Surgeries, Volume 5, Issue 3 (September 2024) – 30 articles

Background: To evaluate analgesic practices in perioperative treatment during the SARS-CoV-2 pandemic; recording parameters collected in the PAIN OUT database, and to compare COVID and no-COVID data. Methods: Data were analyzed for 277 patients (87 COVID-19 confirmed diagnosis and 190 non-COVID): years aged, gender, minutes of surgery duration, Likert Scale punctuation, hours in severe pain, minimum and maximum pain intensity, interference with sleep quality, anxiety, need for help, nausea, drowsiness, itching, dizziness, perception of care, pain relief, participation, satisfaction, and information received. Results: Postoperative mortality 1 month after surgery was recorded at 25.3% in COVID-19. Significant differences were found in postoperative pain intensity (p = 0.019), time with severe pain (p < 0.01), lower sleep quality (p < 0.01), and better outcomes in functional items (p < 0.01); there were more side effects and satisfaction with pain relief (p < 0.01) in COVID-patients than with no COVID-19 patients. Conclusions: In conclusion, COVID-19 patients presented greater intensity and duration of severe postoperative pain, greater somnolence, pruritus, and dizziness, lower physical activity limitation, and higher quality index. Full article

Previous reports showed that prolonged operative time increases the risk of surgical site infection rates, prolonged hospital stays, and potentially higher rates of revision surgeries. In the context of rhinoplasty, the type of nasal deformity may complicate the surgical procedure and increase the operative time. We aimed to investigate the association between the type of nasal deformity and operative time in rhinoplasty patients. This retrospective chart review studies 349 patients who underwent primary and secondary rhinoplasty procedures due to various nasal deformities in King Saud University-Medical City. The primary outcome of the present study was the association between operative time, defined as the time from the initial incision to the completion of skin closure, and the type of nasal deformity. The association between the type of deformity and operative time was assessed using one-way ANOVA and Bonferroni post hoc analysis. There was a statistically significant association between the type of nasal deformity and operative time (p < 0.001). Patients with dorsal, alar base, and tip deformities had significantly longer operative times than patients with isolated dorsal deformities (208.01 ± 57.73 min) (p < 0.001). The analysis also showed that the presence of crooked nose deformities (p < 0.001), an inverted V deformity (p = 0.01), internal nasal valve collapse (p = 0.025), axis deviation (p = 0.003), over-projection, and under-projection significantly increased surgical duration. The complexity of nasal deformities significantly impacts the operative time in rhinoplasty surgeries; more complex deformities that require extensive surgical procedures are associated with a longer operative time. Further research is warranted to corroborate these findings and investigate other potential influencing factors. Full article

Patellar sleeve fractures, though relatively rare, present unique challenges in diagnosis and management. This review aims to provide a comprehensive overview of the current understanding of patellar sleeve fractures, focusing on their epidemiology, clinical presentation, imaging, and management strategies. Epidemiologically, these fractures are uncommon, representing approximately 1% of all fractures in pediatric patients, yet they account for 50% of all patella fractures in this population. They predominantly affect adolescents, with a peak incidence around 12.7 years of age, and are more common in boys, occurring at a ratio of 3 to 5:1. Understanding these demographic patterns is crucial for early recognition and appropriate management. Clinically, patellar sleeve fractures typically present with the sudden onset of severe pain, often associated with explosive activities such as jumping. However, diagnosis can be challenging, particularly in cases with minimal displacement or where alternative muscle groups compensate for the injury. Differential diagnosis is essential, and clinicians should be vigilant for signs such as palpable gaps at the lower pole of the patella and patella alta. Imaging modalities play a vital role in diagnosis, with plain X-rays often revealing no bony damage. Ultrasonography may offer a cost-effective alternative, especially in cases where radiographic findings are inconclusive. Advanced imaging techniques such as MRI can assist in characterizing the extent of the injury and assessing for associated complications. Management strategies encompass a spectrum of approaches, ranging from conservative measures such as immobilization and physical therapy to surgical interventions, including open reduction and internal fixation or arthroscopic surgery. The choice of treatment depends on various factors, including the fracture pattern, displacement, patient age, activity level, and associated injuries. Despite advancements in diagnosis and treatment, the optimal management of patellar sleeve fractures remains a clinical challenge. Further research is warranted to elucidate optimal algorithms for diagnosis and treatment, with the ultimate goal of improving outcomes and reducing the risk of long-term complications associated with this rare but clinically significant knee injury. Full article

Meralgia paresthetica is a compressive neuropathy of the lateral femoral cutaneous nerve. Surgery is the gold standard for severe cases. However, no high-quality evidence exists on which strategy is best: decompression or neurectomy. Data of a consecutive series of 52 patients treated for meralgia paresthetica over 25 years (1997–2022) were retrospectively collected from medical records and telephone interviews. In total, 27 women and 25 men were operated on; 11 patients had iatrogenic meralgia paresthetica. Decompression was performed on 47 patients, and neurectomy in 8 cases (5 primary neurectomies plus 3 failed neurolysis). Out of the patients who underwent decompression, 41 (87.2%) benefited from the treatment; 3 had pain relief, but no benefit on paresthesia; and 3 reported pain persistence. The latter required neurectomy to resolve symptoms. The eight patients who underwent neurectomy experienced symptom relief but had an obvious anesthetic area persisting over years. Complications were rare (3.8%): a groin hematoma in the post-operative course and an inguinal herniation 6 months after surgery. Surgery, be it neurolysis or neurectomy, offers excellent results with low risks. Decompression has been proven to be adequate in almost all patients, avoiding the side effects of neurectomy. The latter should be confined to failed decompression or to iatrogenic meralgia. Full article

Background: The long-term success of dental implants largely depends on achieving primary stability, previously described as crucial to obtaining osseointegration and immediate loading protocol requirements. Implant thread depths seem to be one of the key factors influencing primary stability, particularly in low-density bone. Insertion torque (IT) and resonance frequency analysis (RFA) are considered the most reliable tests to assess primary stability. The aim of this work was to evaluate how different thread depths of commercially available dental implants affect primary stability in low-density D3 bone. Materials and Methods: An in vitro study was carried out between February 2024 and March 2024. Twenty-four dental implants were divided into four groups (six implants each) according to their thread depths (Group A: 4 mm, Group B: 4.5 mm, Group C: 5 mm, Group D: 5.5 mm) and were inserted in D3-type artificial bone blocks. The main outcome variables were the IT and the Implant Stability Quotient (ISQ) measured in four different areas of the implant (buccal, lingual, mesial, and distal) with an Osstel^® ISQ reader. Descriptive and inferential analyses of the data were performed, and the significance value was set at 5%. Results: A total of 24 implants were analyzed. The highest IT values were obtained in Group D, with a mean of 54.03 Ncm (standard deviation (SD) = 8.99), while the lowest measurements were observed in Group A (mean = 25.12; SD: 2.96 N.cm). The mean ISQ values were consistently higher in Group D for each analyzed area, with a mean of 70.13 N.cm (SD = 1.12). Conclusions: Taking into consideration the limitations of this in vitro study, greater thread depths seem to increase the primary stability of dental implants placed in soft bone. Furthermore, a positive correlation was observed between all IT and ISQ values, regardless of the thread depth. Full article

The biomechanical efficacy of nail–plate constructs (NPCs) used in the treatment of traumatic distal femur fractures (DFFs) remains understudied compared to traditional approaches. This systematic review examines the biomechanical efficacy of NPCs compared to alternative approaches for the surgical fixation of DFFs to guide surgical decision-making and improve patient outcomes. This systematic review searched the PubMed, CINAHL, MEDLINE, Web of Science, and SPORT Discus databases from inception until 24 January 2024. Inclusion criteria were biomechanical studies that involved nail–plate combination constructs for DFFs. Six observational studies were included. Of the included studies, five studies utilized synthetic bone models in testing, and one study used both synthetic and cadaveric bone models. All studies found NPCs to have significantly higher axial and torsional stiffness and resistance to loading than distal lateral femoral locking plate (DLFLP) constructs. The 11 mm NPCs were significantly stiffer than the 9 mm NPCs under torsional and axial loading. Only one of two studies found NPCs to have greater axial stiffness than dual-plate (DP) constructs. NPCs and DP constructs had greater torsional and axial stiffness than the plate-only or DP with medial distal tibial plate constructs. NPCs had less displacement and torque than the plate- or nail-only constructs under axial and torsional loads. NPCs demonstrate superior axial and torsional stiffness and resistance to mechanical loads compared to DLFLP. The varying performance between 11 mm and 9 mm NPCs suggests that construct diameter plays a role in mechanical stability. NPCs and DP constructs performed better than plate-only constructs. Future research should explore the impact of varying nail diameters and plate configurations on stability, as well as the clinical efficacy of NPCs across different patient populations, particularly those with varying bone densities, to better understand their performance in real-world scenarios. Full article

The anterior cruciate ligament (ACL) is crucial for knee stability and is often injured in sports, leading to significant issues like degenerative changes and meniscal tears. ACL tears are prevalent in high-school sports injuries, accounting for 50% of knee injuries in the U.S. Surgical reconstruction, often involving bone-patellar tendon-bone (BPTB) or hamstring autografts, is common, with varying success rates and complications. Emerging alternatives like the peroneus longus tendon show promise but require further comparative studies. This prospective and multicentric study included 110 patients who underwent ACL reconstruction from 2020 to 2022. Fifty-five patients received hamstring tendon autografts (Group H) and fifty-five received peroneus longus tendon autografts (Group P). Surgeries were performed by experienced surgeons using standardized techniques. Patients were evaluated using clinical tests and functional scores including the Lysholm Knee Questionnaire and IKDC-2000 at various postoperative intervals up to 24 months. Data were analyzed using SPSS with a significance level set at p < 0.05. Group H showed superior knee function preoperatively and at 24 months postoperatively compared to Group P. Group H had higher Lysholm and IKDC scores consistently throughout the study period. The anterior drawer and Lachman’s tests indicated better knee stability for Group H. Complications were comparable between groups, with specific issues related to donor site morbidity and muscle weakness observed in each. The six-strand hamstring tendon autograft (Group H) demonstrated superior functional outcomes and knee stability compared to the peroneus longus tendon autograft (Group P) for ACL reconstruction. Despite some donor site morbidity, the hamstring tendon showed better long-term recovery and fewer complications. Future studies should explore larger, multicentric cohorts and integrate regenerative medicine techniques to further enhance ACL reconstruction outcomes. Full article

Glioblastoma is the most frequent form of adult-type diffuse gliomas, and it carries a very poor prognosis. Magnetic resonance imaging (MRI) is an indispensable tool for diagnosing and monitoring brain tumors, potentially influencing choices like repeat surgery, biopsy, or alternative management strategies. However, interpreting post-surgical MRI for gliomas can be particularly demanding, especially in differentiating between tumor progression and treatment effects. Recently, a novel score specifically designed for classifying and reporting post-treatment brain tumors on MRI was proposed by a team of neuroradiologists, neurosurgeons, and neuro-oncologists: the Brain Tumor Reporting and Data System (BT-RADS). This review examines the current body of evidence regarding the use of BT-RADS in monitoring adult-type diffuse gliomas following surgery. This classification has demonstrated a number of benefits in terms of prognostic value, treatment decisions, reliability, and the quality of radiology reports. On the other hand, despite the promising diagnostic value in identifying recurrent glioblastoma, there is still some uncertainty in defining the presence or absence of tumor recurrence in the intermediate category 3. In such a category, incorporating advanced techniques such as perfusion-weighted imaging and diffusion-weighted imaging may improve the stratification of patients, avoiding repeat surgery on false positive findings. Full article

Radiation-induced morphea (RIM) is a progressive and irreversible scleroderma encountered after breast radiation therapy. This condition is often underdiagnosed, with confounding differentials including post-radiation fibrosis, infection, inflammatory breast cancer, and cancer recurrence, amongst others. Treatment paradigms differ, and early diagnosis of RIM is essential in preventing further fibrosis and improving quality of life. First-line therapy includes immunosuppressive therapy; surgical management is infrequently described in the literature. Here, we report one of the few reports of completion mastectomy for RIM with postoperative outcomes described. This is a case of a patient who was treated with completion mastectomy with delayed wound closure after developing debilitating RIM status post right breast lumpectomy with radiation for invasive ductal carcinoma. Full article

Introduction: Uterine carcinosarcoma is an aggressive gynecologic malignancy that accounts for 5% of all gynecological malignancies. There is a disproportion in its incidence and mortality among different races. This study describes demographic and clinicopathological factors and racial disparities affecting the survival of patients with uterine carcinosarcoma. Methods: Data on uterine carcinosarcoma patients were obtained from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2020. Results: Of the 11,338 patients identified, the median age at diagnosis was 68 years, and the five-year cause-specific survival (CSS) rate was 38.7%. for all races. Compared with Asian patients (39.5%, 95% CI, 36.0–43.4%), Hispanic patients (39.4%, 95% CI, 36.5–42.5%), and White patients (37.9%, 95% CI, 36.7–39.2%), Black patients accounted for 21% of the patients and had a significantly lower 5-year CSS (95% CI, 27.2–31.2%). The CSS rates were 84.4% (95% CI, 83.3–85.6%) for localized tumors, 68.5% (95% CI, 66.9–70.1%) for regional tumors, and 39.0% (95% CI, 36.9–41.2%) for distant tumors. Multimodal treatment involving chemotherapy, surgery, and radiation improved the overall one- and five-year survival rates by 88.2% (95% CI, 87.0–89.5%) and 52.8% (95% CI, 50.7–55.1%), respectively, across all disease stages. Multivariate analysis identified age >60 years, Black race, tumor size >4 cm, and distant metastases as independent risk factors for mortality (p < 0.0001). Conclusions: This large database study presents the most up-to-date epidemiological information regarding cases of uterine carcinosarcoma. The findings suggest that a combination of surgery, chemotherapy, and radiation may be most efficacious in treating this malignancy, especially in patients with distant disease. Full article

Montgomery’s medialization thyroplasty is a laryngeal frame surgery to treat patients with unilateral vocal cord paralysis. This procedure uses a silicone implant in six sizes each for male and female patients. The results of this technique are generally good; however, the results can be suboptimal in some female patients because of differences in female and male laryngeal anatomy. The angle formed by the thyroid cartilage is greater in women than in men, meaning that the posterior portion of this cartilage is further away from the midline in women. We describe our results using male prostheses to improve suboptimal results in some of our female patients. This study is a retrospective case series study. We included female patients who underwent thyroplasty reintervention from 2014 to 2021 using male Montgomery thyroplasty prostheses. Functional results were studied using maximum phonation time (MPT), the GRBAS scales, and two questionnaires: Voice-Handicap Index 30 and Eating Assessment Tool 10. The functional results for all of these women improved after secondary thyroplasty. In one case, the MPT parameter did not change but patient satisfaction improved. The use of male Montgomery implants in women can be a useful tool to achieve improvement in female thyroplasty failure. Full article

Pilonidal sinus disease increasingly affects children and adolescents. While recurrence rates in adults are lower, with a minimum of 2% per year, and are essentially a function of the surgical approach over time, this is totally different in children. Many studies investigating children and adolescents report much higher recurrence rates. We aimed to gather and concentrate the available data on this matter in our review by searching PubMed, MEDLINE, and Scopus. The crude median recurrence rate of pilonidal sinus disease in children and adolescents was 13% (interquartile range, 7–20%) in our sample of 3599 patients in 42 studies, with a median study size of 52 (interquartile range, 27–96 patients) patients. Time to recurrence was available from eight studies with 1418 patients and its mean or median time to recurrence was usually much less than one year. For both parameters, an association with study size or patient age was not evident. Although treatment algorithms have been developed to adapt treatment to this dire situation, relevant improvements can only be expected if the underlying factors that cause these recurrence dynamics in children, which are substantially different from those in adults, were to be uncovered. Full article

Cervical disc arthroplasty (CDA), also known as cervical artificial disc replacement, has become an alternative for the treatment of cervical spondylosis with radicular or myelopathic symptoms. However, there is limited literature regarding its complications and outcomes. We present two cases that developed C5 nerve palsy (C5P) following two-level CDA. Both patients presented with C5P in a delayed fashion with 2/5 and 1/5 deltoid weakness on MMT, respectively. Postoperative imaging did not demonstrate any spinal cord compression and symptoms resolved (5/5 on MMT) with conservative management in both cases. To our knowledge, these represent the first cases of delayed C5P after cervical arthroplasty reported in the literature. We performed a literature review to further enhance our knowledge regarding CDA. By understanding its pathophysiology and response to treatment, these cases can serve as a guide for spine surgeons and improve their future outcomes. Full article

Background: Metastatic tumors of the oro-facial tissuesare rare, with an incidence ranging between 1% and 8% of all oral malignant tumors. Generally reported with a peak of incidence in the 5–7th decades but possibly occurring at any age, metastases may represent the first sign of an occult cancer or manifest in patients with an already known history of a primary carcinoma, mostly from the lungs, kidney, prostate, and colon/rectum in males, and the uterus, breast, lung, and ovary in females. In the oro-facial tissues, the most involved sites are the oral mucosa, gingiva/jawbones, tongue, and salivary glands. Methods: A broad and deep literature review with a comprehensive analysis of the existing research on oro-facial metastases from renal-cell carcinoma (RCC) was conducted by searching the most used databases, with attention also paid to the clear-cell histological variant, which is the most frequent one. Results: Among the 156 analyzed studies, 206 cases of oro-facial metastases of renal cancer were found in patients with an average age of 60.9 years (145 males, 70.3%; 61 females, 29.6%). In almost 40% of the cases, metastasis represented the first clinical manifestation of the primary tumor, and 122 were histologically diagnosed as clear-cell renal-cell carcinoma (ccRCC) (59.2%). The tongue was involved in most of the cases (55 cases, 26.7%), followed by the gingiva (39 cases, 18.9%), mandible (35 cases, 16.9%), maxilla (23 cases, 11.1%), parotid gland (22 cases, 10.6%), buccal mucosa (11 cases, 5.3%), lips (7 cases, 3.3%), hard palate (6 cases, 2.8%), soft palate, masticatory space, and submandibular gland (2 cases, 0.9%), and lymph nodes, tonsils, and floor of the mouth (1 case, 0.4%). Among the 122 ccRCCs (84 males, 68.8%; 38 females, 31.1%), with an average age of 60.8 years and representing in 33.6% the first clinical manifestation, the tongue remained the most frequent site (31 cases, 25.4%), followed by the gingiva (21 cases, 17.2%), parotid gland (16 cases, 13.1%), mandibular bone (15 cases, 12.2%), maxillary bone (14 cases, 11.4%), buccal mucosa and lips (6 cases, 4.9%), hard palate (5 cases, 4%), submandibular gland and soft palate (2 cases, 1.6%), and lymph nodes, tonsils, oral floor, and masticatory space (1 case, 0.8%). The clinical presentation in soft tissues was mainly represented by a fast-growing exophytic mass, sometimes accompanied by pain, while in bone, it generally presented as radiolucent lesions with ill-defined borders and cortical erosion. Conclusions: The current comprehensive review collected data from the literature about the incidence, site of occurrence, age, sex, and survival of patients affected by oro-facial metastases from renal-cell carcinoma, with particular attention paid to the cases diagnosed as metastases from clear-cell renal-cell carcinoma, which is the most frequent histological variant. Clinical differential diagnosis is widely discussed to provide clinicians with all the useful information for an early diagnosis despite the effective difficulties in recognizing such rare and easily misdiagnosed lesionsTheir early identification represents a diagnostic challenge, especially when the clinical work-up is limited to the cervico–facial region. Nevertheless, early diagnosis and recently introduced adjuvant therapies may represent the key to better outcomes in such patients. Therefore, general guidelines about the clinical and radiological identification of oro-facial potentially malignant lesions should be part of the cultural background of any dentist. Full article

The purpose of this research is to explore the biomechanical consequences of maternal injuries on fetal movements. Additionally, the research aims to comprehend the relationship between these injuries and fetal movement within the amniotic sac and to understand the extent to which the amniotic fluid can provide protection during severe injuries. The focus is on the potential impact these injuries could have on surgical procedures and preventative strategies. Using advanced computational simulations, the study investigates how various maternal injuries can influence the behavior of amniotic fluid and the subsequent stress exerted on fetal development. The findings suggest that maternal injuries can induce stress, primarily affecting the posterior regions of the fetus and the umbilical cord, depending on the boundary and initial conditions. This stress is associated with fetal displacement within the amniotic sac. While the amniotic fluid provides a certain level of protection, its limitations become apparent during severe injuries. These insights have implications for the field of surgery, particularly fetal procedures. They underscore the need for improved protective measures and the development of personalized obstetric and neonatal care strategies. Moreover, the study highlights the potential of computational simulations in aiding surgeons. These simulations can provide a more accurate understanding of the critical areas to focus on during surgical procedures, thereby enhancing the precision and safety of these operations. Full article

The diagnosis of intra-abdominal exsanguination in hemodynamically unstable blunt trauma patients is almost universally determined by Focused Assessment with Sonography in Trauma (FAST). However, FAST has been reported to have poor sensitivity and is therefore associated with false-negative examinations. Our institutional practice includes diagnostic peritoneal aspirate (DPA) following two negative FASTs to address the poor sensitivity. We hypothesized that serial FAST alone would be able to exclude clinically significant abdominal bleeding in an unstable blunt trauma patient. A retrospective cohort study was conducted between 2018 and 2020 at a major tertiary trauma referral hospital, including all blunt trauma patients who were hemodynamically unstable. Two groups were analyzed: 1. “FAST+”: those who had a positive FAST scan and proceeded to a trauma laparotomy, and 2. “DPA”: those who had serial negative FAST scans and proceeded to DPA. Of the 12 patients in the FAST+ group, 92% correctly identified the abdomen as the source of instability. Of the seventeen patients in the DPA group, only two (12%) had positive DPA. Both patients underwent laparotomies, but neither identified an abdominal source of hemodynamic instability. The most common cause of hemodynamic instability in the DPA group was pelvic bleeding from major pelvic ring disruption. The sensitivity and specificity of the serial FAST exam for clinically significant abdominal bleeding were 100% and 94%, respectively. These data suggests that two sequential negative FAST scans are adequate for excluding intra-abdominal bleeding as the source of instability, with further investigation with DPA not identifying any clinically significant sources of intra-abdominal bleeding. Full article

Background: Anterior cruciate ligament (ACL) injuries are prevalent and represent a significant socioeconomic burden, as ACL injuries account for nearly 60% of all knees joint traumas. The purpose of this study is to emphasize the role of arthroscopic ACL reconstruction and the challenges in postoperative pain management. Methods: This study involved 90 patients undergoing ACL reconstruction, categorized into three groups receiving different pain management protocols. The focus was on evaluating the efficacy of multimodal analgesia using lidocaine and magnesium sulfate. The main outcome was pain assessment using the Visual Analog Scale (VAS). Results: Patients receiving fentanyl, lidocaine, and magnesium sulfate (FLM) reported significantly lower pain scores in the postoperative period. Minimal use of additional opioids was observed, suggesting effective pain management with the multimodal analgesia regimen. Conclusions: The study showed that multimodal analgesia, including FLM, effectively manages postoperative pain following ACL reconstruction. This study showed significantly lower pain scores with FLM, highlighting its potential in early postoperative pain relief. Future research should consider long-term outcomes and cost-effectiveness, emphasizing the need for more comprehensive evaluations of multimodal analgesia’s impact. Full article

The skin is crucial for homeostasis and body defense, requiring quick healing to maintain internal balance. Initially used for bone repair, calcium hydroxyapatite (HAp) is now being studied for soft tissue engineering. This literature review investigated HAp’s role in tissue repair through searches on PubMed, Scopus (Elsevier), Science Direct, Springer Link, and Google Scholar databases without time restrictions, using keywords “hydroxyapatite AND skin AND wound” and “hydroxyapatite AND skin repair”. Inclusion criteria encompassed in vivo studies in humans and animals, English publications, full access, and sufficient data on HAp’s role in tissue repair. Exclusions included duplicates, unrelated articles, editor letters, reviews, comments, conference abstracts, dissertations, and theses. Out of the 472 articles initially identified, 139 met the inclusion criteria, with 21 focusing on HAp for tissue repair. Findings indicate that HAp and nano-HAp in skin regeneration are promising, especially when combined with other biomaterials, offering antimicrobial and anti-inflammatory benefits and stimulating angiogenesis. This suggests their potential application in dermatology, surgery, and dentistry, extending HAp’s versatility from hard tissues to enhancing critical properties for soft tissue repair and accelerating healing. Full article

Background: The use of telerehabilitation after sports medicine procedures such as an arthroscopic rotator cuff repair (ARCR) and anterior cruciate ligament reconstruction (ACLR) has rapidly increased in recent years; however, the functional outcomes and patient satisfaction with telerehabilitation compared to in-person rehabilitation remain unclear. The purpose of this study was to compare the functional outcomes and patient satisfaction with telerehabilitation to in-person rehabilitation in a randomized controlled trial after two common sports procedures, ARCR and ACLR. Methods: Two randomized controlled trials were conducted involving patients scheduled to undergo ARCR or ACLR by one of six fellowship-trained sports medicine surgeons between October 2020 and November 2021. Each trial had an enrollment goal of 60 patients. Subjects were randomized 1:1 to receive telerehabilitation or in-person rehabilitation postoperatively. Functional outcome and satisfaction metrics were collected at baseline and at post-operative visits and compared between groups. Results: In total, 16 ACLR patients were enrolled, of whom 10 (62.5%) were assigned to in-person rehabilitation and 6 (37.5%) to telerehabilitation. Additionally, 32 ARCR patients were enrolled, of whom 20 (62.5%) were assigned in-person rehabilitation and 12 (37.5%) were assigned telerehabilitation. In total, of the 30 patients assigned to in-person rehabilitation, none reported a crossover to telerehabilitation. Of the 18 patients initially assigned to telerehabilitation, 12 (67%) completed the final follow-up survey, of which 11 (92%) reported a crossover; 9 patients completed in-person rehabilitation and 2 patients completed hybrid in-person and telerehabilitation. Conclusions: Patients preferred in-person rehabilitation compared to telerehabilitation after ACLR and ARCR, as evidenced by the nearly ubiquitous crossover from telerehabilitation to in-person rehabilitation in both studies. Our findings suggest that telerehabilitation protocols still need to be perfected, and that there may be a role for a hybrid in-person and tele-rehab model. Full article

Background: Skeleton involvement is one of the most significant aspects of Gaucher disease (GD). However, the treatment for spinal involvement in GD among patients undergoing enzyme replacement therapy (ERT) is poorly characterized. We present a case of progressive kyphotic spinal deformity in a young child caused by vertebral involvement, which was managed by posterior spinal fusion without anterior spinal release under ERT. Case presentation: This is a retrospective study. A 10-year-old boy presenting with progression kyphosis (thoracic kyphotic angle of 113°) associated with type-IIIb GD had undergone posterior spinal fusion with segmental pedicle screw fixation (from T6-L3) and Ponte osteotomy. The patient went back to school without further brace protection. Proximal junctional kyphosis (PJK) was observed at 4 months postoperatively. Revision surgery was performed to prevent neurological impairment. Additional posterior spinal fusion from T2–T6 and decompressive laminectomy were performed during the revision surgery. A 2-year follow-up showed no recurrence of PJK and solid fusion was achieved in the patient under ERT and brace protection. Conclusions: Posterior spinal fusion without anterior spinal release is a good treatment option for severe spinal deformity in patients with GD. However, the fusion level and reinforced fixation require careful consideration. Revision surgery and brace protection is needed as long as PJK is observed. Full article

Background: Monteggia-equivalent fractures are similar to Monteggia fractures but involve different patterns and locations. When these fractures include a severe radial head fracture, radial head arthroplasty (RHA) should be considered. RHA can be performed using Kocher’s approach or the less commonly used trans-olecranon approach, which has been less studied. This study evaluates the clinical and radiological outcomes of the trans-olecranon approach for RHA over 15 years. Methods: In this retrospective study, 45 cases of Monteggia-equivalent fractures were analyzed, focusing on patients over 18 with radial head fractures, treated by the same surgeon with RHA and open reduction and internal fixation (ORIF) of the proximal ulna via the trans-olecranon approach. Results: The cohort of 45 patients showed a mean flexion of 112.37° ± 13.7°, mean extension of 24.27° ± 17.9°, mean supination of 57.63° ± 28.9°, and mean pronation of 62.16° ± 29.07°. Clinical and radiographic measurements indicated satisfactory results, with acceptable complication and secondary procedure rates. Conclusion: The trans-olecranon, single-incision approach is effective for managing fractures involving the proximal ulna and radial head, offering adequate access to lateral elbow structures while minimizing damage to surrounding soft tissue. Therefore, this approach should be considered for patients presented with a Monteggia-equivalent fracture and an indication for RHA. Full article

Purpose: Proximal femur fractures (PFFs) in elderly patients lead to decreased productivity. Skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) are non-home destinations for post-discharge disposition. This study aims to evaluate the loss of independence (LOI) following PFFs and examine the economic impact it entails. Method: The literature from various databases was collected and analyzed retrospectively. The inclusion criteria included patients age > 18 years and articles published after 1990. All studies were screened, a PRISMA chart was used to demonstrate the search process, and 24 studies were finally used for review. Results: LOI following PFFs significantly increases with age. Fractures in geriatrics avail a significant amount of post-care resources and had longer lengths of stay. Furthermore, six pre-operative risk factors were identified for non-home disposition, including age > 75, female, non-Caucasian race, Medicare status, prior depression, and Charlson Comorbidity Index. Patients discharged directly to home have lower total costs compared to those discharged to rehabilitation units. Loss of independence increases with advancing age. Conclusions: PFFs can lead to a serious loss of independence among elderly patients. Female gender, advancing age, white population, co-existing morbidities, lack of proper care, post-operative infections, limitation in mobility following surgery, and impaired cognitive function following surgery are the factors that contribute to the decline in the rate of appropriate recovery following surgery. Therefore, these factors could necessitate permanent residence in a nursing facility (IRFs and SNFs), with a direct impact on economic, social, psychological aspects and the healthcare system. Full article

When performing surgical treatment for shoulder dislocation, the Remplissage procedure for large Hill-Sachs lesions, which correspond to off-track lesions, has been reported to yield satisfactory results using an arthroscopic approach. However, in cases of high-energy acute dislocation or acute-on-chronic dislocation, when the humeral head bony defect is too large, severe external rotation limitation may occur postoperatively, and if the bone quality is poor, there is a higher risk of anchor pull-out, leading to potential failure. To overcome these limitations, we opted to apply subscapularis augmentation instead, aiming to achieve satisfactory results. A 21-year-old male patient underwent subscapularis augmentation for a right shoulder dislocation accompanied by severe glenoid bone loss following seizures. Two years and three months later, he experienced another seizure episode without recurrence of right shoulder dislocation and showed satisfactory clinical outcomes. However, he developed a left shoulder dislocation. Therefore, we report a case of subscapularis augmentation as an alternative treatment for shoulder dislocation with significant glenoid bone loss. We aim to present a satisfactory outcome along with a literature review on this approach. Full article

Urinary tract infections (UTIs) are the most common bacterial infections in children, occurring both in children with normal urinary tracts and in ones with urinary tract abnormalities. Children with UTIs can present relevant clinical symptoms and risk long-term consequences. Current recommended preventive measures include chemoprophylaxis and dietary supplements such as cranberry, probiotics and vitamins A and E. Although chemoprophylaxis still represents the gold standard, it raises concerns about antimicrobial resistance. N-acetylcysteine (NAC), a precursor of the antioxidant glutathione, has been proven both to inhibit biofilm formation and to destroy developed biofilms. In adults, NAC has been demonstrated to prevent UTIs and to improve the effect of antibiotics, but so far it has not been analyzed as an antimicrobial option for pediatric UTIs. In this work, we aim to discuss the current applications of NAC in adult urology and its future possible evolutions in pediatric urology. Full article

Laparoscopic cholecystectomy (LC) is the gold standard of treatments for symptomatic gallstone disease. The aim of this study is to determine if postoperative opiate use is reduced with transversus abdominus plane (TAP) and rectus sheath (RS) regional anaesthetic blocks compared to port site local anaesthetic (LA) infiltration. A prospective, randomised cohort study was conducted of adult patients who underwent an emergency LC between 25 April 2022 and 25 May 2023. An amount of 40 mL of 0.375% ropivacaine was infiltrated as either TAP and RS blocks or to port sites. Patient demographics, operative data, and postoperative opioid use were collected from the medical record. In total, 138 patients were enrolled in this study: 73 patients allocated to the LA to port sites cohort (52.9%) and 65 patients in the TAP and RS cohort (43.5%). The most common indication for surgery was acute cholecystitis. The average amount of opiate analgesia use was 115.2 mg in the LA group compared to 61.2 mg in the TAP and RS group (p < 0.05). Optimisation of postoperative pain allows for early recovery, improved patient satisfaction, and improved cost-effectiveness for the health service. With a trend towards multimodal analgesia, the uptake of TAP and RS regional anaesthesia may help to achieve this goal. Full article

Objective: The goal of this systematic review was to identify the mechanisms associated with the enzymatic degradation of collagen and gelatin biomaterials and the possible associated flaws. Methods: Four databases (PubMed, B-On, Cochrane Library, and ResearchGate) were used for the bibliographic search of articles. The research question was formulated using the PCC method, (P): collagen or gelatin sponges, hydrogels, and scaffolds; concept (C): enzymatic degradation of collagen or gelatin sponges, hydrogels, and scaffolds; and context (C): effect of enzymatic action on degradation time of collagen or gelatin sponges, hydrogels, and scaffolds. The search was contextualized according to PRISMA recommendations. The identification and exclusion of evidence followed the PRISMA criteria, with specific inclusion and exclusion factors being stipulated for the selection of articles. The risk of bias assessment was performed using the QUIN Scale. Results: The initial search was composed of 13,830 articles after removing duplicates; 56 articles followed for the full-text reading; 45 were excluded; then, 11 articles were obtained, constituting the results of this systematic review. All studies evaluated the materials using gravimetric analysis, and collagenases were the proteases used for the degradation solution. The materials tested were as follows: human-like collagen (HLC) hydrogel with microbial transglutaminase (MTGase), gelatin sponges subjected to different types of crosslinking, and collagen scaffolds with different types of crosslinking. The period of analysis varied between 0.25 h and 35 days. It was possible to highlight the lack of uniformity in the protocols used, which varied largely, thus influencing the degradation times. The risk of bias was low in nine studies and medium in two studies. Conclusions: This systematic review identified a gap in the literature, highlighting the absence of in vitro studies using human saliva and a collagenase concentration close to the physiological levels to simulate oral dynamics. However, based on existing literature, the mechanisms associated with collagen enzymatic degradation in collagen and gelatin biomaterials were comprehensively understood, answering the first research question postulated. In response to the second research question, the main shortcomings identified in the laboratory evaluation of mechanisms associated with collagen enzymatic degradation in collagen and gelatin biomaterials included the lack of standardization in degradation test protocols; this limited inter-study comparisons, which increased heterogeneity. Additionally, variations in collagenase concentrations and types influenced collagen degradation rates, and inappropriate evaluation intervals hindered the identification of total degradation time. Full article

Necrotizing fasciitis (NF) is a life-threatening soft-tissue infection affecting the deep fascia and subcutaneous tissue. It is characterized by a fulminant course and high mortality rates. NF of the head and neck is very rare, with most cases being odontogenic in origin. The purpose of this study is to comprehensively review the most important features of cervical necrotizing fasciitis (CNF) in adults and add our experience in the management of this entity. The most common isolated organisms are Streptococcus spp. and Staphylococcus spp. If the infection progresses to descending mediastinitis, the prognosis becomes very poor. Since the initial clinical features can be similar to those of a non-necrotizing deep cervical infection, a high degree of suspicion is critical for an early diagnosis. A computed tomography scan is essential for the diagnosis and to define the extent of the infection/rule out descending mediastinitis. Early and aggressive surgical debridement of all compromised tissue and antibiotic therapy and fluid resuscitation are essential and should not wait for bacterial culture results. Despite prompt and adequate treatment, the mortality of CNF can be as high as 35%. Full article

The challenges inherent in spinal oncology are multi-dimensional, stemming from the complex anatomy of the spine, the high risk of neurological complications, and the indispensability of personalized treatment plans. These challenges are further compounded by the variability in tumor types and locations, which complicates the achievement of optimal treatment outcomes. To address these complexities, the manuscript highlights the pivotal role of technological advancements in surgical practices. The review focuses on the evolution of spinal oncology instrumentation, with a special emphasis on the adoption of carbon fiber implants in the management of spinal tumors. The advancements in instrumentation and implant technology are underscored as vital contributors to the improvement in patient outcomes in spine surgery. Carbon fiber implants are lauded for their reduced imaging artifacts, biocompatibility, and favorable mechanical properties. When combined with other technological innovations, these implants have substantially elevated the efficacy of surgical interventions. The review articulates how these advancements emphasize precision, customization, and the integration of innovative materials, significantly enhancing the effectiveness of surgical procedures. This collective progress marks a considerable advancement in the treatment of spinal tumors, highlighting a shift towards more effective, patient-focused outcomes in spinal oncology. Full article

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common liver disease worldwide and simultaneously the most common indication for liver transplants in Western countries This study aims to evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB) on MDASLD histologically and biochemically. 14 studies met our criteria with a total population of 1942 who underwent LSG or RYGB 1–14. The Newcastle-Ottawa Scale (NOS) was used for quality evaluation of the included studies. Results: Both surgeries were effective in decreasing laboratory biomarkers like ALP, GGT, AST, and ALT with non-significant superiority of LSG over RYGB which did not significantly improve the AST level after one year. LSG showed more decrease in ALT levels (MD = −17.56, 95% CI = (−23.04, −12.089), p 0.001) and LSG was associated with increased change in NAS score with slight superiority. Both LSG and RYBG improve NAD and NASH outcomes after one and 10 years of surgery. However, randomized clinical trials with large samples are needed to confirm these results. Full article