Promising results of surgical management of advanced medication related osteonecrosis of the jaws using adjunctive leukocyte and platelet rich fibrin

Background Leukocyte- and platelet-rich fibrin (L-PRF) is an autologous matrix scaffold which regulates inflammation by stimulating cytokines and growth factors that are involved in the immune response. L-PRF is suggested as a viable adjunctive method to surgical interventions due to its advantages on tissue healing. This study aims to retrospectively evaluate the adjunctive role of L-PRF in surgically treated medication-related osteonecrosis of the jaws (MRONJ) patients. Methods Between January 2012 and December 2020, patients with AAOMS stage II and III MRONJ lesions, who were treated surgically with adjunctive use of L-PRF in the authors’ institution were enrolled. Surgical interventions consisted of either marginal resection or sequestrectomy with peripheral ostectomy (SPO) or curettage and L-PRF application. Medical records of these patients were retrospectively reviewed and healing was assessed according to certain parameters including mucosal closure and presence of infection, exposed bone, fistula or radiologic markers of disease progression for a minimum of 12 months. Results Thirteen patients (7 women and 6 men) with an average age of 72.4 years (± 10.61, range 54–84) were included in the study, nine of whom had AAOMS stage III and four stage II MRONJ. Three patients had a marginal resection, nine patients had sequestrectomy with peripheral ostectomy (SPO) and one patient underwent a curettage procedure. All marginal resection and six SPO patients showed complete healing while four patients, who had SPO or curettage experienced incomplete healing. Mean follow up was 20.1 ± 18.29 months. Conclusion The use of L-PRF may be a favorable adjunctive option in the treatment of MRONJ owing to its favorable effects on tissue repair, ease of application, minimally invasive and cost-effective character and autogenous nature. Trial registration Retrospectively registered.

Predicting Outcomes of Talar Osteochondritis Dissecans Lesions in Children

Background: Reports detailing the rates of radiographic healing after treatment of talar osteochondritis dissecans (TOCD) remain scarce. There is also a paucity of data characterizing treatment outcomes and the risk factors associated with poor outcomes in children with TOCD. Purpose: To identify factors associated with healing, assess treatment outcomes, and develop a clinically useful nomogram for predicting healing of TOCD in children. Study Design: Case-control study; Level of evidence, 3. Methods: This was a retrospective review of all patients ≤18 years of age with TOCD from a single pediatric institution over a 12-year period. Surgical treatment was left to the discretion of the treating surgeon based on standard treatment techniques. Medical records and radiographs were reviewed for patient and clinical data, lesion characteristics, and skeletal maturity. Radiographic healing was evaluated at the 1-year follow-up, and patients with complete versus incomplete healing were compared using multivariable logistic regression models to examine the predictive value of the variables. Results: The authors analyzed 92 lesions in 74 patients (mean age, 13.1 ± 2.7 years [range, 7.1-18.0 years]; 61% female). Of these, 58 (63%) lesions were treated surgically (drilling, debridement, microfracture, bone grafting, or loose body removal), and the rest were treated nonoperatively. Complete radiographic healing was seen in 43 (47%) lesions. In bivariate analysis, patients with complete healing were younger ( P = .006), were skeletally immature ( P = .013), and had a lower body mass index (BMI; P < .001) versus those with incomplete healing. In a multivariate regression model, the factors that correlated significantly with the rate of complete healing were age at diagnosis, BMI, and initial surgical treatment. The lesion dimensions were not significantly associated with the likelihood of healing. A nomogram was developed using the independent variables that correlated significantly with the likelihood of complete radiographic healing. Conclusion: Complete radiographic healing of TOCD lesions was more likely in younger patients with a lower BMI. The effect of initial surgical treatment on potential healing rate was greater in older patients with a higher BMI.

Growth Factors in Wound Healing – A Review

The review is an overview of the features of growth factors involved in cellular signaling mechanisms regulating the wound healing process. Understanding the insights of this mechanism is significant for opening therapeutic and research avenues in wound healing. The review highlights the synergistic functioning of most of the growth factors which would enhance the possibility of these factors being the targets for wound care therapy.The significance of the onset and resolution of inflammation in the healing process is better understood clinically and a range of recombinant growth factors to combat this condition have been identified and used to accelerate healing process.The chemotactic and growth regulating factors act as triggers that take the cellular and biochemical components through the inflammation, proliferation, epithelialization, angiogenesis and tissue remodeling phases. Clinical conditions that create alteration in expression of these factors lead to slow and incomplete healing. The review emphasizes on the clinical use of synthetic and recombinant growth factors whose synergistic effects are remarkable. The review covers the specific signaling mechanisms involved in the regulation of these growth factor expressions, specifically the PI3K/AKT, RAS/MAP and JAK pathways; these could be potential targets for future research expansions in this field.

An unusual case of incomplete healing with intraosseous fibrous scar formation in the surgically enucleated site associated with a Type II dens invaginatus: A 4-year follow-up case report

Dens invaginatus is a developmental deformation with varying anatomical features, caused by the envelopment of the enamel organ and/or the Hertwig’s epithelial root sheath within the tooth before calcification completes, increasing the vulnerability of pulpal and periodontal inflammation, posing challenges to treatment, and adequate healing. Cell rest of Malassez, remnants of enamel organ or root sheet may cause cystic lesion formations, also hinder the normal healing process and form a fibrous scar. Intraosseous fibrous scar is a result of incomplete wound healing after periradicular surgery which mimics an asymptomatic residual cyst clinically and radiographically. We herein report a case of a surgically managed an immature maxillary lateral incisor affected with Type II dens invaginatus associated with incomplete periradicular healing presented as intraosseous fibrous scar with a persistent well-defined radiolucency between the healthy trabecular bone. The regular clinical and radiographic follow-up records the asymptomatic endodontically treated dens invaginatus with an intact lamina dura and regular healing trabecular bone pattern. Its 4 years of post-operative evaluation has been presented. Features of this case, causes of such incomplete healing, diagnosis, treatment line, prognosis, and the dilemma of the clinician are discussed together with its probable implications.

Does proctologic surgery really influence sexual behaviors?

Introduction: The percentage of the heterosexual population that has experienced and regularly has anal intercourse ranges from 20% to 35% in the USA. This practice increases to 95% in certain populations, including lesbian, gay, bisexual, and transgender people. Due to the lack of data in the literature about the effect of proctologic surgery on anal intercourse, this study aimed to assess the impact of this surgery on sexual behavior in both genders. Materials and Methods: From March 2016 to February 2018, an anonymous questionnaire was submitted to all patients aged >18 who had undergone proctologic surgery in one of two surgical units at tertiary referral centers and was assessed independently of gender. The exclusion criteria were incomplete healing and < 3 months follow-up. Results: In total, 929 patients answered the questionnaire in full. The overall prevalence of preoperative anal intercourse was 22.5%. The rate of anal intercourse among men was 16.7%, while among women, it was 28.9%. The overall postoperative rate of anal intercourse was 11.8%. The rate of postoperative anal intercourse among those who regularly engaged in anal intercourse preoperatively was 52.6%, with a 47.4% rate of non-completion (p < 0.0001). The experiences reported during intercourse after surgery were mainly pain, stiffness, and partner discomfort. Conclusion: Considering the statistically significant postoperative AI abandonment rate following all types of proctologic surgery, the surgeon has a duty to both treat the disease and to inform the patient about the possible consequences regarding its influence on anal intercourse.

Adjunctive Hyperbaric Oxygen Therapy in Refractory Crohn’s Disease: An Observational Study

Background and Aims. Patients may experience complications of Crohn’s disease (CD) even when treated with optimal medical therapy strategies. Previous data have shown the efficacy of hyperbaric oxygen therapy (HBOT) in the management of complicated CD. However, there is no consensus regarding the optimal number of sessions or duration of treatment regimens. The aim of the present study was to investigate the efficacy of HBOT in CD patients who were refractory to conventional medical management. Methods. This study included patients who underwent HBOT for the treatment of the following complications: perianal fistulizing Crohn’s disease (pCD), enterocutaneous fistulas (ECF), or pyoderma gangrenosum (PG). Complete healing was defined as the closure of external orifice and the absence of active draining (in pCD), complete wound healing (in PG), and granulation or complete wound epithelialization with no enteric draining (in ECF). The persistence of draining and the absence of wound granulation were defined as incomplete healing. Results. Forty patients were included. The mean CD duration was 10.6 ± 5.8 years. pCD comprised most of the included patients (25/62.5%), followed by ECF ( n = 13 / 32.5 % ) and PG ( n = 6 / 15 % ). In two patients (5%), a combination of ECF and PG was diagnosed, and in one patient (2.5%), all three complications were observed. A total of 32 patients (82.5%) had complete healing. Patients with PG had the highest healing rates (100%), followed by those with ECF (84.6%) and pCD (80%). Conclusions. Adjunctive HBO was associated with significant healing rates for CD-associated complications such as pCD, ECF, and PG.

Type 2 immunity induced by bladder extracellular matrix enhances corneal wound healing

The avascular nature of cornea tissue limits its regenerative potential, which may lead to incomplete healing and formation of scars when damaged. Here, we applied micro- and ultrafine porcine urinary bladder matrix (UBM) particulate to promote type 2 immune responses in cornea wounds. Results demonstrated that UBM particulate substantially reduced corneal haze formation as compared to the saline-treated group. Flow cytometry and gene expression analysis showed that UBM particulate suppressed the differentiation of corneal stromal cells into α-smooth muscle actin–positive (αSMA+) myofibroblasts. UBM treatments up-regulated interleukin-4 (IL-4) produced primarily by eosinophils in the wounded corneas and CD4+ T cells in draining lymph nodes, suggesting a cross-talk between local and peripheral immunity. Gata1−/− mice lacking eosinophils did not respond to UBM treatment and had impaired wound healing. In summary, stimulating type 2 immune responses in the wounded cornea can promote proregenerative environments that lead to improved wound healing for vision restoration.

Systematic Postoperative Assessment of a Minimally-Invasive Sheep Model for the Treatment of Osteochondral Defects

To assess the clinical course of a sheep stifle joint model for osteochondral (OC) defects, medial femoral condyles (MFC) were exposed without patella luxation using medial parapatellar skin (3–4 cm) and deep incisions (2–3 cm). Two defects (7 mm diameter; 10 mm depth; OC punch) were left empty or refilled with osteochondral autologous transplantation cylinders (OATS) and explanted after six weeks. Incision-to-suture time, anesthesia time, and postoperative wound or impairment scores were compared to those in sham-operated animals. Implant performance was assessed by X-ray, micro-computed tomography, histology, and immunohistology (collagens 1, 2; aggrecan). There were no surgery-related infections or patellar luxations. Operation, anesthesia, and time to complete stand were short (0.5, 1.4, and 1.5 h, respectively). The wound trauma score was low (0.4 of maximally 4; day 7). Empty-defect and OATS animals reached an impairment score of 0 significantly later than sham animals (7.4 and 4.0 days, respectively, versus 1.5 days). Empty defects showed incomplete healing and dedifferentiation/heterotopic differentiation; OATS-filled defects displayed advanced bone healing with remaining cartilage gaps and orthotopic expression of bone and cartilage markers. Minimally-invasive, medial parapatellar surgery of OC defects on the sheep MFC allows rapid and low-trauma recovery and appears well-suited for implant testing.

Ligasure Hemorrhoidectomy: Updates on Complications after an 18-Year Experience

Background: Hemorrhoidal disease represents one of the most common anorectal disorders in the general population. Energy devices, such as LigaSureTM scalpel, have reshaped the concept of hemorrhoid surgery and in turn, have improved patient outcomes and simplified the work of surgeon. Objective: The study aims to evaluate the outcomes of LigaSureTM hemorrhoidectomy (LH) analyzing main post-operative complications rate, length of stay, operating time and time to return to work. Methods: In this monocentric descriptive study, from June 2001 to February 2019, 1454 consecutive patients, treated with LH for grade III and IV haemorrhoids, were analyzed. Complications were classified in early, late and long-term if they occurred within 1 month, between 1 and 2 months or after 2 months, respectively. Results: (90.2%) of patients were treated in day surgery regimen and mean operating time was 14.3 minutes. The post-operative pain decreased from 3.7 mean VAS on the 1st post-operative day to 0.1 mean VAS on 30th post-operative day. Early complications rate was 2.1%: urinary retention accounted for 1.8% of patients. 0.3% of patients experienced post-operative bleeding and only one required reoperation. Late complications rate was 5.8%: anal stenosis, incomplete healing and anal fissure were detected in 3.6%, 1.2% and 1% of patients, respectively. The Long term complications rate was 5.3 % : anal fistula, soiling, perianal abscess and recurrence were identified in 0.2%, 0.1%, 0.3% and 4.8% of patients, respectively. Conclusion: LH is a safe and fast procedure with a proven minimal complications rate.

Spontaneous Cervical Artery Dissection: A Case Series

Cervical artery dissection refers to dissection of the vertebral or carotid arteries, and accounts for up to 20% of strokes in those under 45. Antithrombotic therapy is therefore essential to limit thrombosis at the site of injury and distal neuronal damage. However, the exact choice of drugs, timing and duration of therapy remain a challenging decision. A review of data was conducted on three cases of unprovoked cervical dissection at our stroke center between 2017 and 2020. They include bilateral internal carotid artery dissection, right vertebral artery dissection, and left internal carotid artery dissection. Three key outcomes were identified: narrowing, occlusion and pseudoaneurysm; such outcomes dictated our management approach. Two patients were given antiplatelet therapy for at least one year. The patient with bilateral dissection was perceived to have higher thromboembolic risk, due to the presence of a free-floating thrombus. Thus, he was anticoagulated for a year, and thereafter given antiplatelet therapy. The evidence behind long-term management of carotid artery dissection remains equivocal. There is no strong evidence favouring anticoagulation over antiplatelets or vice versa. Anticoagulation tends to be preferred in cases of severe stenosis, occlusion or pseudoaneurysm, to reduce the risk of thromboembolic phenomena. Anti-platelets are preferred where there is a high risk of haemorrhagic transformation or contraindication to anticoagulation. The duration of secondary prevention is similarly unclear. Advances in radiology and increased follow-up have resulted in uncertainty on the management of incomplete healing at the six-month point. Varying clinical practice has been identified and there is a lack of a clear guideline. We propose continuing antithrombotic therapy in cases of incomplete healing, as in our case series. Nevertheless, we require more data on the subject and thus suggest an initial nation-wide survey to compare the different management strategies followed by large-scale retrospective analyses comparing long-term outcomes.