Two-stage Operation Research Articles

Single frontotemporal approach for microsurgical clipping of bilateral ophthalmic artery aneurysms: a case report

Abstract Bilateral ophthalmic aneurysms represent a distinct niche of brain aneurysms located in a complex skull base region. When considering surgical treatment, a single-stage approach is often advantageous to minimize operative time, tissue manipulation, and damage to neural and vascular structures compared to a two-stage surgery. Nonetheless, this procedure is not exempt from risks, given that through knowledge, preoperative and intraoperative judgment can be necessary to reduce the significant risk of bilateral vision loss. Thus, a tailored approach often is needed. In this study, we present the case of a 53-year-old female who was diagnosed with bilateral ophthalmic aneurysms during the work-up for chronic headaches. Because of the growth pattern and imminent risk of rupture, she underwent elective microsurgical treatment. A frontotemporal approach ipsilateral to the most lobulated aneurysm was performed. Both aneurysms were successfully clipped in a single craniotomy. Her postoperative imaging demonstrated adequate clipping and an uneventful clinical course. Our case outlines the feasibility of a single approach and contributes to the tailored selection for patients when considering microsurgical treatment for these complex lesions.

Prognosis after one- and two-stage revision surgery for periprosthetic joint infection: A systematic review and meta-analysis.

Revision surgeries for periprosthetic joint infections (PJIs) in arthroplasty can follow either one- or two-stage treatment protocols. Previous studies have reported similar reinfection rates and reductions in complication rates for both treatment options. However, the literature on the selection of one protocol is still controversial. Thus, our aim was to compare the outcomes, including reinfections, complications, reoperations, and mortality, associated with one- and two-stage revision surgeries for PJI via a systematic review and meta-analysis of comparative studies. Comparative studies were identified through searches in PubMed, EMBASE, the Web of Science, and the Cochrane Library as of November 2023. RevMan version 5.3 was used for the analyses. The included studies directly compared one-stage revisions with two-stage revisions for PJI. The primary outcomes included reinfection, complications, reoperation, and mortality. Sixteen cohort studies (fifteen retrospective and one prospective) were included in the systematic review. All studies comprising 2039 patients were included in the meta-analysis. Fourteen studies reported reinfection patient risk postrevision; when pooled via random effects models, 10.02% of patients in the one-stage group and 14.75% of patients in the two-stage group were reinfected, indicating low heterogeneity (risk ratio = 0.69; 95% CI = 0.50 - 0.94, I2 = 0%). A pooled analysis of ten studies reported complications between the two groups. Compared with the two-stage group, the one-stage group was associated with significantly fewer complications (risk ratio = 0.76; 95% CI = 0.63 - 0.91, I2 = 27%). The meta-analysis revealed no significant difference in reoperation events between the 1st-stage and 2nd-stage groups in nine studies (risk ratio = 0.77; 95% CI = 0.59 - 1.01, I2 = 20%) or in mortality in ten studies (risk ratio = 0.93; 95% CI = 0.49 - 1.78, I2 = 0%). Among the available observational studies, the meta-analysis revealed a lower incidence of reinfection and complications in the one-stage group than in the two-stage group, but there were no significant differences in reoperation events or mortalities.

Periprosthetic Joint Infections in Total Hip Arthroplasty: An Integrative Review of Risk Factors, Pathogens, and Treatment Strategies

Objective This study aims to analyze the main risk factors, infectious agents, and treatment protocols for periprosthetic joint infections (PJI) in total hip arthroplasty (THA). Methods A systematic search was conducted in PubMed and related databases for articles published between 2015 and 2025. Studies addressing PJI in THA were included, focusing on clinical outcomes, diagnostic strategies, and therapeutic protocols. Data were descriptively analyzed based on 55 relevant studies. Results Significant risk factors identified include obesity, diabetes, and prior surgical interventions. The primary causative agents were Staphylococcus aureus and Gram-negative bacteria, with fungal infections, though rare, presenting unique challenges. Among therapeutic strategies, two-stage revision surgeries exhibited the lowest failure rates for chronic infections, particularly with the use of antibiotic-loaded cement spacers and multidisciplinary approaches. Conclusion PJI in THA remains a clinical challenge requiring early diagnosis and individualized treatment. Multidisciplinary approaches and robust prevention protocols significantly improve clinical outcomes.

High failure rate in meniscal repair when preceding anterior cruciate ligament reconstruction: An analysis of two-stage surgery for concomitant ACL injury and traumatic meniscus tear.

To investigate the failure rate, predictive factors associated with failure and clinical outcomes after a two-stage surgery; meniscus repair followed by subsequent anterior cruciate ligament (ACL) reconstruction (ACLR). Patients with a concomitant traumatic meniscus tear and ACL injury who underwent a two-stage surgery between January 2015 and January 2021 were identified. The primary outcome was meniscal repair failure, defined as a reoperation (re-repair or resection). A Cox-regression analysis was used in order to analyse factors associated with meniscal repair failure within 3 years after the primary surgery for a meniscal repair. Secondary outcomes were range of motion (ROM), anterior knee laxity and the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 1- and 2-year follow-up. The thresholds of patient acceptable symptom state (PASS), treatment failure (TF) and minimum important change (MIC) were applied to KOOS4 (mean score of the KOOS Pain, Symptoms, Sports/Rec and QoL subscales). A total of 150 patients were included. The meniscal repair failure rate after 3 years was 36.7%. Failure of meniscal repair was significantly associated with a time interval >1 year between the meniscal repair to the ACLR (hazard ratio [HR] = 2.5; 95% confidence interval [CI] = 1.2-5.5; p < 0.01), medial meniscus repair (HR = 2.3; 95% CI = 1.6-3.4; P < 0.01), and female sex (HR = 1.42; 95% CI = 1.0-1.9; p = 0.01). The age of the patient was not associated with meniscal repair failure. At the 6-month follow-up, most patients (72.5%) showed less than 2 mm of knee laxity; four patients (6.7%) experienced loss of extension and four patients (1.7%) experienced loss of flexion. On the KOOS4, at the 2-year follow-up, PASS was achieved in 53.4%, TF occurred in 1.7%, and MIC was reached in 36.4% of patients. The meniscus repair failure rate after the staged procedure was 36.7% at 3 years. A longer time interval from meniscal repair to ACLR, medial meniscus repair, and female sex were associated with an increased risk of meniscal repair failure. Age was not associated with meniscal repair failure. Level IV case series retrospective study.

P-66. Comparison of Periprosthetic Tissue and Cement Spacer Sonicate Fluid Cultures at the Second Stage of Two-Stage Hip and Knee Revision Arthroplasty Surgery for Periprosthetic Joint Infection

Abstract Background Chronic periprosthetic joint infection is commonly managed with two-stage exchange. Clinically, evaluation for persistent infection at the second stage of exchange may inform management. The aim of this study was to evaluate the yield of periprosthetic tissue and antimicrobial-containing cement spacer sonicate fluid cultures at the second stage of two-stage exchange surgeries. Methods Periprosthetic tissue and sonicate fluid cultures of hip and knee cement spacers removed at the second stage of two-stage exchange surgeries between January 2010 and December 2020 were studied. Two or more positive tissue cultures yielding the same organism were considered positive. For sonicate culture, ≥20 CFU/10 ml of sonicate fluid was considered positive. Persistent infection was defined by the presence of at least one of the following: intraoperative purulence, sinus tract, histopathology showing acute inflammation, or clinical signs of infection. Cement spacers were removed as part of spacer exchange if persistent infection was suspected or for insertion of a new implant if infection was not suspected. Results 172 cultures were evaluated, 69% from knees and 31% from hips. Median patient age was 64 years; 53% were men. 38/172 (22%) of cement spacers were removed as part of a spacer exchange and 134/172 (78%) for insertion of a new implant. Persistent infection was present in 49/172 (28%). 18/172 (10%) received antibiotics 2 weeks before culture, including 8/18 (44%) undergoing spacer exchange. For persistent infections, tissue and sonicate culture were positive in 11/49 and 5/49, respectively. In the 123 without persistent infection, no tissue or sonicate cultures were positive. When a new implant was placed, persistent infection was observed in 18/134 (13%), and tissue and sonicate cultures were positive in 4/18 and 1/18, respectively. When a new implant was placed (116) and no infection was found, all tissue and sonicate cultures were negative. After spacer exchange, persistent infection was present in 31/38 (81%), and tissue and sonicate cultures were positive in 8/31 and 3/31, respectively; in the 7 without infection, there were no positive cultures. Conclusion Sonication culture of cement spacers and periprosthetic tissue cultures have low sensitivities for persistent infection. Disclosures Matthew Abdel, MD, Stryker: Advisor/Consultant|Stryker: Royalties Nicholas Bedard, MD, Stryker: Advisor/Consultant Robin Patel, MD, a patent on Bordetella pertussis/parapertussis PCR issued, a patent on a device/method for sonication with royalties paid by Samsung to Mayo Clinic, a: See above|MicuRx Pharmaceuticals and BIOFIRE: Grant/Research Support|PhAST, Day Zero Diagnostics, Abbott Laboratories, Sysmex, DEEPULL DIAGNOSTICS, S.L., Netflix, Oxford Nanopore Technologies and CARB-X: Advisor/Consultant|Up-to-Date and the Infectious Diseases Board Review Course.: Honoraria

One-stage versus two-stage video-assisted thoracic surgery for synchronous bilateral pulmonary nodules: protocol for a single center, non-randomized clinical trial (OTVATS-1)

BackgroundPrevious retrospective studies demonstrated both one-stage and two-stage video-assisted thoracic surgery (VATS) for bilateral pulmonary nodules were safe and feasible in selected patients. However, prospective data is still lacking. The purpose of this trial is to prospectively compare the prognostic and perioperative outcomes between one-stage and two-stage VATS for synchronous bilateral pulmonary nodules.MethodsWe conduct a prospective clinical trial to investigate the surgical outcomes of one-stage and two-stage VATS for patients with synchronous bilateral pulmonary nodules. This trial plan to enroll 198 patients from a single institution during a period of 5 years. The primary outcome is 5-year overall survival. Secondary outcomes include 5-year disease free survival, 3-year overall survival, 3-year disease free survival, overall complications rate, 30-day mortality, pain score after surgery, surgical time, blood loss in the operation, duration of chest tube, length of stay, and quality of life score after surgery.DiscussionTo our knowledge, this study is the first prospective registered clinical trials to compare the clinical outcomes after one-stage or two-stage VATS for synchronous bilateral non-small cell lung cancer.Trail registrationThis study underwent review by the Ethics Committee of China-Japan Friendship Hospital under No. 2023-KY-061-1. It has been officially registered with the China Clinical Trial Registry, TRN: ChiCTR2300071198 and registration date is May. 8, 2023.

One-stage versus two-stage thoracoscopic surgery for synchronous bilateral pulmonary nodules: a propensity score-matched analysis

BackgroundThe aim of this study was to compare the surgical efficacy of one-stage and two-stage video-assisted thoracoscopic surgery (VATS) for bilateral multiple pulmonary nodules (BMPNs).MethodsA retrospective analysis was made of 156 patients, 84 who underwent one-stage and 72 who underwent two-stage VATS for BMPNs at our department between January 2019 and December 2022. Perioperative and long-term outcomes were compared between the two groups using propensity score-matched (PSM) analysis.ResultsThere were 48 patients in each group after PSM. No significant difference was observed in operation time, blood loss, rates of overall complications, and 3-year overall survival (p>0.05) between one-stage and two-stage groups. The one-stage procedure was associated with shorter length of stay (5 days [IQR 4-5.75 days] vs. 9 days [IQR 7–10 days]; p<0.001), as well as lower total cost (14626.3 ± 4149.4 vs. 18975.9 ± 3720.8 USD, p<0.001) compared to the two-stage procedure. The one-stage group was associated with better 3-year RFS compared with the two-stage group (90.7% vs. 75.3%, p = 0.039).ConclusionOne-stage and two-stage VATS for BMPNs are both safe and feasible in selected patients. One-stage procedure possess potential advantages in reducing hospital stay and cost, as well as preventing tumor progression.

Successful staged surgery for advanced esophageal cancer after conversion pancreatoduodenectomy with pancreaticogastrostomy.

Complex surgery during initial cancer treatment can limit surgical options when planning management of a secondary malignancy. Subtotal esophagectomy and pancreatoduodenectomy are the most invasive and difficult procedures in gastroenterological surgery. Surgical cases in which subtotal esophagectomy was performed after pancreatoduodenectomy with pancreaticogastrostomy are extremely rare and challenging procedures due to the resulting complicated anatomical changes. A 60-year-old man with a history of conversion pancreatoduodenectomy with pancreaticogastrostomy for advanced pancreatic head cancer was diagnosed as having advanced thoracic esophageal squamous cell carcinoma. After neoadjuvant chemotherapy, we chose a two-staged surgery with thoracoscopic subtotal esophagectomy. Following percutaneous endoscopic gastrostomy, we performed subtotal esophagectomy, systematic lymph-node dissection, and esophagostomy as the first-stage operation. Fifty-six days later, we performed gastrointestinal reconstruction with pedicle jejunum and microvascular anastomosis by the percutaneous route as the second-stage operation. Postoperatively, the patient was relieved without major complications, and the tumors were amenable to curative pathologic resection. The greatest advantages of staged surgery are to reduce surgical invasiveness and to circumvent the lower rate of curability. Our procedure reported here may be recommended as an option for staged resection and reconstruction in patients with advanced esophageal cancer after pancreatoduodenectomy with pancreaticogastrostomy.

Free Functional Muscle Transfer in Brachial Plexus Injury Patients With Subclavian Artery Injury Using Arteriovenous Loop Grafts.

Free functional muscle transfer (FFMT) for brachial plexus injury (BPI) requires adequate donor arterial flow for successful anastomosis. However, concomitant BPI and subclavian artery injury are not uncommon. Arteriovenous (AV) loop graft is one of the methods used to extend vessels to areas with vascular depletion. This case series aims to report the feasibility and outcomes of AV loop grafts for FFMT in BPI patients with subclavian artery injury. This longitudinal descriptive report included adult patients with BPI and concomitant subclavian artery injury. Patients with adequate intra-operative thoracoacromial and/or thoracodorsal arterial flow, sufficient for FFMT without the need for an AV loop graft, were excluded. Of the 10 initially enrolled patients, three were excluded: two for adequate intra-operative arterial flow, and one for extensive adhesions around the external jugular vein, precluding the index surgery. Seven patients, with a median age of 37 years, mostly male and injured in motorcycle accidents, were included. Four patients underwent a single-stage operation (AV loop graft and FFMT simultaneously), while three patients underwent a two-stage operation. Success rates were 100% for the single-stage operation and 33% for the two-stage operation. The two-stage operation led to increased operative time, extended hospital stays, and anastomosis mismatch challenges. Successful cases regained gracilis muscle motor power for elbow flexion, achieving grade III-IV within 13-29 months. FFMT with AV loop graft for BPI patients with subclavian artery injury is feasible and effective. Despite complex microsurgical requirements, these procedures significantly restore limb functionality when standard FFMT operations are insufficient. ClinicalTrials.gov identifier: NCT06437990.

Fast frequency and phase synchronization of high-stability oscillators with 1 PPS signal from satellite navigation systems

Abstract In this paper, we propose a novel algorithm for fast frequency and phase synchronization of high-stability oscillators synchronized with 1 PPS signal from satellite navigation systems. The algorithm uses a model of a control object in the space of state variables and controls the frequency of an oscillator operating in a phase-locked loop. A new element is the introduction to the theoretical analysis and the design process, the time of entering synchronization. Currently, the literature lacks theoretical analysis and design methodology that considers the impact of the synchronization time on the choice of the steering algorithm and its parameters. All the data needed to determine the numerical values of the model were found experimentally for three different classes of control objects. Short synchronization times, a detailed description of the design methodology, and the use of values measured in the real system distinguish the proposed algorithm from the solutions described in the literature. The effect of optimization was achieved thanks to the algorithm’s two-stage operation. In the first stage, the algorithm aims to minimize the phase error quickly. The best solution for this stage is Sliding Mode Control (SMC). In the second stage, the algorithm strives to maximize the control quality, understood as minimizing the values of Maximum Time Interval Error (MTIE) and Time Deviation (TDEV). The Model Predictive Control (MPC) and Linear-Quadratic Regulator (LQR) optimal control algorithms were used at this stage. The paper also investigated the influence of the tuning parameters of these algorithms (weights as a function of cost) on the long-term behavior of the control system.

Clinical Experience of Dissolvable Calcium Sulfate (Stimulan) Carrier for Antibiotic Delivery in Orthopedic Surgery: A Study of 143 Patients.

Prosthetic bone and joint infections are difficult to treat with varying levels of success with standard therapy. Synthetic calcium sulfate carrier, to which specific antibiotics can be added, can be utilized as an alternative drug delivery system in these cases. We have reviewed clinical outcomes using commercially available pure synthetic calcium sulfate dissolvable beads (Stimulan) loaded with antibiotics in 143 patients undergoing orthopedic surgery for prevention and treatment of joint infection. Stimulan was added after standard surgical procedure in cases of: (1) Established infections, (2) Second stage of previously infected patients, or (3) High risk of infection. The purpose of this study was to (1) Evaluate the efficacy of Stimulan for eradicating the infection in patients with established infection, and (2) To study the efficacy of Stimulan for preventing infection in previously infected and healed, or high-risk group of patients. Established orthopedic surgical procedures (such as debridement, liner exchange, one-stage or two-stage revision surgery, or culture-specific systemic antibiotic therapy) were carried out to treat infection, and Stimulan was added in the medullary canal and soft tissue. In addition, postoperative infection and other complications were recorded. This prospective study data showed postoperative wound drainage in 4.9% and infection in 9.1% of total patients. Success rate after the use of Stimulan was 84.9% for established infected patients, 90.9% for previously infected patients, and about 97% for high-risk group patients. Based on the results of this study, we conclude that Stimulan is an acceptable novel drug delivery system for local antibiotic in septic or aseptic standard orthopedic surgeries. Moreover, postoperative infection rate was lower than any other antibiotic delivery system or drugs used before. Stimulan is also effective as a preventive measure for infection-prone patients.

Two-stage surgery with oblique lateral interbody fusion and posterior fixation in degenerative scoliosis with lumbosacral curve-driven degenerative lumbar scoliosis: a feasible option to prevent postoperative coronal decompensation

ObjectiveThis study aims to introduce a two-stage surgical procedure, namely oblique lateral interbody fusion (OLIF), for spinal disorders treatment. Furthermore, clinical outcomes and imaging results are analyzed between OLIF with posterior fixation and posterior lumbar interbody fusion (PLIF) with fixation for lumbosacral curve-driven degenerative lumbar scoliosis (DLS).Methods146 patients with type 2 DLS who underwent OLIF or PLIF between January 2019 and November 2023 were included. Spinal and pelvic parameters were measured using X-ray imaging before and after surgery. Clinical symptoms were assessed using Oswestry Disability Index (ODI) and visual analog scale (VAS). Operation time, intraoperative blood loss, surgical fixation segments, drainage tube indwelling time, and drainage volume were recorded.Results70 patients underwent OLIF and 76 underwent PLIF. Preoperative and postoperative clinical symptoms remain the same (p > 0.05). OLIF group exhibited significantly less intraoperative blood loss, fewer fixation segments, shorter drainage tube retention time, and reduced drainage volume (p < 0.01). Additionally, improvements in coronal parameters, including coronal balance distance, were more pronounced in OLIF group with less potential postoperative coronal imbalance (p < 0.05).ConclusionFor type 2 DLS, two-stage surgery of OLIF with posterior fixation represents a more efficient surgical approach, reducing surgical fusion segments, causing less trauma and bleeding, and effectively avoiding postoperative coronal plane decompensation than traditional posterior surgery.

Two-stage spinal osteotomy combined with lateral lumbar interbody fusion for lumbar kyphosis: illustrative case

BACKGROUND Adult spinal reconstructive surgery that requires multilevel spinal fusion is highly invasive and requires two-stage surgery using lateral lumbar interbody fusion (LLIF) and/or percutaneous pedicle screw (PPS) fixation to make it less invasive. However, it is still difficult to make spinal osteotomy less invasive, and the high complication rate is an issue. OBSERVATIONS The authors present the surgical techniques of a two-stage Schwab grade 4 spinal osteotomy using LLIF, which could reduce surgical invasiveness and enable good correction and anterior spinal column reconstruction for lumbar kyphosis, and also report a case treated with this procedure. The first surgery consisted of L2–5 LLIF and L6–S1 posterior lumbar interbody fusion with temporary PPS fixation. The second surgery, 2 weeks after the first surgery, was a grade 4 osteotomy performed in the L4 vertebral body at a 30° angle toward the center of the LLIF cage between L3 and L4, followed by PPS fixation from T10 to the pelvis and additional fixation with two collateral rods. LESSONS Two-stage grade 4 osteotomy using LLIF could reduce invasiveness and blood loss while providing good anterior support. This surgical method is expected to make spinal reconstruction surgeries requiring osteotomy less invasive. https://thejns.org/doi/10.3171/CASE24515

Two-Stage Mayo Clinic Class IIIb Celiac Axis Resection for Pancreatic Adenocarcinoma: Stepwise Management.

The National Comprehensive Cancer Network guidelines consider pancreatic cancer with celiac axis (CA), proper hepatic artery (PHA), and superior mesenteric artery (SMA) involvement unresectable. Thus, technical reports and video illustrations of these operations are rare. We report the stepwise management of multivascular reconstruction for Mayo Clinic class IIIb CA resections at New York University Langone Health, a dedicated center of excellence in pancreatic surgery. We illustrated the management of a 56-year-old patient with biopsy-confirmed pancreatic ductal adenocarcinoma arising from the pancreatic body and involving the CA, PHA, SMA, and mesentericoportal venous axis. The preoperative stepwise considerations include: 1) mandatory patient selection; 2) planning vascular reconstructability; 3) tailoring risk assessment while carefully considering the need for total pancreatectomy, total gastrectomy, and mesenteric/hepatic revascularization; and 4) 3D-reconstruction for arterial evaluation. The key intraoperative considerations include: 1) selective and sequential clamping for vascular reconstruction in a "domino" fashion, to minimize warm ischemic time 2) a combined multi-surgeon approach to comprehensively tackle vascular reconstructions; 3) a low threshold for total pancreatectomy to avoid pancreatic leak; and 4) two-stage surgery to reassess the blood supply to the liver and stomach for on-demand gastric preservation instead of a theoretically advised total gastrectomy. Liver, stomach, and bowel vascularization present life-threatening risks that require an extensive preoperative evaluation and a multidisciplinary approach. Our stepwise management for these extensive operations includes total pancreatectomy, "domino" vascular reconstruction, and two-stage surgery.

The Correction of The Auricle in Neurofibroma with Aggressive Tumor Removal Principle and Two Stages Total Ear Reconstruction

Background: Neurofibroma is a major facial hamartoma and is one of the most destructive and debilitating disease affecting the skin, muscle, mucosa, and the skeletal systems. Involvement of the ear usually increases the dimensions of the auricular skin and underlying tissues, distorts normal architecture along with auricular malpositioning, producing an ear that is abnormal in size, shape and position. The correction of the auricle in neurofibroma and benign tumors of the head and neck has been reported, but overall favorable results appear difficult to attain. We present a case of neurofibroma of the auricle in which radical resection was performed, and reconstruction was done in a two-stage surgery with satisfactory result. Patient and Methods: A 30 years-old female presented with type-1 neurofibroma to our office, especially concerned of a large tumor growth on the right auricle. With prior experience in treating microtia cases by Nagata’s method, we performed a two-stage operation on the patient. The first operation involved excising the whole auricular mass, and fabricating as well as grafting of a three-dimensional costal cartilage framework. In the second stage, the ear was elevated.Result: Nine months after the second surgery, the result was satisfactory with good auricular definition attained, and proper elevation of the ear at the correct anatomical site. No sign of neurofibroma recurrence was found on the surrounding reconstructed auricle.Summary: In our experience, the correction Neurofibroma of the ear by using the aggressive tumor removal principle combined with Nagata’s two-stage total ear reconstruction delivered a satisfactory result.

Frontoethmoidal Encephalomeningocele Revisited : The Convenience Of Teamwork Approach, A CaseSeries

Background: Frontoethmoidal encephalomeningocele (FEEM) is a congenital defect of the skull which poses many problems to the patient as it results in many craniofacial and neural morbidities. While recently surgical correction of this disease is done in a single-stage procedure, many in Indonesia still perform twostage surgery which bears more risks and is technically difficult to achieve good aesthetic results. This case series intend to assess the feasibility and convenience of teamwork approach between plastic surgeon and neurosurgeon in correcting FEEM in a single-stage operation. Methods:We reviewed 8 patients with FEEM treated in Plastic and Reconstructive Surgery Division, Cipto Mangunkusumo Hospital Jakarta from November 2005 until March 2010. Four of the cases were secondary cases from Neurosurgery Department, and the other 4 cases were treated in single-stage operation, in teamwork with Neurosurgery Department, using the Chula technique. Results of each surgery was assessed using objective parameters, which are Intercanthal Distance (ICD) and Interorbital Distance (IOD); and also subjective parameters which is aesthetic improvement.Result: All of the patients showed significant improvements in ICD and IOD measurements. No complication was found intra and post-operatively. All patients, especially the ones treated with singlestage surgery show good aesthetic results. Conclusion: To achieve goals of defect correction and aesthetically pleasant appearance, single-stage surgery in teamwork with the neurosurgery department seems to be most suitable and convenient.

Outcomes of Unrestricted Weight-Bearing During Interval Period With Cement-on-Cement Articulating Antibiotic-Loaded Spacers in Two-Stage Revision for Knee Prosthetic Joint Infection.

Two-stage revision is known as the gold-standard method for knee prosthetic joint infection (PJI), but the most suitable treatment method remains controversial. Typically, weight-bearing is restricted during the interval between the stages. The aim of this study was to evaluate the clinical outcomes of unrestricted weight bearing with cement spacers fabricated using the Knee Articulating Spacer Mold (KASM®; Ortho Development Corporation, Draper, UT, USA) for knee PJI. We retrospectively reviewed 16 patients who underwent two-stage revision surgery for knee PJI between April 2015 and March 2020. The procedure involved the removal of the infected prosthetic joints and the insertion of cement spacers made using KASM®. The evaluation focused on the possibility of full-weight bearing gait during the interval between the first and second stages, surgical time, blood loss, complications, and postoperative outcomes, including the Knee Society Score (KSS), Knee Society Function Score, and range of motion (ROM). All patientswere able to walk with full weight-bearing. However,cement spacer dislocationoccurred in one patient(6.3%). During the interval between stages, infection occurred in one patient (6.3%) and debridement was performed. Average interval between the stages was 92.7 days (range, 55-166 days). After the reimplantation, reinfection occurred in two patients (12.5%) out of the 16. Among the 14 patients with successful reimplantation, the average operative time was 116.1 min (range, 76-153 min) and the average perioperative blood loss was 476.1 mL (range, 89.5-859 mL). The KSS was 86.4 (range, 62-100), the Knee Society Function Score was 73.6 (range, 45-100), and flexion ROM was 111.8° (range, 95°-130°) at the latest follow-up.The mean follow-up period was 871 days (range, 117-1103 days). Unrestricted weight-bearing gait using cement spacers during the waiting period for two-stage revision surgery for knee PJI led to favorable outcomesin this case series, which lacked a control group.Further studies are needed to assess whether the benefits of weight-bearing outweigh the risks and improve overall outcomes.

Is the Presence of Sinus Tract in Periprosthetic Joint Infection Still One of the Main Deciding Factors for Septic Revision?

Introduction Two of the most common complications of joint arthroplasty surgery are aseptic and septic loosening. While aseptic loosening has a well-established treatment protocol, and diagnosis is quite straightforward, bacterial colonization of the implants is associated with a more difficult diagnosis and treatment, more surgeries, and higher morbidity for the patient. Accurate diagnosis is essential in choosing the right treatment plan. The aim of the current study was to assess the current diagnostic methods for periprosthetic joint infection and the influence of clinical signs like sinus tract on the treatment algorithm and outcomes of the patients.We wanted to highlight that sinus tract is still one of the major criteria in periprosthetic joint infection diagnosis and its presence increases the probability of choosing the right therapeuticoption. Materials and methods During the three-year period of the study, we included 48 cases of patients who presented in our hospital with pain around their hip or knee prostheses. Inclusion criteria were patients diagnosed with septic or aseptic loosening of the prosthesis that required surgical revision of the implant in one stage or two stages. We excluded patients who did not require surgery yet or had major contraindications for revision surgery, patients who refused surgery, acute periprosthetic joint infections (less than 1 month since implantation), or extrinsic mechanical complications of the prosthesis like periprosthetic fractures, implant dislocations. Results Out of 48 patients, 25 underwent one-stage revision and 23 underwent two-stage revision surgery (septic revision). In the subgroup of two-stage revision, 18 patients (78.2%) presented a sinus tract communicating with the prosthesis, this clinical sign being a major characteristic of the subgroup. We managed to successfully identify 21 out of 23 cases (91.3%) of periprosthetic joint infections prior to or during the surgery. In the two cases in which we misdiagnosed the infection, the sinus tract or a positive bacterial culture was absent prior to surgery, in addition to other clinical or paraclinical findings indicating only a small probability of periprosthetic joint infection, influenced the attending medical doctor's therapeuticdecision. In these particular cases of culture-negative periprosthetic joint infections, the outcome was poor, with patients needing additional surgeries in order to eradicate the infection. Discussion When present, a clear sign of periprosthetic joint infection, such as a sinus tract, facilitates the diagnostic protocol and allows the medical staff to initiate the appropriate treatment earlier. In the absence of such obvious signs, differential diagnosis remains difficult, and we should consider the future development of faster, cheaper, and more accurate tests for periprosthetic joint infectiondiagnosis, especially for chronic low-grade infections that could be easily misdiagnosed.

Long-Term Outcome of Treating Periprosthetic Hip Joint Infection with Local Antibiotics Delivered Through Antibiotic-Impregnated Calcium Hydroxyapatite.

Background/Objectives: This study explores the long-term clinical outcomes of antibiotic-impregnated calcium hydroxyapatite (CHA) as an antibiotic delivery system in treating periprosthetic joint infection (PJI) following total hip arthroplasty (THA). Methods: We conducted a retrospective analysis of 12 patients (13 hips) who were treated with antibiotic-impregnated CHA for PJI after THA and followed for more than 10 years at our institution between 1999 and 2011. The study group comprised six men (seven hips) and six women, with a mean age of 61.4 years. Results: The mean follow-up duration was 13.8 years. After irrigation and debridement with modular component exchange, seven hips in six patients underwent revision surgery; however, PJI relapsed in two hips of two patients with a history of diabetes. Two-stage revision surgery was performed on the two relapsed hips and six scheduled hips with antibiotic-impregnated CHA used to treat all cases of PJI. Infection control (100% rate) was achieved in all joints, and revision surgeries were completed. Two patients died 12 years after the initial procedure, and one died 14 years after the first procedure due to unrelated internal diseases; no infection recurrence was observed. No complications related to antibiotic-impregnated CHA were observed. Conclusions: Our results indicate that antibiotic-impregnated CHA is associated with high success rates in treating PJI after THA, even in cases with advanced disease, and yields satisfactory functional outcomes postoperatively.

A Two-stage Surgery for Completely Degloving Injury of Multiple Fingers: a Retrospective Cohort Study

PurposeThe completely degloving injury of multiple fingers is a challenging clinical problem. Based on our technical experience, a novel two-stage surgery of abdominal hypodermal pocket followed by separation and full thickness skin grafting was conducted. MethodsFrom January 2017 to August 2020, 7 cases (17 fingers) of degloving injury of multiple whole fingers who were treated in a two-stage fashion; an emergency first stage surgery of abdominal hypodermal pocket embedding and a second stage surgery (4 weeks later) of full thickness skin grafting, were retrospectively studied. The results were evaluated according to the patient subjective evaluation, static two-point discrimination and disabilities of the arm, shoulder and hand (DASH) scores and active range of motion (ROM) of metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints. ResultsAll seven cases healed successfully, although two cases experienced distal phalanx necrosis. The affected fingers recovered with a good appearance and soft texture and the results were either satisfying or acceptable for all participants. The active ROM of MP joint ranged from 55° to 64° with an average of 59.5° three months postoperatively and ranged from 70° to 81° with an average of 77.2° six months postoperatively, while the active ROM of PIP joint ranged from 58° to 69° with an average of 64.1° three months postoperatively and from 76° to 86° with an average of 81° six months postoperatively. One year postoperatively, the static two-point discrimination ranged from 7 to 10mm with an average of 8.6mm and DASH scores ranged from 25 to 42 with an average of 37. ConclusionA novel two-stage surgery of abdominal hypodermal separated pockets followed by full thickness is an effective and worthwhile option for treating the completely degloving injury of multiple fingers.