Complication Rates in Intertrochanteric Fractures: A Database Analysis Comparing Sliding Hip Screw and Cephalomedullary Nail.

Objectives: In the treatment of closed intertrochanteric fractures, the two most common treatment options are intramedullary medullary nail (IMN) and dynamic hip screw (DHS), yet the best treatment method remains controversial. The purpose of this study is to determine the difference in mortality and morbidity between IMN and DHS. Secondarily, this study determines which pre-operative risk factors affect rates of morbidity and mortality. Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2006-2016 database was used to search for patients with a closed intertrochanteric hip fracture. Bivariate analysis was performed using Pearson's Chi Square test to determine pre-operative risk factors associated with complications in fixation with IMN and DHS. Significant variables in this analysis, as well as demographic data, were analyzed via binary logistic regression. The results were recorded as odds ratio (OR) and significant differences were based on a P<0.05. Results: After adjusting for demographics and clinical covariates, patients who underwent fixation with IMN had higher 30-day mortality, reintubation, UTI, bleeding, prolonged length of stay, and non-home discharged destination rates compared to DHS. Mortality risk was increased by ascites, disseminated cancer, impaired functional status, history of congestive heart failure, and hypoalbuminemia. Bleeding risk was increased by previous percutaneous coronary (PCI) and transfusions and was decreased by impaired functional status. Myocardial infarction risk was increased by female gender. Conclusion: Our study found that IMN fixation increased risk of mortality, UTI, reintubation, bleeding, prolonged length of stay, and a non-home discharge destination compared to DHS. This study also identified patient risk factors associated with several postoperative complications. These data may better inform orthopaedic surgeons treating closed intertrochanteric fractures.

Metacarpal Stress Fractures in Athletes: A Systematic Review.

BACKGROUND: Stress fractures in general are common injuries; however, there is limited literature on metacarpal stress fractures in athletes. Our objective is to contribute the first systematic review of metacarpal stress fractures in athletes, with a particular focus on epidemiology, presentation, and outcomes. METHODS: A systematic review regarding metacarpal stress fractures in athletes was performed via PubMed, EMBASE, MedLine, Cochrane, and Web of Science. Inclusion criteria consisted of case reports and case series of metacarpal stress fractures in athletes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: A total of 11 studies (29 cases) were included. The mean patient age was 17 years, with 12 men and 15 women. The most common sports were tennis and badminton. The most common presentation was pain in the dorsal aspect of the hand related to activity. All patients underwent successful nonoperative management, with mean return to play of 9 weeks. CONCLUSIONS: Metacarpal stress fractures can present with significant pain and impact performance in athletes who perform sports involving repetitive movements of the hand and wrist. Nonoperative treatment, consisting of abstinence from sport until the patient was pain free combined with gradual return to play, was successful for all patients. The addition of proper technique and training load can result in satisfactory return to play. For patients who present with hand pain related to exercise, particularly a young racquet sport player, metacarpal stress fractures are a "can't miss" diagnosis associated with significant functional impairment.

Hospital teaching status is an independent predictor of surgical intervention of distal radius fractures.

Background: Distal radius fractures are among the most common orthopaedic injuries and are managed both surgically and non-surgically. To date, no study has examined the role hospital teaching status plays in the rates of surgical intervention. Methods: The Nationwide Inpatient Sample (NIS) was queried for years 2003-2014. Patients with a distal radius fracture were identified using International Classification for Disease, Ninth Revision (ICD-9) disease codes. Surgical intervention was determined using ICD-9 procedure codes. Exclusion criteria were patients younger than age 18, polytrauma, open fractures, records with missing data, and records where the primary procedure was something other than open reduction of a radius or ulna fracture, closed reduction of a radius or ulna fracture, or blank. Chi-squared tests were run for demographic and socioeconomic data to identify significant variables. Significant variables were then included alongside hospital teaching status in a binomial logistic regression model. Significance was defined as P < 0.05. Results: A weighted total of 98,831 patients were included in the study. Of those, 45,234 (45.8 %) were treated at teaching hospitals. Patients in teaching hospitals were more likely to be younger, male, non-white, and non-Medicare insured than non-teaching hospitals. Injuries were treated surgically in 64.6 % of total cases. Surgical intervention was more common in teaching hospitals than non-teaching hospitals (69.1 % vs. 60.8 %, P < 0.01). After controlling for demographic and socioeconomic factors, patients at teaching hospitals were 31 % more likely to undergo surgical treatment than those at non-teaching hospitals. Other factors that were independently predictive of surgical treatment were age, race, and insurance type. Conclusion: In the setting of distal radius fractures, teaching hospitals have higher rates of surgical intervention than non-teaching hospitals. These results suggest that the involvement of medical trainees may play a role in the surgical decision-making process.

Laparoscopic cholecystectomy versus conservative management for adults with uncomplicated symptomatic gallstones: the C-GALL RCT.

Background: Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10-15%, and around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease. Objectives: To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care. Design: Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost-utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease. Setting: Secondary care elective settings. Participants: Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion. Interventions: Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management. Main outcome measures: The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones' condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation. Results: Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6-15.0) and 4.7 months (interquartile range 2.6-7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference -0.0, 95% confidence interval (-1.7 to 1.7); p-value 0.996; n = 203 observation/conservative, n = 205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p < 0.001 with a similar pattern for the persistent symptoms score. Within-trial cost-utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference -£1033). A non-significant quality-adjusted life-year difference of -0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of £55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals. Conclusions: The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery. Trial registration: This trial is registered as ISRCTN55215960. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.

The C-GALL study assessed the benefits, in terms of symptoms, quality of life and costs, of cholecystectomy versus observation (conservative management: by the patient and general practitioner that might include dietary advice and pain management and surgery if needed). Four hundred and thirty-four patients with symptomatic gallstones were randomly allocated surgery or conservative management. The main symptom of ongoing bodily pain and some other quality-of-life measures were assessed over the next 2 years using postal questionnaires. After 2 years, 70% of those allocated to surgery had been operated on and 37% of the observation group either had an operation or were waiting for one. There was no difference in bodily pain or overall quality of life between the groups. However, participants in the surgery group reported fewer ongoing problems related to their gallstone disease or after surgery than those in the conservative management group. Surgery was, however, more costly than conservative management. The C-GALL study has shown that for some patients, a conservative management approach may be a sufficient and less costly way of managing their gallstone symptoms rather than going straight on the waiting list for surgery. More research is needed to identify which patients benefit most from surgery.

Role of Authors in the Medical Manuscripts.

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Scaphoid Fractures Requiring Bone Graft: Does Graft Source Matter?

Background: Treatment of scaphoid fractures often requires bone grafting. In such cases, bone graft is traditionally harvested from the iliac crest, but utilizing the distal radius carries less morbidity and is becoming more popular. The purpose of this study is to compare the outcomes of treatment of scaphoid waist fractures with the use of distal radius and iliac crest bone grafts. Methods: A retrospective chart review of patients undergoing repair of a scaphoid waist fracture with bone graft at our institution between 2010 and 2020 was completed. Bone graft was used in patients with nonunion, humpback deformity, or for correction of scaphoid alignment. The primary outcome was rate of union as determined by postoperative X-ray or computed tomography scan. Fisher exact tests, Student t tests, and Mann-Whitney U tests were used as appropriate. Results: Thirty-nine patients were included in the study. Twenty-nine patients were treated with distal radius bone graft, and 10 were treated with an iliac crest graft. There was no statistical difference in union rate between the distal radius and iliac crest cohorts (97% vs 80%, P = .16). There was no significant difference for complication rates, rate of unplanned secondary surgery, time to union, postoperative scapholunate angle, or duration of immobilization. Conclusions: In the fixation of scaphoid waist fractures with bone graft, there is no significant difference in union rate between distal radius and iliac crest grafts. With the well-documented morbidity associated with iliac crest grafts, surgeons should consider using distal radius grafts instead of iliac crest grafts.

Which Pre-Operative, Modifiable Risk Factors are Most Predictive of Complications in orthopedic Upper Extremity Surgery?

Objectives: Identification of modifiable comorbid conditions in the preoperative period is important in optimizing outcomes. We evaluate the association between such risk factors and postoperative outcomes after upper extremity surgery using a national database. Methods: The National Surgical Quality Improvement Program (NSQIP) 2006-2016 database was used to identify patients undergoing an upper extremity principle surgical procedure using CPT codes. Modifiable risk factors were defined as smoking status, use of alcohol, obesity, recent loss of >10% body weight, malnutrition, and anemia. Outcomes included discharge destination, major complications, bleeding complications, unplanned re-operation, sepsis, and prolonged length of stay. Chi square and multivariable logistic regressions were used to identify significant predictors of outcomes. Significance was defined as P<0.01. Results: After applying exclusion criteria, 53,780 patients were included in the final analysis. Preoperative malnutrition was significantly associated with non-routine discharge (OR=4.75), major complications (OR=7.27), bleeding complications (OR=7.43), unplanned re-operation (OR=2.44), sepsis (OR=10.22), and prolonged length of stay (OR=5.27). Anemia was associated with non-routine discharge (OR=2.67), bleeding complications (OR=13.27), and prolonged length of stay (OR=3.26). In patients who had a weight loss of greater than 10%, there was an increase of non-routine discharge (OR=2.77), major complications (OR=2.93), and sepsis (OR=3.7). Smoking, alcohol use, and obesity were not associated with these complications. Conclusion: Behavioral risk factors (smoking, alcohol use, and obesity) were not associated with increased complication rates. Malnutrition, weight loss, and anemia were associated with an increase in postoperative complication rates in patients undergoing upper limb orthopaedic procedures and should be addressed prior to surgery, suggesting nutrition labs should be part of the initial blood work.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma.

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Genomic insights into Yak (Bos grunniens) adaptations for nutrient assimilation in high-altitudes.

High-altitude environments present formidable challenges for survival and reproduction, with organisms facing limited oxygen availability and scarce nutrient resources. The yak (Bos grunniens), indigenous to the Tibetan Plateau, has notably adapted to these extreme conditions. This study delves into the genomic basis of the yak's adaptation, focusing on the positive selection acting on genes involved in nutrient assimilation pathways. Employing techniques in comparative genomics and molecular evolutionary analyses, we selected genes in the yak that show signs of positive selection associated with nutrient metabolism, absorption, and transport. Our findings reveal specific genetic adaptations related to nutrient metabolism in harsh climatic conditions. Notably, genes involved in energy metabolism, oxygen transport, and thermoregulation exhibited signs of positive selection, suggesting their crucial role in the yak's successful colonization of high-altitude regions. The study also sheds light on the yak's immune system adaptations, emphasizing genes involved in response to various stresses prevalent at elevated altitudes. Insights into the yak's genomic makeup provide valuable information for understanding the broader implications of high-altitude adaptations in mammalian evolution. They may contribute to efforts in enhancing livestock resilience to environmental challenges.

Spectral and temporal atomic coherence interaction in Eu3+ : NaYF4 and Eu3+ : BiPO4.

We investigate the spectral and temporal atomic coherence interaction based on out-of-phase fluorescence (FL) and spontaneous parametric four-wave mixing (SFWM) from the hexagonal phase of Eu3+ : NaYF4 and different phases of Eu3+ : BiPO4. Spectral and temporal interactions are interrelated and reduced by about 2 times due to two-photon nested dressing in contrast to the sum of each laser excitation. As the lifetime of photons increases, off-resonance profile cross-interaction decreases because cross-interaction reverses the signal at the near time gate position and keeps it consistent at the far time gate position. Moreover, the thermal phonon dressing at 300 K exhibits 6 times more eminent and obvious temporal interaction than that at 77 K. In a different phase of Eu3+ : BiPO4, there are three dark dips having stronger self-interaction; however, Eu3+ : NaYF4 has two dark dips as Eu3+ : BiPO4 has two phonon dressing. Further, the pure hexagonal phase of Eu3+ : BiPO4 demonstrates the strongest cross-interaction and longest coherent time under the dressing effect due to the smallest dressing phonon detuning and off-resonance profile cross-interaction at PMT2 because the angle quantization is the strongest. Such results can be used for designing novel quantum devices and have potential applications in quantum memory devices.

Analyzing neural activity under prolonged mask usage through EEG.

In recent COVID times, mask has been a compulsion at workplaces and institutes as a preventive measure against multiple viral diseases including coronavirus (COVID-19) disease. However, the effects of prolonged mask-wearing on humans' neural activity are not well known. This paper is to investigate the effect of prolonged mask usage on the human brain through electroencephalogram (EEG), which acquires neural activity and translates it into comprehensible electrical signals. The performances of 10 human subjects with and without mask were assessed on a random patterned alphabet game. Besides EEG, physiological parameters of oxygen saturation, heart rate, blood pressure, and body temperature were recorded. Spectral and statistical analysis were performed on the recorded entities along with linear discriminant analysis (LDA) on extracted spectral features. The mean EEG spectral power in alpha, beta, and gamma sub-bands of the subjects with mask was smaller than the subjects without mask. The performances on the task and the oxygen saturation level between the two groups differed significantly (p < 0.05). Whereas, the blood pressure, body temperature, and heart rate of both groups were similar. Based on the LDA analysis, the occipital and frontal lobes exhibited the greatest variability in channel measurements, with O1 and O2 channels in the occipital lobe demonstrating significant variations within the alpha band due to visual focus, while the F3, AF3, and F7 channels were found to be differentiating within the beta and gamma frequency bands due to the cognitive stimulating tasks. All other channels were observed to be non-discriminatory.

In-Situ Construction of V2 O5 Nanosheet/Nitrogen-Doped Carbon Nanosheet Heterostructures with Interfacial C─O Bridging Bonds as the Cathode Material for Zn Ion Batteries.

Layered oxides are widely used as the electrode materials for metal ion batteries. However, for large radius size ions, such as Zn2+ and Al3+ , the tightly stacked layers and poor electrical conductivity of layered oxides result in restricted number of active sites and sluggish reaction kinetics. In this work, a facile in-situ construction strategy is provided to synthesize layered oxide nanosheets/nitrogen-doped carbon nanosheet (NC) heterostructure, which shows larger interlayer spacing and better electrical conductivity than the layered oxides. As a result, the Zn2+ ion diffusion inside the interlayer gallery is greatly enhanced and the storage sites inside the gallery can be better used. Meanwhile, the NC layers and oxide nanosheets are bridged by the C─O bonds to form a stable structure, which contributes to a better cycling stability than the pure layered oxides. The optimal V2 O5 @NC-400 cathode shows a capacity of 467 mA h g-1 at 0.1 A g-1 for 300 cycles, and long-term cyclic stability of 4000 cycles at 5 A g-1 with a capacity retention of 92%. All these performance parameters are among the best for vanadium oxide-based cathode materials.

Resident involvement in hand and upper extremity surgery: An analysis of 30-day complications.

Background: Rotations in hand and upper extremity surgery are a core component of the Orthopaedic and Plastic Surgery resident training curriculums. This study compares short-term outcomes in hand and upper extremity procedures with and without resident involvement. Methods: The National Surgical Quality Improvement Program database was queried from years 2005-2012 for all procedures distal to the shoulder. Patients were stratified based on whether a resident scrubbed for the procedure. Outcome measures were 30-day mortality, reoperation rate, minor complications, major complications, and length of stay (LOS). Chi-squared tests were used to determine significant variables. Significant variables were included in a binomial multivariate logistic regression model. Results: A total of 7697 patients were included in the study. Of those, 4509 (59 %) had no resident, and 3188 (41 %) had a resident. Patients with resident involvement were less likely to be Caucasian, ASA classification 3 or higher, and outpatient. Cohorts were similar with respect to age, sex, and emergent status. Operative time was 15 min longer in resident cases. Work relative value units were higher in resident cases. In the multivariate logistic regression model, resident involvement had no statistically significant impact on LOS, mortality, reoperation rate, minor complications, or major complications. Subgroup analysis showed increased odds of superficial surgical site infections in resident cases, although this was statistically insignificant (OR 1.35, p = 0.24). Conclusions: Hand and upper extremity procedures with resident involvement do not have any increase in overall adverse short-term outcomes. In appropriately selected cases, residents can participate without compromising patient safety.

Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): pragmatic, multicentre randomised controlled trial.

OBJECTIVE: To assess the clinical and cost effectiveness of conservative management compared with laparoscopic cholecystectomy for the prevention of symptoms and complications in adults with uncomplicated symptomatic gallstone disease. DESIGN: Parallel group, pragmatic randomised, superiority trial. SETTING: 20 secondary care centres in the UK. PARTICIPANTS: 434 adults (>18 years) with uncomplicated symptomatic gallstone disease referred to secondary care, assessed for eligibility between August 2016 and November 2019, and randomly assigned (1:1) to receive conservative management or laparoscopic cholecystectomy. INTERVENTIONS: Conservative management or surgical removal of the gallbladder. MAIN OUTCOME MEASURES: The primary patient outcome was quality of life, measured by area under the curve, over 18 months using the short form 36 (SF-36) bodily pain domain, with higher scores (range 0-100) indicating better quality of life. Other outcomes included costs to the NHS, quality adjusted life years (QALYs), and incremental cost effectiveness ratio. RESULTS: Of 2667 patients assessed for eligibility, 434 were randomised: 217 to the conservative management group and 217 to the laparoscopic cholecystectomy group. By 18 months, 54 (25%) participants in the conservative management arm and 146 (67%) in the cholecystectomy arm had received surgery. The mean SF-36 norm based bodily pain score was 49.4 (standard deviation 11.7) in the conservative management arm and 50.4 (11.6) in the cholecystectomy arm. The SF-36 bodily pain area under the curve up to 18 months did not differ (mean difference 0.0, 95% confidence interval -1.7 to 1.7; P=1.00). Conservative management was less costly (mean difference -£1033, (-$1334; -€1205), 95% credible interval -£1413 to -£632) and QALYs did not differ (mean difference -0.019, 95% credible interval -0.06 to 0.02). CONCLUSIONS: In the short term (≤18 months), laparoscopic surgery is no more effective than conservative management for adults with uncomplicated symptomatic gallstone disease, and as such conservative management should be considered as an alternative to surgery. From an NHS perspective, conservative management may be cost effective for uncomplicated symptomatic gallstone disease. As costs, complications, and benefits will continue to be incurred in both groups beyond 18 months, future research should focus on longer term follow-up to establish effectiveness and lifetime cost effectiveness and to identify the cohort of patients who should be routinely offered surgery. TRIAL REGISTRATION: ISRCTN registry ISRCTN55215960.

Oh nuts, they've got a pelvic kidney - a tricky testicular vein embolisation.

Testicular vein embolisation for varicocele is a common interventional procedure performed in predominantly young, healthy males. Cross-sectional imaging is rarely performed for treatment planning and is often not available. In this case report, we describe a case of testicular vein embolisation in an ipsilateral pelvic kidney where cross-sectional imaging aided treatment planning resulting in successful embolisation.

Cephalomedullary Nailing has a Higher Reoperation Rate Compared to Sliding Hip Screw Fixation in the Treatment of Intertrochanteric Femur Fractures: A Systematic Literature Review and Meta-analysis.

Objectives: Intertrochanteric hip fractures are a common orthopaedic injury in the United States. Complications of surgical treatment include nonunion, lag screw cutout, implant failure, post-operative pain, risk of refracture or reoperation, and infection. The purpose of this study was to compare the rate of complications of sliding hip screw fixation (SHS) compared to cephalomedullary nailing (CMN) for the treatment of closed intertrochanteric femur fractures in adult patients. Methods: PubMed, CINAHL, and Cochrane Library databases were searched for studies comparing SHS to CMN in the treatment of closed intertrochanteric femur fractures in adults. Data were compiled to observe the rate of nonunion, cutout failure, infection, refracture, perioperative blood loss, reoperation, postoperative pain, pulmonary embolism/deep venous thrombosis (DVT), length of hospital stay, and mortality. Results: Seventeen studies were included comprising 1,500 patients treated with SHS and 1,890 patients treated with CMN. Treatment of intertrochanteric femur fractures with SHS demonstrated significantly fewer refractures and reoperations. There was no significant difference in other variables between SHS and CMN treated groups. Conclusion: This meta-analysis shows that the only notable difference in outcomes is patients treated with CMN have a higher rate of refracture and reoperation. With new advances in the development of both CMNs and SHS, further studies will be required to see if these differences persist in the coming years.

Comparison of Treatment Options for Chronic Scapholunate Interosseous Ligament (SLIL): A Systematic Literature Review and Meta-Analysis.

Background: The scapholunate interosseous ligament (SLIL) is an important contributor to wrist stability and functionality. SLIL injury is debilitating and therefore many surgical techniques have been proposed, but the optimal treatment modality remains debated.This meta-analysis reviews the available literature comparing surgical techniques used in the treatment of chronic SLIL to determine the best approach. Methods: An electronic search of the literature was conducted to identify all randomized controlled trials and cohort studies published before January 2019 that evaluated clinical outcomes of capsulodesis reconstruction, the modified Brunelli technique, and the reduction and association of the scaphoid and lunate (RASL) procedure for treatment of chronic SLIL. A chi-square analysis was performed to identify possible differences between each technique for several outcome measures. Results: A total 20 studies encompassing 409 patients met inclusion criteria. Average age among patients was 36.7 years, and 68.2% of patients were male. Reductions in visual analog scale pain scale; Disabilities of Arm, Shoulder, and Hand (DASH) scores; and increases in grip strength and range of motion were observed for all techniques. Capsulodesis was superior to the modified Brunelli technique regarding preserved range of motion. Conclusions: No significant differences were observed among any of the techniques for pain, DASH score, and grip strength outcomes. Capsulodesis, modified Brunelli, and RASL surgical techniques for the treatment of chronic SLIL injuries may all be seen as reliable methods of treatment of chronic SLIL injuries. While future trials directly comparing these methods are needed, this study suggests there is no superiority of one technique over another.

A deviant anterior portal vein in the hepatoduodenal ligament with aberrant origin of hepatic arteries directly from the celiac trunk: A case report of two patients underwent pylorus preserving pancreatoduodenectomy (PPPD).

INTRODUCTION: The portal vein (PV) originates behind the neck of the pancreas, where it is formed classically by the union of the superior mesenteric vein (SMV) and the splenic vein (SV) [1]. It courses upwards towards the liver in the free margin of the lesser omentum, the hepatoduodenal ligament, along with other structures of the portal triad, i.e. proper hepatic artery (PHA) and common bile duct (CBD) anterior to it [1]. The PV is found posterior to the PHA and CBD. The abdominal aorta perfuses abdominal viscera via three ventral branches celiac trunk (CA), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The celiac trunk supplies the derivates of the foregut and is divided into the left gastric artery (LGA), splenic artery (SA), and common hepatic artery (CHA). The CHA, after its origin, is divided into the gastroduodenal artery (GDA) and PHA. After giving off the right gastric artery (RGA), the PHA bifurcates into the right and left hepatic arteries (RHA, LHA) [2]. IMPORTANCE: This case report aims to share the rare variations in the anatomy of hepatoduodenal ligament structures to increase awareness and understanding among fellow surgeons which may reduce complications. CASE PRESENTATION: We are reporting 2 cases in which during pancreaticoduodenectomy Portal vein was present anteriorly in the portal triad and the common hepatic artery was absent; instead, both the right and left hepatic arteries originated directly from the CA posterior to PV. This retro-portal origin of hepatic arteries directly from CA is not reported in Michel's classification of hepatic artery variations [3]. CLINICAL DISCUSSION: The confluence of SMV and SV posterior to the neck of the pancreas forms the PV. The portal vein runs upwards in the free edge of the lesser omentum. Anteriorly it is related to the CBD laterally and CHA anteromedially. Posteriorly it is related to the inferior vena cava (IVC), and PV is separated from IVC by epiploic foramen [4]. The overall reported incidence in the variation of the portal vein anatomy is 25%. Among all the variations seen, the anterior PV with posteriorly bifurcating hepatic artery is present in only 10 % of the cases [5]. There is an increased risk of hepatic artery anatomical variation in the presence of portal vein variants. Michel's classification [6] classified variations in the hepatic artery anatomy. In our cases, the hepatic artery anatomy was standard and was classified as Type 1. The bile duct was normal anatomic (lateral to the PV). Hence our cases are unique in describing isolated variant locations and courses. Detailed information about the anatomy of the portal triad and all possible variants can help reduce the incidence of iatrogenic complications during surgeries like liver transplants and pancreatoduodenectomies. Before the advancement of modern imaging techniques, the variations in the anatomy of the portal triad were clinically irrelevant and considered less significant. However, recent literature supports that variant anatomy of the hepatic portal triad can prolong the time of surgery and increase the risk of iatrogenic complications. The clinical relevance of variable hepatic artery anatomy has immense importance in hepatobiliary surgeries, including liver transplants where the viability of the graft depends on adequate arterial perfusion. In addition to that, in pancreatoduodenectomies, aberrant arterial anatomy with a reteroportal course is associated with an increased number of reconstructions [7] and bilio-enteric anastomosis disruptions since the CBD derives its blood supply from the hepatic arteries. Therefore, the imaging must be carefully interpreted with radiologists' help before surgical planning. As surgeons preoperative imaging is usually seen for the abnormal origin of hepatic arteries and vascular involvement in case of malignancies. "Eyes don't see what mind doesn't know", the anterior portal vein is a rare entity and should be considered while reviewing preoperative imaging for operative planning. In our cases, EUS and CT scans, both were done but we determined resectability on scans and abnormal origin (replaced or accessory arteries) only. Above mentioned findings were noted during surgery but now in every preoperative scan, we try to determine the presence of all possible variations including the reported ones. CONCLUSION: Detailed knowledge about the anatomy of the portal triad and all possible variants can help reduce the incidence of iatrogenic complications during surgeries like liver transplants and pancreatoduodenectomies. It also reduces the time of surgery. A careful review of all possible variations in preoperative scans with appropriate knowledge all anatomical variations helps avoid unpleasant events and hence, reduce morbidity and mortality.