Second-stage Surgery Research Articles

Staged Surgical Resection of Brain Arteriovenous Malformations

Staged treatment of brain arteriovenous malformations (AVMs) is sometimes necessary to minimize risks associated with sudden changes in cerebral hemodynamics. With the increasing availability and optimization of endovascular techniques, multiple surgical resections are rarely necessary, although, due to specific anatomic circumstances, some AVMs still require staged surgery. Here, we describe the largest reported series of staged surgical resections of brain AVMs. This is a retrospective review of surgically resected AVMs at a single institution from 1998-2018. Patients who underwent ≥2 resections within 1 year were reviewed. Only those in whom initial resection was terminated with intention for further resection were included in analysis. Twenty patients underwent deliberately staged resection from 1998-2018. Average age at treatment was 36.2 years (SD 16.5 years). Eleven patients (55%) were female, and 12 (60%) had left-sided AVMs. Median Spetzler-Martin grade was 4 (interquartile range [IQR]: 3-4). Average AVM nidus diameter was 5.0 cm (SD 1.7 cm). Seven patients (35%) presented with AVM rupture, and 12 (60%) presented with focal neurologic deficits without hemorrhage. Seventeen patients (85%) underwent preoperative embolization, median number of embolizations was 3 (IQR: 2-4). Three patients (15%) underwent preoperative radiosurgery. Median number of days between surgeries was 28 (IQR: 8-41 days). Perioperative course was complicated by hemorrhage in 3 patients (15%); 1 required decompressive hemicraniectomy prior to the second stage of surgery. Good functional outcome (defined as modified Rankin Scale score ≤2) was achieved in 14 patients (70%). Staged surgical resection of large and complex AVMs can be performed with good outcomes in carefully selected patients.

Soft Tissue Grafting Around Implants: Why, When, and How?

This paper discusses the role of soft tissue grafting around dental implants. The aim of this review is to present pertinent literature on peri-implant soft tissue including its role, indications for augmentation, techniques used to enhance the quality and/or quantity of the soft tissue, and corresponding timing of those procedures. Most reviewed soft tissue grafting studies in this paper were published in the last 5 years. However, the review also included older articles to mitigate the lack of recent randomized controlled trials or even case series on the reviewed soft tissue graft types. Soft tissue management with custom healing abutments or temporary restorations should be considered whenever possible. Soft tissue grafting to increase the width of keratinized mucosa (KM) seems to result in greater reduction of inflammation signs and a greater maintenance of crestal bone levels. The use of soft tissue grafts to increase soft tissue thickness tends to have a positive effect on maintaining crestal bone levels, especially when used to increase vertical thickness. Apically positioned flaps (APFs) in combination with free gingival grafts (FGGs), subepithelial connective tissue grafts (SCTGs), or xenogenic collagen matrix (XCM) can significantly increase the KM width. Grafts to enhance facial tissue thickness lack evidence to support their long-term impact on mucosal marginal levels. Nonetheless, soft tissue manipulation is frequently performed at second-stage surgery to improve the facial thickness and esthetics. No clear advantages for the timing of soft tissue grafting with regard to clinical outcomes can be delineated when grafting is performed to increase KM or tissue thickness in simultaneous or staged approaches. The decision and timing to treat soft tissue defects should be based on risk assessment at the site and patient levels.

One-Stage Osteochondral Fracture Repair Technique With Knotless Anchors and Interconnected Crossing Suture Sliding Loops for the Knee

Osteochondral fractures of the knee represent a challenging entity to manage since there are many different surgical techniques for cartilage repair or other salvage procedures. In terms of cartilage repair, several hardware devices can be used, and many of them could imply a second-stage surgery for hardware removal. The purpose of this article is to describe in detail a one-stage osteochondral fracture repair technique with knotless anchors and interconnected crossing suture sliding loops for the knee. This technique is a one-stage open or arthroscopic procedure with an unlimited number of loops configurations with no particular need for a second surgery for hardware removal, no knot damage, and without the use of bone tunnels. It can be used in different cartilage anatomic locations, such as femoral condyles, trochlea, patella, or other joints.

A novel digital and visualized guided bone regeneration procedure and digital precise bone augmentation: A case series

Although the traditional bone augmentation technology can basically meet the clinical needs at present, the effect of bone augmentation in most cases is related to the experience of the operator. This study commits to providing a digital solution for precise bone augmentation in the field of oral implantology. After collecting the data of patients' intraoral scanning and DICOM (digital imaging and communications in medicine), the implant position is digitally designed, and the alveolar bone is digitally augmented around the ideal implant position. On the premise of ensuring that the thickness of labial bone is 2 mm, and there is sufficient alveolar bone 3 to 4 mm apically from the ideal gingival margin for implant placing, we carry out excessive augmentation of 0.5 and 1 mm on the labial bone and alveolar crest, respectively, to compensate for possible bone resorption after 6 months. After 3D printing the reconstructed alveolar bone model, the titanium mesh is trimmed and preformed on the alveolar bone model. Outcomes are reported in terms of mean values (5%-95% percentile values). Thirty implant sites have accepted this novel virtually designed alveolar bone augmentation. Before the second-stage surgery, the average vertical bone gain was 2.48 mm (0.29-6.32), the average horizontal bone gain was 4.11 mm (1.19-8.74), the average height of the residual alveolar bone above the implant platform was 1.44 mm (0.59-2.92), the average thickness of the labial bone width at the implant platform was 2.00 mm (0.93-3.64), the average thickness of the labial bone width at 2 mm apically from the implant platform was 2.74 mm (1.40-5.46). The virtual augmentation of each tooth position was 349.41 mm3 (165.70-482.70), while the actual augmentation of each tooth position was 352.94 mm3 (159.24-501.78), the accuracy of the final actual augmentation reached 95.82% (range from 88.53% to 99.15%). This case series suggests that a virtually digital guided bone regeneration (GBR) workflow is precise and controllable. The practicality, safety and effectiveness of this procedure needs to be compared to other bone augmentation procedures in randomized controlled trials.

One‐ versus two‐stage crown lengthening surgical procedure for aesthetic restorative purposes: A randomized controlled trial

This randomized controlled trial aimed to assess the efficacy of a two-stage crown lengthening intervention (SCL) in the aesthetic zone compared with a one-stage crown lengthening procedure (CCL). Thirty subjects were randomly assigned to either SCL (n=15) or CCL (n=15) groups. SCL consisted of full-thickness flaps followed by bone recontouring and gingivectomy 4months postoperatively, if required. In CCL, osseous recontouring after submarginal incisions was performed, followed by flap repositioning. Records were obtained at baseline, 4months (only in SCL), 6months and 12months. Primary outcome was the precision in achieving a pre-determined gingival margin position. Other outcomes considered were changes in the gingival margin position and keratinized tissue width (KTW) at 12months, and patient-reported outcomes (PROMs). Surgical precision was comparable between groups (0.2±0.4mm in the CCL group and -0.2±0.5mm in the SCL group). Four patients in the SCL group (27.7%) did not require a second-stage surgery. KTW was significantly higher in the SCL group (6.3±1.4mm versus 5.0±1.4mm, p=0.017). SCL resulted in a lower impact on quality of life when compared to the CCL group. Both approaches were highly accurate obtaining the desired crown length. SCL was associated with a lower reduction in KTW and more favourable oral health-related quality of life (OHIP-14).

Clinical and volumetric analysis of peri-implant soft tissue augmentation using an acellular dermal matrix: A prospective cohort study.

The role of keratinized mucosa in promoting peri-implant health is controversial, however recent evidence support the use of soft tissue augmentation procedures around dental implants. Soft tissue substitutes have been proposed to replace autogenous connective tissue grafts, therefore the aims of this study are to report clinical and volumetric three-dimensional changes in mucosal thickness (MT) 1 year after treatment with an acellular dermal matrix (ADM). Soft tissue augmentation was performed at second-stage surgery in the premolar maxillary area with an ADM. MT was assessed prior to implant placement and 1, 6, and 12 months after treatment. Digital linear and volumetric measurements were recorded at baseline and after 1 and 12 months. Furthermore, clinical parameters (Probing Pocket Depths, Bleeding On Probing, Plaque Index) and marginal bone loss were also recorded. Esthetic outcomes of treatment were evaluated objectively using the Pink Esthetic Score and through patient reported outcomes. Twelve patients were enrolled in this prospective study. Post-hoc analysis of the assessments with Tukey's honestly significant difference adjustment revealed that the MT had increased significantly from baseline to 1 month (P < 0.001), 6 months (P < 0.001) and 12 months (P < 0.001), and remained stable between 6 months and 12 months (P > 0.05). Based on the volumetric evaluation, a shrinkage of 23.31% occurred from 1 month to 12 months (P > 0.05). A significant increase in MT was reported after 1 year, with a mean gain of 1.25 mm. Soft tissues were stable, with no statistically significant differences between 6 months and 1 year.

Association of the Implant Surface Texture Used in Reconstruction With Breast Cancer Recurrence

The potential association between breast implant-related anaplastic large cell lymphoma (BIA-ALCL) and implant texture has raised concerns about the additional unexpected adverse effects of textured implants, including potentially adverse outcomes for other cancers. In addition to the risk of developing BIA-ALCL, breast cancer survivors may worry about whether the type of implant inserted is associated with recurrence of their original cancer-an issue for which little evidence currently exists. To evaluate the oncologic outcomes of breast cancer according to the surface type of implants used for reconstruction and to identify the independent factors associated with breast cancer recurrence and survival, including implant surface type. This cohort study was conducted at Samsung Medical Center, a single tertiary referral center in Seoul, South Korea. Patients with breast cancer who underwent total mastectomy and immediate 2-stage tissue expander/implant reconstruction between January 1, 2011, and December 31, 2016, were identified from a prospectively maintained database. Patients were categorized into 2 groups according to the surface type of implant used for their reconstruction (smooth or textured implant). These patients were followed up for at least 2 years after insertion of the implant. Data analysis was performed from February 15, 2020, to March 5, 2020. Use of smooth implants vs textured implants at the second-stage operation. The main outcomes of interest were local and regional recurrence-free survival (LRRFS) and disease-free survival (DFS) rates. Cumulative incidence of oncologic events in the smooth implant and textured implant groups and their respective hazard ratios (HRs) were collected and updated regularly. In total, 650 patients (all women, with a mean [SD] age of 43.5 [7.4] years), representing 687 cases, met the inclusion criteria and were followed up for a median (range) duration of 52 (31-106) months. Of the 687 cases, 274 (39.9%) received a smooth implant and 413 (60.1%) received a textured implant. Patients in these 2 surface texture groups had similar characteristics, including tumor staging (stage I: 102 [37.2%] vs 173 [41.9%]; stage II: 93 [33.9%] vs 119 [28.8%]; stage III: 14 [5.1%] vs 20 [4.8%]; P = .50) and rates of adjuvant radiotherapy (42 [15.3%] vs 49 [11.9%]; P = .19) and chemotherapy (113 [41.2%] vs 171 [41.4%]; P = .97). The 5-year LRRFS was 96.7%, and the 5-year DFS was 95.2%. Compared with the use of a smooth implant, textured implant use was statistically significantly associated with lower DFS, and this difference remained significant after adjusting for estrogen receptor (ER) status and tumor stage (HR, 3.054; 95% CI, 1.158-8.051; P = .02). Similar statistically significant associations were observed on multivariable analysis of patients with ER-positive cancer (HR, 3.130; 95% CI, 1.053-9.307; P = .04) and those with invasive cancer (HR, 3.044; 95% CI, 1.152-8.039; P = .03). The association of textured implant use with recurrence (lower DFS) was more prominent in cases with late-stage (stage II or III) tumor (HR, 8.874; 95% CI, 1.146-68.748; P = .04). The LRRFS did not differ statistically significantly according to implant surface texture. This cohort study found that use of textured implants in reconstruction appears to be associated with recurrence of breast cancer. Further investigation is required to verify these results.

4‐year follow‐up of staging surgical treatment for ameloblastoma and no‐grafting implantation: A case report

Background: Two-stage surgical protocol for multicystic mandibular provided satisfactory clinical outcomes. The fenestration procedure reduced the range of tumor and curettage in the second stage sustains the shape of mandibular. With or without bone grafting, osteogenesis and bone reconstruction occurred in mandibular bone defect, which provided adequate bone for implant restoration. Aim/Hypothesis: To provide a reference for evaluating the long-term outcomes of spontaneous osteogenesis and implant restoration after staging surgical treatment for multicystic mandibular ameloblastoma. Materials and Methods: A 17-year-old male was diagnosed as multicystic mandibular ameloblastoma and received a two-stage surgical protocol. Radiographic analysis was taken before and after every stage of the treatment. In the first stage, the ameloblastoma was treated by fenestration and decompression technique. Obvious reduction of the lesion extent was observed 9 months later and the curettage of the cyst was presented in the second stage of surgery without bone substitudes grafting. Osteogenesis was discovered in the 6-month and 9-month follow-up of the second stage surgery. Two 4.5x11.0 mm Ankylos implants were placed 14 months after the second stage surgery. The implants were embedded and the healing abutments were attached to the implants 4 months later. Restoration was accomplished 5 months afterwards. The patient was recalled for clinical examination 2 and 4 years post-restoration. Results: Spontaneous osteogenesis was observed 9 months and 14 months after two-stage surgical treatment. Bone-to-implant contact was displayed according to the post-surgical cone-beam CT scan. Normal functioning of the implant restoration was observed in the 2-year and 4-year follow-up. Neither recurrence of the tumor or implant complications was discovered in this case. Conclusions and Clinical Implications: Implant restoration without bone substitudes grafting after staging surgical treatment for ameloblastoma would receive long-term stable outcome in this case. Keywords: Ameloblastoma, staging surgical treatment, implantation, no-grafting

The results of screw augmentation of acetabular cement spacers for the treatment of periprosthetic hip joint infection

IntroductionProsthesis of antibiotic-loaded acrylic cement (PROSTALAC) is widely used in two-stage revision arthroplasty in periprosthetic joint infection (PJI) after total hip arthroplasty (THA). In our institution, we encountered several cases of acetabular cement spacer dislodgement. The aim of this study was to compare the results of two-stage revision arthroplasties with antibiotic-loaded cement spacers with or without screws on the acetabulum for PJI.Patients and methodsThis retrospective study included 44 patients who underwent a two-stage revision THA for PJI from June 2007 to May 2017. We divided the patients into two groups: group 1 consisted of 21 patients (21 hips) who underwent two-stage revision arthroplasty with screw augmentation, while group 2 consisted of 23 patients (23 hips) who underwent the same surgery without screw augmentation at the acetabular cement spacer. We compared the migration and dislodgement of the acetabular cement spacer between the two groups.ResultsBefore the second-stage surgery, there was less vertical migration of the cement spacer in group 1 compared to group 2 (1.2 mm vs 3.1 mm, p < 0.001). There was also less medial migration of the cement spacer in group 1 (0.6 mm vs 1.6 mm, p = 0.001). After the first stage, the mean Harris Hip score was significantly higher in group 1 than in group 2 (75 vs 65, p = 0.033). Cement spacer rotation or total movement out of the acetabular area occurred in six patients, all in group 2. After first stage reinfection occurred in two patients, one in each group.ConclusionsScrew augmentation to the acetabulum in the first-stage surgery provides better stability of acetabular antibiotic cement spacers without increasing reinfection rate.

Adjuvant Chemotherapy in Two-Stage Tissue Expander/Implant Breast Reconstruction: Does it Affect Final Outcomes?

In immediate two-stage implant-based breast reconstruction, adjuvant chemotherapy, when indicated, is usually conducted between the stages, which might influence the outcomes of the second-stage operation. The purpose of this study was to evaluate the potential influence of adjuvant chemotherapy on the final outcomes of two-stage implant-based reconstructions. Patients who underwent immediate tissue expander/implant breast reconstruction between 2010 and 2016, with completion of both stages, were reviewed. Cases were categorized into two groups-adjuvant chemotherapy and no adjuvant chemotherapy. The rates of adverse outcomes were compared between the groups. A total of 602 cases in 568 patients were analyzed, with a mean follow-up period of 58.5months, including 236 patients receiving adjuvant chemotherapy and 366 patients not receiving adjuvant chemotherapy. The two groups had similar baseline characteristics, except for a significantly higher rate of adjuvant radiotherapy in the former group. The adjuvant chemotherapy group showed significantly higher rates of overall complications (odds ratio [OR] 2.127, 95% confidence interval [CI] 1.231-3.676), including infections (OR 4.239, 95% CI 1.059-16.970), severe capsular contractures (OR 2.107, 95% CI 1.067-4.159), and reconstruction failures (OR 12.754, 95% CI 1.587-102.481) compared with the control group, after adjusting for other variables, including adjuvant radiotherapy. In the analysis regarding the influence of chemotherapy regimens, the use of sequential anthracycline/cyclophosphamide and taxane, and concurrent 5-fluorouracil, doxorubicin and cyclophosphamide, were associated with increased risks for adverse outcomes compared with the no chemotherapy group, while the use of other regimens, including anthracycline/cyclophosphamide alone, was not. Adjuvant chemotherapy might influence the final outcomes of two-stage implant-based reconstruction.

UV-Mediated Photofunctionalization of Dental Implant: A Seven-Year Results of a Prospective Study.

Our objective was to evaluate the seven-year results of photofunctionalized implants placed in regular, complex, and cancer-related cases. This study was a prospective, single-center study. Photofunctionalization was performed immediately prior to implantation with Ultraviolet (UV) light for 15 minutes. The success rate of each patient group and the influential factors on implant failure were analyzed. Seventy implants in 16 patients were included. Four implants were left submerged (sleep). The seven-year success rate of 30 implants in regular cases and 21 implants in complex cases was 100%. The success rate of 15 implants in cancer-related cases was 22.2%, in which implants were placed in resection or reconstructed sites with or without pre- or postoperative radiation history. Implant stability quotient (ISQ) values increased at second-stage surgery by 3.2 in regular cases and by 21.9 in complex cases, while it decreased by −3.5 in cancer cases. Multivariate analysis indicated that bone quality, location, and cancer resection significantly influenced implant failure. A very reliable seven-year success rate was obtained by UV-photofunctionalized implants in regular and complex cases, even with significant site-development procedures. However, the success rate in cancer cases was significantly and remarkably lower, suggesting remaining challenges of pathophysiologically compromised conditions, such as bone resection, segmental defect, and radiation.

Liver regeneration after performing associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) is histologically similar to that occurring after liver transplantation using a small-for-size graft.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can achieve marked future liver remnant (FLR) hypertrophy but this procedure is associated with a risk of mortality due to liver failure because of an insufficient FLR functional increase, a situation comparable to small-for-size syndrome (SFSS) after living-donor liver transplantation (LDLT). The clinical data, morphologic volume changes, and histopathologic and immunohistochemical findings in hepatocytes and bile ductules were compared between ALPPS (n = 10) and LDLT with a risk for SFSS (n = 12). Although the patient characteristics and short-term outcome differed between the groups, the mean hypertrophy ratios with respect to liver volume for the FLR after performing the first-stage ALPPS procedures resembled those in small-for-size grafts after similar time intervals: 1.702 ± 0.407 in ALPPS vs. 1.948 ± 0.252 in LDLT (P = 0.205). The histologic grades for sinusoidal dilation (P = 0.896), congestion (P = 0.922), vacuolar change (P = 0.964), hepatocanalicular cholestasis (P = 0.969), and ductular reaction (P = 0.728) within the FLR at the second-stage operation during ALPPS or implanted graft were all similar between the groups. The hepatic regenerative process may be similar in ALPPS and LDLT using a small-for-size graft. Reducing the hepatic vascular inflow that may be excessive for the FLR volume during the first stage of ALPPS might enhance the functional recovery since measures with a similar effect appear to lessen the likelihood of SFSS.

Surgical Planning for Cleft Lip and/or Palate-Induced Moderate-to-Severe Midfacial Hypoplasia.

Distraction osteogenesis and conventional bimaxillary orthognathic surgery have been performed for the treatment of midfacial hypoplasia for a long time. However, the effect of these 2 techniques on the maxilla, mandible, and whole-facial profile is significantly different. In this study, we aimed to measure the pre- to post-treatment changes in maxillary prominence, mandible size, and facial length and compare them between these 2 techniques to inform selection of the best technique. This single-center, retrospective study included 35 patients with a cleft lip and/or palate-induced midfacial hypoplasia; 25 were treated using rigid external distraction osteogenesis and 10 using bimaxillary orthognathic surgery. Three-dimensional measures of changes in facial structure were obtained from reconstructed computed tomography images and used to compare the effects of the 2 techniques. Satisfactory appearance and occlusion were achieved in all patients. Three-dimensional reconstruction of the craniofacial skeleton revealed significant maxillary advancement (P < 0.001), mandibular (clockwise) rotation (P < 0.001), and increased facial length (P < 0.001) after rigid external distraction osteogenesis and obvious shortening of the mandibular body (P < 0.001) after bimaxillary orthognathic surgery. Distraction osteogenesis can be selected as the first choice of treatment for cleft lip and/or palate-induced midfacial hypoplasia. A mandibular setback procedure can be performed as a second-stage surgery when severe temporomandibular joint complications develop with distraction osteogenesis. Bimaxillary orthognathic surgery results in an obvious shortening of the mandibular body, which is not a natural change in facial morphology. Therapeutic III.

High-Power Diode Laser for Second-Stage Implant Surgery in an Anticoagulated Patient: A Clinical Case Letter.

Not required.

Rehabilitation of one-piece screw-retained implant crowns placed at second-stage surgery-a retrospective patient series.

To evaluate the esthetic and functional rehabilitation of single implants delivering the final crown during second-stage surgery. In 26 single-tooth implants, the impressions were taken immediately after implant placement to fabricate the final crowns. During the second-stage surgery, the screw-retained hybrid crowns were delivered. Six months to 3years after placement of the crown, a modified pink esthetic score (PES) was measured. Additionally, the number of treatment sessions was recorded. The mesial and distal contact points and the static and dynamic occlusion were examined. Patients' satisfaction was measured using a questionnaire. In this retrospective study, 21 posterior and 5 anterior implants were included. The average pink esthetic score was 11.3 out of 14. The most frequent limitations were incomplete papillae and deficits of the alveolar ridge. The average number of appointments was three, consisting of impression taking and surgery consent, implant placement, and crown delivery. Average patients' satisfaction was 46.7 out of 50 and thus, extremely high. The presented approach allows the second-stage surgery and delivery of the final restoration for single-tooth implants in the same session. As the peri-implant mucosa is adapted to the final restoration in the first place, a more natural emergence profile is achieved. However, there is an increasing risk for reduced or missing papillae. Patients' satisfaction is generally very high. A method for direct definitive prosthetic restoration during the exposure of single-tooth implants is examined, advantages and disadvantages will be described, and patient acceptance is validated.

No-wait two-stage flowshop problem with multi-task flexibility of the first machine

For the creation of intelligent management systems in hospitals, efficient resource arrangement is essential. Motivated by a real-world scenario in hospitals, we introduce the no-wait two-stage flowshop scheduling problem with the first-stage machine having multi-task flexibility. In this problem, each job has two operations which are processed in order on a two-stage flowshop without preemption and time delay between or on machines. The multi-task flexibility allows the first-stage machine to process the second-stage operations. The goal is to minimize the maximum completion time of all jobs. To the best of our knowledge, this is a pioneering work on this problem. We discover several novel structural properties, based on which we present a linear-time combinatorial algorithm with an approximation ratio 138. This problem and its variants can find many other meaningful applications in modern manufacturing systems, such as the robot cell scheduling with computer numerical control machines or printed circuit boards. The idea behind our algorithm may inspire more practical algorithms.

An articulated spacer made of new primary implants in two-stage exchange for infected total knee arthroplasty may provide durable results.

Our objective is to describe our early and mid-term results with the use of a new simple primary knee prosthesis as an articulating spacer in planned two-stage management for infected knee arthroplasty. As a second objective, we compared outcomes between the group with a retained first stage and those with a complete two-stage revision. We included 47 patients (48 knees) with positive criteria for infection, with a minimum two-year follow-up, in which a two-stage approach with an articulating spacer with new implants was used. Patients with infection control, and a stable and functional knee were allowed to retain the initial first-stage components. Outcomes recorded included: infection control rate, reoperations, final range of motion (ROM), and quality of life assessment (QoL) including Western Ontario and McMaster Universities osteoarthritis index, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, 12-Item Short-Form Health Survey questionnaire, and University of California Los Angeles (UCLA) activity score and satisfaction score. These outcomes were evaluated and compared to additional cohorts of patients with retained first-stage interventions and those with a complete two-stage revision. Mean follow-up was 3.7 years (2.0 to 6.5). Eight knees failed directly related to lack of infection control (16%), and two patients (two knees) died within the first year for causes not directly related, giving an initial success rate of 79% (38/48). Secondary success rate after a subsequent procedure was 91% (44/48 knees). From the initially retained spacers, four knees (22%) required a second-stage revision for continuous symptoms and one (5%) for an acute infection. There were no significant differences regarding the failure rate due to infection, ROM, and QoL assessment between patients with a retained first-stage procedure and those who underwent a second-stage operation. Our protocol of two-stage exchange for infected knee arthroplasties with an articulating spacer and using new primary knee implants achieves adequate infection control. Retained first-stage operations achieve comparable results in selected cases, with no difference in infection control, ROM, and QoL assessment in comparison to patients with completed two-stage revision surgery. Cite this article: Bone Joint J 2020;102-B(7):852-860.

Osteotome Sinus Floor Elevation and Implant Placement in Grafted Sockets After Extraction

Immediate bone grafting procedures were proposed to preserve bone volume in residual damaged alveolar walls and to prevent the expansion of the sinus floor in the maxillary molar region. The use of an osteotome allows vertical bone augmentation and localized sinus elevation with minimal surgical trauma. The aim of this study is to evaluate the clinical outcome of implant placed in previously grafted alveoli that were expanded at a second-stage surgery by an osteotome technique. At the 6-month follow-up, the use of the osteotome technique for vertical expansion of the grafted tissue was considered a predictable procedure in the implant surgery. Although these are promising clinical results, further studies are needed to better understand the healing process of grafted biomaterials in relationship with dental implants.

Complete caudal duplication syndrome

Caudal duplication syndrome (CDS) is associated with duplications involving the gastrointestinal, genitourinary, and spine/spinal cord. It is rare to encounter a single infant with all of the mentioned abnormalities, meanwhile, with duplex pelvis and both lower limbs. Here we firstly present a male infant with an omphalocele; bilateral cryptorchidism; congenital intestinal malrotation; spina bifida; duplex pelvis, lower limbs, penis, urogenital system, ileum, colon, rectum, anus, and blood vessels of pelvic. We call it complete caudal duplication syndrome. The first-stage of operation was performed and the 4-year follow-up showed no obvious growth and development restriction. It was planned to perform second-stage surgery.

Study on the effect of simple incision of ventral tunica albuginea on the correction of penile curvature in hypospadias

Objective: To investigate the therapeutic effect of simple tunica albugineaincision and ventral penile lengthening surgery on the correction of penile curvature due to asymmetry of the cavernous bodies in hypospadias. Methods: A retrospective analysis was performed in 39 children with hypospadias who underwent simple tunica albuginea incision and ventral penile lengthening surgery for correcting asymmetry of the cavernous bodies from January 2016 to December 2018(36 of them were from Department of Pediatric Urology surgery, The Children's Hospital, Zhejiang University School of Medicine, and 3 from Department of Urology surgery, Affiliated Hospital ofJiaxing University), all of whom aged from 0.5 to 5, with a median age of 1.1 years. During the first stage of the operation, firstly penile skin and sarcoma was released by completely degloving the skin and fascia of penis, secondly the factor of short urethral plate was solved by transection of urethral plate, and then the dorsal length of penis (A), the ventral length of the penis before and after straightening by incision of tunica albuginea (B and C) were measured and recorded; onto the second stage of the operation, an artificial erection test was performed to observe the curvature of the penis, the dorsal and ventral length of the penis (D and E) were measured. The dorsal and ventral length of the penis before and after straightening were compared. Results: The dorsal length of penis (A) was 33-39(35.6±3.2) mm, the length of ventral length of penis before straightening (B) was 28-35 (29.8±2.8) mm and the length of ventral length of penis after straightening (C) was 32-38 (34.3±2.1) mm, which were measured during the first stage of operation, and the difference between B and C was statistically significant (P<0.05), while the difference between A and C was not statistically significant (P>0.05). The dorsal length of penis (D) was34-41 (36.4±2.5) mm and the ventral length of penis (E) was 33-40 (35.7±3.6) mm, which were measured during the second stage of operation, and there was no significant difference between D and E (P>0.05). The degree of penile curvature at the time of erection was less than 15° by measuring with the side photos in all patients during 0.5 to 2.5 years of follow-ups with an average of 1.7 years. Conclusions: Penile curvature due to the asymmetry of the cavernous bodies could be effectively corrected by simple incision of ventral tunica albuginea, which showed a good result of early follow-up. The effect of this surgery on ventral penile straightening could be verified by measuring and comparing the ventral and dorsal length of penis during surgery.