Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review

Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions. Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies (N = 1,419 patients) and 81 NVBG studies (N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman–Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure. Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05–0.13] and 0.08 [95% CI 0.06–0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04–2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08–1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06–1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16–2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13–3.66) and NVBG (IRR 1.39, CI: 1.16–1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type (p > 0.05). Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.

Completion Posterior Quadrant Disconnection After Failed Temporal Lobectomy: 2-Dimensional Operative Video

Epilepsy is a chronic seizure disorder that affects about 1% of the global population.1 When seizure freedom cannot be obtained solely through antiseizure medicines (ASMs), the condition is termed medically refractory epilepsy (MRE).2,3 Though posterior quadrant disconnection (PQD) is underutilized in our experience, it is a highly effective surgical procedure for MRE restricted to the temporal, parietal, and/or occipital lobes.4-12 In this operative video, we demonstrate a right-sided completion PQD following failed temporal lobectomy in an 8-yr-old female with focal MRE. We review technical nuances, including (1) extension/revision of prior scalp incision, (2) placement of subdural strip for the identification of phase reversal and central sulcus, (3) disconnection of parietal and occipital lobes, (4) extension of the corticectomy to the pia overlying the falcotentorial junction and into the prior temporal lobectomy defect, and (5) posterior disconnection of the corpus callosum. Postoperatively, the patient experienced subtle left-arm weakness and central fever, both of which resolved. An external ventricular drain (EVD) was placed in the ventricle/operative cavity and left for 3 to 4 d until the draining cerebrospinal fluid (CSF) cleared. As of 3-mo follow-up, she has been seizure-free without complications. In summary, PQD is a safe and effective treatment option for MRE that can be utilized not only as an initial operation but also after failed surgery. Appropriate patient consent was obtained to perform this procedure and present this clinical case and surgical video for academic purposes. Image at 4:00 licensed under CC BY-2.5, 2006, modified from http://upload.wikimedia.org/wikipedia/commons/7/70/Lateral_head_skull.jpg (flipped and rotated). Image at 4:42, Public Domain: Gray H. Anatomy of the Human Body. 1918. Bartleby.com, https://commons.wikimedia.org/wiki/File:Lobes_of_the_brain_NL.svg; flipped, modified. Image at 6:42, Public Domain: House EL, Pansky B. A Functional Approach to Neuroanatomy. 1960. McGraw-Hill Book Company; https://upload.wikimedia.wikipedia.commons/5/52/Lawrence_1960_2.3.png; modified.

Cheek-midface lifting with lateral canthoplasy for the repair of complex iatrogenic lower eyelid ectropion

Purpose: To assess the efficiency and safety of cheek-midface lifting for the ophthalmoplastic reconstructive surgical repair of cicatricial lower eyelid malpositions after previously failed surgery. Methods: In two ophthalmoplastic clinics, 14 eyelids of 13 patients underwent transconjunctival cheek-midface lifting. In a retrospective audit, changes in margin-reflex distance 2 (MRD2), snap-back test, the position of the eyelid after surgery including improving of the presurgical scleral show, the overall patient’s satisfaction as well as complications after surgery were recorded. Results: Following transconjunctival cheek-midface lifting, there was a significant improvement of MRD2, snap-back test, and the scleral show ( p < 0.001, respectively). However, in three patients the scleral show persisted despite improved MRD2. All patients were satisfied with the results of the surgery. No post-surgical long-term complications were developed. Conclusion: Cheek-midface lifting can be a useful technique in severe cicatricial lower eyelid ectropion after previously failed surgery and is a safe and effective reconstructive method for ophthalmic surgeons with good cosmetical results and little postoperative long-term complications.

Flow Simulation in the Upper Respiratory Tract of Two Obstructive Sleep Apnea Patients with Successful and Failed Surgery

Obstructive sleep apnea (OSA) is a common disorder which may need to be treated by the upper respiratory tract (URT) surgery. To increase the success rate of the URT surgery, it is crucial to understand the flow features in the URT models. In this work, the turbulent flow characteristics in four 3D anatomically accurate URT models reconstructed from two OSA subjects with successful and failed surgery are numerically studied by the large-eddy simulation (LES) and unsteady Reynolds-averaged Navier-Stokes (RANS). The features of velocity fields, pressure fields, and wall shear stress fields as well as the spectral analysis of wall shear stress between successful and failed surgery are explored. The results indicate that LES is capable of capturing flow patterns and flow oscillation and is effective for OSA surgery prediction. Even if the unsteady RANS can obtain the correct pressure drop across the airways, it may not be appropriate to be used for surgery prediction. Moreover, it is found that the quality of oscillating signal of wall shear stress is a key factor in surgery prediction. In a successful surgery, the wall shear stress oscillation is always strong, and the oscillating signal can perform a dominant frequency near 3~5 Hz, while in a failed surgery it does not show this clear intrinsic property. The results not only will gain new insights in the URT surgical planning but also will improve the prediction of surgical outcome for OSA patients.

Wilkie's syndrome in an adolescent female patient

<p>One of the rare cases of the upper gastrointestinal tract obstruction is superior mesenteric artery syndrome (SMAS) but potentially life-threatening if not recognized early. It is due to loss of fat pad between the aorta and SMA which will lead to a compression of the third portion of the duodenum. It has a different angle which will lead to different presentations as well as severity. We are reporting the 15 year-old (y/o) female who is medically free, presented to the emergency department (ED) complaining of severe colicky epigastric abdominal pain for the last 5 days in the epigastric area. The diagnosis of SMAS was made after clinical and radiological investigation. After proper supportive resuscitative measures, definitive management of the surgery was done by laparoscopic approach (duodenojejunostomy). The diagnosis of SMA syndrome is considered challenging due to many presentations and might be confused with other clinical conditions. Unless early diagnosed and treated, the outcome might be catastrophic. Medical treatment is attempted first in many cases depending on the severity and presentation but if failed, surgery will be the best option.</p>

Subacute uterine inversion following an induced abortion in a teenage girl: a case report

Background Subacute uterine inversion is a very rare complication of mid-trimester termination of pregnancy that should be considered in a situation where unsafe abortion occurs. Case presentation We present a case of subacute uterine inversion complicated by hypovolemic shock following an unsafe abortion in a 17-year-old nulliparous unmarried girl. She presented with a history of collapse, mass protruding per vagina that followed Valsalva, and persistent lower abdominal pain but not vaginal bleeding. This followed her second attempt to secretly induce an abortion at 18 weeks amenorrhea. On examination, she was agitated, severely pale, cold on palpation, with an axillary temperature of 35.8 °C, a tachycardia of 143 beats per minute and unrecordable low blood pressure. The abdomen was soft and non-tender with no palpable masses; the uterine fundus was absent at its expected periumbilical position and cupping was felt instead. A fleshy mass with gangrenous patches protruding in the introitus was palpated with no cervical lip felt around it. We made a clinical diagnosis of subacute uterine inversion complicated with hypovolemic shock and initiated urgent resuscitation with crystalloid and blood transfusion. Non-operative reversal of the inversion failed. Surgery was done to correct the inversion followed by total abdominal hysterectomy due to uterine gangrene. Conclusion Our case highlights an unusual presentation of subacute uterine inversion following unsafe abortion. This case was managed successfully but resulted in significant and permanent morbidity.

Fascia lata augmented nasal transposition of split lateral rectus in complete oculomotor nerve palsy with a previous failed surgery

Purpose: To report our experience in the management of a complete oculomotor nerve palsy with a previous failed surgery. Methods: We used a fascia lata augmented nasal transposition of the split lateral rectus in a patient who had complete oculomotor nerve palsy with recurrent exotropia after previous recession-resection surgery. The lateral rectus muscle was split in half, and then joined end-to-end with fascia strips with a 5-0 polyester nonabsorbable suture. The superior and inferior fascia strips were transposed to the adjacent of the superior and inferior corners of the insertion of medial rectus. With the globe being adducted about 10 degrees, the strips were sutured on the globe using fixed 5-0 polyester sutures. Results: The patient showed orthotropic alignment at the primary position at the 5-month post-operation follow-up. Conclusion: With adequate preoperative imaging-aided evaluation and meticulous intraoperative exploration, fascia lata augmented nasal transposition of split lateral rectus could be an option of treatment for complete oculomotor nerve palsy after a previous failed surgery.