Spectrum of renal diseases caused by monoclonal immunoglobulin: experience from an Australian tertiary referral centre over a 10-year period.

Can endothelial cell dysfunction decide surgical wound health in bone sarcoma? Prospective study evaluating factors predicting wound complications in sarcoma.

The optimal time interval between the two surgical stages of a delayed coloanal anastomosis has never been investigated. Assess the influence of time interval on anastomotic leakage occurrence. Retrospective cohort study. Multicentric study (30 colorectal centers). All patients who underwent delayed coloanal anastomosis (2010-2021). anastomotic leakage in relation to the time interval between the two surgical stages. A total of 506 patients (female: 42%, median age: 62.1 years) underwent delayed colo-anal anastomosis, 63% immediately after a low anterior resection (primary delayed coloanal anastomosis) and 37% after failure of primary pelvic surgery as a salvage procedure (salvage delayed coloanal anastomosis). The main reasons for salvage delayed coloanal anastomosis were chronic pelvic sepsis (42%) and rectovaginal fistula (38%). The mean time interval between two stages was 8.6 ± 3.8 days, ranging from 1 to 22 days. In the entire cohort, the incidence of anastomotic leakage was 18% (89/506, 95 CI [14%, 21%]) and time interval did not affect the occurrence of anastomotic leakage (p = 0.529). In sub-group analysis, anastomotic leakage risk was not associated with time interval among primary delayed coloanal anastomosis patients (p = 0.579) whereas it was for salvage delayed coloanal anastomosis patients (p = 0.013). In salvage delayed coloanal anastomosis patients, multivariate analysis showed that a longer time interval (adjusted OR=0.89, 95 CI [0.81-0.98], p = 0.035) and surgery in centers performing ≥4 delayed coloanal anastomosis per year (adjusted OR = 0.07, 95 CI [0.01-0.36], p = 0.011) were significantly linked to a lower risk of anastomotic leakage. Each additional day between the two salvage delayed coloanal anastomosis procedures was estimated to reduce the risk of anastomotic leakage by 11%. The retrospective design. In the context of primary delayed coloanal anastomosis, increasing the time interval between the two stages of delayed coloanal anastomosis does not influence the risk of anastomotic leakage. For salvage delayed coloanal anastomosis, extending the time interval significantly reduces the risk of anastomotic leakage.

Hepaticojejunostomy strictures (HJSS), recurrent cholangitis, and jaundice are major complications of surgical hepaticojejunostomy. Previously, HJSS was managed using percutaneous procedures and balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography. However, endoscopic ultrasound-biliary drainage (EUS-BD) was recently reported to be an effective salvage procedure. EUS-BD as a primary drainage method using a trans-endosonographically created route (trans-ESCR) has not been previously evaluated. We enrolled consecutive patients who underwent EUS-BD for HJSS at the Juntendo University Hospital between March 2017 and December 2022. After ESCR maturation, multiple plastic stents were placed for 1 year with or without cholangioscopic evaluation. We evaluated the technical and clinical success rates, stent removal, HJSS recurrence, and related adverse events. Thirty-seven patients required EUS-guided hepaticogastrostomy/hepaticojejunostomy (n=36/1). The technical and clinical success rates were 94.6% and 100.0%, respectively, and 17% of patients experienced adverse events. Cholangioscopy via ESCR was performed in 19 patients to evaluate the strictures and manage concomitant stones. The success rate of stent removal after multiple stent placements for more than 1 year was 83%. Primary EUS-BD and trans-ESCR are feasible and effective in the management of HJSS. Further prospective studies are needed to confirm the results of this pilot study.

Background Tibial osteomyelitis frequently requires plastic surgical input for effective long-term management, particularly where debridement results in bone or implant exposure. While orthopaedic and antimicrobial protocols are well established, reconstructive technique plays a critical role in minimising recurrence and preserving limb function. This study reviews 10 years of single-stage treatment at a bone infection centre. Methods A retrospective study of patients who underwent single stage tibial osteomyelitis debridement and reconstruction in a single bone infection centre from 2012-2024. Patient demographics, including age, gender, length of follow up were recorded. Reconstructive methods and outcomes including operative complications or recurrence of infections were reviewed. Results A total of 172 patients were identified (102 males, 70 females), with a minimum follow-up of six months. The average age was 54 years. Of the 172: 93 with free flaps, 61 with local flaps (55 muscle flaps and 6 fasciocutaneous), and 20 with direct closure or flap re-raise. In the free flap group, seven patients required urgent salvage procedures, four of which resulted in flap loss. Among the local muscle flaps, there were no partial or total flap losses. Of the six fasciocutaneous flaps, one flap loss and one experienced distal tip necrosis. There were no major complications in the direct closure group. Other complications—such as swelling and delayed wound healing—were observed in 9 patients across the entire cohort. Infection recurrence occurred in 15 patients (8.7%): 5 in the free flap group, 6 in the local flap group, and 4 in the direct closure group. Of these, three patients required amputation due to persistent infection; the remaining 12 were managed with re-debridement and further reconstruction Conclusion Plastic surgical reconstruction is central to the successful management of tibial osteomyelitis. While free flaps remain the mainstay for larger or complex defects, local flaps and direct closure can be safe and effective alternatives in selected cases.

In vitro kinematic analysis of a new patient-matched polycarbonate urethane radiocarpal interposition arthroplasty.

Preoperative malnutrition is associated with increased treatment failure and salvage procedures following surgical fixation of ankle and pilon fractures.

ABSTRACTIntroductionDual kidney transplantation (DKT) represents a method of expanding the donor pool and minimizing kidney nonutilization. For kidneys with severe renal artery atherosclerosis, back‐bench eversion endarterectomy (EE) may be performed as a salvage procedure to further promote utilization.MethodsWe report five cases of DKT in which both kidneys underwent EE prior to implantation.ResultsMean donor age was 60.2 ± 5.5 years, mean KDPI 84 ± 15%, and mean terminal serum creatinine 0.88 ± 0.3 mg/dL. There were three expanded criteria and three donations after circulatory death donors. All but one kidney was managed with hypothermic machine preservation (five with suboptimal pump parameters) and two were imported. Percentage glomerulosclerosis on biopsy ranged from 7% to 30% and cold ischemia times from 19.2 to 33.5 h. Mean recipient age was 63.0 ± 6.5 years, mean EPTS 65 ± 30%, and mean dialysis duration 19 ± 10.3 months. All recipients were chosen based on out‐of‐sequence allocation (median match run sequence #1480). Operating times ranged from 4 to 7 h; three cases were performed as unilateral and two bilateral extraperitoneal transplants. Three patients experienced delayed graft function; initial length of hospital stay ranged from 3 to 7 days. At 6 months follow‐up, mean serum creatinine was 1.6 ± 0.3 mg/dL and GFR 46 ± 17 mL/min/1.73m2. One patient died at 43 months, but the remaining four patients are doing well at a mean follow‐up of 29 months. There were no vascular complications.ConclusionBased on this preliminary experience, we believe that acceptable outcomes can be achieved with DKT in appropriately selected cases, even in the setting of severe donor renal artery atherosclerosis requiring dual endarterectomy.

A multidisciplinary emergency protocol reduces revascularization time in major upper and lower limb replantations.

The main complications after complex talar fractures, especially with respect to open injuries, are avascular necrosis (AVN) and fracture-related infection (FRI) Their treatment is a source of discussion, and reconstruction options are scarce.A descriptive longitudinal study of three cases with a two-stage tibiocalcaneal (TC) arthrodesis (talectomy followed by a retrograde nailing and two tantalum spacers) is presented.Information on infection relapse and fusion of the arthrodesis was collected, along with demographic, radiological, and functional variables (such as Manchester–Oxford Foot Questionnaire, MOXFQ, values; EuroQol index values; and visual analogue scale for pain, VAS-pain, values)After a minimum of 3 years, no infection relapse or pseudoarthrosis was observed. Leg alignment was comparable to the contralateral side. Functional and pain tests showed optimal values: MOXFQ index of 16.6, mean EuroQol index of 0.782, and mean VAS-pain of 19.For a salvage procedure in FRIAVN of the talus, this two-stage TC arthrodesis is a safe procedure in terms of infection and provides good functional outcomes.

No consensus exists regarding the utilization of the lower extremity superficial venous system compared with the deep veins in free flap procedures for limb salvage. This study analyzed the risks of venous complications associated with superficial and deep venous anastomoses for lower extremity reconstruction.A retrospective review was performed on patients who required free flap reconstruction of the lower extremity between 2016 and 2024. The recipient veins were characterized as deep (venae comitantes) or superficial (saphenous veins). Flaps with two venous anastomoses were further classified as deep, superficial, or combined venous drainage. The primary study outcome was composite venous complications, which included venous congestion, flap hematoma, and partial and total flap necrosis during index hospitalization.A total of 333 patients underwent free flap reconstruction of the lower extremity. Of these patients, 31 (9.3%) experienced the primary outcome. Free flaps with superficial-only drainage had a significantly higher rate of venous complications (27.8%) than those with deep (8.6%) or combined (4.3%) drainage systems. Multivariate analysis showed that flaps anastomosed to superficial veins had significantly higher odds of venous complications (OR = 4.11, CI: 1.24-11.9, p = 0.049) than those utilizing a deep drainage system.This study showed higher rates of venous complications with the use of superficial venous drainage in lower-extremity free flaps. Although efforts should be made to incorporate a deep venous recipient, superficial veins may be used as an adjunct in certain situations with good reconstructive outcomes.

Recurrent stress urinary incontinence (rSUI) poses a management challenge to clinicians and patients due to limited evidence on optimal salvage options following failed prior procedures. This study aims to assess the efficacy of urethral bulking agents (UBAs) as a salvage treatment for rSUI. A systematic review and meta-analysis was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A search was conducted using Embase (Ovid), PubMed (Medline) and Cochrane databases. All studies involving women who underwent UBA for rSUI were included. Five hundred sixty-three studies were screened for inclusion; 249 were excluded as duplicates and 261 studies were excluded as irrelevant, leaving 53 full-text studies for eligibility assessment. Thirty-nine studies were excluded during full text review, leaving 14 studies that met inclusion criteria. The reference lists of these studies were screened to identify a further six studies. Ultimately, a total of 20 studies were selected for qualitative and quantitative analysis. The selected studies utilised a variety of subjective patient-reported outcome measures and objective measures. Subjective patient satisfaction ranged from 45.10% to 96.50%, with a pooled rate of 77.00%. Objective cure and improvement ranged from 19.60% to 83.00%, with a pooled rate of 56.00%. Patient-reported cure and improvement ranged from 67% to 83% in primary UBA populations, and 56.50% to 75.00% in salvage UBA populations. Rates of re-intervention following salvage UBAs ranged from 9.80% to 42.00%. UBAs offer a viable salvage option for women with rSUI, especially those desirous of a minimally invasive approach with low complication rates and rapid recovery.

BackgroundEmergency department thoracotomy (EDT) is a high-risk, salvage procedure performed during the resuscitation of critically injured patients who are in extremis or experience cardiac arrest immediately before or after arrival at the emergency department (ED) following trauma. Despite its potential to improve outcomes in selected patients, its indications and ideal clinical applications remain controversial due to significant risks of morbidity and mortality. In Saudi Arabia, trauma is responsible for approximately 20% of fatalities and is the leading cause of disability-adjusted life-years lost among males. However, there is limited research on EDT outcomes in this region.MethodsThis retrospective cohort study was conducted at a tertiary academic trauma center in Riyadh with dedicated trauma and surgical services. Medical records from 2015 to 2023 were reviewed to identify adult patients who underwent EDT, using trauma team activations as a screening criterion. Data collected included demographics, mechanisms of injury, procedure indications, and timing.ResultsDuring the study period, the center averaged 151 trauma activations per year, identifying 11 patients who underwent EDT. All were male, with a mean age of 35.64 ± 8.89 years. Blunt trauma was the cause in 64.6% of cases. Of these, 45.4% met the Eastern Association for the Surgery of Trauma (EAST) guideline recommendations for EDT, while 18.2% had contraindications. Traumatic arrest in the ED or prehospital settings was the most common indication 72.7%. Mean time between ED arrival to procedure initiation was 25.45 ± 15.85 min. One patient survived to discharge. Among 45 traumatic arrests screened, 4.44% lacked documentation for withholding EDT despite conditional guideline recommendations.ConclusionsGiven the limited data available on EDT in the MENA region, our study offers important perspectives from a high-volume trauma center in KSA, where the rate of EDT was found to be very low. This low rate is likely due to the predominant injury patterns observed, presenting few candidates who might benefit from the procedure. At the same time, most patients who may have benefited based on guideline recommendations did undergo the procedure. These findings emphasize the need for heightened clinician awareness and systematic decision-making regarding EDT in trauma care. To enhance the generalizability of our findings and assess EDT’s utility in regional settings, further research involving larger multicenter registries is necessary in the country and the region.

Free flap reconstruction is essential for treating intraoral defects; however, failure can lead to complex and prolonged complications. While various monitoring methods have been employed to prevent such situations, they are qualitative and sometimes unfamiliar to novices. The purpose of this study was to develop a user-friendly model using artificial intelligence that quantitatively represents flap status. We analyzed 1877 images from 131 patients who underwent free flap reconstruction for intraoral defects between June 2021 and March 2024. Since patients with vascular damage were very few in number, class weighting and focal loss techniques were used to address this imbalance. The proposed model achieved high overall accuracy and F1 scores of 0.9867 and 0.9863, respectively. This study introduces the first deep learning model for intraoral flaps and demonstrates the possibility of quantitative measurement of flap changes. This tool can assist surgeons in making timely decisions regarding salvage procedures and facilitate easier monitoring for resident care-givers.

Impact of cement use and stem length on clinical outcomes in revision reverse shoulder arthroplasty: is a short stem with cementless fixation a viable option?

PurposeTibiotalocalcaneal (TTC) fusions are often performed as a salvage procedure in patients with severe hindfoot arthritis or hindfoot deformity. Comorbidities in this patient cohort are frequent, leading to increased risk of postoperative complications. Arthroscopic debridement may afford better wound healing and possible improvement of blood supply. This study compares the outcome of a challenging set of patients undergoing TTC fusion with either arthroscopic or open technique.MethodsFor this cohort study, the data for patients undergoing TTC fusion from 2009 to 2018 was prospectively collected and the study design is retrospective. 58 consecutive cases were identified; in 51 cases a TTC fusion was performed while in 7 cases a tibiotalar fusion was performed in the setting of a preexisting talocalcaneal fusion. Arthroscopic technique was used in 22 fusions and open technique in 36 fusions.ResultsAn overall union rate of 89.7% was achieved. Five tibiotalar non‐unions and one non‐union of both the tibiotalar and talocalcaneal joints was documented. In the arthroscopic fusion group the non‐union rate was 9.1% while in the open group it was 11.1%. The overall reoperation rate was 17%. No patient in the arthroscopic fusion group required a reoperation, whereas in the open group the reoperation rate was 27.8%. In patients with PROs the AOS score improved from 53.1 to 26.2 for the arthroscopic group and from 57.2 to 32.3 for the open group. The satisfaction score improved from 1.4 to 2.7 in the arthroscopic group, and 1.1 to 2.8 in the open group.ConclusionsArthroscopic TTC fusions are a viable alternative to the open procedure. Nonunion rates are similar, while wound complication rates and reoperation rates are lower. Outcomes measured by PROs are comparable.Level of EvidenceLevel IV, case cohort study.

To describe the surgical approach used in horses undergoing C7-T1 ventral interbody fusion using a kerf cut cylinder (KCC) implant and report the short- and long-term outcomes. Observational retrospective study. A total of 38 client-owned horses. Medical records of horses that underwent ventral interbody fusion because of C7-T1 cervical vertebral stenotic myelopathy from 2004 to 2024 were reviewed. Preoperative variables included age, sex, breed, and affected site(s). Surgical variables included types of KCC used, intraoperative complications, and anesthesia related complications. Long-term outcomes were obtained by telephone interviews with the owners, trainers, and/or attending veterinarians. A total of 38 horses had a KCC placed and 34 of 38 horses (89%) were discharged from the hospital and were alive >3 months postoperatively. Long-term follow-up was available for 32 horses (median, 48 months; range: 3-144), two horses were unavailable for long-term follow-up. A total of 30 of 38 horses (79%) were deemed to have successful outcomes; a total of 19 of 38 horses (50%) returned to riding, training, or showing in their respective disciplines and 11 of 38 horses (29%) were allowed unrestricted paddock turnout or were in active rehabilitation with improved clinical signs. Ventral interbody fusion of C7-T1 had anatomical challenges. Laryngeal spasm was the most common short-term complication, but C7-T1 ventral interbody fusion using the KCC was associated with acceptable morbidity and good long-term outcomes. Ventral interbody fusion of C7-T1 using a KCC implant can be successfully performed in equine patients with good prognosis, and ventral interbody fusion of the cervical spine should not be considered a salvage procedure.

Is Scaphoid Reconstruction Still an Option for Scaphoid Nonunion With Established Arthritis? A Retrospective Study of a Group of Patients.

Multidisciplinary limb salvage care is associated with decreased mortality without increasing revascularization in major amputations.

We compared the radiographic union and magnitude of humpback deformity correction when using different vascularized bone grafts (VBGs) and nonvascularized bone grafts (NVBGs) in the treatment of unstable scaphoid nonunions (USNUs). This was a retrospective radiographic review of 93 patients with an USNU treated between 2013 and 2022 at a single center by a single surgeon. Inclusion criteria included skeletally mature patients with radiographic evidence of an USNU resulting from failure of either nonsurgical or operative treatment. There were three treatment groups. Two groups were treated with either a palmar radiocarpal artery (PRCA) VBG or a 1,2 intercompartmental supraretinacular (1,2 IC-SRA) VBG. The third group comprised patients who were treated with a heterogeneous mix of NVBGs. Patients were followed radiographically at regular intervals until they were deemed healed or underwent a salvage procedure because of treatment failure. Measurements of carpal and scaphoid alignment were then repeated on the final imaging series and compared to preoperative measurements. Ninety patients were included in the final analysis. PRCA VBG had the highest radiographic union rate, followed by 1,2 IC-SRA VBG and finally NVBGs. PRCA VBG had a significantly higher rate of union than NVBGs. Scapholunate angle change and scaphoid length change were greatest with PRCA VBG. These differences were statistically significant for the former when compared with 1,2 IC-SRA VBG and NVBGs and for the latter when compared with the 1,2 IC-SRA VBG in both univariate and multivariable analyses. PRCA VBG had the highest radiographic union rate compared with alternative grafts as well as providing the greatest degree of humpback deformity correction in the treatment of USNUs. Therapeutic IV.