Single Surgical Technique Research Articles

Using the superiorly based pharyngeal flap to surgically manage cleft velopharyngeal insufficiency: a cohort study

Introduction: The surgical management of velopharyngeal insufficiency is traditionally guided by algorithms based on dynamic imaging, such as nasoendoscopy and video fluoroscopy. In practice, however, surgeons often favour a single surgical technique in all patients—irrespective of observed velopharyngeal closure pattern. In this study, we examine the utility of the superiorly based pharyngeal flap for correcting velopharyngeal insufficiency in a cohort of patients with varied velopharyngeal closure patterns. Methods: A retrospective cohort study was conducted of velopharyngeal insufficiency patients treated by a single surgeon at the Royal Children’s Hospital, Melbourne, between 2008 and 2015. Prior to surgery, patients underwent speech evaluation as well as nasopharyngoscopy for assessment of velopharyngeal closure pattern. Irrespective of the closure pattern observed, patients were treated using a superiorly based pharyngeal flap. Following surgery, serial evaluations for residual velopharyngeal insufficiency and surgical complications were performed. Results: A total of 18 cleft palate patients met the criteria for study inclusion. Preoperative speech evaluation revealed mild velopharyngeal insufficiency in one patient (5.6%), moderate velopharyngeal insufficiency in nine patients (50%), and severe velopharyngeal insufficiency in eight patients (44.4%). Repeat speech evaluation one year after surgery demonstrated correction of velopharyngeal insufficiency in 17 patients, representing a 94.4 per cent success rate. Furthermore, only two patients experienced postoperative snoring (11.1%). Conclusion: Consideration of velopharyngeal closure pattern is not required for effective surgical management of velopharyngeal insufficiency.

Long-Term Follow-Up After Laparoscopic Radical Prostatectomy for Localized and Locally Advanced Prostate Cancer

Objective To explore the impact of laparoscopic radical prostatectomy (LRP) on lower urinary tract symptoms and erectile function. Materials and Methods A retrospective study was conducted on patients who underwent LRP at the Civil Hospital Ahmedabad’s Urology Department from June 2008 to June 2023. Results Major complications following LRP are generally rare, including bladder neck stenosis, erectile dysfunction, and urinary incontinence. The incidence of erectile dysfunction varies widely, ranging from 11-87%, and urinary incontinence ranges from 0-87%, depending on the definitions used. Functional decline typically peaks shortly after surgery, with the most rapid recovery occurring within the first year post-LRP. Some patients continue to improve gradually over time. However, for some men, these adverse effects can be long-lasting. Other, less common side effects should also be considered. Despite significant technological advancements in the past 20 years, no single surgical technique has emerged as superior in terms of long-term outcomes, as surgical volume, surgeon experience, and patient characteristics remain key determinants. Conclusion When discussing treatment options for prostate cancer, it is crucial to consider potential complications like erectile dysfunction and urinary incontinence following LRP, as well as the expected recovery period. Counseling is provided to patients, taking into account their age and overall health profile. Surgical advice is given to eligible patients after evaluating the risk-benefit ratio. Patients who are older or do not meet the criteria are given appropriate guidance. All patients are informed about the possible complications after surgery and are presented with the option of palliative care or surgical treatment.

Decreasing Osteomyelitis Occurrence in Remaining Bone After Partially Resected Infected Bone.

After partial bone resection for osteomyelitis there is a high rate of osteomyelitis occurrence in the remaining bone due to adherent bacterial biofilm, dysvascular infected spongiosum bone, and absence of a surgical technique that can prevent osteomyelitis developing in the remaining bone. Presented is a surgical procedure using a dicalcium phosphate bone void filler putty with antibiotics placed into the remaining bone to prevent the development of osteomyelitis, therefore preventing amputation. This procedure has an osteomyelitis eradication rate of 94.8% and also decreases the rate of lower-extremity amputations. This procedure provides a single stage surgical technique for infected open bone defects decreasing the previously reported high osteomyelitis reoccurrence rate of 57.1% to 5.2%.

Coronary unroofing does not fits all anomalous aortic origin of coronary arteries.

Anomalous aortic origin of coronary artery (AAOCA) is the second leading cause of sudden cardiac death in children and young adults. Intramural-interarterial course is the most frequent anatomic variation and coronary unroofing is widest adopted for surgical management. Symptoms recurrence is described regardless of the technique used. This study aims to describe how an anatomic patient-centered approach aimed to restore a normal coronary artery take-off is associated with symptoms resolution. From 2008 to 2021, 25 patients were operated on for an AAOCA at a median age of 20 years. Nineteen patients had a right AAOCA and six had left AAOCA. Intramural course was present in 18 patients. Seventy-six percent were symptomatic. No episodes of aborted sudden cardiac death before surgery was described in the population. Surgical technique used were coronary unroofing in 18 patients, coronary neo-ostioplasty in 3, coronary Reimplantation in 3, and main pulmonary artery re-location in 1. No hospital mortality or reoperation was observed in our experience as well as major complications related to surgery. Mean hospital length of stay was 8.5 days. None of patients reported symptoms recurrence at follow-up. Young athletes returned to play competitive sport. Postoperative computed tomography scan evaluation showed a general improvement of the take-off angle. AAOCA requires a patient anatomic-based surgical management. There is not a single surgical technique that can fits all anatomic subtype of AAOCA. Surgical techniques may be selected on the base of the preoperative images and intraoperative findings. In our experience, this policy is associated with no symptoms recurrence.

How to Address Scar Pincushioning and Webbing of the Nasal Dorsum Using Surgical Defatting and Z-plasty

Nonmelanoma skin cancer is the most common cancer, typically growing in sun-exposed areas, such as the nose. After complete excision of the tumor, the subsequent scar may exhibit multiple complications that are easily noticeable and cosmetically unsatisfactory. When performing a revision of such a scar, using a single surgical technique may be insufficient; rather, the surgeon may need to carefully plan and utilize several techniques to achieve the best cosmetic outcome. Here, we report a case that demonstrates successful use of surgical defatting and Z-plasty techniques to revise a scar of the nasal dorsum that exhibited pincushioning and webbing.

Decannulation of Tracheostomy-Dependent Patients: Results and Review of Techniques of Reconstructive Transoral Laser Microsurgery.

This study aims to demonstrate the benefit of reconstructive transoral laser microsurgery (R-TLM) in decannulation of tracheostomy-dependent patients with airway obstruction. A consecutive series of tracheostomy-dependent patients who underwent R-TLM using multiple techniques described in our previous works, were reviewed for outcomes especially for decannulation. Full airway examination was essential to determine the anatomical and functional sites of obstruction to establish the surgical plan including R-TLM techniques needed to improve airway prior to permanent decannulation. Twenty-two patients were treated. Eighteen subjects were successfully decannulated. Single or multiple R-TLM surgical technique(s) was/were performed during the same surgery to treat upper airway stenosis at the level of the hypopharynx, larynx, and trachea. The mean number of surgeries per patient was 2.1. Patients were followed up for at least 12 months. R-TLM combines different surgical techniques which can be used individually or combined in a stepwise surgical plan for permanent decannulation of tracheostomy-dependent patients with a previous history of decannulation failure secondary to airway obstruction. Accurate preoperative examination gives valuable information about airway and allows establishing a stepwise surgical plan that may need multiple surgeries for full permanent decannulation of these patients.

Pain versus Gain: Multiport versus single-port thoracoscopic surgery for pediatric pneumothorax a case series

BackgroundThe indications for single-incision thoracoscopic surgery in children are expanding. We present outcome comparisons in single versus multi-port surgical technique for management of Primary Spontaneous Pneumothorax (PSP) in seven children. MethodsThis retrospective chart review of the outcomes from a single-surgeon's experience in thoracoscopic technique over a two-year period includes seven cases, divided into two groups: traditional multiport video assisted thoracoscopic surgery (MP-VATS) (n = 3) versus single-port VATS (SP-VATS) (n = 4). Data for patient demographics, chest tube placement, operation details, opioids usage, and postoperative course were recorded and analyzed. ResultsSeven patients had a median age of 14.88 years [range 12–17 years] with a male predominance 67% MP-VATS and 75% SP-VATS (p = 0.41). Average time to surgery: 3.6 days (p = 0.21) operating time: 1.2 hours (p = 0.09). Estimated blood loss was higher for MP-VATS 5.33 ml vs SP-VATS 2.25 ml but not statistically significant (p = 0.11). Opioids given in the post-operative period until chest tube removal were similar: MP 0.19 vs SP 0.12 mg/kg (p = 0.17). Time to chest tube removal was significantly longer at 5.54 vs 3.59 days for MP-VATS vs SP-VATS (p < 0.05). Length of stay was 10.46 vs 8.33 days for MP-VATS vs SP-VATS (p = 0.30). One SP patient had recurrent pneumothorax after chest tube removal, requiring replacement of chest tube, one MP patient required an additional surgery for contralateral PSP. ConclusionIn this small case series, outcomes were similar for MP-VATS and SP-VATS for PSP, but chest tube removal was earlier in SP. This provides a convincing basis to expand the usage for this technique.

Duodenal ulcer perforation: A systematic literature review and narrative description of surgical techniques used to treat large duodenal defects.

There is no consensus on optimal surgical treatment of large duodenal defects arising from perforated ulcers, even though such defects are challenging to repair and inadequate repair is associated with high morbidity and mortality. The aim of this study was to carry out a systematic literature review of different surgical techniques used to treat large duodenal perforations, provide a narrative description of these techniques, and propose a framework for approaching this pathology. PubMed/MEDLINE database was searched for articles published in English between January 1, 1970, and December 1, 2020. Studies describing surgical techniques used to treat giant duodenal ulcer perforation and their outcomes in adult patients were included. No quantitative analysis was planned because of the heterogeneity across studies. Out of 960 identified records, 25 studies were eligible for inclusion. Two randomized controlled trials, one case-control trial, three cohort studies, 14 case series, and 5 case reports were included. Eight main surgical approaches are described, ranging from simple damage-control operations, such as the omental plug and triple-tube techniques, all the way to complex resections, such as gastrectomy. Evidence on surgical treatment of large duodenal defects is of poor quality, with the majority of studies corresponding to Oxford levels 3b-4. Current evidence does not support any single surgical technique as superior in terms of morbidity or mortality, but choice of technique should be guided by several factors including location of the perforation, degree of duodenal tissue loss, hemodynamic stability of the patient, as well as expertise of the operating surgeon. SR with more than two negative criteria, Level IV.

The Role of Lateral Internal Sphincterotomy in Haemorrhoidectomy: A Study in a Tertiary Care Center.

BackgroundHemorrhoids are a common condition that presents with bleeding per rectum, pain at rest and defecation, mucosal discharge, and prolapse. Surgical hemorrhoidectomy is the treatment method of choice for Grade 3 and Grade 4 hemorrhoids. Hemorrhoidectomy is associated with postoperative pain and no single surgical technique has been proved to significantly reduce the pain. We analyzed in our study the effect of lateral internal sphincterotomy with hemorrhoidectomy on postoperative pain, anorectal function, and retention of urine after the Milligan and Morgan technique.MethodsThis randomized, prospective, and comparative study included 200 Grade 3 and Grade 4 hemorrhoids patients who were scheduled for surgical management. The patients were classified randomly into two groups with an equal number of participants: Group A underwent Milligan & Morgan open hemorrhoidectomy and Group B underwent lateral internal sphincterotomy (LIS) in addition to Milligan and Morgan open hemorrhoidectomy. Postoperative pain was recorded using the Visual Analog Scale (VAS) score for up to 48 hours. Postoperative bleeding, urinary retention, and bowel and gas incontinence were noted. Long-term follow-up at six and 24 months for anal stenosis, anal fissure, incontinence, and recurrence was also noted.ResultsPatients who underwent LIS showed a significant reduction in postoperative pain at 12 hours (p=0.0008*), 24 hours (p=0.000*), and 48 hours (p=0.003*); the time taken to request rescue analgesia was similar between the two groups (p=0.07). Side effects, such as postoperative bleeding and urinary retention, were significantly lower after LIS (p=0.001* and p=0.01*, respectively), and gas incontinence was significantly higher after LIS (p=0.002*). The long-term outcomes of anal fissure were significantly higher without LIS at six months (p=0.02*) and 24 months (p=0.04*) and those of anal stenosis were significantly higher without LIS at six months (p=0.04*).ConclusionsFrom our study, we conclude that postoperative pain, bleeding, and urinary retention were significantly lower after LIS, and gas incontinence was transient. The long-term outcomes, which included anal stenosis and anal fissure, were significantly lower after LIS. However, bowel and gas incontinence and recurrence were not altered. Therefore, we conclude that the addition of LIS to hemorrhoidectomy improves patient outcomes in terms of postoperative pain and anorectal function.

Single incision, minimally invasive fasciotomy of the anterior and lateral leg compartments with decompression of the superficial peroneal nerve

BackgroundThere is a considerable overlap of symptoms between chronic exertional compartment syndrome (CECS) of the anterior and lateral compartments of the lower leg and entrapment neuropathy of the superficial peroneal nerve (SPN). We describe a minimally invasive, single incision surgical technique for release of both the compartments and the SPN in the same setting. The operative technique involves a minimal anterolateral approach at the level where the SPN pierces the subcutaneous fascia. MethodsNineteen patients were operated with the method and 24 anterolateral compartments (5 cases with bilateral CECS) were released. Anterior and lateral, proximal and distal fasciotomies were performed sequentially with the use of a specific instrument designed for carpal tunnel release (KnifeLight®, Stryker). This is a modification of a fasciotome with an intergrated light source which allows for transillumination of the subcutaneous tissues. The SPN and its main branches with their anatomical variations were explored and decompressed at the same setting. ResultsPatients who met the inclusion criteria were reviewed at one year postoperatively with a Numeric Analog Pain Scale (NAS) and the Linkert satisfaction scale. There were 5 men and 10 women, aged 35.7 (21–60) years. The NAS scores improved by a mean 6 points (p<0.0001) postoperatively and 86.6% (13/15) of the patients were either satisfied or very satisfied with the operation. There were no intraoperative complications. There were two patients with SPN neuropathy symptoms postoperatively, one of whom required revision surgery. One patient had recurrence of less intense symptoms in the first postoperative year with no need for reoperation. ConclusionsThe simultaneous release of the anterolateral compartment of the leg and decompression of the SPN with the described technique was safe and effective. It combined the advantages of a single, minimally invasive approach with the subcutaneous transillumination, and had a high patient satisfaction and a low recurrence rate. Level of evidenceRetrospective case series, Level IV.

Respect or resect: A single strategy does not fit all.

Mitral valve (MV) repair for mitral regurgitation (MR) due to posterior leaflet (PL) prolapse is achieved nowadays with a great success rate and a good survival, similar, in certain subgroups. In this paper, Sakaguchi et al describe their results in two groups of patients with PL prolapse. Some patients underwent resection (resection group) and others chordal replacement with/out limited resection (respect group). Results were similar in terms of survival and MR recurrence. Our goal is to eliminate, as much as possible, MR when a patient with degenerative MR is operated on. Reduction of the mitral orifice and consequently an increase of the transmitral gradient is the rule. MV repair for degenerative MR provides great results, but there is not a single surgical technique. A close evaluation of the anatomical findings will allow us to choose the best strategy for the individual patient. An open mind is the most important characteristic that a surgeon should have to repair a prolapsing PL without residual regurgitation and dangerous gradients.

Long-term results of in-the-bag primary intraocular lens implantation in children younger than 24 months.

The purpose of this study was to analyze the safety of primary intraocular lens implantation in a large number of eyes in children aged <24 months. The medical records of patients aged 5-24 months, who underwent primary intraocular lens implantation in the capsular bag, were reviewed. A foldable three-piece acrylic intraocular lens was implanted by the same surgeon using a single surgical technique. Patients who had <1 year of follow-up after the surgery were excluded. The main outcome measurements included visual acuity, myopic shift, follow-up complications, and additional surgeries. Sixty-eight patients (93 eyes) were analyzed. The mean age of the patients at the time of surgery was 15.06 ± 6.19 months (range: 5-24 months), and the spherical equivalent 1 month after surgery was 3.62 ± 2.32 D. After 5.67 ± 3.10 years, the spherical equivalent was -0.09 ± 3.22 D, and the corrected distance visual acuity was 0.33 ± 0.33 and 0.64 ± 0.43 logMAR in bilateral and unilateral cases, respectively (p=0.000). The highest myopic shift was observed in infants who underwent surgery at ages 5 and 6 months. The most frequent complications included visual axis opacification and corectopia. Glaucoma and retinal detachment were not reported. Primary in-the-bag intraocular lens implantation in children aged 5-24 months is safe, and is associated with low rates of adverse events and additional surgery.

Recommendations for Patients with High Return to Sports Expectations after TKA Remain Controversial.

(1) Background: Improved surgical techniques and implants in total knee arthroplasty (TKA) have led to broader indications for surgical interventions of osteoarthritis of the knee. There is a growing young and active patient subgroup with high return to sports (RTS) expectations after TKA. The current lack of evidence regarding RTS capacity in this patient cohort, requires the consolidation of experts’ opinions and experiences to address the special needs among these patients. The aim of this study was to assess current expert opinions in regard to preoperative patient assessment, surgical technique and decision-making and patient counseling for these patients. (2) Methods: We performed a survey among surgeons specialized in arthroplasty with a questionnaire designed to assess current recommendations, surgical techniques, and implant preferences as well as patient counseling in patients with high expectations for RTS after TKA. (3) Results: The majority of surgeons are in favor of return to low-impact sports after TKA within 3 to 6 months. Some even recommend return to high-impact sports. Despite improvement of surgical techniques and implants, we observed no clear preference for a single surgical technique or implant specification in active patients. (4) Conclusions: Current evidence for sports-associated complications after TKA is scarce. Despite a growing array of surgical techniques and implants, the available literature is still controversial with no single surgical technique or TKA design distinguishing itself clearly from others. Surgeons’ recommendations are mostly based on their experience and training. Nonetheless, we observed growing faith in modern implants with some surgeons even recommending high-impact sports after TKA.

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.

To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5mm) and when hysteroscopic treatment is inconclusive.

26. Posterior ligamentous reinforcement does not prevent proximal junctional kyphosis in adult spinal deformity

BACKGROUND CONTEXT Violation of the posterior soft tissues is believed to contribute to the development of proximal junctional kyphosis (PJK). Clinical and biomechanical studies have suggested that augmentation of the posterior ligamentous structures (PLS) may help prevent PJK. PURPOSE To determine whether augmentation of the PLS from the UIV-1 to UIV+1 prevents PJK. STUDY DESIGN/SETTING Single-surgeon retrospective cohort study. PATIENT SAMPLE One hundred fifty adult spinal deformity patients. OUTCOME MEASURES PJK (defined as a proximal junctional angle ≥20°) at final follow-up. METHODS We conducted a retrospective cohort study of 150 adult spinal deformity patients who underwent ≥5 level fusions to the pelvis by a single surgeon between 2014 and 2017. Exclusion criteria included neuromuscular or congenital scoliosis (18 patients), or follow-up less than 1 year (24 patients), leaving 108 patients available for final analysis. Patients were divided into two groups: PLS+ patients had reconstruction of the PLS between UIV+1 and UIV-1 with a surgical nylon tape while PLS- patients did not. Demographics, surgical data, and sagittal alignment parameters were compared between the cohorts. The primary outcome of interest was the development of PJK at final follow-up (1 or 2 years). A subgroup propensity match and backward stepwise logistic regression model were utilized to control for surgical and radiographic differences in the cohorts. RESULTS Thirty-one patients (28.7%) were PLS+. There were no differences with regard to preoperative or final sagittal alignment parameters, number of levels fused (10.7±3.8 vs 9.7±3.8, p=0.331), and BMI (24.9±5.2 vs 27.0±6.9 kg/m2, p=0.143), though the PLS+ cohort was older (64.1±10.4 vs 51.3±21.4 years, p=0.002) and had greater 6-week corrections in sacral slope (SS), pelvic tilt (PT), pelvic incidence-lumbar lordosis (PI-LL), C7-S1 sagittal vertical axis (C7 SVA), and T1 pelvic angle (T1PA), p 0.05 for 6-week changes in SS, PT, LL, PI-LL, C7 SVA, T1PA, thoracic kyphosis, thoracolumbar kyphosis, and cervical lordosis), PLS augmentation was still not associated with a lower rate of PJK (29% PLS+ vs 38.7% PLS-, p=0.367). In our multivariate analysis, only increased sagittal malalignment and failure to restore sagittal balance were retained as having independent associations with PJK, while PLS+ was not retained in the model. CONCLUSIONS Even after controlling for relevant variables such as age, preoperative alignment, and degree of correction, PLS reinforcement at the UIV+1 did not reduce the incidence of PJK at 1 year. Our findings emphasize the multifactorial nature of PJK and the difficulty of preventing PJK with a single surgical technique FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Buck's fascia repair with glanuloplasty in hypospadias surgery: A simple approach with excellent outcome

Hypospadias is a common problem encountered in surgical practice and its repair is challenging because of various complications. Urethro-cutaneous fistula is the most common postoperative complication (incidence of 0-33%). Different types of intermediate protective layers have been used in attempts to decrease UCF formation; however, no single surgical technique is ideal. The aim of this study was to compare use of dartos fascia and Buck's fascia as intermediate layers in prevention of the formation of UCF. This was a prospective, comparative study conducted over a period of 2 years from January 2014 to December 2015. Patients with primary hypospadias without or with mild ventral penile curvature were included in the study. Patients were categorised into two groups, A and B, with alternate patients assigned to each group. Patients in group A underwent Snodgrass repair with urethroplasty by two-layer subepithelial closure and dartos tissue as an intermediate layer. Patients in group B underwent a urethral repair followed by Buck's fascia repair as intermediate layer and glanuloplasty after excision of a triangular skin strip on either side of the urethral plate. Patients were followed at regular intervals for a minimum of 6 months and complications were noted. Over a period of 2 years, 160 patients were included in the study: 80 patients in group A and 80 patients in group B. The age of patients ranged from 1 year to 4.6 years, with a mean age of 1.8 years. Postoperative complications are listed in the summary table. A protective intermediate layer between the neourethra and the skin can be used to reduce fistula formation. We describe a technique of urethroplasty using Buck's fascia as intermediate layer and glanuloplasty, with excellent results. Buck's fascia over the corpora spongiosum which is deficient ventrally in hypospadias is not completely absent, and can be easily used to cover the neourethra, needs minimal dissection and hence vascularity of tissues is preserved (summary Fig.). We used this Buck's fascia as a second protective layer over the neourethra in an attempt to decrease UCF formation, and compared it with use of dartos fascia. In our study, UCF occurred in 2.5% of patients in the Buck's fascia group and 12.5% of patients in the dartos group, a statistically significant difference. We believe that the native Buck's fascia lateral to spongiosum is a more appropriate, natural, and strong layer to cover the neourethra. Use of Buck's fascia as an intermediate layer along with glanuloplasty is simple and very effective in preventing UCF formation and glanular dehiscence. We recommend the use of Buck's fascia as an intermediate layer to cover the neourethra to reduce incidence of postoperative complications and improve results.

Caudal septum surgery techniques reviewed.

The caudal septum has important functional and aesthetic implications. Deviations in this area can result in important nasal obstruction due not only to blockage of the nasal passage but also to compromise of the internal nasal valve. Cosmetically, alterations in the caudal septum can result in a twisted nasal tip, loss of projection, rotation, and imbalance in the ala-columellar relationship. Contemporary surgical options will be discussed showing how to preserve, reshape, and reinforce the caudal septum to obtain a final looking nose that is not only functional but also aesthetically pleasing. Recent publications have shown that cartilage preservation and remodeling techniques can be efficient in the treatment of the caudal septum. Adequate preoperative diagnosis must be made to be able to create a step-wise approach evolving from simple suturing techniques to more complex ones that require the use of grafts to reposition and keep the caudal septum in the midline with an adequate functional and cosmetic outcome. Adequate management of the caudal portion of the nasal septum is a challenge because of its importance in nasal function and cosmetic final results. There are many surgical options that can be used to correct and align this structure and there is no one single surgical technique that can be used in all cases. A step-wise approach is presented covering the different techniques used today evolving from simple to more complicated ones. The final surgical objective should be cosmetically pleasing noses that function appropriately.

Is bone graft fundamental in opening wedge high tibial osteotomy? Evaluation of the short-term results of opening wedge high tibial osteotomy without using bone graft

Introduction High tibial osteotomy has been described as an effective procedure for treatment of medial compartmental osteoarthritis of knee. Many techniques have been developed (closing wedge, opening wedge, etc.), but opening (medial) and closing (lateral) wedge osteotomies are the most commonly used. The use of autograft was the gold standard in opening wedge osteotomy for a long time. Patients and methods This is a prospective study carried on 32 knees in 19 patients in a period between January 2011 and January 2013, with a mean follow-up of 17.4±2.87 months. There were 12 males and seven females, with a mean age of 42.5±10.68 years. There were 13 cases with 26 knees with primary osteoarthritis and six were post-traumatic. The preoperative varus angle was measured by the hip–knee–ankle angle on standing scanogram. A single surgical technique was used for knees: medial opening high tibial osteotomy with locked plate fixation but without filling the defect. The preoperative genu varum could not exceed 15°. The following were evaluated: International knee Documentaion committee Scoring (IKDC) functional score and long-leg standing film were performed preoperatively, postoperatively, and at follow-up to evaluate limb alignment and validate the precision of the correction and its stability over time. Results Bone union occurred at 4.3 months on average; two knees required revisions (6.25%). The first was because of delayed union and was revised with an autograft at the seventh month, and another case of nonunion with implant failure was revised at the fourth month by total knee replacement. Before the surgery, the average varus was174±2.18° (165°–176°); after the surgery, the hip–knee–ankle angle was183°±1.88° (179°–184°) (P=0.0001). This correction was maintained at follow-up. Average Knee Score was improved from 68.0±20 preoperatively to 91.0±19 postoperatively. The Visual Analog Scale score was 76±23 and 38±19 at preoperative and postoperative, respectively, with an average reduction of 38 points. Full weight-bearing without assistance was possible after 3 months on an average. Conclusion Union of the arthritic knees was possible without using bone graft (BG). The time to union was comparable to that after using (BG). Meanwhile, It avoids the risks and complications that might be associated with the use BG or Bone substitutes.

Unstable PIP Fracture-Dislocations

Purpose: Multiple techniques exist as part of the armamentarium for the management of Proximal Interphalangeal (PIP) joint fracture-dislocations. Of these, unstable lesions with hard reduction are the most complicated to handle. This study aims to compare the biomechanical results obtained with volar plate arthroplasty (VPA) and the hemihamate arthroplasty (HHA). Materials and Methods: We used 20 fingers from 8 cadaveric hands. We created a 50% defect on the base of the middle phalanges to simulate an unstable fracture-dislocation. The 2 techniques were assigned randomly to the different fingers (10 for each technique). A biomechanical harness was used to carry all PIP joints from extension to complete flexion. The amount of dorsal translation of the subluxation was recorded digitally at full extension. We recorded the angle at which subluxation occurred for each specimen. Results: The average of dorsal displacement of the middle phalanx did not show statistical significant difference (0.02 mm for the HHA and 0.01 mm for the VPA). All the fingers with VPA coursed with flexion contracture as opposed to the HHA. Conclusions: The VPA and the HHA are current techniques used for the management of unstable PIP fracture-dislocations. The 2 procedures manage to maintain reduction throughout the range of flexo-extension. Surgeons must choose between a little more invasive technique with double incision, hamate block bone graft with potential discomfort in the donor area and screw fixation on the recipient middle phalanx not leading to flexion contracture (HHA); versus a single surgical approach technique -dorsal or ventral- which provides stability but may course with certain flexion contracture.

Effect of First Metatarsophalangeal Joint Arthrodesis on PROMIS Functional Outcomes and Radiographic Alignment for Hallux Rigidus

Category: Midfoot/Forefoot Introduction/Purpose: Improvement in first ray alignment after arthrodesis of the arthritic first metatarsophalangeal (MTP) joint has been shown, yet few studies have attempted to correlate radiographic alignment with functional outcomes. The purpose of this study was to determine if 1st MTP joint deformity due to hallux rigidus correlates with patient reported pain and function, and whether there is a correlation between outcomes and radiographic measurements made before and after surgery. We also sought to determine how 1st MTP joint arthrodesis affects patient reported pain and function in a series of patients with hallux rigidus using a validated outcome measure. Methods: We conducted a retrospective study on patients treated with 1st MTP joint arthrodesis for diagnosis of hallux rigidus from 2012 to 2014 using a single surgical technique. The hallux-valgus angle (HVA), intermetatarsal angle (1-2 IMA) and lateral talar first metatarsal angle (L1TMTA) were measured independently by the senior author and an Orthopaedic Surgery fellow on pre- and post-operative radiographs. Inter-observer and intra-observer coefficients of repeatability were calculated. Pre- and post- operative physical function and pain scores were generated using the Patient Reported Outcome Measurement Information System (PROMIS). Paired t-test was used to detect differences. Bivariate analysis was used to assess radiographic measurement and PROMIS score correlation. Results: 30 subjects met inclusion criteria for radiographic analysis. Mean pre- and post-operative IMA, HVA and LT1MTA are shown in Table I. 23 subjects had pre-operative PROMIS data. Mean pre-operative pain and function were 72.7 and 32.0. Only pre-operative HVA significantly correlated with pre-operative physical function scores, with Pearson correlation value of 0.507 (p = 0.014). 7 subjects had pre- and post-fusion PROMIS data with average follow up 173 days post-fusion (minimum 130, maximum 196). Mean change in pain and function were -9.14 (p = 0.094) and 6.57 (p = 0.31), respectively. Only change in patient reported pain significantly correlated with change in HVA, with a Pearson correlation value of -0.76 (p = 0.05). Interclass correlation coeffecients for interoperator reliability ranged from 0.835 to 0.998. Conclusion: 1st MTP joint arthrodesis significantly improved radiographic IMA, HVA and LT1MTA for patients with hallux rigidus. In a small series of patients, arthrodesis improved patient reported pain and function, but this was not significant. Only pre-operative HVA correlated with pre-operative physical function, while only change in HVA correlated with change in patient reported pain after arthrodesis. Special attention should be paid to the HVA for the patient undergoing 1st MTP arthrodesis for hallux rigidus.