Integrated Laparoscopic Management of Parastomal and Midline Incisional Double Hernias: A Staged Approach Including Hartmann's Reversal and Hernia Repair.

Parastomal hernia (PH) following Hartmann's procedure is a common late-term complication and is often combined with an incisional hernia (IH). The surgical treatment for double hernias with an end colostomy is complex and challenging. We present a 54-year-old woman with an end colostomy and combined hernias (PH and midline IH) after an emergency Hartmann's procedure for diverticular perforation of the sigmoid colon underwent staged surgery. First, laparoscopic Hartmann's reversal (LHR) and PH repair with primary suture were performed. Ten months later, "intraperitoneal onlay mesh repair (IPOM) plus" methods were implemented for IH repair. Both surgeries were successfully conducted using a laparoscopic approach, and no evidence of hernia recurrence has been observed in the 12 months after the second surgery. This case report provides valuable insights into the surgical strategy for double hernias with an end colostomy.

Staged circumferential lumbar fusions have less intraoperative complications and shorter operative time with no difference in 30-, 90-, and 1-year complications: a propensity-matched cohort analysis of 190 patients.

BACKGROUND CONTEXT: Circumferential lumbar fusions (cLFs) are becoming more common with increasing and more minimally invasive anterior access techniques. Staging allows reassessment of indirect decompression and alignment prior to the posterior approach, and optimization of OR time management. Safety of staging has been well documented in deformity surgery but has yet to be delineated in less extensive, degenerative cLFs. PURPOSE: The purpose of this study is to compare perioperative complications and outcomes between staged versus single-anesthetic circumferential fusions in the lumbar spine. STUDY DESIGN: Propensity-matched comparative observational cohort. PATIENT SAMPLE: Patients who underwent cLFs for lumbar degenerative disease. OUTCOME MEASURES: In-hospital, 30-day, 90-day, and 1-year complications. METHODS: From 123 patients undergoing single-anesthetic and 154 patients undergoing staged cLF, 95 patients in each group were propensity-matched based on age, sex, BMI, ASA score, smoking, revision, and number of levels. We compared perioperative, 30-day, 90-day, and 1-year complications between the two cohorts. RESULTS: Mean days between stages was 1.58. Single-anesthetic cLF had longer total surgery time (304 vs 240 minutes, p<.001) but shorter total PACU total time (133 vs 196 minutes, p<.001). However, there was no difference in total anesthesia time (368 vs 374 minutes, p=.661) and total EBL (357 vs 320cc, p=.313). Intraoperative complications were nine incidental durotomies in the single-anesthetic and one iliac vein injury in the staged group (9% vs 1%, p=.018). There was no difference of in-hospital (38 vs 31, p=.291), 30-day (16 vs 23, p=.281), 90-day (10 vs 15, p=.391), 1-year complications (9 vs 12, p=.644), and overall cumulative 1-year complications (54 vs 56, p=.883) between the two cohorts. CONCLUSIONS: There is a decrease in total surgical time and intraoperative complications during staged compared with single-anesthetic cLF with no difference in in-hospital, 30-day, 90-day, and 1-year complications between approaches.

Who gets staged surgery in severe pediatric and adolescent spine deformity?

BACKGROUND: There is significant debate regarding the indications of staged surgery for severe adolescent spinal deformity, and the factors associated with the decision to perform staged compared to same-day surgery have not been previously investigated. Thus, the purpose of this study was to determine which factors were most strongly associated with this decision. METHODS: A prospective multicenter registry of adolescent patients with severe spinal deformity was reviewed. Two cohorts were identified: those who underwent a planned staged surgical procedure for deformity correction and those who underwent a same-day procedure. Patients who underwent an unplanned staged procedure secondary to complications during the initial procedure were excluded. Comparisons were made between these cohorts with respect to preoperative patient and radiographic variables to determine which factors were associated with the decision to perform a staged procedure. Surgical data was also compared to evaluate for differences in the intraoperative management of staged versus same-day patients. RESULTS: Two hundred and twenty-nine patients with severe spinal deformities were identified. Forty patients (17%) underwent a planned staged procedure and 189 patients (80%) underwent a same-day procedure. On univariate analysis of preoperative variables, patients who underwent staged surgery had a significantly younger age at surgery, greater major curve magnitude, greater major curve AVT to CSVL, lesser thoracic spine height, greater radiographic trunk shift, and a greater proportion of patients undergoing revision surgery (as opposed to primary correction) compared to those who underwent a planned single-stage procedure. Multivariate logistic regression of pre-operative variables showed that age < 16 years, maximum cobb angle ≥ 120 degrees, major curve AVT to CSVL of ≥ 3.5 cm, and revision surgery were independently associated with the decision to perform a staged procedure. Intraoperatively, patients in the staged cohort more frequently underwent combined anterior and posterior procedures, grade 4 or higher Schwab osteotomies, and had a greater number of levels fused. CONCLUSION: There is substantial variability with respect to the decision to perform surgery for severe adolescent spine deformities in a staged versus same-day fashion. This large analysis of prospectively collected data is the first to describe the factors most strongly associated with the decision to perform a staged procedure and may help guide the surgical decision-making for these patients.

Two-Stage Surgical Management for Acutely Presented Large Vestibular Schwannomas: Report of Two Cases.

The surgical management of vestibular schwannomas should be based on their presentation, neuro-imaging findings, surgeons' expertise, and logistics. Multi-stage surgery can be beneficial for large-sized lesions with acute presentations. Herein, we highlighted the indications for two cases managed initially through the retrosigmoid and, subsequently, translabyrinthine approaches. The first case presented with acute balance and gait issues and a long history of hearing loss and blurred vision. Neuroimaging findings revealed a cerebellopontine angle lesion, resembling a vestibular schwannoma, with significant brainstem compression and hydrocephalus. Due to the rapidly deteriorating clinical status and large-sized tumor, we first proceeded with urgent decompression via a retrosigmoid approach, followed by gross total resection via a translabyrinthine approach two weeks later. The second case presented with gradually worsening dizziness and hemifacial numbness accompanied by acute onset severe headaches and hearing loss. Neuroimaging findings showed a large cerebellopontine angle lesion suggestive of a vestibular schwannoma with acute intratumoral hemorrhage. Given the acute clinical deterioration and large size of the tumor, we performed urgent decompression with a retrosigmoid approach followed by gross total resection through a translabyrinthine approach a week later. Post-surgery, both patients showed excellent recovery. When managing acutely presented large-sized vestibular schwannomas, immediate surgical decompression is vital to avoid permanent neurological deficits.

Comparison of Staged vs Same-Day Circumferential Spinal Fusions for Adult Spinal Deformity.

BACKGROUND: Patients often undergo circumferential (anterior and posterior) spinal fusions to maximize adult spinal deformity (ASD) correction and achieve adequate fusion. Currently, such procedures are performed in staged (ST) or same-day (SD) procedures with limited evidence to support either strategy. This study aims to compare perioperative outcomes and costs of ST vs SD circumferential ASD corrective surgeries. METHODS: This is a retrospective review of patients undergoing circumferential ASD surgeries between 2013 and 2018 in a single institution. Patient characteristics, preoperative comorbidities, surgical details, perioperative complications, readmissions, total hospital admission costs, and 90-day postoperative care costs were identified. All variables were tested for differences between ST and SD groups unadjusted and after applying inverse probability weighting (IPW), and the results before and after IPW were compared. RESULTS: The entire cohort included a total of 211 (ST = 50, SD = 161) patients, 100 of whom (ST = 44, SD = 56) underwent more than 4 levels fused posteriorly and anterior lumbar interbody fusion (ALIF). Although patient characteristics and comorbidities were not dissimilar between the ST and SD groups, both the number of levels fused in ALIF and posterior spinal fusion (PSF) were significantly different. Thus, using IPW, we were able to minimize the cohort incongruities in the number of levels fused in ALIF and PSF while maintaining comparable patient characteristics. In both the whole cohort and the long segment fusions, postoperative pulmonary embolism was more common in ST procedures. After adjustment utilizing IPW, both groups were not significantly different in disposition, 30-day readmissions, and reoperations. However, within the whole cohort and the long segment fusion cohort, the ST group continued to show significantly increased rates of pulmonary embolism, longer length of stay, and higher hospital admission costs compared with the SD group. CONCLUSIONS: Adjusted comparisons between ST and SD groups showed staging associated with significantly increased length of stay, risk of pulmonary embolism, and admission costs.

Staged osteotomy in lateral position for the treatment of severe kyphotic deformity secondary to ankylosing spondylitis: a retrospective study.

BACKGROUND: Patients with severe kyphotic deformity (Cobb > 100°) secondary to ankylosing spondylitis (AS) occasionally cannot undergo corrective surgery in the prone position. Osteotomy in the lateral position might provide a possible solution. In this study, we aim to evaluate the clinical efficacy and safety of staged osteotomy in the lateral position for the treatment of AS-related severe kyphosis with a minimum of 2-year follow-up. METHODS: In total, 23 patients who underwent staged osteotomy in the lateral position from October 2015 to June 2017 were analyzed. In the first stage of surgery, all but one patient underwent a single-level Ponte osteotomy, which was followed by a pedicle subtraction osteotomy in the second stage. Mean follow-up was 30.8 ± 4.6 months. Global kyphosis (GK), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), osteotomized vertebra intervertebral angle (OVI), chin-brow vertical angle (CBVA), Oswestry Disability Index (ODI) score and Scoliosis Research Society-22 Patient Questionnaire (SRS-22) were all compared pre- and postoperation. RESULTS: All kyphosis parameters were significantly improved (all P < 0.05). GK was corrected from 115.0 ± 13.4° to 46.5 ± 9.0° postoperatively, with a mean correction of 68.5°. SVA was improved from 21.2 ± 5.1 cm to 5.1 ± 1.8 cm postoperatively. After surgery, CBVA was adjusted from 64.1 ± 23.2° to 5.7 ± 10.6° and OVI was changed from 9.0 ± 2.7° to - 20.1 ± 5.6°. Both the ODI and SRS-22 showed substantial improvements (all P < 0.05). Four patients with mild complications were observed perioperatively. CONCLUSION: In AS patients with severe kyphosis, satisfactory correction can be safely achieved with staged osteotomy in the lateral position, which can not only correct the sagittal imbalance of the spine with acceptable complications but also facilitate the placement of the intraoperative position.

Staged or Simultaneous Surgery for Colon or Rectal Cancer with Synchronous Liver Metastases: Implications for Study Design and Clinical Endpoints.

In patients presenting with colorectal cancer and synchronous liver metastases, the disease burden related to the liver metastasis is the driving cause of limited longevity and, eventually, risk of death. Surgical resection is the potentially curative treatment for colorectal cancer liver metastases. In the synchronous setting where both the liver metastases and the primary tumor are resectable with a relative low risk, the oncological surgeon and the patient may consider three potential treatment strategies. Firstly, a "staged" or a "simultaneous" surgical approach. Secondly, for a staged strategy, a 'conventional approach' will suggest removal of the primary tumor first (either colon or rectal cancer) and plan for liver surgery after recovery from the first operation. A "Liver first" strategy is prioritizing the liver resection before resection of the primary tumor. Planning a surgical trial investigating a two-organ oncological resection with highly variable extent and complexity of resection as well as the potential impact of perioperative chemo(radio)therapy makes it difficult to find the optimal primary endpoint. Here, we suggest running investigational trials with carefully chosen composite endpoints as well as embedded risk-stratification strategies to identify subgroups of patients who may benefit from simultaneous surgery.

Accelerated Bilateral Hip Arthroscopy (1 Week Apart): Outcomes Compared With Delayed Bilateral Procedure (4-12 Weeks) and Case-Control Matched Unilateral Arthroscopy.

BACKGROUND: Staged bilateral hip arthroscopy is an option for athletes who have symptomatic bilateral femoroacetabular impingement; however, the optimal timing of the second procedure is unknown. PURPOSE: To evaluate minimum 2-year outcomes for patients undergoing accelerated bilateral arthroscopy against those undergoing (1) delayed bilateral and (2) unilateral arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review was performed of prospectively collected data from patients undergoing bilateral primary hip arthroscopy for femoroacetabular impingement between 2009 and 2022. Inclusion criteria entailed competitive athletes with concurrent bilateral symptoms at initial presentation. Exclusion criteria (either hip) were Tönnis grade >1, dysplasia (lateral center-edge angle <25°), Perthes disease, protrusio acetabuli, and avascular necrosis. Two groups were established based on the duration between procedures: within 7 days (accelerated group) and within 4 to 12 weeks (delayed group). Patients from the accelerated group were matched in a 1:2 ratio with patients undergoing unilateral surgery based on age ±2 years, sex, and athletic status. Minimum 2-year postoperative patient-reported outcomes (PROs) (including modified Harris Hip Score, University of California Los Angeles activity scale, 36-Item Short Form Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index), rates of achieving the minimal clinically important difference, rates of continuing to play main sport, and satisfaction were compared between groups. RESULTS: A total of 131 athletes (262 hips) with bilateral femoroacetabular impingement were included: 91 in the accelerated group and 40 in the delayed group. Duration between surgeries was 0.99 ± 0.02 and 6.35 ± 2.18 weeks, respectively. All accelerated athletes were each successfully matched to 2 athletes with unilateral procedures (N = 182). All 3 groups demonstrated significant improvement from baseline across all PROs (P < .001 for all). Acquired change in PROs was similar and not significantly different between groups (P > .05). Satisfaction with relief from pain was achieved by 85.9% of patients in the accelerated group compared with 83.1% in the delayed group (P = .053) and 87.3% in the unilateral group (P = .933). The minimal clinically important difference for the modified Harris Hip Score was achieved by 84.9% of patients in the accelerated group compared with 91.5% in the delayed group (P = .212) and 87.6% in the unilateral group (P = .456). At 2 years postoperatively, the continue-to-play rate was 73.6% for the accelerated group compared with 77.1% for the delayed group (P = .577) and 73.0% for the unilateral group (P = .903). There were no increased complications associated with the accelerated group. CONCLUSION: Accelerated bilateral hip arthroscopy 1 week apart was a safe and effective treatment option for athletes with bilateral symptoms. Improvement in PROs and continue-to-play rates were comparable with those after a delayed duration between procedures and with those case-control matched athletes undergoing unilateral arthroscopy.

Staged surgery for irregular giant pituitary adenomas: A report of two cases.

The resection of giant pituitary adenomas is one of the most challenging brain surgeries, especially when the giant pituitary adenomas have an irregular shape or irregular growth position. The purpose of the present study is to propose staged surgery for irregular giant pituitary adenomas through a retrospective analysis of two cases. The cases of two patients with irregular giant pituitary adenomas who underwent staged surgery are retrospectively analyzed. In one case, a 51-year-old male was hospitalized after 2 months of memory loss. Brain MRI showed that the pituitary adenoma was paginated and located in the sellar and right suprasellar regions, with a size of ~6.15×6.11×5.69 cm. In the second case, a 60-year-old male had a history of intermittent vertigo for 10 years and paroxysmal amaurosis for 1 year. Brain MRI showed that the pituitary adenoma grew laterally and eccentrically, and was located in the sellar region, with a size of ~4.35×3.96×3.07 cm. Both patients underwent staged surgery; more specifically, the tumors were totally removed through two-stage surgery. In the first-stage operation, most of the tumor was removed by the microscopic transcranial approach, while in the second-stage operation, the residual tumor was removed by the endoscopic transsphenoidal approach. Both patients recovered well without obvious postoperative complications after staged surgery. There was no recurrence during the follow-up. Staged surgery is characterized by only treating tumors in the visual field and achieving a total tumor resection, which has the advantages of a high tumor resection rate, high safety and fewer postoperative complications. Staged surgery is especially suitable for irregular giant pituitary adenomas with an irregular shape or irregular growth position.

Nationwide Outcomes of Immediate Versus Staged Surgery for Newborns with Rectosigmoid Hirschsprung Disease.

PURPOSE: Debate exists on whether patients with Hirschsprung Disease (HD) should undergo immediate resection during their newborn hospitalization or undergo a staged procedure. This study sought to compare postoperative outcomes among newborns receiving immediate versus staged surgery for rectosigmoid HD. METHODS: The Nationwide Readmission Database was queried (2016-2018) for newborns with HD who underwent surgical resection during their newborn hospitalization (immediate) versus planned readmission (staged). Those who did not receive rectal biopsy or had long-segment or total colonic HD were excluded. A propensity score-matched analysis (PSMA) of patients receiving either surgery was constructed utilizing >70 comorbidities. Outcomes were analyzed using standard statistical tests. RESULTS: 1,048 newborns with HD were identified (56% immediate vs. 44% staged). Staged resection was associated with higher total hospitalization cost ($56,642 vs. $50,166 immediate), p = 0.014. After PSMA, the staged cohort was more likely to require home healthcare at discharge and experience unplanned readmission (40% vs. 23%). These patients experienced more gastrointestinal complications (40% vs. 22%) on readmission, especially Hirschsprung-associated enterocolitis (35% vs. 20%). CONCLUSION: Newborns receiving staged procedures for HD experience higher rates of unplanned readmission complications and incur higher hospitalization costs. This information should be utilized to defray healthcare utilization costs for newborns with HD. TYPE OF STUDY: Retrospective Comparative. LEVEL OF EVIDENCE: III.

Large Vestibular Schwannoma: A Two-Stage Surgery.

Treatment of large vestibular schwannoma (VS) has historically centered on total resection of the lesion. Staged surgery has been used for VS that is highly vascularized, unexpected events during surgery, and thinned and stretched facial nerve with serious adherence causing difficult dissection. We present a case of a patient with a large VS resected through a two-stage surgery through the same retrosigmoid craniotomy.

Clinical and oncological outcomes in single-stage versus staged surgery for pediatric craniopharyngiomas: a multicenter retrospective study.

PURPOSE: Craniopharyngiomas (CPGs) are aggressive brain tumors responsible of severe morbidity in children. The best treatment strategies are under debate. Our study evaluates surgical, pituitary, and hypothalamic outcomes of a tailored staged-surgical approach compared to a single-stage radical approach in children with CPGs. METHODS: Multicenter retrospective study enrolling 96 children treated for CPGs in the period 2010-2022. The surgical management was selected after a multidisciplinary evaluation. Primary endpoint includes the inter-group comparison of preservation/improvement of hypothalamic-pituitary function, the extent of resection, and progression-free survival (PFS). Secondary endpoints include overall survival (OS), morbidity, and quality of life (QoL). RESULTS: Gross Total Resection (GTR) was reached in 46.1% of cases in the single-stage surgery group (82 patients, age at surgery 9 ± 4.7 years) and 33.3% after the last operation in the staged surgery group (14 patients age 7.64 ± 4.57 years at first surgery and 9.36 ± 4.7 years at the last surgery). The PFS was significantly higher in patients addressed to staged- compared to single-stage surgery (93.75% vs 70.7% at 5 years, respectively, p = 0.03). The recurrence rate was slightly higher in the single-stage surgery group. No significant differences emerged in the endocrinological, visual, hypothalamic outcome, OS, and QoL comparing the two groups. CONCLUSIONS: In pediatric CPGs' surgical radicality and timing of intervention should be tailored considering both anatomical extension and hypothalamic-pituitary function. In selected patients, a staged approach offers a safer and more effective disease control, preserving psychophysical development.

Successful short interval staged surgery in synchronous type A aortic dissection and giant abdominal aortic aneurysm patient.

The surgical therapy of synchronous type A aortic dissection and abdominal aortic aneurysm is complex and rarely reported, especially, when the abdominal aortic aneurysm is unsuitable for intervention. Recently, we have successfully performed sequential two staged surgeries on a 46-year-old woman. The first stage surgeries consisted of the Bentall procedure, total aortic arch replacement, and frozen elephant trunk implantation. The second stage surgeries included replacement from the descending aorta to the sub-renal abdominal aorta, reconstruction of the blood flow to the spinal, the celiac trunk artery, the left and right renal artery, the superior and inferior mesenteric artery, and the iliac artery of both sides. The interval between two surgeries was very short (42 days). The patient was recovered, and all functions of her body were reserved. According to our experience, it is feasible to prevent aortic rupture by short interval staged surgery in selected patients with synchronous type A aortic dissection and un-interventionable abdominal aortic aneurysm.

Staged surgery for closed Lisfranc injury with dislocation.

Objective: To investigate the clinical efficacy of staged surgery for patients with closed Lisfranc injury and dislocation. Methods: This study included 48 patients with acute closed Lisfranc injury and dislocation admitted between July 2016 and July 2021. The patients were divided into two groups. 23 patients in group A underwent staged surgeries included emergency reduction within 4-8 h after injury, and open reduction and internal fixation of Lisfranc injury and first tarsometatarsal joint fusion after the swelling had subsided. 25 patients in group B underwent open reduction and internal fixation as an elective procedure after the swelling had subsided. American Orthopedic Foot and Ankle Society (AOFAS) midfoot scores and visual analog scale (VAS) scores were used for assessment at the final follow-up. Results: A total of 48 patients with closed Lisfranc injury and dislocation were included. The lengths of hospitalization were 11.52 ± 1.61 day and 19.80 ± 2.37 day in groups A and B, respectively. The total lengths of surgery were 67.34 ± 1.71 min and 104.36 ± 8.31 min in groups A and B, respectively. 48 patients completed the final follow-up (follow-up period range: 12-24 months, mean: 18 months). All fractures had healed at 12-18 weeks after surgery (mean: 14.6 weeks). At the 1-year postoperative follow-up, the AOFAS and VAS score was 86.87 ± 4.24 and 1.91 ± 0.78, respectively, during weight-bearing walking in group A patients and 71.72 ± 5.46 and 3.20 ± 1.17 in group B. By the end of the follow-up period, only 2 patients in group B had developed traumatic arthritis and no patients had joint re-dislocation or required secondary surgery. Conclusion: Staged surgery for closed Lisfranc injury with dislocation reduced the incidence of perioperative complications and achieved good surgical outcomes while shortening the lengths of surgery and hospitalization.

Staged Surgery for Intra-Extracranial Communicating Jugular Foramen Paraganglioma: A Case Report and Systematic Review.

Staged surgery strategy was preferred for patients with intra-extracranial communicating jugular foramen paraganglioma (IECJFP). A female patient who presented mild tinnitus, headache, and dizziness, together with preoperative related imaging, was diagnosed with a left intra-extracranial communicating jugular foramen lesion in November 2015 and accepted an initial operation for the intracranial tumor by retrosigmoid approach. The pathologic report was paraganglioma. In November 2021, a subtotal resection of the extracranial tumor was conducted for prominent lower cranial nerves (LCNs) deficit and middle ear involvement by infratemporal approach. In patients with IECJFP accompanied by LCNs deficit and middle ear involvement, an initial surgery for extracranial lesion and a second procedure for intracranial tumor were appropriate. However, the first operation for the intracranial lesion was preferred in IECJFP cases without LCNs deficit and middle ear involvement, as it could remove compression to the neurovascular structure and brain stem, clarify a pathological diagnosis, avoid a CSF leak, and prevent a severe neurological disorder from extracranial lesion excision. Subtotal resection of the extracranial tumor would be performed when lesion became larger combined with obvious LCNs disorder and tympanic cavity involvement. Consideration of specific staged surgical strategy for IECJFP in accordance with preoperative LCNs deficit and tympanic cavity involvement could prevent critical postoperative neurological deficit and improve quality of life in the long term.

Staged lensectomy and vitrectomy in the management of stage 5C retinopathy of prematurity with corneal opacification: long-term follow up.

AIM: To verify the feasibility and safety of staged lensectomy and vitrectomy in stage 5C retinopathy of prematurity (ROP) with corneal opacification. METHODS: This was a retrospective, interventional, consecutive case series. Twenty-two eyes of 18 stage 5C ROP patients with corneal opacification were included. Regular combined lensectomy and vitrectomy were not prescribed due to the invisible fundus. Staged lensectomy and posterior vitrectomy were performed. The anatomical and visual outcomes were reviewed at the final follow-up visit. RESULTS: The mean gestational age of ROP patients was 29.3±1.6wk (range: 27-32wk), comprising 8 males and 10 females. The average birth weight was 1363.0±300.0 g. All the eyes had corneal opacity and flat or disappeared anterior chambers pre-operatively. Two eyes had complicated cataract and 7 eyes had retrolental fibroplasia. Six eyes had posterior pupillary synechiae or membranes. Seven (31.8%) eyes had vascularly active retinas. The average interval between two procedures was 6.8±4.6mo (2.5-18.5mo). After surgeries, all the patients had normal anterior chambers. Fourteen eyes had clear corneas. The intraocular pressure of 3 eyes with glaucoma was controlled by medication. Two eyes had ocular phthisis. The retina was reattached in 3 eyes and partially attached in 11 eyes. Visual acuity ranged from no light perception to hand motion. CONCLUSION: Staged lensectomy and vitrectomy are procedures that can halt progression to further complications and preserve some useful eyesight in stage 5C ROP patients with corneal opacification. The earlier the lensectomy is performed, the better the prognosis is.

Reduced complication rate with simultaneous detethering and spinal deformity correction surgery compared to staged surgeries in patients with early onset scoliosis.

PURPOSE: In patients with early onset scoliosis (EOS) and intraspinal anomalies, surgery may be necessary for both the tethered spinal cord (TSC) and spinal deformity. The purpose of this study was to determine if there is a difference in complications when TSC release and surgery for spinal deformity correction (SDC) are performed separately compared simultaneously. METHODS: EOS patients with TSC who underwent detethering and SDC surgeries were identified through a multicenter registry. Patients were stratified into two groups. The simultaneous cohort consisted of patients receiving both detethering and SDC surgeries in a single anesthetic event on the same day, and the staged cohort consisted of patients undergoing detethering and SDC on two separate occasions. Postoperative complications up to 180 days for either surgery were assessed. RESULTS: Twenty five (65.8%) patients were staged and 13 (34.2%) underwent a simultaneous approach. Percent curve correction following SDC surgery did not significantly differ between the groups (p = 0.36). Within 90 days postoperatively, 16 complications in 11 patients (44.0%) occurred in the staged group, whereas no complications occurred in the simultaneous cohort (p = 0.006). From 90-days to 180-days postoperatively, 4 additional complications in 3 patients (12.0%) occurred in the staged group, with no complications reported in the same timeframe for the simultaneous cohort. CONCLUSION: To our knowledge, this is the largest multicenter comparative study to date, and it suggests that a simultaneous approach can be performed safely for EOS patients undergoing detethering and SDC surgeries, with a potentially lower risk profile than the traditional staged approach to these pathologies. LEVEL OF EVIDENCE: Level III.

The Efficacy and Outcome of a Two-Staged Operation for Irreducible Knee Dislocation: A Prospective Short-Term Follow-Up.

Background: Irreducible knee dislocation (IKD) is a very rare but serious type of knee dislocation; it can lead to soft tissue necrosis due to incarceration of the medial structures and faces great difficulty in the postoperative rehabilitation, too. IKD needs careful pre-operative planning. There is no universal agreement about the appropriate surgical strategy for IKD. The purpose of this study was to investigate the clinical efficacy, safety, and outcome of the two-staged operation in treatment of IKD. Methods: IKD patients were included from June 1, 2016 to May 31, 2020. In the stage-1 surgery, acute reduction and extra-articular structure repair were performed. Following an intermediate rehabilitation, delayed cruciate ligament reconstructions were performed in stage-2. Physical examination, CT, MRI, and X-ray were performed during the pre-operative period. Knee function, joint stability, ligament laxity, knee range of motion (ROM), and alignment were accessed at follow-ups. The minimum and maximum follow-up times were 0.5 years and 1 year, respectively. Results: In total, 17 IKD patients were included. There were three subjects (17.65%) missing at the 1 year follow-up and the average follow-up was 11.18 ± 2.53 months. After stage-1, normal alignment and superior valgus/varus stability were restored in most subjects; however, a notable anterior-posterior instability still existed in most patients. The intermediate rehabilitation processed smoothly (6.94 ± 1.20 weeks), and all patients achieved knee ROM of 0-120° finally. At 0.5 years and 1 year follow-up after stage-2, all subjects had achieved normal knee stability, ROM, and satisfying joint function. No infection or DVT was observed. Conclusions: The two-staged operation for IKD has superior efficacy on knee stability and function, and it can facilitate the rehabilitation and achieve satisfactory short-term outcome.

Staged revision still works for chronic and deep infection of total elbow arthroplasty?

PURPOSE: Infected total elbow arthroplasty (TEA) is challenging. We evaluate the clinical and radiologic outcomes for chronic and deep infection of TEA with two-stage revision surgery. METHODS: A total of 10 elbows were included in the study. The mean age was 69.1 ± 15 years (range, 34-83 years). The mean follow-up was 62 (range, 24-108) months. The clinical outcomes were assessed using a visual analog scale (VAS), range of motion (ROM) arc, and Mayo elbow performance score (MEPS). Moreover, radiographic outcomes, time to revision, pathogenic bacteria, preoperative complications, and disease period were evaluated. RESULTS: Mean preoperative VAS score of 6.1 had improved to 3.3. Mean preoperative ROM was 68° (flexion-extension), which improved to 86.7°. Mean preoperative MEPS was 46 (range, 0-70), which improved to 75.5 (range, 35-85). The mean disease duration was 8.4 months (range, 5-20 months). The most common causative organism was methicillin-resistant Staphylococcus aureus. The second revision rate was 80% at the final follow-up. Radiographic outcome at final follow-up showed that 3 (30%) of 10 patients exhibited radiolucency evidence around the components. Three patients showed nonprogressive radiolucency around the implant interfaces without other indications of infection at the most recent follow-up. CONCLUSION: In patients with chronic and deep infection of TEA, two-stage revision can be an affordable option for eradication of the infection, relieving pain, and restoring joint function. However, the high second revision rate owing to bone and soft-tissue deficits remains a critical issue. LEVEL OF EVIDENCE: Level IV, Case series, Treatment study.

Cost savings for single event multilevel surgery in comparison to sequential surgery in ambulatory children with cerebral palsy.

BACKGROUND: The purpose of this study was to determine the differences in billable provider charges between single event multilevel surgery (SEMLS) based on comprehensive gait analysis and a staged surgical approach (SSA) without comprehensive gait analysis for the orthopedic treatment of ambulatory children with cerebral palsy (CP). METHODS: The charges associated with nine common orthopedic surgical combinations (both unilateral and bilateral, soft tissue or soft tissue plus bony) for children with CP were determined and compared between SEMLS and SSA. The charges included surgical, anesthesia, operating room, recovery room, hospital stay, physical therapy, and, for SEMLS only, comprehensive computerized gait analysis. RESULTS: Total charges to complete each combination was higher for SSA than for SEMLS. The differential ranged from $10,247 to $75,069 with the percentage difference ranging from 20% to 47%. The mean difference was $43,606 (p = 0.0002). The dollar difference (r = 0.98, p < 0.0001) and percentage difference (r = 0.79, p = 0.01) were both related to the total charge of the SEMLS surgery. SIGNIFICANCE: Financial costs are lower for SEMLS vs. SSA for the treatment of multilevel gait issues in children with CP. The cost of gait analysis is much smaller than the cost differential between SEMLS and SSA. Although some patients who have SEMLS may need additional orthopedic surgery with associated costs, this is also possible for SSA. Therefore, due to the many benefits of SEMLS, which also include more informed treatment decision-making as well as reduced time away from school and work (for caregivers), SEMLS guided by gait analysis is recommended over SSA for the treatment of gait disorders in children with CP.