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New Online Studies

 

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March, 2017

 

Advanced Wound Healing

Potential Future Applications for Negative Pressure Wound Therapy and Installation Devices
Reuben A. Falola, MPH, Medical Student Research Scholar, Caitlin M. Ward, BA, Student, Madison J. Kim, Student, Tammer Elmarsafi, DPM, MBBCh, Diabetic Limb Salvage Fellow, John S. Steinberg, DPM, Attending Physician, Karen K. Evans, MD, Attending Physician, Christopher E. Attinger, MD, Attending Physician, Paul J. Kim, DPM, MS, Attending Physician, Department of Plastic Surgery, Center for Wound Healing, Georgetown University Hospital, Washington, DC

 

Dec-2016 - 761

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Abstract


Negative-pressure wound therapy (NPWT) applies vacuum pressure to a wound bed sealed by an adhesive dressing to improve wound healing. A cleansing solution, often antibiotics or saline, may be instilled into the wound bed concurrently and removed via suction, thus enhancing the therapeutic effect. The therapeutic effect results from improved blood flow and removal of inflammatory factors. Since 1995, the FDA has approved NPWT for medical use. Since then, this technology has been applied to different types of wounds, including diabetic and decubitus ulcers and postsurgical incisional wounds. There are many applications for NPWT that remain to be explored. In this article, we postulate on novel and future uses for NPWT, including application in targeted drug delivery, stem cell therapy, and the prospect of combination with filtration devices, adaptable smart dressings, and remote monitoring.

 

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General Surgery

Neurofibroma of the Gallbladder Not Associated with Neurofibromatosis
Tsutomu Namikawa, MD, PhD, Associate Professor, Department of Surgery, Yasuhiro Kawanishi, MD, Medical Staff, Department of Surgery, Yuki Fujieda, MD, Medical Staff, Department of Surgery, Kazune Fujisawa, MD, Assistant Professor, Department of Pathology, Eri Munekage, MD, Assistant Professor, Department of Surgery, Masaya Munekage, MD, PhD, Assistant Professor, Department of Surgery, Hiromichi Maeda, MD, PhD, Assistant Professor, Cancer Treatment Center, Hiroyuki Kitagawa, MD, PhD, Assistant Professor, Department of Surgery, Michiya Kobayashi, MD, PhD, Professor, Cancer Treatment Center, Department of Human Health , and Medical Sciences, Kazuhiro Hanazaki, MD, PhD, Professor, Department of Surgery, Kochi Medical School, Kochi, Japan

 

Dec-2016 - 800

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Abstract


An 82-year-old woman had visited her local clinic with a history of abdominal discomfort and dyspepsia related to meals over a period of several months. Esophagogastroduodenoscopy revealed a superficial spreading tumor that, on biopsy, was proven to be an adenocarcinoma, and colonoscopy revealed an ascending mass that was found to be an adenocarcinoma on biopsy, so the patient was referred to our hospital. Abdominal computed tomography revealed a mass in the ascending colon with regional lymph node swelling and a gallbladder stone measuring 1.5 cm in diameter. The patient underwent laparoscopy-assisted distal gastrectomy with cholecystectomy and right colectomy with regional lymph node dissection, resulting in a diagnosis of poorly differentiated adenocarcinoma invading the gastric submucosal layer and moderately differentiated tubular adenocarcinoma invading the colonic serosa with lymph node metastasis. Macroscopic examination of the gallbladder revealed a well-circumscribed, solid tumor measuring 0.3 × 0.3 cm with a firm consistency in the neck portion associated with lithiasis. Microscopic examination of the gallbladder tumor revealed infiltration of spindle-shaped neoplastic cells that were arranged in a fasciculated and woven pattern in abundant intersecting bundles. Immunohistochemical analyses were positive for S-100 protein and neurofilament. Although neurofibromas commonly occur in the superficial skin or subcutaneous region, isolated neurofibroma of the gallbladder is quite rare. To the best of our knowledge, this is only the 11th case of a neurofibroma of the gallbladder to be reported in English literature. In the present case, as in most previously reported cases, the tumor was found incidentally in the resected gallbladder following cholecystectomy for cholecystolithiasis.

 

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Endoluminal Vacuum Therapy as Treatment for Anastomotic Colorectal Leakage

Giovanni Milito, MD, PhD, Associate Professor, Department of Surgery, University Hospital of Tor Vergata , Rome, Italy, Giorgio Lisi, MD, Resident, Department of Surgery, University Hospital of Borgo Roma, Verona, Italy, Dario Venditti, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata , Rome, Italy, Michela Campanelli, MD, Resident, Department of Surgery, University Hospital of Modena, Modena, Italy, Elena Aronadio, MD, Resident, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Simona Grande, Intern, Department of Surgery, University Hospital of Messina, Messina, Italy, Francesca Cabry, MD, Researcher, Department of Surgery, University Hospital of Modena, Modena, Italy, Michele Grande, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy

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Abstract


Background: The clinical leakage rate after anterior resection varies from 2.8–20%, with a 6–22% mortality rate and a 10–80% risk of permanent stoma. Endo-SPONGE® (B. Braun Melsungen AG, Melsungen, Germany) may treat extraperitoneal anastomotic leakage in the lesser pelvis. It consists of an open-pored sponge inserted into the cavity. A drainage tube fixed to a low vacuum drainage system is then connected to the sponge through the anus.
Material and Methods: Between January 2007 and December 2014, 14 patients with anastomotic leakage following low anterior resection were treated with Endo-SPONGE® and were prospectively evaluated. In all patients, a CT-scan was performed and they received an intravenous antibiotic therapy with piperacillin+tazobactam (4.5g,3 times/daily). Complete healing was defined as endoscopically proven closure of the insufficiency cavity with a normal mucosa.
Results: Stapled straight end to end, colorectal anastomoses were performed in all patients between 3–7 cm above the anal verge, a protective loop ileostomy was performed in every patient. The diagnosis of anastomotic leakage was performed after a median interval of 14 days, the median size of the cavity was 81x46 mm. Fluid collection was drained, percutaneosly in 12 cases, surgically in two patients. The median duration of therapy was 35 days, with 3–14 sponge exchanges for each patient. Median healing time was 37 days. No intraoperative complications were recorded, however, we found five cases of mild anal pain treated medically.
Conclusion: Considering the literature and our results, the Endo-SPONGE® seems an effective, minimally invasive procedure to treat extraperitoneal anastomotic leakage, reducing morbidity, mortality, and hospital stay.

 

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Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): From A to Z
Gianlorenzo Dionigi, MD, FACS, 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and , Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Matteo Lavazza, MD , 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and , Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Alessandro Bacuzzi, MD, Division of Anesthesia, Ospedale di Circolo, Fondazione Macchi, Varese, Italy, Davide Inversini, MD, 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and , Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Vincenzo Pappalardo, MD , 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and , Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Ralph P. Tufano, MBA, MD, Division of Head and , Neck Endocrine Surgery, Department of Otolaryngology-Head , and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, Hoon Yub Kim, MD, PHD, Department of Surgery, KUMC Thyroid Center, Korea University College of Medicine, Seoul, Korea, Angkoon Anuwong, MD, Minimally Invasive and , Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand

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We depict the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Patient selection criteria are (1) ultrasonographically (US) estimated thyroid diameter no larger than 10cm, (2) US estimated gland volume ≤45mL, (3) nodule size ≤5mm, (4) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (5) follicular neoplasm, and (6) papillary microcarcinoma without evidence of metastasis. TOETVA is carried out through a three-port technique placed at the oral vestibule, one 10mm port for 30° endoscope and two additional 5mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscles bilaterally. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments. Intraoperative neuromonitoring is used for identification and dissecting and monitoring both the superior and inferior laryngeal nerves.

 

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Hernia Repair

Long-Term Outcome After Laparoscopic Repair of Primary, Unilateral Inguinal Hernia Using a Self-Adhering Mesh
Tim Tollens, MD, Consultant, Halit Topal, MD, Surgical Trainee, Alexander Lucardie, BSc, Registrar, Koen Vermeiren, MD, Consultant, Chris Aelvoet, MD, Consultant, Kurt Devroe, MD, Consultant, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium

Dec-2016 - 769

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Abstract


Following our previous study about a lightweight self-adhering mesh (Adhesix®, Cousin Biotech, Wervicq-Sud, France; distributed by Davol Inc., subsidiary of C.R. Bard, Inc.), we report the long-term results with the use of this mesh in patients treated for a primary, unilateral inguinal hernia without any other hernias. Prospectively collected data of 100 patients between February 2011 and February 2014 were analyzed. The mean follow-up time was 2.7 years (range 1–4), and mean length of hospital stay was 0.6 days (range 0.5–1). At the time of the last follow-up visit, two patients (2%) had a recurrent inguinal hernia. Compared to preoperative values, patients reported a significant reduction in their pain sensation (visual analogue scale, VAS) after one month (4.61 vs. 1.32; P<0.001). A difference in VAS scores remained significant at the last follow-up visit (1.31 vs. 0.28; P<0.001). Patients reported high quality of life scores. Only one patient (1%) developed a clinically significant seroma that required an evacuating puncture. Two patients (2%) had superficial wound infections. Neither mesh infections nor mortalities occurred. This study, with a long follow-up, confirms our previous results: use of the Adhesix® mesh is safe, feasible, and efficient in laparoscopic hernia repair.

 

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Laparoscopic Treatment of Giant Ventral Hernia: Experience of 35 Patients

Michele Grande, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata , Rome, Italy, Giorgio Lisi, MD, Resident, Department of Surgery, University Hospital of Borgo Roma, Verona, Italy, Michela Campanelli, MD, Resident, Department of Surgery, University Hospital of Modena, Modena, Italy, Simona Grande, Intern, Department of Surgery, University Hospital of Messina, Messina, Italy, Dario Venditti, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Casimiro Nigro, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Francesca Cabry, MD, Researcher, Department of Surgery, University Hospital of Modena, Modena, Italy, Massimo Villa, MD, PhD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy

807

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Abstract


Background: Minimal access surgery for incisional hernia repair is still debated, especially for giant wall defects. Laparoscopic repair may reduce pain and hospital stay. This study was designed to evaluate the feasibility of the laparoscopic technique in giant hernia.
Materials and Methods: From 2007 to 2013, 35 consecutive patients with giant ventral hernia, according to the Chevrel classification, underwent laparoscopic repair. Fourteen patients were obese, with a body mass index (BMI) > 30 and in 21 patients the mean BMI was 24 (range 22–28). In all patients, the wall defect was larger than 20 cm.
Results:
Mean operative time was 159±30 minutes, and, for defects larger than 25 cm, it was 210±20 minutes. Patient conversion did not occur. In 29 patients, the mean wall defect was 20x25 cm, and in six patients the mean wall defect was 26x31 cm, and, as measured from within the peritoneal cavity, the mean overlap was 5 cm (range 3–6). Short-term antibiotic prophylaxis consisted of Cefazolin 2 g IV (intravenous) the day of surgery. All patients were discharged within 72–96 hrs. The mean follow-up was 24 months. No infection occurred and no chronic pain was recorded. However, three seroma were observed (outpatient treatment) and two xiphoid recurrences were observed.
Conclusions: Laparoscopic hernia repair is technically feasible and is safe in patients with giant fascial defects as well as obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence. This approach should be reserved for patients with no history of previous hernia repair. Further studies are expected to confirm these promising results.

 

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Real-World Clinical Quality Improvement for Complex Abdominal Wall Reconstruction
Bruce Ramshaw, MD, Professor and Chair, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, Brandie (Remi) Forman, BA, Hernia Clinician and Patient Care Manager, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, Karla Moore, PhD, Dean, Academic Assessment and Planning, Daytona State College, Daytona Beach, Florida, Eric Heidel, PHD, Assistant Professor, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, Michael Fabian, MD, Surgeon, Department of Surgery , Halifax Health, Daytona Beach, Florida, Greg Mancini, MD, FACS, Associate Professor, Program Director, Department of Surgery, University Surgeons Associates, Knoxville, Tennessee, Girish P. Joshi, MBBS, MD, FFARCSI, Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Director of Perioperative Medicine and Ambulatory Anesthesia , Parkland Health and Hospital System, Dallas, Texas

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Introduction: Traditional methods of clinical research may not be adequate to improve the value of care for patients undergoing abdominal wall reconstruction (AWR). These patients are prone to high complication rates and high costs. Here, we describe a clinical quality improvement (CQI) effort to enhance outcomes for patients undergoing AWR.
Materials and Methods: CQI was applied for the entire care cycle for consecutive patients who underwent AWR from August 2011–September 2015. Initiatives for improving value during this period included use of long-term resorbable synthetic mesh as well as administration of preoperative bilateral transversus abdominus plane (TAP), and intraoperative abdominal wall blocks using long-acting bupivacaine as a part of a multimodal regimen. Outcomes data that measure value in the context of AWR were collected to compare outcomes for the patients who received TAP blocks only, TAP and intraoperative blocks, and those who received no block.
Results: One hundred and two patients who had AWR for abdominal wall pathology were included. Outcomes including total opioid use, duration of stay and opioid use in the postanesthesia care unit (PACU), length of hospital stay (LOS), major wound complications, and costs, all improved over time. Specifically, PACU opioid use, total opioid use, and LOS were decreased in the two groups that received blocks versus a group that did not have any type of block.
Conclusions: CQI program implementation in patients undergoing AWR resulted in measurable improvement of value-based outcomes over time. A CQI effort applied to the entire patient cycle of care should be routinely utilized.

 

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Orthopaedic Surgery

Intraarticular Administration of Tranexamic Acid is Safe and Effective in Total Knee Arthroplasty Patients at High-Risk for Thromboembolism
Ronald E. Delanois, MD, Director, Hip, Knee, and Shoulder Surgery, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Chukwuweike Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Jaydev B. Mistry, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Melbin Thomas, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Prathik P. Mudaliar, BS, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Vidur Tangri, BS, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

Dec-2016 - 792

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Introduction: Tranexamic acid (TXA) is an antifibrinolytic agent that can be used to reduce blood loss in total knee arthroplasty (TKA) patients. Due to its thrombogenic properties, intravenous (IV) TXA is contraindicated in patients who have an increased risk of arterial or venous thrombosis. For such patients, intraarticular (IA) TXA may be a safe alternative. In this study, we compare: 1) complication rates; 2) intraoperative blood loss; and 3) need for transfusion in TKA patients who received IA TXA versus patients who used IV TXA.
Materials and Methods: A retrospective chart review of a single surgeon was performed for patients who received a TKA and had either IV TXA or IA TXA (due to increased risk of thrombosis). This yielded 60 patients who had a mean age of 65 years (range, 36 to 84 years). Twenty-six patients received IA TXA as a consequence of being ineligible for IV TXA, because of increased risk for arterial or venous thromboembolism. Thirty-four patients received IV TXA. Complication rates and need for transfusion were evaluated as categorical variables. Amount of blood loss was evaluated as a continuous variable. All categorical variables and continuous variables were analyzed using chi-square test and student’s t-test respectively.
Results: Overall, four patients (7 %) developed complications after the procedure, three of which were in the IA cohort and one in the IV cohort (p= 0.444). In the IA cohort, two patients developed arthrofibrosis and subsequently underwent manipulation under anesthesia. Additionally, one patient in this group developed a hematoma one week after TKA. This patient was managed conservatively until the condition resolved, and no further issues have been reported. One patient in the IV cohort developed a deep vein thrombosis, which was appropriately treated with no further issues. There was no significant difference in mean blood loss or number of transfusions between patients who received IA TXA or IV TXA (289 mL vs. 268 mL, p= 0.503; 3 vs. 4, p= 0.651, respectively).
Conclusion: High-risk patients who have contraindications against intravenous TXA may be good candidates for intraarticular TXA. Our study demonstrated no significant differences in complication rates, blood loss, and transfusion rates in patients who received intravenous TXA as compared to those who received intraarticular TXA during total knee arthroplasty. We conclude that the intraarticular administration of TXA may be a safe and effective alternative for patients who have contraindications against intravenous TXA.

 

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A Randomized, Multicenter, Double-Blind Study of Local Infiltration Analgesia with Liposomal Bupivacaine for Postsurgical Pain Following Total Knee Arthroplasty: Rationale and Design of the Pillar Trial

Stan Dysart, MD, Board Certified Orthopaedic Surgeon, Pinnacle Orthopaedics, Marietta, Georgia, Mark A. Snyder, MD, Director of the Orthopaedic Center of Excellence at Good Samaritan Hospital, Wellington Orthopaedics and Sports Medicine, Cincinnati, Ohio, Michael A. Mont, MD, Chairman of the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio

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Dec-2016 - 777

Abstract


Introduction: Liposomal bupivacaine, a prolonged-release formulation of bupivacaine hydrochloride, is indicated for infiltration into the surgical site for postsurgical analgesia. Results from previous total knee arthroplasty (TKA) studies suggest that analgesic efficacy associated with liposomal bupivacaine may be impacted by variability in infiltration technique. The PILLAR study is designed to assess liposomal bupivacaine efficacy in TKA using a standardized infiltration protocol.
Materials and Methods/Design: This phase 4, multicenter, randomized, double-blind, controlled, parallel-group study will compare the safety and efficacy of infiltration with liposomal bupivacaine versus standard bupivacaine for postsurgical pain control in adults undergoing primary unilateral TKA. All subjects will receive a standardized pre-surgical analgesic regimen, and will be randomized to receive either liposomal bupivacaine 266 mg/20 mL (admixed with standard bupivacaine 0.5% 20 mL and expanded to a total volume of 120 mL) or bupivacaine 0.5% 20 mL (expanded to a total volume of 120 mL). The study drug will be infiltrated using six syringes (prefilled with 20 mL of study drug solution) to deliver 1-1.5 mL infusions into prespecified periarticular tissues. All subjects will receive standardized postsurgical analgesia and access to rescue medication. The co-primary efficacy endpoints are area under the curve of visual analog scale pain intensity scores from 12–48 hours postsurgery and total postsurgical opioid consumption from 0–48 hours. Secondary efficacy endpoints include other pain assessments, time to first use of rescue medication, discharge readiness, use of skilled nursing facilities, and hospital length of stay. Safety will be evaluated based on adverse events.
Discussion/Conclusion: The use of a standardized protocol comparing infiltration of equal volumes of the study drug, designed by experienced investigators to ensure complete coverage of all areas innervating the surgical site while minimizing leakage of study drug, will help define the role of liposomal bupivacaine in the setting of TKA.

 

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Factors Predisposing to Dislocation After Primary Total Hip Arthroplasty: A Multivariate Analysis of Risk Factors at 7 to 10 Years Follow-up
Michele Francesco Surace, MD, Professor and Director of the Residency Program, Orthopedics and Trauma Clinic, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy, Luca Monestier, MD, Orthopedic Surgeon, Orthopedic and Trauma Unit, ASST Sette Laghi, Varese, Italy, Fabio D’Angelo, MD, Professor, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Director Orthopedic and Trauma Unit, ASST Sette Laghi, Varese, Italy, Andrea Bertagnon, MD, Resident, Orthopedics and Trauma Clinic, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy

Dec-2016 - 778

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Background: Dislocation of primary THA (total hip arthroplasty) is one of the most undesirable complications with an incidence ranging from 2% to 5%. Several risk factors are described, related to the patient, surgery, or prosthetic design. The aim of the study was to assess risk factors and their potential influence on dislocation.
Materials and Methods: 387 primary THA were performed between September 2005 to December 2008 at our institute (Varese, Italy) through a modified posterior-lateral approach. Clinical evaluation was based on range of motion (ROM) and Harris Hip Score; femoral offset, acetabular inclination, and anteversion were measured on plain radiograms. Data were analyzed by SPSS software (SPSS, Inc., Chicago, Illinois).
Results: Excellent ROM and Harris Hip Scores were achieved in more than 95% of patients (p<0.05). The offset was restored in all patients. Most of the cases had their cup positioned in the “safe zone” (both inclination and anteversion). Six dislocations (1.87%) occurred: significant correlation was found between dislocation and preoperative diagnosis of femoral neck fracture.
Conclusions: THA dislocation rate appears not to be related to patient biometric parameters and prosthesis design. Femoral neck fracture is reported as the major risk factor for this complication, probably caused by higher preoperative activity and lesser compliance of the patient.

 

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Three-Year Results with a Ringless Third-Generation Porous Plasma Sprayed Acetabular Component in Primary Total Hip Arthroplasty

Keith R. Berend, MD, Vice President, Joint Implant Surgeons, Inc., New Albany, Ohio, Chief Executive Officer and President, White Fence Surgical Suites, New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Joanne B. Adams, BFA, CMI, Research Director and Medical Illustrator, Joint Implant Surgeons, Inc., New Albany, Ohio, Michael J. Morris, MD, Treasurer, Joint Implant Surgeons, Inc., New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Adolph V. Lombardi Jr., MD, FACS, President, Joint Implant Surgeons, Inc., New Albany, Ohio, Clinical Assistant Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio

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Introduction: We previously reported promising early results in patients undergoing primary total hip arthroplasty (THA) with a third-generation cementless acetabular system that has a porous plasma-sprayed coating on a titanium alloy substrate shell, a ringless barb and groove locking mechanism, and a vitamin E-infused highly crosslinked polyethylene insert. The purpose of this study was to examine the outcomes and need for revision in a subset of patients previously reviewed who now have potential for three-year follow-up.
Patients and Methods: A query of our practice registry revealed 235 consented patients (241 hips) who underwent cementless primary THA performed by three surgeons with the G7® Acetabular System (Zimmer Biomet, Warsaw, Indiana) between April 2013 and September 2013. All liners were vitamin E-infused highly crosslinked polyethylene with a neutral face. Mean patient age was 65.8 years and mean BMI was 31.3 kg/m2. Heads used were 179 Biolox® delta (74%; CeramTec AG, Plochingen, Germany) and 62 cobalt-chromium (26%), with diameters of 32mm in 105 (41%) and 36mm in 136 (56%).
Results: A minimum three-year follow-up was available for 152 hips in 146 patients. Harris Hip Scores improved from 47.8 to 88.2, and UCLA activity scale from 3.9 to 5.4. One patient from this study period required cup revision secondary to failure of biological fixation at 15.1 months postoperative. There have been no dislocations or other revisions of the acetabular component. Kaplan-Meier survival with endpoint of acetabular revision was 99.5% (95% CI: 99.0% to 100%) at 3.4 years. Radiographic findings in all cases were satisfactory position and alignment with no radiolucencies observed.
Conclusion: In this study, with minimum three-year follow-up, good results with 99.5% survival were achieved using a third-generation cementless acetabular system with a ringless barb and groove locking mechanism.

 

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Efficacy of Adductor Canal Blockade Compared to Multimodal Peri-Articular Analgesia Following Total Knee Arthroplasty

Chukwuweike U. Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Jaydev B. Mistry, MD, Research Fellow , Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore , Baltimore, Maryland , Priya Jha, BS, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland , Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Melbin Thomas, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore , Baltimore, Maryland, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Ronald E. Delanois, MD, Director, Hip, Knee, and Shoulder Surgery, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore , Baltimore, Maryland

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Introduction: Postoperative pain after total knee arthroplasty (TKA) can be an impediment to patient recovery. Many commonly used pain control modalities are effective, but are also associated with adverse effects. Other modalities, such as adductor canal blocks (ACB) and multimodal periarticular analgesia (MPA), have gained popularity due to their efficacy and high safety profile. However, to the best of our knowledge, there are no published studies indicating if a therapeutic advantage exists between the two pain control modalities. Therefore, the purpose of this study was to assess the: 1) length of stay; 2) level of pain; 3) discharge status; and 4) opioid consumption, in TKA patients who received either ACB or MPA.
Materials and Methods: A single hospital, single surgeon database was reviewed for patients who had a TKA between January 2015 and April 2016, and received either ACB or MPA. This search yielded 98 patients who had a mean age of 63 years (range, 38 to 90 years), comprised of 29 men and 69 women. Patients were divided into those who received ACB alone (n= 54) and those who received MPA alone (n= 44). With the use of electronic medical records, demographic and endpoint data were obtained. Pain was quantified using the Visual Analog Scale (VAS). Continuous variables were compared using the student’s t-test, while categorical variables were compared utilizing a chi-square test.
Results: The mean length of hospital stay (LOS) was significantly shorter for patients who had ACB when compared to patients who had MPA (2.12 days vs. 2.88 days; p = 0.005). There was no significant difference in VAS scores (p= 0.448), proportion of patients discharged home (p= 0.432), or total opioid consumption (p= 0.247) between the two groups.
Conclusion: Total knee arthroplasty patients who received an adductor canal block had shorter lengths of stay when compared to those who received multimodal peri-articular analgesia. Shortened hospital stays may be cost-effective for institutions and providers, however, larger studies are needed to further assess the effect on quality of care provided.

 

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Development of an Encompassing Questionnaire for Evaluating the Outcomes Following Total Knee Arthroplasty

Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Melbin Thomas, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Chukwuweike U. Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Julio J. Jauregui, MD, Research Fellow, Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, Randa K. Elmallah, MD, Resident, Department of Orthopaedic Surgery, University of Mississippi , Jackson, Mississippi, Martin Roche, MD, Chief, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida, Michael A Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: There are many standardized scales and questionnaires used to evaluate TKA patients; however, individually they do not always assess patients adequately. Consequently, many are used in combinations to provide a thorough evaluation. However, this leads to redundancy, confusion, and an excessive patient time-burden. Therefore, the purpose of this study was to develop a usable combined knee questionnaire that combines questions in a non-redundant manner. Specifically, we aimed to: 1) create a combined knee questionnaire that encompasses questions from multiple systems, while eliminating redundancy; 2) correlate the new system with the existing validated questionnaires; and 3) determine the length of time it takes to administer this new questionnaire.
Materials and Methods: In a previous study, it was determined that the six most commonly cited validated systems to assess the knee were the: Knee Society Score (KSS), The Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lower Extremity Functional Scale (LEFS), Activity Rating Scale (ARS), and Short-Form-36 (SF-36). Therefore, we ensured that the new questionnaire encompassed all elements of these systems. After development of the combined questionnaire, we co-administered it to 20 subjects alongside the above validated questionnaires. We then transposed the corresponding answers from the combined questionnaire to each selected validated system to perform an intra-class correlation analysis. In addition, we recorded the length of time it took to administer the new questionnaire and compared it to the time it took to administer the individual validated questionnaires.
Results: Intra-class correlation analysis demonstrated statistically significant positive correlations between the KSS, WOMAC, KOOS, LEFS, ARS, SF-36, and the corresponding questions in the combined questionnaire. The mean length of time it took to administer the combined questionnaire (mean, 10.1 minutes, range, 6.6 to 12.6 minutes) was significantly shorter than the time it took to administer the selected validated questionnaires (mean, 21.3 minutes, range, 17.3 to 24.1 minutes).
Conclusion: We have proposed an all-encompassing combined knee questionnaire that eliminates redundancy and inefficiency during the evaluation of TKA patients. It is a reliable, time-efficient system that can be utilized to fill out the most commonly used questionnaires for assessing TKA. Standardization and uniform use of this questionnaire may simplify future patient assessment following TKA.

 

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Achilles Tendon Repair Using the InternalBrace™ Principle

Graeme P. Hopper, MBChB, MSc, MRCS, Speciality Registrar, West of Scotland Orthopaedics, Glasgow, Scotland, UK, Gordon M. Mackay, MD, FRCS(Orth), FFSEM(UK), Professor, University of Stirling, Stirling, Scotland, UK

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Despite extensive research, the management of acute ruptures of the Achilles tendon remains an area of controversy, and there is no consensus regarding the optimal treatment. An InternalBrace™ (Arthrex, Inc., Naples, Florida) is a ligament augmentation repair using high strength sutures/tape and knotless bone anchors which encourages healing and allows early mobilization. This article describes, with video illustration, a knotless Achilles tendon repair technique using the InternalBrace™ principle.

 

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Intrawound Vancomycin Powder Reduces Early Prosthetic Joint Infections in Revision Hip and Knee Arthroplasty
Jeffrey E Otte, MD, Resident, Orthopedic Surgery , Mount Carmel Health Systems, Columbus, Ohio, Joel R. Politi, MD, Associate Faculty Member, Department of Orthopedic Surgery, Mount Carmel Healthy Systems, Columbus, Ohio, Bryan Chambers, MD, Associate Faculty Member, Department of Orthopedic Surgery, Mount Carmel Health Systems, Columbus, Ohio, Craig A. Smith, MD, Resident, Orthopedic Surgery , Mount Carmel Health Systems, Columbus, Ohio

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Abstract


Intrawound vancomycin powder has shown efficacy and safety in decreasing postoperative spine infections, but its use in arthroplasty has not been well established. The purpose of this study was to compare the rate of early prosthetic joint infections (PJI) with and without the use of intrawound vancomycin powder during joint arthroplasty. A retrospective cohort of all patients who underwent primary or revision hip or knee arthroplasty by two surgeons over a two-year period at a single hospital system was evaluated. The control group received standard systemic prophylaxis only, whereas the treatment group received 1 g of vancomycin powder in the surgical wound in addition to systemic prophylaxis. A statistically significant decrease in the overall PJI rate was found in the treatment group (4/816=0.49%) compared to the control group (13/824=1.57%; p=0.0479). Subgroup analysis demonstrated a trend toward fewer PJIs in the vancomycin group, however, only the revision procedures showed a statistically significant reduction in early PJIs after the initiation of vancomycin (7/180=3.89% to 0/134=0%; p=0.0217). The use of intrawound vancomycin powder was associated with a significant reduction in the overall incidence of early PJIs following joint arthroplasty, however, only the revision procedures demonstrated a significant reduction in the rate of early PJIs.

 

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Early Termination of Randomized Clinical Trials in Orthopaedics
Nicolas Piuzzi, MD, Clinical Fellow, Department of Orthopaedic Surgery, Cleveland Clinic , Cleveland, Ohio, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Chukwuweike U. Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, George Muschler, MD, Attending Physician, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Kurt P. Spindler, MD, Director of Research, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Michael A Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Randomized controlled clinical trials (RCTs) in orthopaedics, similar to all medical fields, provide the highest level of clinical data and constitute the cornerstone for evidence-based therapeutic advances. Orthopaedic clinical trials face the same challenges as in other medical fields, such as insufficient recruitment, unforeseen adverse events, and futility. In this article, we highlight the reasons for early termination of clinical trials and provide examples of each type.

 

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The Learning Curve Associated with the Administration of Intra-Articular Liposomal Bupivacaine for Total Knee Arthroplasty: A Pilot Study
Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Randa K. Elmallah, MD, Resident, Department of Orthopaedic Surgery, University of Mississippi , Jackson, Mississippi, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, George A. Yakubek, DO, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Mhamad Faour, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Alison K. Klika, MS, Research Program Manager, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Carlos A. Higuera, MD, Attending Physician, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Robert M. Molloy, MD, Director of Adult Reconstruction, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: Liposomal bupivacaine is a long-acting, local, injectable anesthetic that is used to potentially mitigate post-operative pain after total knee arthroplasty (TKA). In addition, it may reduce opioid use in the post-operative period and shorten lengths-of-stay (LOS). There have been mixed results in the literature with regards to its efficacy, which raises questions regarding the injection technique used. Therefore, we evaluated the learning curve associated with injection techniques prior to, and after, formal teaching. Specifically, we compared differences in: 1) opioid use; 2) LOS; 3) pain intensity; and 4) discharge disposition in patients who did not receive liposomal bupivacaine (no infiltration cohort), received liposomal bupivacaine with less optimal technique (subpar infiltration), and received liposomal bupivacaine with appropriate technique (optimal infiltration) during their primary TKA.
Materials and Methods: A 1:1:1 ratio of 54 consecutive cases of patients who had no liposomal bupivacaine infiltration, those who had subpar infiltration, and those who had optimal infiltration were included. To evaluate opioid use, the dosages were obtained and converted to their respective morphine milliequivalents (mEq). The total mEq usage was obtained for the day of surgery through post-operative day (POD) 3. LOS was recorded in days. Pain scores were calculated using the visual analogue scale (VAS), obtained from the first post-operative physical therapy note. Discharge status was recorded as discharged to home or rehabilitation. We used an ANOVA test for continuous and X2-square test for categorical variables.
Results: When compared to patients who had no infiltration, patients who had subpar infiltration had significantly lower opioid use on day 0, while patients who had optimal infiltration had lower opioid use on post-operative day (POD) 0 and 3. When comparing techniques, opioid use was lower on day 3 for patients who had optimal, as compared to subpar technique. However, LOS and VAS were not significantly different among the three groups. The rehab discharge rate was lower for patients who had optimal as compared to subpar technique.
Conclusion: There is a learning curve associated with liposomal bupivacaine use, and incorporating an appropriate technique can markedly affect post-operative outcomes. This should be taken into account when evaluating the potential benefits of this peri-articular injection. It appears that liposomal bupivacaine may decrease opioid use and pain scores when optimal infiltration techniques are used.

 

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Chronic Achilles Tendon Rupture Treated with Allograft: A Case Report
Giuseppe Restuccia, MD, Specialist , Department of Orthopedics and Traumatology, S.O.D Ortopedia e Traumatologia AOUP, Pisa, Italy, Alessandro Lippi, MD, Specialist , Department of Orthopedics and Traumatology, S.O.D Ortopedia e Traumatologia AOUP, Pisa, Italy, Francesco Casella, MD, Resident , Department of Orthopedics and Traumatology, University of Pisa, Pisa, Italy, Carmine Citarelli, MD, Resident , Department of Orthopedics and Traumatology, University of Pisa, Pisa, Italy, Federico Sacchetti, MD, Resident , Department of Orthopedics and Traumatology, University of Pisa, Pisa, Italy, Maurizio Benifei, MD, Specialist , Department of Orthopedics and Traumatology, S.O.D Ortopedia e Traumatologia AOUP, Pisa, Italy

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In clinical practice, chronic Achilles tendon ruptures are uncommon. Usually, these lesions are discovered four to six weeks after injuries. More frequently, Achilles tendon ruptures are acute and treated with tendon sutures.1 Many surgical techniques are available to treat chronic lesions such as sutures or V-Y elongation with or without augments.2-3 Our case is about a chronic Achilles tendon rupture discovered two years after injury. Our patient came to our attention with a 6 cm tendon gap. We performed tendon repair with cadaver allograft. After four years of follow-up, our patient has a complete functional recovery and he can normally perform daily and working tasks without pain.

 

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Neuro and Spine Surgery

How to Direct the Neuronal Growth Process in Peripheral Nerve Regeneration: Future Strategies for Nanosurfaces Scaffold and Magnetic Nanoparticles
Andrea Poggetti, MD, Orthopaedic Surgeon, 1st Orthopaedic Department, University of Pisa, Pisa, Italy, Pietro Battistini, MD, Orthopaedic Surgeon, 1st Orthopaedic Department, University of Pisa, Pisa, Italy, Paolo Domenico Parchi, MD, PhD+, Orthopaedic Surgeon, 1st Orthopaedic Department, University of Pisa, Pisa, Italy, Michela Novelli, PhD, Associate Professor, Pathology Unit, University of Pisa, Pisa, Italy, Simona Raffa, PhD, Associate Professor , Institute for Medical Science , and Technology, Scotland, United Kingdom, Marco Cecchini, PhD, Research Assistant, NEST Istituto Nanoscienze-CNR, University of Pisa, Pisa, Italy, Anna Maria Nucci, MD, Resident, 1st Orthopaedic Department, University of Pisa, Pisa, Italy, Michele Lisanti, MD, PhD, Professor in Chief, 1st Orthopaedic Department, University of Pisa, Pisa, Italy

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Currently, the gold standard to repair large nerve defects is the autologous nerve graft. These solutions offer a mechanical support, adhesion substrates, and, with Schwann cells (SC), a source of neurotropic factors for axonal growth. The technical limits are the donor side damage, multiple surgical accesses, and the unavailability of large amounts of grafts. In recent years, several researchers focused their attention on the interaction between cells (nervous and glial) and physic-chemical cues that arise from the extracellular milieu. Nanotechnologies produce surfaces that mimic the topographical signals (physical stimuli) that arise from enterprise content management (ECM) to modulate the forces acting during axonal elongation. The use of magnetic nanoparticles (MNPs) seems to be able to guide and to boost the nerve regeneration. Both research areas could be improved through surfaces functionalization by biological molecules (proteins/peptides, growth factors, etc.). In the future, the aim will be to help recovery after peripheral nerve lesion by producing a tridimensional structured conduit, then repeat the ECM architecture and take advantage of MNPs internalized by cells and guide them through tension forces by external magnetic fields to stimulate and direct axon growing. The aims of this review were to evaluate the findings of studies that used physical stimuli (nanoscaffold surfaces and MNPs) used for peripheral nerve regeneration support. The future trends in the field of peripheral nerve regeneration continue to produce a wide variety of new techniques to improve the opportunity for advances to treat peripheral nerve injuries.

 

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A Portable Shoulder-Mounted Camera System for Surgical Education in Spine Surgery
Martin H. Pham, MD, Neurosurgery Resident, Department of Neurosurgery , Keck School of Medicine, University of Southern California, Los Angeles, California, Ifije E. Ohiorhenuan, MD, PhD, Neurosurgery Resident, Department of Neurosurgery , Keck School of Medicine, University of Southern California, Los Angeles, California, Neil N. Patel, MD, Orthopedic Surgery Spine Fellow, Orthopedic Surgery , Keck School of Medicine, University of Southern California, Los Angeles, California, Andre M. Jakoi, MD, Orthopedic Surgery Spine Fellow, Orthopedic Surgery , Keck School of Medicine, University of Southern California, Los Angeles, California, Patrick C. Hsieh, MD, Associate Professor, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, Frank L. Acosta, MD, Associate Professor, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, Jeffrey C. Wang, MD, Professor, Chief, Orthopedic Spine Service, Co-Director, USC Spine Center, Orthopedic Surgery , Keck School of Medicine, University of Southern California, Los Angeles, California, John C. Liu, MD, Professor, Co-Director, USC Spine Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California

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The past several years have demonstrated an increased recognition of operative videos as an important adjunct for resident education. Currently lacking, however, are effective methods to record video for the purposes of illustrating the techniques of minimally invasive (MIS) and complex spine surgery. We describe here our experiences developing and using a shoulder-mounted camera system for recording surgical video. Our requirements for an effective camera system included wireless portability to allow for movement around the operating room, camera mount location for comfort and loupes/headlight usage, battery life for long operative days, and sterile control of on/off recording. With this in mind, we created a shoulder-mounted camera system utilizing a GoPro™ HERO3+, its Smart Remote (GoPro, Inc., San Mateo, California), a high-capacity external battery pack, and a commercially available shoulder-mount harness. This shoulder-mounted system was more comfortable to wear for long periods of time in comparison to existing head-mounted and loupe-mounted systems. Without requiring any wired connections, the surgeon was free to move around the room as needed. Over the past several years, we have recorded numerous MIS and complex spine surgeries for the purposes of surgical video creation for resident education. Surgical videos serve as a platform to distribute important operative nuances in rich multimedia. Effective and practical camera system setups are needed to encourage the continued creation of videos to illustrate the surgical maneuvers in minimally invasive and complex spinal surgery. We describe here a novel portable shoulder-mounted camera system setup specifically designed to be worn and used for long periods of time in the operating room.

 

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Biosurgical Hemostatic Agents in Neurosurgical Intracranial Procedures
Roberto Gazzeri, MD , Neurosurgery Consultant , Department of Neurosurgery, San Giovanni Addolorata Hospital, Rome, Italy, Marcelo Galarza, MD , Neurosurgery Consultant , Regional Service of Neurosurgery, School of Medicine, University of Murcia, Murcia, Spain, Giorgio Callovini, MD , Neurosurgery Consultant , Department of Neurosurgery, San Giovanni Addolorata Hospital, Rome, Italy, Alex Alfieri, MD , Chairman of Neurosurgery , Department of Neurosurgery , and Spinal Surgery, Ruppiner Kliniken, Neuruppin, Germany

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Intraoperative hemostasis during neurosurgical procedures is one of the most important aspects of intracranial surgery. Hemostasis is mandatory to keep a clean operative field and to prevent blood loss and postoperative hemorrhage. In neurosurgical practice, biosurgical hemostatic agents have proved to be extremely useful to complete the more classic use of electrocoagulation. During recent years, many biosurgical topical hemostatic agents were created. Although routinely used during neurosurgical procedures, there is still a great deal of confusion concerning optimal use of these products, because of the wide range of products, as absorbable topical agents, antifibrinolytics agents, fibrin sealants and hemostatic matrix, which perform their hemostatic action in different ways. The choice of the hemostatic agent and the strategy for local hemostasis are correlated with the neurosurgical approach, the source of bleeding, and the neurosurgeon’s practice. In this study, the authors review all the different sources of bleeding during intracranial surgical approaches and analyze how to best choose the right topical hemostatic agent to stop bleeding, from the beginning of the surgical approach to the end of the extradural hemostasis after dural closure, along all the steps of the neurosurgical procedure.

 

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Scalp Metastasis from Glioblastoma Multiforme: A Case Report and Literature Review
Marco Mammi, MD, Resident, Unit of Neurosurgery, Roberto Altieri, MD, Resident , Unit of Neurosurgery , Alessandro Agnoletti, MD, Neurosurgeon, Unit of Neurosurgery, Paolo Pacca, MD, Neurosurgeon, Unit of Neurosurgery , Federica Franchino, MD, Neuro-Oncologist, Unit of Neuro-Oncology, Diego Garbossa, MD, Neurosurgeon, Unit of Neurosurgery , Alessandro Ducati, MD, Professor of Neurosurgery, Director of Unit of Neurosurgery, Antonio Melcarne, MD, Neurosurgeon, Unit of Neurosurgery , Department of Neuroscience, University School of Medicine, Turin, Italy

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Glioblastoma multiforme (GBM) is a common malignant brain tumor that rarely metastasizes extracranially, despite its aggressive clinical course. This report details the case of a young man presenting with a single subcutaneous localization of GBM that arose six months after initial surgery and recurred after excision. Only six other cases of scalp metastasis of GBM following surgery have been described in the literature, each with peculiar features. Whenever feasible, surgery is the most effective way to obtain local control of disease. However, a correct approach must be carefully planned to minimize the risks of recurrence and wound dehiscence.

 

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Gynecology

The Impact of a Topical Sexual Enhancement Cream on the Female Sexual Response and Its Relationship to Clitoral Blood Flow
Michael Pelekanos, MD, Vice Chair, Obstetrics and Gynecology Department, Female Pelvic Medicine and Reconstructive Surgery, West Penn Allegheny Health System, Pittsburgh, Pennsylvania, Guy M Stofman, MD, Chief Plastic Surgery, University of Pittsburgh Medical Center, Mercy Division, Clinical Professor of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, Neil Niren, MD, Clinical Instructor, Dermatology, University of Pittsburgh School of Medicine, Private Practice, Dermatology, Pittsburgh, Pennsylvania

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OBJECTIVE: The aim of this investigation was to determine, through two Investigational Review Board (IRB)-approved studies, if a new topical vasodilating cream (NTVC; Life Science Enhancement Corporation, Pittsburgh PA) could improve female sexual response. Study I subjectively evaluated sexual female response as accessed by a modification of the Female Intervention Efficacy Index (FIEI). FIEI was developed at the University of California as an immediate outcome measure of medical intervention to treat female sexual dysfunction.1 In Study II, 10 randomly selected positive responders from Study I were subsequently analyzed objectively with clitoral plethysmography in order to determine the effect of the NTVC and placebo on blood flow.2
RESULTS: In the subjective Study I (81 patients ranging in age from 18 to 63), a positive response trend for the NTVC was demonstrated compared to the placebo. In the objective Study II, 10 randomly selected patients who responded positive in Study I were objectively evaluated for response of increased blood flow in the clitoris after application of both the NTVC and placebo. The clitoral blood flow was shown to have increased with statistical significance for the NTVC in all 10 patients compared to the placebo, with the NTVC exhibiting an average 69% increase in clitoral blood flow.
CONCLUSIONS: The female sexual response is complex. In the subjective Study I, the NTVC demonstrated positive trends for enhanced lubrication, genital sensation, intercourse, and overall sexual experience. In the objective Study II, 10 of the positive subjective responders from Study I were randomly selected to evaluate their response to the NTVC compared to the placebo. This was done via Doppler plethysmography (DP). All 10 patients demonstrated a statistically significant response rate for increase in clitoral blood flow using the NTVC compared to the placebo, with an average blood flow increase of 69%. This portion of the investigation demonstrates a significant positive end organ response to the NTVC. The positive subjective trends combined with the significant and substantial increase in clitoral blood flow may result in enhanced female sexual satisfaction.

 

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