Surgical Side Research Articles

Computed tomography radiomics in predicting patient satisfaction after robotic-assisted total knee arthroplasty.

After robotic-assisted total knee arthroplasty (RA-TKA) surgery, some patients still experience joint discomfort. We aimed to establish an effective machine learning model that integrates radiomic features extracted from computed tomography (CT) scans and relevant clinical information to predict patient satisfaction three months postoperatively following RA-TKA. After careful selection, data from 142 patients were randomly divided into a training set (n = 99) and a test set (n = 43), approximately in a 7:3 ratio. A total of 1329 radiomic features were extracted from the regions of interest delineated in CT scans. The features were standardized using normalization algorithms, and the least absolute shrinkage and selection operator regression model was employed to select radiomic features with ICC > 0.75 and P < 0.05, generating the Rad-score as feature markers. Univariate and multivariate logistic regression was then used to screen clinical information (age, body mass index, operation time, gender, surgical side, comorbidities, preoperative KSS score, preoperative range of motion (ROM), preoperative and postoperative HKA angle, preoperative and postoperative VAS score) as potential predictive factors. The satisfaction scale ≥ 20 indicates patient satisfaction. Finally, three prediction models were established, focusing on radiomic features, clinical features, and their fusion. Model performance was evaluated using Receiver Operating Characteristic curves and decision curve analysis. In the training set, the area under the curve (AUC) of the clinical model was 0.793 (95% CI 0.681-0.906), the radiomic model was 0.854 (95% CI 0.743-0.964), and the combined radiomic-clinical model was 0.899 (95% CI 0.804-0.995). In the test set, the AUC of the clinical model was 0.908 (95% CI 0.814-1.000), the radiomic model was 0.709 (95% CI 0.541-0.878), and the combined radiomic-clinical model was 0.928 (95% CI 0.842-1.000). The AUC of the radiomic-clinical model was significantly higher than the other two models. The decision curve analysis indicated its clinical application value. We developed a radiomic-based nomogram model using CT imaging to predict the satisfaction of RA-TKA patients at 3 months postoperatively. This model integrated clinical and radiomic features and demonstrated good predictive performance and excellent clinical application potential.

Early effectiveness of local injection of multimodal drug cocktail during anterior cruciate ligament reconstruction and its influence on cartilage

To explore the early effectiveness and influence on cartilage of local injection of multimodal drug cocktail (MDC) during anterior cruciate ligament reconstruction (ACLR). Between February 2022 and August 2023, patients undergone arthroscopic ACLR using autologous hamstring tendons were selected as the study subjects. Among them, 90 patients met the selection criteria and were randomly divided into 3 groups ( n=30) according to the different injection drugs after ligament reconstruction. There was no significant difference in baseline data such as gender, age, body mass index, surgical side, disease duration, preoperative thigh circumference, and preoperative levels of tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), IL-1, matrix metalloproteinase 3 (MMP-3), MMP-13, and aggrecan (ACAN) in synovial fluid between groups ( P>0.05). After the ligament reconstruction during operation, corresponding MDC (consisting of ropivacaine, tranexamic acid, and betamethasone in group A, and ropivacaine, betamethasone, and saline in group B) or saline (group C) were injected into the joint and tendon site, respectively. The length of hospital stay, postoperative tramadol injection volume, incidence of complications, degree of knee joint swelling and range of motion, visual analogue scale (VAS) score, International Knee Documentation Committee (IKDC) score, Lyshlom score, and Hospital for Special Surgery (HSS) score were recorded and compared between groups. The T2 * values in different cartilage regions were detected by MRI examination and the levels of TNF-α, IL-6, IL-1, MMP-3, MMP-13, and ACAN in synovial fluid were detected by ELISA method. The patients in group A, B, and C were followed up (12.53±3.24), (13.14±2.87), and (12.82±3.32) months, respectively. All incisions healed by first intention. Compared with group C, group A and group B had shorter length of hospital stay, less tramadol injection volume, and lower incidence of complications, showing significant differences ( P<0.05); there was no significant difference between group A and group B ( P>0.05). The degree of knee swelling in group A was significantly less than that in group B and group C ( P<0.05), but there was no significant difference between group B and group C ( P>0.05). At 3, 6, 12, 24, and 48 hours after operation, VAS scores of group A and group B were significantly lower than those of group C ( P<0.05); at 72 hours after operation, there was no significant difference among the three groups ( P>0.05). At 3 days, 14 days, and 1 month after operation, the range of motion of knee joint in group A were significantly better than those in group C ( P<0.05), and there was no significant difference between the other groups ( P>0.05). At 1 month after operation, the IKDC score of group A and group B was significantly higher than that of group C ( P<0.05); there was no significant difference among the three groups at other time points ( P>0.05). There was no significant difference in Lyshlom score and HSS score among the three groups at each time point ( P>0.05). At 14 days after operation, the levels of IL-1 and IL-6 in the synovial fluid in groups A and B were significantly lower than those in group C ( P<0.05). There was no significant difference in the levels of TNF-α, MMP-3, MMP-13, and ACAN between groups A and B ( P>0.05). At 1 month after operation, there was no significant difference in the above indicators among the three groups ( P>0.05). At 3, 6, and 12 months after operation, there was no significant difference in the T2 * values of different cartilage regions among the three groups ( P>0.05). Injecting MDC (ropivacaine, tranexamic acid, betamethasone) into the joint and tendon site during ACLR can achieve good early effectiveness without significant impact on cartilage.

Tinnitus: an underreported condition following microvascular decompression for hemifacial spasm

PurposeWhile hearing loss is a well-known condition following microvascular decompression (MVD) for hemifacial spasm (HFS), tinnitus is an underreported one. This study aims to identify prevalence, characteristics, severity, and predictors of tinnitus following MVD for HFS.MethodsA single-center cohort of 55 HFS patients completed a questionnaire approximately 5 years following MVD. Data encompassed tinnitus presence, side, type, onset, and severity measured by a 10-point Visual Analogue Scale (VAS). Descriptive, correlation, and logistic regression analyses were conducted.Results At surgery, participants’ median age was 58 years (IQR 52–65). The median duration of HFS symptoms before surgery was 5 years (IQR 3–8), slightly predominant on the left (60%). Postoperative tinnitus was reported by 20 patients (36%), versus nine (16%) that reported preoperative tinnitus. Postoperative tinnitus was ipsilateral on the surgical side in 13 patients (65%), bilateral in six (30%), and contralateral in one (5%). Among patients with bilateral postoperative tinnitus, 33% did not have this preoperatively. Tinnitus was continuous in 70% of cases and pulsatile in 30%. Onset of new tinnitus was in 58% immediately or within days, in 25% within three months, and in 17% between three months and one year after surgery. The mean severity of postoperative tinnitus was 5.1 points on the VAS. Preoperative tinnitus and presence of arachnoid adhesions had suggestive associations with postoperative tinnitus in initial analyses (p = 0.005 and p = 0.065). However, preoperative tinnitus was the only significant predictor of postoperative tinnitus (p = 0.011).ConclusionTinnitus is a common condition following MVD for HFS, with a moderate overall severity. Causes behind postoperative tinnitus remain obscure but could be related to those of postoperative hearing loss in this patient population. Clinicians should be aware of tinnitus following MVD and vigilantly monitor its occurrence, to facilitate prevention efforts and optimize outcome for HFS patients undergoing MVD.

Abstract PO4-22-12: Robot-assisted nipple-sparing mastectomy using da Vinci SP single-port system: primary results from the pilot trial RASPIM-01

Abstract Background Robot-assisted breast surgery was developed in 2014 for nipple-sparing mastectomy through a concealable lateral chest wall incision smaller. Although successful experiences have been reported using a multi-arm surgical robotic system, collisions between robotic arms and instruments often result in the discontinuation of console workflow and limit the performance of the surgical robot. Compared to multi-armed robot systems, the SP system is single-armed, equipped with flexible instruments containing multiple joints that may avoid instrument collision, a controllable camera reducing visual dead spots, and a designated non-third-party port that allows single-port entry and full deployment of the instrument. The RASPIM-01 trial (NCT05448963) is a single-armed pilot study assessing the feasibility of robot-assisted nipple-sparing mastectomy (NSM) using a new SP system. Method This study is a pilot trial conducted in a single-arm, non-randomized design with a recruitment of 30 participants. The SP surgical robot is used in NSM through the lateral chest wall incisions. The major inclusion criteria are 1) Breast cancer with preoperative clinical tumor sizes less than 5 cm, with an adequate tumor-skin distance of at least 3mm, and without nipple-areolar involvement in at least 1cm around the nipple by image, 2) Breast cancer up to clinical stage IIIA (T3, N1-2) showing adequate response to neoadjuvant therapy and meeting criteria 1), 3) Germline pathogenic/likely pathogenic BRCA1 or 2 variant carriers with or without a breast cancer diagnosis, requiring unilateral or bilateral therapeutic mastectomy or prophylactic mastectomy. Exclusion criteria include extensive breast skin or nipple involvement such as inflammatory breast cancer, Paget’s disease, nipple discharge associated with malignancy, image suggestive of cancer involvement of the nipple and subareolar tissue, and stage III breast cancer without response to neoadjuvant therapy, and previous radiotherapy of the surgical side breast. The endpoint measurements include Primary endpoint: The ability to complete nipple-sparing mastectomy with an SP system in the per-protocol population without additional assistant port or conversion to open surgery. Statistical analysis includes point estimation with a 95% confidence interval to analyze the mean or proportion of key performance parameters. No interim analysis will be performed due to the limited number intended to recruit. Results The study recruited 30 breast cancer patients and conducted 30 NSMs, while no prophylactic mastectomy case was recruited. The median age was 44 years old, BMI was 22.4 (18.9-30.0) kg/m2. Median tumor size was 3.0 (1.0-14.6) cm, and axillary lymph node metastases were present in 7 cases (23.3%). T2 (13 cases, 43.3%) tumors were the majority, followed by Tis (10 cases, 33.3%), T1 (5 cases, 16.7%), and T3 (2 cases, 6.7%). The anatomical stages of invasive cancer were Ia (16.7%), IIa (26.7%), IIb (16.7%), and IIIa (6.7%), among them 9 (30.3%) received neoadjuvant chemotherapy before surgery. All NSMs met the primary endpoint of successful completion using the SP robot system without conversion to open mastectomy or the addition of an assistant port. Median console time was 108.5 (73-285) min and docking time was 2.5 (1-9) min. Specimen weight was 311.6 (107-838) gm, while 2 (6.7%) cases had their nipple excised due to cancer-involved margin reported from the frozen section. Twenty-six (86.6%) cases received autologous free flap reconstruction, among which 25 (83.3%) cases received DIEP, and 1 (3.3%) received PAP reconstruction. Four cases received implant (2 cases, 6.7%) or tissue expander (3 cases, 6.7%). Conclusion This is the first NSM clinical trial operated with SP surgical robot system and met its primary endpoint showing the feasibility to conduct NSM. Secondary and exploratory endpoints data will be reported after the completion of clinical follow-ups. Citation Format: Wen-Ling Kuo, Chia-Huei Chu, Jung-ju Huang. Robot-assisted nipple-sparing mastectomy using da Vinci SP single-port system: primary results from the pilot trial RASPIM-01 [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-22-12.

Risk communication in cataract surgery

PurposeRisk communication is an integral aspect of shared decision-making and evidence-based patient choice. There is currently no recommended way of communicating risks and benefits of cataract surgery to patients. This...

Asymmetric gap balancing improves knee kinematic following primary total knee arthroplasty

PurposeThe purpose of this study was to demonstrate closer-to-normal knee kinematics following primary total knee arthroplasty (TKA) performed establishing asymmetric gap balancing intraoperatively.Material and methodTwo age-, sex-, BMI-matched groups of patients underwent medially stabilized TKA because of isolated knee disease. Group A (12 patients) underwent “unrestricted” kinematic alignment (uKA) according to Howell while group B (15 patients) received robot-assisted “simplified” KA (sKA) with an alignment goal (Hip-Knee-Ankle axis-HKA) ± 5° respect to the mechanical axis. Intraoperatively, in group B, the flexion gap at 90° was first set at an average of 1.5 mm (0–5 mm; SD 4.4 mm) tighter in the medial compartment with respect to the lateral; in the same way, the extension gap was then set at an average of 2.0 mm (0–4.5 mm; SD 3.1 mm) tighter in the medial compartment with respect to the lateral. All patients, including a non-arthritic cohort (group C: 5 controls) underwent gait analysis using an instrumented treadmill (WalkerView–WV) equipped with an instrumented belt armed with a 3D video camera. The WV software evaluated multiple spatiotemporal and kinematic parameters, including: (1) contact time (s); (2) knee ROM during gait cycle; (3) step length percentage with respect to total gait (%) and pure step length (cm). Statistical analyses included t-Test and ANOVA and were conducted by using SPSS.ResultsAt the final FU, significant differences were noted during gait between the two TKA groups (uKA-sKA) and the controls. Both TKA groups showed superior mean contact time on the surgical knee (uKA 1 s; sKA 0.97 s) as compared to the controls (0.72 s) (P = 0.002) while no differences were found between them (P = 0.11). TKA groups showed a lower, maximum ROM in the surgical knee (mean uKA 36º; mean sKA 49º) relative to the controls (mean 57º) (P < 0.05) but a statistical difference was found between them (P = 0.003). Both TKA groups showed a higher step length percentage with respect to the total gait and a shorter step length on the surgical side (uKA: mean 8.28% and mean step length 35.5 cm; sKA: mean 8.38% and mean step length 34.6 cm) in comparison to the controls (mean 3.38%; mean step length 71.4 cm) (P < 0.05) while no statistical differences were found between them.ConclusionTo our knowledge, this was the first study to exhibit the kinematic advantages of a slightly asymmetric gap balancing during KA TKA. Combining a medially-stabilized implant design and a surgical technique aiming to obtain a tighter medial compartment represents a promising approach to improve outcomes after TKA.Graphical

Protecting the non-operative lobe/s of the operative lung can reduce the pneumonia incidence after thoracoscopic lobectomy: a randomised controlled trial

Lung isolation usually refers to the isolation of the operative from the non-operative lung without isolating the non-operative lobe(s) of the operative lung. We aimed to evaluate whether protecting the non-operative lobe of the operative lung using a double-bronchial blocker (DBB) with continuous positive airway pressure (CPAP) could reduce the incidence of postoperative pneumonia. Eighty patients were randomly divided into two groups (n = 40 each): the DBB with CPAP (Group DBB) and routine bronchial blocker (Group BB) groups. In Group DBB, a 7-Fr BB was placed in the middle bronchus of the right lung for right lung surgery and in the inferior lobar bronchus of the left lung for left lung surgery. Further, a 9-Fr BB was placed in the main bronchus of the operative lung. In Group BB, routine BB placement was performed on the main bronchus on the surgical side. The primary endpoint was the postoperative pneumonia incidence. Compared with Group BB, Group DBB had a significantly lower postoperative pneumonia incidence in the operative (27.5% vs 5%, P = 0.013) and non-operative lung (40% vs 15%) on postoperative day 1. Compared with routine BB use for thoracoscopic lobectomy, using the DBB technique to isolate the operative lobe from the non-operative lobe(s) of the operative lung and providing CPAP to the non-operative lobe(s) through a BB can reduce the incidence of postoperative pneumonia in the operative and non-operative lungs.

Catheter-based and surgical treatment for aortic valve diseases

The pathophysiology of aortic valve diseases is of predominantly degenerative nature, characterized by calcific aortic valve stenosis, which is associated with areduction in prognosis. The prevalence of aortic valve insufficiency also increases with advancing age. Timely causal treatment is crucial in the management of aortic valve diseases. Following the indication for intervention, the heart team plays acentral role in evaluating the results and making therapeutic decisions that consider the patient's preferences. In the assessment of treatment options, considerations regarding the long-term perspective are particularly crucial, especially in younger patients. The most common therapeutic approach for aortic valve diseases is the introduction of anew valve prosthesis. In the majority of cases, this is now achieved through catheter-based implantation of abioprosthetic heart valve, known as transcatheter aortic valve implantation (TAVI). Open surgical aortic valve replacement (AVR) is favored in younger patients with low surgical risk or in the case that TAVI is not feasible. In AVR, both biological and the longest-lasting mechanical prosthesis types are used. Surgical repair techniques are primarily applied in cases of aortic valve regurgitation. Notably, TAVI, as well as surgical procedures for the treatment of aortic valve diseases, have undergone significant advancements in recent years, including expanded indications for TAVI and, on the surgical side, in particular the development of minimally invasive surgical techniques.

Imaging risk factors for postoperative cerebral infarction in adults with ischemic Moyamoya disease

Objective: To investigate the imaging factors associated with postoperative cerebral infarction in adult patients aged 18 and above with ischemic Moyamoya disease. Methods: The clinical data of adult patients who underwent surgeries for ischemic Moyamoya disease in the Department of Neurosurgery at Peking University International Hospital from October 2015 to October 2020 were retrospectively analyzed. Of the 239 patients, 120 were male and 119 were female, with ages ranging from 18 to 63 (41.7±10.3) years. A total of 239 patients(290 cases) underwent direct and indirect combined revascularization (CR).Gender, age, surgical side, preoperative transient ischemic attack (TIA), presence of old cerebral infarction, and imaging features were compared between the patients with (48 cases) and without (242 cases) cerebral infarction within 1 week after surgery. Multivariate logistic binary regression model was used to analyze the imaging risk factors of postoperative cerebral infarction. Results: Cerebral infarction occurred in 48 cases(16.5%) among the 290 CR group within 1 week after surgery. The proportion of patients with TIA, old cerebral infarction, ICA stenosis, A1 segment stenosis, M1 segment stenosis, abnormal posterior cerebral artery (PCA), and unstable compensation before CR in the cerebral infarction group was higher than that in the non-cerebral infarction group (P<0.05).Preoperative TIA (OR=4.514, 95%CI: 1.920-10.611), old cerebral infarction (OR=2.856,95%CI:1.176-6.936), A1 stenosis (OR=7.027,95%CI:1.877-26.308), M1 stenosis (OR=6.968,95%CI:2.162-22.459), abnormal PCA (OR=4.114,95%CI:1.330-12.728)and unstable compensation (OR=4.488,95%CI:1.194-16.865) were risk factors for cerebral infarction after CR surgery (all P<0.05). Conclusion: Among the imaging factors, TIA, old cerebral infarction, A1 stenosis, M1 stenosis, abnormal PCA and unstable compensation were risk factors for cerebral infarction in adult patients with ischemic Moyamoya disease treated by combined revascularization.

Effect of transnasal humidified rapid insufflation ventilatory exchange on cerebral oxygen saturation during induction of general anesthesia in patients undergoing traumatic brain injury emergency surgery

To evaluate the effect of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) on regional cerebral oxygen saturation (rScO2) during induction of general anesthesia in patients undergoing traumatic brain injury (TBI) emergency surgery. A prospective randomized controlled trial was conducted. The TBI emergency general anesthesia patients who underwent intracranial hematoma removal surgery at the Northern Jiangsu People's Hospital from January to July in 2023 were enrolled. The patients were divided into a conventional mask ventilation group and a THRIVE group using a random number table method. The patients in the conventional mask ventilation group were anesthetized and induced to pre oxygenate without positive pressure ventilation in the front mask for 10 minutes, with an oxygen flow rate of 8 L/min and an fraction of inspired oxygen (FiO2) of 1.00. After anesthesia induction for about 90 s, tracheal intubation was performed after the muscle relaxant took effect (patient's jaw muscle was relaxed). The patients in the THRIVE group were pre oxygenated with THRIVE for 10 minutes, with an oxygen flow rate of 30 L/min and a FiO2 of 1.00. During anesthesia induction, the oxygen flow rate was increased to 50 L/min, and anesthesia induction medication was used. The lower jaw of patient was supported with both hands to maintain airway patency, and the patient's mouth was kept closed throughout the process. After the muscle relaxant took effect (the patient's jaw muscle was relaxed), tracheal intubation was performed. At the time of patient entering the operating room, 10 minutes of pre oxygenation, and immediately after successful intubation, rScO2 was measured on the surgical and non-surgical sides. At the same time, ultrasound was used to measure the cross-sectional area (CSA) of the gastric antrum and arterial blood gas analysis was performed. The partial pressure of end-tidal carbon dioxide (PETCO2) during the first mechanical ventilation after successful tracheal intubation, the incidence of hypoxemia [pulse oxygen saturation (SpO2) < 0.95] during tracheal intubation, as well as prognostic indicators such as the length of intensive care unit (ICU) stay, total length of hospital stay, and Glasgow outcome scale (GOS) score at discharge were recorded. During the study period, a total of 70 TBI patients underwent emergency general anesthesia surgery, of which 2 patients died postoperatively, 2 patients were unable to cooperate with closed mouth breathing, and 3 patients had poor ultrasound image acquisition in the gastric antrum, all of whom were excluded. A total of 63 patients were ultimately enrolled, including 32 in the conventional mask ventilation group and 31 in the THRIVE group. There were no statistically significant differences in gender, age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, Glasgow coma scale (GCS) score, optic nerve sheath diameter (ONSD), baseline vital signs, fasting situation, anesthesia time, surgical time, and intraoperative blood loss between the patients in the two groups, indicating comparability. When entering the operating room, there was no statistically significant difference in rScO2 on the surgical and non-surgical sides, and blood gas analysis indexes arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2) between the patients in the two groups. When pre oxygenated for 10 minutes, both the surgical and non-surgical sides rScO2 levels in the THRIVE group were significantly higher than those in the conventional mask ventilation group (surgical side: 0.709±0.036 vs. 0.636±0.028, non-surgical side: 0.791±0.016 vs. 0.712±0.027, both P < 0.01), and the PaO2 was significantly increased [mmHg (1 mmHg ≈ 0.133 kPa): 450.23±60.99 vs. 264.88±49.33, P < 0.01], PaCO2 was significantly reduced (mmHg: 37.81±3.65 vs. 43.59±3.76, P < 0.01), and the advantage continues tilled immediately after successful intubation. There was no statistically significant difference in CSA at each time point of ultrasound examination between the two groups. Compared with the conventional mask ventilation group, the patients in the THRIVE group showed a significant decrease in PETCO2 during the first mechanical ventilation after successful tracheal intubation (mmHg: 43.10±2.66 vs. 49.22±3.31, P < 0.01), and the incidence of hypoxemia during tracheal intubation was also significantly reduced [0% (0/31) vs. 28.12% (9/32), P < 0.01]. In terms of prognostic indicators, there was no statistically significant difference in the length of ICU stay and total length of hospital stay between the patients in the conventional mask ventilation group and the THRIVE group [length of ICU stay (days): 10 (9, 10) vs. 10 (9, 11), total length of hospital stay (days): 28.00 (26.00, 28.75) vs. 28.00 (27.00, 29.00), both P > 0.05]. However, the proportion of patients in the THRIVE group with a good prognosis at discharge (GOS score > 3) was significantly higher than that in the conventional mask ventilation group [35.5% (11/31) vs. 12.5% (4/32), P < 0.05]. THRIVE can significantly increase rScO2 during anesthesia induction in TBI emergency surgery patients and improve their neurological function prognosis.

1248 Optimal Connectivity Map Predicts Seizure Freedom Rates After Laser Interstitial Thermal Therapy in Mesial Temporal Lobe Epilepsy

INTRODUCTION: Laser Interstitial Thermal Therapy (LiTT) is increasingly becoming a first-line surgical therapy for mesial temporal lobe epilepsy (mTLE). While promising, its seizure outcomes have also been highly variable, presumably due to an incomplete understanding of mechanisms behind LiTT. Epilepsy is a network disorder, and therefore it is crucial to account for both the effect on local destruction of epileptogenic foci, as well as global intervention of limbic circuitry, to elucidate the circuit-level mechanisms of LiTT and devise improved ablation strategies. In this study, we explore LiTT's network-level effect by investigating functional connectivity patterns and identifying optimal connectivity patterns predictive of seizure freedom. METHODS: 27 mTLE patients who underwent unilateral LiTT were classified as seizure-free (ILAE Class I) or seizure-present (ILAE Class II–VI) cohort based on one-year postoperative outcomes. Individual ablation volumes were segmented from intraoperative MRI sequences. Ablation volumes were seeded into a normative functional connectome (Brain Genomics Superstruct Project) to extract patient-specific connectivity profiles associated with ablation volumes. FC patterns were compared between the two cohorts to produce voxel-wise “t-maps” to identify local and global differences in connectivity strengths predictive of seizure freedom. RESULTS: Ten mTLE patients achieved complete seizure freedom. In seizure-free patients, right ablated volumes shared higher FC with regions such as calcarine, cuneus, and thalamic anterior pulvinar nucleus than patients with seizure presence. CONCLUSIONS: For the right-sided ablations, seizure freedom was associated with a distinctive whole-brain connectivity pattern beyond the local surgical target. Further investigation is required to explore if this pattern is specific between the two surgical sides in mTLE population.

Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis.

Previous studies have demonstrated the clinical efficacy of decompression alone in lower-grade spondylolisthesis. A higher rate of surgical revision and a lower rate of back pain relief was also observed. However, there is a lack of relevant biomechanical evidence after decompression alone for lower-grade spondylolisthesis. Evaluating the biomechanical characteristics of total laminectomy, hemilaminectomy, and facetectomy for lower-grade spondylolisthesis by analyzing the range of motion (ROM), intradiscal pressure (IDP), annulus fibrosus stress (AFS), facet joints contact force (FJCF), and isthmus stress (IS). Firstly, we utilized finite element tools to develop a normal lumbar model and subsequently constructed a spondylolisthesis model based on the normal model. We then performed total laminectomy, hemilaminectomy, and one-third facetectomy in the normal model and spondylolisthesis model, respectively. Finally, we analyzed parameters, such as ROM, IDP, AFS, FJCF, and IS, for all the models under the same concentrate force and moment. The intact spondylolisthesis model showed a significant increase in the relative parameters, including ROM, AFS, FJCF, and IS, compared to the intact normal lumbar model. Hemilaminectomy and one-third facetectomy in both spondylolisthesis and normal lumbar models did not result in an obvious change in ROM, IDP, AFS, FJCF, and IS compared to the pre-operative state. Moreover, there was no significant difference in the degree of parameter changes between the spondylolisthesis and normal lumbar models after undergoing the same surgical procedures. However, total laminectomy significantly increased ROM, AFS, and IS and decreased the FJCF in both normal lumbar models and spondylolisthesis models. Hemilaminectomy and one-third facetectomy did not have a significant impact on the segment stability of lower-grade spondylolisthesis; however, patients with LDS undergoing hemilaminectomy and one-third facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models.

Quantitative comparison of three thyroidectomy approaches on neck muscles, voice, and swallowing functions

ObjectiveThis study compares endoscopic thyroidectomy by gasless unilateral axillary approach (ETGUA) and sternocleidomastoid leading-edge approach (SLEA) with conventional open thyroidectomy (COT) in hemithyroidectomy. The main focus is on the protection of neck muscles (sternocleidomastoid, omohyoid, sternothyroid) and the postoperative function of voice and swallowing yielded through these common approaches. MethodsA total of 302 patients who underwent hemithyroidectomy were enrolled and divided into three groups: ETGUA (n = 101), SLEA (n = 100), and COT (n = 101). Ultrasound was used to measure the thickness of bilateral neck muscles, including the sternocleidomastoid, omohyoid, and sternothyroid. The changes in thickness on the surgical side compared to the non-surgical side. Analyzed factors included muscle thickness changes, Swallowing Impairment Score (SIS), Voice Handicap Index (VHI), Scar Cosmesis Assessment and Rating (SCAR), Neck Incision Index (NII), surgery duration, drainage volume, hospitalization, and number of lymph nodes. ResultsThe clinical characteristics among the three groups were consistent except for differences in sex, age, and BMI. Metrics such as sternocleidomastoid muscle, NII, hypocalcemia, postoperative PTH, transient hoarseness, and number of lymph nodes showed no significant differences among the three groups. However, significant differences were found in the duration of surgery, drainage volume, hospitalization period omohyoid muscle, Sternohyoid muscle, VHI, SIS, and SCAR (all p < 0.001). ConclusionIn comparison to COT, ETGUA and SLEA demonstrate superiority in protecting neck muscles and preserving voice and swallowing function without compromising surgical safety or radicality.

Diaphragmatic dysfunction is associated with postoperative pulmonary complications and phrenic nerve paresis in patients undergoing thoracic surgery

PurposeWe aimed to quantify perioperative changes in diaphragmatic function and phrenic nerve conduction in patients undergoing routine thoracic surgery.MethodsA prospective observational study was performed in patients undergoing esophageal resection or pulmonary lobectomy. Examinations were carried out the day prior to surgery, 3 days and 10–14 days after surgery. Endpoints for diaphragmatic function included ultrasonographic measurements of diaphragmatic excursion and thickening fraction. Endpoints for phrenic nerve conduction included baseline-to-peak amplitude, peak-to-peak amplitude, and transmission delay. Measurements were assessed on both the surgical side and the non-surgical side of the thorax.ResultsForty patients were included in the study. Significant reductions in diaphragmatic excursion were seen on the surgical side of the thorax for all excursion measures (posterior part of the right hemidiaphragm, p < 0.001; hemidiaphragmatic top point, p < 0.001; change in intrathoracic area, p < 0.001). Significant changes were seen for all phrenic nerve measures (baseline-to-peak amplitude, p < 0.001; peak-to-peak amplitude, p < 0.001; transmission delay, p = 0.041) on the surgical side. However, significant changes were also seen on the non-surgical side for all phrenic nerve measures (baseline-to-peak amplitude, p < 0.001; peak-to-peak amplitude, p < 0.001; transmission delay, p = 0.022). A postoperative reduction in posterior diaphragmatic excursion of more than 50% was significantly associated with postoperative pulmonary complications (coefficient: 2.69 (95% CI [1.38, 4.01], p < 0.001).ConclusionThoracic surgery caused a significant unilateral reduction in diaphragmatic excursion on the surgical side of the thorax, which was accompanied by significant changes in phrenic nerve conduction. However, phrenic nerve conduction was also significantly affected on the non-surgical side to a lesser extent, which was not mirrored in diaphragmatic excursion. Our findings suggest that phrenic nerve paresis plays a role in postoperative diaphragmatic dysfunction, which may be a contributing factor in the pathogenesis of postoperative pulmonary complications.Clinical trials registration numberNCT04507594.

Strength and Functional Outcomes Following Achilles Tendon Reconstruction With Hamstring Tendon Autograft Augmentation.

The proposed advantages of hamstring autograft reconstruction when compared to alternative procedures, such as flexor hallucis longus (FHL) transfer, V-Y lengthening, and allograft reconstruction, are improved healing and reproduction of normal tendon biomechanics and reduced morbidity within the foot and ankle. In this study, we examined the effect of Achilles tendon reconstruction using hamstring autografts on strength and functional outcomes. Patients who underwent Achilles repair with a hamstring autograft for insertional or midsubstance tendinopathy, delayed diagnosis of rupture, or infection after primary repair were evaluated for inclusion. Forty-six patients were identified; 12 further augmented with an FHL transfer are included in the analysis. Isokinetic testing was completed with a Biodex dynamometer under supervision of a physical therapist masked to surgical side. Pre- and postoperative Foot and Ankle Outcome Scores (FAOS, before March 2016) or Patient-Reported Outcomes Measurement Information System (PROMIS, after March 2016) surveys were collected. For knee flexion, peak torque was not significantly different when comparing operative and nonoperative sides at 180 degrees/second (45.38 Nm vs 45.96 Nm; P = .69) nor at 300 degrees/second (44.2 Nm vs 47.02 Nm; P = .069). Knee extension absolute peak torque was only found to be significantly weaker on the operative side at the faster testing (75.5 Nm vs 79.56 Nm; P < .05). Peak ankle plantarflexion torque was significantly weaker on the operative side at both the slower speed (60 degrees/second: 39.9 Nm vs 48.76 Nm; P < .005) and the faster speed (120 degrees/second: 31.3 Nm vs 40.7 Nm; P < .001). Average power for ankle plantarflexion did not differ significantly from the operative side to the nonoperative side in the slower test (26.46 W vs 27.48 W; P = .60) but did significantly differ on the faster test (32.13 W vs 37.63 W; P = .041). At an average of 19.9 months postoperation, all physical function and pain-related patient-reported outcome scores showed clinically and statistically significant improvement. Achilles reconstruction with a hamstring autograft ± FHL transfer allowed patients with severe Achilles pathology to return to good subjective function, with modest deficits in calf strength compared with the uninjured side. Overall knee flexion strength did not appear impaired. These results suggest that hamstring autograft reconstruction is a viable method to treat these complex cases involving a lack of healthy tissue, allowing patients to return to symptom-free physical function and athletic activity. Level IV, case series.

WITHDRAWN: [Translated article] In vitro elution of local anaesthetics from PMMA bone cement

Background and aimCurrently, we do not have a gold standard for pain management after total knee arthroplasty. We may use one of more drug delivery systems, none of which are ideal.An ideal depot delivery system would provide therapeutic, nontoxic, doses of drug at the surgical side, especially during 72h postoperatively.The bone cement used in arthroplasties has been used as a drug delivery system, especially antibiotics, since 1970. Based on this principle, we developed this study with the aim to characterize the elution profile of two local anaesthetics (lidocaine hydrochloride and bupivacaine hydrochloride) from PMMA (polymethilmethacrylate) bone cement. Material and methodsPalacos® R+G bone cement and lidocaine hydrochloride or bupivacaine hydrochloride specimens were obtained depending on the study group. These specimens were immersed in PBS (phosphate buffered saline) and removed from the solution at different set times.Subsequently, the concentration of local anaesthetic in the liquid was analyzed by liquid chromatography. ResultsThe percentage of lidocaine eluted from PMMA bone cement in this study was 9.74% of the total lidocaine content per specimen at 72h and 18.73% at 336h (14 days). In case of bupivacaine, the elution percentage was 2.71% of the total bupivacaine content per specimen at 72h and 2.70% at 336h (14 days). ConclusionsLocal anaesthetics elute in vitro from PMMA bone cement, reaching doses at 72h close to the doses used in anaesthetic blocks.

Clinical study of lumbar stability after unilateral biportal endoscopy in the treatment of degenerative lumbar diseases

Objectives: To investigate the clinical efficacy of unilateral biportal endoscopy (UBE) in the treatment of degenerative lumbar disease (DLD) and its impact on postoperative lumbar stability. Methods: This is a retrospective case series study. A total of 109 cases of DLD treated with UBE in the Department of Orthopaedic, Beijing Chaoyang Hospital Affiliated to Capital Medical University from July 2020 to June 2022 were analyzed retrospectively. There were 47 males and 62 females, aged (53.3±8.2) years (range: 21 to 80 years). The surgical segments were single segment in 80 cases, two segments in 25 cases, and three segments in 4 cases. The low back pain and leg pain of visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI) were evaluated before and after operation. The modified MacNab criteria were used for evaluation of the clinical consequences. Postoperative three-dimensional lumbar CT was performed to observe the preservation of the facet joints and the angle of the medial surface of the facetectomy(β angle). At 12 months after surgery, X ray of the flexion and extension lumbar spine were reviewed. The comparison and analysis of the data were conducted using paired sample t tests or generalized estimation equations. Results: All 109 patients underwent operative procedures successfully. The operation time was (94.5±37.1) minutes (range:56 to 245 minutes), the times of X ray was 6.8±4.0 (range:4 to 16 times), and the days of hospitalization was (5.3±3.7) days (range:4 to 14 days). Complications included dural tears in 4 cases, transient lower limb numbness in 4 cases, epidural hematoma in 2 case. The follow-up time was (19.6±7.2) months (range:12 to 36 months). The postoperative low back pain VAS, leg pain VAS, JOA score and ODI were significantly improved(all P<0.05). According to the modified MacNab criteria, the excellent and good rate was 88.99%(97/109) at 12 months after surgery. One case underwent revision surgery because of recurrent lumbar disc herniation. In term of radiographic evaluation, the area of the surgical side facet joints after UBE surgery was reserved more than 60%. The β angle was less than 90° in all patients. After 12 months of surgery, there was no surgical segment instability or spondylolisthesis by the X-ray of the flexion and extension lumbar spine. Conclusion: UBE can achieve satisfactory clinical efficacy in the treatment of DLD, and maintain the stability of the lumbar spine.

Measuring pulsatile cortical blood flow and volume during carotid endarterectomy.

Carotid endarterectomy (CEA) involves removal of plaque in the carotid artery to reduce the risk of stroke and improve cerebral perfusion. This study aimed to investigate the utility of assessing pulsatile blood volume and flow during CEA. Using a combined near-infrared spectroscopy/diffuse correlation spectroscopy instrument, pulsatile hemodynamics were assessed in 12 patients undergoing CEA. Alterations to pulsatile amplitude, pulse transit time, and beat morphology were observed in measurements ipsilateral to the surgical side. The additional information provided through analysis of pulsatile hemodynamic signals has the potential to enable the discovery of non-invasive biomarkers related to cortical perfusion.

Mid-term effects of unicompartmental knee arthroplasty combined with anterior cruciate ligament reconstruction for the medial compartment osteoarthritis with anterior cruciate ligament deficiency by proportioning with the pure medial compartment osteoarthritis

Objective: To evaluate the mid-term efficacy of one-stage unicompartmental knee arthroplasty (UKA) combined with anterior cruciate ligament (ACL) reconstruction in the treatment of medial compartment osteoarthritis (OA) with ACL deficiency. Methods: Retrospective cohort study. The clinical data of 13 patients (14 knees) who underwent UKA with ACL reconstruction for knee medial compartment OA combined with ACL deficiency in Wangjing Hospital of China Academy of Chinese Medical Sciences from January 2012 to January 2020 were retrospective analyzed. A 1∶1 proportioning study was conducted with 13 patients (14 knees) who underwent UKA due to medial compartment OA with intact ACL during the same period. The matching conditions were the same gender, age, surgical side, anesthesia method, comorbidities, and imaging lesions. There were 26 patients (28 knees) in the two groups, including 6 males (6 knees) and 20 females (22 knees), aged (58.9±4.2) years. The range of motion (ROM) and Oxford Knee Score (OKS) were used to evaluate the knee joint function at the last follow-up. The anteroposterior, lateral and axial X-ray films of the knee joint and the weight-bearing full-length X-ray films of the lower limbs were taken during follow-up. The hip knee ankle (HKA) angle, the posterior slope angle (PSA) of tibial prosthesis, and the anterior tibial translation (ATT) were recorded and compared between the two groups. The progression of lateral compartment OA, prosthesis loosening, and dislocation were evaluated. The mid-term follow-up clinical efficacy of the two surgical methods was compared, and the etiology of the patients was analyzed to verify the clinical efficacy and patient selection of one-stage UKA combined with ACL reconstruction. Results: The follow-up time of the two groups was (7.14±2.45) years. At the last follow-up, there was no significant difference in joint ROM between the combined group and the UKA group (120.90°±2.95° vs 122.29°±3.22°, P=0.260). There was no significant difference in OKS score between the two groups [(42.50±1.99) vs (43.21±2.26), P=0.380]. There was no significant difference in HKA angle and ATT distance between the two groups before operation (both P>0.05). At the last follow-up, the results were better than those before operation, and the differences were statistically significant (both P<0.05). At the last follow-up, there was no significant difference in HKA Angle between the combined group and the simple group (177.79°±1.25 ° vs 177.86°±1.29°, P=0.880). Tibial prosthesis PSA and ATT distance were not significantly different between the two groups [(4.57°±0.94° vs 4.50°±1.34°and (0.21±0.89) mm vs (0.14±1.35) mm, both P>0.05)]. There was no prosthesis loosening and obvious progression of lateral compartment OA in both groups at the last follow-up. Conclusion: For young patients with medial compartment OA secondary to ACL deficiency, UKA combined with ACL reconstruction is recommended, it can obtain good mid-term results.

Functional and esthetic outcomes of virtual surgical planning versus the conventional technique in mandibular reconstruction with a free fibula flap: A retrospective study of 24 cases

This study aimed to compare the functional and esthetic results in patients following mandibular reconstruction with a free fibula flap (FFF) by virtual surgical planning (VSP) versus the conventional technique. Patients who had undergone mandibular reconstruction with a FFF by VSP or the conventional technique were retrospectively assessed. The two groups were compared regarding functional and esthetic variables with appropriate scales preoperatively, intraoperatively, and postoperatively. Twenty-four patients were evaluated in two groups: conventional (n = 8) and VSP (n = 16). The mean amount of mandibular asymmetry was 2.62 mm (SD = 1.59) in the conventional group and 1.19 mm (SD = 1.32) in the VSP group. Of the patients who underwent conventional surgery, 12.5% had mandibular asymmetry of <2 mm and 87.5% had asymmetry of 2–5 mm. Of the VSP patients, 61.5% had mandibular asymmetry of <2 mm and 38.5% had mandibular asymmetry of 2–5 mm (p = 0.03). The mean difference in size of mandibular angle on the surgical and control sides was not significantly different between the two groups (p = 0.62). The difference in mean length of the mandibular body on the surgical side relative to the control side was not significant between the two groups (p = 0.75). Differences in functional variables between the two groups were not significant. Within the limitation of the study, it seems that the VSP technique resulted in better facial symmetry and superior esthetic outcomes compared with the conventional technique.