Reconstructive Surgical Techniques Research Articles

Туберкулезный спондилит грудопоясничной локализации: выбор оптимального метода хирургического лечения на основе систематизированного обзора литературы

Introduction Tuberculous spondylitis is the most common extrapulmonary tuberculosis. The thoracolumbar lesion due to tuberculous spondylitis is one of the most difficult locations for surgical treatment. Analysis of the recent literature shows a limited amount of data on the results of various current surgical reconstruction techniques. Purpose To review the literature on surgical treatment of thoracolumbar tuberculous spondylitis published during the last five years and judge upon an optimal method. Materials and methods A systematic literature review was performed of the sources from eLibrary, PubMed, Cochrane Library databases. Inclusion criteria: etiologically verified tuberculous spondylitis of thoracolumbar location, follow-up ≥ 1 year, patients older than 18 years. Twenty-one studies that summarize 1,209 cases were selected. Patients were divided into three groups depending on the method of spinal reconstruction (group 1 – ventral approach, group 2 – combined approach, group 3 – dorsal approach). Surgical indicators, correction of kyphotic deformity and its dynamics in the long-term period, rates of complications and the length of hospital stay were analyzed. Results and discussion Blood loss and duration of the intervention were significantly lower in the reconstruction of the thoracolumbar spine from the dorsal approach (599.6 ± 195.1 ml and 196.3 ± 35.6 min). Correction of kyphotic deformity from posterior and combined approaches was higher than in the reconstruction from the ventral approach (64 and 69 %, respectively). At the same time, an inverse proportional dependence of the degree of correction loss in the long-term period was revealed, which was higher with anterior fusion (7.3° ± 1.7° according to Cobb). The duration of hospital stay was shorter in patients with reconstructions from the dorsal approach (13.7 ± 8.2 days). The rate of complications in group 3 was significantly lower (p < 0.0001), while the assessment of their structure indicates prevalence of neurological deficits in dorsal reconstructions, while in ventral and combined reconstructions, infectious complications, pneumothorax, and chronic pain syndrome in the area of autologous costal graft harvesting. Conclusion The optimal method of surgical treatment of thoracolumbar tuberculous spondylitis is a three-column reconstruction from the dorsal approach. The advantages of the method are a decrease in the rate of postoperative complications, a reduction in the duration of inpatient treatment, surgical blood loss and duration of surgical intervention.

Harnessing the Power of Artificial Intelligence: Revolutionizing Free Flaps Monitoring in Head and Neck Tumor Treatment.

Treating head and neck tumors has undergone significant advancements, focusing on improving the patient's quality of life after treatment. Reconstructive surgical techniques with free flaps have been vital in restoring anatomy, function, and aesthetics, reducing morbidity from locoregional treatments. Monitoring free flaps is crucial to detect and address any vascular compromise that may lead to flap failure. Various monitoring techniques have been employed in free flap monitoring. However, standardizing them presents a challenge due to the need for more consensus among surgeons and variability in techniques, costs, and training requirements. Artificial intelligence (AI) shows promise in standardizing monitoring practices and reducing the operator-dependent variability. AI techniques have been explored to improve monitoring and early detection of complications in free flap surgeries, and they have shown high accuracy in analyzing images and predicting flap outcomes. Despite the potential benefits, implementing AI in free flap monitoring remains challenging. Standardization of input data, interpretation, cost, training, and accounting for patient and flap variability are crucial considerations. Further research, including multicenter studies, validation, and collaboration amongst clinicians, researchers, and AI experts is needed to overcome these challenges.

Simultaneous medial unicompartmental knee replacement and anterior cruciate ligament reconstruction: a narrative review and technical note.

Reconstruction of the anterior cruciate ligament (ACL) simultaneously with medial unicompartmental knee arthroplasty (UKA) has been suggested as an alternative treatment in patients with ACL deficiency and localized osteoarthritis (OA) in young patients. The objectives of this review were to report the current concepts on the topic and describe an original surgical technique of simultaneous medial UKA and ACL reconstruction. A literature search was performed on PubMed, including articles written in English until June 2021. The articles regarding ACL reconstruction and UKA were reviewed using the narrative approach. Inclusion criteria: (I) original articles about ACL reconstruction and unicompartmental knee replacement; (II) written in English; (III) involving three or more cases. Two non-blinded authors reviewed the titles and abstracts of each article identified in the literature search. The articles regarding ACL reconstruction and UKA were reviewed using the narrative approach. There is controversial evidence about performing the UKA simultaneously with an ACL reconstruction. Biomechanical and clinical studies show that the benefits of restoring good joint stability outweigh the possible risks associated with performing both surgeries at the same time. With this strategy, it is possible to obtain good clinical results with a high survival rate of the implant and patient satisfaction.

Yang-Monti ileal ureter: An approach to complex upper urinary tract reconstruction – A case report and literature review

Complex ureteral stricture is a challenge for the reconstructive urologist, the surgical technique depends on the length of the segment. Surgical expertise is fundamental due to the limited surgical management in this scenario. We aim to describe the surgical technique and long-term follow-up of complex ureteral injury reconstruction with the Yang-Monti ileal ureter approach, which can be achieved successfully. A literature review was made using Medscape, Embase, and SciELO databases. We describe the cases of two female patients who had complex ureteral injury after urological procedures. Due to the extent of the ureteral stricture, the Yang-Monti ileal ureter was the best option to preserve renal function successfully in these patients. The Yang-Monti ileal ureter is a feasible surgical technique for the reconstruction of complex ureteral strictures when other approaches have failed. The right selection of patients is fundamental to achieving good results.

Abductor Pollicis Longus Tendon Abnormalities and Release in Children With Congenital Clasped Thumb.

Congenital clasped thumb is associated with deficient thumb extensor tendons. Reconstruction includes tendon transfer. Here, we describe a variant of the abductor pollicis longus (APL) tendon, not previously reported, contributing to the flexion deformity. The purpose of this study is to report examples of and offer surgical repair techniques for APL variants identified in patients with clasped thumb. We reviewed records of 11 consecutive patients undergoing reconstruction for clasped thumb. Surgical anatomy of the APL tendon was evaluated in all patients, followed by release of aberrant APL attachments. Participants were invited to return for an in-person assessment with a certified hand therapist. Data were collected regarding intraoperative findings, surgical techniques for reconstruction, postoperative thumb motion, and patient and caregiver satisfaction. Eleven children (12 thumbs) underwent aberrant APL release and rerouting between 2019 and 2021. Preoperatively, all thumbs were passively correctible to 0° of extension. In all patients, the APL was found to terminate palmar to the metacarpophalangeal (MCP) joint, creating an MCP flexion moment when tensioned. The average age at surgery was 7 years (range: 1-15 years), and the average follow-up was 14.2 months (range: 1-21 months). The mean postoperative thumb radial abduction was 55° (range: 20°-75°). When reconstructing clasped thumbs, surgeons should explore the presence of APL abnormalities. Release and centralization of the APL can improve thumb position and function. This technique may avoid the need for extra-anatomical tendon transfer in patients with clasped thumb.

Многоэтапные операции при стриктурах передней уретры: оценка сексуальной функции.

Introduction. Any sexual dysfunction or complications associated with urethral stricture reconstruction can negatively affect quality of life and patient satisfaction with treatment results, even if the operation is considered 'successful' and urethral patency is restored. According to the literature data, the frequency of erectile dysfunction detected after urethroplasty varies from 0 to 40%. However, most publications are focused on the study of sexual disorders caused bulbar urethral reconstruction and one-stage surgical techniques. Purpose of the study. To evaluate sexual function in patients undergoing multi-stage urethroplasty. Materials and methods. The study included 73 men aged 18–84 years who underwent multi-stage urethroplasty for the anterior urethral structures in 2010–2019. Penile strictures were present in 39 (53.4%) patients, bulbar strictures in 7 (9.6%), penile bulbar strictures in 15 (20.5%) and multifocal strictures in 12 (16.4%) cases. The length of the strictures was 7.27 ± 3.26 (2–18) cm. The effect of staged urethral surgery on sexual function was studied using the IIEF-5, MSHQ-EjD, and MSHQ-InS questionnaires. The mean time from surgery to evaluation of sexual function was 67.8 ± 32.3 (14–134) months. Wilcoxon signed rank test, Mann-Whitney U test, and Kruskal-Wallis H test were used to test for differences in preoperative and postoperative values. Differences were considered significant at p < 0.05. Results. There were no significant changes in the initial indicators of the IIEF-5 questionnaire compared to the postoperative ones (19.67 ± 3.45 (5 – 25) vs 21.73 ± 2.47 (6 – 24) points; the mean difference was (Δ) 2.1, 95% confidence interval (95% CI) 16.1 – 20.2, p = 0.468). The total score of the MSHQ-EjD questionnaire increased from 14.67 ± 3.33 (1 – 28) to 25.41 ± 5.65 (1 – 34) points, the mean difference (Δ) was 10.8, 95% confidence interval (95% CI) – 15.4 – 18.9 (p < 0.001). Similar improvements were observed in the analysis of preoperative and postoperative scores of the MSHQ-InS questionnaire (17.31 ± 4.67 (5 – 30) vs. 24.61 ± 4.13 (8 – 30) points; Δ = 7.2; 95% CI: 15.4 – 18.8, p = 0.036). Conclusions. Patients who underwent multi-stage urethroplasty have minimal changes in erectile function and significant improvements in ejaculatory function, as well as the expressiveness of sexual satisfaction.

Single Pedicle Advancement Flap Models for Teaching Veterinary Reconstructive Surgical Techniques.

Reconstructive surgical techniques are used in both general and referral veterinary practice to facilitate closure of challenging wound defects. During veterinary studies, there are often limited opportunities for students to practice these techniques on live patients or cadavers. Surgical models, including suture pads and ovariohysterectomy models, have been successfully incorporated into veterinary teaching, providing students with additional practice. Models to simulate veterinary reconstructive surgical techniques are lacking. In the current study, a single pedicle advancement flap model was designed. The design consisted of a silicone model secured by a plate, providing tension. Fifth-year veterinary science students (n = 34) were surveyed to assess the model's impact on surgical technique and confidence. Students were also assessed to determine surgical technique using the models. It was hypothesized that students who had two additional practice sessions using the models (Trial group, n = 17) would show greater improvement in technique than students who had no practice sessions between assessments (Control group, n = 17). Students strongly agreed (median score 5/5) that using the model helped to reinforce the subdermal plexus flap technique and improved their confidence in performing a subdermal plexus flap. Students from both groups performed significantly better in the follow-up assessment compared to the initial assessment. No significantly greater improvement was observed in technique between the control and the trial groups. Results suggest that the students' reconstructive surgical technique improved after a single practice session and that the single pedicle advancement flap model can be used synergistically with other teaching methods.

Secure reconstruction after pancreaticoduodenectomy: Review and improved our continuous duct-to-mucosa anastomosis

Abstract Pancreatic anastomotic leakage is the most common major complication after pancreaticoduodenectomy (PD). The incidence of pancreatic anastomotic leak or fistula has declined to less than 20%, and mortality from this complication has decreased to less than 10% in recent years. The ideal surgical procedures to achieve the most secure pancreaticojejunostomy were compared and reviewed. A single-institution and personal experience was retrogradely compared with two periods between 1988 and 2017, which involved 121 patients who were designed to compare the outcome of complications with or without pancreatic stump by four to six sutures before continuous duct-to-mucosa PD. The surgical reconstruction technique was standardized and unique, and the pancreaticojejunal anastomosis was created using the duct-to-mucosa without (group A, n = 62) and with (group B, n = 59) interrupted stump sutures. The rate of grade A pancreatic fistula was 6.9% in group A and 0% in group B (P < 0.05). Postoperative mortality was 0% in group B. No patient underwent reoperative PD due to pancreatic anastomotic leak. The length of stay during admission and after surgery was significant lower in group B, which was due to less complication after surgery. Interrupted suture of pancreatic stump with a continuous duct-to-mucosa end-to-side pancreaticojejunostomy plus external drainage is the best secure method for pancreaticojejunostomy after PD.

Reconstruction of the Axillary Region after Excision of Hidradenitis Suppurativa: A Systematic Review.

Introduction Hidradenitis suppurativa (HS) is a chronic, debilitating, recurrent, auto-inflammatory disease of the pilosebaceous units of the skin. The axillary region is the most affected anatomical site and its reconstructive options include skin grafts, local random plasties, regional axial flaps, and regional perforator flaps. The main aim of this systematic review is to identify the best surgical technique for axillary reconstruction in the context of HS, in terms of efficacy and safety. Methods We adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol build-up. The literature search was performed using MEDLINE, Embase, and Cochrane library databases, updated to March 2021. Quality was assessed for each study, through the National Institutes of Health Quality Assessment Tool. Results A total of 23 studies were included in the final analysis. We reviewed a total of 394 axillary reconstructions in 313 patients affected by HS Hurley Stage II or III. Skin grafts were associated with the highest overall complication rate (37%), and highest rate of reconstruction failure (22%). Between thoraco-dorsal artery perforator flap, posterior arm flap, and parascapular flap, the latter showed fewer total complications, recurrences, and failures. Conclusion Regional axial flaps should be considered as the best surgical approach in the management of advanced HS. The parascapular flap emerges as the most effective and safest option for axillary reconstruction. Local random flaps might be considered only for selected minor excisions, due to the higher risk of recurrence. The use of skin grafts for axillary reconstruction is discouraged.

A simple surgical technique for sellar closure after transsphenoidal resection of pituitary adenomas in the context of risk factors for cerebrospinal fluid leaks and meningitis.

The transsphenoidal approach is the standard for most pituitary tumors. Despite low morbidity, postoperative CSF fistulas and meningitis are specific complications. Various surgical closure techniques for intraoperative CSF (iCSF) leak and sellar reconstruction have been described. For many years the authors have applied synthetic materials for iCSF leak repair and sellar closure in a standardized fashion in their department. Here they analyze the surgical outcome as well as risk factors for iCSF leak and meningitis. All patients with transsphenoidal resection of a pituitary adenoma performed by the same surgeon between January 2013 and December 2019 were screened retrospectively. A small amount of iCSF flow without a diaphragmatic defect was classified as a minor leak, and obvious CSF flow with or without a diaphragmatic defect was classified as a major leak. In case of iCSF leak, a fibrin- and thrombin-coated sponge was used to cover the diaphragmatic defect and another one was used for the sellar opening. A gelatin sponge was placed in the sphenoid sinus as an abutment. The primary and secondary outcomes were the number of postoperative CSF (pCSF) leaks and meningitis, respectively. Clinical, histological, and perioperative data from medical records were collected to identify risk factors for CSF leak and meningitis. Of 417 transsphenoidal surgeries, 359 procedures in 348 patients with a median age of 54 years were included. There were 96 iCSF leaks (26.7%; 37.5% major, 62.5% minor). In 3 of 359 cases (0.8%) a pCSF fistula occurred, requiring revision surgery in 2 patients and a lumbar drain in 1 patient. Meningitis occurred in 3 of 359 cases (0.8%). All 3 patients recovered without sequelae after antibiotic therapy. According to univariate analysis, risk factors for iCSF leak were macroadenoma (p = 0.006) and recurrent adenoma (p = 0.032). An iCSF leak was found less often in functioning adenomas (p = 0.025). In multivariate analysis recurrent tumors remained as a risk factor (p = 0.021) for iCSF leak. Patients with iCSF leak were at increased risk for a pCSF leak (p = 0.005). A pCSF leak in turn represented the key risk factor for meningitis (p = 0.033). Patients with macroadenomas and recurrent adenomas are especially at risk for iCSF leak. An iCSF leak in turn increases the risk for a pCSF leak, which carries the risk for meningitis. The authors' surgical technique leads to a very low rate of pCSF leaks and meningitis without using autologous graft materials. Hence, this technique is safe and improves patient comfort by avoiding the disadvantages of autologous graft harvesting.

The exstrophy experience: A national survey assessing urinary continence, bladder management, and oncologic outcomes in adults

The bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of congenital genitourinary malformations with an incidence of 1:10,000 to 1:50,000. Advances in reconstructive surgical techniques have improved clinical outcomes, but there is a paucity in data about disease sequela in adulthood. This is the largest survey to date in the United States exploring the urinary continence, bladder management, and oncologic outcomes in adults with BEEC. Respondents were over the age of 18 with a diagnosis of bladder exstrophy, cloacal exstrophy, or epispadias. They were treated at the authors' institution, included in the Association for the Bladder Exstrophy Community (A-BE-C) mailing list, and/or engaged in A-BE-C social media. A survey was created using uniquely designed questions and questionnaires. Survey responses between May 2020 and July 2020 were processed using Research Electronic Data Capture (REDCap). Quantitative and qualitative statistics were used to analyze the data with significance at p<0.05. A total of 165 patients completed the survey. The median age was 31.5 years (IQR 25.9-45.9). Many patients considered themselves continent of urine, with a median satisfaction score of 74 (IQR 50-97) on a scale from 0 (consider themselves to be completely incontinent) to 100 (consider themselves to be completely continent). There was less leakage among those with a continent urinary diversion compared to those who void or catheterize per urethra (p=0.003). Patients with intestinal-urinary tract reconstruction, such as augmentation cystoplasty or neobladder creation, were more likely to perform bladder irrigations (p=0.03). Patients with continent channels were more likely to report UTI than all other forms of bladder management (89.0% vs. 66.2%, p=0.003). Three (1.9%) patients were diagnosed with bladder cancer. A small portion of patients (27.2%) were given bladder cancer surveillance recommendations by a physician. Most patients achieved a satisfactory level of urinary continence, with the highest continence rates in those with a continent urinary diversion. Those with intestinal-urinary tract reconstruction were more likely to perform bladder irrigations, perhaps to avoid complications from intestinal mucous production. The rates of self-reported UTI and were higher in patients with continent channels, but recurrent UTIs were not affected by the type of genitourinary reconstruction. Bladder cancer exists in this population, highlighting the need for long-term follow-up. Most BEEC patients achieve a satisfactory level of urinary continence, with the best outcomes in those with a continent urinary diversion. This population requires long-term follow-up with a transitional urologist to ensure adequate oncologic care.

Early and midterm results of valve-sparing aortic root reconstruction with a bovine pericardium patch for patients with acute type a aortic dissection.

We evaluated the feasibility, effectiveness, and safety of valve-sparing aortic root reconstruction with a bovine pericardium patch for patients with acute type A aortic dissection (ATAAD). From January 2016 to January 2021, 895 consecutive patients with ATAAD received surgical treatment at our hospital. After applying our exclusion criteria, 508 patients were included in this research. Based on the attending surgeon's judgment and preference, 192 patients underwent our novel surgical novel surgical technique of valve-sparing aortic root reconstruction (repair group [RG]) and 316 patients underwent the Bentall procedure (Bentall group [BG]). In the RG, the early mortality rate was 4.2% (8/192). In the BG, the early mortality rate was 5.1% (16/316). There were no significant differences between groups. The incidence of postoperative renal failure in the BG was significantly higher than that in the RG. The mean follow-up time was 2.93 years (standard deviation, ±1.38 years). There were no significant differences between groups regarding ATAAD-related mortality and reoperation. In the RG, the rate of freedom from aortic root reoperation at 5 years was 98.2%, and the grade of aortic regurgitation 6 months later was significant less than that before surgery, and it did not worsen during later follow-up. Valve-sparing aortic root reconstruction with a bovine pericardium patch can be successfully performed for selected patients with ATAAD and is associated with low in-hospital and late mortality rates and low root reoperation rates during early and midterm follow-up.

Surgical complications in immediate and delayed breast reconstruction: A systematic review and meta-analysis.

Because of improved aesthetic results, immediate breast reconstruction has become the most widely used timing of reconstruction following mastectomy. Many studies report complication rates between immediate and delayed reconstructions at certain medical institutions, but no systematic reviews exist to summarize the literature. This systematic review was conducted to assess the outcomes in women who underwent immediate versus delayed breast reconstruction following mastectomy for breast cancer. Cochrane, PubMed, and EMBASE electronic databases were screened, and data were extracted from included studies. The clinical outcomes assessed were surgical complications, length of postoperative hospital stay, and reoperation rate. A total of 30 studies met the inclusion criteria for the review and provided enough data to be included in the meta-analysis (14,034 patients). Women receiving immediate breast reconstruction were significantly more likely to experience surgical complications (OR 1.30, 95% CI 1.03, 1.65; p=0.03). Sensitivity analysis showed that women receiving immediate reconstruction were also more likely to experience infection (OR 1.41, 95% 1.04, 1.92; p=0.03) and hematoma/seroma (OR 2.01, 95% CI 1.27-3.17; p=0.003). Furthermore, a separate sensitivity analysis showed no significant differences in reported outcomes when comparing studies whose patient cohorts received post-mastectomy radiation therapy (PMRT). This study provides evidence that immediate breast reconstruction generally increases the risk of complications in comparison with delayed reconstruction. Additional prospective and observational studies are needed to determine the role of PMRT and reconstruction surgical technique in the incidence of complications between immediate and delayed reconstructions.

Biomechanical Comparison of 3 Medial Patellofemoral Complex Reconstruction Techniques Shows Medial Overconstraint but No Significant Difference in Patella Lateralization and Contact Pressure

The purpose of this study was to investigate biomechanical differences of medial patellofemoral ligament (MPFL) reconstruction, medial quadriceps tendon femoral ligament (MQTFL) reconstruction, and a combination of these techniques to restore lateral patellar constraint and contact pressures. Eight fresh frozen cadaver knees were mounted to a custom jig with physiological quadriceps tendon loading. Flexion angles and contact pressure (CP) were dynamically measured using Tekscan® pressure sensors and Polhemus® Liberty 6 degree of freedom (6DOF) positioning sensors in the following conditions: 1) intact 2) MPFL and MQTFL deficient, 3) MPFL reconstructed, 4) Combined MPFL+ MQTFL reconstructed, and 5) MQTFL reconstructed. Lateral patellar translation was tested using horizontally directed 30 N force applied at 30° of knee flexion. The knees were flexed in dynamic fashion, and CP values were recorded for 10°, 20°, 30°, 50°, 70°, and 90° degrees of flexion. Group differences were assessed with ANOVA's followed by pairwise comparisons with Bonferroni correction. MPFL (P= .002) and combined MPFL/MQTFL (P= .034) reconstruction significantly reduced patellar lateralization from+19.28% (9.78%, 28.78%) in the deficient condition to-17.57% (-27.84%,-7.29%) and-15.56% (-33.61%, 2.30%), respectively. MPFL reconstruction was most restrictive and MQTFL reconstruction the least-7.29% (-22.01%, 7.45%). No significant differences were found between the three reconstruction techniques. Differences in CP between the three reconstruction techniques were not significant (<.02 MPa) at all flexion angles. The present study found no significant difference for patellar lateralization and patellofemoral CP between MPFL, combined MPFL/MQTFL, and MQTFL reconstruction. All 3 techniques resulted in stronger lateral patellar constraint compared to the native state, while the MQTFL reconstruction emulated the intact state the closest. Various surgical techniques for medial patellofemoral complex reconstruction can restore patellar stability with similar patellofemoral articular pressures.

Midfoot Nail-Plate-Constructs for Charcot Neuroarthropathy: A Cohort Study with Midterm Follow Up

Category: Midfoot/Forefoot; Diabetes; Other Introduction/Purpose: Charcot neuroarthropathy (CN) is a complex disease process with progressive degeneration of normal bone architecture. Treatment options for CN include both conservative measures and operative management with the goal of achieving or maintaining a plantigrade ulcer-free foot. Operative treatment of CN varies widely with regards to timing and type of interventions. Surgical interventions include debridement, exostectomy, and complex reconstructions. The technique of intramedullary beaming with supplemental medial locking plate (referred to here as a Midfoot Nail Plate Construct (MNPC)) utilizes large diameter intramedullary screws linked to a medial locked plate for midfoot stabilization which is the focus of this study. Methods: Nineteen patients (20 limbs) with midfoot CN treated at our institution by a single surgeon between January 2017 - December 2021 met inclusion criteria and were included in our MNPC cohort. Retrospective chart review was performed to obtain demographic data, comorbidities, previous treatment data, ambulation status pre/post intervention, radiographic (Brodsky) classification, time to intervention, number of operations, and outcomes after operative management with MNPCs with a descriptive statistical analysis. Furthermore, post-intervention outcomes (rates of post-operative ulceration, post-operative infection, and amputation) were compared to the our previously studied institutional baseline data of post- surgical complications of CN in 58 patients treated between 2005-2016 with limited and reconstructive techniques without MNPCs. Results: The mean age of the MNPC cohort was 56.3 (range 37 - 73 years), mean BMI was 39.4, and 73.7% of patients had diabetes (mean A1c 7.34, A1c range 5.8 to 10.5). 43% had undergone previous non-operative management and 19% received prior operative treatment. Mean follow up was 19.9 months (range 3 - 47 months). Average time from presentation to intervention was 10.1 months (range 1 - 32 months). Post-intervention rates of ulceration, infection, and amputation for the MNPC cohort were 30%, 25%, and 15% respectively. Compared to our institutional baseline data of complications after limited and reconstructive surgical techniques without MNPCs from 2005-2017, MNPC had a lower rate of ulceration and amputation. Ulceration rate after limited, reconstructive, and MNPC were 34.4%, 42.3%, and 30% respectively. Infection rates were 25%, 42.3%, and 25%, with amputation rates of 21.9%, 23%, and 15% respectively. Conclusion: Despite continued innovation in surgical management of CN of the foot, post-intervention complication rates remain high. This study provides patient and outcome data for Midfoot Nail Plate Constructs as a treatment for CN in a large cohort with midterm follow up. Compared to our own institutional historical data prior to adoption of this technique, MNPCs have an equivalent infection rate and lower rate of ulceration and amputation at an average of 19 month follow-up.

Comparison of three surgical techniques of posterolateral knee reconstruction: A cadaver study

BackgroundInjuries to the posterolateral corner (PLC) of the knee are often overlooked but, require reconstruction in order to restore stability in varus and external rotation. Among the many anatomic and non-anatomic PLC reconstruction techniques available, the modified Larson (mLR), LaPrade (LPR) and Versailles reconstruction (VR) procedures are widely used. HypothesisThe hypothesis was that anatomic PLC reconstruction (VR and LPR procedures) provides better restoration and control of external rotation. Patients and methodsFifteen fresh-frozen cadaveric knees were tested to compare the 3 procedures. Varus laxity on stress radiographs in full knee extension and external rotatory laxity on dial test at 30° flexion were quantified at 3 phases: intact knee, PLC sectioned and PLC reconstructed. ResultsMean varus laxity did not differ significantly between techniques in intact knees (p=.14), after PLC sectioning (p=.14) or after PLC reconstruction (p=.17). After PLC reconstruction, varus laxity was restored, with no statistical difference between mLR, VR and LPR compared to intact test values (respectively, -1.0, -1.3 and -1.5; p=.98). In all 3 groups, mean external rotation laxity on dial test at 30° flexion did not significantly differ between intact knees (p=.32) and after PLC sectioning (p=.15). After PLC reconstruction, the mLR technique was significantly less effective in restoring rotational stability than the VR and LPR techniques (p=.025). DiscussionThe VR technique provided similar outcomes to LPR for restoring stability in varus and external rotation. The 2 “anatomic” reconstruction procedures (VR and LPR) were significantly more effective than the modified Larson technique for external rotation control, confirming the study hypothesis. Consequently, it remains preferable to use anatomic techniques in multiligament injuries involving the PLC. Level of evidenceIV, cadaver study.

Trileaflet semilunar valve reconstruction: pulsatile in vitro evaluation.

OBJECTIVESResidual regurgitation is common after congenital surgery for right ventricular outflow tract malformation. It is accepted as there is no competent valve solution in a growing child. We investigated a new surgical technique of trileaflet semilunar valve reconstruction possessing the potential of remaining sufficient and allowing for some growth with the child. In this proof-of-concept study, our aim was to evaluate if it is achievable as a functional pulmonary valve reconstruction in vitro.METHODSExplanted pulmonary trunks from porcine hearts were evaluated in a pulsatile flow-loop model. First, the native pulmonary trunk was investigated, after which the native leaflets were explanted. Then, trileaflet semilunar valve reconstruction was performed and investigated. All valves were initially investigated at a flow output of 4 l/min and subsequently at 7 l/min. The characterization was based on hydrodynamic pressure and echocardiographic measurements.RESULTSEight pulmonary trunks were evaluated. All valves are competent on colour Doppler. There is no difference in mean pulmonary systolic artery pressure gradient at 4 l/min (P = 0.32) and at 7 l/min (P = 0.20). Coaptation length is increased in the neo-valve at 4 l/min (P < 0.001, P < 0.001, P = 0.008) and at 7 l/min (P < 0.001, P = 0.006, P = 0.006). A windmill shape is observed in all neo-valves.CONCLUSIONSTrileaflet semilunar valve reconstruction is sufficient and non-stenotic. It resulted in an increased coaptation length and a windmill shape, which is speculated to decrease with the growth of the patient, yet remains sufficient as a transitional procedure until a long-term solution is feasible. Further in vivo investigations are warranted.

Radiation therapy in breast cancer: a narrative review on current standards and future perspectives

: Mastectomy and reconstructive procedures have been refined over the decades, allowing for aesthetic outcomes close to the native breast shape and in symmetry with the contralateral intact breast or even to improve breasts appearance and symmetry. Similarly, improvements in radiation oncology can help reduce treatment related toxicity and improve outcomes. However, postmastectomy radiation therapy (PMRT) is associated with poor cosmetic outcomes and increased rate complications in patients who undergo breast reconstruction. Radiation therapy planning should be guided by disease stage, risk of recurrence, correct definition of the target volumes and treatment objectives. Currently, there are guidelines endorsed by European Society for Radiotherapy and Oncology (ESTRO) for target volume delineation for breast cancer and elective nodal volumes, including after immediate reconstruction. Correct target volume delineation, along with meticulous radiation planning, total dose and fractionation, dose homogeneity, and organs at risk (OAR) doses are significant for reducing radiation-induced toxicity. Currently, tremendous efforts are done by different groups to improve aesthetic outcomes without compromising disease outcomes in breast cancer patients who are candidates for mastectomy and radiation therapy. The current paper summarizes key principles in PMRT, considering new surgical techniques for immediate breast reconstruction and new, partly experimental radiation techniques including future trials and proton beam irradiation.

Post-traumatic instability of the first metatarsophalangeal joint: a novel surgical technique of capsular reconstruction in a young kickboxer.

Aim To report a novel surgical technique of capsular reconstruction of post-traumatic instability of the first metatarsophalangeal joint (MTPJ). Methods The clinical case is related to a 24-year-old male athlete whose clinical symptoms began with pain and spontaneous dislocation of the left first MTPJ during a kickboxing fight. He received conservative treatment (cryotherapy and rest) at first. Afterwards, he referred persistent hallux instability associated with moderate pain, despite normal anatomic alignment with no evidence of first ray deformity. Plain traditional x-rays of the left foot, magnetic resonance imaging (MRI), static and dynamic ultrasonography (US) and clinical tests were performed in order to diagnose capsular ligamentous structure lesions. Results The plain x-rays showed hallux abductus angle of 3°. The MRI and US demonstrated a rupture of the lateral capsular ligamentous structures and detachment of the abductor tendon. The pull out medium-lateral of the capsule with the abductor suture was performed as a treatment for dynamic hallux varus deformity. At six-month follow up, the patient walked without lameness with complete active and passive range of motion and with a stable first MTPJ. Conclusion The patient presented with the post traumatic instability of the first metatarsophalangeal joint treated with a novel surgical technique of capsular reconstruction. The patient returned to the full weight-bearing in only 2 months of rehab. To the best of our knowledge, the surgical correction proposed has not been previously described.

Periprosthetic Postoperative Humeral Fractures After Shoulder Arthroplasty.

The increased utilization of shoulder arthroplasty, including revision procedures, combined with rises in life expectancy, is expected to translate into a substantial increase in periprosthetic humeral fractures. The evaluation and management of these fractures needs to be updated to consider fractures that complicate anatomic and reverse arthroplasties and contemporary short-stem and stemless implants. Although conservative treatment is successful in a large proportion of these fractures, several surgical reconstructive techniques are required for the management of all fracture types. Surgical options include internal fixation, graft augmentation, standard revision procedures, and occasionally complex reconstructions including modular segmental prosthesis and allograft prosthetic composites. Most studies on the outcomes of periprosthetic humeral fractures have analyzed small samples and have typically reported on anatomic total shoulders with a standard-length humeral implant. Additional research is required to optimize the management of periprosthetic postoperative humeral fractures in the era of reverse arthroplasty, short stems, and stemless arthroplasty.