Age-adjusted Charlson Comorbidity Index as an effective tool for the choice between simultaneous or staged bilateral total knee arthroplasty.

INTRODUCTION: The choice between simultaneous and staged bilateral total knee arthroplasty (BTKA) remains controversial. Age-adjusted Charlson Comorbidity Index(CCI) is a promising tool for risk-stratification. We aimed to compare the outcomes between patients who underwent simultaneous and staged BTKA, stratified by age-adjusted CCI scores. MATERIALS AND METHODS: We conducted this retrospective, single-surgeon case series from 2010 to 2020. This study consisted of 1558 simultaneous BTKA and 786 staged BTKA procedures. The outcome domains included 30-day and 90-day readmission and 1-year reoperation events. We performed multivariate regression analysis to compare the risk of readmission and reoperation following simultaneous and staged BTKA. Other factors included age, sex, body mass index, diabetes mellitus, rheumatoid arthritis, smoking, receiving thromboprophylaxis and blood transfusion. RESULTS: The rates of 30-day, 90-day readmission and 1-year reoperation following simultaneous BTKA was 1.99%, 2.70% and 0.71%, respectively. The rates of 30-day, 90-day readmission and 1-year reoperation following staged BTKA was 0.89%, 1.78% and 0.89%, respectively. For patients with age-adjusted CCI ≥ 4 points, simultaneous BTKA was associated with a higher risk of 30-day (aOR:3.369, 95% CI:0.990-11.466) and 90-day readmission (aOR:2.310, 95% CI:0.942-5.668). In patients with age-adjusted CCI ≤ 3 points, the risk of readmission and reoperation was not different between simultaneous or staged BTKA. CONCLUSION: Simultaneous BTKA was associated with an increased risk of short-term readmissions in patients with age-adjusted CCI ≥ 4 points but not in those with age-adjusted CCI ≤ 3 points. Age-adjusted CCI can be an effective index for the choice between simultaneous and staged BTKA procedures.

Beyond one step: unveiling optimal approach for bilateral knee arthroplasty - a comprehensive meta-analysis.

BACKGROUND: Total knee arthroplasty (TKA) is an efficient and common procedure used to treat advanced osteoarthritis of the knee. Geriatric patients make up the majority of TKA patients. For the surgical management of bilateral knee arthritis, there is still debate regarding whether to do a simultaneous or staged TKA. We through this study have gathered data and aimed to assess the safety of simultaneous bilateral TKA in patients. MATERIALS AND METHODS: We conducted a study according to the PRISMA guidelines by searching through various databases for the following search terms: total knee arthroplasty (TKA), complications following TKA, bilateral TKA, and bilateral vs. unilateral TKA. The search included case series and clinical trials and excluded review articles, yielding 24 articles from the original search. We extracted data upon the outcomes in patients undergoing simultaneous bilateral TKA. We performed additional bias assessments to validate our search algorithm and results. RESULTS: One hundred and three published articles were identified, and twenty-four that included a total of 2, 18,385 patients were included in the meta-analysis. 93,074 patients underwent simultaneous bilateral TKA and 125,311 patients underwent staged bilateral TKA. Simultaneous bilateral TKA was associated with significantly increased mortality rate (P < 0.00001, Odd's ratio [OR] 1.86, 95% Confidence interval [CI] 1.53-2.26), increased incidence of pulmonary embolism (P < 0.00001, OR 1.58, 95% CI 1.30-1.91), deep venous thrombosis (P < 0.00001, OR 1.31, 95% CI 1.17-1.46), and neurological complications (P < 0.002, OR 1.44, 95% CI 1.14-1.82). There were no significant differences in cardiac complications between both the procedures (P = 0.60, OR 0.93, 95% CI 0.70-1.23). CONCLUSION: Staged bilateral TKA is associated with less complication rates as compared to simultaneous bilateral TKA. Hence, patients should be counselled and selected based on the risks respective to each strategy.

Evaluation of staged autologous blood transfusion during extracorporeal membrane oxygenation decannulation: A retrospective study.

BACKGROUND: Clinical blood resources are scarce and autologous blood transfusion for extracorporeal membrane oxygenation (ECMO) withdrawal is less studied. OBJECTIVES: To assess the use of staged autotransfusion during ECMO decannulation. METHODS: The study included ECMO withdrawal patients. Patients in the autologous transfusion group underwent staged transfusion during ECMO withdrawal, while those in the control group received 2.0 units of allogeneic packed red blood cells (RBCs) to increase hemoglobin (Hb). Parameters such as Hb, hematocrit (Hct), adverse events, decannulation success rate, volume of allogeneic RBC transfusions, and transfusion costs were compared. RESULTS: A total of 82 Chinese patients were enrolled, with a mean age of 46 years, 27 were female, and the top three primary diagnoses were cardiac arrest, acute myocarditis, and severe pneumonia. There were 41 individuals in the autologous blood transfusion group and 41 in the control group. No significant differences were observed in Hb, Hct, adverse events, and the success rate for decannulation between the two groups (all P > 0.05). Compared with the control group, the volume of allogeneic RBC transfusions [0 (0∼1.50) U vs. 3.5 (1.88∼40) U, P < 0.001] and the total cost [130 (130∼390) Chinese Yuan (CNY) vs. 910 (487.50, 1040) CNY, P = 0.002] were lower in the autologous transfusion group. CONCLUSION: In comparison with allogeneic RBC transfusion, staged autotransfusion during ECMO decannulation not only effectively maintained Hb levels but also reduced the requirement for allogeneic RBC transfusions. In addition, this approach decreased the associated costs and did not increase the risk of clinical adverse events.

An Eye on the First Surgical Side: Appreciating the Potential Impacts of a Second DBS Lead on Ipsilateral Symptoms.

Clinical Vignette: A 63-year-old man with severe essential tremor underwent staged bilateral ventralis intermedius (Vim) deep brain stimulation (DBS). Left Vim DBS resulted in improved right upper extremity tremor control. Months later, the addition of right Vim DBS to the other brain hemisphere was associated with acute worsening of the right upper extremity tremor. Clinical Dilemma: In staged bilateral Vim DBS, second lead implantation may possibly alter ipsilateral tremor control. While ipsilateral improvement is common, rarely, it can disrupt previously achieved benefit. Clinical Solution: DBS programming, including an increase in left Vim DBS amplitude, re-established and enhanced bilateral tremor control. Gap in Knowledge: The mechanisms underlying changes in ipsilateral tremor control following a second lead implantation are unknown. In this case, worsening and subsequent improvement after optimization highlight the potential impact of DBS implantation on the ipsilateral side. Expert Commentary: After staged bilateral Vim DBS, clinicians should keep an eye on the first or original DBS side and carefully monitor for emergent side effects or worsening in tremor. Ipsilateral effects resulting from DBS implantation present a reprogramming opportunity with a potential to further optimize clinical outcomes. Highlights: This case report highlights the potential for ipsilateral tremor worsening following staged bilateral DBS and provides valuable insights into troubleshooting and reprogramming strategies. The report emphasizes the importance of vigilant monitoring and individualized management in optimizing clinical outcomes for patients undergoing staged bilateral DBS for essential tremor.

Staged versus non-staged elective hybrid iliofemoral revascularization - analysis of ten years of prospective data.

INTRODUCTION: Reports of large series of hybrid iliofemoral revascularization for chronic lower limb ischemia are scarce. The aims of this study were to evaluate outcomes for staged and non-staged procedures, and to evaluate risk factors for outcomes at 90 days. MATERIALS AND METHODS: Patients were consecutively included between 2013 and 2023. Surgical site infection (SSI) was defined by the ASEPSIS criteria and major adverse limb events (MALE) as onset of acute or continuing or worsening chronic limb ischemia or major amputation. Factors associated with outcomes were tested in a multivariable logistic regression analysis and expressed in Odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Patients undergoing non-staged procedures (n=124) had higher TASC (Trans-Atlantic Inter-Society Consensus) class representing anatomical occlusive complexity, more often through-and through femoral guidewire access, more endoprosthesis, more covered stents, longer procedure time with open groin wounds, and less contralateral femoral access, than those undergoing staged procedures (n=31). The median time interval between the staged procedures was one day, and iliac stenting was done first in 77%. The median in-hospital stay was non-significantly longer in staged procedure (8 versus 6 days, p=0.053). The overall SSI and MALE rates were 25.8% and 20.0%, respectively, without differences between groups. Diabetes mellitus (OR 3.7, 95% CI 1.2 - 7.2]) and presence of a foot ulcer (OR 3.7, 95% CI [1.5 - 9.4]) were independently associated with MALE at 90 days. Postoperative hyperglycemia was non-significantly associated with SSI (OR 2.1 [95% CI 1.0 - 4.5], p=0.066) in multivariable analysis. CONCLUSION: The risks of SSI and MALE after elective hybrid iliofemoral revascularization were high. There appears to be no benefit in performing staged as opposed to non-staged procedures. The extent of iliofemoral occlusive disease according to the TASC classification had little influence on outcomes whereas diabetes mellitus and presence of a foot ulcer had greater impact on MALE.

Shehata technique versus Fowler-Stephens orchidopexy in intra-abdominal testis: A meta-analysis.

INTRODUCTION: The management of intra-abdominal testis (IAT) represents a significant clinical challenge, necessitating the transposition of the testis from the abdominal cavity to the scrotum. This procedure is rendered complex by the abbreviated length of the testicular vessels. OBJECTIVE: Our purpose in this study was to conduct a systematic review and meta-analysis comparing Shehata technique (ST) versus Fowler Stephens technique (FST) in treating patients with IAT. STUDY DESIGN: We conducted a comprehensive literature search using several databases, including Ovid Medline, Cochrane, PubMed, Google Scholar, Web of Sciences, EMBASE, and SCOPUS until February 2024. This study included research that compared ST and FST for managing intra-abdominal testis. We evaluated the rates of atrophy and retraction, as well as the overall success rates, for both techniques. RESULTS: Six studies were identified as appropriate for meta-analysis, comparing orchidopexy performed using the ST with 169 patients, against the FST involving 162 patients. The comparison showed no statistically significant age difference at the time of surgery between the groups (I2 = 0%) (WMD 0.05, 95% CI - 1.24 to 1.34; p = 0.94). Operative time in first the stage was lower in the FST group than ST group (I2 = 95%) (WMD 10.90, 95% CI 1.94 to 19.87; p = 0.02). Operative time in the second stage was lower in the ST group than FST group (I2 = 83%) (WMD - 6.15, 95% CI - 12.21 to -0.10; p = 0.05). Our analysis showed that ST had a similar atrophy rate (I2 = 0%) (OR: 0.45, 95% CI: 0.20 to 1.01; p = 0.05). No difference was found between techniques in terms of retraction rate (I2 = 0%) (OR: 0.64, 95% CI: 0.17 to 2.47; p = 0.52). The ST demonstrated a notably higher overall success rate compared to FST (I2 = 1%) (RR: 1.14, 95% CI: 1.03 to 1.27; p = 0.009). Overall success rate in ST and FST were 87% and 74%, respectively. Overall atrophy rate in ST and FST were 5% and 12%, respectively. Overall retraction rate in ST and FST were 5% and 10%, respectively. DISCUSSION: The ST, renowned for its pioneering two-stage laparoscopic approach that leverages mechanical traction to lengthen the testicular vessels, is gaining popularity due to its recognized safety and efficacy. Conversely, the Fowler-Stephens technique, a traditional method that relies on collateral blood supply for testicular mobilization, has come under examination for its potential link to an increased risk of testicular atrophy. CONCLUSION: This meta-analysis reveals that the Shehata technique has similar or better outcomes compared to the Fowler-Stephens technique in IAT management. Further prospective multicentric randomized controlled trials are warranted.

Staged Bi-compartmental Knee Arthroplasty for Contralateral Compartment Failure After Medial Unicompartmental Knee Arthroplasty in Dialysis Patients: Two Case Reports.

Unicompartmental knee arthroplasty (UKA) is a minimally invasive surgical technique with good clinical outcomes; however, its outcomes in patients undergoing hemodialysis are unknown. Herein, we report two cases of patients undergoing hemodialysis who underwent staged bi-compartmental UKA (Bi-UKA) for early contralateral compartment failure after medial UKA. We describe the case of early contralateral compartment failure after medial UKA in two women patients aged 71 and 72 years with a dialysis history of seven and 22 years, respectively. Three months after right medial UKA, she had persistent joint edema and arthralgia after minor trauma, with recurrent gait disturbance in the first case. An MRI showed a bone marrow lesion in the contralateral compartment, and a lateral UKA was added. In the second case, the knee pain worsened without any trigger three years after leaving the medial UKA. A subchondral insufficiency fracture (SIF) was diagnosed by a plain radiograph showing a radiolucent area on the lateral femoral condyle. Gait disturbance did not improve, and a lateral UKA was performed. In our hospital, medial UKA was performed on seven knees of dialysis patients in 10 years since 2011, and contralateral compartment failure was observed in two knees at an early stage. In both cases, lumbar bone density was normal and there was no postoperative overcorrection in leg alignment, but a SIF of the contralateral side occurred, suggesting that bone fragility of the contralateral compartment due to long-term dialysis was the underlying cause. Staged Bi-UKA was minimally invasive and useful as a revision surgery.

Integrated Laparoscopic Management of Parastomal and Midline Incisional Double Hernias: A Staged Approach Including Hartmann's Reversal and Hernia Repair.

Parastomal hernia (PH) following Hartmann's procedure is a common late-term complication and is often combined with an incisional hernia (IH). The surgical treatment for double hernias with an end colostomy is complex and challenging. We present a 54-year-old woman with an end colostomy and combined hernias (PH and midline IH) after an emergency Hartmann's procedure for diverticular perforation of the sigmoid colon underwent staged surgery. First, laparoscopic Hartmann's reversal (LHR) and PH repair with primary suture were performed. Ten months later, "intraperitoneal onlay mesh repair (IPOM) plus" methods were implemented for IH repair. Both surgeries were successfully conducted using a laparoscopic approach, and no evidence of hernia recurrence has been observed in the 12 months after the second surgery. This case report provides valuable insights into the surgical strategy for double hernias with an end colostomy.

Health Economic Evaluation of Patients With Colorectal Liver Metastases Randomized to ALPPS or TSH: Analysis From the LIGRO Trial.

Objective: This is a preplanned, health economic evaluation from the LIGRO trial. One hundred patients with colorectal liver metastases (CRLM) and standardized future liver remnant <30% were randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or two-staged hepatectomy (TSH). Summary Background Data: TSH, is an established method in advanced CRLM. ALPPS has emerged providing improved resection rate and survival. The health care costs and health outcomes, combining health-related quality of life (HRQoL) and survival into quality-adjusted life years (QALYs), of ALPPS and TSH have not previously been evaluated and compared. Methods: Costs and QALYs were compared from treatment start up to 2 years. Costs are estimated from resource use, including all surgical interventions, length of stay after interventions, diagnostic procedures and chemotherapy, and applying Swedish unit costs. QALYs were estimated by combining survival and HRQoL data, the latter being assessed with EQ-5D 3L. Estimated costs and QALYs for each treatment strategy were combined into an incremental cost-effectiveness ratio (ICER). Nonparametric bootstrapping was used to assess the joint distribution of incremental costs and QALYs. Results: The mean cost difference between ALPPS and TSH was 12,662€, [95% confidence interval (CI): -10,728-36,051; P = 0.283]. Corresponding mean difference in life years and QALYs was 0.1296 (95% CI: -0.12-0.38; P = 0.314) and 0.1285 (95% CI: -0.11-0.36; P = 0.28), respectively. The ICER was 93,186 and 92,414 for QALYs and life years as outcomes, respectively. Conclusions: Based on the 2-year data, the cost-effectiveness of ALPPS is uncertain. Further research, exploring cost and health outcomes beyond 2 years is needed.

Hybrid stage 1 palliation with simultaneous off-pump ventricular assist device placement in neonates with high-risk single ventricle anatomy: Initial experience.

Background: Infants with single ventricle heart disease and severe atrioventricular valve regurgitation have poor outcomes following conventional staged palliation. As such, ventricular assist device (VAD) placement along with hybrid stage 1 palliation has been proposed as a bridge to heart transplant. We present a novel surgical technique for VAD implantation concurrent with hybrid stage 1 that avoids cardiopulmonary bypass. Methods: We performed a retrospective review of our institutional experience with this novel surgical technique. Results: Three patients (weight, 2.7-3.5 kg; age, 3 to 5 days) underwent hybrid stage 1 with VAD placement, consisting of bilateral 3.5-mm expandable polytetrafluoroethylene (PTFE) pulmonary artery bands, a ductal stent, a 6-mm Berlin Heart outflow cannula onto the main pulmonary trunk with a 10-mm graft, a 6-mm Berlin Heart outflow cannula onto the right atrium, and a 10-mL Berlin Heart pump. In patients with severe aortic arch hypoplasia or coarctation, a 4-mm PTFE graft was sewn from the VAD outflow graft to the innominate artery to protect coronary and cerebral perfusion. Procedures were performed off bypass with minimal blood product use. Patients were extubated on postoperative days 2, 2, and 5. There were no procedural complications. All patients were transferred out of the intensive care unit and demonstrated appropriate weight gain. Anticoagulation strategy was bivalirudin and antiplatelet therapy. The patients underwent transplantation after 149 days, 157 days, and 288 days of support. Conclusions: Off-pump single ventricle VAD placement is technically feasible and can be done at the time of hybrid stage 1 palliation with minimal operative morbidity as a bridge to transplant.

Nearly 14-Fold Increased Risk of Manipulation Under Anesthesia After Total Knee Arthroplasty When Previous Contralateral Total Knee Arthroplasty Required Manipulation Under Anesthesia.

BACKGROUND: Stiffness remains a common complication after primary total knee arthroplasty (TKA). Manipulation under anesthesia (MUA) is the gold standard treatment for early postoperative stiffness; however, there remains a paucity of data on the risk of MUA after primary TKA if a prior contralateral TKA required MUA. METHODS: We performed a retrospective review of 3,102 patients who had staged primary TKAs between 2016 and 2021. The mean body mass index was 33 (range, 18 to 59) and the mean age was 67 years (range, 24 to 91). The mean preoperative range of motion for the first TKA was 2 to 104°, and for the contralateral TKA was 1 to 107°. The primary outcomes were MUA following first and second primary TKAs. Multivariable Poisson regressions were used to evaluate associations between risk factors and outcomes. RESULTS: The rate of MUA after the first TKA was 2.6% (n = 83 of 3,102) and 1.3% (n = 40 of 3,102) after the contralateral TKA. After adjustment, there was a nearly 14-fold higher rate of MUA after the second TKA if the patient had an MUA after the first TKA (relative risk, 13.80; 95% CI [confidence interval], 7.14 to 26.66). For the first TKA, increasing age (adjusted risk ratio [ARR], 0.65; 95% CI, 0.50 to 0.83) and increasing body mass index (ARR, 0.65; 95% CI, 0.47 to 0.90) were associated with lower risk for MUA. For the second TKA, increasing age was associated with a lower risk of MUA (ARR, 0.60; 95% CI, 0.45 to 0.80). CONCLUSIONS: For patients undergoing staged bilateral TKA, patients who undergo MUA following the first primary TKA are nearly 14-fold more likely to undergo an MUA following the contralateral primary TKA than those who did not have an MUA after their first TKA.

Lesion durability found during mandated percutaneous catheter ablation after surgical cryo-ablation for treatment of non-paroxysmal atrial fibrillation.

OBJECTIVES: Current recommendations support surgical treatment of atrial fibrillation (AF) in patients indicated for cardiac surgery. These procedures are referred to as concomitant and may be carried out using radiofrequency energy or cryo-ablation. This study aimed to assess the electrophysiological findings in patients undergoing concomitant cryo-ablation. METHODS: Patients with non-paroxysmal AF undergoing coronary artery bypass grafting and/or valve repair/replacement were included in the trial if concomitant cryo-ablation was part of the treatment plan according to current guidelines. The patients reported in this study were assigned to undergo staged percutaneous radiofrequency catheter ablation (PRFCA), i.e., hybrid treatment, as a part of the SURHYB trial protocol. RESULTS: We analyzed 103 patients who underwent PRFCA 105 ± 35 days after surgery. Left and right pulmonary veins (PVs) were found isolated in 65 (63.1%) and 63 (61.2%) patients, respectively. The LA posterior wall isolation and mitral isthmus conduction block were found in 38 (36.9%) and 18 (20.0%) patients, respectively. Electrical reconnections (gaps) in the left PVs were more often localized superiorly than inferiorly (57.9% vs. 26.3%, P = 0.005) and anteriorly than posteriorly (65.8% vs. 31.6%, P = 0.003). Gaps in the right PVs were more equally distributed anteroposteriorly but dominated in superior segments (72.5% vs. 40.0%, P = 0.003). There was a higher number of gaps on the roof line compared to the inferior line (131 (67.2%) vs. 67 (42.2%), P < 0.001). Compared to epicardial cryo-ablation, endocardial was more effective in creating PVs and LA posterior wall isolation (P < 0.05). Cryo-ablation using nitrous oxide (N20) or argon (Ar) gas as cooling agents was similarly effective (P = NS). CONCLUSIONS: The effectiveness of surgical cryo-ablation in achieving transmural and durable lesions in the left atrium is surprisingly low. Gaps are located predominantly in the superior and anterior portions of the PVs and on the roof line. Endocardial cryo-ablation is more effective than epicardial ablation, irrespective of the cooling agent used.

Two big bones, one big decision: When to fix bilateral femur fractures.

PURPOSE: For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. METHODS: The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. RESULTS: 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. CONCLUSION: Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

A case report of the treatment of carotid artery stenosis by staged angioplasty based on intraoperative TCD monitoring.

Objective: Cerebral hyperperfusion syndrome (CHS) is the most severe complication of carotid artery stenting (CAS) or endarterectomy (CEA). Staging treatment can effectively reduce the risk of CHS without increasing the risk of ischemic stroke. The first stage of balloon dilatation is critical for staged treatment. However, the successful criterion of the first stage balloon dilatation is still inconsistent. Method: In the current study presents a case of a 61-year-old male with bilateral internal carotid subtotal occlusion, transcranial doppler (TCD) was used to measure middle cerebral artery (MCA) flow rate on the narrow side of surgery and the results are promising. Result: Intraoperative TCD monitoring is expected to be an evaluation criterion for staged angioplasty for carotid artery stenosis. Conclusion: The approach of blood flow velocity in the brain based on intraoperative measurement of TCD during the treatment of this patient is a new idea for staging treatment in the future.

Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort.

PURPOSE: Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. METHODS: A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. RESULTS: The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). CONCLUSION: Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.

Identification of youth at clinical high-risk for psychosis: A community-based study from India.

AIM: A two-stage process, wherein self-report screening precedes the structured interview, is suggested for identifying individuals at clinical high-risk for psychosis (CHR-P) in community samples. Aim of this study was to screen a community youth sample from India for CHR-P using the two-stage method. Specific objectives were to assess concordant validity of the self-report measure and predictive validity of the two-stage method. METHODS: Based on probability sampling, 2025 youth aged 15-24 years were recruited from one rural and one urban area of Telangana, a Telugu-speaking state in India. Telugu version of the PRIME Screen-Revised (PS-R) and structured interview for psychosis-risk syndromes (SIPS) were used. CHR-P positive and negative cohorts were followed-up for transition to psychosis at 3-monthly intervals. RESULTS: One hundred ten individuals screened positive on PS-R. SIPS conducted on 67 out of 110 individuals confirmed 62 (92.54%) to be CHR-P positive. PS-R showed 98.41% sensitivity and 90.74% specificity. Among CHR-P positive, three participants transitioned to psychosis in 15 months. The hazard ratio for psychosis transition was 11.4. CONCLUSIONS: Screening accuracy of PS-R in the community youth sample in Telangana is optimum. The hazard ratio for psychosis transition in the community identified CHR-P indicates good predictive validity for the two-stage method.

Technical Aspects and Outcome of Multi-Staged and Single-Staged Thoracoabdominal Fenestrated Endovascular Aortic Repair.

PURPOSE: In some cases of endovascular thoracoabdominal or juxtarenal aortic aneurysm repair, a thoracic endograft in combination with a fenestrated renovisceral device may be needed in order to create a sufficient proximal landing zone. This study aimed to evaluate the technical aspects and postoperative morbidity of a single- or 2-stage approach. METHODS: Eighty-seven consecutive patients undergoing thoracic endovascular aortic repair (TEVAR) in combination with elective fenestrated repair (fenestrated endovascular aortic repair [FEVAR]; fenestrated Anaconda device) from 2015 to 2022 were included in this retrospective bicentric study. Underlying pathologies, aortic morphology, technical details, and postoperative morbidity were recorded. RESULTS: Single-staged ("1S," n=61) and 2-staged ("2S," n=26) interventions were compared. Indications were thoracoabdominal aneurysms (TAAAs) (Crawford I-IV) (n=56, 64%) and juxtarenal aneurysms (n=31, 36%). In 2S, the proportion of TAAA was higher than in 1S (2S: 77%, 1S: 59%; p=0.001). In 2S, the covered length of the descending aorta was longer (1S: 128±60 mm, 2S: 202±64 mm; p=0.003). Temporary aneurysm sack perfusion (TASP) was established in 11 (18%) of 1S and 1 (4%) of 2S patients (p=0.079), as well as cerebrospinal fluid (CSF) drainage catheter in 48 (79%) of 1S and 19 (73%) of 2S. The rate of spinal cord ischemia (SCI) and the severity of SCI were not different in both groups, with a total of 3 cases of persisting paraplegia. The rate of access complications was higher in 2S (n=6, 23%) than in 1S (n=4, 7%; p=0.027). Postoperative 30 day morbidity did not significantly differ in both groups and neither did 30 day mortality (4.6% in 1S vs 3.8% in 2S; p=0.083). CONCLUSION: The combination of TEVAR and FEVAR using a fenestrated endograft is feasible and safe. Aortic morphology does not change significantly after endovascular repair. A single-staged strategy is feasible with excellent results, especially in Crawford IV, Crawford V, or juxtarenal aneurysms. Two-staged repair is recommended in cases with long aortic coverage and a higher American Society of Anesthesiologists (ASA) class. Follow-up data are needed to evaluate the long-term stability of the TEVAR/FEVAR interconnection. CLINICAL IMPACT: Our study has revealed the safety and efficacy of the combination of TEVAR and FEVAR in the treatment of TAAAs and juxtarenal aneurysms with compromised supravisceral landing zones. A single-staged concept is not necessary in all cases. Staged procedures may reduce postoperative morbidity in cases with long aortic coverage and higher ASA class.

The interval between staged bilateral total knee arthroplasties does not affect early complications of the second knee or long-term function of the first and second knees.

BACKGROUND: This study explored the optimal time interval between staged bilateral total knee arthroplasty (BTKA) to minimize early complications of the second TKA and maximise the long-term function of the first and second knees. METHODS: We retrospectively reviewed 266 patients who underwent staged BTKA between 2013 and 2018. Groups 1-4 had time intervals between BTKAs of 1-6, 6-12, 12-18, and 18-24 months, respectively. Demographics, postoperative complications within 90 days of the second TKA, Knee Society Score (KSS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) score were compared among the groups. RESULTS: In total, 54, 96, 75, and 41 patients were assigned to groups 1-4, respectively. Although group 1 had the highest overall complication rate (11.11%), there was no significant difference in the complication rate among the four groups. Also, no significant differences were found among the four groups in functional and patient-reported outcomes, in either the first or second knee at 5 years postoperatively, including KSS-knee, KSS-function, WOMAC-pain, WOMAC-stiffness, and WOMAC-physical function. The interval between BTKA did not influence complications or the function of the second knee. The TKA type (posterior-stabilised vs. medial-pivot) and age did not correlate significantly with any scores. CONCLUSIONS: There was no group difference in early complications of the second TKA, and postoperative function was equivalent between the two knees and did not vary by the interval between surgeries. The results of this study give surgeons and patients more choices. If patients cannot tolerate severe symptoms in the contralateral knee after the first TKA, the second TKA should be performed as early as possible. If knee joint function is not well recovered after the first TKA, and patients are anxious to undergo the second TKA, surgeons can advise patients to postpone the operation based on these results.