Primary versus revision total shoulder arthroplasty: comparing relative value and reimbursement trends

Background: Total shoulder arthroplasty (TSA) has been demonstrated to be an effective treatment for multiple shoulder pathologies. The purpose of our study was to compare the relative value units (RVUs) per minute of surgical time for primary and revision TSA.Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients that underwent primary TSA, one-component revision TSA, and two-component revision TSA between January 1, 2015 and December 31, 2017 using current procedure terminology codes. RVUs were divided by mean operative time for each procedure to determine the amount of revenue generated per minute. Rates were compared between the groups using a one-way analysis of variance with post-hoc Tukey test. Statistical significance was set at p<0.05.Results: When dividing compensation by surgical time, we found that two-component revision generated more compensation per minute compared to primary TSA (0.284±0.114 vs. 0.239±0.278 RVU per minute or $10.25±$4.11 vs. $8.64±$10.05 per minute, respectively; p=0.001). Conclusions: The relative value of revision TSA procedures is weighted to account for the increased technical challenges and time associated with these procedures. This study confirms that reimbursement is higher for revision TSA compared to primary TSA.

Clinical Outcome and Biomechanical Analysis of Dynamic Hip Screw Combined with Derotation Screw in Treating Displaced Femoral Neck Fractures Based on Different Reduction Qualities in Young Patients (≤65 Years of Age)

Objective. To examine the clinical results and biomechanical mechanism of the dynamic hip screw (DHS) and derotation screw (DS) in the treatment of displaced femoral neck fractures (FNF) based on different reduction qualities in young patients (≤65 years of age). Methods. All patients with FNF who received closed reduction and internal fixation with DHS+DS from January 2014 to August 2019 were retrospectively analyzed. Data on demographics, surgery, clinical outcomes, and postoperative complications were collected. According to the reduction quality immediately after surgery, all patients were categorized into the positive buttress reduction group (PBRG) and the anatomical reduction group (ARG). The complications and clinical outcomes were compared between the two groups. Meanwhile, the biomechanical mechanism of different reduction qualities was further analyzed with finite element analysis (FEA). The distribution of von Mises stress, the peak stress of internal fixation, and the displacement of the proximal fragment were compared between the two groups. Results. A total of 68 patients were included in our study. Among them, 31 were divided into the PBRG while 37 were in the ARG. The surgical time and fluoroscopy time were significantly shorter in the PBRG than in the ARG ( p < 0.05 ). The degree of femoral neck shortening and the varus change of the femoral-neck shaft angle were lower in the PBRG compared to the ARG ( p < 0.05 ). The excellent-good rate of the Harris hip score was higher in the PBRG compared to the ARG (83.9% vs. 64.8%). The FEA results demonstrated that the stress of DHS+CS and the downward displacement of the proximal femoral neck fragment were greater in the ARG than in the PBRG. Conclusion. For displaced FNF with difficulty to achieve reduction, DHS+CS combined with positive buttress reduction was an effective treatment in young patients due to better mechanical support, shorter surgical time, less radiation exposure, and higher excellent-good rate of Harris hip score.

Comparison of Robotic and Conventional Unicompartmental Knee Arthroplasty Outcomes in Patients with Osteoarthritis: A Retrospective Cohort Study

Robotic-arm-assisted unicompartmental knee arthroplasty (RUKA) was developed to increase the accuracy of bone alignment and implant positioning. This retrospective study explored whether RUKA has more favorable overall outcomes than conventional unicompartmental knee arthroplasty (CUKA). A total of 158 patients with medial compartment osteoarthritis were recruited, of which 85 had undergone RUKA with the Mako system and 73 had undergone CUKA. The accuracy of component positioning and bone anatomical alignment was compared using preoperative and postoperative radiograph. Clinical outcomes were evaluated using questionnaires, which the patients completed preoperatively and then postoperatively at six months, one year, and two years. In total, 52 patients from the RUKA group and 61 from the CUKA group were eligible for analysis. The preoperative health scores and Kellgren–Lawrence scores were higher in the RUKA group. RUKA exhibited higher implant positioning accuracy, thus providing a superior femoral implant angle, properly aligned implant placement, and a low rate of overhang. RUKA also achieved higher accuracy in bone anatomical alignment (tibial axis angle and anatomical axis angle) than CUKA, but surgical time was longer, and blood loss was greater. No significant differences were observed in the clinical outcomes of the two procedures.

Clinical impact of Sim & Size® simulation software in the treatment of patients with cerebral aneurysms with flow-diverter Pipeline stents

Objectives This study evaluated the clinical impact of the Sim&Size® simulation software on the endovascular treatment with flow-diverter stents of patients with unruptured saccular intracranial aneurysms. Methods This monocentric retrospective study evaluated a cohort of patients treated with flow-divert stents between June 1, 2014, and December 31, 2019, for cerebral aneurysms. Patients belonged to two groups, patients treated with and without the Sim&Size® simulation software. Univariate, bivariate, and multivariate analyses were used to evaluate the clinical impact of simulation software. Results Out of the 73 interventions involving 68 patients analyzed by the study, 76.7% were simulated using the Sim&Size® simulation software, and 23.3% were not. Patients treated with the simulation software had shorter stent lengths (16.00 mm vs. 20.00 mm p-value = 0.001) and surgical time (100.00 min vs. 118.00 min p-value = 0.496). Also, fewer of them required more than one stent (3.6% vs. 17.6% p-value = 0.079). Three patients belonging to the non-stimulated group presented hemorrhagic complications. Conclusions Using the Sim&Size® simulation software for the endovascular treatment of intracranial aneurysms with pipeline flow-diverter stents reduces the stent length.

Six-year experience of microvascular free-flap reconstruction of head and neck neoplasms

Introduction: Microvascular free-flap reconstruction is one of the treatment options after large resection of head and neck neoplasms. The objectives of this study are to identify short-term outcomes and risk factors for flap complication in patients who underwent neoplasms resection of head and neck with microvascular free-flap reconstruction. Methods: Retrospective study of patients who underwent surgery for head and neck neoplasm with microvascular free-flap reconstruction between January 2014-2020. Complications were studied at 30-days follow-up and divided into medical and flap complications. Factors independently associated with flap complication were analyzed. Results: We included 31 patients (15 men). The mean age was 60 years. Reconstruction was performed with radial-forearm flap in 74% (n=23) and with free-fibula flap in 26% (n=8). Mean surgical time was 420 minutes. Median hospital length of stay was 7 days. Medical complications were of 23%. Minor complications were of 35% and major of 32%. There was no mortality in 30-days follow-up. Flap complications were of 35%. Reintervention was of 29%, surgical site infection of 9%, dehiscence of 29% and flap loss of 9.7%. Surgical site infection was independently associated with prolonged surgical time (Odds ratio [OR]=1.03, IC95%=0.98-1.04, p=0.02) and body mass index equal to or greater than 30 (OR=1.38, IC95%=0.84-2.26, p=0.04) while flap loss was associated with prolonged surgical time (OR=1.02, IC95%=0.99-1.04, p=0.01). Conclusion: Microsurgical free-flap reconstruction should be considered in our population in patients with large head and neck neoplasms. Preoperative assessment of the risk of postoperative complications is essential before selecting patients for this surgery.

Comparison of perioperative parameters in one-handed rotational phacoemulsification versus conventional phacoemulsification and femtosecond laser-assisted cataract surgery

AIM: To compare perioperative parameters of one-handed rotational phacoemulsification technique (one-handed phaco-roll) with each of other two techniques, “Divide et Conquer” and femtosecond laser-assisted cataract surgery (FLACS) METHODS: In this retrospective and comparative cohort study, eyes with uncomplicated cataract (nuclear density grade 2 to 3) treated routinely with one-handed phaco-roll (n=23; Group 1) or “Divide et Conquer” (n=23; Group 2) or FLACS (n=23; Group 3) were enrolled. Intraoperative parameters including effective phaco-time (EPt), ultrasound time (USt), aspiration time, surgical time, phacoemulsification (phaco)-power, balanced salt solution (BSS) use, cumulative dissipated energy (CDE) were recorded and compared. Clinical outcomes including best corrected visual acuity (BCVA), corneal endothelial cell density (ECD), endothelial cell loss (ECL), central corneal thickness (CCT) and central macular thickness (CMT), were assessed and compared pre-operatively and at 1mo after surgery. RESULTS: Aspiration and surgical time, and BSS used were lower in Group 1 (P<0.01) than other groups. EPt, phaco-power and CDE were lower in Group 1 (P<0.05) than Group 2 but not significantly different from Group 3. In Group 1, USt was lower (P<0.05) than Group 2 but higher (P<0.05) than Group 3. BCVA improved in all groups without significant difference between Group 1 and the other ones. No significant differences regarding all post-operative morphologic outcomes (ECD, ECL, CCT, CMT) were reported. No clinical complications occurred. CONCLUSION: One-handed phaco-roll seems to be less time-consuming than “Divide et Conquer” and FLACS and less energy-consuming than “Divide et Conquer”. Furthermore, one-handed phaco-roll seems to have an equal safety profile compared to the other two techniques.

Major advances in minimally traumatic surgery in implantodontics: the concise systematic review

Introduction: Dental implant procedures have reached about one million dental implants per year in the world. In this context, it is necessary to establish the state of the art of minimally traumatic procedures for dental implants, especially after bone graft procedures and/or the use of biomaterials for bone elevation. In this context of optimizing techniques for better management of dental implants, faster and more accurate methods were developed by dentists, with post-operative results with better results and quality of life, through minimally invasive procedures. Objective: To carry out a concise systematic review of minimally traumatic surgery for dental implants, as well as to elucidate the main techniques for this. Methods: The rules of the Systematic Review Platform-PRISMA were followed. The survey was conducted from July 2021 to October 2021 and was developed based on Scopus, PubMed, Science Direct, Scielo, and Google Scholar. Study quality was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results: Since the most primordial extraction techniques were created and developed, several attempts have been made to minimize the professional's effort, reduce surgical time and alleviate bleeding and inflammatory processes, edema, pain, and ecchymosis that can affect patients, in the trans and postoperative periods. Thus, the maximum preservation of the integrity of the soft tissues (papillae and free and inserted gingival band) adjacent to the prosthetic spaces should be sought; preservation of the alveolar bone ridge level. Based on the histological concept in which living tissues are formed by cells joined by thin elastic tissue and with nerve fibrils, capillaries, lymphatic and blood vessels. The disruption of these cells by surgical trauma provides the release of enzymes that delay healing. For this reason, surgical trauma should be minimized. Conclusion: There are many attempts to minimize the professional effort, reduce surgical time and alleviate bleeding and inflammatory processes, edema, pain, and ecchymosis that can affect patients. Thus, the maximum preservation of the integrity of the soft tissues adjacent to the prosthetic spaces and the preservation of the level of the ridge of the alveolar bone to achieve a minimization of surgical trauma must be sought.

Major approaches to minimally traumatic surgery in dentistry: a systematic review

Introduction: It is estimated that in minimally traumatic dental surgery, synthesis studies with meta-analysis and decision analysis represent almost 29% of all studies. Most of the selected studies were carried out in the USA, Netherlands, and UK. These three countries and 15 journals accounted for nearly 50% of all publications. The remaining works were published in another 61 journals and originated from 32 other countries, including Brazil. Objective: This study aimed to demonstrate, through literature review and case reports, the evolution and consequent importance of improving minimally traumatic surgery techniques in dentistry. It was hypothesized that there were statistically significant results about advances in the attempt to minimize trauma. Methods: The research was carried out from July 2021 to October 2021 and developed based on Google Scholar, Scopus, PubMed, Scielo, and Cochrane Library. The inclusion and exclusion criteria were systematic review studies, meta-analysis, controlled and randomized cases, non-randomized clinical cases, and opinion articles, which addressed the term minimally traumatic surgery in dentistry. The quality of the studies was based on the GRADE instrument. The risk of bias was analyzed according to the Cochrane instrument. Results: Since the most primordial extraction techniques were created and developed, several attempts have been made to minimize the professional's effort, reduce surgical time and alleviate bleeding and inflammatory processes, edema, pain, and ecchymosis that can affect the patients, in the trans and postoperative periods. Thus, the maximum preservation of the integrity of the soft tissues (papillae and free and inserted gingival band) adjacent to the prosthetic spaces should be sought; preservation of the alveolar bone ridge level. Based on the histological concept in which living tissues are formed by cells joined by thin elastic tissue and with nerve fibrils, capillaries, lymphatic and blood vessels. The disruption of these cells by surgical trauma provides the release of enzymes that delay healing. For this reason, surgical trauma should be minimized. Conclusion: There are many attempts to minimize the professional effort, reduce surgical time and alleviate bleeding and inflammatory processes, edema, pain, and ecchymosis that can affect patients. Thus, the maximum preservation of the integrity of the soft tissues adjacent to the prosthetic spaces and the preservation of the level of the ridge of the alveolar bone to achieve a minimization of surgical trauma must be sought.

Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background: An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair. Purpose: The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials. Study Design: Meta-analysis; Level of evidence, 1. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time. Results: There were 10 RCTs that qualified for the meta–analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], –0.73 [95% CI, –1.70 to 0.25]; P = .14; I2 = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I2 = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I2 = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I2 = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I2 = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I2 = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I2 = 15%). Conclusion: Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high–quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.

Pac-Man Method: A New Technique for Nuclear Management Of Posterior Polar Cataract

Purpose We introduce an innovative technique, “Pac-Man”, for the nuclear management of posterior polar cataracts and compare it with “Chop in situ” and “Fishbowl” techniques. Method A total of 60 eyes from 60 patients were randomly assigned to groups A, B, and C, with 20 eyes in each group. Pac-Man, Chop in situ, and Fishbowl techniques were used for groups A, B, and C. In the Pac-Man method, adequate single trench sculpts, and a right-sided lateral sculpt were performed and cracked. The triangular piece was emulsified, after which the rest of the nucleus looked like a “Pac-Man” cartoon. Techniques were compared by age, visual outcome, Posterior Capsule Rupture (PCR), Cumulative Dissipated Energy (CDE), and time of surgery. Result Postoperative BCVA was significantly improved after surgery ( P = 0.0001, paired t-test). Time taken for surgeries were 25 ± 2.57, 30 ± 3.78, 40 ± 3.25 min, the CDE were 10 ± 0.95, 20 ± 1.2, 15 ± 0.48, and the PCR were 0%, 5%, and 10% for group A,B,C respectively. The total number of PCR was 3 out of 60 patients, and the percentage was 5.00%. Conclusion The “Pac-Man” method is a recommended technique due to its visual outcome, reduced surgical time, less CDE, and less chance of PCR.