Well-established Surgical Technique Research Articles

The Healing and Aging-related Properties of Adipose Tissue Fragments Obtained through the Guided SEFFI Procedure’s Mechanical Fragmentation are Facilitated by the Exosomes Present in the Final Injection

The Injection of autologous Adipose-Derived Stem Cells (ADSCs) and Stromal Vascular Fraction (SVF) into dermal and subdermal layers can improve skin volume and rejuvenation. The SEFFI (Superficial Enhanced Fluid Fat Injection) technique, which involves minimal manipulation of autologous microfragmented adipose tissue, was utilized for harvesting and re-injection, using the SEFFILLER™ disposable medical device. Mechanical fragmentation of adipose tissue is a well-established surgical technique that stimulates tissue regeneration, filler, and biological activity. The study evaluated the biological properties (regenerative and anti-aging) of different harvest and processing fat graft methods among which the fragmented adipose tissue, specifically focusing on the presence of exosomes. Exosomes, nanometer-sized vesicles produced by cells for cellular communication, were found to contain miRNAs with anti-inflammatory, regenerative, and vascular content. The products’ contained exosomes were confirmed in the study through electron microscopy, Western Blotting, gene expression, and sequencing of miRNA content.

Müller muscle-Conjunctival Resection (MMCR) Surgery: A Comprehensive Literature Review.

This literature review aims to provide a comprehensive overview of the current understanding, indications, techniques, outcomes, and complications of Müller muscle-conjunctival resection (MMCR) surgery. It also addresses areas of debate with MMCR such as predictability concerning Phenylephrine response as well as the amount of muscle resection required. This literature review was compiled based on the available evidence from PubMed from 1975 to August 2023. The success rate of MMCR ranges from 72% to 95%, with high patient satisfaction reported in most studies. The exact range of eyelid elevation after MMCR is variable, with a reported average of 2.1 mm MRD1 elevation. MMCR is a well-established surgical technique used to correct upper eyelid ptosis that results from dysfunction or attenuation of the levator aponeurosis. MMCR proved to be a safe and effective procedure with a high patient satisfaction rate and low risk of complications.

Endovascular balloon usage in endoscopic third ventriculostomy for hydrocephalus during a national shortage: case series and technical note.

Endoscopic third ventriculostomy (ETV) is a well-established surgical technique for treating hydrocephalus. Many providers have transitioned to utilizing the specialized Neuroballoon for the stoma dilation in ETV; however, these devices are intermittently unavailable during supply chain shortages. We present the experience of employing cardiac angioplasty and neurovascular balloons as substitutes for the Neuroballoon in 3 patients. The scepter balloon (Microvention), priced at $1800 compared to the standard $300 Neuroballoon (Integra), proved effective, but its pliability presented technical challenges. The substantial cost differential compared to a Neuroballoon ($300) raises economic considerations. The Cardiac TREK balloon (Abbott) was similarly effective, while also being easier to manage endoscopically and cheaper at $158. These experiences support the viability of non-neuroendoscopic specialized balloons as alternatives for ETV dilation of the floor of tuber cinereum.

Laparoscopic Versus Open Gastrectomy for Advanced Gastric Cancer: A Meta-Analysis of Randomized Controlled Trials.

Laparoscopy-assisted gastrectomy (LAG) is a well-established surgical technique in treating patients with early gastric cancer. However, the efficacy and safety of LAG versus open gastrectomy (OG) in patients with advanced gastric cancer (AGC) remains unclear. We systematically searched PubMed, Embase, and Cochrane Library in June 2023 for RCTs comparing LAG versus OG in patients with AGC. We pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) for binary and continuous endpoints, respectively. We performed all statistical analyses using R software version 4.3.1 and a random-effects model. Nine RCTs comprising 3827 patients were included. There were no differences in terms of intraoperative complications (RR 1.14; 95% CI 0.72 to 1.82), number of retrieved lymph nodes (MD -0.54lymph nodes; 95% CI -1.18 to 0.09), or mortality (RR 0.91; 95% CI 0.30 to 2.83). LAG was associated with a longer operative time (MD 49.28minutes; 95% CI 30.88 to 67.69), lower intraoperative blood loss (MD -51.24milliliters; 95% CI -81.41 to -21.06), shorter length of stay (MD -0.83days; 95% CI -1.60 to -0.06), and higher incidence of pancreatic fistula (RR 2.44; 95% CI 1.08 to 5.50). Postoperatively, LAG was also superior to OG in reducing bleeding rates (RR 0.44; 95% CI 0.22 to 0.86) and time to first flatus (MD -0.27days; 95% CI -0.47 to -0.07), with comparable results in anastomotic leakage, wound healing issues, major complications, time to ambulation, or time to first liquid intake. In the long-term analyses at 3 and 5years, there were no significant differences between LAG and OG in terms of overall survival (RR 0.99; 95% CI 0.96 to 1.03) or relapse-free survival (RR 0.99; 95% CI 0.94 to 1.04). This meta-analysis of RCTs suggests that LAG may be an effective and safe alternative to OG for treating AGC; albeit, it may be associated with an increased risk for pancreatic fistula.

Latissimus dorsi flap for breast reconstruction: a large single-institution evaluation of surgical outcome and complications

PurposeThe use of autologous tissues is considered gold standard for patients undergoing breast reconstruction and is the preferred method in the post-radiation setting. Although the latissimus dorsi flap (LDF) has been replaced by abdominal flaps as technique of choice, it remains a valuable option in several specific clinical situations and its use has been regaining popularity in recent years. In this work, we present an 18-year retrospective analysis of a single-institution single-surgeon experience with LDF-based reconstruction with focus on early complications and reconstructive failures.MethodsHospital records of all patients undergoing breast surgery for any reason in the Certified Breast Cancer Center, Regio Klinikum Pinneberg, Germany between April, 1st 2005 and October, 31st 2022 were reviewed. 142 consecutive LDF-based reconstructive procedures were identified. Detailed information was gathered on patient characteristics, treatment-related factors, and complications.ResultsOne hundred forty patients (139 female, 1 male) received 142 LDF-based surgeries. The flap was used mainly for immediate breast reconstruction with or without implant (83% of patients), followed by defect coverage after removal of a large tumor (7%), implant-to-flap conversion with or without placement of a new implant (6%), and delayed post-mastectomy reconstruction (4%). The use of LDF decreased between 2005 and 2020 (2005: 17, 2006: 13, 2007: 14, 2008: 16, 2009: 5, 2010: 9, 2011: 8, 2012: 3, 2013: 10, 2014: 8, 2015: 8, 2016: 7, 2017: 7, 2018: 4, 2019: 4, 2020: 2, 2021: 6, 2022: 4). Surgery was performed for invasive breast cancer in 78%, ductal carcinoma in situ in 20% and other reasons such as genetic mutation in 1% of patients. Ipsilateral radiation therapy was received by 12% of patients prior to LDF surgery and by 37% after the surgery. 25% of patients were smokers. The median duration of surgery, including all procedures conducted simultaneously such as e.g., mastectomy, axillary surgery, or implant placement, was 117 min (range 56–205). Patients stayed in the hospital for a median of 7 days (range 2–23 days). The most common complication was seroma (26%), followed by wound dehiscence (8%), surgical site infection (7%), partial skin and/or nipple necrosis of any size (7%) and hematoma requiring surgical evacuation (2%). 19% of all patients required seroma aspiration or drainage, mostly at the donor site and performed under ultrasound guidance in the ambulatory setting. Flap loss due to necrosis occurred in 2% of patients.ConclusionsLatissimus dorsi flap is a well-established surgical technique commonly used for immediate breast reconstruction as well as defect coverage in locally advanced breast cancer. To the best of our knowledge, this is one of the largest single-surgeon analyses of early complications in patients receiving LDF. As expected, seroma was the most common complication observed in nearly one third of patients and requiring a therapeutic intervention in every fifth patient. Serious adverse events occurred rarely, and flap loss rate was very low.

Is Minimally Invasive Spinal Surgery Superior to Endoscopic Spine Surgery in Postoperative Radiologic Outcomes of Lumbar Spine Degenerative Disease? A Systematic Review.

Minimally invasive spinal surgery (ESS) are both well-established surgical techniques for lumbar spinal stenosis; however, there is limited literature comparing the efficacy of the two techniques with respect to radiologic decompression data. In this review, PubMed, Google Scholar, and Scopus databases were systematically searched from inception until July 2022 for studies that reported the radiologic outcomes of endoscopic and minimally invasive approaches for decompressive spinal surgery, namely, the spinal canal area, neural foraminal area, and neural foraminal heights. Of the 378 articles initially retrieved using MeSH and keyword search, 9 studies reporting preoperative and postoperative spinal areas and foraminal areas and heights were finally included in our review. Of the total 581 patients, 391 (67.30%) underwent MISS and 190 (32.70%) underwent ESS. The weighted mean difference between the spinal canal diameter in pre- and postoperative conditions was 56.64 ± 7.11 and 79.52 ± 21.31 mm2 in the MISS and ESS groups, respectively. ESS was also associated with a higher mean difference in the foraminal area postoperatively (72 ± 1 vs. 35.81 ± 11.3 mm2 in the MISS and ESS groups, respectively), but it was comparable to MISS in terms of the foraminal height (0.32 ± 0.037 vs. 0.29 ± 0.03 cm in the MISS and endoscopic groups, respectively). Compared with MISS, ESS was associated with improved radiologic parameters, including spinal canal area and neural foraminal area in the lumbar spinal segments. Both techniques led to the same endpoint of neural decompression when starting with a more severe compression. However, the present data do not allow the correlation of the radiographic results with the related clinical outcomes.

Wrist Arthrodesis Using the Medartis Carpometacarpal Joint Sparing Plate.

Total wrist arthrodesis is a well-established surgical technique that provides reliable pain relief in patients with advanced wrist disease. Key limitations of existing plating systems include hardware pull-out, hardware failure, and nonunion. There is limited literature on the newer style carpometacarpal joint (CMCJ) sparing plating system, produced by Medartis. The objective of this study was to determine the long-term clinical and radiological outcomes of wrist arthrodesis with a CMCJ sparing wrist plate. This study retrospectively identified 23 wrist arthrodeses using the Medartis CMCJ sparing plate for review. This study assessed the outcomes of 18 unilateral wrist fusions and 1 bilateral wrist fusion. The study group consisted of 12 men and 5 women with an average age of 56 years (range: 29-82 years) with a mean follow-up period of 17 months. At the time of follow-up, all patients' wrists had fused without postsurgical complication. The final grip strength in the operative hand was 28.2 kg/cm2, which was 87% of the contralateral side. The mean Quick Disabilities of the Arm, Shoulder, and Hand score at follow-up was 23.9, with all patients returning to daily living activities and work. Patients reported minimal pain (1.3/10), with almost all (17/18) satisfied with the outcome of the surgery and describing that they would recommend this procedure. Our case series highlights that the Medartis wrist arthrodesis plate is a newer design that is a well-tolerated option for wrist arthrodesis based on clinical assessment, functional hand assessment, and patient satisfaction, when compared with the existing literature on traditional plating systems.

Open retropubic radical prostatectomy: Still a well-established surgical technique for prostate cancer management

IntroductionThe surgical treatment options for prostate cancer have changed rapidly, given the expansion of robotics. However, open retropubic radical prostatectomy (ORP) will continue to be performed in areas with financial limitations or with limited access to robotics. The purpose of this study was to determine the long-term oncological outcomes, to categorize complication rates and to examine the early continence rates in patients treated with ORP. MethodsWe identified all patients who underwent ORP at our institution between 2000 and 2020. A standardized pad test was used to determine the early continence rates upon catheter removal, the late continence around a year after surgery was determined by the number of pads per day. The Clavien-Dindo classification was used to report the complication rates. The biochemical recurrence (BCR)-free survival and overall survival (OS) rates were defined using the Kaplan–Meier method and log-rank analysis. Multivariable Cox-regression models were used to test the effect of different factors on biochemical recurrence. ResultsWe analyzed 1095 patients. The median follow-up was 93.4 months. An overall 10-year BCR-free survival and OS of 73% and 82% respectively was found. A complication rate for Clavien Dindo≥3 was seen in 4.8% of patients. The early continence rate was 81.4% and the late continence 89,1%. Preoperative PSA level, Gleason score sum, pT stage, lymph node status, and surgical margin status were independent predictors of BCR (p<0.001, 95% CI). Limitations include retrospective and single center study design. ConclusionsORP is a surgical procedure that provides excellent oncological- and early continence-rates.

Effect of bimedial recession on near distance disparity in esotropia

Bilateral medial rectus recession (BMR) and unilateral recession-resection (RR) are well-established surgical techniques for esotropia. There is no consensus on which is preferable although convention suggests a greater effect of BMR on near deviation. We present a series of patients who underwent BMR for esotropia and the effect on the near and distance angles.

Atrial Cannulation During Resuscitative Clamshell Thoracotomy.

Resuscitative thoracotomy and clamshell thoracotomy are performed in the setting of traumatic arrest with the intent of controlling hemorrhage, relieving tamponade, and providing open chest cardiopulmonary resuscitation. Historically, return of spontaneous circulation rates for penetrating traumatic arrest as well as out of hospital survival have been reported as low as 40% and 10%. Vascular access can be challenging in patients who have undergone a traumatic arrest and can be a limiting step to effective resuscitation. Atrial cannulation is a well-established surgical technique in cardiac surgery. Herein, we present a case series detailing our application of this technique in the context of acute trauma resuscitation during clamshell thoracotomy for traumatic arrest in the emergency department. A retrospective case series of atrial cannulation during traumatic arrest was conducted in Charlotte, NC at Carolinas Medical Center an urban level 1 trauma center. The mean rate of return of spontaneous circulation in our series, 60%, was greater than previously published upper limit of return of spontaneous circulation for penetrating causes of traumatic arrest. Intravenous access can be difficult to establish in the hypovolemic and exsanguinating patient. Traditional methods of vascular access may be insufficient in the setting of central vascular injury. Atrial appendage cannulation during atrial cannulation is a quick and reliable technique to achieve vascular access that employs common methods from cardiac surgery to improve resuscitation of traumatic arrest.

Effects of Botulinum Toxin Type A on the Axial Skin Flap Survival.

BACKGROUNDA suitable pharmacological substitute for the well-established surgical delay technique for axial skin flaps regarding increasing viability is elusive. We aimed to evaluate the effects of botulinum toxin type A (BTA) on the axial skin flap survival in a rat model.METHODSThe present controlled experimental study was performed in Kerman University of Medical Science, Kermanshah, Iran during 2016-2017 on three groups of rats. Group 1 (control group) had no preconditioning while Groups 2 and 3 were preconditioned by the intradermal injection of normal saline (0.5 ml) in the cephalic end of the skin flap and the injection of the BTA (1.6 units Neuronex) reconstituted in normal saline, respectively. Two weeks after this intervention in each group, the flap was raised and kept in situ and a biopsy was simultaneously taken for evaluating neoangiogenesis, followed by evaluating flap necrosis after two weeks of following-up by photography.RESULTSAlthough BTA induced angiogenesis significantly, it failed to reduce the area of necrosis compared to the other groups.CONCLUSIONBTA was effective in increasing angiogenesis in the axial skin flap although it was unable to reduce necrosis.

Therapeutic management of acute type A aortic intramural hematoma

ObjectivesThe proper therapeutic management for acute type A aortic intramural hematoma (IMH) is still controversial. The purpose of this study was to compare the outcomes following emergency surgery or conservative treatment for patients with this disease.MethodsFrom January 2015 to December 2018, 124 consecutive patients were diagnosed with an acute type A aortic IMH and were included in this study. According to our surgical indications, they were divided into two groups: an operation group (OG) and a conservative treatment group (CG).ResultsOf 124 patients, 83 (66.9%) patients accepted emergency surgery and 41 (33.1%) patients accepted strict conservative treatment. There were no differences between these two groups in early mortality and complications. However, the late mortality of patients in the CG was significantly higher than for patients in the OG. A maximum aortic diameter in the ascending aorta and aortic arch ≥ 45 mm and maximum thickness of IMH in the same section ≥ 8 mm were risk factors for IMH related death in patients undergoing conservative treatment.ConclusionsThe mortality associated with emergency surgery for patients with acute type A aortic IMH was satisfactory. In clinical centers with well-established surgical techniques and postoperative management, emergency surgical treatment may provide a better outcome than medical treatment for patients with acute type A aortic IMH.

Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability in the Athlete – Key Considerations for Rehabilitation

The Latarjet procedure with transfer of the coracoid process and its attached conjoint tendon is a well-established surgical technique for the treatment of anterior glenohumeral instability in patients with anteroinferior bone loss and/or high risk for recurrence. Biomechanical and clinical studies have shown excellent results and high rates of return to sports. However, there is an absence of standardized, objective criteria to accurately assess an athlete’s ability to progress through each phase of rehabilitation. Return to sports rehabilitation, progressed by quantitatively measured functional goals, may improve the athlete’s integration back to sports participation. Therefore, the purpose of this clinical commentary is to provide a rehabilitation protocol for the Latarjet procedure, progressing through clearly defined phases, with guidance for safe and effective return to sport. Recommended criteria are highlighted which allows the clinician to progress the patient through each phase appropriately rather than purely following timeframes from surgery. This progression ensures the patient has completed a thorough rehabilitation program that addresses ROM, strength, power, neuromuscular control and a graded return to play.Level of Evidence: 5

Calcitonin Gene-Related Peptide Enhances Distraction Osteogenesis by Increasing Angiogenesis.

Distraction osteogenesis (DO) is a well-established surgical technique for treating bone defect and limb lengthening. The major drawback of DO is the long treatment period as the external fixator has to be kept in place until consolidation is completed. Calcitonin gene-related peptide (CGRP) has been reported to promote angiogenesis by affecting endothelial progenitor cells (EPCs) in limb ischemia and wound healing. Thus, the goal of this study was to evaluate the angiogenic effect of exogenous CGRP on bone regeneration in a rat DO model. Exogenous CGRP was directly injected into the bone defect after each cycle of distraction in vivo. Microcomputed tomography, biomechanical test, and histological analysis were performed to assess the new bone formation. Angiography and immunofluorescence were performed to assess the formation of blood vessels. CD31+CD144+ EPCs in the bone defect were quantified with flow cytometry. In in vitro study, bone marrow stem cells (BMSCs) were used to investigate the effect of CGRP on EPCs production during endothelial differentiation. Our results showed that CGRP significantly promoted bone regeneration and vessel formation after consolidation. CGRP significantly increased the fraction of CD31+CD144+EPCs and the capillary density in the bone defect at the end of distraction phase. CGRP increased EPC population in the endothelial differentiation of BMSCs in vitro by activating PI3K/AKT signaling pathway. Furthermore, differentiated EPCs rapidly assembled into tube-like structures and promoted osteogenic differentiation of BMSCs. In conclusion, CGRP increased EPC population and promoted blood vessel formation and bone regeneration at the defect region in a DO model. Impact statement Distraction osteogenesis (DO) is a well-established surgical technique for limb lengthening and bone defect. The disadvantage of this technique is that external fixator is needed to be kept in place for about 12 months. This may result in increased risk of infection, financial burden, and negative psychological impacts. In this study, we have injected calcitonin gene-related peptide (CGRP) into the defect region after distraction and found that CGRP enhanced vessel formation and bone regeneration in a rat DO model. This suggests that a controlled delivery system for CGRP could be developed and applied clinically for accelerating bone regeneration in patients with DO.

Computed Tomography in the Evaluation of Fontan Circulation.

The Fontan procedure is a well-established surgical technique to improve survival in patients with univentricular heart disease. The procedure reroutes the systemic venous flow to the lungs, bypassing the right ventricle. The originally proposed method involved direct anastomosis of the right atrium to the pulmonary artery. Since then, several modifications have been made in the original technique leading to the modern Fontan, or total cavopulmonary connection. The modern Fontan technique has shown improved surgical outcomes and increased life expectancy in patients with univentricular disease. Due to the increased survival of these patients, long-term complications are becoming more prevalent. Common complications of Fontan procedure include right atrial dilatation and thrombosis; conduit stenosis and thrombosis; right-to-left and left-to-right shunts; hepatic congestion and cirrhosis; and lymphovascular. Computed tomography (CT) can reliably depict the normal Fontan anatomy and various postoperative complications. A fundamental understanding of the techniques of CT, including imaging protocols and common interpretive pitfalls, allows targeted imaging and precise reporting of clinically significant findings. Radiologists should be familiar with the multiple stages of single-ventricle palliation, normal Fontan anatomy, pathophysiology, and imaging features of common Fontan-related complications.

Cervical Intervertebral Cages: Past, Present, Innovations, and Future Trends with Review of the Literature.

Abstract Background Data: Anterior cervical discectomy and fusion (ACDF) has been the standard treatment for degenerative conditions of the cervical spine. Since the introduction of the procedure in the fifties, ACDF has become quite popular and a gold standard procedure. Autologous iliac crest bone grafts were used for fusion with associated drawbacks that mandated the introduction of new metallic substitutes with various fillers. Many improvements and enhancements to these cages were implemented with rising controversial issues. Purpose: To review the available data of cervical cages and the recent status of ACDF using standalone cages. Study Design: A narrative literature review. Patients and Methods: We reviewed the English literature through the last two decades for the most up-to-date available data of the cervical cages and reported the current status of ACDF outcomes using standalone cages. We ran a search using PubMed, Cochrane, and Google Scholar using different relevant keywords and extracted the most relevant researches according to our study aim. We focused on special titles that we thought were most relevant to the spinal surgeon's daily practice. Results: A great number of cervical cages with different shapes and designs are available for ACDF. Spinal surgeons are confronted with a huge array of cervical cages introduced every day by many medical industry competitors. Clinical and radiological outcomes are generally very satisfactory regardless of the type and material of cages used. Composite or titanium-coated PEEK cervical cages and 3D-printed and porous titanium cages are under evaluation. Self-locking standalone cages showed great advancement and development with promising outcomes. Conclusion: ACDF is a well-established surgical technique in the management of cervical spondylotic radiculopathy and/or myelopathy. Large numbers of cervical cages with different shapes, designs, and compositions are available in the market with generally satisfactory clinical and radiological outcomes. Spinal surgeons should be aware of the available cervical cages and choose the most suitable to their patient’s medical and socioeconomic status. New industrial technology has the potential to improve the load-bearing surface, lower cage dislocation and subsidence, and osteointegration. Composite cages, self-locking cages, and absorbable cages are fairly newly introduced cages and still under evaluation. Multicenter long-term prospective randomized controlled trials are mandatory for obtaining first-class evidence-based medical data on ACDF. (2020ESJ213) Abstract Background Data: Anterior cervical discectomy and fusion (ACDF) has been the standard treatment for degenerative conditions of the cervical spine. Since the introduction of the procedure in the fifties ACDF have become quite popular and gold standard procedures. Autologous iliac crest bone grafts were used for fusion with associated drawbacks that mandates the introduction of new metallic substitutes with various fillers. Lots of improvements and enhancements of these cages were supposed with arising controversial issues. Purpose: To review the available data of cervical cages and the recent status of ACDF using standalone cages. Study Design: narrative literature review. Patients and Methods: We reviewed the English literature for the most up-to-date available data of the cervical cages and reported the current status of ACDF outcomes using standalone cages. We ran a search using PubMed, Cochrane, and Google Scholar using different relevant keywords and extracted the most relevant researches according to our study aim. We focused on special titles that we thought they are most relevant to the spinal surgeon daily practice. Results: a great number of cervical cages with different shape and designs are available for ACDF. Spinal surgeons are confronted with a huge array of cervical cages introduced every day by many medical industrial competitors. Clinical and radiological outcomes are generally very satisfactory regardless the type and material of cages used. Composite or titanium coated PEEK cervical cages are under evaluation as well as 3D print and porous titanium cages. Self-locking standalone cages showed a great advancement and development with promising outcomes. Conclusion: ACDF is a well-established surgical technique in the management of cervical spondylotic radiculopathy and/or myelopathy. Large numbers of cervical cages with different shapes, designs, and compositions are available in the market with generally satisfactory clinical and radiological outcomes. Spinal surgeons should be aware of available cervical cages and choose the most suitable to their patient’s medical and socioeconomic status. New industrial technology has the potentials of improving load-bearing surface, lower cage dislocation and subsidence, and improve osteointegration. Composite cages, self-locking cages, absorbable cages are fairly introduced cages and still under evaluation. Multicenter long-term prospective randomized controlled trials are mandatory for first class evidence based medical data in ACDF. (2020ESJ213)

Tibial tubercle osteotomy in revision total knee arthroplasty: A systematic review.

Tibial tubercle osteotomy (TTO) is a well-established surgical technique to deal with a stiff knee in revision total knee arthroplasty (RTKA). However, several reports have described potential osteotomy-related complications such as non-union, tibial tubercle migration and fragmentation, and metalware related pain. To evaluate the literature and estimate the efficiency of TTO in RTKA in terms of osteotomy union, knee mobility and complications. MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials were investigated for completed studies until February 2020. The principle outcome of the study was the incidence of union of the osteotomy. Secondary outcomes were the knee range of motion as well as the TTO-related and overall procedure complication rate. Fifteen clinical studies with a total of 593 TTOs were included. The TTO union rate was 98.1%. Proximal migration and anterior knee pain were the most common TTO-related complications accounting for 6.9% and 6.4% of all cases, respectively. However, only 2.2% of cases suffering from anterior knee pain needed hardware removal. Knee flexion was improved from 82.9° preoperatively to 100.1° postoperatively and total knee range of motion was increased from 73.4° before surgery to 97° after surgery. Stiffness requiring manipulation under anesthesia was recorded in 4.6% of cases. No major complications were reported. The current systematic review supports the use of TTO in RTKA, as it is associated with high union rate, significant improvement in knee motion and low osteotomy-related complication risk that rarely leads to secondary tibial tubercle procedures.

Un nouveau système d’évaluation du handicap de l’épaule après l’arthrodèse scapulo-thoracique chez les patients souffrant de dystrophie facio-scapulo-humérale

BackgroundScapulothoracic arthrodesis (STA) is a well-established surgical technique to provide scapular stabilization in patients with facioscapulohumeral dystrophy (FSHD). There is no staging or scoring systems available to guide surgical decision. The aim of this study was to develop a staging system to evaluate the shoulder disability in patients with FSHD to guide surgical decision making and assess its reliability among surgeons. MethodsFifty-seven shoulders of 29 patients (15 male, 14 female) with an average age of 34.5 years (13–73) were included. Six stages of the disease were defined to create a system consisting of shoulder elevation, deltoid function and scapular winging. Patients were assessed by two independent orthopaedic surgeons who were blind to each other. Statistical analyses included mean and standard deviation for descriptive variables, Pearson's correlation and Cohen's Kappa for inter and intra observer agreement. ResultsMeasurement of elevation showed excellent correlation in both inter- and intraobserver assessment. There was substantial agreement on deltoid function and moderate agreement on scapular winging. Decision on stage showed excellent agreement on inter observer and substantial agreement on intra observer assessment. Surgical decision using the stage showed excellent agreement on both inter and intra observer assessment. ConclusionThis novel staging system has an excellent inter observer agreement on FSHD patients’ shoulder disability. This would provide surgeons a beneficial tool to define patient groups that would have negatively or positively affected from STA.

A novel shoulder disability staging system for scapulothoracic arthrodesis in patients with facioscapulohumeral dystrophy

BackgroundScapulothoracic arthrodesis (STA) is a well-established surgical technique to provide scapular stabilisation in patients with facioscapulohumeral dystrophy (FSHD). There is no staging or scoring systems available to guide surgical decision. The aim of this study was to develop a staging system to evaluate the shoulder disability in patients with FSHD to guide surgical decision-making and assess its reliability among surgeons. MethodsFifty-seven shoulders of 29 patients (15 male, 14 female) with an average age of 34.5 years (13–73) were included. Six stages of the disease were defined to create a system consisting of shoulder elevation, deltoid function and scapular winging. Patients were assessed by two independent orthopaedic surgeons who were blind to each other. Statistical analyses included mean and standard deviation for descriptive variables, Pearson's correlation and Cohen's Kappa for inter- and intraobserver agreement. ResultsMeasurement of elevation showed excellent correlation in both inter- and intraobserver assessment. There was substantial agreement on deltoid function and moderate agreement on scapular winging. Decisions on stage showed excellent agreement on interobserver and substantial agreement on intraobserver assessment. Surgical decision using the stage showed excellent agreement on both inter- and intraobserver assessment. ConclusionThis novel staging system has an excellent inter observer agreement on FSHD patients’ shoulder disability. This would provide surgeons a beneficial tool to define patient groups that would have negatively or positively affected from STA.

Fat Therapeutics: The Clinical Capacity of Adipose-Derived Stem Cells and Exosomes for Human Disease and Tissue Regeneration.

Fat grafting is a well-established surgical technique used in plastic surgery to restore deficient tissue, and more recently, for its putative regenerative properties. Despite more frequent use of fat grafting, however, a scientific understanding of the mechanisms underlying either survival or remedial benefits of grafted fat remain lacking. Clinical use of fat grafts for breast reconstruction in tissues damaged by radiotherapy first provided clues regarding the clinical potential of stem cells to drive tissue regeneration. Healthy fat introduced into irradiated tissues appeared to reverse radiation injury (fibrosis, scarring, contracture and pain) clinically; a phenomenon since validated in several animal studies. In the quest to explain and enhance these therapeutic effects, adipose-derived stem cells (ADSCs) were suggested as playing a key role and techniques to enrich ADSCs in fat, in turn, followed. Stem cells - the body’s rapid response ‘road repair crew’ - are on standby to combat tissue insults. ADSCs may exert influences either by releasing paracrine-signalling factors alone or as cell-free extracellular vesicles (EVs, exosomes). Alternatively, ADSCs may augment vital immune/inflammatory processes; or themselves differentiate into mature adipose cells to provide the ‘building-blocks’ for engineered tissue. Regardless, adipose tissue constitutes an ideal source for mesenchymal stem cells for therapeutic application, due to ease of harvest and processing; and a relative abundance of adipose tissue in most patients. Here, we review the clinical applications of fat grafting, ADSC-enhanced fat graft, fat stem cell therapy; and the latest evolution of EVs and nanoparticles in healing, cancer and neurodegenerative and multiorgan disease.