ptosis of pupil sparing type. Patients with neurogenic, aponeurotic ptosis, mechanical ptosis, Blepharophimosis syndrome, patients with previous failed ptosis surgery and patients with corneal anomalies were excluded. After history and examination, Cycloplegic retinoscopy was done, which was repeated after surgical intervention. All interventions were done by a single ophthalmic surgeon. The patients were examined and discharged on the second post operative day. All data including preoperative and postoperative recordings of spherical and cylindrical values were collected on a self-designed proforma. Follow up period was extended to 3 months. At 3rd month cycloplegic retinoscopy was done and change in character of refractive status was analyzed. Mean change in refractive status was calculated by difference of preoperative and postoperative sphere and cylinder values.&#x0D; Results: Mean age of patients was 4.26 ± 3.78 years. Mean change in spherical value after treatment was 0.447 ± 0.339. This difference was statistically significant with p-value = 0.000. While mean change in cylindrical value after treatment was 0.640 ± 0.580. This difference in cylinder value after treatment was also statistically significant with p-value = 0.000.&#x0D; Conclusion: Levator muscle resection has a significant effect on refractive status of the patients with congenital ptosis.

HemiCAP® implantation after failed previous surgery for osteochondral lesions of the talus

BackgroundThe aim of this study is to enhance data about the effectiveness of HemiCAP® implantation after failed previous surgery for osteochondral defects (OCDs). Methods12 consecutive patients were retrospectively included in this study. The American Orthopedic Foot and Ankle Society Score (AOFAS), the Visual Analogue Scale (VAS) score for pain, the sub-scales Pain and Disability of the Foot Function Index (FFI-P and FFI-D) Score, and the patients’ satisfaction were evaluated. ResultsAOFAS increased from poor to fair (p < 0.001), VAS score decreased from moderate to mild pain (p = 0.001), the final FFI-P and FFI-D were 37.50 ± 18.54 and 33.44 ± 16.24, respectively (p < 0.001). Five patients were not satisfied, three were moderately satisfied and four were highly satisfied. One implant repositioning, one ankle fusion (implant failing) and an additional surgery (double arthrodesis) were performed during the follow-up. Neither intra- nor postoperative complications were registered. ConclusionDespite the clinical improvement, pain was still present at the final follow-up. Metal resurfacing might not be considered a definitely valid alternative for treatment of OCDs after failed previous surgery. Level of evidenceLevel III, retrospective study.

Efficacy and Safety of CT-Guided 125I Seed Implantation As a Salvage Treatment for Locally Recurrent Head and Neck Soft Tissue Sarcoma after Surgery and External Beam Radiotherapy: A 12-Year Study at a Single Institution

The treatment for locally recurrent head and neck soft tissue sarcoma (HNSTS) after failure of previous surgery and external beam radiotherapy (EBRT) remains a problematic challenge without widely accepted recommendations. We aimed to evaluate the efficacy and safety of CT-guided radioactive 125I seed (RIS) implantation for the treatment of locally recurrent HNSTS after surgery and EBRT and analyze the prognostic factors of efficacy. Between December 2006 and February 2018, 25 patients with locally recurrent HNSTS after failure of surgery and EBRT were erolled. We re-staged the recurrent tumors according to the American Joint Committee On Cancer (AJCC) System for soft tissue sarcoma of the head and neck sarcoma (8th ed, 2017) when analyzing the data. All these patients successfully underwent treatment with computed tomography (CT)-guided 125I seed implantation. The postoperative evaluation of seed and dose distribution was performed immediately after surgery. The primary endpoints included the objective overall response rate (ORR) and local progression-free survival (LPFS), and the secondary endpoints were overall survival (OS) and safety profiles. Following 125I seed implantation brachytherapy, the ORR was 72.0%, median LPFS was 16.0 months and median OS was 28.0 months. Furthermore, the 1-, 2-, 3-, 4- and 5-year LPFS rates were 65.6%, 48.1%, 34.4%, 22.9%, and 22.9% respectively and the 1-, 2-, 3-, 4- and 5-year survival rates were 70.8%, 56.9%, 46.6%, 40.8%, and 34.0%, respectively. Multivariate analyses showed that the recurrent T stage (T4 vs ≤ T3；hazard ratio [HR]= 4.020; 95% confidence interval [CI]= 1.117-14.466; P=0.033) and histological grade (G3 vs ≤ G2；HR= 3.260; 95% CI= 1.031-10.306; P=0.044) were independent prognostic factors of LPFS, whereas only the histological grade (G3 vs ≤ G2；HR= 3.230; 95% CI=1.061-9.834; P=0.039) was an independent predictor of OS. The major adverse events were skin/mucosal toxicities, which were generally of lower grade (≤ grade 2) and well tolerated. RIS implantation could be an effective and safe alternative treatment for locally recurrent HNSTS after failure of surgery and EBRT. Recurrent T stage and histological grade were the main factors influencing the efficacy.