Conjoint Tendon Lengthening Improves Internal Rotation Following Reverse Total Shoulder Arthroplasty: A Cadaveric Study.

INTRODUCTION: Reverse Shoulder Arthroplasty (RSA) is a common procedure for treating a variety of shoulder pathologies. However, many patients struggle with postoperative internal rotation deficits, which often hinder their activities of daily living. The conjoint tendon provides an anatomic barrier that can impede the postoperative internal rotation of the shoulder, and this study aims to evaluate the effect of a conjoint tendon lengthening on the glenohumeral range of motion following RSA. METHODS: This study used ten fresh-frozen cadaver specimens of the upper extremity. An RSA was implanted using a standard deltopectoral approach, and the range of motion was assessed post-implantation. Following this, the conjoint tendon was identified and lengthened using a tendon sheath z-plasty, and the range of motion was re-recorded. Statistical significance for the range of motion gains after conjoint tendon lengthening was determined with a significance level of p < 0.05. RESULTS: Following the lengthening of the conjoint tendon, there were statistically significant improvements in all ranges of motion (p < 0.05). Subjects demonstrated a notable gain in internal rotation to the back by 10.3 cm (p < 0.01), and all ranges of motion increased by at least 10°, except for forward flexion, which increased by 6° (p < 0.001). CONCLUSIONS: This study suggests that lengthening the conjoint tendon improves postoperative range of motion of the glenohumeral joint after RSA, offering a potential solution to a considerable internal rotation deficits that are commonly encountered post-RSA. Subsequent clinical and biomechanical studies should assess the stability of the shoulder joint following conjoint tendon lengthening.

Predictive Refined Computational Modeling of ACL Tear Injury Patterns.

Anterior cruciate ligament (ACL) ruptures are prevalent knee injuries, with approximately 200,000 ruptures annually, and treatment costs exceed USD two billion in the United States alone. Typically, the initial detection of ACL tears and anterior tibial laxity (ATL) involves manual assessments like the Lachman test, which examines anterior knee laxity. Partial ACL tears can go unnoticed if they minimally affect knee laxity; however, they will progress to a complete ACL tear requiring surgical treatment. In this study, a computational finite element model (FEM) of the knee joint was generated to investigate the effect of partial ACL tears under the Lachman test (GNRB® testing system) boundary conditions. The ACL was modeled as a hyperelastic composite structure with a refined representation of collagen bundles. Five different tear types (I-V), classified by location and size, were modeled to predict the relationship between tear size, location, and anterior tibial translation (ATT). The results demonstrated different levels of ATT that could not be manually detected. Type I tears demonstrated an almost linear increase in ATT, with the growth in tear size ranging from 3.7 mm to 4.2 mm, from 25% to 85%, respectively. Type II partial tears showed a less linear incline in ATT (3.85, 4.1, and 4.75 mm for 25%, 55%, and 85% partial tears, respectively). Types III, IV, and V maintained a nonlinear trend, with ATTs of 3.85 mm, 4.2 mm, and 4.95 mm for Type III, 3.85 mm, 4.25 mm, and 5.1 mm for Type IV, and 3.6 mm, 4.25 mm, and 5.3 mm for Type V, for 25%, 55%, and 85% partial tears, respectively. Therefore, for small tears (25%), knee stability was most affected when the tears were located around the center of the ligament. For moderate tears (55%), the effect on knee stability was the greatest for tears at the proximal half of the ACL. However, severe tears (85%) demonstrated considerable growth in knee instability from the distal to the proximal ends of the tissue, with a substantial increase in knee instability around the insertion sites. The proposed model can enhance the characterization of partial ACL tears, leading to more accurate preliminary diagnoses. It can aid in developing new techniques for repairing partially torn ACLs, potentially preventing more severe injuries.

Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft.

PURPOSE: To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up. METHODS: Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients' satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score. RESULTS: The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal. CONCLUSIONS: Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

Foot Surgery Using Resorbable Magnesium Screws.

The use of bioabsorbable magnesium (Mg) screws is new in foot surgery. Their relative merit over conventional titanium screws has not yet been proven. This prospective case series study was conducted to compare the clinical and radiological outcomes of bioabsorbable Mg screws and titanium screws. A consecutive series of patients (n = 60; 11 men and 49 women) underwent corrective hallux valgus surgery. The minimum follow-up period was 1 year. The assessment was based on a patient questionnaire, including the American Orthopedic Foot and Ankle Society (AOFAS) hallux valgus score, visual analog scale, patient's global impression of change (PGIC), and fifth metatarsus circumference (IF5C). The radiographic assessment included the intermetatarsal and hallux valgus angles, as well as time to osteotomy union and hardware failure. At 1 year, similar results were obtained radiographically. The healing of the osteotomies was significantly faster in the Mg group. Hardware failure was common in the Mg group (5/26) than in the TI group (0/34) but hardware removal was more common in the TI group (6/34) versus the MG group (0/26). IF5C increased by 8 ± 2 mm in the Mg group. The AOFAS and PGIC scores at 6 months were similar. Validated foot scores and radiographic analysis indicated that there was no detectable difference between the groups. The fast achievement of osteotomy union compensates for a high rate of hardware failure, resulting in patient satisfaction and avoiding reoperation for hardware removal.

Segmentation of polyps based on pyramid vision transformers and residual block for real-time endoscopy imaging.

Polyp segmentation is an important task in early identification of colon polyps for prevention of colorectal cancer. Numerous methods of machine learning have been utilized in an attempt to solve this task with varying levels of success. A successful polyp segmentation method which is both accurate and fast could make a huge impact on colonoscopy exams, aiding in real-time detection, as well as enabling faster and cheaper offline analysis. Thus, recent studies have worked to produce networks that are more accurate and faster than the previous generation of networks (e.g., NanoNet). Here, we propose ResPVT architecture for polyp segmentation. This platform uses transformers as a backbone and far surpasses all previous networks not only in accuracy but also with a much higher frame rate which may drastically reduce costs in both real time and offline analysis and enable the widespread application of this technology.

Epidemiology of Primary Shoulder Dislocations. A Cohort Study from a Large Health Maintenance Organization: 2004 to 2019.

BACKGROUND: Previous epidemiological studies on shoulder instability evaluated specific and relatively small subgroups of patients. OBJECTIVES: To determine the incidence rate of primary shoulder dislocations. METHODS: Cohort analysis of electronic health records from 2004 to 2019 was conducted in a urban district of a major health maintenance organization (HMO) in Israel. Patients presented with primary shoulder dislocation that was treated with closed reduction in any medical facility within the district. Overall incidence density rates (IDR) of primary shoulder dislocations and stabilization surgeries were determined. RESULTS: Over a period of 16 years 13,158 patients underwent closed reduction of primary shoulder dislocation. Of those, 712 shoulder stabilization surgeries were performed (5%). The IDR of primary shoulder dislocations were 124 per 100,000 person-years. The IDR of primary shoulder stabilizations were 7 per 100,000 person-years. The peak in the number of dislocations was observed in those 20-29 years old and ≥ 60 years of. In patients under 59 years old, dislocations were more common in men. In those ≥ 60 years of age, dislocations were more common in women. Most shoulder stabilization surgeries were performed on young patients. The annual mean time from the first dislocation to stabilization surgery linearly declined to 6 months in 2019. CONCLUSIONS: The IDR of primary shoulder dislocations calculated from the largest HMO in Israel were 124 per 100,000 person-years. Shoulder dislocations had bimodal age distribution. Overall, 5% of the patients (mainly young) with shoulder dislocations underwent shoulder stabilization surgery during the study period.

Epidemiology of primary shoulder dislocations requiring surgery: A cohort study from a major trauma center during 7 years.

PURPOSE: The epidemiology of shoulder instability in the general population is lacking. The aim of the current study was to determine the incidence rate of primary shoulder dislocations requiring surgical interventions in a major trauma center within a large maintenance organization. METHODS: A retrospective cohort analysis of electronic health records database from 1 January 2014 and 31 December 2020 was conducted in major rural trauma center. This study included all patients aged 10 years or older with a primary shoulder dislocation that were treated with closed reduction in the emergency room department. An overall incidence density rates (IDR) (per 100,000 person-years) of primary shoulder dislocations and stabilization surgeries were determined for the entire cohort. The data was used to evaluate the age-specific and gender-specific epidemiology. RESULTS: During the study period of 7 years there were 1,302 patients who underwent closed reduction after a primary shoulder dislocation (mean age 45 years). Of those, a total of 106 shoulder stabilization surgeries (8%) were performed. The IDR of primary shoulder dislocations was 179 per 100,000 person-years. The IDR of primary shoulder stabilizations was 15 per 100,000 person-years. The peak in number of dislocations was observed in the age groups of 20-29 years and over 60 years. In the age groups under 59 years dislocations were more common in men while in ages over 60 years dislocations were more common in women. The vast majority of shoulder stabilization surgeries were performed in young patients (age under 39 years). CONCLUSION: The IDR of primary shoulder dislocations calculated from a major trauma center of the largest health maintenance organization in Israel was 179 per 100,000 person-years. Shoulder dislocations had bimodal age distribution. Overall, eight percent of the patients (mainly young) with shoulder dislocations underwent shoulder stabilization surgery during the study period.

Comparing Sublingual and Inhaled Cannabis Therapies for Low Back Pain: An Observational Open-Label Study.

BACKGROUND AND OBJECTIVE: Medical cannabis is becoming an acceptable treatment modality in medicine, especially for pain relief. Concurrently, cannabis use is becoming more prevalent worldwide, a public demand-driven trend despite the lack of established scientific basis. This observational open-label study sought to investigate the effectiveness of cannabis therapy for alleviating low back pain symptoms. METHODS: Two types of cannabis treatment modalities were sequentially administered to chronic low back pain patients. After an initial 1-month washout period (WO1), the first modality was cannabidiol (CBD)-rich sublingual extract treatment administered for 10 months. Following another washout period, the second modality, Δ9-tetrahydrocannabinol (THC)-rich smoked inflorescence (whole dried cannabis flowers) was administered for 12 months. RESULTS: Enrolled in the study were 24 patients whose advanced imaging studies (i.e. computerized tomography or magnetic resonance imaging of the lumbar spine) revealed disc herniation or spinal stenosis. Three patients dropped out of extract therapy treatment but resumed study participation to receive THC-rich smoking therapy. After a minimum of 2 years, cannabis therapy had reduced lower back pain symptoms, as assessed by Oswestry Disability Index, the SF-12 patient-reported outcome questionnaire, and the visual analogue scale. Pain reduction was not significant during the extract treatment part of the study; however, pain reduction was significant during the inhaled therapy part of the study. CONCLUSIONS: Our findings indicate that inhaled THC-rich therapy is more effective than CBD-rich sublingual extract therapy for treating low back pain and that cannabis therapy is safe and effective for chronic low back pain.

Mild radiographic osteoarthritis is associated with increased pain and dissatisfaction following total knee arthroplasty when compared with severe osteoarthritis: a systematic review and meta-analysis.

PURPOSE: The association between severity of radiographic osteoarthritis with patient pain, function, and satisfaction following total knee arthroplasty has been disputed. The discrepancies in current literature prompt us to further examine this association in a systematic review and meta-analysis. METHODS: The OVID-Medline, Embase, and Web of Science databases were searched from their inception up to Mar 2020. The main independent variable was osteoarthritis severity as defined by preoperative radiographs. The outcomes measured were pain, function and satisfaction following total knee arthroplasty. A minimum of three studies assessing the same patient-reported outcome measures were included in the meta-analysis, as well as those separating patients by chronic pain or dissatisfaction. RESULTS: 29 studies were included in this study. Significant heterogeneity was seen between radiographic evaluation and reported outcomes. Patients with only mild radiographic osteoarthritis were more likely to suffer from chronic pain (odds ratio = 2.45, 95% CI = 1.80-3.34, p < 0.001) and dissatisfaction (odds ratio = 2.43, 95% CI = 1.79-3.31, p < 0.001) compared to patients with severe osteoarthritis. A significant association was found between mild radiographic severity and lower total Western Ontario and McMaster Universities Osteoarthritis scores (95% CI = - 0.37-0.06, p = 0.006) as well as Knee Society Scores (CI: - 0.54-0.16, p < 0.001). CONCLUSION: Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis. They are also at risk for chronic pain and dissatisfaction and should be consulted about this risk prior to surgery. LEVEL OF EVIDENCE: III.

Screening of Human Immunodeficiency Virus (HIV) among Newly Diagnosed Tuberculosis Patients in Eastern Sudan.

Tuberculosis (TB) is a leading cause of death in patients infected with Human Immunodeficiency Virus (HIV), and HIV infection is the most potent risk factor for the development of active TB disease from a latent TB infection. This study aims to determine the seroprevalence of HIV among newly diagnosed TB patients in Kassala state eastern Sudan. This was a descriptive, hospital-based, cross-sectional study of 251 active and newly diagnosed TB patients, selected by simple random sampling. Blood samples and demographic data were collected from each patient. TB was diagnosed by direct ZN smear and molecular detection by Xpert MTB/RIF. The serum samples were tested for HIV using 4th generation enzyme-linked immunosorbent assay (ELISA). The prevalence of HIV was 13.9% (35/251), the infection rate among pulmonary TB was 17%, whereas that in extrapulmonary TB was 4.8%, the prevalence was (18.2%) in the males, and (7.2%) in the females. In conclusion: TB/HIV co-infection in the Eastern part of Sudan was high compared with the global prevalence, all TB patients should therefore be assessed for HIV risk factors and advised to undergo HIV testing.

Efficacy of Anti-inflammatory Treatment Versus Rescue Analgesia After Arthroscopic Partial Meniscectomy in Nonarthritic Knees: A 3-Arm Controlled Study.

BACKGROUND: There is currently no consensus regarding the appropriate treatment for postoperative pain after arthroscopic partial meniscectomy (APM). Prescribing a mild non-anti-inflammatory protocol of rescue analgesia may be sufficient to avoid the side effects of opioids or anti-inflammatories. PURPOSE/HYPOTHESIS: The purpose was to compare the efficacy of pain reduction after APM in nonarthritic knees using betamethasone or celecoxib as anti-inflammatory analgesics versus acetaminophen or tramadol as rescue analgesics. The hypothesis was that there is no advantage for anti-inflammatories in achieving postoperative immediate pain relief after APM in nonarthritic knees compared with a simple nonopioid treatment. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This 3-arm controlled study evaluated postoperative pain levels and analgesic consumption in patients who underwent primary APM (under general anesthesia) at a single institution from December 2018 to December 2019. Patients were prospectively divided into 3 treatment groups: (1) betamethasone injection at the end of the procedure, (2) oral celecoxib prescription, or (3) neither treatment (control). All groups were instructed to take supplementary acetaminophen as needed. Patients were also allowed to take tramadol as needed to evaluate the need for opioids. At postoperative weeks 1, 2, and 3, patients completed the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, and results were compared between time points and groups. RESULTS: A total of 99 patients were included in the treatment groups: betamethasone group (32 patients), celecoxib group (30 patients), and control group (37 patients). At baseline, there were no statistically significant differences between the groups in age, sex, body mass index, level of activity, comorbidities, or surgical findings. KOOS Pain scores improved at every time point for all 3 groups (P < .001), and no differences in scores were observed among groups. The consumption of acetaminophen or tramadol as rescue analgesia throughout the follow-up period was negligible among groups. CONCLUSION: During the first 3 postoperative weeks after APM in nonarthritic knees, pain was efficiently controlled by betamethasone or celecoxib; however, pain was also efficiently controlled by minimal consumption of acetaminophen with negligible use of tramadol. Therefore, acetaminophen could be prescribed as an effective first-line postoperative analgesic after APM.

The rise, fall and resurrection of chemical-induced resistance agents.

Since the discovery that the plant immune system could be augmented for improved deployment against biotic stressors through the exogenous application of chemicals that lead to induced resistance (IR), many such IR-eliciting agents have been identified. Initially it was hoped that these chemical IR agents would be a benign alternative to traditional chemical biocides. However, owing to low efficacy and/or a realization that their benefits sometimes come at the cost of growth and yield penalties, chemical IR agents fell out of favour and were seldom used as crop protection products. Despite the lack of interest in agricultural use, researchers have continued to explore the efficacy and mechanisms of chemical IR. Moreover, as we move away from the approach of 'zero tolerance' toward plant pests and pathogens toward integrated pest management, chemical IR agents could have a place in the plant protection product list. In this review, we chart the rise and fall of chemical IR agents, and then explore a variety of strategies used to improve their efficacy and remediate their negative adverse effects. © 2021 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Preoperative pain sensitivity questionnaire helps customize pain management after arthroscopic partial meniscectomy.

PURPOSE: To evaluate correlations between preoperative pain sensitivity and postoperative analgesic consumption together with pain perception shortly after arthroscopic partial meniscectomy in non-arthritic knees. METHODS: Ninety-nine patients who underwent primary arthroscopic meniscectomy were prospectively divided into three postoperative treatment groups that were prescribed with betamethasone injection (at the end of surgery), oral celecoxib or rescue analgesia (control). Preoperative pain sensitivity was evaluated by pain sensitivity questionnaires (PSQ). Patients were followed for the first three postoperative weeks to evaluate knee injury and osteoarthritis outcome score (KOOS) pain scores and analgesics consumption. Statistical analysis included correlations among preoperative pain sensitivity, postoperative pain levels and analgesics consumption. A receiver operating characteristic curve was plotted to investigate the cutoff values of the PSQ score to predict insufficient postoperative pain reduction. RESULTS: There were no differences at baseline among all study groups in age, sex, BMI, level of activity, comorbidities and surgical findings. At the final follow-up, KOOS pain scores improved in all groups (p < 0.001). Mean final KOOS pain scores were 76.1 ± 15.2 for the betamethasone group, 70.8 ± 12.6 for the celecoxib group and 78.7 ± 11.6 for the control group. No differences in scores were observed among groups (n.s.). In the control group, a negative correlation was observed between PSQ score and KOOS-pain scores at the end of the follow-up in addition to a positive correlation between PSQ score and rescue analgesia consumption at the first postoperative week. The optimal cutoff value for PSQ score to predict insufficient improvement in KOOS-pain subscale was 5.0 points. CONCLUSIONS: A cutoff value of pain sensitivity questionnaire score above 5.0 points was determined to identify patients with higher sensitivity to pain who underwent arthroscopic partial meniscectomy. These patients reported relatively increased pain and consumed more rescue analgesics postoperatively unless treated with a single intraoperative corticosteroids injection or oral non-steroidal anti-inflammatories. Therefore, surgeons can use pain sensitivity questionnaire score as a preoperative tool to identify patients with high sensitivity to pain and customize their postoperative analgesics protocol to better fit their pain levels. LEVEL OF EVIDENCE: II.

Morphological and Histological Changes in the Human Anterior Cruciate Ligament after Rupture.

BACKGROUND: Injuries to the anterior cruciate ligament (ACL) are common and complete tears often fail to heal. ACL reconstruction is considered the surgical gold standard of care for ACL injuries in young active patients. OBJECTIVES: To determine the corresponding morphological and histological features of the torn ACL in different time periods after injury. METHODS: The study included 28 remnant specimens of torn ACLs from patients who had ACL reconstruction surgery of the knee. The remnant pathology was evaluated by its morphology during arthroscopy and by histopathologic measurements. RESULTS: At surgery there were three progressive and distinct morphological tear patterns. The first pattern was noticed within the first 3 months from injury and showed no scar tissue. The second pattern appeared later and was characterized by the appearance of scar tissue with adhesion to the femoral wall. The third pattern was characterized by adhesion of the ACL remnant to the posterior cruciate ligament. The histological changes of the first morphological pattern showed abundance of blood vessels and lymphocytes at the torn femoral end with few irregular collagen fibers. The second and third tear patterns showed decrement in the number of blood vessels and lymphocytes with longitudinally oriented collagen fibers. CONCLUSIONS: The morphological features of the ACL remnant in the first 3 months after injury showed no scar tissue and its histological features had the characteristics of a reparative phase. This phase was followed by a prolonged remodeling phase that ended with attachment of the remnant to the posterior cruciate ligament.

The Reliability of Classifying the Morphology of Anterior Cruciate Ligament Remnants during Surgery.

Arthroscopic classification of the torn anterior cruciate ligament (ACL) morphology is fundamental for clinical studies on emerging techniques such as repair and preservation. At present, the most acknowledged classification is Crain description of four morphological patterns. The purpose of the study was to analyze the intra- and interobserver reliability of Crain classification in patients undergoing ACL reconstruction surgeries. The study included 101 patients who had ACL reconstruction surgery between the years 2014 and 2017. The morphological pattern of ACL remnant scar formation during surgery was observed and classified according to Crain by three orthopaedic surgeons. Inter- and intraobserver reliabilities were measured using kappa statistics. Intraobserver reliability for the Crain classification ranged from 0.63 to 0.83 (substantial to almost perfect agreement). Interobserver reliability was 0.51 (moderate agreement). In almost a third of the cases, observers reported on additional morphological pattern of scar formation that was not well defined by Crain. A modified classification of four patterns was suggested: (A) without scar tissue, (B) with adhesion to the femoral notch (wall or roof), (C) with adhesion to the notch and posterior cruciate ligament (PCL), and (D) with adhesion to the PCL. Reanalysis of these four morphological configurations resulted in interobserver reliability of 0.82 (almost perfect agreement). In conclusion, the Crain classification of torn ACL remnant morphology has moderate interobserver reliability; however, a suggested classification with modified and additional configurations has almost perfect reliability and may be useful for studies on ACL repair and preservation.

Bridging the Accessibility Gap of Cannabinoid Medicine and Arabic Culture.

Arabs are a large minority group in the Israeli society. With the increasing use of medical cannabis throughout Israel due to changing governmental policies, the interactions of the Arab society with medical cannabis becomes of scientific and medical relevance. Recreational cannabis use is considered haram (forbidden) in Islam. However, most religious scholars agree that medical cannabis usage might be justified as zarurat (emergency and life-saving, therefore allowed) use. Obstacles to medical cannabis use within the Arabic population may relate to language barrier and/or cultural barriers. There are few Arabic-speaking web-based medical-cannabis support groups, and little official information about it is available in the Arabic language. In order for the full benefits of medical cannabis to reach the entire Israeli population, a government-sponsored web-based educational program is necessary in Hebrew and Arabic, both of which are among the nation's official languages, thereby contributing to the equalization of health resource accessibility.

Percutaneous surgery of the forefoot compared with open technique - Functional results, complications and patient satisfaction.

BACKGROUND: The use of percutaneous surgery is currently very common in foot and ankle surgery. The following prospective open-label patient-preference based study compares the traditional open technique versus the percutaneous surgery technique. METHODS: The current study describes the results of 287 patients operated due to forefoot deformities either by open surgery or percutaneously. 96 of them underwent hallux valgus corrective surgery. The rest had lesser toe deformities. They were followed for a period of up to 24 months, to assess the surgery related pain, complications, and patient satisfaction. 112 patients were operated using a conventional open technique were compared to 175 patients treated using a percutaneous technique. Technique choice was left to the patient preference, though older patients with disturbed blood flow, were advised to undergo percutaneous surgery. RESULTS: There is less pain using the percutaneous techniques relative to the open technique during the first 6 post-operative weeks. The 6, and 24 months FAOS score is similar in both groups. Complications are rare in any of the groups, with a significantly higher ASEPSIS score in the open surgery group. CONDCLUSIONS: Percutaneous forefoot surgery appears safe and efficacious, demonstrating equal radiographic (in a 96 strong cohort of hallux valgus patients) and clinical results at six and 24 months. Due to less post-operative pain, and less infection risk it appears that percutaneous techniques are superior to open technique in some respects of treatment and indeed the PGIC of patients was significantly higher in this group.

Simultaneous local excision of synchronous rectal polyps by transanal endoscopic microsurgery.

BACKGROUND: The approach to surgical resection of multiple rectal lesions when endoscopic polypectomy is unsuccessful has historically been radical rectal resection with total mesorectal excision. This approach is fraught with high morbidity and mortality. We explored the possibility of performing one transanal endoscopic microsurgery procedure to resect multiple synchronous rectal lesions. MATERIALS AND METHODS: A retrospective analysis of all adult patients undergoing transanal endoscopic microsurgery at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed for all patients with synchronous rectal lesions that were excised via one transanal endoscopic microsurgery procedure. RESULTS: Of the 158 patients who underwent transanal endoscopic microsurgery during the study period, 14 (8.8%) had two or more synchronous rectal lesions resected. The mean tumor size was 2.5 cm (range 0.5-3.5). The mean distance from the anal verge for the upper/proximal lesions: 10 ± 2.5 cm, and for the lower/distal lesions: 7 ± 2 cm. Mean operative time was 112 minutes (range 75-170). Median hospitalization time was 3 days (range 2-4). Two patients had urinary retention. No other complications were noted. All the transanal endoscopic microsurgery specimens were with clear margins. CONCLUSION: Transanal endoscopic microsurgery is a safe and feasible procedure for patients with multiple rectal lesions. We demonstrate no increase in surgical time, completeness of specimen resection, no increase in complications or hospital length or stay when compared to patients undergoing transanal endoscopic microsurgery for a single lesion.

Comparing the Temperature Effect of Dedicated Minimally Invasive Motor System to the Discontinuous Use of Rotatory Burrs in the Correction of Hallux Valgus.

The purpose of this study was to compare 2 motor systems for percutaneous osteotomy. The study consisted of 2 stages. In the first stage, bone temperatures during osteotomy using burrs or saw was measured using a thermal camera. In the second stage, the tissue and burr temperature elevation during surgery in 80 consecutive patients (96 feet) with hallux valgus undergoing distal first metatarsal and phalangeal osteotomies (hallux and in 61/96 feet lesser digits) were measured. The burr osteotomy procedure included the use of irrigated 2- or 4.1 mm rotary wedge burrs in discontinuous cutting bursts of less than 20 seconds. Tissue surface temperature was measured with a thermal camera. The temperature generated during the procedure was found to be significantly associated with the burr diameter used but was not affected by the type of motor. At the 6-week visit, thickness of the soft tissues over the first metatarsal head was similar in both groups. Temperature control using a noninvasive thermal camera is recommended to prevent tissue damage associated with heat generated during the use of rotary burrs. A dedicated low-speed high-torque system does not seem to be necessary and standard orthopaedic equipment can be used.Levels of Evidence: Level II: Comparative prospectively collected series.