Recent Follow-up Research Articles

Shoulder arthroplasty in patients with a history of epilepsy is safe and effective

BackgroundThe safety of shoulder arthroplasty for patients with a history of convulsive seizures is unknown. Concerns include the possibility of a postoperative seizure resulting in dislocation, cuff disruption, or implant failure. We sought to compare outcomes and complications following shoulder arthroplasty in patients with and without a history of convulsive seizures. MethodsOur institutional Total Joint Registry Database was queried to identify all patients with a history of convulsive seizures who had undergone a primary shoulder arthroplasty between 2000 and 2018. The query identified 56 shoulders (49 patients) with an average age of 61.8 years. 51.8% of patients were female. This cohort was matched 2:1 to a group of patients with similar surgical and demographic characteristics who did not have a seizure history. Kaplan–Meier estimates and univariate Cox regression models were utilized to compare implant survival and reoperation rates. Patient-reported outcomes, including the American Shoulder and Elbow Surgeons score were also extracted. ResultsAt most recent follow-up, cumulative reoperation rates were equivalent between the groups (P = .9) with 3 reoperations out of 56 shoulders (5.4%) in the seizure group, and 7 reoperations out of 112 shoulders (6.3%) in the nonseizure group. Rates of implant revision were also similar. Five-year Kaplan–Meier survival estimates free of reoperation were 97.8% (95% confidence interval, 91.1-100.0) in the seizure group and 93.1% (95% confidence interval, 87.4-98.9) in the nonseizure group. Postoperatively, 23 of 56 patients in the seizure group had at least 1 known seizure after their index arthroplasty, at an average of 4.4 years after surgery. None of the patients with postoperative seizures sustained a dislocation. Altogether only 3 episodes of prosthetic dislocation were observed, all in the nonseizure group. The only complication attributable to a seizure was an early postoperative seizure resulting in subscapularis failure, although this patient never underwent reoperation. Patient-reported outcomes and range of motion were similar between groups, with average American Shoulder and Elbow Surgeons scores of 77.2 and 74.9 in the seizure and nonseizure groups, respectively (P = .6). DiscussionReoperation rates and implant survival following shoulder arthroplasty were similar when comparing patients with and without a history of convulsive seizures. Postarthroplasty seizures occurred in a notable number of patients but did not result in any major complications. While it remains prudent to ensure that patients’ seizures are well controlled prior to arthroplasty, our data suggest that individuals with a convulsive seizure disorder can undergo shoulder arthroplasty safely.

Outcomes of Kahook Dual Blade Goniotomy for Uveitis Associated Open Angle Glaucoma or Ocular Hypertension.

Kahook Dual Blade (KDB) goniotomy can successfully lower intraocular pressure in some patients with uveitis-associated ocular hypertension or glaucoma. The purpose of this study was to report a case series of patients that underwent KDB goniotomy at a single institution for uveitis-associated ocular hypertension or glaucoma with an open angle. We performed a retrospective chart review of all patients with uveitis-associated ocular hypertension or glaucoma who underwent KDB goniotomy with trabecular meshwork excision alone or in combination with phacoemulsification cataract surgery at a single center between August 2017 and February 2020. The case series included 45 eyes of 37 patients. All eyes developed ocular hypertension refractory to maximum-tolerated medical therapy and required surgical intervention. Two eyes were excluded as they were lost to follow-up before 5 months postoperatively. Surgical success was defined as reaching the goal intraocular pressure or lower for each patient, including ongoing medical therapy. At most recent follow-up, 25 (55.6%) of 45 eyes had an intraocular pressure that was at goal. Mean follow-up time was 15.2±12.1 months ranging from 0.5 to 36 months postoperatively, considering that patients were eliminated from the data analysis once they required a second surgery. The mean number of preoperative medications, including oral carbonic anhydrase inhibitors was 3.7±1.2 medications. The mean number of postoperative medications through the last clinic visit was 2.5±1.9 medications for a mean reduction of 1.2±1.6 medications ( P -value <0.0001*). This larger case series shows that some patients with uveitis-associated ocular hypertension or glaucoma with an open angle may have success with KDB goniotomy.

Outcomes in Sutured Versus Sutureless Wound Closure in Pediatric Cataract Surgery.

To analyze the postoperative course, specifically postoperative complications, of pediatric patients who underwent cataract surgery by a single surgeon. The type of wound closure was compared to provide an evidence-based approach to surgical technique in pediatric cataract surgery. This retrospective study analyzed pediatric patients who underwent cataract extraction by a single surgeon from 2014 to 2020. Excluded from the study were patients with postoperative follow-up of less than 1 month. The primary outcome compared postoperative complications between patients with sutured and sutureless wound closure. Other outcomes analyzed included intraocular pressure, mean corrected distance visual acuity, and incidence of procedure needed to remove posterior capsule opacification. The study comprised 116 eyes with sufficient follow-up; 86 had sutureless wound closure and 30 had sutured wound closure. An intraocular lens was placed in 52% of eyes in the sutureless group and in 80% of eyes in the sutured group. There was no statistically significant difference between preoperative and postoperative intraocular pressure between groups. The best corrected distance visual acuity was better in the sutured group at 6 months but not at the most recent follow-up visit. No cases of endophthalmitis were found in either group. There was no statistically significant difference between the incidence of retinal detachments and iris prolapse. The incidence of endophthalmitis, retinal detachment, and iris prolapse was similar between pediatric patients who underwent cataract removal with sutureless versus sutured wound closure. Therefore, it may be reasonable to avoid the suture after pediatric cataract surgery. [J Pediatr Ophthalmol Strabismus. 2023;60(2):147-151.].

The role of urethral ligation after AUS failure and end stage urethra

To provide our single-center experience with an approach to refractory stress urinary incontinence (SUI) with permanent urethral ligation (PUL) and suprapubic tube (SPT) placement, in hopes of contributing to the limited body of research surrounding this surgical treatment option for patients with end-stage urethra (ESU). All patients undergoing PUL with SPT placement from 01/01/2018 to 04/30/2022 were identified from an institutional database. Institutional Review Board exempt status was granted for the conduct of this study. Patients were seen postoperatively at 1month and 1year. If there were any concerns of incontinence, an antegrade urethrogram via the SPT was performed. Descriptive statistics were used to evaluate patients. Seven patients underwent PUL with SPT in our timeframe and were included in the study. All patients previously had an AUS placed, and two patients had a urethral sling previously placed. The median follow-up time was 21months, ranging between 2 and 48months. Complications included bladder spasms (43%) and continued leakage per urethra (14%). Of the 7 patients, 6 have reported continence through their urethra at their most recent follow-up. This initial data suggest that PUL with SPT placement may be a viable surgical approach to treating refractory SUI, especially for patients with ESU who wish to avoid the morbidity associated with more formal supravesical diversion. Further study of this technique and longer follow-up is required to determine its long-term efficacy and tolerability for patients.

Management of chronic Achilles tendon tear by reverse gastrocnemius turndown flap and augmentation with FHL tendon – A case series

Background: Chronic Achilles tendon ruptures are defined as tears that occur 4–6 weeks after injury and also those that fail to heal at 6–12 weeks. Reduced plantar flexion, discomfort, trouble walking, chronic pain, poor wound healing, and rerupture are all problems of chronic tears. The V-Y flap, turndown flap, peroneus tendon graft, flexor digitorum graft, and flexor hallucis longus (FHL) graft are just a few of the operations proposed and claimed to have great post-operative clinical results. Aims and Objectives: This study aims to evaluate the functional outcome of tendon debridement, gastrocnemius turndown flap, and augmentation with FHL tendon to reconstruct a chronic Achilles tendon tear. Materials and Methods: This study included 12 patients with chronic Achilles tendon rupture. The gastrocnemius turndown flap, which was augmented with FHL tendon, was used to treat all of the patients in the study. The American Orthopaedic Foot and Ankle Society (AOFAS) score, Achilles Tendon Total Rupture Score (ATRS) score, and ability to do repetitive single affected side heel raiseswere the outcomes evaluated in this study. Results: After a year of follow-up, the mean AOFAS score increased from 61.17 points preoperatively to 86.67 points. The mean ATRSimproved significantly from 41.91 points preoperatively to 84.41 points at the most recent follow-up (P&lt;0.05). One of the patients developed a superficial wound infection, treated with wound debridement, and antibiotics. One year after surgery, all patients could do single-leg heel raises. There was no sign of rerupture. Conclusion: Reverse gastrocnemius turndown flap with FHL tendon is a well-tolerated and effective treatment of chronic TA rupture.

Acromiohumeral cerclage in reverse total shoulder arthroplasty for recurrent instability.

Recurrent shoulder instability after reverse total shoulder arthroplasty (rTSA) presents a challenging clinical problem. A handful of cases have been reported describing stability achieved only after revision rTSA with cerclage augmentation. We describe an acromiohumeral cerclage technique, where the humeral component is fixed with a nonabsorbable, high-tensile suture tape looped through transosseous acromial drill tunnels as an augment to salvage shoulder stability. All patients treated with acromiohumeral cerclage in rTSA for instability between November 1, 2015, and February 1, 2020, with minimum 1-year follow-up were included. Demographic information, baseline preoperative and postoperative range of motion at most recent follow-up, American Shoulder and Elbow Surgeons (ASES) shoulder scores, and visual analog scale (VAS) scores were recorded and compared. Ten patients, 4 female and 6 male, aged 64.3±7.4 years (range, 53-77 years) with the mean postoperative follow-up of 23 months were included; 90% underwent surgery on the dominant side. Patients underwent an average of 2.1±1.9 prior revisions (range, 0-7), over an average of 10.4 months (range, 0-72 months), before revision with suture cerclage augmentation was performed. All patients either had significant past shoulder history at other institutions and/or comorbidities that added significant complexity to their cases, with an average of 0.6±0.9 (range, 0-3) prior other shoulder operations performed before their initial rTSA. The average decrease in VAS score among the 10 patients was 4.3±2.7 (P<.05), ranging from 0 to 8 points. The average increase in ASES score was 51.3±21 (P<.05), ranging from 13.3 to 69.9 points. The average increase in active forward elevation for 8 patients was 79°±39° (P=.0008), ranging from 40° to 160°. All patients have remained stable with well-positioned prostheses since their final operations with no recurrent dislocations or acromial complications. Two patients unable to travel for an office visit were contacted via phone and answered questions to obtain postoperative ASES and VAS scores. Acromiohumeral cerclage suture augmentation in revision rTSA may be a useful, simple surgical strategy to employ with other revision and augmentation techniques to treat cases of recurrent, chronic instability, particularly in the setting of multiple revisions.

Adjuvant therapy in early uterine serous carcinoma (324)

<b>Objectives:</b> Uterine serous carcinomas represent approximately 10% of all endometrial cancers but are responsible for nearly 40% of all endometrial cancer-related deaths. Given the relatively low incidence of this disease, there are limited prospective data to guide adjuvant treatment decisions in early-stage disease. The purpose of this study was to evaluate the impact of adjuvant therapy on recurrence-free and overall survival in women with stage I-II pure uterine serous carcinoma. <b>Methods:</b> IRB approval was obtained. Using an institutional pathology database, we retrospectively identified all patients with 2009 FIGO stage I and II pure uterine serous carcinoma treated at a single institution from January 2006 to December 2019. Demographic, clinical-pathologic, treatment, and outcome data were collected using the electronic medical record. Serous histology was confirmed by a gynecologic pathologist, and only cases of pure uterine serous histology were included. Data were compared using descriptive statistics. Survival analyses were performed using Kaplan-Meier and Cox proportional hazard methods. <b>Results:</b> Ninety-four patients meeting inclusion criteria were identified with a median follow-up time of 33.5 months. The median age was 68 years (range: 49-87), the majority of patients were White (<i>n</i>=78, 83.0%), and the median BMI was 30.7 (range: 14.2-57.3). The minimally-invasive surgical staging was performed in 59.6% of cases (<i>n</i>=56). Most patients had stage IA disease (<i>n</i>=70, 74.5%), and lymphadenectomy was performed in 90.4% of cases (<i>n</i>=85). Most patients (<i>n</i>=79, 84.0%) received adjuvant therapy, and a majority of patients received a combination of systemic chemotherapy and radiation therapy (<i>n</i>=55, 58.5%), with the most common combination being chemotherapy plus vaginal brachytherapy (<i>n</i>=42, 44.7%). Most patients (<i>n</i>=77, 81.9%) remained without evidence of recurrent disease at the most recent follow-up, while 17 patients (18.1%) had experienced recurrence. Patients who received six cycles of adjuvant chemotherapy experienced improved overall survival (p=0.004) and improved recurrence-free survival (p=0.02) compared to those who received no adjuvant chemotherapy. <b>Conclusions:</b> Patients with surgically staged early pure serous uterine carcinoma who received six cycles of adjuvant chemotherapy had significantly improved overall and recurrence-free survival compared to those who did not receive adjuvant chemotherapy.

Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations.

Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection. The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up. A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups. Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.

Comparison of Intramedullary Interlocking Nailing (IMLNG) and Minimally Invasive Plate Osteosynthesis (MIPO) in Treating Extra Articular Distal Tibial Fractures

Background: Due to limited blood flow and sparse soft tissue coverage, treating distal tibia fractures presents a considerable challenge for orthopaedic surgeons. Objective: Our study's objectives were to compare the outcomes of the two treatment modalities of minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) for extraarticular distal tibia fractures. Study Design: Randomized Controlled Trial Place and Duration of the Study: This study was conducted at Department of Orthopedic and Spine Surgery Sughra Shafi Medical Complex, Narowal from March 2021 to March 2022. Material Methods: During A total of 59 patients ( 30 in IMLN group and 29 in MIPO group), both male and female, with AO Type A, b and C distal tibial fractures lasting less than three days and ages ranging from 20 to 60, were enrolled for this research. At the most recent follow-up, clinical and radiological data were assessed. Results: The average duration to union was 21.9 weeks in the IMN group and 19.9 weeks in the MIPO group, and all of the examined patients eventually recovered. In the IMN group, the time to union was substantially greater (p= 0.001). Conclusion: Low operating, union, and hospitalisation times make MIPO advantageous. In order to lessen the morbidity of these patients, we advise using the minimally invasive plate osteosynthesis (MIPO) procedure as the first line of treatment for distal tibia fractures.. Keywords: Distal tibia fracture, minimally invasive plate osteosynthesis, intramedullary nailing,

Prospective evaluation of complications associated with orthosis and prosthesis use in canine patients.

IntroductionThe use of orthoses and prostheses is expanding in veterinary medicine. However, research evaluating the efficacy and complications of these devices in veterinary patients is limited. The primary objective of this study was to prospectively determine the complications and outcomes associated with custom orthosis and prosthesis use in the canine patient.Materials and MethodsThis was a prospective, clinical trial that followed patients for 12 months following device fitting. Owner-perceived complications, clinical metrology instruments, and objective gait analysis were used as outcome measures at various time points. The patients were grouped into the following four major categories: Patients with a carpal orthosis, patients with a stifle orthosis, patients with a tarsal orthosis, and patients with a prosthetic device.ResultsForty-three patients were included in the study. Thirty-nine out of 43 patients (91%) experienced at least one complication, with 7/7 (100%) prosthesis patients experiencing at least one complication. At least one skin complication was reported for the following patient groups during the first 3 months of use: 8/14 (58%) stifle orthoses, 9/10 (90%) carpal orthoses, 6/10 (60%) tarsal orthoses, and 4/7 (58%) prostheses. Patient non-acceptance of the device was identified in 2/15 (14%) stifle orthoses, 1/10 (10%) tarsal orthoses, and 4/7 (55%) prostheses. One out of 15 (7%) stifle orthoses, 4/10 (40%) carpal orthoses, 4/10 (40%) tarsal orthoses, and 1/7 (15%) prostheses experienced mechanical device problems necessitating repair. The majority of patients with carpal and stifle orthoses showed improvement on objective gait analysis in percent body weight distribution of the affected limb between baseline and the most recent follow-up without the device donned: 83% (n = 6) of patients with carpal orthoses, 100% (n = 11) of patients with stifle orthoses. None of the patients with tarsal orthoses showed a similar improvement (0%; n = 4).Discussion and conclusionThree major complications associated with canine orthosis and prosthesis use were identified in this study as follows: Skin complications (abrasions, loss of hair, and sores), mechanical device problems, and patient non-acceptance of the device. Owners should be notified of these potential complications prior to pursuing orthoses or prostheses as a potential treatment option. Although clinical improvement was noted in the majority of patients with stifle and carpal pathology, given the lack of a control group, it is unknown how much of this improvement can be attributed to the orthoses.

Outcome of Scapular Ewing Sarcoma.

Ewing sarcoma is a common primary bone tumor, often located in the distal femur or pelvis. Although the scapula is a flat bone similar to the pelvis, scapular Ewing sarcoma is rare. The aim of this study was to review our institution's experience with the management of scapular Ewing sarcomas. We reviewed 9 patients with an Ewing sarcoma of the scapula, which included 5 males and 4 females with a mean age of 19±6 years. All patients were treated with chemotherapy and local control. Local control included surgical resection (n=7) and definitive radiotherapy (n=2). Mean follow-up was 6 years. Prior to induction chemotherapy, the mean tumor size and volume were 10±2 cm and 181±112 cm3, respectively. Following induction chemotherapy, there was a reduction in the mean tumor size (6±3, p=0.02) and volume (20±12 cm3, p<0.01). The mean tumor necrosis in patients undergoing resection was 72±23%. The median survival was 30-months, and the 5-year disease specific survival was 38%. At most recent follow-up, the mean Musculoskeletal Tumor Society Score was 79±14%. Scapular Ewing sarcoma is a rare, aggressive tumor. Even with chemotherapy and local control with surgery or definitive radiotherapy, patient survival is poor.

Neurocognitive Performance in Adults Treated With Radiation for a Primary Brain Tumor

PurposeThe contributory effects of radiation dose to different brain regions on neurocognitive performance after radiation therapy (RT) for primary brain tumors is not well known. Methods and MaterialsIn this retrospective cohort study, 30 patients with brain tumors treated with photon RT were identified, and radiation dosimetric parameters across brain regions were calculated. All patients had longitudinal neurocognitive evaluations at baseline and after treatment. Generalized estimating equations were used to model each neurocognitive endpoint over time in a multivariable analysis, while adjusted for multiple comparisons of brain regions. ResultsMedian follow-up from RT to last assessment was 4.1 years. Fewer years of formal education and older age at the time of RT were associated with lower scores in language, verbal memory, and working memory, after adjustment for baseline scores in multivariable analyses. Higher radiation dose to specific brain regions was not associated with declines in any of the evaluated cognitive domains. On average, there was no clinically significant decline (magnitude of z score change >1) between first and last neurocognitive evaluation. Across each individual cognitive domain, fewer than 15% of patients were impaired at most recent follow-up. ConclusionsIn this small study of 30 patients treated with RT for a primary brain tumor, brain region dosimetry was not associated with decline in cognitive performance. Older age at time of RT and fewer years of formal education were associated with declines in cognitive performance, suggesting that effects of nondosimetric factors on cognitive performance should be considered alongside treatment factors and dosimetry in neuro-oncology research.

Evaluation of the Quality Management System due to the Implementation of the SLIPTA Program at the Bamenda Regional Hospital Laboratory, Cameroon

Background and Aims: Improving the Quality Management System (QMS) of clinical laboratories and achieving accreditation are important in health care delivery. It can be achieved by implementing the World Health Organizaton Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA). The SLIPTA program was introduced to the Bamenda Regional Hospital (BRHL) in 2010. Our objectives were to identify improvements and evaluate the QMS at the BRHL. Training, mentorship, and improvement of laboratory infrastructure were considered for the program to succeed.&#x0D; Materials and Methods: Secondary data from the WHO SLIPTA assessment reports of the BRHL between November 2009 and March 2018 were extracted. The assessments were conducted by the WHO African Society for Laboratory Medicine (ASLM) SLIPTA certified and competent auditors, using the SLIPTA checklist. The final percentage score(s)/star(s) of the assessments was/were identified as improvements, and the evaluation was done by taking the difference between an absolute score of the Quality System Essentials (QSE) of the baseline recent follow-up assessment.&#x0D; Results: A total of nine SLIPTA assessments were carried out. The results indicated great improvements in the QMS from a baseline score of 18% (0-star) to 82% (3-stars) at the recent follow-up assessment. There were also significant changes in the QSE, with the final absolute scores ≥ 58% in all aspects and the greatest change registered in the management review (94%).&#x0D; Conclusions: We identified incredible improvements and magnificent changes in the QMS at the BRHL that were due to training, mentorship, and improvements in infrastructure resulting from the implementation of the SLIPTA program.

The Supported vs Unsupported Ross in Pediatric Patients: Neoaortic Root and Ventricular Function

The supported Ross is used to mitigate the neoaortic root dilation that has been described with the unsupported Ross. There is limited literature assessing the efficacy of the supported Ross in young patients. In this study, the fate of the neoaortic root was compared in the supported and unsupported Ross procedure in adolescent patients. A retrospective review was performed of patients who underwent the Ross procedure between 1996 and 2019. An analysis was conducted of patients aged 10 to 18 years who underwent the supported and unsupported Ross operation, without a Konno enlargement, to assess for longitudinal echocardiographic changes. Given differences in follow-up time, both regression analysis and Mann-Whitney nonparametric tests were used to correct for time from discharge to most recent follow-up. The median follow-up time for supported and unsupported Ross patients without a Konno enlargement was 2.90 years (0.21-13.03 years) and 12.13 years (2.63-19.47 years), respectively. Unsupported Ross patients experienced a higher rate of change per year in the aortic annulus (P= .003 and P= .014) and aortic sinus (P= .002 and P= .002) diameters, respectively. There was no significant difference in the rate of change of end-diastolic left ventricular internal diameter (P= .703 and P= .92) and aortic insufficiency (P= .687 and P= .215) between the supported and unsupported Ross patients. Progressive dilation of the neoaortic root in unsupported Ross patients is significantly mitigated with the supported Ross with excellent stability. The supported Ross is safe and effective and may play an increasing role in the management of children with aortic disease.

A Rare Traumatic Event: Description of a Parailiac Hernia in a Young Female following Blunt Trauma

Traumatic abdominal wall hernias are a rare event following blunt trauma. This case report details the course of a traumatic left parailiac hernia in an 18-year-old female initially diagnosed on CT imaging. The timing of repair in such hernias is largely debated, and this patient’s repair was delayed by significant operative intra-abdominal injuries, recurrent orthopaedic surgeries, and an infected hematoma at the hernia site. Ultimately, it was repaired primarily three months after the initial trauma. At most recent follow-up, there was no recurrence of the hernia but the patient was dissatisfied with cosmesis. The cumulative literature is lacking data on the treatment of traumatic hernias and there is no consensus as to the ideal timing and method of repair; therefore, the strategies described in this case report of a successful traumatic hernia repair are important to establishing guidelines for such trauma.

Effect of the Reversed L-Shaped Osteotomy on the Round Sign: Not All Hallux Valgus Deformities May Need Proximal Derotation to Correct the Radiographic Appearance of Metatarsal Pronation.

Background:Metatarsal pronation has been claimed to be a risk factor for hallux valgus recurrence. A rounded shape of the lateral aspect of the first metatarsal head has been identified as a sign of persistent metatarsal pronation after hallux valgus correction. This study investigated the derotational effect of a reversed L-shaped (ReveL) osteotomy combined with a lateral release to correct metatarsal pronation. The primary hypothesis was that most cases showing a positive round sign are corrected by rebalancing the metatarsal-sesamoid complex. We further assumed that the inability to correct the round sign might be a risk factor for hallux valgus recurrence.Methods:We retrospectively evaluated 266 cases treated with a ReveL osteotomy for hallux valgus deformity. The radiologic measurements were performed on weightbearing foot radiographs preoperatively, at an early follow-up (median, 6.2 weeks), and the most recent follow-up (median, 13 months). Univariate and multivariate logistic regression analyses identified risk factors for hallux valgus recurrence (hallux valgus angle [HVA] ≥ 20 degrees).Results:A preoperative positive radiographic round sign was present in 40.2% of the cases, of which 58.9% turned negative after the ReveL osteotomy (P < .001). Hallux valgus recurred in 8.6%. Risk factors for recurrence were a preoperative HVA >30 degrees (odds ratio [OR] = 5.3, P < .001), metatarsus adductus (OR = 4.0, P = .004), preoperative positive round sign (OR = 3.3, P = .02), postoperative HVA >15 degrees (OR = 74.9; P < .001), and postoperative positive round sign (OR = 5.3, P = .008). Cases with a positive round sign at the most recent follow-up had a significantly higher recurrence rate than those with a negative round sign (22.7% vs 5.9%, P < .001).Conclusion:The ReveL osteotomy corrected a positive round sign in 58.9%, suggesting that not all hallux valgus deformities may need proximal derotation to negate the radiographic appearance of the round sign. A positive round sign was found to be an independent risk factor for hallux valgus recurrence. Further 3-dimensional analyses are necessary to better understand the effects and limitations of distal translational osteotomies to correct metatarsal pronation.Level of Evidence:Level IV, case series.

Paper 65: Arthroscopic rotator cuff repair with and without acromioplasty in the treatment of full-thickness rotator cuff tears: long term follow-up of a multicenter, randomized controlled trial

Objectives:In our previous trial of 86 patients randomized to undergo rotator cuff repair with or without acromioplasty, no differences in functional and quality-of-life indices at 24-months post-operative were observed. At that time point, four patients (9%) in the group without acromioplasty required reoperation due to persistent symptoms (1 with a type-II acromion and 3 with type-III acromion) while no patients that underwent acromioplasty had follow-up surgery. This is consistent with other short-term studies; however, no long-term follow-up of a randomized clinical trial has been conducted. The aim of this study was to re-evaluate the patients from the original trial determine the long-term efficacy of performing a subacromial decompression in cases of full thickness rotator cuff tears.Methods:This is a secondary study based on a previous multi-centre, double-blind, balanced randomization (1:1), parallel-group study with patients allocated to arthroscopic rotator cuff repair with (ACR) or without acromioplasty (No ACR). Recruitment for the original study was conducted between June 2003 and February 2009 with 24-month follow-up taking place between 2005 and 2011. This secondary study was conducted between April 2015 and March 2021 with all patients randomized in the main study comprising the study sample. Additional exclusion criteria were those who were unable or unwilling to provide informed consent. Patients from the original study were invited by a blinded assessor to return for a follow-up visit involving the same methodology as their previous visits. The visit included completion of a patient-reported outcome, the Western Ontario Rotator Cuff score (WORC) and clinical assessment. If a participant was unable to return for a clinical evaluation, they were asked to complete the WORC by mail.Results:Eighty-six patients were randomized in the original trial. Fifty-seven of those completed the long-term follow-up, 31 of 45 from the No ACR group and 25 of 41 from the ACR group. Sixty-one percent in the No ACR group and 64% in the ACR group were male. The mean (SD) duration of follow-up was 11.2 (2.4) years for No ACR and 11.5 (2.6) years for ACR, respectively. Mean (SD) age of patients at the time of initial surgery for the No ACR group was 58.5 (8.4) and for the ACR group was 56.2 (7.8), while mean age at the most recent follow-up was 69.0 (9.3) for No ACR and 67.7 (7.7) for ACR. Mean (SD) WORC scores at pre-operative, 24-months and long-term follow-up are presented by group in Table 1. There was no significant difference in WORC between the No ACR and ACR groups at the time of long-term follow-up (p=0.30). WORC score maintained a significant improvement from pre-operative scores in both groups (p < 0.001). In the initial study at 24-months post-operative, four patients were identified in the No ACR group who underwent revision surgery. Of those, 2 returned for long-term follow-up and 2 did not. In long term follow-up, another 6 patients were identified that underwent additional surgery on their study shoulder since the 24-month follow-up, including 3 rotator cuff revisions, 1 total shoulder arthroplasty, and 2 unknown shoulder surgeries (patient-reported). Therefore, 10 (22%) of the 45 patients in the No ACR group underwent further shoulder surgery. One participant, 2% of the initial 41 patients allocated to ACR, underwent a revision shoulder surgery.Conclusions:The main finding of this study was that at long-term (mean 11 years post-operative) follow-up of patients randomized to undergo rotator cuff repair with or without acromioplasty, there was no difference in patient-reported outcome, specifically WORC scores. Both groups maintained improved outcomes from their pre-operative status. However, revision rate was significantly higher in those that did not undergo acromioplasty at the time of their initial surgery.Figure 1.Patient flow through study.Figure 2.WORC scores over time by group.

Pairing 40-mm Femoral Heads With the Smallest Compatible Acetabular Components in Total Hip Arthroplasty: Mid-Term Outcomes in 177 Cases.

Contemporary total hip arthroplasty (THA) often employs larger femoral heads to optimize hip stability. However, pairing 40-mm femoral heads with the smallest compatible acetabular components poses a potential risk for implant failure. The purpose of this study is to evaluate the outcomes of primary THAs using 40-mm femoral heads and the smallest compatible acetabular components. Between 2007 and 2018, 177 primary THAs involving 40-mm femoral heads and acetabular components ≤56 mm with highly cross-linked polyethylene liners were identified. Mean age was 61 years, 56% were females, and mean body mass index was 32 kg/m2. Cumulative incidences of dislocation, any revision, and any reoperation were determined utilizing a competing risk model. Osteolysis and femoral head penetration were assessed at minimum 8-year follow-up (n= 16). Mean follow-up was 6 years. There were no cases of liner fractures or dissociations. The 10-year cumulative incidences of dislocation, any revision, and any reoperation were 3.6%, 4.2%, and 6.8%, respectively. Mean linear femoral head penetration was 0.01 mm/y and mean volumetric wear rate was 50 mm3/y. One THA demonstrated stable, asymptomatic periacetabular radiolucent lines at most recent follow-up. In 177 primary THAs pairing 40-mm femoral heads with the smallest compatible acetabular components, there were no liner fractures or dissociations. The cumulative incidence of dislocation was modest at 10 years. The cumulative incidences of any revision and any reoperation were low at mid-term. IV.

Clinical impact of extended field radiation therapy in Stage III carcinoma cervix versus conventional field techniques: A comparative study.

The aim of the study was to examine tumor control and clinical outcomes of extended field irradiation and compare it with those treated with conventional field in same disease profile and also to determine toxicities associated with radiation treatment. This study included 50 biopsy-proven and registered International Federation of Gynecology and Obstetrics Stage III cases of carcinoma cervix treated with concurrent computed tomography (injection cisplatin 40 mg/m2 weekly) + external beam radiotherapy (EBRT) upto 50 Gy + high-dose-rate intracavitary brachytherapy (ICBT) (22.5 Gy). Twenty-five patients were randomized to each arm. Arm A: Conventional field EBRT 50 Gy with concurrent weekly chemotherapy followed by ICBT. Arm B: Extended field EBRT 50 Gy with concurrent weekly chemotherapy followed by ICBT. At 12-month follow-up, 43 patients (86%) had attained CR. Overall, seven patients (14%) were in noncomplete response (CR) group (non-CR = patients with partial response, stable disease, or progressive disease). The non-CR rate was 16% for Arm A and 20% for Arm B. Among seven patients of non-CR group, six had local disease and one had failure at distant site. Five (10%) patients died in this study, 2 (8%) in Arm A and 3 (12%) patients in Arm B. Residual disease was seen in 2 (4%) patients. Grade III diarrhea was seen in eight patients (16%), 3 in Arm A (12%) and 5 in Arm B (20%). Fifteen patients (30%) developed Grade III skin toxicity. Seven patients in Arm A (28%) and 8 patients (32%) in Arm B developed Grade III toxicity. Twenty-five (50%) cases presented with varying stages of vaginal adhesions and stenosis. Majority of patients achieved CR with minimal acute and late toxicities with similar results in both arms. No patient had pelvic or para-aortic metastasis until recent follow-up.

Tibial metaphyseal cones combined with short stems perform as well as long stems in revision total knee arthroplasty

BackgroundsThere is uncertainty around optimal tibial stem length in revision total knee arthroplasty (rTKA) utilizing a tibial trabecular metal (TM) cone. The purpose of this study was to compare: (1) functional outcomes, (2) radiographic outcomes and (3) implant survivorship in rTKA utilizing TM cones combined with either short stems (SS) or long stems (LS) at minimum 2 years follow‐up.MethodsIn this retrospective, multi‐centre study, patients undergoing rTKA utilizing a TM cone between 2008 and 2019 were included. Patients were divided into: SS group (no diaphyseal engagement), and LS group (diaphyseal engagement). All relevant clinical charts and post‐operative radiographs were examined. Oxford Knee Score (OKS) and EuroQol‐5D (EQ‐5D‐5L) data were collected at most recent follow‐up.ResultsIn total, 44 patients were included: 18 in the SS group and 26 in the LS group. The mean time of follow‐up was 4.0 years. Failure free survival was 94.4% for the SS group and 92.3% for the LS group. All failures were for prosthetic joint infections managed with debridement, antibiotics, and implant retention. At most recent follow‐up, 3 patients demonstrated radiographic signs of lucency (1 SS 2 LS, P = 1) and the mean OKS were 37 ± 4 and 36 ± 6 (P = 0.73) in the SS and LS groups, respectively.ConclusionTibial SS combined with TM cones performed as well as LS in rTKA at minimum 2 years follow‐up. A tibial SS in combination with a TM cone is a reliable technique to achieve stable and durable fixation in rTKA.