Rate Of Secondary Surgery Research Articles

Comparison of One-Level versus Two-Level Anterior Cervical Discectomy and Fusion: Clinical and Radiograph Follow-Up at 60 Months in Patients Serving as Control Groups in Randomized Trials

Introduction Anterior cervical discectomy and fusion (ACDF) has become a standard surgical option for patients with neck pain or radicular symptoms who failed nonoperative care. Although outcomes are generally good in patients undergoing single-level procedures, results for two-level cases have been less consistent. The purpose of this study was to compare results of single level. ACDF with those of two-level ACDF in patients serving as control groups in a total disc replacement trial. Materials and Methods This was a post hoc analysis of data from two control arms of the Food and Drug Administration regulated trial for the Mobi-C artificial disc. As the control treatment, ACDF with allograft and anterior plate was performed at one level in 81 patients and at two levels in 105 patients for the treatment of symptomatic disc degeneration. The study selection criteria, surgical technique, and outcome measures were identical with the only exception being pathology and surgery at one or two levels. Radiographic assessments were performed by an independent laboratory. In the two-level group, both the levels had to be radiographically fused for the patient to be considered fused. Results Gender, age, body mass index, and 5-year follow-up rates (∼ 75%) were similar in the two groups. Operative time and blood loss were significantly less in the single-level cases ( p < 0.05). Preoperative Neck Disability Index (NDI) scores were similar in the two groups and both improved significantly by 6 weeks and remained significantly improved through follow-up ( p < 0.05). The scores improved by approximately 50% in both the groups. Scores in the single-level group were significantly less at several time points. Visual analog scale scores assessing neck and arm pain followed a pattern similar to NDI, with significant improvement in both groups at 6 weeks' postoperative being maintained through 5 years, with few significant differences between groups. Both groups had significant improvements in SF-12 PCS and MCS scores by 6 months which were maintained throughout follow-up. The single-level group had significantly greater PCS scores at 12-month follow-up and thereafter ( p < 0.05). There were no significant differences in MCS scores between the groups. At 5 years, there was no significant difference in index level secondary surgery rates (11.1 vs. 16.2%). At 60 months, the one-level group fusion rate was 93.3versus 86.1% in the two-level group (not statistically significant). Fusion rates were significantly greater in the one-level group at 6 and 12 months. There was a trend (not statistically significant) for greater adjacent segment degeneration at the inferior segment in the two-level group. Conclusion The design of the disc replacement study created a unique opportunity to compare one- versus two-level ACDF control groups, which used the same inclusion/exclusion criteria and evaluations. Single-level ACDF outcomes were better on a few measures. However, patients in both groups had significantly improved scores on various outcome measures early after surgery and these improvements were maintained throughout 5-year follow-up.

Radiographic Outcomes of a Mobile-Bearing Total Ankle Replacement.

Contemporary total ankle prostheses embody design changes intended to address weaknesses in first-generation implants. Due to these changes, outcomes of the newer designs are of particular interest. We have previously published self-reported patient outcomes for the STAR (Scandinavian Total Ankle Replacement) prosthesis. The present study documents radiographic outcome measurements for the STAR prosthesis at intermediate to long-term follow-up. Of 89 consecutive ankle replacements performed between July 1998 and April 2007, 79 had a minimum follow-up of 2 years and were followed prospectively. Serial radiographs were measured by 2 of the authors, including varus, valgus, alpha, beta, and gamma angles, as well as point contact ratio. Inter- and intrarater reliability was calculated and reported. A "severe" subgroup of patients with preoperative coronal plane deformity exceeding 10 degrees was assessed separately. Preoperative and immediate postoperative measurements were compared and maintenance of correction evaluated on subsequent radiographs. Heterotopic ossification and pericomponent lucency were documented and followed, and subsequent procedures were recorded to follow survivorship. The mean follow-up was 8.0 years. Of the 79 ankles, 25 underwent a secondary surgery (31.6%). Coronal correction averaged 5.1 degrees (P < .001), and this was maintained to final follow-up. The severe subgroup (n = 21), with a mean preoperative coronal angulation of 16.1 degrees, was corrected to 4.6 degrees at final follow-up (P < .001). The severe subgroup had a higher secondary surgery rate at 33.3%, with metallic component revision or failure occurring in 3 cases (14.3%) compared to 8 (10.1%) in the entire cohort. The heterotopic ossification rate was 100%, slightly higher than prior reports. STAR prosthesis survivorship was similar to that documented in prior studies of second-generation implants in European patient cohorts. Statistically significant correction in coronal alignment was achieved immediately after surgery and maintained until a final mean follow-up of 8 years, even in patients with preoperative deformity greater than 10 degrees. Level III, retrospective cohort study.

La estandarización en el trasplante endotelial de membrana de Descemet: resultados de las primeras 450 cirugías

ObjectivesTo evaluate the clinical outcome of the first 450 consecutive cases after Descemet membrane endothelial keratoplasty (DMEK), as well as the effect of standardization of the technique. Material and methodsComparison between 3 groups: Group I: (cases 1-125), as the extended learning curve; Group II: (cases 126-250), transition to technique standardization; Group III: (cases 251-450), surgery with standardized technique. Best corrected visual acuity, endothelial cell density, pachymetry and intra- and postoperative complications were evaluated before, and 1, 3 and 6 months after DMEK. ResultsAt 6 months after surgery, 79% of eyes reached a best corrected visual acuity of≥0.8 and 43%≥1.0. Mean preoperative endothelial cell density was 2,530±220 cells/mm2 and 1,613±495 at 6 months after surgery. Mean pachymetry measured 668±92 μm and 526±46 μm pre- and (6 months) postoperatively, respectively. There were no significant differences in best corrected visual acuity, endothelial cell density and pachymetry between the 3 groups (P > .05). Graft detachment presented in 17.3% of the eyes. The detachment rate declined from 24% to 12%, and the rate of secondary surgeries from 9.6% to 3.5%, from group I to III respectively. ConclusionsVisual outcomes and endothelial cell density after DMEK are independent of the technique standardization. However, technique standardization may have contributed to a lower graft detachment rate and a relatively low number of secondary interventions required. As such, DMEK may become the first choice of treatment in corneal endothelial disease.

Success of High Tibial Osteotomy in the United States Military.

Background:Historically, high tibial osteotomy (HTO) has been performed to treat isolated medial gonarthrosis with varus deformity.Purpose:To evaluate the occupational outcomes of HTO in a high-demand military cohort.Study Design:Case-control study; Level of evidence, 3.Methods:A retrospective analysis of active duty service members undergoing HTO for coronal plane malalignment and/or intra-articular pathology was performed using the Military Health System between 2003 and 2011. Demographic parameters and surgical variables, including rates of perioperative complications, secondary surgery, activity limitations, and medical discharge, were extracted from electronic medical records. For the current study, cumulative failure was defined as conversion to knee arthroplasty or postoperative medical discharge for persistent knee dysfunction. Univariate and multivariate analyses were performed to identify statistical associations with cumulative failure after HTO.Results:A total of 181 service members (202 HTOs) were identified at an average follow-up of 47.5 months (range, 24-96 months). Mean age was 35.7 years (range, 19-55 years), and the majority were men (93%) and of enlisted rank (78%). All index procedures utilized a valgus-producing, opening wedge technique. Concomitant or staged procedures were performed in 87 patients (48%), including 40 ligamentous, 48 meniscal, and 48 chondral procedures. Complications occurred in 19.3% of knees (n = 39), with unplanned reoperation in 26 knees (12.8%). Fifty-three patients (40.7%) had minor activity limitations during military duty postoperatively. Eleven knees (5.4%) underwent conversion to total knee arthroplasty. The cumulative failure rate was 28.2% (n = 51) at 2- to 8-year follow-up. Patient age younger than 30 years at the time of surgery was associated with an independently higher risk of failure, whereas sex, concomitant/staged procedures, and perioperative complications were not significantly associated with subsequent failure.Conclusion:At short- to midterm follow-up, nearly 72% of all service members undergoing HTO returned to military duty and were free from conversion knee arthroplasty.

Ultrasound-guided gradual reduction using flexion and abduction continuous traction for developmental dysplasia of the hip: a new method of treatment.

We describe our experience in the reduction of dislocation of the hip secondary to developmental dysplasia using ultrasound-guided gradual reduction using flexion and abduction continuous traction (FACT-R). During a period of 13 years we treated 208 Suzuki type B or C complete dislocations of the hip in 202 children with a mean age of four months (0 to 11). The mean follow-up was 9.1 years (five to 16). The rate of reduction was 99.0%. There were no recurrent dislocations, and the rate of avascular necrosis of the femoral head was 1.0%. The rate of secondary surgery for residual acetabular dysplasia was 19.2%, and this was significantly higher in those children in whom the initial treatment was delayed or if other previous treatments had failed (p = 0.00045). The duration of FACT-R was significantly longer in severe dislocations (p = 0.001) or if previous treatments had failed (p = 0.018). This new method of treatment is effective and safe in these difficult cases and offers outcomes comparable to or better than those of standard methods.

Clinical Outcomes of Primary Palatal Surgery in Children with Nonsyndromic Cleft Palate with and without Lip.

This study presents clinical outcomes of primary cleft palate surgery, including rate of oronasal fistula development, rate of velopharyngeal insufficiency (VPI) requiring secondary surgery, and speech outcomes. We examined the effect of cleft type on the clinical outcomes. Retrospective analysis was performed using clinical records of all patients who received a primary palatoplasty at the Cleft Palate Clinic at Seoul Asan Medical Center, South Korea, between 2007 and 2012. The study included 292 patients with nonsyndromic overt cleft palate (±cleft lip). The results revealed that the rate of oronasal fistula was 7.9% and the incidence of VPI based on the rate of secondary palatal surgery was 19.2%. The results showed that 50.3% of all the patients had received speech therapy and 28.8% and 51.4% demonstrated significant hypernasality and articulatory deficits, respectively. The results of the rate of VPI and speech outcomes were significantly different in terms of cleft type. Except for the rate of oronasal fistula, patients with cleft palate generally exhibited better clinical outcomes compared to those with bilateral or unilateral cleft lip and palate. This study suggests that several factors, including cleft type, should be identified and comprehensively considered to establish an optimal treatment regimen for patients with cleft palate.

Clinical Outcome of 500 Consecutive Cases Undergoing Descemet's Membrane Endothelial Keratoplasty

To evaluate the clinical outcome of 500 consecutive cases after Descemet's membrane endothelial keratoplasty (DMEK) and the effect of technique standardization. Prospective, interventional case series at a tertiary referral center. A total of 500 eyes of 393 patients who underwent DMEK for Fuchs' endothelial corneal dystrophy, bullous keratopathy, or previous corneal transplant failure. Best-corrected visual acuity (BCVA), endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications were evaluated before and 1, 3, and 6 months after DMEK. Comparison between 2 groups (group I: cases 1-250, outcome of "early surgeries" during transition to technique standardization; group II: cases 251-500, outcome of "late surgeries" after technique standardization). At 6 months, 75% of eyes reached a BCVA of ≥20/25 (≥0.8), 41% of eyes achieved ≥20/20 (≥1.0), and 13% of eyes achieved ≥20/18 (≥1.2) (n=418) when excluding eyes with ocular comorbidities (n=57). When including all available eyes at 6 months (n=475), 66% of eyes reached a BCVA of ≥20/25 (≥0.8), and 36% of eyes achieved ≥20/20 (≥1.0). Mean ECD decreased by 37% (±18%) to 1600 (±490) cells/mm2 (n=447) at 6 months (P<0.001). Postoperative pachymetry averaged 525 (±46) μm compared with 667 (±92) μm preoperatively (P<0.001). None of these parameters differed among the 2 groups (P>0.05). (Partial) graft detachment presented in 79 eyes (15.8%), and 26 eyes (5.2%) required a secondary surgery within the first 6 months (re-bubbling in 15, secondary keratoplasty in 11). With technique standardization, the postoperative complication rate decreased from 23.2% to 10% (P<0.001) and the rate of secondary surgeries decreased from 6.8% to 3.6% (P=0.10). In comparison with earlier endothelial keratoplasty techniques, DMEK may consistently give higher visual outcomes and faster visual rehabilitation. When used for the extended spectrum of endothelial pathologies, DMEK proved feasible with a relatively low risk of complications. Technique standardization may have contributed to a lower graft detachment rate and a relatively low secondary intervention rate. As such, DMEK may become the first choice of treatment in corneal endothelial disease.

Outcomes of ab interno trabeculectomy with the trabectome by degree of angle opening

AimTo analyse ab interno trabeculectomy (AIT) with the trabectome and combined phacoemulsification with AIT (phaco-AIT) by Shaffer angle grade (SG).MethodsProspective study of AIT and phaco-AIT with narrow angles of SG≤2...

Indolent infection in nonunion of the distal femur.

In the treatment of nonunions of the distal femur, infection should be excluded. However, it is difficult to determine whether the nonunion is infected or not with negative history and signs of infection. The purpose of this study was to investigate indolent infection as a cause of presumptive aseptic distal femur nonunion. All presumptive aseptic distal femur nonunions treated from 1998 to 2008 were retrospectively reviewed. Any patient with suspected of having an infection clinically was excluded. Multiple tissue cultures were performed at the nonunion site. The main outcomes were to analyze the rate of positive cultures in presumptive aseptic distal femur nonunion and to compare the rate of secondary surgery in positive and negative culture groups. Of the 22 patients, 3 (13.6%) had positive culture results. The organisms cultured were Staphylococcus aureus, Staphylococcus epidermidis, and Enterobacter cloacae. The overall rate of infection was 9.1% (2/22), and one patient underwent a secondary procedure. In the open fracture group, 2 of 10 patients (20%) had positive cultures; all developed infection. In the closed fracture group, 1 of 12 patients (8.3%) had positive culture results, but Infection did not occur in the patient with a 3-week intravenous antibiotic treatment. The postoperative infection rate was 67% (2/3) in patients with positive intraoperative cultures, while 0% (0/18) in the group with negative intraoperative cultures (p<0.001). The presence of indolent infection can be verified in patients with presumptive aseptic nonunion of distal femoral fractures by obtaining intraoperative biopsy tissue cultures. Positive intraoperative culture results were related with postoperative infection.

Cephalometric outcomes of orthognathic surgery in hemifacial microsomia.

Hemifacial microsomia is a hypoplastic disorder of the first and second branchial arches that significantly impacts on the development of the jaws, leading to malocclusion and facial asymmetry. There is little in the literature regarding the application of orthodontic/orthognathic approaches to the correction of these deformities and the stability of the surgical results. To address this, a retrospective chart review of 10 patients with complete orthodontic records and greater than 1 year of follow-up was performed. Posteroanterior cephalograms were assessed by modified Grummons analysis to determine mandibular offset (deviation of the chin point from the skeletal midline) and occlusal cant. These measurements were performed at 3 time points (T1: preoperative, T2: immediate postoperative, T3: follow-up) to elucidate the surgical movement (T2-T1), the postoperative relapse (T3-T2), and the net gain movement (T3-T1). Maxillary movements were quantified, and the occlusal cant was expressed as a ratio between vertical heights of the maxilla at the first molar on each side. One sample t test demonstrated statistically significant surgical movement and net gain. Relapse was statistically insignificant. Repeated-measures analysis of variance demonstrated similar results for chin point position relative to the putative midline. Our results suggest that a combined orthodontic/orthognathic approach at skeletal maturity delivers improved occlusal outcomes in the long term as assessed by chin point deviation and occlusal cant, but secondary surgery rates are higher than those for orthognathic surgery in other patient groups. We advocate limiting surgery to skeletal maturity whenever possible to achieve stable long-term results while limiting morbidity and number of procedures.

Success of High Tibial Osteotomy in the United States Military

Historically, high tibial osteotomy (HTO) has been performed to treat isolated medial gonarthrosis with varus deformity. More recently, HTO has been utilized in conjunction with chondral, ligamentous, and/or meniscal procedures in young active patients with subtle varus malignment. However, occupational outcomes in a high-demand military cohort are largely unknown. A retrospective analysis of active duty servicemembers undergoing high tibial osteotomy for coronal plane malalignment and/or intra-articular pathology were isolated from the Military Health System Management Analysis and Reporting Tool between 2003 and 2011. Demographic variables such as age, sex, rank, and branch of service were extracted, and extensive medical record review was performed to identify surgical variables, including the rates of perioperative complications, radiographic findings, secondary surgery (including revision), activity limitations, and medical discharge as confirmed by the U.S. Army Physical Disability Agency database. For the current study, cumulative failure was defined as conversion to knee arthroplasty, or medical discharge with persistent knee dysfunction after index HTO. Univariate and multivariate analysis were performed to identify statistical associations with cumulative failure after HTO. A total of 80 patients with 93 HTOs were identified at an average follow-up of 43.7 months (range, 24-93 months). The mean age of all servicemembers was 35.5 years (range, 20-55), and the majority were males (91%) and of enlisted rank (76%). Approximately 92% of surgeries involved plate fixation, while the remainder utilized circular or monolateral external fixation. Concomitant or staged procedures were performed in 45 servicemembers (56%), including 29 ligamentous, 24 meniscal, and 21 chondral procedures. Complications necessitating unplanned reoperation occurred in 10 cases (11%), including infection (n=3), nonunion (n=2), fracture (n=2), hardware failure (n=1), dehiscence (n=1), and flexion contracture (n=1). Additionally, symptomatic hardware was noted after 18 surgeries (19%) and occasional knee pain was noted in 26 extremities (28%). When considering those individuals remaining on active duty, 21(26%) servicemembers were unable to return to full duty and required permanent activity limitations. Of the 80 servicemembers, 7 individuals received medical discharge for persistent knee pain or disability, and an additional 7 underwent conversion to total knee arthroplasty. The cumulative failure rate for all servicemembers was 18% at 2-8 year follow-up. In a young, active military population, HTO is moderately effective for the treatment of medial unicompartmental disease with associated intra-articular knee pathology. At early to mid-term follow-up, 82% of patients returned to military duty and were free from conversion knee arthroplasty. High tibial osteotomy is a useful in the treatment of medial unicompartmental disease and has demonstrated success in an active US military population at a minimum of 2-year follow-up.

Are There Risk Factors for Complications of Perforator-based Propeller Flaps for Lower-extremity Reconstruction?

Conventional pedicled flaps for soft tissue reconstruction of lower extremities have shortcomings, including donor-site morbidity, restricted arc of rotation, and poor cosmetic results. Propeller flaps offer several potential advantages, including no need for microvascular anastomosis and low impact on donor sites, but their drawbacks have not been fully characterized. We assessed (1) frequency and types of complications after perforator-based propeller flap reconstruction in the lower extremity and (2) association of complications with arc of rotation, flap dimensions, and other potential risk factors. From 2007 to 2012, 74 patients (44 males, 30 females), 14 to 87years old, underwent soft tissue reconstruction of the lower extremities with propeller flaps. General indications for this flap were wounds and small- and medium-sized defects located in distal areas of the lower extremity, not suitable for coverage with myocutaneous or muscle pedicled flaps. This group represented 26% (74 of 283) of patients treated with vascularized coverage procedures for soft tissue defects in the lower limb during the study period. Minimum followup was 1year (mean, 3years; range, 1-7years); eight patients (11%) were lost to followup before 1year. Complications and potential risk factors, including arc of rotation, flap dimensions, age, sex, defect etiology, smoking, diabetes, and peripheral vascular disease, were recorded based on chart review. Twenty-eight of 66 flaps (42%) had complications. Venous congestion (11 of 66, 17%) and superficial necrosis (seven of 66, 11%) occurred most frequently. Eighteen of the 28 complications (64%) healed with no further treatment; eight patients (29%) underwent skin grafting, and one patient each experienced total flap failure (2%) and partial flap failure (2%). In those patients, a free anterolateral thigh flap was used as the salvage procedure. No correlations were found between complications and any potential risk factor. We were not able to identify any specific risk factors related to complications, and future multicenter studies will be necessary to determine which patients or wounds are at risk of complications. Propeller flaps had a low failure rate and risk of secondary surgery. These flaps are particularly useful for covering small- and medium-sized defects in the distal leg and Achilles tendon region and are a reliable and effective alternative to free flaps. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Transcortical Screw Fixation of the Olecranon Shows Equivalent Strength and Improved Stability Compared With Tension Band Fixation

Currently, the standard for 21-B3.1 olecranon fracture fixation is the tension band wire construct described by the AO foundation. Although this technique effectively repairs displaced olecranon fractures and osteotomies, it is associated with a high rate of secondary surgery for implant removal due to hardware "back out," prominence, and discomfort. The senior author of this study has used transcortical screw fixation for olecranon fractures and osteotomies to avoid hardware discomfort but has been unable to find literature documenting the strength of this method. Accordingly, we compared the strength and stability of transcortical screw fixation with tension band fixation of simple transverse olecranon fractures under cyclical loading. Eighteen fourth-generation synthetic biomechanical testing ulnas underwent a transverse olecranon osteotomy and were repaired by tension banding or screw fixation. Two 4.0 mm partially threaded screws inserted across the fracture gap into the anterior cortex of the ulna achieved screw fixation. Ulnas were tested in 2 ways as follows: (1) cyclic loading that simulated pushing up from a chair; and (2) single cycle loading to failure. Fracture displacement was recorded using a transducer that was placed on the posterior surface of the ulna. Differences between screw fixation and tension banding in the peak displacement during cyclic loading and single cycle load to failure were not significant. Screw fixation did show significantly less "trough" displacement (resting position between cycles) during cyclic loading indicating less plastic deformation. In a synthetic bone model of simple transverse olecranon fractures, screw fixation provided equivalent strength and less plastic deformation as compared with tension banding.

Open Reduction and Internal Fixation of Radial Head Fractures: Do Outcomes Differ Between Simple and Complex Injuries?

Radial head fractures can occur in isolation or in association with elbow and forearm injuries. Treatment options include nonoperative management, fragment or whole-head excision, open reduction and internal fixation (ORIF), and radial head arthroplasty. However, the evidence supporting ORIF for repairable radial head fractures is inconclusive. We compared patients undergoing ORIF for isolated radial head fractures or for radial head fractures associated with other fractures or elbow dislocations in terms of patient-related disability, presence of posttraumatic arthritis, complications, and rate of reoperation for capsular release. Between 1997 and 2008, 52 patients underwent ORIF of the radial head for isolated radial head fractures (simple group) and 29 underwent ORIF for radial head fracture with an associated fracture or dislocation (complex group). General indications for ORIF included displaced radial fractures, large articular surface fragments, and greater than 2mm of displacement and/or a mechanical block to forearm rotation or associated fractures or ligament injuries requiring surgery. Thirty-one patients (60%) in the simple group and 20 (69%) in the complex group were available for followup at a mean of 4years (range, 1.0-9.5years). We evaluated the patients using a validated self-reported pain and disability questionnaire (Patient-rated Elbow Evaluation [PREE]). Records review included radiographic examination and assessment of major complications and secondary surgery rates for capsular release. With the numbers available, the groups were not different in terms of the mean PREE scores (8 versus 15 for the simple and complex groups, respectively; p = 0.13, lower values indicate lower pain and disability). The simple and complex groups were also not different with the numbers available in terms of major complications (13% versus 25%, respectively; p = 0.29) or secondary capsular release (3% versus 20%, respectively; p = 0.07). At short term, we found no differences between patients treated with ORIF for isolated radial head fractures and those treated for radial head fractures in association with other elbow injuries with regard to pain and disability scores; loss to followup in this series precludes making statements with great confidence about function after these injuries. However, the substantial capsular release and complication rates should weigh into the preoperative discussion with patients before selecting ORIF for radial head fractures. Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Titanium and Biodegradable Plates for Treating Midfacial Fractures

The purpose of the present study was to evaluate the use of titanium plates and screws (TPSs) versus biodegradable plates and screws (BPSs) for fixation of midfacial fractures. In addition, complications related to the plates and rates of secondary surgery for plate removal were compared. From March 2005 to March 2012, 109 patients were enrolled in this study. Fifty-six patients with TPSs implanted to fix midfacial fractures (group A) and 53 patients with BPSs to treat midfacial fractures (group B) were evaluated. Patients' histories of plate-related nonunion, infection, displacement, pain, and palpability and secondary surgery for plate removal were checked. None of the study participants developed nonunion issues related to the TPSs or BPSs. Six patients in group A developed complications associated with TPSs and 5 patients underwent secondary surgery for plate removal. One patient (1.8%) had a plate-related infection, 1 patient (1.8%) developed plate extrusion, 1 patient (1.8%) had plate-associated chronic pain, 2 patients (3.6%) complained of palpability, and 2 patients (3.6%) developed psychological problems (1 patient developed 2 complications). In contrast, only 1 patient in group B (2%) complained of temporary palpability, and this problem disappeared over time. None of the patients in group B complained of any other problems. The results indicated that BPSs and TPSs have the potential for successfully treating midfacial fractures. BPSs are suitable for treating midfacial fractures and could serve as an alternative for TPSs in selected cases.

Risk of Osteonecrosis among Persons with Osteoarthritis of the Knee: Findings from the UK based General Practice Research Database

Anterior Cervical Discectomy and Fusion (ACDF) is a widely utilized surgical treatment for cervical disc disease. Despite success of ACDF, concerns regarding adjacent segment degeneration led to the design and development of cervical disc arthroplasty (CDA). We performed a systematic review of studies comparing the efficacy and safety profile of CDA versus ACDF. We searched databases Pubmed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) for prospective randomized controlled studies comparing CDA with ACDF with at least 24-month follow-up. Studies were evaluated for level of bias. Data regarding clinical outcomes, postoperative kinematic changes, procedure or device related adverse events and types and rates of secondary surgeries were extracted. A total of 142 articles were retrieved of which 8 articles satisfied the inclusion and exclusion criteria. These eight studies cover five different disc devices (BRYAN, PRESTIGE, ProDisc-C, Kineflex|C and Porous Coated Motion). There are significant differences in some patient reported clinical outcomes favoring arthroplasty over ACDF. Arthroplasty also preserved motion at the operated site while fusion reduced range of motion at the fused segments. The type and rate of adverse events, postoperative complications and secondary surgeries are similar between the two groups. The rate of surgeries for adjacent level degeneration is similar between CDA and ACDF. Cervical Disc Arthroplasty is a viable alternative procedure in the surgical management of cervical disc disease with similar safety profiles and at least equivalent and possibly superior clinical outcomes compared to Anterior Cervical Discectomy and Fusion. There does not appear to be significant differences in reoperation rates for adjacent level degeneration between the two procedure types. Future long-term follow up studies are needed to make a more robust conclusion on the overall effectiveness of CDA.

Frequency of pharyngoplasty after primary repair of cleft palate in northern Finland

One measure of primary cleft palate repair success is the subsequent need for secondary pharyngoplasty due to velopharyngeal insufficiency. This study aimed to assess primary palatoplasty outcomes and frequency of secondary pharyngoplasty. A total of 138 patients underwent palatoplasty between 1998 and 2011. All patients were treated with 1-stage palatoplasty closing the hard and soft palate concurrently. Overall frequency of pharyngoplasty after palatoplasty was 21% of patients. The rate of secondary surgery was significantly higher for girls (27%) than for boys (13%). Patients with cleft lip and palate were more likely to require secondary pharyngoplasty (24%) than the patients with soft and hard cleft palate (20%). Surgical technique and cleft severity were significant factors for secondary surgery. Pharyngoplasty was least common in patients whose palatal clefts were treated at 9 to 12 months of age. The majority of patients undergoing primary palatal repair do not need secondary pharyngoplasty.

Cervical artificial disc replacement with ProDisc-C: Clinical and radiographic outcomes with long-term follow-up

Cervical artificial disc replacement (ADR) is indicated for the treatment of severe radiculopathy permitting neural decompression and maintenance of motion. We evaluated the clinical and radiographic outcomes in cervical ADR patients using the ProDisc-C device (DePuy Synthes, West Chester, PA, USA) with a 5–9year follow-up. Data were collected through a prospective registry, with retrospective analysis performed on 24 consecutive patients treated with cervical ADR by a single surgeon. All patients underwent single- or two-level ADR with the ProDisc-C device. Outcome measures included neck and arm pain (visual analogue scale), disability (neck disability index [NDI]), complications and secondary surgery rates. Flexion-extension cervical radiographs were performed to assess range of motion (ROM) of the device and adjacent segment disease (ASD). Average follow-up was 7.7years. Neck and arm pain improved 60% and 79%, respectively, and NDI had an improvement of 58%. There were no episodes of device migration or subsidence. Mean ROM of the device was 6.4°. Heterotopic ossification was present in seven patients (37%). Radiographic ASD below the device developed in four patients (21%) (one single-level and three two-level ADR). No patient required secondary surgery (repeat operations at the index level or adjacent levels). Fourteen out of 19 patients (74%) were able to return to employment, with a median return to work time of 1.3months. The ProDisc-C device for cervical ADR is a safe option for patients providing excellent clinical outcomes, satisfactory return to work rates and maintenance of segmental motion despite radiographic evidence of heterotopic ossification and ASD on long-term follow-up.

A Single-Stage Treatment Protocol for Presumptive Aseptic Diaphyseal Nonunions

To review the results of a single-stage treatment protocol for presumptive aseptic diaphyseal nonunion with a well-healed wound and no infection history. Retrospective comparative study. Tertiary referral center. We retrospectively reviewed all presumptive aseptic diaphyseal nonunions treated by a single-stage protocol. There were 104 patients who met the inclusion criteria. Eighty-seven patients were available for follow-up through to complete healing (83.7% follow-up rate). The protocol entails withholding preoperative antibiotics, removing the implant, performing open debridement or canal reaming, taking 5 cultures of the nonunion site or canal reamings, followed by antibiotic administration, and revision open reduction and internal fixation or exchange nailing. If intraoperative cultures are positive, long-term antibiotics are begun specific to organism sensitivities. To analyze the rate of positive cultures and to compare the rate of secondary surgery to promote healing in positive and negative culture groups. Intraoperative cultures were positive in 28.7% (25/87) of patients with complete follow-up. The overall rate of secondary surgery for persistence of nonunion was 12.6% (11/87). In patients with positive intraoperative cultures, rate of secondary surgery was 28% (7/25) versus 6.4% (4/62) in the group without positive intraoperative cultures (P = 0.01). A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions was effective in obviating further revision surgery in 93.6% of truly aseptic cases and in 72% of positive culture cases and is still employed at our institution.

A Systematic Review of Outcomes Following Repair of Complex Ventral Incisional Hernias With Biologic Mesh

Repair of contaminated/infected ventral incisional hernias is marked by high rates of recurrence, complications, and/or explantation of synthetic mesh. Biologic mesh products are recommended for repair to permit reconstruction and reduce complications. A systematic review of PubMed, EMBASE, and Cochrane databases identified English-language articles reporting postoperative outcomes (e.g., hernia recurrence, infection, mesh explantation) in patients undergoing contaminated/infected ventral incisional herniorrhaphy. Eleven studies met inclusion criteria and contained quantitative outcome data. All were retrospective chart reviews of biologic mesh use (mostly human acellular dermal matrix). Hernia recurrence and wound infection rates were highly variable and inconsistently reported across studies. Mesh explantation was rarely reported. Outcome variability is likely owing to heterogenous patient populations, surgical technique variations, and follow-up duration. Biologic mesh use in contaminated/infected herniorrhaphy was marked by low reported rates of secondary surgeries for infected mesh removal. Data from large, well-controlled, prospective trials with biologic mesh products are needed.