Low-Dose Irradiation and Rotating-Hinge Revision for the Treatment of Severe Idiopathic Arthrofibrosis Following Total Knee Arthroplasty: A Review of 60 Patients With a Mean 6-Year Follow-Up.

BACKGROUND: Severe idiopathic arthrofibrosis after total knee arthroplasty (TKA) is a challenging problem to treat. Low-dose irradiation may decrease fibro-osseous proliferation, while rotating-hinge (RH) revision allows for distal femur shortening and collateral ligament sacrifice. This study reports the clinical outcomes and implant survivorship in patients treated with low-dose irradiation and RH revision for severe idiopathic arthrofibrosis following TKA. METHODS: A retrospective review was performed on 60 consecutive patients. Patients who had greater than 80° arc of knee motion or less than 15° flexion contracture were excluded. Mean follow-up was 6 years (range, 2 to 14). Kaplan-Meier survivorship analyses were performed, and logistic regressions were used to determine associations between preoperative patient characteristics and clinical outcomes. RESULTS: Median flexion contracture and median terminal flexion at presentation were 20 and 70°, respectively; at final follow-up, 59 of 60 patients (98%) had ≤10° flexion contracture and 49 of 60 patients (82%) had ≥90° of flexion. The 10-year survivorship free from reoperation for any reason, revision for any reason, and revision for aseptic loosening were 63, 87, and 97%, respectively. There were 27% percent of patients who underwent a manipulation under anesthesia postoperatively, which was the most common reason for return to the operating room. A greater number of prior surgeries was significantly associated with worse range of motion at the final follow-up (P = .004). There were no known radiation-associated complications. CONCLUSIONS: Patients with severe idiopathic arthrofibrosis following TKA treated with low-dose irradiation and RH revision maintained a gain in knee range of motion of 60° with reliable flexion contracture correction at a mean 6-year follow-up. A manipulation under anesthesia was common in the postoperative period. Survivorship free from revision for aseptic loosening was excellent at 10 years.

Are surgeons ready to get the COVID-19 vaccine?

BACKGROUND: Vaccination against COVID-19 has started in several countries already and is on its way in others. However, there is an important hesitance towards the vaccine. The aim of this study is to evaluate the vaccination hesitance and main concerns towards the vaccine among surgeons. METHODS: An anonymous survey of 16 questions was sent to 138 Belgian surgeons before the start of vaccination in Belgium. The questions were divided into sections, evaluating demographics, COVID-19 test status and symptoms, the surgeon's opinion on the COVID-19 vaccination and their main concerns. RESULTS: Ninety-three out of 138 surgeons (67.4%) completed the survey: two-third of them were residents. Sixty-nine surgeons (74.2%) do want to get vaccinated. Forty-two surgeons (45.2%) feel like they do not have enough information about the vaccine. Residents feel significantly more underinformed than consultants (52.3% and 29.0%, respectively). Surgeons who feel to be well-informed are more willing to get vaccinated (92.2%) compared to those who feel to have a lack of information (52.4%). The main concerns among surgeons include effectiveness (26.9%), safety and side effects (19.4%) and organisation and vaccination strategy (12.9%). Twenty-five surgeons (26.9%) have no concerns at all. CONCLUSION: Most surgeons (74.2%) are ready for their COVID-19 vaccine. However, some of the surgeons are still doubtful about the vaccine. A lack of information plays a major role in their scepticism. A strong communication strategy is necessary to educate, reassure and motivate surgeons to get vaccinated.

Intermediate-Term Results of 142 Single-Design, Rotating-Hinge Implants: Frequent Complications May Not Preclude Salvage of Severely Affected Knees.

Rotating-hinge knee prostheses have low survivorship and high complications except in primary arthroplasties in elderly patients. We retrospectively reviewed 142 single third-generation design, rotating hinge prostheses (11 primary procedures and 131 revisions) at 57 months follow up. Implant survival was 73%. Successful two-stage reimplantation for prosthetic infection was 78.4% but new infection rate was 22%. The tibial component was durable while the femoral component was problematic. We observed only one patellar maltracking and no polyethylene wear. A third generation rotating-hinge arthroplasty reconstruction was reliable in complex problems. Outcomes in primary situations were excellent. Complications were the rule rather than the exception in revisions. With timely intervention, attention to soft tissue coverage, and realistic expectations, complications were contained and functional benefits were appreciable.

Anterior distal femoral osteotomy for removal of long femoral stems in revision knee arthroplasty.

Osteotomies of the proximal femur and proximal tibia in revision arthroplasty are well described while guidelines for distal femoral osteotomy are limited. Femoral stems are used with increasing frequency for fixation of revision components in knee arthroplasty and their removal is technically challenging particularly in the setting of infection. We describe a technique of anterior distal femoral osteotomy for revision knee arthroplasty to assist with removal of well-fixed long stemmed cemented or porous femoral components, as well as debridement of infection while preserving bone stock and soft tissue attachments.

Artificial Intelligence in Plastic Surgery: Insights from Plastic Surgeons, Education Integration, ChatGPT's Survey Predictions, and the Path Forward.

Background: Artificial intelligence (AI) is emerging as a transformative technology with potential applications in various plastic surgery procedures and plastic surgery education. This article examines the views of plastic surgeons and residents on the role of AI in the field of plastic surgery. Methods: A 34-question survey on AI's role in plastic surgery was distributed to 564 plastic surgeons worldwide, and we received responses from 153 (26.77%) with the majority from Latin America. The survey explored various aspects such as current AI experience, attitudes toward AI, data sources, ethical considerations, and future prospects of AI in plastic surgery and education. Predictions from AI using ChatGPT for each question were compared with the actual survey responses. Results: The study found that most participants had little or no prior AI experience. Although some believed AI could enhance accuracy and visualization, opinions on its impact on surgical time, patient recovery, and satisfaction were mixed. Concerns included patient privacy, data security, costs, and informed consent. Valuable AI training data sources were identified, and there was agreement on the importance of standards and transparency. Respondents expected AI's increasing role in reconstructive and aesthetic surgery, suggesting its integration into residency programs, addressing administrative challenges, and patient complications. Confidence in the enduring importance of human professionals was expressed, with interest in further AI research. Conclusion: The survey's findings underscore the need to harness AI's potential while preserving human professionals' roles through informed consent, standardization, and AI education in plastic surgery.

Low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty.

Treatment options for arthrofibrosis following total knee arthroplasty include manipulation under anesthesia, open or arthroscopic arthrolysis, and revision surgery to correct identifiable problems. We propose preoperative low-dose irradiation and Constrained Condylar or Rotating-hinge revision for severe, idiopathic arthrofibrosis. Irradiation may decrease fibro-osseous proliferation while constrained implants allow femoral shortening and release of contracted collateral ligaments. Fourteen patients underwent fifteen procedures for a mean overall motion of 46° and flexion contracture of 30°. One patient had worsening range of motion while thirteen patients had 57° mean gain in range of motion (range 5°-90°). Flexion contractures decreased by a mean of 28°. There were no significant complications at a mean follow up of 34 months (range 24 to 74 months).

Intramedullary rod and cement static spacer construct in chronically infected total knee arthroplasty.

Two-stage reimplantation, with interval antibiotic-impregnated cement spacer, is the preferred treatment of prosthetic knee joint infections. In medically compromised hosts with prior failed surgeries, the outcomes are poor. Articulating spacers in such patients render the knee unstable; static spacers have risks of dislocation and extensor mechanism injury. We examined 58 infected total knee arthroplasties with extensive bone and soft tissue loss, treated with resection arthroplasty and intramedullary tibiofemoral rod and antibiotic-laden cement spacer. Thirty-seven patients underwent delayed reimplantation. Most patients (83.8%) were free from recurrent infection at mean follow-up of 29.4 months. Reinfection occurred in 16.2%, which required debridement. Twenty-one patients with poor operative risks remained with the spacer for 11.4 months. All patients, during spacer phase, had brace-free ambulation with simulated tibiofemoral fusion, without bone loss or loss of limb length.

Low-dose Preoperative Unshielded Radiation Is Effective in Heterotopic Ossification Prophylaxis and Does Not Affect Porous Fixation in Total Hip Arthroplasty at 2 Years Minimum Follow-up: A Radiographic Study.

BACKGROUND: Heterotopic ossification (HO) is a frequent complication of total hip arthroplasty (THA). HO can cause pain, limitation of range of motion, and instability. Radiation therapy (RT) for HO prophylaxis is well established but may interfere with early porous ingrowth and pullout strength of implants, as suggested by two animal studies. Although shielding of the bone from irradiation may theoretically protect ingrowth, it has been found to reduce RT effectiveness. Despite the popularity of porous implants in THA, the frequency of HO, and use of RT in its prophylaxis, the effect of RT on porous implant fixation in THA has not been previously reported. At our institution, we use unshielded, single-dose, preoperative 700 to 800 centigrays RT for HO prophylaxis in high-risk patients. We hypothesize that this RT protocol is effective and the press-fit technique protects porous implants during early ingrowth; therefore, long-term implant fixation is not compromised. METHODS: This was a retrospective study aiming to determine fixation of porous THA implants, healing of trochanteric osteotomies, and efficacy of HO prophylaxis with this RT protocol. RESULTS: Thirty-nine patients with follow-up of 24 to 144 months (average 59.7 months) were included. All 26 porous-coated femoral implants (11 revisions and 15 primary) were well fixed. There were 33 porous-coated acetabular implants (18 revisions and 15 primary). Thirty (91%) were well fixed, and three revision implants (9%) demonstrated radiolucent lines in two zones, but patients were clinically asymptomatic. All nine trochanteric osteotomies healed uneventfully. RT provided effective HO prophylaxis in 33 of 39 hips (85%). CONCLUSIONS: Single, low-dose, preoperative RT without shielding does not increase aseptic loosening of porous implants manufactured with plasma porous spray or nonunion of extended trochanteric osteotomies. This protocol provides effective HO prophylaxis in high-risk patients undergoing primary and revision THA.

Decancellation sacral osteotomy in iliosacral tumor resection: a technique for precise sacral margins.

En bloc resection of iliosacral sarcomas is a surgical challenge. There are substantial risks of inadequate margins, local recurrence, and nerve root loss when pelvic sarcomas involve sacral root canals and foramina. The decancellation technique uses principles similar to transpedicle decancellation in spinal deformity correction to perform the sacral osteotomy in iliosacral tumor resection. The technique aims at improving sacral margins and minimizing loss of neural function. We performed a decancellation osteotomy in five patients with sarcomas requiring difficult oblique or sagittal sacral osteotomies and selective root sacrifice. Through laminectomy and without anterior exposure, a precise full-thickness osteotomy of the sacrum was performed without major technique-related morbidities or complications. This was followed by formal pelvic resection and reconstruction. Surgical margins were adequate in all patients and all tumor-free nerve roots were preserved.

The Impact of Coronavirus Disease 2019 on Plastic Surgery Training: The Resident Perspective.

The coronavirus disease 2019 (COVID-19) pandemic has led to marked changes in surgical training, including that of plastic surgery residents. We performed a survey to gain an insight into the self-reported current and future impact of COVID-19 on plastic surgery residents. METHODS: A 20-point questionnaire was designed by a panel of surgical trainees and trainers, which was filled in by Belgian plastic surgery residents and their international network of peers between 19 and 26 April 2020-week 6 of stringent Belgian lockdown measures. Questions covered the impact of COVID-19 on surgical activity, surgical training, and the future of training. RESULTS: Thirty-five of 38 plastic surgery residents in Belgium filled in the questionnaire, as did 51 of their international peers from 9 other countries. Decreased surgical activity of >75% was reported by 86% of Belgian trainees and by 73% of international colleagues. All consultations were stopped for 26% of Belgian trainees and 37% of international peers. Forty-six percents of Belgian trainees and 27% of international peers were reassigned to different departments. Eighty-five percent of all trainees felt surgical training had suffered, yet 54% of Belgian residents and 39% of international peers felt training should not be prolonged. Anxiety regarding the pandemic was present in 54% of Belgian residents and 69% of international colleagues. CONCLUSIONS: This is the first report, expressing the voice of a representative group of plastic surgery residents, showing a significant impact of COVID-19 on training and activity. A joint effort is needed to provide continued forms of education by virtual education and skills-based learning.

Proximal Femoral Bone Cyst After Single Screw Fixation for Slipped Capital Femoral Epiphysis: A Case Report.

CASE: An 11-year-old female patient underwent bilateral in situ fixation for slipped capital femoral epiphyses using single, cannulated, stainless steel screws. She presented 12 years later with a large osteolytic lesion of the proximal femur, which only involved 1 side. Histological evaluation showed a foreign-body reaction and synovial lining. Infection was ruled out and dynamic hip screw stabilization, and bone grafting were performed. The bone graft healed, and the hardware was removed to prevent a similar reaction. In retrospect, postoperative radiographs at 7 weeks showed subtle osteolysis along the screw. CONCLUSION: Intra-articular drilling, vertical screw placement into the posterior epiphysis, and the prominent screw head may have led to this unexpected complication.

Epidemiology and clinical management of HIV-HBV coinfected patients in a large AIDS Reference Center in Belgium.

Objectives: Human immunodeficiency virus (HIV) and hepatitis B virus (HBV) are both worldwide health concerns with similar routes of transmission and no curative treatment to date. Coinfection is associated with increased morbidity and mortality. We aim to provide epidemiological data about HIV-HBV coinfected patients and asses if management of patients following European recommendation (EACS) was achieved in a large AIDS Reference Center in Belgium. Methods: Retrospective review of the HIV database of Saint-Pierre University Hospital in Brussels (Belgium) focusing on HIV-HBV coinfected patients in active follow-up. We classified patients in six serological profiles: (A) patients with active chronic HBV infection (HBsAg positive and HBeAg positive), (B) patients with persistent chronic HBV infection (HBsAg positive and HBeAg negative), (C) patients with isolated core antibody (isolated anti-HBc positive), (D) patients with resolved HBV infection (anti-HBc positive and anti-HBs positive), (E) vaccinated patients (anti-HBs positive), and (F) patients with all above markers negative. Chronic HBV infection (cHBV) was defined by two positive hepatitis B surface antigens (AgHBs positive) with at least 6-month intervals and chronic HBeAg positive group by a positive AgHBe (Ag HBe positive). We reviewed individual files of HIV-HBV chronically coinfected patients to assess if European recommendations in terms of HBV coinfection management were adequately followed in our center. Results: Among 2601 HIV-infected patients in active follow-up, 98 (3.8%) were chronically infected with HBV. Median age of chronically coinfected patients was 46 years with male predominance and heterosexual Africans representing the majority. Among the chronically coinfected patients, 33.7% were HBeAg positive carriers. Mean HBV DNA and ALT/AST were significantly higher in the chronic HBeAg positive (cHBeAg positive) patients compared to chronic HBeAg negative patients (cHBeAg negative). Nearly 95% of the cHBV patients were treated with two anti-HBV drugs (99% for the cHBeAg positive group), with 79% having Tenofovir (TDF) in their antiretroviral treatment history. 8% were screened for hepatitis D virus (HDV) antibodies. Liver fibrosis, upper endoscopy and alpha-foetoprotein were assessed at least once in the last 5 years in 32%, 31% and 32% of cHBV patients respectively. cHBeAg positive patients were not significantly monitored closer except for liver fibrosis assessment in 52% (p < 0.0017). Conclusion: The prevalence of cHBV coinfection in the Saint-Pierre HIV cohort is lower than in neighboring European countries. Hepatic monitoring should be reinforced in our cHBV and cHBeAg positive patients because of higher risk of progression to cirrhosis progression and hepatocellular carcinoma.

Obstructive teratoma in the right ventricle of a newborn: a case report.

BACKGROUND: A newborn was diagnosed by echocardiogram with an asymptomatic cardiac mass in the right ventricle after a systolic cardiac murmur was detected at birth. CASE PRESENTATION: Nine days after birth, the newborn presented with three syncopal episodes and oxygen desaturation which required resuscitation. The mass induced a complete right ventricular outflow tract obstruction. The presence of a patent foramen oval and a patent ductus arteriosus explained the absence of symptoms at birth. Surgery was rapidly considered since the situation was life threatening. The tumor was successfully resected. The mass was a mature teratoma confirmed by microscopic examination, illustrated by pictures and video. CONCLUSIONS: This case was unique because of the absence of symptoms in the first 9 days of the newborn's life even though symptoms should have mounted due to the obstruction postpartum. The delay was correlated to the closure of the patent ductus arteriosus. It is recommended that newborns with any cardiac mass be followed up regularly due to hemodynamic changes at birth.

Radiation-Induced Sarcoma After Heterotopic Ossification Prophylaxis: A Case Report.

CASE: Heterotopic ossification (HO) is a pathological formation of bone in nonosseous tissue and is a common complication of orthopaedic procedures. Radiotherapy is often used to prevent HO despite the small risk of secondary malignancy. Here, we report a case of a patient who developed a periprosthetic, radiation-induced sarcoma after delivery of a single fraction of 7 Gy for HO prophylaxis. This sarcoma was found to lie entirely within the treatment field and occurred within 5 years of radiation. CONCLUSION: Appropriate counseling regarding radiation-induced sarcoma formation should be provided to patients considering radiotherapy for this HO prophylaxis.

The subinguinal retroperitoneal approach for fractures of the acetabulum: a modified ilioinguinal approach.

The classic ilioinguinal approach is a standard procedure with reportedly high success rates in many displaced fractures of the acetabulum. Intraarticular visualization and exposure of the anterior wall and the quadrilateral plate are its main limitations. We propose a subinguinal approach based on the principle used for oncologic procedures that naturally require large exposures. The approach involves a retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allow ample exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the apparent magnitude of the procedure, closure is fairly simple and anatomical because repair of the inguinal canal floor is not required. This modification may compensate for the limitations of the classic approach without additional risks or morbidities.