Suture button versus syndesmosis screw constructs for acute ankle diastasis injuries: A meta-analysis and systematic review of randomised controlled trials

BackgroundAnkle syndesmotic injuries can be surgically managed with syndesmosis screws (SS) or suture button (SB) fixation. We performed a meta-analysis of randomized controlled trials (RCTs) aiming to compare the clinical and complication profiles of both modalities.MethodsA multi-database search up to 4th of March 2018 was performed according to PRISMA guidelines. All RCTs comparing both techniques and published in English were included.ResultsFive RCTs with a total of 280 patients (140 SB, 140 SS) were included for analysis. SB had a statistically significant higher AOFAS score at 1 year (mean difference = 5.46, 95% CI = 0.40–10.51, p = 0.03) and lower implant failure rate (OR = 0.03, 95% CI = 0.01–0.15, p < 0.001). Infection and wound issues were marginally higher with SB (OR = 1.4, 95% CI = 0.4–4.85, p = 0.60). No other parameters showed statistically significant difference.ConclusionsBoth constructs yielded similar clinical outcomes. The 1 year AOFAS score was higher in SB but clinical significance is unlikely. SB had significantly fewer implant failures.Level of evidence: Level I.     

Evaluación de los patrones de recurrencia por grupos de riesgo tras nefrectomía por cáncer renal

IntroductionRecurrence trends after renal cell cancer nephrectomy are not clearly defined.ObjectiveTo evaluate recurrence trends according to recurrence risk groups (RRG).Material and methodRetrospective analysis of 696 patients with renal cell cancer treated with nephrectomy between 1990-2010.Three RRG were defined according to the presence of anatomopathological variables (pTpN stage, nuclear grade, tumor necrosis [TN], sarcomatoid differentiation [SD], positive resection margin [RM]):-Low RG (LRG): pT1pNx-0 G1-4, pT2pNx-0 G1-2; no TN, SD and/or RM (+).-Intermediate RG (IRG): pT2pNx-0 G3-4; pT3-4pNx-0 G1-2; LRG with TN.-High RG (HRG): pT3-4pNx-0 G3-4; pT1-4pN + ; IRG with TN and/or SD; LRG with SD and/or RM (+).The Kaplan-Meier method has been used to evaluate recurrence-free survival as a function of RRG. The log-rank test was used to evaluate differences between survival curves.ResultsThe median follow-up was 105 (IQR 63-148) months. Of the total series, 177 (25.4%) patients presented recurrence: distant 15.9%, local 4.9% and 4.6% distant and local.The recurrence rate varied according to the RRG with values of 72.9% for HRG, 16.9% for IRG and 10.2% for LRG (p = .0001). Most cases in LRG presented single organ recurrence (72.2%) (p = .006). The LRG experienced recurrence as single metastasis in 50% of cases, compared to 30% and 18.6% in IRG and HRG, respectively (p = .009).The most common sites of recurrence were lung and abdomen. Lung recurrence predominated in the HRG (72.9%) (p = .0001) and abdominal, in the LRG (83.3%) with a tendency to significance (p = .15).ConclusionsRecurrence rates (especially bone and lung) increase with higher RG. Single organ recurrences and single metastases are more frequent in LRG.     

Fijación del material protésico en la hernioplastia inguinal abierta: sutura vs. cola sintética

IntroductionThe use of synthetic glues has become normal practice in several surgical fields. The objective of this study is to compare the short and medium term results of glue and conventional suture in the fixation of the prosthesis in open inguinal hernia repair with a plug and patch technique.Materials and methodsA comparative prospective study was conducted on 198 patients with a diagnosis of a non-recurrent inguinal hernia subjected to open surgery and randomly assigned to mesh fixation with cyanoacrylate glue (n = 101) or with suture (n = 98). The demographic characteristics, short-term complications, hospital stay, time off work, hernia recurrence, and chronic inguinal neuralgia, were analysed.ResultsThe overall morbidity was 13.9% in the glue group, and 30.9% in the suture group. No undue inflammatory reactions or mesh migration were observed in the group. The post-operative stay was 14.7 h for the glue group, and 19.1 h in the suture group (P < .0001). No differences were found regarding days off work. The short-term morbidity was higher in the suture group (19.6% vs. 10.9%). After one year, there was one recurrence in the suture group (1%), and none in the glue group. However, the incidence of moderate/severe intensity chronic neuralgia was 2.9% in the glue group, and 10.3% in the suture group (P = .03).ConclusionThe use of cyanoacrylate is safe and effective in open inguinal hernia repair, with good results in the short and medium term.     

Inter and intra-observer reliability in assessment of the position of the lateral sesamoid in determining the severity of hallux valgus

BackgroundThe position of the lateral sesamoid on standard dorso-plantar weight bearing radiographs, with respect to the lateral cortex of the first metatarsal, has been shown to correlate well with the degree of the hallux valgus angle. This study aimed to assess the inter- and intra-observer error of this new classification system.MethodsFive orthopaedic consultants and five trainee orthopaedic surgeons were recruited to assess and document the degree of displacement of the lateral sesamoid on 144 weight-bearing dorso-plantar radiographs on two separate occasions. The severity of hallux valgus was defined as normal (0%), mild (≤50%), moderate (51–≤99%) or severe (≥100%) depending on the percentage displacement of the lateral sesamoid body from the lateral cortical border of the first metatarsal.ResultsConsultant intra-observer variability showed good agreement between repeated assessment of the radiographs (mean Kappa = 0.75). Intra-observer variability for trainee orthopaedic surgeons also showed good agreement with a mean Kappa = 0.73. Intraclass correlations for consultants and trainee surgeons was also high.ConclusionThe new classification system of assessing the severity of hallux valgus shows high inter- and intra-observer variability with good agreement and reproducibility between surgeons of consultant and trainee grades.     

Trauma surgery by general surgeons: Still an option for proximal femoral fractures?

IntroductionSurgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored.MethodsPatients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were >170/year (high volume), 96–170/year (medium volume) and <96/year (low volume).ResultsIn 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p = 0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580–0.958; p = 0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995–0.999; p = 0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997–1.018; p = 0.175).ConclusionSurgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures.     

Effect of tumor size on recurrence-free survival of upper tract urothelial carcinoma following surgical resection

ObjectiveTo identify predictors of recurrence-free survival (RFS) based on the clinicopathological features of patients with upper tract urothelial carcinoma (UTUC) who have undergone radical nephroureterectomy (RNU) with bladder cuff resection.Materials and methodsWe retrospectively reviewed the records of patients from October 1998 to July 2012 at our tertiary institution and identified 120 patients with sufficient data who underwent RNU for UTUC. We recorded various clinical and histopathological parameters as potential predictors of outcome. Recurrence was defined as any occurrence of urothelial carcinoma after RNU either intravesically, local/regionally, or at distant sites. Univariate, multivariate, and RFS analyses were conducted using the Cox regression and Kaplan-Meier methods.ResultsThe median age of our cohort was 71 years (interquartile range: 64–78). Median RNU-specimen tumor size was 3.0 cm (interquartile range: 2.0–5.0 cm). Fifty-four patients (45%) had a tumor<3.0 cm and 66 (55%) had a tumor≥3.0 cm. Eighty patients (66.7%) had organ-confined UTUC (≤pT2) and 40 (33.3%) had non–organ-confined UTUC (≥pT3). Sixty-five patients (54.2%) experienced at least 1 recurrence. Forty-three patients (35.8%) had at least 1 episode of intravesical recurrence and 28 (23.3%) had distant recurrence. A multivariate analysis revealed non–organ-confined disease (hazard ratio [HR] = 3.62, P<0.001), tumor diameter≥3 cm (HR = 1.97, P = 0.011), and male gender (HR = 1.81, P = 0.047) to be significant independent predictors of disease recurrence. The 5-year RFS rate was 46.9% and 25.8% for patients with tumor size<3 and≥3 cm, respectively.ConclusionsFollowing RNU, the incidence of recurrence remains high among patients with UTUC. In our cohort of patients, tumor diameter≥3.0 cm, non–organ-confined UTUC, and male gender constitute important risk factors for poor RFS outcomes following RNU. These patients require diligent postoperative surveillance and may potentially benefit from perioperative systemic therapy.     

There is a difference in functional ankle stability between different types of footwear in male athletes: A cross-sectional study

ContextLateral ankle sprains (LAS) are among the most common injuries in sports, with a poor long – term prognosis due to high chronicity and recurrence rates. Chronic ankle instability (CAI) results up to 40% of people that endured a first – time LAS.ObjectiveThe aim of this study was to compare ankle stability between groups characterised by the use of different types of footwear during their sport activities.DesignCross-sectional study.SettingFirm training surface, local sport clubs.ParticipantsFifty - one male subjects were recruited, distributed in four groups based on the type of footwear they use during their sport activities.Main outcome measuresAll subjects performed four clinical ankle stability tests, and completed the Dutch version of the Cumberland Ankle Instability Tool (CAIT) and Profile of Mood States (POMS). All clinical ankle stability tests were performed barefoot.ResultsSubjects performing their sport activities barefoot scored better than subjects performing their sport with shoes at the multiple hop test (p = .002 to .047) and executed the figure–of–8 hop test significantly faster than subjects with submalleolar ankle support (AS) (p = .019). Subjects with submalleolar AS and studs showed significantly better results than subjects with supramalleolar AS on the CAIT– score (p = .024, p = .030) and the side– hop test (p = .050, p = .045). They also scored significantly better than subjects with submalleolar AS for the side – hop test (p = .032), foot – lift test (p = .019) and figure–of 8 hop test (p = .011).ConclusionBarefoot sports performing subjects appear to have better ankle stability compared to subjects performing their sports with shoe support. Subjects performing sports with high AS appear to have worst ankle stability.Level of evidence: Level III, Cross–sectional study.     

Oncological outcomes of laparoscopic nephroureterectomy with pluck method for distal ureter resection

ObjectiveTo report the oncologic outcomes of upper tract urothelial carcinoma treated with laparoscopic nephroureterectomy and pluck method for distal ureter resection.Materials and methodsBetween May 2004 and November 2015, 118 patients with upper urinary tract urothelial carcinoma received laparoscopic radical nephroureterectomy with endoscopic bladder cuff excision at our institution. The medical records were reviewed retrospectively for clinical and pathological results. Cox regression analyses were performed on factors related to oncological outcomes.ResultsThe median follow-up was 26 months. Bladder recurrence was found in 27 patients (22.9%), extravesical retroperitoneal recurrence in four patients (3.4%), and metastases in 17 patients (14.4%). Multivariate analyses showed that male sex was associated with higher bladder recurrence [odds ratio (OR) = 2.2; 95% confidence interval (CI), 1.02–4.78; p = 0.045)], tumor size had significant correlation with locoregional recurrence (OR = 1.29; 95% CI, 1.07–3.43; p = 0.029), tumor stage was significantly correlated with subsequent metastasis (OR = 2.08; 95% CI, 1.21–3.56; p = 0.008) and overall survival (OR = 1.84; 95% CI, 1.06–3.22 ; p = 0.031), and tumor size correlated significantly with cancer-specific survival (OR = 2.57; 95% CI, 1.16–5.72; p = 0.021).ConclusionsTumor size and tumor stage were significantly associated with survival (cancer-specific and overall survival) in patients receiving nephroureterectomy with pluck method.     

A meta-analysis of the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in stroke survivors

Study DesignSystematic review and meta-analysis.IntroductionPrior reviews on the effects of anodal transcranial direct current stimulation (a-tDCS) have shown the effectiveness of a-tDCS on corticomotor excitability and motor function in healthy individuals but nonsignificant effect in subjects with stroke.PurposeTo summarize and evaluate the evidence for the efficacy of a-tDCS in the treatment of upper limb motor impairment after stroke.MethodsA meta-analysis of randomized controlled trials that compared a-tDCS with placebo and change from baseline.ResultsA pooled analysis showed a significant increase in scores in favor of a-tDCS (standard mean difference [SMD] = 0.40, 95% confidence interval [CI] = 0.10–0.70, p = 0.010, compared with baseline). A similar effect was observed between a-tDCS and sham (SMD = 0.49, 95% CI = 0.18–0.81, p = 0.005).ConclusionThis meta-analysis of eight randomized placebo-controlled trials provides further evidence that a-tDCS may benefit motor function of the paretic upper limb in patients suffering from chronic stroke.Level of EvidenceLevel 1a.     

Return to sport following Lisfranc injuries: A systematic review and meta-analysis

BackgroundInformation regarding return rates (RR) and mean return times (RT) to sport following Lisfranc injuries remains limited.MethodsA systematic search of nine major databases was performed to identify all studies which recorded RR or RT to sport following lisfranc injuries.ResultsSeventeen studies were included (n = 366).For undisplaced (Stage 1) injuries managed nonoperatively (n = 35), RR was 100% and RT was 4.0 (0–15) wks. For stable minimally-displaced (Stage 2) injuries managed nonoperatively (n = 16), RR was 100% and RT was 9.1 (4–14) wks.For the operatively-managed injuries, Percutaneous Reduction Internal Fixation (PRIF) (n = 42), showed significantly better RR and RT compared to both: Open Reduction Internal Fixation (ORIF) (n = 139) (RR — 98% vs 78%, p < 0.019; RT — 11.6 wks vs 19.6 wks, p < 0.001); and Primary Partial Arthrodesis (PPA) (n = 85) (RR — 98% vs 85%, p < 0.047; RT — 11.6 wks vs 22.0 wks, p < 0.002).ConclusionsStage 1 and stable Stage 2 Lisfranc injuries show good results with nonoperative management. PRIF offers the best RR and RT from the operative methods, though this may not be possible with high-energy injuries.Level of Evidence: IV. Systematic Review of Level I to Level IV Studies.     

Gaining Consent for Carotid Surgery: A Simulation-Based Study of Vascular Surgeons

AimDespite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA).MethodsThirty-two surgeons [Group 1: junior surgical trainees – performed 0 CEA's (n = 11); 2: senior vascular trainees – 1–50 CEA's (n = 11); 3: consultant vascular surgeons – > 50 CEA's (n = 10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors.ResultsThere was no difference in performance between the junior and senior trainees (1: median 91 range 64–121; 2: median 100.5 range 66–125; p = 0.118 1 vs. 2 Mann–Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89–1 142; p = 0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (α = 0.832).Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p < 0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p < 0.0001) than their junior counterparts. They were less likely to discuss infection (p < 0.0001).ConclusionSenior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.     

Five mm laparoscopic varicocelectomy versus conventional varicocele ligation in young men with symptomatic varicocele: A randomized clinical study

ObjectivesTo compare the therapeutic success, morbidity and the costs of 5 mm laparoscopic varicocele ligation (LV) compared to inguinal varicocelectomy (IV).Patients and methodsEighty patients with idiopathic symptomatic varicocele of grades I–III diagnosed by clinical examination and Doppler ultrasonography were randomly assigned to LV or IV (40 patients in each group). The mean patient age was 25.2 ± 1.4 (range 18–40) years. Of the 80 patients treated 21.3% had a left-sided varicocele, 70% had bilateral varicoceles and 8.8% a right-sided varicocele. Of 136 varicoceles, 37 (27.2%) were grade III, 51 (37.5%) grade II and 48 (35.3%) were grade I. The indications for varicocele ligation were: abnormal spermiogram in 47 patients (58.7%), scrotal pain in 19 (23.8%) and cosmetic impairment in 14 (17.5%). A total of 136 varicocele ligations were performed (67 IV and 69 LV). All patients were followed up for 4–8 months to assess early complications, testicular size, late complications and persistence or recurrence of the varicocele.ResultsLV was associated with shorter operative time, shorter hospital stay and lower cost compared to IV. The overall incidence of postoperative complications including hydrocele, epididymitis and local pain was significantly higher among patients undergoing IV compared with LV (17.5% vs 5%). The incidence of persistent varicoceles was not significantly different between the 2 groups, but the varicocele recurrence rate was significantly lower in the LV compared to the IV group (5% vs. 17.5%, p ≤ 0.02).ConclusionsLV is a less invasive treatment than IV for managing male varicoceles. It is also associated with lower costs and better outcomes and should therefore be the preferred method of treatment for male varicoceles.     

Arthroscopically measured syndesmotic stability after screw vs. suture button fixation in a cadaveric model

BackgroundAppropriate management of ankle syndesmotic instability is needed to prevent the development of complications. Previous biomechanical studies have evaluated movement of the fibula after screw or suture button fixations with different results, most likely being caused by variations in experimental setups that did not mirror the in vivo clinical setting. This study aimed to arthroscopically compare in a cadaveric model the stability of syndesmotic fixation with either a suture button or syndesmotic screw.MethodsEight fresh matched pairs of human ankle cadaver specimens (above knee) underwent arthroscopic assessment with (1) intact ligaments, (2) after complete disruption, and (3) after repair with either a quadracortical syndesmotic screw or suture button construct. In every stage, four loading conditions were considered under 100N of direct force: 1) unstressed, 2) lateral hook test, 3) anterior to posterior (AP) translation test, and 4) posterior to anterior (PA) translation test. Coronal plane tibiofibular diastasis, as well as sagittal plane tibiofibular translation, were arthroscopically measured.ResultsCoronal plane anterior and posterior tibiofibular diastasis and sagittal plane tibiofibular translation were measured using probes of increasing diameters. Following screw fixation, syndesmotic stability was similar to the uninjured syndesmosis in the coronal plane (anterior, median 0.0 mm [IQR 0.0–0.3] vs. 0.3 mm [IQR 0.2–0.3]; p = 0.57; posterior, median 0.1 mm [IQR 0.0–0.4] vs. 0.2 mm [IQR 0.1–0.3]; p = 1.0) but more rigid in the sagittal plane (median 0.0 mm [IQR 0.0–0.1] vs. 1.0 mm [IQR 0.4–1.5]; p = 0.012). Repairing the unstable syndesmosis with a suture button construct resulted in coronal plane stability similar to the uninjured syndesmosis (anterior, median 0.2 mm [IQR 0.1–0.3] vs. 0.2 mm [IQR 0.1–0.3]; p = 0.48; posterior, median 0.2 mm [IQR 0.1–0.3] vs. 0.3 mm [IQR 0.1–0.5]; p = 0.44). However, sagittal plane fibular motion remained unstable as compared to the uninjured syndesmosis (median 2.2 mm [IQR 1.6–2.6] vs. 0.8 mm [IQR 0.4–1.3]; p = 0.012).ConclusionCurrent fixation methods for syndesmotic disruption maintain coronal plane fibular stability. Screw and suture button constructs, however, respectively resulted in greater or insufficient constraint to fibular motion in the sagittal plane as compared to the intact syndesmotic ligament. These findings suggest that neither traditional screw nor suture button fixations optimally stabilize the syndesmosis, which may have implications for postoperative care and clinical outcomes.     

Outcome of patients in laparoscopic training courses compared to standard patients

Background & aimCurrent Laparoscopic simulators have limited usefulness and patients have been used for training since the dawn of surgery. NUGITS (Northumbrian Upper Gastro Intestinal Team of Surgeons) Laparoscopic Skills courses utilise hands-on experience with simulators moving to live operating on volunteer patients. It is vital to know that the volunteer patient is not disadvantaged by greater surgical risk.MethodsThis was a case-controlled prospective comparison of patients undergoing both Laparoscopic Cholecystectomy (LC) [n = 51] and Laparoscopic Inguinal Hernia (LIH) [n = 62] during NUGITS training courses. They are compared with a matched (age, sex and ASA grade) control group LC (n = 51) and LIH (n = 62) operated on by consultants. The outcome measures were surgical peri-and post-operative complications, post-operative hospital stay, readmission and early recurrence of inguinal hernia (<6 months).ResultsIn the LC cohort, there was no significant difference in the length of hospital stay (p = 0.07) or readmission (p = 0.16) in both the groups. The mean operating time was higher in the trainee compared to the control group (p = 0.001). There was no difference in the post-operative morbidity or mortality in either group. In LIH cohort, the mean operating time was higher in the trainee compared with the control group. There was no significant difference in post-operative complications (p > 0.05) and early post-operative recurrence of hernia (p > 0.05).ConclusionThe post-operative outcomes of patients undergoing laparoscopic surgery during laparoscopic training courses are similar to consultant-operated patients. Thus, it is acceptable and safe to encourage patients to volunteer for laparoscopic training courses.     

Diagnosis of postoperative recurrence of Crohn disease with MR-enterography: Value of diffusion-weighted imaging

PurposeTo compare the diagnostic capabilities of MR enterography (MRE) using contrast-enhanced (CE) sequences with those of MRE using diffusion-weighted (DW) imaging for the diagnosis of postoperative recurrence at the neo-terminal ileum and/or anastomosis after ileocolonic resection in patients with Crohn disease (CD), and to clarify the role of additional DW imaging to CE-MRE in this context.Material and methodsForty patients who underwent ileal resection for CD, and both endoscopy and MRE within the first year after surgery were included. There were 21 men and 19 women, with a mean age of 38 years ± 12 (SD) years (range: 18–67 years). MRE examinations were blindly analyzed independently by one senior (R1) and one junior (R2) radiologist for the presence of small bowel postoperative recurrence at the anastomotic site. During a first reading session, T2-, steady-state- and DW-MRE were reviewed (DW-MRE or set 1). During a separate distant session, T2-, steady-state- and CE-MRE were reviewed (CE-MRE or set 2). Lastly, all sequences were analyzed altogether (set 3). Performances of each reader for the diagnosis of postoperative recurrence were evaluated using endoscopic findings as the standard of reference (Rutgeerts score ≥ i2b).ResultsFifteen patients out of 40 (37.5%) had endoscopic postoperative recurrence at the anastomotic site. Sensitivity for the diagnosis of postoperative recurrence was 73% (95% CI: 51–96%) for R1 and 67% (95% CI: 43–91%) for R2 using set 1, and 80% (95% CI: 60–100%) for both readers using set 2. There was no significant differences in sensitivity between reading set 1 and reading set 2, for either R1 or R2 (R1, P  > 0.99; R2, P = 0.48). Specificity was 96% (95% CI: 88–100%) for both readers using set 1 or using set 2. Reading set 3 yielded an area under the ROC curve (AUC) of 0.93 (95% CI: 0.84–1) versus 0.89 (95% CI: 0.75–1) with set 1 (P = 0.18) and versus 0.89 (95% CI: 0.78–1) with set 2 (P = 0.21). No significant differences in AUC were found between set 1 or 2 and set 3 (P = 0.18), nor between set 1 and 2 (P = 0.76). Accuracies were 88% (95% CI: 74–95%) and 85% (95% CI: 71–93%) for DW-MRE for R1 and R2, respectively; 90% (95% CI: 77–96%) for CE-MRE for both readers; and 93% (95% CI: 80–97%) and 88% (95% CI: 74–95%) for R1 and R2 with set 3, respectively.ConclusionDW-MRE has diagnostic capabilities similar to those of CE-MRE for the diagnosis of postoperative recurrence of CD at the anastomotic site.     

Tibiotalocalcaneal arthrodesis with distal tibial allograft for massive bone deficits in the ankle

BackgroundThe purpose of this study was to assess the outcomes of distal tibial structural allograft to obtain a stable TTC fusion.MethodsRetrospectively, ten patients were carried out with a minimum one year follow-up. The median age was 72 (33–81). The median BMI was 28 (24–33). Indications for TTC arthrodesis included failed total ankle arthroplasty (n = 7 patients), prior nonunion (n = 2 patients), and a trauma injury.ResultsUnion rate was 80%. The median initial height of the distal tibial allograft was 19 mm (14–24 mm). In seven cases the allograft did not lose height. The AOFAS score median was 69 (31–84). SF-12 median physical component was 39 (30–53), and 59 (23–62) for mental component. The VAS median was 2 (0–8).ConclusionsTTC using distal tibial allograft shows a lower rate of collapse than other structural grafts and provides a fusion rate higher or in accordance with the literature.Level of evidenceLevel IV, retrospective case series.     

Long-term outcomes of pediatric laparoscopic needled-assisted inguinal hernia repair: A 10-year experience

PurposeLaparoscopic inguinal hernia repair (LIHR) has gained wide acceptance over the past decade, although studies with longer term follow-up are lacking. We present one of the largest cohorts of children undergoing laparoscopic needle-assisted repair (LNAR) with long-term follow-up.MethodsA clinical quality database was maintained for children ≤ 14 years of age who underwent laparoscopic needle-assisted repair between 2009 and 2017 with review of follow-up through 2019. De-identified data was reviewed.Results1023 patients with 1457 LNAR were included during the 10-year period. Mean age at surgery was 2.56 years (2 days to14 years). The overall hernia recurrence rate was 0.75% (11/1457). A total of four postoperative hydroceles required intervention. Preterm infant repair done < 60w post conceptional age had a significantly lower recurrence rate (0.63%) than other patients (0.82%) (p < 0.01). 64.2% of patients had clinical follow-up over a period of 11 years with a mean follow-up of 5.97 years.ConclusionWe present a large cohort study of consecutive pediatric laparoscopic hernia repairs followed over an 11-year period. LNAR is safe and effective for term and preterm patients with similar complication rates to other techniques, including open repair. Additionally, our results suggest that preterm infants may have superior outcomes with this method.Level of EvidenceLevel III – Retrospective Comparative Study.     

Candidates to salvage therapy after external-beam radiotherapy of prostate cancer: Predictors of local recurrence volume and metastasis-free survival

PurposeThe purpose of this study was to assess the predictors of metastasis-free survival (MFS) and of the volume of the local recurrence in patients with rising prostate-specific antigen (PSA) serum level after radiotherapy for prostate cancer and referred for prostate magnetic resonance imaging (MRI) and biopsy in view of salvage treatment.Materials and methodsA total of 132 consecutive men (median age, 70 years; IQR, 66–77 years) with rising PSA after prostate radiotherapy who underwent prostate MRI and biopsy in view of salvage treatment between January 2010 and July 2017 were retrospectively evaluated at a single center. MFS predictors were assessed with Cox models. Predictors of the volume of the local recurrence (number of invaded prostate sectors at biopsy) were assessed using Poisson regression among variables available at PSA relapse.ResultsAt multivariate analysis, an initial Gleason score ≥ 8 (OR = 7 [95% confidence interval (CI): 1.2–40]; P = 0.03), a recent radiotherapy (OR = 17 [95% CI: 3.9–72]; P < 0.0001), the use of androgen deprivation therapy at PSA relapse (OR = 12.5 [95% CI: 2.8–57]; P = 0.001) and the number of invaded prostate sectors (OR = 1.5 [95% CI: 1.1–2]; P = 0.007) and maximum cancer core length (OR = 0.7 [95%CI: 0.6–0.9]; P = 0.002) at biopsy performed at PSA relapse were significant MFS predictors. The PSA level at relapse was significant independent predictor of the volume of local recurrence only when used as a continuous variable (P = 0.0002) but not when dichotomized using the nadir + 2 threshold (P = 0.41).ConclusionPathological and clinical factors can help predict MFS in patients with rising PSA after prostate radiotherapy and candidates to salvage treatment. The PSA level at relapse has strong influence on the local recurrence volume when used as a continuous variable.     

Influence of depth of neuromuscular blockade on surgical conditions during low-pressure pneumoperitoneum laparoscopic cholecystectomy: A randomized blinded study

Study objectiveTo evaluate the influence of neuromuscular blockade (NMB) on surgical conditions during low-pressure pneumoperitoneum (8 mm Hg) laparoscopic cholecystectomy (LC), while comparing moderate and deep NMB. Secondary objective was to evaluate if surgical conditions during low-pressure pneumoperitoneum LC performed with deep NMB could be comparable to those provided during standard-pressure pneumoperitoneum (12 mm Hg) LC.DesignProspective, randomized, blinded clinical trial.SettingOperating room.PatientsNinety ASA 1–2 patients scheduled for elective LC.InterventionsPatients were allocated into 3 groups: Group 1: low-pressure pneumoperitoneum with moderate-NMB (1–3 TOF), Group 2: low-pressure pneumoperitoneum with deep-NMB (1–5 PTC) and Group 3: standard pneumoperitoneum (12 mm Hg). Rocuronium was used to induce NMB and acceleromiography was used for NMB monitoring (TOF-Watch-SX).MeasurementsThree experienced surgeons evaluated surgical conditions using a four-step scale at three time-points: surgical field exposure, dissection of the gallbladder and extraction/closure.Main resultsLow-pressure pneumoperitoneum (Group 1 vs. 2): good conditions: 96.7 vs. 96.7%, 90 vs. 80% and 89.6 vs. 92.3%, respectively for the time-points, p > 0.05. No differences in optimal surgical conditions were observed between the groups. Surgery completion at 8 mm Hg pneumoperitoneum: 96.7 vs. 86.7%, p = 0.353.Standard-pressure pneumoperitoneum vs. low-pressure pneumoperitoneum with deep NMB (Group 3 vs. 2): good conditions: 100% in Group 3 for the three time-points (p = 0.024 vs. Group 2 at dissection of the gallbladder). Significantly greater percentage of optimal conditions during standard-pressure pneumoperitoneum LC at the three time points of evaluation.ConclusionsThe depth of NMB was found not to be decisive neither in the improvement of surgical conditions nor in the completion of low-pressure pneumoperitoneum LC performed by experienced surgeons. Surgical conditions were considered better with a standard-pressure pneumoperitoneum, regardless of the depth of NMB, than during low-pressure pneumoperitoneum with deep NMB.