Team Of Surgeons Research Articles

Quel est le meilleur fixateur externe pour la fixation des fractures de la diaphyse tibiale par arme à feu ?

IntroductionThe present study aimed to evaluate the functional and radiological outcomes of AO type monolateral external fixator (AO-EF) and Ilizarov type external fixator (I-EF) in definitive fixation of tibial shaft fractures due to gunshot injury. HypothesisPatients undergoing I-EF would have faster fracture healing with the help of early weight-bearing and the functional scores would be better compared to AO-EF. Material and methodsThe study consisted of 76 (67M, 9F) patients who underwent surgery between 2010 and 2016 for tibial shaft fracture due to low-velocity gunshot injury (LVGI). The patients were divided into two groups according to the fixation method (AO-EF and I-EF) which was discussed by the surgeon team due to their experience. The average age at the time of injury was 37.8±9.8 (20 to 59 years). Groups are compared according to LEFS score, coronal-sagittal-rotational angle, Johner-Rush score, and complications such as nonunion, malunion, osteomyelitis, and pin-tract infection. The mean follow-up time 31.61±3.83 months (between 24 and 44 months). ResultsNo statistical difference was found between groups in terms of demographic characteristics. There was no statistical difference between groups regarding body mass index (BMI). LEFS score and operation duration were higher in the I-EF group (p=0.000 and p=0.006 respectively, p˂0.05). In the I-EF group, hospitalization period, full weight-bearing time, and healing time was shorter than the AO-EF group (p=0.001, p=0.000, and p=0.025 respectively, p˂0.05). DiscussionAlthough AO-EF has advantages such as ease of application and short surgery time in the definitive fixation of LVGI tibia shaft fractures, I-EF is a superior technique in terms of functional scores. However, I-EF is a surgical approach that requires relatively more experience. Therefore, the choice of fixator should be determined according to the surgeon's experience in the permanent treatment of LVGI tibial shaft fractures.Level of Evidence: IV; retrospective, case-control study.

Bone Metastases: State of the Art in Minimally Invasive Interventional Oncology.

Bone is the third most common site involved by cancer metastases, and skeleton-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a consequence of nerve or spinal cord compression often affect patients' functional independence and quality of life unfavorably. The annual medical-economic burden related to bone metastases is a substantial component of the total direct medical cost estimated by the National Institutes of Health. There have been substantial recent advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions for the management of patients with osseous metastatic disease. These advances include thermal ablation, cementation with or without osseous reinforcement with implants, osteosynthesis, thermal and chemical neurolyses, and palliative injections, which are progressively incorporated into the management paradigm for such patients. These interventions are performed in conjunction with or are supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesic agents to achieve durable pain palliation, local tumor control, or cure, and they provide a robust armamentarium for interventional radiologists to achieve safe and effective treatment in a multidisciplinary setting. In addition, these procedures are shifting the patient management paradigm in modern-era practice. The authors detail the state of the art in minimally invasive percutaneous image-guided musculoskeletal oncologic interventions and the role of radiologists in managing patients with skeletal metastases. ©RSNA, 2021.

Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature

BackgroundSecondary vaginal stenosis may occur after reconstruction of genital malformations in childhood or after failed vaginal aplasia repair in adults. AimThis study focusses on the results of the surgical treatment of these patients in our multidisciplinary transitional disorders/differences of sex development team of pediatric surgeons and gynecologists. MethodsA retrospective analysis was carried out on adult and female identified disorders/differences of sex development patients with vaginal stenoses treated between 2015 and 2018 in a single center with revision vaginoplasty. The underlying type of malformation, the number and surgical techniques of vaginoplasties in infancy, techniques of revision of the stenotic vagina, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. A review of literature with regard to recommended surgical techniques of revision vaginoplasties was accomplished. OutcomesTo describe the surgical technique, the main outcome measures of this study are vaginal calipers after revision vaginoplasty as well as ability for sexual intercourse. ResultsThirteen patients presented with vaginal stenosis with a median age of 19 years (range 16–31). All patients had one or more different types of vaginoplasties in their medical history, with a median age at first vaginoplasty of 15 months (0–233). Underlying anatomical conditions were urogenital sinus (n = 8), vaginal agenesis (n = 2), persistent cloacae (n = 2), and cloacal exstrophy (n = 1). The main symptoms were disability of sexual intercourse in 13 patients due to stenotic vaginal tissue. The most frequently performed surgical technique was partial urogenital mobilization with a perineal or lateral flaps (n = 10), followed by bowel vaginoplasty (n = 2), in 1 patient a revision vaginoplasty failed due to special anatomical conditions. In a median follow-up of 11 months, all but one patient presented with physiological vaginal length and width, and normal sexual intercourse in those with a partnership. Clinical ImplicationsPerineal flap with partial urogenital mobilization should be considered as a treatment of choice in severe cases of distal vaginal stenosis and after multiple failed former vaginoplasties, while bowel vaginoplasty should be reserved only for cases of complete cicatrization or high located stenosis of the vagina. Strengths & LimitationsThe strength of this study is the detailed description of several cases while the retrospective character is a limitation. ConclusionIn patients after feminizing genital repair, perineal flap with partial urogenital mobilization provides a normal anatomical outcome and allows unproblematic sexual intercourse. Ellerkamp V, Rall KK, Schaefer J, et al. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021;18:1797–1806.

Approach to management of pancreatic strictures: the gastroenterologist's perspective.

Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management.

Multidisciplinary Approach in Teaching Diagnostic Radiology to Medical Students: The Development, Implementation, and Evaluation of a Virtual Educational Model.

The aim of this study was to develop, implement, and evaluate the effectiveness of an online multidisciplinary approach for teaching diagnostic radiology to medical students. An online 10-session case-based learning course was designed and taught by a multidisciplinary team of radiologists, surgeons, and internists. Session topics included common clinical case scenarios for different systems and were hosted on a videoconferencing platform. Students from six medical schools across Texas enrolled in the course. The effectiveness of each session was evaluated using a pretest-posttest design. Students completed a final survey after the course to evaluate their experience. An average of 108 attended the live sessions, with attendance peaking at 220. On average, 75 students completed both the pretest and posttest of each session. Posttest scores were an average of 46% higher than pretest scores. A total of 109 students completed the final survey; more than 90% of participants agreed that the program was relevant, that its multidisciplinary approach was valuable, and that it increased their knowledge of imaging as a diagnostic tool. Seventy-four percent said that the program increased their interest in radiology. Almost all participants said that the topics presented were thought to be "excellent and clinically important to learn" by most of the students (70%). Participants reported increased confidence in basic radiology skills after completion of the program. An online multidisciplinary approach can be feasibly implemented to address the radiology education needs of a large number of medical students across a group of medical schools.

O31 Central venous access in ventilated COVID-19 patients: a vascular surgery perspective

IntroductionThe number of patients on intensive care units (ICU) increased manifold during the initial COVID-19 surge and medical staff were relocated to help compensate. The need for central venous catheters (CVCs) increased accordingly and comprised a significant workload under challenging circumstances. Several models were proposed to manage the lines. We assigned a vascular team of vascular surgeons and interventional radiologists for CVCs in ICU. We report on the workload, outcomes and lessons learned.Method50 consecutive ventilated COVID-19 patients in ICU (median age 63 years, 80% male) who had a CVC inserted by the vascular team from March to May 2020 were assessed. Median follow up was 18 days (range 14– 29 days) after ICU admission.Result166 CVCs (80 VasCaths) were inserted. Femoral access was preferred. Each patient required a median of 3 lines (IQR 2–4). CVCs were exchanged after median 7 days (IQR 4–9) for thrombosis (35%), infection (24%) or prophylactically (41%). Our learning curve included the establishment of an online referral pathway, CVC teams of two operators, extended disposable CVC kits and ICU based ultrasound scanners. Additional staffing and retraining were avoided. There were no technical complications.ConclusionVentilated COVID-19 patients require multiple CVCs which is a challenging workload during a pandemic. Vascular surgeons and interventional radiologists with endovascular skills are well positioned to perform central venous cannulation to alleviate the burden on critical care teams. Our lessons learned can help to provide a safe and efficient model amidst the ongoing national outbreaks.Take-home MessageWith the postponement of many elective vascular procedures during the pandemic crisis, the involvement of vascular surgeons in a dedicated Lines team is an important way that they can contribute given their proficiency with wires and cannulation equipment, as well as familiarity in femoral triangle and jugular anatomy. The retraining of staff and additional on-call rotas can then be avoided.

Outpatient total ankle replacement.

Since the development of the last generation of implants total ankle replacements (TAR) is becoming more and more popular in patients and in specialized surgeon teams, the trend for outpatient surgery is growing, and protocols now are well established for hip or knee replacement. We adapted a protocol for outpatient TAR and hypothesized that it could be performed safely as standard procedure. Twenty-five consecutive patients among 141 TAR were treated with our outpatient protocol relying on three fundamentals: bleed control, pain control, and autonomy. They received 1g of tranexamic acid before surgery, and after discard from post-operative care unit, they were operated under long-lasting nerve block precociously relayed by oral NSAIDs and had an immediate full weight-bearing authorization at discharge. No patients we readmitted for an acute care following TAR, especially for haematoma or uncontrolled pain. Mean VAS was < 1 before discharge from post-operative care unit and < 2 until day 90. One patient had a delayed wound healing treated surgically at day 30 without implant revision. Outpatient TAR is possible and safe if a risk management process is used, and the three basic principles for outpatient procedures are respected: bleed control, pain control, and patient autonomy. We consider now this modality as a routine.

Current Trends in Orthognathic Surgery in Poland—A Retrospective Analysis of 124 Cases

The analysis aims at assessing the current trends in orthognathic surgery. The retrospective study covered a group of 124 patients with skeletal malocclusion treated by one team of maxillofacial surgeons at the University Hospital in Zielona Góra, Poland. Various variables were analysed, including demographic characteristics of the group, type of deformity, type of osteotomy used, order in which osteotomy was performed and duration of types of surgery. The mean age of the patients was 28 (ranging from 17 to 48, SD = 7). The group included a slightly bigger number of females (59.7%), with the dominant skeletal Class III (64.5%), and asymmetries were found in 21.8% of cases. Types of osteotomy performed during surgeries were divided as follows: LeFort I, segmental LeFort I, BSSO, BSSO with genioplasty, LeFort I with BSSO, LeFort I with BSSO and genioplasty, segmental LeFort I with BSSO, isolated genioplasty. Bimaxillary surgeries with and without genioplasty constituted the largest group of orthognathic surgeries (49.1%), and a slightly smaller percentage were one jaw surgeries (46.7%). A statistically significant correlation was found between the type of surgery and the skeletal class. In patients with skeletal Class III, bimaxillary surgeries were performed significantly more often than in patients with skeletal Class II (57.5% vs. 20.0%; p = 0.0002). The most common type of osteotomy in all surgeries was bilateral osteotomy of the mandible modo Obwegeser–Epker in combination with Le Fort I maxillary osteotomy (42.7%). The order of osteotomies in bimaxillary surgeries was mandible first in 61.3% of cases. The longest surgery was bimaxillary osteotomy with genioplasty (mean = 265 min), and the shortest surgery was isolated genioplasty (mean = 96 min). The results of the analysis show a significant differentiation between the needs of orthognathic surgery and the types of corrective osteotomy applied to the facial skeleton.

A Heart Surgery Simulator With an Integrated Supervision System for Self-Learning the Key Steps and Pitfalls of the Mitral Valve Repair: Initial Investigation.

Over the years, surgical education has dramatically improved and has become increasingly innovative. Almost all educational programs in surgery now rely on sophisticated training boxes and simulators that enable surgical instruments to be handled and surgical procedures to be trained in a safe environment. However, simulators need constant feedback from supervising senior surgeons, who only have limited teaching time available. We describe a cardiac surgery simulator with an integrated supervision system for self-learning how to repair a mitral valve. We developed a mitral surgery simulator with integrated sensors to generate, record, and display quantitative data on trainee performance in relation with the mitral valve repair procedure. A team of experienced cardiac surgeons defined critical areas of the model and an algorithm to identify inconsistent movements, in terms of error types and out-of-bound actions. The device provided real-time feedback on the accuracy of the stitches placed. Four experienced cardiac surgeons and 3 advanced cardiac-surgery used the simulator and were asked to evaluate specific parameters of the system on a scale ranging from 1 to 10. All surgeons completed a P2 resection, followed by implanting a 32-mm mitral ring. The simulator detected 2 stitches that were placed in dangerous zones and another stitch that was placed in an inappropriate position. Users scored the real tissue feeling and interactivity of the model 9.5/10. This heart-surgery simulator offers a real-life model for learning about and training in mitral valve surgery, which could potentially replace the experienced surgeon's teaching role.

Clinical outcome and multifidus muscle changes of transforaminal lumbar interbody fusion

Background: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has shown to have smaller skin incision, decreased muscular dissection, and less retraction of the thecal sac, compared to conventional open approach. However, its effects on long term functional outcome and degenerative changes of paraspinal muscles are still obscure. Materials and Methods: We studied 81 patients treated by one team of surgeons at a single institution. In the two level spinal fusion, 18 patients underwent conventional TLIF (C TLIF) and 20 patients underwent MIS TLIF. In three level spinal fusion, 23 patients were treated with C TLIF and 20 patients were treated with MIS TLIF. Clinical outcomes included mean operative times, volume of blood loss, percentage of early ambulation, visual analog scale (VAS), and oswestry disability index (ODI) were analyzed. The change of multifidus muscle was calculated from magnetic resonance imaging (MRI) taken before and 6-month after the operation. Results: Lesser blood loss was noted in the MIS TLIF group compared to the conventional group in two- or three-level circumferential spinal fusion. Early ambulation (within 3 days after operation) was found in the MIS TLIF groups. Analysis of VAS scores at leg area showed no significant differences in improvement between each group at 18 month follow up. The postoperative ODI score was significantly less in the MIS TLIF groups than in the C TLIF groups after 6 month follow up. In three segment spinal fusion, MIS TLIF minimized multifidus muscle atrophy, when compared with C TLIF. Conclusion: MIS TLIF in three level lumbar fusion not only has a better functional recovery but also ameliorates the degenerative change of multifidus muscle.

Case report on the management of failed tunneled hemodialysis catheter insertion

Hemodialysis vascular access is critical to ensuring adequate hemodialysis sessions. Tunneled internal jugular vascular (IJV) access is a type of intermediate access that has become increasingly useful in low- and middle-income countries, where there are not many vascular surgeons with expertise in arteriovenous fistula creation. We presented a 69-year-old male who had complicated IJV catheter insertion, with the catheter located in the pulmonary vascular bed of the left lung and associated left-sided hemothorax. He was managed by multidisciplinary team of nephrologists, radiologists, and cardiothoracic surgeons, who removed the catheter under fluoroscopic guidance without any complication or need for open thoracotomy. The case highlighted the utility of fluoroscopy in aiding hemodialysis catheter insertion, removal, and management of its complications.

The Interdisciplinary Approach and New Technologies in the Scientific and Clinical Development of Otorhinolaryngology.

The experience of the FMBA NMRCO of Russia in implementing the concept of an interdisciplinary approach and the use of new technologies in the diagnosis, treatment, and rehabilitation of diseases of the ENT organs is discussed. It is noted that otorhinolaryngology is closely associated with a number of basic medical sciences and related clinical disciplines, which is reflected in the structure of the center: in addition to otorhinolaryngological departments, in which high-tech surgical interventions on ENT organs are performed, there are scientific and clinical departments: maxillofacial and plastic surgery, ophthalmology and neurosurgery, as well as the country’s only center for professional pathology of ENT organs. Thus, in the general structure of the NMRCO’s medical services, the share of medical care in specialties related to otorhinolaryngology is about 40%. Several departments deal with oncological diseases of the head and neck organs. Complex high-tech surgeries of cancer patients are performed by interdisciplinary teams of maxillofacial surgeons, oncologists, otosurgeons, and neurosurgeons, and interaction with the departments of phoniatrics and physiotherapy and medical rehabilitation provides them with full-fledged postoperative rehabilitation. The NMRCO’s experience shows that the widespread introduction of an interdisciplinary approach into clinical practice makes it possible to increase the efficiency of diagnostics, treatment, and rehabilitation of patients with otorhinolaryngological pathology.

Análisis de los resultados y los factores adversos de la reparación artroscópica de las lesiones del subescapular de origen degenerativo

ObjectiveTo carry out a review of degenerative subscapularis ruptures (SSC) after their arthroscopic repair and to evaluate whether the results are comparable in terms of pain and function to those of younger patients with traumatic ruptures. MethodsThe data of 80 SSC tears of the 660 rotator cuff tears operated on by the same team of surgeons from June 2008 to June 2018 were retrospectively reviewed. The clinical data of the surgical indications were collected: age, gender, laterality, intervention delay, associated pathologies, location of pain, value of the Visual Analogue Scale (VAS) and the Constant-Murley test (CMT); surgical data were also collected: type and size of lesion, associated biceps injury and associated surgical procedure, coracoid stenosis and associated surgical procedure, number and type of anchors used. A statistical study was performed with multiple linear regression test, parametric tests (Student's t or ANOVA) and non-parametric tests. ResultsOf 80 patients, 36 were women (45%) and 44, men (55%); mean age 61years (range 47 to 81); mean delay of surgery 3.5months (range 1 to 6); right shoulder affected in 46 cases (57.5%), left in 34 (42.5%); 22 (27.5%) were isolated lesions, 58 (72.5%) were associated with supraspinatus rupture (SE). The mean improvement was 5.0 points in terms of the VAS and 39.9 points on average in the CMT. New breakage rate, 1.25%. Adverse factors: size of the tear, delay in intervention, women. Patients with type I-B rupture have a better overall result in the CMT than types I-A and III. The longer the delay, the worse results are observed, both for the VAS and the CMT. Women present worse and statistically significant results both in the VAS (P=.00) and in the CMT (P=.01). ConclusionsExcellent and good results have been obtained in this group of patients, but there are adverse factors such as the size of the tear, the duration of the symptoms and the association of other pathologies, especially in women.

Hands-On Workshops Improve Emergency Department Physicians' Self-Reported Understanding of Pediatric Hand Injuries.

The aims of this study were to assess emergency department (ED) physician perception of hand injuries and improve their understanding and confidence in treating these injuries. Combined didactic and hands-on workshops for ED physicians were developed and run by a team of medical students, plastic surgeons, and ED physicians. The workshops consisted of a short review by a hand surgeon followed by hands-on sessions involving radiograph assessment, administration of local anesthetic, closed reduction, and splinting. Two sessions, 6 months apart, were provided. The workshops were evaluated using preworkshop and postworkshop questionnaires to assess the following domains: confidence and competence in treating hand injuries, knowledge of basic hand injury care, and feedback on the intervention itself. Fifty physicians participated in the workshops. After the workshops, physician recognition of hand fracture reduction as a critical skill increased. Self-efficacy ratings of fracture assessment, administration of local anesthetic, performing a reduction, and applying postreduction immobilization increased. Median scores on knowledge-testing questions also increased postintervention from 73.3% (95% confidence interval, 70.2-78.5) to 86.7% (95% confidence interval, 79.3-86.2) (P < 0.05). Finally, physicians reported that they found the intervention educational, useful, and important, and approximately 90% of participants indicated they intended to change their practice based on this intervention. Knowledge sharing between specialists and generalists through combined didactic and hands-on workshops is an effective and well-received method of refining physician knowledge and increasing confidence in treating subspecialty-specific clinical presentations.

Flap Monitoring using Thermal Imaging Camera: A Contactless Method.

To determine the accuracy of the thermal imaging camera for the detection of vascular insult before the onset of permanent tissue damage. Descriptive study. Department of Burn and Plastic Surgery, from July to December 2019. The thermal image was used as an adjunct to clinical assessment in 84 flaps. Both pedicled and free flaps were performed in the study with a frequency of 68 (81%) and 16 (19%), respectively. Flap monitoring was performed regularly for five days by same team of surgeons and nurses. Flap vascularity was assessed by temperature gradient colour coding of thermal image taking the clinical assessment like colour, temperature, capillary refill, as a gold standard. Sensitivity and specificity of the thermal camera were calculated. The age range of patients was from 5 years to 55 years. The diagnostic accuracy of thermal imaging camera was calculated to be 96.43% with a sensitivity of 98.7%, specificity of 75%. The positive predictive value was found to be 97.4%, negative predictive value was 85.7%, the false-negative value was 14.3%, and the false-positive value was 2.6%. Thermal imaging camera is an effective and useful adjunct for clinical assessment, as it is an easy and contactless technique. Key Words: Flir one, Flap monitoring, Thermal imaging camera.

Ruptured Abdominal Aortic Aneurysm Associated with Left Colon Gangrene and Neurological Disorders, a Very Rare and Life-Threatening Combination.

Background: We report the management of a very rare combination of two severe surgical emergencies, ruptured aortic aneurysm with gangrene of the left colon. Both events separately present a high mortality rate in ruptured aortic aneurysms with 48.5%.&#x0D; Case report: We present the case of a 59-year-old woman that was admitted to the service of Emergencies at University Hospital Center “Mother Theresa” of Tirana on January 4th of 2013, after being transferred from the Regional Hospital of Durres diagnosed with ruptured aortic aneurysm based on an unclear CT. The patient arrived in a state of profound hypovolemic shock after suffering cardiac arrest and underwent resuscitation at the ICU of Durres Hospital ( no exact information of the anoxic brain time).&#x0D; After a brief volemic compensation in our ICU, the patient was taken to the operating room. Intraoperatively we found an infrarenal r AAA and gangrene of the sigmoid and left colon. Resection and reconstruction by the interposition of a tube graft were performed, followed by a left large hemicolectomy with temporary colostomy realized by the team of general surgeons. Three months later they performed colorectal-anastomosis as a second step operation.&#x0D; Postoperatively the patient had a period of 3 weeks stay in the ICU, mostly due to neurological complications after the ischemic stroke, and on January 29 of 2013, she returned to the Service of Neurology at the Hospital of Durres for further neurological rehabilitation. One year later, in the ambulatory routine check, the patient presented full recovery from surgery and a complete central and peripheral neurological rehabilitation.&#x0D; Conclusions: Ruptured aortic aneurysm with gangrene of the left colon is a very rare and severe combination caused by the hypoperfusion of the inferior mesenteric artery in the presence of hypovolemic shock and insufficient collateral circulation. The strategy of treatment includes fast diagnosis, short hypotensive resuscitation, cell-saving and autotransfusion, and the simplest possible surgical reconstruction for both emergencies.

Large Invasive Adrenal Cortical Carcinoma in a Patient With Neurofibromatosis Type I

Background: Adrenal cortical carcinoma is a rare neoplasm. Adrenal cortical carcinoma has previously been reported in less than 10 cases of patients with Neurofibromatosis Type I. Clinical Case: A 44-year-old Hispanic man with Neurofibromatosis Type I (NF1) presented with progressive hypoxia, tachypnea and abdominal pain. Intubation was required with 100% FiO2. CT angiogram of the chest and abdomen showed a 9.5 cm left adrenal mass with tumor thrombus in the left adrenal vein, distal left renal vein, IVC extending into the right atrium, suggestive of an adrenocortical carcinoma. Café-au-spots, neurofibromas and Lisch nodules were seen on physical exam but no signs suggestive of a functional adrenal cortical carcinoma. Transthoracic echocardiogram demonstrated a large well circumscribed echo-dense mass filling the right atrial cavity. Hemodynamically he was unstable with labile blood pressures due to right atrium thrombus burden. He was supported pending pheochromocytoma investigation. Biochemical work up revealed an elevated 24-hour free cortisol concentration of 95.9 ug/d (<=60ug/d) with a normal 24-hour urine metanephrine and normetanephrine [140ug/d (55-320ug/d) and 448 ug/d (114-865ug/d]. Plasma free metanephrine level was normal 0.43 (0.00-0.49nmol/L) and the normetanephrine levels was increased at 2.7 (0.00-0.89nmol/L) consistent with stress response. Serum aldosterone level and renin activity with potassium and DHEA-S levels were normal. Once pheochromocytoma was ruled out, he successfully underwent a left nephrectomy, left adrenalectomy, IVC thrombectomy, right atrium thrombectomy under a multidisciplinary team of surgeons. Surgery was well tolerated and he was discharged home 11 days later. Pathology confirmed adrenal cortical carcinoma, stage 4, with involvement of endocardium and left renal vein with mitotic count greater than 20/50 high-power fields, consistent with a high-grade tumor. Summary: Patients with NF1 have a higher predilection to develop tumors including pheochromocytoma, paraganglioma, gastrointestinal stromal tumor, and pancreatic neuroendocrine tumor. NF1 association with adrenal tumors is well known, most commonly pheochromocytomas which occur in 0.1–5.7% of patients with NF1. However, based on a literature search there have been less than 10 case reports which postulate an association between NF1 and ACC. Genetic analysis of these reported cases suggest a loss of heterozygosity at the NF1 locus as a possible explanation of development of ACC in patients with NF1. Conclusion: Adrenal cortical carcinoma is rare but should be considered in a patient with NF1 and adrenal mass when plasma/urine metanephrines are not suggestive of pheochromocytoma.

Safety of Tumescent Liposuction Under Local Anesthesia in 9,002 Consecutive Patients.

Liposuction has become one of the most popular aesthetic procedures today. Among the different anesthesia methods, tumescent local anesthesia (TLA) has been shown to be the safest. Liposuction is typically performed as an outpatient procedure under minimal oral sedation and without the need for any intravenous (IV) fluid administration. To record complications in a larger series of patients undergoing liposuction in TLA. Between 2003 and 2020, 9,002 consecutive patients underwent liposuction in TLA with the same team of surgeons. The occurrence of complications was recorded in detail. There were neither fatal complications nor damage to deeper structures such as nerves, blood vessels, muscles, lungs, abdominal organs, nor permanent lymphedema. A total of 19 of the following side effects, mainly minor, required closer follow-up or intervention: allergic drug reaction to doxycycline (0.06%), seroma (0.04%), large hematoma (0.03%), erysipelas (0.02%), transient acrocyanosis (0.02%), deep vein thrombosis (0.01%), skin necrosis (0.01%), and generalized edema (0.01%). Liposuction in TLA is a reliable and safe procedure if it is performed by an experienced surgeon and the guidelines of care are strictly followed.

Which external fixation method is better for the treatment of tibial shaft fractures due to gunshot injury?

IntroductionThe present study aimed to evaluate the functional and radiological outcomes of AO type monolateral external fixator (AO-EF) and Ilizarov type external fixator (I-EF) in definitive fixation of tibial shaft fractures due to gunshot injury. HypothesisPatients undergoing I-EF would have faster fracture healing with the help of early weight-bearing and the functional scores would be better compared to AO-EF. Material and methodsThe study consisted of 76 (67M, 9F) patients who underwent surgery between 2010 and 2016 for tibial shaft fracture due to low-velocity gunshot injury (LVGI). The patients were divided into two groups according to the fixation method (AO-EF and I-EF) which was discussed by the surgeon team due to their experience. The average age at the time of injury was 37.8±9.8 (20 to 59 years). Groups are compared according to LEFS score, coronal-sagittal-rotational angle, Johner-Rush score, and complications such as nonunion, malunion, osteomyelitis, and pin-tract infection. The mean follow-up time 31.61±3.83 months (between 24 and 44 months). ResultsNo statistical difference was found between groups in terms of demographic characteristics. There was no statistical difference between groups regarding body mass index (BMI). LEFS score and operation duration were higher in the I-EF group (p=0.000 and p=0.006 respectively, p˂0.05). In the I-EF group, hospitalization period, full weight-bearing time, and healing time was shorter than the AO-EF group (p=0.001, p=0.000, and p=0.025 respectively, p˂0.05). DiscussionAlthough AO-EF has advantages such as ease of application and short surgery time in the definitive fixation of LVGI tibia shaft fractures, I-EF is a superior technique in terms of functional scores. However, I-EF is a surgical approach that requires relatively more experience. Therefore, the choice of fixator should be determined according to the surgeon's experience in the permanent treatment of LVGI tibial shaft fractures. Level of evidenceIV; retrospective, case-control study.

Modified Mclaughlin procedure for neglected posterior dislocation of shoulder: short-term results

&lt;p&gt;Between 2017 to 2020, A prospective case series for assessment of short-term outcomes was carried out on 10 shoulders with 3 being bilateral cases and diagnosed as neglected posterior dislocation of shoulder at a tertiary care centre and treated with the Modified Mclaughlin procedure. All patients had articular defect ranging from 27-46% as confirmed with computerised tomography. All the surgeries were carried out by a single team of surgeons. After 24 weeks follow up of 10 shoulders with mean age 32 years, all patients were found to have excellent results in terms of ROWE and constant score. Patients had significant reduction in VAS score. Timely diagnosis of articular involvement plays a vital role in management for which computed tomography has a pivotal role. Depending upon the articular involvement, line of management is to be decided. So, it can be concluded that, in cases of articular defect &amp;gt;25% following posterior dislocation of shoulder, better outcomes can be achieved with modified Mclaughlin procedure in terms of radiographic union and clinical scoring.&lt;/p&gt;