Spinal catheter revision in pediatric intrathecal baclofen pumps: risk factors and postoperative outcomes.

OBJECTIVE: Intrathecal baclofen (ITB) pumps are commonly used in pediatric patients with cerebral palsy (CP) and medically refractory spasticity. However, catheter malfunction and associated risk factors are not well understood. The aim of this study was to examine potential risk factors for spinal catheter malfunction and characterize postoperative follow-up to understand the clinical consequences. METHODS: Patients who received ITB pump replacement or revision at Boston Children's Hospital between 2010 and 2023 were retrospectively reviewed. The spinal catheter revision cohort (SCRC) included patients whose spinal catheter was occluded requiring lumbar catheter revision. The second cohort included abdominal pump replacements only (APRC). Between-group comparisons and multivariable regression identified factors associated with catheter revision and postoperative outcomes. RESULTS: Forty-one (33.6%) patients underwent spinal catheter revision and were compared with 81 patients (66.4%) who underwent abdominal pump replacement only. Younger age at surgery and an elevated preoperative lower-extremity modified Ashworth scale grade were associated with spinal catheter revision (p < 0.05). Catheter model type, tip location, and history of spinal fusion were not associated with obstruction. Postoperatively, SCRC patients experienced a higher rate of infection (17.1%) relative to APRC patients (0%) within 30 days from their ITB pump replacement procedure (p < 0.05) and greater likelihood of subsequent ITB system removal compared with the APRC (24.4% vs 7.4%, p < 0.05). Although not differing preoperatively, SCRC patients had lower postoperative ITB doses when compared with the APRC group (median dose 143 vs 350 µg/day, p < 0.05) at hospital discharge and remained statistically different at the 6-month and 1-year follow-ups (p < 0.05). There were no postoperative differences in baclofen overdose, withdrawal, or median number of hospital readmissions within 30 days. Overall, 31.7% of spinal catheter revisions were unanticipated by the clinical team at time of surgery. CONCLUSIONS: Younger age at surgery and increased preoperative lower-extremity tone may be risk factors for catheter obstruction, resulting in a higher rate of postoperative infection and subsequent ITB pump removal compared with pump replacement alone. Spinal catheter occlusion can complicate revision or replacement procedures, especially when unanticipated. Routine clinical assessment may be inadequate for diagnosing insidious catheter malfunction. Catheter occlusion deserves further study, and routine assessment of catheter patency may be warranted to prevent suboptimal tone therapy.

Strains on the human femur after revision total knee arthroplasty: An in vitro study using digital image correlation.

Pain at the tip of the stem of a knee prosthesis (End-of-Stem Pain) is a common problem in revision total knee arthroplasty (TKA). It may be caused by a problematic interaction between stem and bone, but the exact biomechanical correlate is still unknown. On top of this, there is no biomechanical study investigating End-of-Stem Pain at the distal femur using human specimens. Aim of this study was to find out whether the implantation of a revision total knee implant leads to high femoral surface strains at the tip of the stem, which the authors expect to be the biomechanical correlate of End-of-Stem Pain. We implanted 16 rotating hinge knee implants into 16 fresh-frozen human femora using the hybrid fixation technique and comparing two reaming protocols. Afterwards, surface strains on these femora were measured under dynamic load in two different load scenarios (climbing stairs and chair rising) using digital image correlation (DIC) and fracture patterns after overcritical load were analysed. Peak surface strains were found at the tip of the stem in several measurements in both load scenarios. There were no significant differences between the two compared groups (different trial sizes) regarding surface strains and fracture patterns. We conclude that implantation of a long intramedullary stem in revision TKA can lead to high surface strains at the tip of the stem that may be the correlate of femoral End-of-Stem Pain. This finding might allow for a targeted development of future stem designs that can lead to lower surface strains and therefore might reduce End-of-Stem Pain. Digital Image Correlation proved valid for the measurement of surface strains and can be used in the future to test new stem designs in vitro.

Failure of the Yoke With a Rotating-Hinge Total Knee Arthroplasty: A Case Report.

CASE: A patient underwent revision of a total knee replacement to a cementless rotating-hinge prosthesis. The femoral component became loose, but due to the patient's frailty and cognitive decline, revision was not performed. Subsequently, the yoke failed, dissociating the femoral and tibial components, necessitating a single-stage revision. CONCLUSION: This case underlines the need for robust fixation of components of rotating-hinge knee replacements to avoid mechanical failures. It contributes valuable insights to the limited literature on yoke failure in total knee arthroplasty, emphasizing the importance of implant design, patient selection, and surgical technique to prevent such complications.

Periprosthetic giant cell tumour of the tibia: en bloc resection and megaprosthesis revision.

We present a case detailing the diagnosis and management of a periprosthetic giant cell tumour in a female patient in her 70s, who had undergone total knee arthroplasty (TKA) for primary osteoarthritis in her right knee 7 years prior. The patient reported 4 months of painful weight-bearing. Various imaging modalities, including plain radiographs, CT scans and MRI, revealed a sizeable lytic lesion beneath the TKA prosthesis, along with loosening of the tibial component.Blood tests and analyses of synovial fluid ruled out periprosthetic joint infection, and a biopsy confirmed the diagnosis of a giant cell tumour of the bone. Treatment entailed en bloc resection of the tumour and revision of the TKA using a hinged, oncological-type megaprosthesis. Surgical procedures involved careful resection of the proximal tibia, preservation of vasculature and the creation of a medial gastrocnemius muscle flap. Following surgery, the patient underwent supervised rehabilitation with a functional brace.

Comparative study of percutaneous endoscopic lumbar decompression and traditional revision surgery in the treatment of symptomatic adjacent segment degeneration.

OBJECTIVE: The objective of this study is to evaluate and compare the surgical outcomes and complications of Percutaneous Endoscopic Lumbar Decompression (PELD) and traditional revision surgery in treating symptomatic Adjacent Segment Degeneration (ASD). This comparison aims to delineate the advantages and disadvantages of these methods, assisting spine surgeons in making informed surgical decisions. METHODS: 66 patients with symptomatic ASD who failed conservative treatment for more than 1 month and received repeated lumbar surgery were retrospectively collected in the study from January 2015 to November 2018, with the average age of 65.86 ± 11.04 years old. According to the type of surgery they received, all the patients were divided in 2 groups, including 32 patients replaced the prior rod in Group A and 34 patients received PELD at the adjacent level in Group B. Patients were followed up routinely and received clinical and radiological evaluation at 3, 6, 12 months and yearly postoperatively. Complications and hospital costs were recorded through chart reviews. RESULTS: The majority of patients experienced positive surgical outcomes. However, three cases encountered complications. Notably, Group B patients demonstrated superior pain relief and improved postoperative functional scores throughout the follow-up period, alongside reduced hospital costs (P < 0.05). Additionally, significant reductions in average operative time, blood loss, and hospital stay were observed in Group B (P < 0.05). Notwithstanding these benefits, three patients in Group B experienced disc re-herniation and underwent subsequent revision surgeries. CONCLUSIONS: While PELD offers several advantages over traditional revision surgery, such as reduced operative time, blood loss, and hospital stay, it also presents a higher likelihood of requiring subsequent revision surgeries. Future studies involving a larger cohort and extended follow-up periods are essential to fully assess the relative benefits and drawbacks of these surgical approaches for ASD.

Revisional bariatric surgery using robotic-assisted surgery in a national medical center in Mexico.

Long-term postoperative complications of metabolic and bariatric surgery (MBS) are more frequent than those of primary surgery. Robotic-assisted procedures offer several advantages over traditional laparoscopy, but there are limited data. A retrospective study of 29 patients who underwent a revisional robotic-assisted Roux-en-Y gastric bypass (RRYGB) in a Tertiary Level Hospital. Variables included were demographics, causes for revision, operative details, complications, and weight loss outcomes up to 54 month post-RRYGB. Causes for conversion were weight loss failure (WLF), weight regain (WR), Gastroesophageal Reflux Disease (GERD), or Joint Pain (JP). We assessed 29 patients. Causes for conversion included WLF (34%), WR (15%), WR with GERD (20%), GERD (24%), and JP (3%). Initial BMI was 53.43 kg/m2 ± 8.75. Mean length of hospital stay (LOS) was 2 days. Total operative time was 126 min. ± 43.45. Excess weight loss at 1 year post-surgery was 82.66% (p < 0.0001), with mean BMI of 30.93 kg/m2 (p < 0.001). At 3 years, mean %EWL was 71.26% and a mean BMI 33.81 kg/m2 (p < 0.0001). At 4.5 years, mean %EWL was 59.29% and mean BMI 37.27 kg/m2 (p < 0.0001). One complication (8%) was found (jejunojejunal stenosis). There was no mortality. The initial experience with RRYGB shows acceptable outcomes, including low morbidity, no mortality, excellent weight loss after the revisional surgery, and promising reduction in operative times, with important implications on reduction of the total cost of the procedure.

Stoma associated complications after diverting loop ileostomy, end ileostomy or split stoma formation after right sided colectomy-a retrospective cohort study (StoComSplit Analysis).

BACKGROUND: For high-risk patients receiving right-sided colectomy, stoma formation is a safety strategy. Options are anastomosis with loop ileostomy, end ileostomy, or split stoma. The aim is to compare the outcome of these three options. METHODS: This retrospective cohort study included all patients who underwent right sided colectomy and stoma formation between January 2008 and December 2021 at two tertial referral centers in Switzerland. The primary outcome was the stoma associated complication rate within one year. RESULTS: A total of 116 patients were included. A total of 20 patients (17%) underwent primary anastomosis with loop ileostomy (PA group), 29 (25%) received an end ileostomy (ES group) and 67 (58%) received a split stoma (SS group). Stoma associated complication rate was 43% (n = 21) in PA and in ES group and 50% (n = 34) in SS group (n.s.). A total of 30% (n = 6) of patients in PA group needed reoperations, whereas 59% (n = 17) in ES and 58% (n = 39) in SS group had reoperations (P = 0.07). Wound infections occurred in 15% (n = 3) in PA, in 10% (n = 3) in ES, and in 30% (n = 20) in SS group (P = 0.08). A total of 13 patients (65%) in PA, 7 (24%) in ES, and 29 (43%) in SS group achieved stoma closure (P = 0.02). A total of 5 patients (38%) in PA group, 2 (15%) in ES, and 22 patients (67%) in SS group had a stoma-associated rehospitalization (P < 0.01). CONCLUSION: Primary anastomosis and loop ileostomy may be an option for selected patients. Patients with end ileostomies have fewer stoma-related readmissions than those with a split stoma, but they have a lower rate of stoma closure. CLINICAL TRIAL REGISTRATION: Trial not registered.

Pedicle screw insertion into infected vertebrae reduces operative time and range of fixation in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis: a multicenter retrospective cohort study.

BACKGROUND: Minimally invasive posterior fixation surgery for pyogenic spondylitis is known to reduce invasiveness and complication rates; however, the outcomes of concomitant insertion of pedicle screws (PS) into the infected vertebrae via the posterior approach are undetermined. This study aimed to assess the safety and efficacy of PS insertion into infected vertebrae in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis. METHODS: This multicenter retrospective cohort study included 70 patients undergoing minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis across nine institutions. Patients were categorized into insertion and skip groups based on PS insertion into infected vertebrae, and surgical data and postoperative outcomes, particularly unplanned reoperations due to complications, were compared. RESULTS: The mean age of the 70 patients was 72.8 years. The insertion group (n = 36) had shorter operative times (146 versus 195 min, p = 0.032) and a reduced range of fixation (5.4 versus 6.9 vertebrae, p = 0.0009) compared to the skip group (n = 34). Unplanned reoperations occurred in 24% (n = 17) due to surgical site infections (SSI) or implant failure; the incidence was comparable between the groups. Poor infection control necessitating additional anterior surgery was reported in four patients in the skip group. CONCLUSIONS: PS insertion into infected vertebrae during minimally invasive posterior fixation reduces the operative time and range of fixation without increasing the occurrence of unplanned reoperations due to SSI or implant failure. Judicious PS insertion in patients with minimal bone destruction in thoracolumbar pyogenic spondylitis can minimize surgical invasiveness.

Comparison of operatively and nonoperatively treated isolated Weber B ankle fractures: a systematic review and meta-analysis.

BACKGROUND: Despite fractures of Isolated Weber B being prevalent, there is a lack of clarity regarding the relative effectiveness of surgical versus conservative treatment. This systematic review and meta-analysis aimed to investigate the clinical effects and complications of surgical versus conservative treatment of the Isolated Weber B ankle fractures. METHODS: This study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on Isolated Weber B ankle fractures repaired through surgical versus conservative treatment. Through a comprehensive meta-analysis, several outcomes were evaluated, including post-operative function, complications and reoperation rate. RESULT: Six articles involving 818 patients who met the inclusion criteria. Among these participants, 350 were male and 636 were female. 651 patients received conservative treatment, while 396 underwent surgical intervention. The findings indicate no significant differences in OMAS, FAOQ, PCS, MCS scores, and return to work between surgical and non-surgical treatments for isolated Weber B ankle fractures. However, compared with surgical treatment, non-surgical treatment has a higher AOFAS score(MD = -5.31, 95% CI = [-9.06, -1.55], P = 0.20, I2 = 39%), lower VAS score(MD = 0.72, 95% CI = [0.33, 1.10], P = 0.69, I2 = 0%), lower complication rate (RR = 3.06, 95% CI = [1.58, 6.01], P = 0.05, I2 = 54%), and lower reoperation rate(RR = 8.40, 95% CI = [1.57, 45.06], P = 0.05, I2 = 67%).

Effect of an exercise intervention targeting hip strengthening in patients undergoing revision total hip replacement-A study protocol for a multicenter randomized controlled trial.

BACKGROUND: Limited evidence exists regarding the effectiveness of pain relief and functional improvement in patients undergoing revision total hip replacement (THR). Furthermore, there are no clinical guidelines or consensus on optimal rehabilitation after revision THR. PURPOSE: The primary aim of this study was to compare the effectiveness of an exercise intervention targeting hip strengthening with standard community-based rehabilitation in patients undergoing revision THR. METHODS: This multicenter randomized controlled assessor-blinded trial will be conducted at eight hospitals and multiple municipality rehabilitation centers in Denmark. A total of 84 patients undergoing revision THR are estimated to be allocated to either an exercise intervention targeting hip strengthening (NEMEX-STR) or standard community-based rehabilitation (Usual care). Recruitment was initiated in November 2022 and is expected to be completed by June 2024. The primary outcome is change in functional performance measured by the 30 s chair stand test, from baseline to 4 months after the start of intervention. Secondary outcomes include hip disability and osteoarthritis outcome score; 40 m fast-paced walk test; 9-step timed stair climb test; leg extensor muscle power; global perceived effect; and adverse events. Other outcomes include The International Physical Activity Questionnaires, pain intensity, and European quality of life-5 dimensions. An intention-to-treat approach will be used for analyzing changes in primary and secondary outcome measures. The trial was approved by the Central Denmark Region Committees on Health Research Ethics (Journal No 1-10-72-134-22) and registered on the Central Denmark Regions' internal list of research projects (Journal No 1-16-02-285-22). DISCUSSION: To our knowledge, this study is the first to explore different rehabilitation programs after revision THR through a randomized controlled trial. The results will provide clinically relevant evidence for optimal rehabilitation after revision THR for improving functional performance, physical function, and quality of life, with great importance for patients, relatives, physiotherapists, and decision-makers. CLINICALTRIAL: GOV: NCT05657054.

[Cup Placement in Thumb Carpometacarpal Joint Prostheses: The Role of the Guidewire]. / Pfannenplatzierung bei Daumensattelgelenksprothesen: Die Rolle des Führungsdrahts.

BACKGROUND: The increasing use of thumb carpometacarpal joint prostheses for advanced CMC 1 (carpometacarpal) joint arthritis reflects the success of the latest prosthesis generations, which has been achieved through their improved functional outcomes and lower complication rates. Precise alignment of the prosthesis cup parallel to the proximal joint surface of the trapezium is essential for stability and the prevention of dislocation. This is a challenging surgical step, particularly for surgeons new to this technique. Despite adequate positioning of the guidewire, misplacements of the cup may occur, necessitating intraoperative revision. MATERIAL AND METHODS: This study examined the deviations in cup and guidewire positioning in thumb carpometacarpal joint prosthesis implantations by inexperienced and experienced surgeons through radiological analysis of 65 prostheses. RESULTS: Both inexperienced and experienced surgeons achieved precise guidewire positioning with mean deviations of<2.2°. Inexperienced surgeons showed significantly larger cup deviations in the dorsopalmar and lateral view (7.6±6.1° and 7.3±5.9°) compared with experienced surgeons (3.6±2.7° and 3.6±2.5°; p=0.012, p=0.017). The deviation of the cup position exhibited by inexperienced surgeons tends to be in the direction opposite to the initial guidewire position (p<0.0038). CONCLUSION: The results highlight the current challenges in cup positioning depending on a surgeon's level of experience, questioning the reliability of the current guidewire placement.

[GMK rotating hinge prosthesis. A valid option for complex revision knee prosthetic surgery]. / Prótesis bisagra rotatoria GMK. Una opción válida para la cirugía de revisión protésica compleja de rodilla.

INTRODUCTION: revision joint replacement surgery presents a surgical challenge. The use of rotating hinge prostheses is an option in patients with femorotibial bone defects, ligament insufficiency, or significant deformities. The aim of this study was to evaluate the clinical, functional, and radiological outcomes of a series of patients who underwent surgery using the GMK Hinge (Medacta®) rotational hinge model. MATERIAL AND METHODS: a descriptive, retrospective, and analytical study was conducted on a series of 36 patients, with a mean age of 72.5 years (47-85), operated on by the same surgical team between January 2015 and January 2022. The etiology of revision was chronic infection in 38.9% of cases, instability in 33.3%, aseptic loosening in 19.4%, and stiffness in 8.4%. The Knee Society Score (KSS) and the Forgotten Joint Score (FJS) were used to assess functional outcomes. The degree of femorotibial bone defect was evaluated using the Anderson Orthopaedic Research Institute (AORI) classification. Postoperative complications are also recorded. RESULTS: a total of 36 patients, 17 males and 19 females, were included, with a mean follow-up of 30 months (12-66). Twelve patients had type 1 defects, ten had 2A defects, ten had 2B defects, and two had type 3 defects on the femoral side, with the use of wedges required for asymmetrical defects (21 patients). The predominant tibial defect was type 1 without the need for wedges. The majority achieved a satisfactory outcome on the KSS scale (72.2 ± 9.4), with significant differences compared to the previous KSS (54.3 ± 8.9). A score of 31 (12-67) was also obtained on the FJS scale. Postoperative complications were present in 16.7% of patients. CONCLUSIONS: complex prosthetic revision surgery using a rotating hinge prosthesis represents a suitable therapeutic option, yielding appropriate clinical and functional outcomes, albeit not without complications.

INTRODUCCIÓN: la cirugía de revisión protésica constituye un reto quirúrgico. La utilización de prótesis tipo bisagra rotatoria es una opción en pacientes con defectos óseos femorotibiales, insuficiencia ligamentosa o importantes deformidades. El objetivo del presente estudio es evaluar los resultados clínicos, funcionales y radiológicos de una serie de pacientes intervenidos mediante un modelo de bisagra rotacional GMK Hinge (Medacta®). MATERIAL Y MÉTODOS: estudio descriptivo retrospectivo y analítico que incluyó una serie de 36 pacientes, con edad media de 72.5 años (47-85) intervenidos entre Enero de 2015 y Enero de 2022 por el mismo equipo quirúrgico. La etiología de revisión fue infección crónica en 38.9%, inestabilidad en 33.3%, aflojamiento aséptico en 19.4% y rigidez en 8.4%. Para la evaluación de resultados funcionales se utiliza la escala Knee Society Score (KSS), así como la escala Forgotten Joint Score (FJS). El grado de defecto óseo femorotibial se evaluó mediante la clasificación de Anderson Orthopaedic Research Institute (AORI). También se registraron las complicaciones postquirúrgicas. RESULTADOS: se analizó un total de 36 pacientes, 17 varones y 19 mujeres, con seguimiento medio de 30 meses (12-66). Se encontraron doce pacientes con defectos tipo 1, diez con defectos 2A, diez con defectos 2B y dos con defecto tipo 3 en la vertiente femoral, siendo necesario la utilización de cuñas en defectos asimétricos (21 pacientes). El defecto tibial mayoritario fue el tipo 1 sin necesidad de cuñas. La mayoría obtuvo un resultado satisfactorio en la escala KSS (72.2 ± 9.4), con diferencias significativas respecto al KSS previo (54.3 ± 8.9). Se obtuvo también una puntuación de 31 (12-67) en la escala FJS. Presentaron complicaciones postoperatorias 16.7% de los pacientes. CONCLUSIONES: la cirugía de revisión protésica compleja mediante prótesis tipo bisagra rotacional constituye una correcta opción terapéutica, presentando resultados clínicos y funcionales adecuados, no exentos de complicaciones.

Reversal Surgery for Split Stoma with Peristomal Incision is Associated with Improved Postoperative Outcome in Patients with Crohn's Disease.

BACKGROUND: Temporary stoma formation is common in Crohn's disease (CD), while stoma reversal is associated with postoperative morbidity. This study aimed to evaluate the postoperative outcomes of split stoma reversal, SSR (i.e., exteriorization of proximal and distal ends of the stoma through a small common opening) and end stoma closure, ESC (i.e., the proximal stump externalized, and distal end localized abdominally. METHODS: Patients with CD who underwent stoma reversal surgeries between January 2017 and December 2021 were included. Demographic, clinical, and postoperative data were collected and analyzed to evaluate outcomes of reversal surgery. RESULTS: A total of 255 patients who underwent stoma reversal surgeries met the inclusion criteria. SSR was superior to ESC in terms of operative time (80.0 vs. 120.0, p = 0.0004), intraoperative blood loss volume (20.0 vs. 100.0, p = 0.0002), incision length (3.0 vs. 15.0, p < 0.0001), surgical wound classification (0 vs. 8.3%, p = 0.04), postoperative hospital stay (7.0 vs. 9.0, p = 0.0007), hospital expense (45.6 vs. 54.2, p = 0.0003), and postoperative complications (23.8% vs. 44.3%, p = 0.0040). Although patients in the ESC group experienced more surgical recurrence than those in the SSR group (8.3% vs. 3.2%) during the follow-up, the Kaplan-Meier curve analysis revealed no statistical difference (p = 0.29). CONCLUSIONS: The split stoma can be recommended when stoma construction is indicated in patients with Crohn's disease.

Pathological characteristics of reoperated regrowing clinically nonfunctioning pituitary tumor cases in comparison with initial surgical cases.

Objective: Postoperative nonfunctioning pituitary tumor (NFPT) regrowth is a significant concern, but its predictive factors are not well established. This study aimed to elucidate the pathological characteristics of NFPTs indicated for reoperation for tumor regrowth. Methods: Pathological, radiological, and clinical data were collected from patients who underwent repeat operation for NFPT at Moriyama Memorial Hospital (MMH) between April 2018 and September 2023. For comparison, we also gathered data from patients who underwent initial surgery for NFPT during the same period at MMH. Results: Overall, 61 and 244 NFPT patients who respectively underwent reoperation and initial operation were evaluated. The mean period between the previous operation and reoperation was 113 months. Immunonegativity for any adenohypophyseal hormone was significantly more frequent in the reoperation group than in the initial operation group. In addition, the rate of hormone-negative but transcription factor-positive (H-/TF+) tumors among silent gonadotroph tumors was significantly higher in the reoperation group than in the initial operation group. Furthermore, seven silent corticotroph tumors (SCTs) in the reoperation group were ACTH-negative but TPIT-positive. Because most of the previous surgeries were performed in other hospitals a long time ago, we could procure the previous pathological results with immunohistochemistry (IHC) only from 21 patients. IHC for TF had not been performed in all the previous specimens. IHC for adenohypophyseal hormone was almost the same as the current results, and many H-/TF+ tumors were previously diagnosed as NCT. In addition, the reoperated patients were classified into 3 groups on the basis of the condition of the previous operation: gross total resection (GTR), 12 patients; subtotal resection (STR), 17 patients; and partial resection (PR), 32 patients. The mean Ki-67 LI in the GTR, STR, and PR subgroups were 1.82, 1.37, and 0.84, respectively, with the value being significantly higher in the GTR subgroup than in the PR subgroup (P < 0.05). Conclusions: The ratio of H-/TF+ tumors is significantly higher in symptomatically regrown tumors than in the initial cases, which used to be diagnosed as NCT. PR cases tend to grow symptomatically in a shorter period, even with lower Ki-67 LI than GTR cases.

Management of Cochlear Implant Electrode Arrays Misplaced in the Internal Auditory Canal: A Systematic Review.

OBJECTIVE: Misplacement of electrode arrays in the internal auditory canal (IAC) presents a unique clinical challenge. Speech recognition is limited for cochlear implant (CI) users with misplaced arrays, and there are risks with revision surgery including facial and/or cochlear nerve injury. DATABASES REVIEWED: PubMed, Embase, and Scopus. METHODS: A literature search was performed from inception to September 2023. The search terms were designed to capture articles on misplaced arrays and the management options. Articles written in English that described cases of array misplacement into the IAC for children and adults were included. The level of evidence was assessed using Oxford Center for Evidence Based Medicine guidelines. Descriptive statistical analyses were performed. RESULTS: Twenty-eight cases of arrays misplaced in the IAC were identified. Thirteen (46%) were patients with incomplete partition type 3 (IP3), and 7 (25%) were patients with common cavity (CC) malformations. Most misplaced arrays were identified postoperatively (19 cases; 68%). Of these cases, 11 (58%) were managed with array removal. No facial nerve injuries were reported with revision surgery. Eight cases (42%) were left in place. Several underwent mapping procedures in an attempt improve the sound quality with the CI. CONCLUSION: Electrode array misplacement in the IAC is a rare complication that reportedly occurs predominately in cases with IP3 and CC malformations. Removal of misplaced arrays from the IAC reportedly has not been associated with facial nerve injuries. Cases identified with IAC misplacement postoperatively can potentially be managed with modified mapping techniques before proceeding with revision surgery.

Ventriculoperitoneal shunt infection and malfunction in adult patients: incidence, risk factors, and long-term follow-up of single institution experience.

Ventriculoperitoneal shunt surgery was developed to manage excessive cerebrospinal fluid (CSF) in the brain's ventricles and is considered a mainstream treatment. Despite the development of the shunt device system, various complications still occur. In this study, we reported 307 cases and a long-term follow-up of at least five years of adult patients who underwent VP shunt surgery and analyzed various factors that may affect revision surgery. A retrospective study was conducted at Asan Medical Center, Korea, a tertiary medical center. We reviewed 307 cases from January 2012 to December 2018. The patients' neurological status, predisposing medical conditions, laboratory findings, and other operation-related factors were reviewed using electrical medical records. The normal function group comprised 272 cases (88.6%), and the overall incidence of revision group comprised 35 cases (11.4%). Of the 35 revision surgery cases, 30 (85.71%) were due to shunt malfunctions, such as obstruction, overdrainage, and valve-related errors while 5 (14.29%) were due to shunt infection. Patient demographics, mental status, and operation time did not influence revision as risk factors. Serum laboratory findings showed no statistical difference between the two groups. The white blood cell (WBC) count in the CSF profile differed significantly between the two groups. The Hakim Programmable valve (Codman, USA) is mainly used in our center. In addition, various shunt systems were used, including Strata Regulatory valve (Medtronic, USA), proGAV (Aesculap, USA), and Accu-Flo (Codman, USA). This study analyzed the factors affecting long-term outcomes. Based on these findings, efforts are needed to achieve more favorable outcomes in the future.

Risk Factors for Re-treatment After Keratorefractive Lenticule Extraction (KLEx) for Myopia and Myopic Astigmatism.

PURPOSE: To identify potential risk factors that increase the likelihood of re-treatment following keratorefractive lenticule extraction (KLEx) for myopia and myopic astigmatism. METHODS: This was a retrospective study of patients with myopia and myopic astigmatism who underwent KLEx using the VisuMax 500 laser (Carl Zeiss Meditec) between April 2015 and December 2020. Patients were assigned to one of two groups: the control group and the re-treatment group (if they had additional refractive surgery within 2 years of the primary treatment). The effect of different preoperative, intraoperative, and postoperative parameters on the re-treatment rate was analyzed. RESULTS: Overall 1,822 eyes of 938 patients were analyzed. In total, 2.96% of eyes (n = 54) underwent re-treatment. The re-treated patients were more likely to be women and have high myopia, high astigmatism, steep corneas, higher ocular residual astigmatism, and residual myopic and/or astigmatic refractive error. In contrast, no significant correlation was found between re-treatment rate and age, chord µ, type of astigmatism, and corneal thickness. CONCLUSIONS: Factors associated with higher rates of retreatment after KLEx included female gender, manifest refractive high myopia (> -5.00 diopters [D]), astigmatism (> 2.00 D), spherical equivalent (> 6.00 D), ocular residual astigmatism, steeper corneas, and postoperative residual myopic and astigmatic refractive errors. This study may help to preoperatively detect patients at risk for re-treatment, improve preoperative patient counseling, and optimize patient selection to reduce future re-treatment rates. [J Refract Surg. 2024;40(6):e362-e370.].

The Fisher Subunit Anatomical Approach for Cleft Lip Revisions: An Evolution and Case Series.

ABSTRACT: Many techniques exist to reapproximate a cleft lip but can leave unsatisfactory results with nonanatomic scars and a short upper lip, creating a need for revision. Many revisions focus on adjacent tissue transfers and realignment of landmarks, but in the senior authors' experience, recreating the defect and utilizing the Fisher repair for revision have led to aesthetically pleasing results and less noticeable scars. A database was collected that included all cleft lip revisions performed at a large, comprehensive children's hospital from October 2018 to July 2021. Inclusion criteria included any cleft patient with a cleft lip revision performed by two craniofacial surgeons. Data collected included sex, characteristics of the cleft lip, age at initial and index repair, type of initial repair, previous revisions, type of revision with any additional tissue rearrangement, and any nose repair. Sixty-five patients were included in the study for analysis. The type of initial repair was known in sixty-four cases (98%), and fifty-four were Millard repairs (83%). Twenty-two patients (33%) had a previous revision prior to their index revision. Sixty patients (92%) underwent the Fisher repair technique for their index revision and forty-six patients (70%) underwent nasal revision. In follow-up, all patients demonstrated an improvement in lip aesthetics. This study demonstrates a large subset of patients that have undergone cleft lip revision using the Fisher technique. In the senior surgeons' experience, the Fisher repair technique in the setting of cleft lip revision is an ideal way to address the shortcomings of historical repair techniques.

Evaluating the risk of return to the operating room across all elective orthopaedic procedures.

BACKGROUND: Although elective procedures have life-changing potential, all surgeries come with an inherent risk of reoperation. There is a gap in knowledge investigating the risk of reoperation across orthopaedics. We aimed to identify the elective orthopaedic procedures with the highest rate of unplanned reoperation and the reasons for these procedures having such high reoperation rates. METHODS: Patients in the NSQIP database were identified using CPT and ICD-10 codes. We isolated 612,815 orthopaedics procedures from 2018 to 2020 and identified the 10 CPT codes with the greatest rate of unplanned return to the operating room. For each index procedure, we identified the ICD-10 codes for the reoperation procedure and categorized them into infection, mechanical failure, fracture, wound disruption, hematoma or seroma, nerve pathology, other, and unspecified. RESULTS: Below knee amputation (BKA) (CPT 27880) had the highest reoperation rate of 6.92% (37 of 535 patients). Posterior-approach thoracic (5.86%) or cervical (4.14%) arthrodesis and cervical laminectomy (3.85%), revision total hip arthroplasty (5.23%), conversion to total hip arthroplasty (4.33%), and revision shoulder arthroplasty (4.22%) were among the remaining highest reoperation rates. The overall leading causes of reoperation were infection (30.1%), mechanical failure (21.1%), and hematoma or seroma (9.4%) for the 10 procedures with the highest reoperation rates. CONCLUSIONS: This study successfully identified the elective orthopaedic procedures with the highest 30-day return to OR rates. These include BKA, posterior thoracic and cervical spinal arthrodesis, revision hip arthroplasty, revision total shoulder arthroplasty, and cervical laminectomy. With this data, we can identify areas across orthopaedics in which revising protocols may improve patient outcomes and limit the burden of reoperations on patients and the healthcare system. Future studies should focus on the long-term physical and financial impact that these reoperations may have on patients and hospital systems. LEVEL OF CLINICAL EVIDENCE: IV.