Uneventful Healing Research Articles

Preemptive Endoluminal Vacuum Therapy to Reduce Morbidity After Minimally Invasive Ivor Lewis Esophagectomy: Including a Novel Grading System for Postoperative Endoscopic Assessment of GI-Anastomoses.

Preemptive endoluminal vacuum therapy (pEVT) is a novel concept to reduce postoperative morbidity and has the potential to disrupt current treatment paradigms for patients undergoing esophagectomy. Endoluminal vacuum therapy is an accepted treatment for AL after esophagectomy. Retrospective analysis of patients undergoing minimally invasive Ivor Lewis esophagectomy with pEVT between 11/2017 and 10/2020. The sponge was removed endoscopically after 4-6 days, and anastomosis and gastric conduit were assessed according to a novel endoscopic grading system. Further management was customized according to endoscopic appearance and clinical course. Endpoints were postoperative morbidity and AL rate, defined according to the Clavien-Dindo (CD) and International Esodata Study Group classifications. PEVT was performed in 67 consecutive patients, 57 (85%) were high-risk patients with an ASA score >2, WHO/ECOG score >1, age >65 years, or BMI >29 kg/m2. Thirty patients experienced textbook outcome, and overall minor (≤CD IIIa) and major (≥CD IIIb) morbidity was 40.3% and 14.9% respectively. 30-day-mortality was 0%. Forty-nine patients (73%) had uneventful anastomotic healing after pEVT without further endoscopic treatment. The remaining 18 patients (27%) underwent prolonged EVT with uneventful anastomotic healing in 13 patients (19%), contained AL in 4 patients (6%), and 1 uncontained leakage (1.5%) in a case with proximal gastric conduit necrosis, resulting in an overall AL rate of 7.5%. PEVT is an innovative and safe procedure with a promising potential to reduce postoperative morbidity after minimally invasive Ivor Lewis esophagectomy and may be particularly valuable in highly comorbid cases.

Clinical effectiveness of a topical subgingival application of injectable platelet-rich fibrin as adjunctive therapy to scaling and root planing: a double-blind, split-mouth, randomized, prospective, comparative controlled trial.

The purpose of this randomized, controlled, split-mouth clinical trial was to clarify the clinical efficacy of using injectable platelet-rich fibrin (i-PRF) as an adjunctive subgingival irrigation to scaling and root planing (SRP) in the treatment of periodontitis. The study was conducted in 15 patients suffering from stage II to III with grade B to C periodontitis with bilateral periodontal pockets (≥ 5 mm) on a minimum of two teeth without degree II or III of furcation involvement or tooth mobility. The evaluated clinical parameters were: Plaque Index (PI), bleeding on probing (BOP), probing pocket depth (PPD), clinical attachment level (CAL), and gingival recession at baseline and after 3 months. After full-mouth supra- and subgingival SRP, the sites were randomly divided into test sites receiving the subgingival application of i-PRF and controls treated with saline. The Wilcoxon test and Mann-Whitney U test were used for intra- and inter-group comparisons, respectively. In total, 726 sites were treated (388 test group and 338 control group) with no uneventful healing effects. Statistically significant decreases in PI (P = .001), BOP (P = .001 for both groups), PPD (P = .001 and P = .000 for test and control groups, respectively), CAL (P = .015 and P = .001 for test and control groups, respectively) between pretreatment and 3 months posttreatment were noted in both test and control groups. For inter-group comparisons, there was no statistically significant difference in all clinical indices (P > .05). In this study, both groups were clinically effective as nonsurgical periodontal treatments, without any clinical benefits of using i-PRF.

Foot lesion in a male Boer goat associated with caprine digital dermatitis

AbstractA case of interdigital hyperplasia and digital dermatitis on the dorsal aspect of the right hind digit in an adult male Boer goat was described. The digital dermatitis was complicated by granular ulceration of the skin on the dorsal aspect of the foot. Histologically, the lesion was characterised by the presence of numerous papillae‐like growths in the epidermis. Some papillae had mononuclear inflammatory cells. A number of papillae‐like growths hardly had any cells in the core; however, a few plasma cells and lymphocytes were present. The goat was moderately lame on the affected limb. The lesion was excised surgically and healed without any complication. Surgical excision proved to be uneventful healing.

Congenital Maxillary Double Lip: A Case Report

A double lip is an infrequent anomaly that may either be congenital or acquired. It commonly effects the upper lip with more predilection in males. Double lip may require surgical correction for aesthetic or masticatory reasons. Treatment includes excision of the mucosa and submucosal tissue that gives good result. A 19-year-old male presented with bulge under central portion of upper lip with no constriction. Surgical correction was done using an elliptical incision to remove excess mucosal tissues. Satisfactory aesthetic result was obtained with an uneventful healing.

Interfragmentary Gap Discrepancy after Intraoral one-plate fixation in Mandibular angle fracture

Purpose: Mandibular angle fractures (MAF) recorded many complications following various treatment techniques. Inter-fragmentary gap, strain and movement appear to be responsible for most of the complications with predilection towards the inter-fragmentary gap. This study aimed to calculate and assess the resulted post-treatment inter-fragmentary gap using cone beam computed tomography (CBCT) and its effect on the healing outcome and complications after mini plate fixation at Champy’s osteosynthesis line in MAFs. Patients and methods Twenty-five patients with MAF were subjected to intra-oral open reduction and fixation through semi-rigid min plate fixation near the superior border of the mandible at Champy’s osteosynthesis line. The linear inter-fragmentary gap in the mesio-distal plane and the bucco-lingual splay were measured at the inferior border of the mandible after fixation of the fractured bony segments in the final properly aligned position, immediately postoperative, on a CBCT. The healing process was clinically followed for 3 months postoperatively to record any complications. Results Uneventful healing was reported in the expected normal duration. At the inferior border of the mandible, the mean mesio-distal inter-fragmentary gap recorded a low value of 0.3 mm. In the bucco-lingual plane, inter-fragmentary lingual splay gap at the inferior border recorded a higher value yet with no clinical effect on healing;1.8 mm. Conclusion Semi-rigid Champy’s mini plate is dependable in MAF treatment with predictable acceptable mixed primary and secondary healing outcomes despite the resulted radiographic yet clinically insignificant inter-fragmentary gap and lingual splay at the mandibular inferior border

Arthroscopic Knotless Separate Layer Transosseous Equivalent Repair of Delaminated Rotator Cuff Tears

Delamination of rotator cuff tears presents a challenge for surgeons. Recognizing and repairing such a complex tear pattern often require innovative approaches to achieve an anatomic restoration of footprint. In this Technical Note, we described our preferred method that anatomically repairs both layers of delaminated rotator cuff tear separately in a knotless transosseous equivalent technique. Two sutures are placed to the articular layer in a cinch stitch configuration. Then, closed-loop end sutures are passed through both layers while keeping the closed-loop end at the working portal. The free ends of cinch stitches are loaded to anchors with a preloaded fiber tape loop, which is placed to the medial row while approximating the articular layer onto its footprint. Fiber tapes are then shuttled through both layers of tendon with the help of a previously placed closed-loop suture. Finally, the lateral row anchors are placed while fiber tapes are tensioned in a cross-bridge configuration. We believe that this technique may facilitate uneventful healing of delaminated rotator cuffs by providing the biomechanical properties of transosseous equivalent repair.

Revision of failed resection arthroplasty of the CMC-1 joint using acostochondral graft

To correct and prevent the proximalisation of the 1st ray by safe stabilisation using an autologous costochondral graft. Reduction of pain and maintaining good pinch and grip strength while preserving the important opposition of the thumb. Painful proximalisation of the 1st ray after failed trapeziectomy with contact between the base of the 1st metacarpal and the trapezoid or scaphoid. Painful conditions following trapeziectomy for other causes. Perioperative antibiotic prophylaxis is required. Extension of the previous incision and exposure of the sensitive radial branches and the radial artery. Longitudinal incision of the capsule and excision of the scar from the trapezium cavity. Dissection of the scar tissue directly around the metacarpal1 base. After longitudinal resection of the oblique trapezoid surface, insertion of asuture anchor into the scaphoid joint surface close to the trapezoid. Removal of an approximately 2 cm long piece of rib cartilage from the middle costal arch. Insertion of the costochondral graft into the trapezium space and fixation with the suture anchor. Stable capsule closure. Suction drain. Skin suture. Thumb-forearm splint. Postoperative immobilisation of the carpometacarpal (CMC)-1 joint for 4weeks in medium abduction position. In case of uneventful wound healing also with awell-fitting orthosis. Afterwards independent movement exercises and exercises in warm water. Hand therapy only in case of difficult mobilisation at the earliest 2months after surgery. From 2015-2018, 18patients underwent surgery using this technique. The follow-up was at least 2years after surgery. Of the 15patients available for follow-up, 93% were classified as good and improved according to the Conolly-Rath score.

Augmented reality navigation method for recontouring surgery of craniofacial fibrous dysplasia

The objective of this study is to introduce the application of augmented reality (AR) navigation system developed by the authors in recontouring surgery of craniofacial fibrous dysplasia. Five consecutive patients with craniofacial fibrous dysplasia were enrolled. Through three-dimensional (3D) simulation, a virtual plan was designed to reconstruct the normal anatomical contour of the deformed region. Surgical recontouring was achieved with the assistance of the AR navigation system. The accuracy of the surgical procedure was assessed by superimposing the post-operative 3D craniomaxillofacial model onto the virtual plan. The pre-operative preparation time and operation time were also counted. In all patients, AR navigation was performed successfully, with a mean ± SD of the errors of 1.442 ± 0.234 mm. The operative time of the patients ranged from 60 to 80 min. The pre-operative preparation time was 20 min for each patient. All the patients showed uneventful healing without any complications, in addition to satisfaction with the post-operative aesthetics. Using our AR navigation system in recontouring surgery can provide surgeons with a comprehensive and intuitive view of the recontouring border, as well as the depth, in real time. This method could improve the efficiency and safety of craniofacial fibrous dysplasia recontouring procedures.

Keystone Flap for Reconstruction of Sacral and Ischial Pressure Injury

Introduction: Reconstruction of sacral and ischial pressure injury offers great challenges due to its high complication and recurrence rate. Providing durable tissue coverage with minimal donor site morbidity is paramount while ensuring fast operative time for the patients who often possess multiple comorbidities. This study aims to present cases of sacral and ischial pressure injury reconstruction using a keystone flap. Method: A retrospective study was performed by reviewing data from fifteen patients with a sacral and ischial pressure injury who underwent reconstruction using various types of keystone flaps in our center between 2019 and 2020. Results: The patients’ age ranged from 10 to 83 years old (average, 40.5 years old). The average wound dimensions were 9.4 ± 3.1 cm x 6.5 ± 2.7 cm and the mean area of the defects was 52.3 ± 35.7 cm2, with the largest defect was 15 x 12 cm (141.3 cm2). Mean operative time was 140 ± 24.5 minutes with nine wounds were reconstructed using type IV keystone flap (60%) and six patients using type IIA (40%). Postoperative complications occurred in three patients (20%). Other patients resulted in uneventful complete healing. Conclusion: The keystone flap is reliable, simple, has a fast technique, and minimal donor site morbidity to cover the defects of sacral and ischial pressure injury. Performing thorough debridement, choosing the right type of keystone flap, elevating the flap adequately to allow mobilization, preserving perforator “hotspots”, and suturing of the flap without tension are keys to achieve satisfactory results.

Postendodontic pain: a practical approach to diagnosis and management.

Endodontic treatment is a routine procedure performed by general dental practitioners and endodontists on a daily basis. Fortunately, most patients undergoing endodontic therapy show a favorable outcome with uneventful healing. However, some patients develop pain following endodontic therapy. A majority of these patients develop acute, nociceptive pain ("flare-up") that resolves with appropriate treatment and subsequent healing. The dental profession is very adept at successfully managing the acute pain that occurs early following endodontic treatment. A minority of patients, however, develop ongoing pain following root canal therapy, termed chronic if persisting for 3 months or more. The diagnosis and management of chronic postendodontic pain are often challenging. This article aims to review pain following endodontic therapy, ranging from acute to chronic pain and its management, with specific emphasis on chronic pain, its pathophysiology, clinical features, diagnostic criteria, and management modalities. Endodontic treatment rarely leads to chronic neuropathic pain; however, when the nerve injury occurs and results in posttraumatic trigeminal neuropathic pain (PTNP), treatment options are very limited and rarely successful. Therefore, all steps should be taken to avoid nerve injury. Prevention of endodontic treatment related PTNP is crucial and achieved through early recognition, and prompt management.

Evaluation of Platelet Rich Fibrin Sandwiching technique with mixture of alloplastic bone graft and Hyaluronic Acid in repair of Recurrent Oronasal Fistula

Aim: is to evaluate efficacy of platelet rich fibrin (PRF) sandwiching technique associated with hyaluronic acid (HyA) mixed with alloplastic bone graft in closure of recurrent oronasal fistula after previously alveolar cleft grafting. Subjects and Methods: Our study conducted on 24 patients with recurrent unilateral oronasal fistula complaining of oronasal leakage. They were divided into two random equal groups. Group I, alveolar cleft defect was packed with alloplastic bone graft ( osteon II collagen) between two layers of PRF gel. While, in group II, alveolar cleft defect was packed with a mixture of alloplastic bone graft (osteon II collagen) and HyA between the two layers of PRF gel. All patients were observed clinically and radiographically (CBCT) for evaluation after three and six months postoperatively. Results: Our clinical results revealed that, all patients had uneventful wound healing except 4 cases in group I and one case in group II which had wound dehiscence and graft exposure at 1-week postoperatively. The radiographic results by CBCT scans showed a better new bone formation and good osseous union obliterating the oronasal defect.in group II than group I. There was a significant difference between bone density and bone resorption values in both groups at all intervals. Conclusion : Our results demonstrated that PRF sandwiching technique combined with a mixture of alloplastic bone graft and HyA could provide a favorable bony and soft tissue barriers for closure of recurrent oronasal fistula in alveolar cleft patients.

Endosteal substitution with medial plate in the treatment of acute distal femur fracture (AO/OTA type A): surgical technique and case-series.

Distal Femur fractures account for 4- 6% of all femur fractures and can be challenging to treat. The aims of this study are: (1) to describe a surgical technique using a medial distal femur endosteal plate to augment the stability of standard lateral plate fixation; (2) to report the results of a case-series of acute distal femur fractures (AO/OTA Type A/ Vancouver periprosthetic fractures Type C) treated using this technique. This study describes the surgical steps for placement of a medial endosteal plate in combination with lateral locking plate in a cadaver model using fluoroscopy guidance. In addition, a retrospective database chart review for all patients with acute distal femur fractures treated with this technique over the last five years was performed. Exclusion criteria were involvement of type B and C distal femur intraarticular fractures, treatment with other endosteal substitutions (i.e., intramedullary nail fixation and fibula allograft), and treatment for non-union or pathological fractures. Twelve patients were identified with mean age of 75years. All patients were female and all of them were allowed full weight bearing and full range of motion exercises immediately post-operatively. The complete follow up for one patient was not available; however, the mean fracture union was confirmed at 3.8months in 10 of 12 patients. One patient had a failed construct at three months in the context of a periprosthetic fracture with a loose implant that was initially thought to be stable. One acute superficial surgical site infection was reported and healed uneventfully following debridement, primary closure, and antibiotic treatment. We believe that the placement of a medial endosteal plate can be a useful augment for standard lateral plate fixation in acute distal femur fractures, particularly in the context of severe comminution or poor bone quality. Uneventful healing was confirmed in 10 of 12 cases and no patients were restricted with regard to motion or weight bearing immediately post-operatively. Further studies with larger sample size would be required to fully assess this technique. IV. Therapeutic Study (Surgical technique and Cases-series).

Forehead flap: a reconstructive option in selected complex defects following resection of oral cancers staged T4

<p class="abstract"><strong>Background:</strong> Head and neck squamous carcinoma constitutes 30% of malignancies in our region, oral carcinoma being most common among them. Most of these tumours involve lower gingivobuccal sulcus and buccal mucosa. 80% patients present with locally advanced disease. Following resection of these tumours, reconstruction of composite defects is challenging. Though microvascular free flaps are ideal in such cases, it is not always feasible due to malnutrition, peripheral vascular disease, sometimes non–availability of microvascular surgeon and financial constraints. Pectoralis major myocutaneous flap, the workhorse of reconstruction is bulky, non-pliable and cannot be advanced over intact mandible. Forehead flap in complex defects is pliable, versatile, has excellent vascularity and colour matching, easy to harvest and suitable in selected cases and as salvage flap when other flaps fail. The aim of the study was to document outcome of folded forehead flap reconstruction of complex defects following resection of T4 staged oral carcinoma.</p><p class="abstract"><strong>Methods:</strong> This retrospective study in a tertiary rural hospital included 31 patients with oral carcinoma staged T4. The patients underwent folded forehead flap reconstruction for full thickness cheek defects with some extending into oral commissure and lower lip, along with segmental or alveolar resection of mandible or maxilla.</p><p class="abstract"><strong>Results: </strong>27 patients had uneventful healing, 2 had wound dehiscence and 2 had necrosis of distal part of flap. Patients with externally rotated flap had mild trismus and patients in whom forehead flap was used to reconstruct the oral commissure had oral incompetence.</p><p class="abstract"><strong>Conclusions: </strong>Folded forehead flap is good reconstructive option in complex full thickness defects of cheek and as salvage reconstruction.</p>

Zygomatic implant penetration to the central portion of orbit: a case report

BackgroundZygomatic implants have been proposed in literature for atrophic maxillary fixed oral rehabilitations. The aim of the present research was to evaluate, by a clinical and tomography assessment, a surgical complication of a zygomatic implant penetration to the orbit.Case presentationA 56 year-old female patient was visited for pain and swelling in the left orbit after a zygomatic implant protocol. The orbit invasion of the zygomatic implant screw was confirmed by the CBCT scan. The patient was treated for surgical implant removal and the peri- and post-operative symptoms were assessed. No neurological complications were reported at the follow-up. The ocular motility and the visual acuity were well maintained. No purulent secretion or inflammatory evidence were reported in the post-operative healing phases.ConclusionThe penetration of the orbit during a zygomatic implant positioning is a surgical complication that could compromise the sight and movements of the eye. In the present case report, a zygomatic implant removal resulted in an uneventful healing phase with recovery of the eye functions.

Evaluation of the Efficay of Computer Guided Lag Screw Fixation in Comparison to Conventional Lag Screw Fixation in Anterior Mandibular Fractures. Randomized Clinical Trial (RCT)

Background and Objective: This study aimed to compare the use of computer guided technology to placelag screws in anterior mandibular fracture in comparison to convectional techniqueMaterials and Method: This study included twenty-six patients divided into two equal groups, wherefixation in group A utilized computer guided patient specific guide to fix anterior mandibular fractures usinglag screws. In group B anterior mandibular fractures were fixed using lag screws in the conventional way.Both groups were compared in terms of stability and the need of auxiliary fixation devices.Results: Both techniques showed uneventful healing and showing insignificant difference between themconcerning stability and the need for auxiliary fixation device.Conclusion: Although the use of computer guided technology didn’t offer significant advantage over theconventional technique yet it provides more easy and reliable way especially for beginners introduced tothe technique.

Clinical, radiographical and histological evaluation of alveolar ridge preservation with an autogenous tooth derived particulate graft in EDS class 3\u20134 defects

BackgroundThe shrinkage of alveolar bone dimensions after tooth extraction is a well-known issue. This clinical phenomenon poses a challenge for clinicians aiming at implant-prosthetic treatment. BonMaker® ATB is a novel autogenous bone grafting material, produced by the mechanical and chemical processing of natural teeth. This pilot case report aims at providing a clinical, radiographical, and histological evaluation of the safety and efficacy of Bonmaker ATB powder in the treatment of EDS class 3–4 postextraction sockets with alveolar ridge preservation.MethodsA total of 9 teeth were extracted from 5 patients. The extracted teeth were prepared immediately with the Bonmaker® device. The extraction sockets were filled up with ATB powder. Six months after extraction, standardized intraoral x-rays and CBCT scans were performed. Re-entry was performed under local anaesthesia. Core biopsies were harvested for histological analysis and implants were placed.ResultsHorizontal alveolar dimension loss occurred, even though ARP was performed, but the horizontal shrinkage was moderate. Vertical dimensions did not show loss of volume, but increased defect fill. Core biopsies showed ATB particles surrounded by newly formed bone and connective tissue. According to histomorphometric analysis, the harvested samples contained 56% of newly formed bone on average, and only a mean of 7% of non-remodelled ATB material was observed.ConclusionThe preliminary clinical, radiographical, and histological results of Bonmaker® autogenous tooth graft therapy indicate that ATB may be safely and successfully used as a grafting material for ARP. Optimal graft incorporation and histologically proven effective remodelling, as well as uneventful wound healing support the clinical application of ATB to minimize post-extraction hard tissue loss. Further research is needed to exploit the full potential of ATB and to evaluate the long-term peri-implant hard and soft tissue stability of ATB-treated post-extraction sites.

Auricular Cartilage Graft, An Alternative for Bony Palatal Defect? A Case Report.

A 51year old male patient reported with a chief complaint of nasal regurgitation of fluids since a period of 1year. Patient was operated once earlier with soft tissue palatal closure following which there was recurrence of symptoms. In this case, the defect was managed with an auricular cartilage graft followed by palatal mucosal closure. The healing was uneventful till the latest follow-up. Rationale of this case report lies in its approach to manage an oronasal communication which recurred following a soft tissue closure. Various management strategies have been applied in literature which included grafts, alloplastic materials and vascular free tissue transfer. Following informed and written consent, Patient was operated under General Anaesthesia and was observed for a follow-up period of 2years. There was uneventful healing along with improvement in patient's phonation and diet. Complete resolution of nasal regurgitation was achieved. The auricular cartilage graft used for reconstruction in this case is comparatively less invasive and provides an additional advantage of a double layered closure.

Application of Virtual Planning for Three-Dimensional Guided Maxillofacial Reconstruction of Pruzansky-Kaban III Hemifacial Microsomia Using Custom Made Fixation Plate.

Pruzansky-Kaban III hemifacial microsomia (HFM) is a rare congenital facial deformity, and it is challenging to reconstruct the facial appearance. The aim of the present study was to describe a technique of application of virtual planning for three-dimensional (3D) guided maxillofacial reconstruction of Pruzansky-Kaban III HFM using custom made fixation plate. With the help of 3D models, a preoperative virtual planning and surgical simulation were performed. Computer-aided design/computer-aided manufacture (CAD/CAM) patient customized guides and custom fixation plates were designed to reconstruct the maxillofacial skull intraoperatively. Assessment was achieved through evaluation of the postoperative effects, such as imaging, facial appearance recovery and operation time. Five patients with Pruzansky-Kaban III HFM were enrolled into this study. The results showed an exceptional accuracy between the preoperative virtual planning and the outcomes actually achieved postoperatively. Intraoperative measurements were no longer needed and the different surgical steps became more simple and easier. The total time was distributed as: 160 minutes for the surgical time, 40 minutes for preoperative virtual plan, and 80 minutes for designing the patient specific cutting guides and custom fixation plates. The operating time and tissue damage were reduced. All cases underwent uneventful healing without any complications. The technique of patient specific guides and custom fixation plates is a reliable method of conveying the virtual plan to the operative field with higher efficiency in patients with Pruzansky-Kaban III HFM.

Rockwood Grade-III Acromioclavicular Joint Separation: A Cost-Effectiveness Analysis of Treatment Options.

Background:The treatment of Rockwood Grade-III acromioclavicular (AC) joint separation has been widely disputed since the introduction of the classification system. The present literature does not reach consensus on whether operative or nonoperative management is more advantageous, nor does it effectively distinguish between operative measures. We hypothesized that nonoperative treatment of Rockwood Grade-III AC joint separation would be more cost-effective when compared with surgical options.Methods:We created a decision-tree model outlining the treatment of Rockwood Grade-III separations using nonoperative management or hook-plate, suture-button, or allograft fixation. After nonoperative intervention, the possible outcomes predicted by the model were uneventful healing, delayed operative management, a second round of sling use and physical therapy, or no reduction and no action; and after operative intervention, the possible outcomes were uneventful healing, loss of reduction and revision, and depending on the implant, loss of reduction and no action, or removal of the implant. A systematic review was conducted, and probabilities of each model state were averaged. A cost-effectiveness analysis was conducted both through rollback analysis yielding net monetary benefit and through incremental cost-effectiveness ratios (ICERs). Thresholds of $50,000/quality-adjusted life-year (QALY) and $100,000/QALY were used for ICER analysis. Furthermore, a sensitivity analysis was utilized to determine whether differential probabilities could impact the model.Results:Forty-five papers were selected from a potential 768 papers identified through our literature review. Nonoperative treatment was used as our reference case and showed dominance over all 3 of the operative measures at both the $50,000 and $100,000 ICER thresholds. Nonoperative treatment also showed the greatest net monetary benefit. Nonoperative management yielded the lowest total cost ($6,060) and greatest utility (0.95 QALY). Sensitivity analysis showed that allograft fixation became the favored technique at a willingness-to-pay threshold of $50,000 if the rate of failure of nonoperative treatment rose to 14.6%. Similarly, at the $100,000 threshold, allograft became dominant if the probability of failure of nonoperative treatment rose to 22.8%.Conclusions:The cost-effectiveness of nonoperative treatment is fueled by its notably lower costs and overall high rates of success in Grade-III separations. It is important to note that, in our analysis, the societal cost (measured in lost productivity) of nonoperative treatment neared that of surgical treatment, but the cost from the health-care system perspective was minimal. Physicians should bear in mind the sensitivity of these conclusions and should consider cost-effectiveness analyses in their decision-making guidelines.Level of Evidence:Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Paradoxical reactions in spinal tuberculosis: A case series

Introduction: Clinical or radiological worsening of pre-existing tubercular lesions or appearance of new lesions in patients who have shown initial improvement following antitubercular chemotherapy (ATT) is termed as a paradoxical reaction (PR). The appearance of these lesions after spine surgery raises the possibilities of drug resistance, treatment failure, and surgical site infection. This retrospective case series aims to describe the presentation of PRs in spinal tuberculosis (TB), identify risk factors, and propose a treatment plan for PRs within the spine. Materials and Methods: Nine patients (2 males and 7 females; mean age 31.2 years), who underwent posterior transpedicular decompression and instrumented fusion for spinal TB, presented 4–7 weeks later with a soft, large swelling at the surgical site. In one patient, the swelling had burst through the skin resulting in a discharging wound. Two patients had screw pullout with local kyphosis. All patients had been started on ATT only after index surgery and had experienced improvement in constitutional symptoms, pain, and neurology. Magnetic resonance imaging showed large fluid collection at the surgical site without any new bony lesions. Results: All patients underwent surgical debridement with two patients requiring revision instrumentation. Examination of tissue and fluid revealed caseating granulomas and mycobacteria. Continuation of the same ATT led to uneventful healing. Conclusion: PRs in patients with spinal TB presented with a cold abscess at the surgical site between 4 and 7 weeks after starting ATT. Surgical drainage with debridement and continuation of ATT without changes to the regimen led to uneventful healing in all patients. Young age, female sex, thoracic lesions, and patients virgin to ATT prior to surgery were risk factors.