Is Internal brace augmentation a gold standard treatment compared to isolated Modified Brostrom Gould repair for chronic lateral ligament ankle instability? Effect on functional outcome and Return to preinjury activity: A retrospective analysis.

INTRODUCTION: Modified Brostrom Gould (MBG) repair is widely accepted procedure for chronic lateral ankle instability (CLAI), but there are limitations with regards to strength of repair and risk of reinjury and complications. Internal brace has been recently used as augmentation of standard MBG repair. It provides stronger construct, facilitates early mobilisation and protects repaired ligament with minimal surgical morbidity. The aim of present study is to compare the outcome of MBG repair without and with Internal brace augmentation (IB) in CLAI. METHODS: Retrospective analysis of 172 patients with CLAI who underwent MBG repair with or without IBA between November 2017 and October 2019. Patients were evaluated for Visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), Patients subjective satisfaction and return to preinjury activity level. RESULTS: 148 patients were included in the study with 87 in MBG group and 61 in IB group. The mean age, average injury-surgery interval and mean follow up duration was 40.6 ± 11.2 vs 37.5 ± 14.7 years, 13.1 ± 10.3 vs 14.1 ± 8 months and mean follow up duration of 24.2 ± 5.1 vs 20.7 ± 6.0 months respectively (p > 0.05). The mean time to return to preinjury activity level was significantly better in IB group compared to MBG group of 12.1 ± 2.3 vs 20.3 ± 3.9 weeks, p < 0.001. 55 (90.2%) patients in IB and 73 (83.7%) in MBG group return to preinjury activity level. Mean postoperative VAS score (1.9 ± 1.5 vs. 1.7 ± 1.4, p = 0.428), Mean MOxFQ score (19.7 ± 22.2 vs. 18.2 ± 15.4, p = 0.674) showed no significant difference between MBG and IB group respectively, at final follow up. CONCLUSION: The use of IB augmentation with MBG repair showed significantly better outcome in terms of early rehabilitation and return to preinjury activity level compared to isolated MBG repair. The functional outcome and VAS score were better in IB group compared to MBG group with no significant difference. LEVEL OF EVIDENCE: Level IV retrospective study.

Bleomycin Electrosclerotherapy Treatment in the Management of Vascular Malformations.

BACKGROUND: Intralesional injection of a sclerosing agent is a standard treatment for vascular malformations, but many repeat treatments are often required to achieve a response. The temporary application of an electrical field to the treated area increases cellular membrane permeability and therefore augments drug delivery. OBJECTIVE: To report a case series of patients with vascular malformations who received bleomycin electrosclerotherapy (EST). MATERIALS AND METHODS: A prospective observational case series of patients with vascular malformations treated with bleomycin EST. Only patients who did not respond or had limited response to standard sclerotherapy were included. The response to the treatment was assessed using a global assessment score and patient-reported outcome measures. RESULTS: Thirty patients were treated with EST. Most of the patients had venous malformations (57%). Complete response or significant improvement was observed in 17 (57%) and 7 (23%) patients, respectively. Most of the patients were satisfied or very much satisfied with the outcome of the treatment. Most commonly reported complications were swelling, pain, and bleeding. CONCLUSION: Electrosclerotherapy is a promising method of augmenting the efficacy of intralesional bleomycin injections when treating vascular malformations. It can potentially lead to a reduction in the administered dose and number of treatment sessions needed.

Effectiveness of Cadaveric Simulation in Neurosurgical Training: A Review of the Literature.

OBJECTIVE: Increased restrictions on working hours and the resultant decrease in theater time coupled with greater scrutiny to demonstrate proficiency at surgical tasks has resulted in the incorporation of simulators for surgical training. This literature review describes the use of cadaveric simulators in postgraduate neurosurgical training, with the aim to analyze their effectiveness in improving surgical performance. METHODS: An electronic literature search of the MEDLINE, Embase, and Cochrane Library databases was conducted to identify studies that look at the efficacy of cadaveric simulation in neurosurgical training. Studies that were eligible were those that assessed either objectively or subjectively the effectiveness of human cadaver models in cranial or spinal neurosurgical training. Studies that did not assess efficacy on training, looked at animal cadavers, or noncadaveric simulators were excluded. RESULTS: Twelve studies were deemed to meet the eligibility criteria. Only 4 of the studies used objective measures to assess the effectiveness of cadaveric simulators on training. Most studies reported a positive impact of cadaveric simulators on training. CONCLUSIONS: Most studies identified in this review failed to provide strong objective evidence for effectiveness in achieving competency and good outcomes in the theatres. Lack of use of validated skills assessment tools prevented studies from associating cadaveric training with improvement in operating skills. Future studies should aim to address these shortcomings and focus on validating cadaveric simulation, ensuring only those that improve performance of both technical and nontechnical skills are pursued.

Methodological shortcomings in the literature evaluating the role and applications of 3D training for surgical trainees.

AIM: There has been an increased interest in the use of three-dimensional (3D) technology in surgical training. We wish to appraise the methodological rigor applied to evaluating the role and applications of 3D technology in surgical training, in particular, on the validity of these models and assessment methods in simulated surgical training. METHODS: Literature search was performed using MEDLINE with the following terms: "3D"; "surgery"; and "training". Only studies evaluating the role of 3D technology in surgical training were eligible for inclusion and assessed for the level of evidence, validity of the simulation model, and assessment method used. RESULTS: A total of 93 studies were analyzed, and majority of reviewed articles focused on 3D displays (36) and 3D printing (35). Most of these studies were case series, the most common assessment was subjective (69), with objective assessment used by 57 studies. Very few studies provided evidence for validity of the model or the assessment methods used. CONCLUSIONS: 3D technology has a great potential in simulated surgical training. However, the validity of this technology and strong evidence for its beneficial effects in surgical training is lacking. Further work on validation of 3D technology and assessment tools is needed.

Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic Review and Meta-Analysis OBJECTIVE.: To identify whether intramuscular local anesthetic infiltration prior to wound closure was effective in reducing postoperative pain and facilitating early discharge following lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Local anesthetic infiltration prior to wound closure may form part of the multimodal strategy for postoperative analgesia, facilitating early mobilization and discharge. Although there are a number of small studies investigating its utility, a quantitative meta-analysis of the data has never been performed. METHODS: This review was conducted according the PRISMA statement and was registered with the PROSPERO database. Only randomized controlled trials were eligible for inclusion. Key outcomes of interest included time to first analgesic demand, total postoperative opiate usage in the first 24 hours, visual analogue score (VAS) at 1, 12 and 24 hours and postoperative length of stay. RESULTS: Eleven publications fulfilled the inclusion criteria. A total of 438 patients were include; 212 in the control group and 226 in the intervention group. Local anesthetic infiltration resulted in a prolonged time to first analgesic demand (mean difference (MD) 65.88 minutes, 95% confidence interval (95% CI) 23.70 to 108.06, P.0.002) as well as a significantly reduced postoperative opiate demand (M.D. -9.71 mg, 95% CI -15.07, -4.34, p = 0.0004). There was a small but statistically significant reduction in postoperative visual analogue score (VAS) at 1 hour (M.D. -0.87 95%CI -1.55, -0.20, p = 0.01), but no significant reduction at 12 or 24 hours (p = 0.93 and 0.85 respectively). CONCLUSION: This systematic review and meta-analysis provides evidence that postoperative intramuscular local anaesthetic infiltration reduces postoperative analgesic requirements and the time to first analgesic demands for patients undergoing lumbar spine surgery. Key research priorities include optimization of the choice and strength of local anaesthetic agent and health-economic analyses to strengthen the case for routine use of postoperative local anesthetics in lumbar spine surgery. LEVEL OF EVIDENCE: 1.

Effects of habitual physical activity on microsurgical performance.

We investigated the effect of physical activity on microsurgical performance. Forty novice candidates and 6 expert controls did a series of consecutive end-to-end microvascular anastomoses. To assess performance, we did a hand motion analysis and correlated the results with levels of habitual physical activity. Higher levels of activity in the novice candidates correlated with slower completion of anastomosis for medical students on day 1 (p=0.0035) and day 5 (p=0.0003). The same pattern was seen for postgraduate trainees on day 1 (p=0.024) and day 5 (p=0.0063). Higher level of activity also correlated with an increase in path length (total distance travelled and direction of travel) and in total movements on day 1 for medical students (p=0.016 and p=0.0021, respectively), and in total path length on day 1 for postgraduate trainees (p=0.0305).

A nutrient combination designed to enhance synapse formation and function improves outcome in experimental spinal cord injury.

Spinal cord injury leads to major neurological impairment for which there is currently no effective treatment. Recent clinical trials have demonstrated the efficacy of Fortasyn® Connect in Alzheimer's disease. Fortasyn® Connect is a specific multi-nutrient combination containing DHA, EPA, choline, uridine monophosphate, phospholipids, and various vitamins. We examined the effect of Fortasyn® Connect in a rat compression model of spinal cord injury. For 4 or 9 weeks following the injury, rats were fed either a control diet or a diet enriched with low, medium, or high doses of Fortasyn® Connect. The medium-dose Fortasyn® Connect-enriched diet showed significant efficacy in locomotor recovery after 9 weeks of supplementation, along with protection of spinal cord tissue (increased neuronal and oligodendrocyte survival, decreased microglial activation, and preserved axonal integrity). Rats fed the high-dose Fortasyn® Connect-enriched diet for 4 weeks showed a much greater enhancement of locomotor recovery, with a faster onset, than rats fed the medium dose. Bladder function recovered quicker in these rats than in rats fed the control diet. Their spinal cord tissues showed a smaller lesion, reduced neuronal and oligodendrocyte loss, decreased neuroinflammatory response, reduced astrocytosis and levels of inhibitory chondroitin sulphate proteoglycans, and better preservation of serotonergic axons than those of rats fed the control diet. These results suggest that this multi-nutrient preparation has a marked therapeutic potential in spinal cord injury, and raise the possibility that this original approach could be used to support spinal cord injured patients.