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European Journal of Obstetrics,... Jun 2024Malposition of the fetal head, defined as occiput transverse or posterior positions, occurs in approximately 5% of births. At full cervical dilatation, fetal malposition...
INTRODUCTION
Malposition of the fetal head, defined as occiput transverse or posterior positions, occurs in approximately 5% of births. At full cervical dilatation, fetal malposition is associated with an increased risk of rotational vaginal birth. There are three different rotational methods: manual rotation, rotational ventouse or rotational (Kielland's) forceps. In the absence of robust evidence, it is not currently known which of the three methods is most efficacious, and safest for parents and babies.
OBJECTIVE
To gain greater insights into opinions and preferences of rotational birth to explore the acceptability and feasibility of performing a randomised trial comparing different rotational methods.
MATERIAL AND METHODS
A survey was sent via email to obstetricians from the British Maternal Fetal Medicine Society, as well as expert obstetricians and active academics in ongoing research in the UK. The questions focussed on perceived competence, preferred rotational method, location (theatre or labour room), willingness to recruit to an RCT, and its outcome measures. Closed questions were followed by the option of free text to allow further comments. The free text answers underwent thematic analysis.
RESULTS
252 consultant obstetricians responded. The majority stated they were competent in performing manual rotation (88.1%). Half felt proficient using Kielland's rotational forceps (54.4%). Most obstetricians felt skilled in rotational ventouse (76.2%). Manual rotation was the preferred first rotational method of choice in cases of both occiput transverse and posterior positions. The decision for which rotational method to attempt first was considered case-dependent by many. Two thirds of obstetricians would usually conduct rotational births in theatre (67.9%). Over half (52%) do not routinely use intrapartum ultrasound. Most (62.7%) would be willing to recruit to a randomised controlled trial comparing manual versus instrumental rotation. Over half (57.2%) would be willing to recruit to the same RCT if they were the most senior doctor competent in rotational vaginal birth supervising a junior.
CONCLUSION
There is a wide range of practice in conducting rotational vaginal births in the UK. An RCT to investigate the impact of different rotational methods on outcome would be both feasible and desirable, especially in research-active hospitals.
PubMed: 38843726
DOI: 10.1016/j.ejogrb.2024.05.045 -
Plastic and Reconstructive Surgery.... Jun 2024The umbilicus detachment and reinsertion in umbilical float mini-abdominoplasty results in its lower position with or without shape distortion. This event creates a...
BACKGROUND
The umbilicus detachment and reinsertion in umbilical float mini-abdominoplasty results in its lower position with or without shape distortion. This event creates a stigmatizing look, elongating the upper abdomen and creating variable grades of infra umbilical/pubis bulging. This lack of proportion causes an unpleasant, artificial look, and is very difficult to fix. The study aimed to describe a sequence of abdominoplasty and combined upper abdomen horizontal muscle plications to correct umbilicus malposition after a mini-abdominoplasty.
METHODS
Over a period of 24 months, 12 patients underwent a liposuction (suction-assisted liposuction) and abdominoplasty with horizontal supraumbilical muscle plication. All patients underwent objective measurements before and after the procedure, using digital image measurements by Mirror Image software, version 6.0 (Fairfield, N.J.). The follow-up evaluation was performed 12 months postoperatively. Statistical analysis was performed using IBM SPSS Statistics V26.
RESULTS
Over 24 months, 12 patients (100%), who underwent abdominoplasty combined with horizontal plication in the upper abdominal wall, have shown adequate umbilicus elevation (2.98 ± 0.242 cm; 95% confidence level), restoring the abdominal muscle wall proportion at 12 months follow-up. One patient (8%) had a seroma, and one (8%) had a small muscular hernia (1.5 cm) in the lower abdomen.
CONCLUSIONS
The combination of abdominoplasty and upper horizontal muscle plication can fix the malpositioned umbilicus, restoring the aesthetic and anatomic proportions in those patients who underwent an umbilical float mini-abdominoplasty.
PubMed: 38841533
DOI: 10.1097/GOX.0000000000005873 -
Arthroscopy Techniques May 2024Valgus instability can occur after total knee arthroplasty (TKA) due to traumatic medial collateral ligament (MCL) injury, component malpositioning, or progressive...
Valgus instability can occur after total knee arthroplasty (TKA) due to traumatic medial collateral ligament (MCL) injury, component malpositioning, or progressive ligamentous laxity. Although revision TKA with exchange of the polyethylene to a varus-valgus-constrained liner can reduce laxity due to MCL insufficiency, isolated liner exchange in the setting of collateral ligament insufficiency may lead to greater strain at the cement-bone or implant-cement interface and possibly a greater rate of aseptic loosening. Anatomic MCL reconstruction can be performed in conjunction with liner exchange to restore stability and reduce strain compared with liner exchange alone. The purpose of this Technical Note is to describe a technique for MCL reconstruction and liner exchange for treatment of valgus instability after TKA.
PubMed: 38835466
DOI: 10.1016/j.eats.2024.102942 -
Musculoskeletal Surgery Jun 2024Reports of adverse reactions to metal debris contributed in part to a decline in use of large-bearing metal-on-metal total hip devices. We hypothesize an optimal...
BACKGROUND
Reports of adverse reactions to metal debris contributed in part to a decline in use of large-bearing metal-on-metal total hip devices. We hypothesize an optimal trunnion design may reduce risk of this failure mode in large-bearing total hip arthroplasty systems. The purpose of this study is to report mid- to long-term outcomes for a single-surgeon series of 211 total hip arthroplasties using the large-bearing Biomet Magnum metal-on-metal system.
MATERIALS AND METHODS
Between December 2004 and January 2016, the primary surgeon performed 211 uncemented Magnum total hip arthroplasties in 181 patients. The average length of follow-up was 10.1 ± 3.5 years (range 8-18 years).
RESULTS
Using failure of any component as the endpoint, the overall survivorship rate was 98.1% at 10 years and 97.4% at 18 years. These eight failures (3.8% of cohort) included one case of adverse wear-related failure (0.5%), two cases of acetabular ingrowth failure (0.9%), three cases of trunnion corrosion (1.4%), one failure of late infection (0.5%), and one inappropriate revision of components for trochanteric nonunion without instability (0.5%). Excluding failed cases, all components were radiographically stable with no radiolucencies. Except for the one wear failure, ion testing revealed that 97.2% of cases were within optimal whole blood metal ion levels with the remaining ion test results within acceptable levels.
CONCLUSIONS
With the uncemented Magnum metal-on-metal total hip, we achieved 97.4% 18-year implant survivorship, exceeding the NICE criteria and registry benchmarks for implant survivorship. We observed a trunnion corrosion rate of 1.4% and no cases of instability. The single case of adverse wear-related failure was caused by acetabular component malposition.
PubMed: 38833069
DOI: 10.1007/s12306-024-00831-3 -
EFORT Open Reviews Jun 2024Accurate component placement in shoulder arthroplasty is crucial for avoiding complications, achieving superior biomechanical performance and optimizing functional... (Review)
Review
Accurate component placement in shoulder arthroplasty is crucial for avoiding complications, achieving superior biomechanical performance and optimizing functional outcomes. Shoulder and elbow surgeons have explored various methods to improve surgical understanding and precise execution including preoperative planning with 3D computed tomography (CT), patient-specific instrumentation (PSI), intraoperative navigation, and mixed reality (MR). 3D preoperative planning facilitated by CT scans and advanced software, enhances surgical precision, influences decision-making for implant types and approaches, reduces errors in guide pin placement, and contributes to cost-effectiveness. Navigation demonstrates benefits in reducing malpositioning, optimizing baseplate stability, improving humeral cut, and potentially conserving bone stock, although challenges such as varied operating times and costs warrant further investigation. The personalized patient care and enhanced operational efficiency associated with PSI are not only attractive for achieving desired component positions but also hold promise for improved outcomes in complex cases involving glenoid bone loss. Augmented reality (AR) and virtual reality (VR) technologies play a pivotal role in reshaping shoulder arthroplasty. They offer benefits in preoperative planning, intraoperative guidance, and interactive surgery. Studies demonstrate their effectiveness in AR-guided guidewire placement, providing real-time surgical advice during reverse total shoulder arthroplasty (RTSA). Additionally, these technologies show promise in orthopedic training, delivering superior realism and accelerating learning compared to conventional methods.
PubMed: 38828974
DOI: 10.1530/EOR-23-0200 -
Cureus May 2024The incidence of facial nerve paralysis is approximately 30 per 100,000 persons annually. Although it is often idiopathic, as in Bell's palsy, it can also result from... (Review)
Review
The incidence of facial nerve paralysis is approximately 30 per 100,000 persons annually. Although it is often idiopathic, as in Bell's palsy, it can also result from infections, trauma, or neoplasms. Facial nerve paralysis may present with partial or total facial paresis, lagophthalmos, denervation of the lacrimal gland, and other ocular abnormalities. While dry eye is a commonly expected outcome of facial nerve injury, some patients may paradoxically experience epiphora and hyperlacrimation. In this review, we examine this phenomenon and its mechanisms in facial nerve injury. Several mechanisms have been proposed for epiphora and hyperlacrimation, including aberrant axonal regeneration, which is known to cause crocodile tears syndrome; ocular irritation due to dry eye, resulting in increased reflex lacrimation due to disruption of the tear film; and impaired drainage of tears caused by paralysis of the orbicularis oculi muscle and malposition of the eyelids. Understanding the pathophysiology of these symptoms is crucial in guiding the management of patients with facial nerve injury. Further experimental and clinical studies focusing on the quantification of tear production and localization of nerve damage will help improve our understanding of the neuroanatomical correlates of this paradoxical manifestation.
PubMed: 38826950
DOI: 10.7759/cureus.59440 -
Hip & Pelvis Jun 2024Total hip arthroplasty (THA) is an effective treatment for osteoarthritis, and the popularity of the direct anterior approach has increased due to more rapid recovery... (Review)
Review
Total hip arthroplasty (THA) is an effective treatment for osteoarthritis, and the popularity of the direct anterior approach has increased due to more rapid recovery and increased stability. Instability, commonly caused by component malposition, remains a significant concern. The dynamic relationship between the pelvis and lumbar spine, deemed spinopelvic motion, is considered an important factor in stability. Various parameters are used in evaluating spinopelvic motion. Understanding spinopelvic motion is critical, and executing a precise plan for positioning the implant can be difficult with manual instrumentation. Robotic and/or navigation systems have been developed in the effort to enhance THA outcomes and for implementing spinopelvic parameters. These systems can be classified into three categories: X-ray/fluoroscopy-based, imageless, and computed tomography (CT)-based. Each system has advantages and limitations. When using CT-based systems, preoperative CT scans are used to assist with preoperative planning and intraoperative execution, providing feedback on implant position and restoration of hip biomechanics within a functional safe zone developed according to each patient's specific spinopelvic parameters. Several studies have demonstrated the accuracy and reproducibility of robotic systems with regard to implant positioning and leg length discrepancy. Some studies have reported better radiographic and clinical outcomes with use of robotic-assisted THA. However, clinical outcomes comparable to those for manual THA have also been reported. Robotic systems offer advantages in terms of accuracy, precision, and potentially reduced rates of dislocation. Additional research, including conduct of randomized controlled trials, will be required in order to evaluate the long-term outcomes and cost-effectiveness of robotic-assisted THA.
PubMed: 38825818
DOI: 10.5371/hp.2024.36.2.87 -
Journal of Neurosurgery May 2024The placement of flow-diverting devices has become a common method of treating unruptured intracranial aneurysms of the internal carotid artery. The progressive...
OBJECTIVE
The placement of flow-diverting devices has become a common method of treating unruptured intracranial aneurysms of the internal carotid artery. The progressive improvement of aneurysm occlusion after treatment-with low complication and rupture rates-has led to a dilemma regarding the management of aneurysms in which occlusion has not occurred within 6-24 months. The authors aimed to identify clinical consensus regarding management of intracranial aneurysms displaying persistent filling 6-24 months after flow diversion and to ascertain questions that may drive future investigation.
METHODS
An international panel of 67 experts was invited to participate in a multistep Delphi consensus process on the treatment of intracranial aneurysms after failed flow diversion.
RESULTS
Of the 67 experts invited, 23 (34%) participated. Qualitative analysis of an initial survey with open-ended questions resulted in 51 statements regarding management of aneurysms showing persistent filling after flow diversion. The statements were grouped into 8 categories, and in the second round, respondents rated the degree of their agreement with each statement on a 5-point Likert scale. Flow diverters with surface modifiers did not influence administration of dual-antiplatelet therapy according to 83%. Consensus was also reached regarding the definition of treatment failure at specific time points, including at 6 months if there is aneurysm growth or persistent rapid flow through the entirety of the aneurysm (96%), at 12 months if there is aneurysm growth or symptom onset (78%), and at 24 months if there is persistent filling regardless of size and filling characteristics (74%). Although experts agreed that the degree of intimal hyperplasia or in-device stenosis could not be ascertained by noninvasive imaging alone (83%), only 65% chose digital subtraction angiography as the preferred modality. At 6 and 12 months, retreatment is preferred if there is persistent filling with aneurysm growth (96%, 96%), device malposition (48%, 87%), or a history of subarachnoid hemorrhage (65%, 70%), respectively, and at 24 months if there is persistent filling without reduction in aneurysm size (74%). Experts favored treatment with an additional flow diverter (87%) over aneurysm clipping, applying the same principles for follow-up (83%) and treatment failure (91%) as for the first flow diverter.
CONCLUSIONS
The authors present the consensus practices of experts in the management of intracranial aneurysms without occlusion 6-24 months after treatment with a flow-diverting device.
PubMed: 38820616
DOI: 10.3171/2024.3.JNS2499 -
The Journal of Craniofacial Surgery May 2024This study aimed to investigate the clinical characteristics of patients with complications following inadequate primary orbital fracture repair and to evaluate surgical...
OBJECTIVE
This study aimed to investigate the clinical characteristics of patients with complications following inadequate primary orbital fracture repair and to evaluate surgical outcomes of secondary revision orbital reconstruction.
METHODS
The authors retrospectively reviewed data from 41 patients who underwent revision orbital reconstruction by a single surgeon following complications from primary orbital fracture repair performed elsewhere. Clinical characteristics, including enophthalmos, exophthalmos, diplopia, ocular motility limitation, epiphora, infraorbital hypoesthesia, infection, eyelid malposition, lagophthalmos, hypoglobus, and compressive optic neuropathy, were assessed. Surgical outcomes of revision surgery were evaluated to determine improvements in clinical deficits and postoperative patient satisfaction.
RESULTS
The most common postoperative complications of primary orbital fracture repair were enophthalmos (n=20/41) and diplopia (n=20/41). The mean time between primary and revision surgeries was 67.2 months (range: 1-276 mo). Revision surgery significantly improved enophthalmos, diplopia (Hess area ratio), epiphora (Munk score), periorbital pain, and exophthalmos (P=0.003, P=0.001, P<0.001, P<0.001, and P=0.007, respectively) compared to the pre-revision state. In addition, 6 patients experienced improved infraorbital hypoesthesia. Among the 41 patients, 23 were very satisfied, 17 were satisfied, and 1 was neutral after revision orbital reconstruction.
CONCLUSIONS
Our study highlights the positive impact of revision orbital reconstruction in addressing complications from inadequate primary orbital fracture repair. Surgeons should consider revision surgery to address clinical deficits following prior surgery, especially when anatomic abnormalities are evident in imaging studies, regardless of the time lapse since the initial surgery or concerns about tissue fibrosis and fat atrophy.
PubMed: 38819131
DOI: 10.1097/SCS.0000000000010378 -
Unfallchirurgie (Heidelberg, Germany) Jul 2024Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually...
BACKGROUND
Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature.
METHODOLOGY
As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this.
RESULTS
The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X‑ray images in 2 planes (true AP and Y‑images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X‑ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks).
CONCLUSION
Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.
Topics: Humans; Child; Adolescent; Shoulder Fractures; Germany; Traumatology; Algorithms; Child, Preschool; Male; Practice Guidelines as Topic; Female; Consensus; Acute Care Surgery
PubMed: 38814464
DOI: 10.1007/s00113-024-01440-2