Multimodal treatments of brain arteriovenous malformations: a comparison of microsurgical timings after endovascular embolization.

Background: To compare the clinical outcomes of hybrid microsurgery and embolization with multi-staged procedure for patients harboring brain arteriovenous malformations (bAVMs). Methods: We retrospectively reviewed bAVM patients from a multicenter, prospectively collected database (NCT03774017) between June 2016 and June 2020. Patients were divided into single-staged hybrid operation (HO) group and multi-staged operation (MO) group according to the received treatment, in which microsurgeries were performed with embolization in a single setting or with multi-stage procedure, respectively. Cases were 1:1 matched between the two groups. Outcomes were compared between groups, which included neurological deficits (NDs), perioperative rupture, and proportion of complete resection. Variables associated with NDs were analyzed. Results: In total, 198 out of 544 cases were identified, including 120 in the HO group and 78 in the MO group. Sixty-six cases were matched in each group resulting in a total of 132 patients in this case-controlled study. Mean age was 29.2 years old, with 82 (62.1%) being male. No significant difference was observed in baseline demographics and clinical characteristics between the two groups. There were 7 ruptures occurred in the interval between embolization and microsurgery for MO group while none in the HO group (P=0.023). This yielded a rupture risk of 4.1% per year for the MO group. Duration of surgical resection was significantly reduced in HO group (P=0.001). Compared to MO, HO was more favorable to avoid short-term NDs (3.0% vs. 15.2%, P=0.021), but long-term outcomes were similar. The HO modality (OR, 0.110; 95% CI: 0.017-0.737; P=0.023) was confirmed as the protective factor for short-term NDs. Conclusions: HO is an effective setup to treat complex bAVMs with avoiding interval hemorrhage risk and reducing surgical risk. We also observed overall similar obliteration rate and resulting clinical outcomes between HO and MO.

Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty.

Background: Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs). Material and methods: Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides. Results: The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in "exposure" (9.5 vs 16.5 minutes) and "closure" steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides. Conclusion: Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical "exposure" and "closure" were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.

Single-Stage Posterior Approach for a Neglected Severe Kyphotic Spine With a Three-Year Follow-Up.

Neglected spinal tuberculosis with severe kyphosis is uncommon. Spinal tuberculosis can present with back pain, neurological deficits, cold abscesses, or severe deformities. Diagnosis is made using laboratory, imaging, and tissue studies. Management can be done medically or surgically. As neurological deficits or severe deformities worsen, most surgeons prefer a surgical option. There have been different opinions regarding the surgical approach for spinal tuberculosis. This is a case of neglected spinal tuberculosis with severe kyphotic deformity treated with single-stage posterior instrumentation and fusion without any complications within in a three-year follow-up period.

Perioperative outcome and complications following single-staged Posterior Spinal Fusion (PSF) using pedicle screw instrumentation in Adolescent Idiopathic Scoliosis (AIS): a review of 1057 cases from a single centre.

BACKGROUND: There has been a growing interest in using all pedicle screw construct in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) surgery in recent years. However, studies focusing on perioperative outcome and complications utilizing only pedicle screw system in AIS population are lacking. This study aims to evaluate perioperative outcomes and to determine the prevalence of major and minor complications following single-staged PSF for AIS. METHODS: In this retrospective study of prospectively collected data, 1057 AIS patients operated between 2012 and 2019 were included. Main outcome measures were operative time, intraoperative blood loss, allogeneic blood transfusion rate, length of hospital stay after surgery, complication rate, and mean drop of haemoglobin (Hb) level. We documented the number of fusion levels, screw density, and postoperative radiographic parameters. RESULTS: There were 917 females and 140 males. Majority were Lenke 1 curve type (46.9%). Mean age was 15.6 ± 3.7 years, with mean BMI of 18.6 ± 3.2 kg/m2. Mean operative time was 146.8 ± 49.4 min. Average intraoperative blood loss was 952.9 ± 530.4 ml with allogeneic blood transfusion rate of 5%. Mean screw density was 1.27 ± 0.21 screws per fusion level. Average hospital stay after surgery was 3.5 ± 0.9 days. Twenty-four complications were documented: twelve superficial infections (1.14%), five transient neurological deficits (0.47%), two deep infections (0.19%), two superior mesenteric artery syndrome, and one case each (0.09%) for massive intraoperative blood loss, intraoperative seizure, and lung atelectasis. CONCLUSION: AIS patients treated with single-staged PSF using pedicle screw construct had a 0.95% rate of major complications and 1.32% rate of minor complications. Rate of neurologic complication was 0.47% while non-neurologic postoperative complications was 1.80% with infection being the leading complication at 1.32%.

Cervical corpectomy in delayed presentation of irreducible cervical dislocation: experience with eight cases.

OBJECTIVE: To describe a single-staged procedure for the management of neglected subaxial cervical spine injuries. METHODS: Between January 2012 and December 2014, 12 patients presented to us with healed cervical sub axial dislocations. The deformities could not be reduced using skull traction. Eight were operated with anterior cervical corpectomy. American spinal injury Association (ASIA) grade, Neck Disability index (NDI), and Visual analog scale (VAS) score were recorded throughout the patient course and CT was done at 12 months for assessment of fusion. RESULTS: Four patients improved from ASIA C to ASIA D, two patients improved from ASIA B to ASIA E, one patient improved from ASIA D to ASIA E and one patient remained static at ASIA B. All patients except one showed evidence of fusion on CT scan at 12 months. NDI improved from preoperative range (18-32, mean 25) to postoperative range (8-16 mean, 11.25), VAS from preoperative range (3-6, mean 4.25) to postoperative range (1-3, mean 1.75). CONCLUSIONS: Single-stage in situ fixation does not disrupt ongoing natural healing and has good clinical and radiological outcomes.

Single-staged male bladder exstrophy-epispadias complex reconstruction with pubic bone adaptation without osteotomy: 15-year single-center experience.

PURPOSE: To represent the 15 years' experience of an academic referral center for the reconstruction of bladder exstrophy-epispadias complex with a modified single-stage approach. Single-staged reconstruction techniques are commonly used for classic bladder exstrophy. However, combined bladder closure and epispadias repair have been taken into great consideration in patients with initially failed reconstruction or delayed primary closure. METHODS: A total of 49 boys underwent 1-stage bladder and epispadias repair with pubic bone adaptation and without the application of pelvic osteotomy. The mean ± SD age at surgery was 5.23 ± 2.04 months. Continence and social dryness were assessed in the follow-ups with 3 months intervals for the first year and biannually thereafter. RESULTS: The mean ± SD of follow-up was 127.25 ± 71.32 months. Urethrocutaneous fistula, stricture, wound infection, and hemiglans were developed in six distinct patients. However, no other major complications were noted. Three patients (6.1%) remained incontinent; while 32 (65.3%) children were socially continent and 14 (28.6%) children were waiting for toilet training. All the patients without previous failed closure were socially continent, while all incontinent patients had two failed closures in their history. No patient was rendered hypospadiac. CONCLUSION: Based on the experience of this institution, the application of single-stage reconstructive techniques can lead to continence, cosmetically pleasing appearance with promising outcomes, and reduction of overall operations, hospital stay and costs in the majority of cases as compared to multiple surgical procedures.

Perioperative outcome of severe rigid idiopathic scoliosis: Single-staged posterior spinal fusion utilizing a dual attending surgeon strategy. A report of 41 patients.

PURPOSE: Various surgical strategies including combined approach and spinal osteotomies in severe rigid scoliosis had been reported with significant perioperative complication rates. The use of single-staged posterior spinal fusion (PSF) utilizing a dual attending surgeon strategy for severe rigid scoliosis has not been widely reported. METHODS: This was a retrospective study aimed to evaluate the perioperative outcome of single-staged PSF in severe rigid idiopathic scoliosis patients (Cobb angle ≥90° and ≤30% flexibility). Forty-one patients with severe rigid idiopathic scoliosis who underwent single-staged PSF were included. The perioperative outcome parameters were operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, preoperative and postoperative hemoglobin, transfusion rate, patient-controlled anesthesia morphine usage, length of postoperative hospital stay, and perioperative complications. Radiological parameters included preoperative and postoperative Cobb angle, correction rate, side-bending flexibility, and side-bending correction index. RESULTS: The mean age was 16.9 ± 5.6 years. The mean preoperative Cobb angle was 110.8 ± 12.1° with mean flexibility of 23.1 ± 6.3%. The mean operation duration was 215.5 ± 45.2 min with mean blood loss of 1752.6 ± 830.5 mL. The allogeneic blood transfusion rate was 24.4%. The mean postoperative hospital stay was 76.9 ± 26.7 h. The mean postoperative Cobb angle and correction rate were 54.4 ± 12.8° and 50.9 ± 10.1%, respectively. The readmission rate in this cohort was 2.4%. Four perioperative complications were documented (9.8%), one somatosensory evoke potential signal loss, one superficial infection, one lung collapse, and one superior mesenteric artery syndrome. CONCLUSIONS: Severe rigid idiopathic scoliosis treated with single-staged PSF utilizing a dual attending surgeon strategy demonstrated an average correction rate of 50.9%, operation duration of 215.5 min, and postoperative hospital stay of 76.9 h with a 9.8% perioperative complication rate.

Single-staged Bilateral Revision Knee Prosthesis Results.

Total knee arthroplasty (TKA) can become impaired in the functionality of the bone-prosthetic unit for various reasons, thereby leading to prosthetic loosening. For patients with bilateral aseptic loosening, revision knee arthroplasty surgery is usually performed in different sessions. Today, with developing anesthetic techniques, the patients' intraoperative and postoperative additional medical treatment needs are reduced; there is a reduction in complication rates too. Complications such as laryngospasm, bronchospasm, malignant hyperthermia, respiratory depression, postoperative delirium, or cognitive dysfunction can be seen. In the postoperative period, patient satisfaction, with adequate pain control, makes the rehabilitation of the knee is easier and shortens the duration of hospital stay. In addition, the risks of complications such as deep venous thrombosis, pulmonary embolism, pneumonia, and urinary retention are decreased with early rehabilitation, preventing the development of arthrofibrosis. Maximum recovery in the early postoperative period may be possible with the early recovery of movement. Between the years 2017 and 2018, patients admitted to our hospital for bilateral TKA application due to bilateral aseptic loosening and the early results of the application of bilateral revision TKA in one session with four selected patients are compared according to the requirements for blood transfusion and overall costs. Patient selection was shared with the anesthesiologist and the decision to continue bilaterally was made in the intraoperative assessment. In patients who did not develop any pathologies in the initial operation, the second operation was performed, where the risks of the second operation were not taken into account. As a result, we conclude that bilateral revision TKA application on correct patient selection is a surgical procedure that can be performed safely by an experienced team.

Transpedicular Decompression/Debridement and Posterior Spinal Fusion With Instrumentation for Single-Level Thoracic Spinal Tuberculosis With Myelopathy-Is Anterior Column Reconstruction Necessary?

OBJECTIVES: The purpose of this study is to study the safety and efficacy of single-stage transpedicular decompression/debridement and instrumented posterior spinal fusion for single-level thoracic spinal tuberculosis with myelopathy without anterior column reconstruction. SUMMARY OF BACKGROUND DATA: Existing literature has many reports of transpedicular decompression/debridement and instrumented posterior spinal fusion with anterior column reconstruction. The quoted loss of correction is around 2°, but there is no strong evidence analyzing the loss of kyphosis correction, assessment of fusion in the same, without anterior column reconstruction. STUDY DESIGN: Retrospective study. METHODS: Study consisted of 57 patients of single-level thoracic tuberculosis with myelopathy from a single center who fulfilled the selection criteria. All underwent pedicle screw-rod instrumentation (2 up and 2 down), bilateral transpedicular decompression/debridement of granulation tissue/abscess, followed by instrumented posterior spinal fusion with local bone/B-tri-calcium phosphate. Patients were analyzed clinically (ASIA scoring) and radiologically by radiographs for kyphosis correction and CT scans at 2 years (for assessment of fusion). The grade of destruction was correlated with loss of kyphosis correction and neurologic improvement. RESULTS: There are 43 female and 14 male patients with a mean age of 46.7 years (18.4-74.2), mean follow-up of 3.4 years (2.1-8.4). The mean pre-op Cobb angle is 26.4° and mean correction obtained is 12.6° (47.8%). The mean loss of kyphosis after 2 years' follow-up is 3.6° (13.6%). The mean American Spinal Injury Association (ASIA) grade improvement after surgery is 1.05 (p = .001). There is no correlation observed between neurologic recovery and grade of destruction (R = -0.11). There is no correlation between the improvement in kyphosis and neurologic recovery (R = -0.05). Two-year postoperative CT scan showed solid interbody (55 patients) and posterior fusion (57 patients). CONCLUSION: Significant neurologic recovery, kyphosis correction, and posterior/interbody bony fusion can be obtained by transpedicular decompression/debridement and instrumented posterior spinal fusion (without anterior reconstruction) with maintained correction at 2 years.

Forehead galeal pericranial flap for single-staged total upper eyelid reconstruction in sebaceous gland carcinoma excision.

PURPOSE: To present a successful case of single-staged total upper eyelid reconstruction after sebaceous gland carcinoma excision by using forehead galeal pericranial flap. OBSERVATIONS: An 80-year-old female with a progressively enlarged left upper eyelid mass presented with ocular irritation, blurred vision, and gritty sensation despite topical antibiotics treatment. This multinodular mass involved the left total upper eyelid, compromised corneal surface integrity, and caused complete ptosis. Excisional biopsy confirmed advanced sebaceous gland carcinoma, which was followed by extensive excision. The resultant total upper eyelid defect was reconstructed by a forehead galeal pericranial flap accompanied by anterior and posterior lamellar grafts. For the 34-month follow-up period, patient remained symptom-free without tumor recurrence and achieved acceptable cosmetic outcome. CONCLUSION: The forehead galeal pericranial flap appears to be effective as single-staged total upper lid reconstruction following extensive sebaceous gland carcinoma excision to restore eyelid function, avoid corneal exposure, and achieve acceptable cosmesis.

Active Staphylococcus aureus infection: Is it a contra-indication to the repair of complex hernias with synthetic mesh? A prospective observational study on the outcomes of synthetic mesh replacement, in patients with chronic mesh infection caused by Staphylococcus aureus.

INTRODUCTION: The management of chronic mesh infection is challenging and controversial. The use of synthetic material to repair the abdominal wall in the infected setting is not recommended, especially in the presence of active infection caused by Staphylococcus aureus. METHODS: This is a prospective observational study designed to evaluate the outcomes in patients with active mesh infection caused by Staphylococcus aureus. Patients underwent simultaneous removal and replacement of polypropylene mesh. The treatment protocol included the complete removal of infected mesh, followed by the anatomical reconstruction, and reinforcement of the abdominal wall using a new onlay polypropylene mesh. Early and late wound complications, medical complications, and hernia recurrences were analyzed. RESULTS: From 2006 until 2014, 22 patients with a mean age of 57.2 years and mean BMI of 29,3 kg/m2 were studied. Sinuses were present in 21 patients. A recurrent ventral hernia was observed in 14 patients; two patients required a complex abdominal wall reconstruction due to enteric fistulas. Bowel resections or other potentially contaminated procedures were associated in 10 patients. Fourteen patients (63.6%) had an uneventful postoperative course; 5 (22.7%) patients had wound infections requiring debridement and three required partial (2) or total (1) mesh removal. Two patients died due to medical complications. Adverse results on long-term follow-up included one hernia recurrence after complete mesh removal and one persistent sinus after partial mesh removal requiring a reoperation to remove mesh remnants. All of the patients were considered free of infection after a mean follow-up of 44 months. CONCLUSIONS: Synthetic mesh replacement in patients with active Staphylococcus aureus infection has an acceptable incidence of postoperative wound infection and prevents hernia recurrence. Large-pore polypropylene mesh is a suitable material to be used in the infected surgical field as an onlay graft.