Application of optimized three-dimensional digital surgical guide plates for complex midfacial fractures

IntroductionThe treatment of midfacial fractures is always difficult. The purpose of this study was to verify whether optimized three-dimensional (3D) digital surgical guide plates combined with preformed titanium plates improved the treatment effect in complex midfacial fractures.Patients and methodsTwenty-six patients with complex midfacial fractures were recruited and randomized into three groups: ten for Group A, eight for Group B, and eight for Group C. Group A was treated with a combination of preformed titanium plates and optimized 3D digital surgical guide plates. Group B was treated with preformed titanium plates only. Group C was treated conventionally. Clinical effects, patient-reported outcome measures (PROMs), midfacial contour, facial symmetry, surgical accuracy, △orbital volume (the absolute value of the bilateral orbital volume difference), and maximum deviation were evaluated in each of the three groups.ResultsGroup A had the best postoperative clinical effects and patient-reported outcomes. Significant improvements in midfacial contour (L1[0.72±0.29 mm, P = 0.001], L2[1.04±0.46 mm, P < 0.001]), facial symmetry (S1[0.71±0.30 mm, P < 0.001], S2[0.96±0.58 mm, P < 0.001], S3[0.86±0.40 mm, P < 0.001], S5[0.81±0.16 mm, P = 0.003], S8[0.95±0.30 mm, P < 0.001], S9[1.03±0.38 mm, P < 0.001], S11[0.64±0.46 mm, P < 0.001]) and surgical accuracy (M1[R, 0.82±0.31 mm, P < 0.001], M2[R, 0.87±0.44 mm, P < 0.001], M3[L, 0.88±0.22 mm, P = 0.004], M3[R, 1.06±0.31 mm, P = 0.003], M4[L, 0.96±0.45 mm, P = 0.008], M4[R, 1.11±0.57 mm, P = 0.003], M5[R, 0.76±0.26 mm, P < 0.001], M6[L, 1.00±0.46 mm, P = 0.003], M6[R, 1.00±0.58 mm, P = 0.001], M7[0.87±0.53 mm, P = 0.001], M8[R, 0.91±0.53 mm, P < 0.001], M9[R, 0.81±0.32 mm, P = 0.010], M10[R, 1.19±0.42 mm, P = 0.009], M11[L, 0.85±0.51 mm, P = 0.021], M11[R, 0.96±0.49 mm, P = 0.003]) were found in Group A compared with the other two groups. The results of △orbital volume and maximum deviation analysis showed an ideal surgical treatment effect in Group A.ConclusionOptimized 3D digital guide plates can accurately locate preformed titanium plates and effectively improve the treatment effect in complex midfacial fractures.     

Complications of percutaneous image-guided screw fixation: An analysis of 94 consecutive patients

PurposeThe purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures.Materials and methodsFrom July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (< 24 hours) and delayed (> 24 hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.ResultsA total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7 ± 12.7 [SD] years; age range: 32–88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and > 24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%).ConclusionThe rate of per-procedural and early (within 24 hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (> 24 hours).     

What makes fixation of femoral neck fractures fail? A systematic review and meta-analysis of risk factors

IntroductionThis systematic review aims to provide an overview of predictors for failure of treatment of displaced femoral neck fracture (dFNF) with internal fixation and quantify their risk of fixation failure in a meta-analysis.Patients and methodsPubMed, Embase, Web of Science, Cochrane Library, and EMCare were searched for original studies published from January 2000, including adult patients with an internally fixated dFNF, that reported data on predictors for fixation failure defined as revision surgery due to non-union, avascular femoral head necrosis or cut-out of implant. RevMan version 5 software was used to pool univariable Odds Ratio's (OR) for predictors of fixation failure by means of a random effects model.ResultsThis review included 16 articles (15 articles cohort studies and one randomised trial). Twenty-four predictors for fixation failure were identified and analysed, 16 of which were evaluated in just one study. Data of 7 predictors were pooled in a meta-analysis. Female sex (OR 1.78, 95% confidence interval [CI] 1.26–2.52), smoking (OR 3.64, 95% CI 1.68–7.91), age >50 years (OR 3.64, 95% CI 1.68–7.91), inadequate fracture reduction (OR 2.28, 95% CI 1.62–3.22), fixation with cannulated screws (CS) or pins compared to fixed angle devices (OR 2.16, 95% CI 1.03–4.54) were identified as significant predictors for fixation failure.ConclusionThis study can help surgeons to choose the preferred treatment for patients with a dFNF and substantiate future algorithms and guidelines for treatment of FNF.     

Analysis of Plasma Products for Cellular Contaminants: Comparing Standard Preparation Methods

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First intention vertebroplasty in fractures within an ankylosed thoracolumbar spinal segment

PurposeTo evaluate the outcome of percutaneous vertebral cementoplasty (PVC) as the first-line treatment for traumatic thoracolumbar fractures within an ankylosed spinal segment.Materials and methodsThirty-one patients (15 men, 16 women; mean age: 79.2 ± 11 [SD] years; age range: 66–95 years) with thoracolumbar fractures within an ankylosed spine segment without neurological impairment treated with PVC were retrospectively evaluated. All patients were controlled at six weeks and one year after PVC. Ankylosing conditions, fractures sites and types, radiological consolidation, spinal complications were assessed. Anterior/posterior vertebral height ratios were measured before and after PVC. Postoperative pain relief and treatment success (radiological fracture consolidation) rates were considered.ResultsThe 31 patients had a total of 39 fractures (19 stable [49%], 20 unstable [51%]) treated with PVC. Primary success rate of PVC (initial fracture consolidation without complication) was 61% (19/31). Seven patients (7/31; 23%) exhibited new fractures, and the secondary success rate of PVC (global fracture consolidation one year after repeat PVC) was 87% (34/39). Global consolidation rates of unstable fractures were 85% (17/20) of treated levels. Pain score was null in 84% patients (26/31) one year after PVC. There were no significant differences between pre-PVC (0.62 ± 0.18 [SD]; range: 0.22–0.88) and post-PVC (0.60 ± 0.18 [SD]; range: 0.35–0.88) vertebral height ratios (P = 0.94).ConclusionPVC conveys a high overall success rate and effectively controls pain in patients with vertebral fractures within ankylosed spine segments.     

Biportal endoscopic versus microscopic discectomy for lumbar herniated disc: a randomized controlled trial

BACKGROUND CONTEXTBiportal endoscopic discectomy has been frequently performed in recent years and has shown acceptable clinical outcomes. However, evidence regarding its efficacy and safety remains limited.PURPOSEThis study aimed to compare the clinical efficacy and safety of biportal endoscopic with that of open microscopic discectomy in patients with single-level herniated lumbar discs.STUDY DESIGNProspective, randomized, multicenter, open-label, assessor-blind, non-inferiority controlled trial.PATIENT SAMPLESixty-four participants suffering from low back and leg pain with a single-level herniated lumbar disc and required discectomy.OUTCOME MEASURESOutcomes were assessed with the use of patient-reported outcome measures (PROMs), visual analog scale (VAS) pain score for surgical site, low back and lower extremity, Oswestry Disability Index (ODI) for lumbar disabilities, European Quality of Life-5 Dimensions value for quality of life, and painDETECT for neuropathic pain. Surgery-related outcomes such as hospital stay, operation time, and opioid usage were collected. Adverse events occurring during the follow-up period were also noted.METHODSAll participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic (biportal group) or microscopic discectomy (microscopy group). The primary outcome was the difference in ODI scores at 12-months post surgically based on a modified intention-to-treat strategy, with a non-inferiority margin of 12.8 points. The secondary outcomes included PROMs, surgery-related outcomes, and adverse events.RESULTSThe ODI score at the 12-month follow-up was 11.97 in the microscopy group and 13.89 in the biportal group (mean difference, 1.92; 95% confidence interval [CI], -3.50 to 7.34), showing the non-inferiority of biportal group. The results for the secondary outcomes were similar to those for the primary outcome. Creatinine phosphokinase ratios were low in the biportal group. Early surgical site pain was slightly lower in the biportal group (mean difference of VAS pain score at 48-hr, -0.98; 95% CI, -1.77 to -0.19). Adverse events including reoperation showed no significant difference between the groups.CONCLUSIONBiportal endoscopic discectomy was non-inferior to microscopic discectomy over a 12 month period. Biportal endoscopic discectomy is suggested to be a relatively safe and effective surgical technique with the slight advantage of reduced muscle damage. However, the clinical implications of surgical site pain should be carefully considered.     

Biological versus mechanical prostheses for aortic valve replacement

ObjectivesLong-term real-world outcomes are critical for informing decisions about biological (Bio) or mechanical (Mech) prostheses for aortic valve replacement, particularly in patients aged between 50 and 65 years. The objective was to compare long-term survival and major adverse cardiac and cardiovascular events (ie, stroke, reoperation, and major bleeding) within this population.MethodsThis was a multicenter observational study including all patients aged between 50 and 65 years who underwent an aortic valve replacement because of severe isolated aortic stenosis between the years 2000 and 2018. A total of 5215 patients from 27 Spanish hospitals were registered with a follow-up of 15 years. Multivariable analyses, including a 2:1 propensity score matching (1822 Mech and 911 Bio) and competing risks analyses were applied.ResultsBio prostheses were implanted in 19% of patients (n = 992). No significant differences were observed between matched groups in long-term survival (hazard ratio [HR], 1.14; 95% confidence interval [CI], 0.88-1.47; P = .33). Stroke rates were higher for Mech prostheses, but not significant (HR, 0.72; 95% CI, 0.50-1.03; P = .07). Finally, higher rates of major bleeding were found in the Mech group (HR, 0.65; 95% CI, 0.49-0.87; P = .004), whereas reoperation was more frequent among the Bio group (HR, 3.04; 95% CI, 1.80-5.14; P < .001). Bio prostheses increased from 13% in the period from 2000 to 2008 to 24% in 2009 to 2018.ConclusionsLong-term survival was comparable among groups in patients between 50 and 65 years of age. Mech prostheses were associated with a higher risk of major bleeding, whereas Bio prostheses entailed higher reoperation rates. Bio prostheses seem a reasonable choice for patients between 50 and 65 years in Spain.     

Comparative study on the manually-controlled variable-rate versus fixed-rate infusion of norepinephrine for preventing hypotension during spinal anesthesia for cesarean delivery

Study objectivePrevious studies have shown that prophylactic norepinephrine infusion is superior to intermittent bolus administration in preventing post-spinal hypotension. Nevertheless, it is still controversial whether manually-controlled variable-rate infusion is more effective than fixed-rate infusion. The purpose of the present study was to compare the efficacy of variable-rate infusion and fixed-rate infusion of norepinephrine for prophylaxis against maternal hypotension and maintaining hemodynamic stability during spinal anesthesia for cesarean delivery to determine more effective mode for clinical practice.DesignA prospective randomized, controlled study.SettingOperating room, Women's Hospital, Zhejiang University School of Medicine.PatientsA total of 161 parturients scheduled for elective cesarean delivery with spinal anesthesia were randomized into Group F (fixed-rate infusion) and Group V (variable-rate infusion).InterventionsParturients received prophylactic norepinephrine infusion concurrent with the intrathecal injection at rate started at 0.05 μg/kg/min. In Group F, norepinephrine was administered continuously at a fixed (on-off) rate, and a bolus of norepinephrine 5 μg or 10 μg was given when systolic blood pressure (SBP) decreased by 20% or more of baseline. In Group V, manually adjusted norepinephrine infusion within the range 0–0.14 μg/kg/min, according to SBP at 1-min intervals until delivery, aim to maintain values close to the baseline.MeasurementsDuring the study period, the incidence of maternal hypotension, hemodynamic performance, the number of physician interventions, reactive hypertension, bradycardia, nausea, vomiting, norepinephrine cumulative dose (before delivery), and neonatal outcomes were recorded.Main resultsThe incidence of maternal hypotension was significantly lower in Group V than that in Group F (9% versus 30%) (P < 0.001). No significant difference was found in the serial changes in SBP and heart rate (HR) for the first 15 min. Group V showed higher frequency of physician interventions compared with the Group F (P < 0.001). The incidence of hypertension, severe hypotension, nausea, vomiting, bradycardia, norepinephrine cumulative dose, and neonatal outcome were comparable between the two groups.ConclusionWhen norepinephrine was infused at an initial dose of 0.05 μg/kg/min for preventing hypotension during spinal anesthesia for cesarean delivery, due to technical limitations of inadequate dose design in this study, neither a variable-rate infusion (need more physician intervention) nor a fixed-rate infusion regimen (experience more transient hypotension) was optimal. However, in terms of clinical importance, how to prevent the parturients from experiencing more incidence of hypotension might be a greater concern for anesthesiologists.     

Clinical and radiological outcome after minimally invasive surgical approach for type II unstable odontoid fractures

IntroductionAnterior odontoid screw fixation is a valid surgical option for unstable odontoid fractures, as type II Anderson D’Alonzo fractures. Grauer further divided type II fractures in subtypes according to the fracture line, providing recommendations for implementation of screw fixation techniques.ObjectivePrimary endpoint of our study is to evaluate the postoperative results of minimally invasive odontoid screw insertion in terms of outcome, fusion rate and stability of cranio-cervical junction. Secondary endpoint was to investigate the influence of age or fractures’ features on outcome and fusion rate.Materials and methodsWe report the clinical and radiological features of 32 patients harbouring unstable type II fractures operated by a minimally invasive odontoid screw insertion technique. All patients underwent a high resolution multiplanar CT in order to assess fracture features according to Grauer's classification; the integrity of ligaments was investigated by MRI. In addition, a preoperative neurological performance (modified Rankin Scale, mRS) was evaluated for patients either directly or interviewing their families. Follow-up at one, three and six months and 1 year have been performed (averaging 13.5 months) by cervical CT (fusion rate and stability) and mRS update. In order to investigate the influence of age on postoperative neurological performance, two groups (≤ 50 yrs, 9 pts/ > 50 yrs, 23 pts) were separately considered and analysed. Overall, we observed no surgery related complications. We also analysed the fusion rate and its correlation with patient age and Grauer's subtype of fracture.ResultsAt last available clinical follow-up, the preoperative performance was preserved (mRS 0/1: 24, 75%; mRS 2–4: 9, 15%) although with slight reduction of intact patients (mRS 0: 22 vs. 19; 71.8 vs. 59.3%). Younger patients (≤ 50 yrs) fared significantly better than older ones, achieving a good clinical outcome (mRS 0/1) in 100% vs. 69.5% (9/9 vs. 16/23 pts). Statistical analysis showed a fair correlation between age and outcome. Other factors such as sex and Grauer's type did not influence significantly the clinical outcome. Nine patients did not complete a full radiological follow-up and were therefore excluded from analysis of radiological outcome. Among the remaining 23 patients, only 25% of those who were followed three months or less showed fusion; conversely, all patients who have been examined from 6 to 48 months fused. Among the non-union patients, two underwent a second surgery by posterior approach.ConclusionsIn our recent experience, the minimally invasive AOSF proved safe and effective in treating odontoid peg fractures. Selection based on Grauer's type is mandatory to achieve best results. While in the elderly, an anterior approach is well accepted as the first choice treatment, we recommend that this option should be offered as a suitable alternative to Halo or orthosis also in younger patients since it provides prompt, excellent clinical outcome and high fusion rate especially in this age group.     

Anatomic evaluation of Pancoast tumors using three-dimensional models for surgical strategy development

ObjectivePancoast tumor resection planning requires precise interpretation of 2-dimensional images. We hypothesized that patient-specific 3-dimensional reconstructions, providing intuitive views of anatomy, would enable superior anatomic assessment.MethodsCross-sectional images from 9 patients with representative Pancoast tumors, selected from an institutional database, were randomly assigned to presentation as 2-dimensional images, 3-dimensional virtual reconstruction, or 3-dimensional physical reconstruction. Thoracic surgeons (n = 15) completed questionnaires on the tumor extent and a zone-based algorithmic surgical approach for each patient. Responses were compared with surgical pathology, documented surgical approach, and the optimal “zone-specific” approach. A 5-point Likert scale assessed participants' opinions regarding data presentation and potential benefits of patient-specific 3-dimensional models.ResultsIdentification of tumor invasion of segmented neurovascular structures was more accurate with 3-dimensional physical reconstruction (2-dimensional 65.56%, 3-dimensional virtual reconstruction 58.52%, 3-dimensional physical reconstruction 87.50%, P < .001); there was no difference for unsegmented structures. Classification of assessed zonal invasion was better with 3-dimensional physical reconstruction (2-dimensional 67.41%, 3-dimensional virtual reconstruction 77.04%, 3-dimensional physical reconstruction 86.67%; P = .001). However, selected surgical approaches were often discordant from documented (2-dimensional 23.81%, 3-dimensional virtual reconstruction 42.86%, 3-dimensional physical reconstruction 45.24%, P = .084) and “zone-specific” approaches (2-dimensional 33.33%, 3-dimensional virtual reconstruction 42.86%, 3-dimensional physical reconstruction 45.24%, P = .501). All surgeons agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction benefit surgical planning. Most surgeons (14/15) agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction would facilitate patient and interdisciplinary communication. Finally, most surgeons (14/15) agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction's benefits outweighed potential delays in care for model construction.ConclusionsAlthough a consistent effect on surgical strategy was not identified, patient-specific 3-dimensional Pancoast tumor models provided accurate and user-friendly overviews of critical thoracic structures with perceived benefits for surgeons' clinical practices.     

Diagnostic performance of ultra-low dose versus standard dose CT for non-traumatic abdominal emergencies

PurposeThe purpose of this study was to compare the diagnostic performance of ultra-low dose (ULD) to that of standard (STD) computed tomography (CT) for the diagnosis of non-traumatic abdominal emergencies using clinical follow-up as reference standard.Materials and methodsAll consecutive patients requiring emergency abdomen-pelvic CT examination from March 2017 to September 2017 were prospectively included. ULD and STD CTs were acquired after intravenous administration iodinated contrast medium (portal phase). CT acquisitions were performed at 125 mAs for STD and 55 mAs for ULD. Diagnostic performance was retrospectively evaluated on ULD and STD CTs using clinical follow-up as a reference diagnosis.ResultsA total of 308 CT examinations from 308 patients (145 men; mean age 59.1 ± 20.7 (SD) years; age range: 18–96 years) were included; among which 241/308 (78.2%) showed abnormal findings. The effective dose was significantly lower with the ULD protocol (1.55 ± 1.03 [SD] mSv) than with the STD (3.67 ± 2.56 [SD] mSv) (P < 0.001). Sensitivity was significantly lower for the ULD protocol (85.5% [95%CI: 80.4–89.4]) than for the STD (93.4% [95%CI: 89.4–95.9], P < 0.001) whereas specificities were similar (94.0% [95%CI: 85.1–98.0] vs. 95.5% [95%CI: 87.0–98.9], respectively). ULD sensitivity was equivalent to STD for bowel obstruction and colitis/diverticulitis (96.4% [95%CI: 87.0–99.6] and 86.5% [95%CI: 74.3–93.5] for ULD vs. 96.4% [95%CI: 87.0–99.6] and 88.5% [95%CI: 76.5–94.9] for STD, respectively) but lower for appendicitis, pyelonephritis, abscesses and renal colic (75.0% [95%CI: 57.6–86.9]; 77.3% [95%CI: 56.0–90.1]; 90.5% [95%CI: 69.6–98.4] and 85% [95%CI: 62.9–95.4] for ULD vs. 93.8% [95%CI: 78.6–99.2]; 95.5% [95%CI: 76.2–100.0]; 100.0% [95%CI: 81.4–100.0] and 100.0% [95%CI: 80.6–100.0] for STD, respectively). Sensitivities were significantly different between the two protocols only for appendicitis (P = 0.041).ConclusionIn an emergency context, for patients with non-traumatic abdominal emergencies, ULD-CT showed inferior diagnostic performance compared to STD-CT for most abdominal conditions except for bowel obstruction and colitis/diverticulitis detection.     

Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky

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Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients

ObjectivesHistorically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients.MethodsA prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2–4 weeks, and 3, 6 and 12 months after fracture.Results102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2–4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0–8) vs. 5 (0–10), p = 0.19) and ADL scores (85 (25–100) vs. 78.6 (5–100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%.ConclusionsThe vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.     

Hypofractionated versus conventional fractionated radiotherapy for breast cancer in patients with reconstructed breast: Toxicity analysis

PurposeThis study investigated whether hypofractionated adjuvant radiotherapy (RT) increased breast-related complication(s) compared to conventional fractionated RT in reconstructed breast cancer patients.MethodsWe conducted a retrospective review including 349 breast cancer patients who underwent immediate breast reconstruction following mastectomy or breast-conserving surgery (BCS) between 2009 and 2018 at two institutions. All patients were treated with adjuvant RT via either a conventional fractionated or hypofractionated regimen. We defined a major breast complication as a breast-related toxic event requiring re-operation or re-hospitalization during the follow-up period after the end of RT.ResultsThe median follow-up was 32.3 months (4.8–118.5 months); 126 patients had conventional fractionated RT, and 223 patients received hypofractionated RT. In patients with mastectomy, there was no significant difference in the occurrence of any or major breast-related complications between the two fractionation regimens. In patients undergoing BCS, incidence of any breast complication showed no difference between two RT groups and no major breast complication was reported as well. Hypofractionated RT did not increase major wound problem (infection and dehiscence) compared to conventional RT. Incidence of major contracture was significantly lower in hypofractionated RT.ConclusionsThere was no significant difference in the occurrence of any or major breast-related complications between the two different fractionation regimens, even in patients with mastectomy. Hypofractionated RT may be used comparable to conventional fractionated RT in terms of breast-related complications in reconstructed breast cancer patients. The prospective randomized trial would be necessary to clarify this issue.     

Radiofrequency ablation versus surgical resection for the treatment of oligometastatic lung disease

PurposeThe purpose of this study was to compare efficacy and tolerance between radiofrequency ablation (RFA) and surgery for the treatment of oligometastatic lung disease.Materials and methodsThis retrospective study reviewed patients treated in two institutions for up to 5 pulmonary metastases with a maximal diameter of 4 cm and without associated pleural involvement or thoracic lymphadenopathy. Patient demographics, tumor characteristics, treatment outcome, and length of hospital stay were compared between the two groups. Efficacy endpoints were overall survival (OS), progression-free survival (PFS) and pulmonary or local tumor progression rates.ResultsAmong 204 patients identified, 78 patients (42 men, 36 women; mean age, 53.3 ± 14.9 [SD]; age range: 15–81 years) were treated surgically, while 126 patients (59 men, 67 women; mean age, 62.2 ± 10.8 [SD]; age range: 33–80 years) were treated by RFA. In the RFA cohort, patients were significantly older (P < 0.0001), with more extra-thoracic localisation (P = 0.015) and bilateral tumour burden (P = 0.0014). In comparison between surgery and RFA cohorts, respectively, the 1- and 3-year OS were 94.8 and 67.2% vs. 94 and 72.1% (P = 0.46), the 1- and 3-year PFS were 49.4% and 26.1% vs. 38.9% and 14.8% (P = 0.12), the pulmonary progression rates were 39.1% and 56% vs. 41.2% and 65.3% (P > 0.99), and the local tumour progression rates were 5.4% and 10.6% vs. 4.8% and 18.6% (P = 0.07). Tumour size > 2 cm was associated with a significantly higher local tumor progression in the RFA group (P = 0.010). Hospitalisation stay was significantly shorter in the RFA group (median of 3 days; IQR = 2 days; range: 2–12 days) than in the surgery group (median of 9 days; IQR = 2 days; range: 6–21 days) (P < 0.01).ConclusionRFA should be considered a minimally-invasive alternative with similar OS and PFS to surgery in the treatment of solitary or multiple lung metastases measuring less than 4 cm in diameter without associated pleural involvement or thoracic lymphadenopathy.     

Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis

ObjectiveMultiple treatment options for acetabular fractures in geriatric patients exist. However, no large-scale studies have reported the outcomes of acute total hip arthroplasty (THA) in this patient population. We systematically evaluated all available evidence to characterize clinical outcomes, complications, and revisions of acute THA for acetabular fractures in geriatric patients.MethodsMeta-analysis of 21 studies of 430 acetabular fractures with mean follow-up of 44 months (range, 17−97 months). Two independent researchers searched and evaluated the databases of Ovid, Embase, and United States National Library of Medicine using a Boolean search string up to December 2019. Population demographics and complications, including presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE), were recorded and analyzed.ResultsWeighted mean Harris Hip Score was 83.3 points, and 20% of the patients had reported complications. The most common complication was HO, with a rate of 19.5%. Brooker grade III and IV HO rates were lower at 6.8%. Hip dislocation occurred at a rate of 6.1%, 4.1% of patients developed VTE, deep infection occurred in 3.8%, and neurological complications occurred in 1.9%. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the time to each revision was described in only a few studies. The revision rate was 4.3%.ConclusionsAcute THA is a viable option for treatment of acetabular fracture and can result in acceptable clinical outcomes and survivorship rates in older patients but with an associated complication rate of approximately 20%. Considering the limited treatment options, THA might be a viable alternative for appropriately selected patients.     

Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis

ObjectiveMultiple treatment options for acetabular fractures in geriatric patients exist. However, no large-scale studies have reported the outcomes of acute total hip arthroplasty (THA) in this patient population. We systematically evaluated all available evidence to characterize clinical outcomes, complications, and revisions of acute THA for acetabular fractures in geriatric patients.MethodsMeta-analysis of 21 studies of 430 acetabular fractures with mean follow-up of 44 months (range, 17−97 months). Two independent researchers searched and evaluated the databases of Ovid, Embase, and United States National Library of Medicine using a Boolean search string up to December 2019. Population demographics and complications, including presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE), were recorded and analyzed.ResultsWeighted mean Harris Hip Score was 83.3 points, and 20% of the patients had reported complications. The most common complication was HO, with a rate of 19.5%. Brooker grade III and IV HO rates were lower at 6.8%. Hip dislocation occurred at a rate of 6.1%, 4.1% of patients developed VTE, deep infection occurred in 3.8%, and neurological complications occurred in 1.9%. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the time to each revision was described in only a few studies. The revision rate was 4.3%.ConclusionsAcute THA is a viable option for treatment of acetabular fracture and can result in acceptable clinical outcomes and survivorship rates in older patients but with an associated complication rate of approximately 20%. Considering the limited treatment options, THA might be a viable alternative for appropriately selected patients.