Enhanced recovery after surgery (ERAS) is a multimodal protocol applied towards perioperative patient care. ERAS programs are implemented by a multidisciplinary team centered around the patient, incorporating outpatient clinical staff, preoperative nurses, anesthesiologists, operative nurses, postoperative recovery staff, floor inpatient nurses, dieticians, physical therapists, social workers, and surgeons. Initial studies on perioperative care measures focused on cardiac surgery. Subsequently, the development of the ERAS Study Group in 2001 focused on colorectal surgery and postoperative outcome measures. Today, ERAS protocols have been implemented across many surgical subspecialties including: bariatric, breast, plastic, cardiac, colorectal, esophageal, head and neck, hepatic, gynecologic, neurosurgical, orthopedic, pancreatic, thoracic, and urologic surgery. The goal of ERAS programs is to promote rapid recovery as quantified by decreasing the length of hospital stay, complications, and cost of specific surgical interventions. In the setting of the opioid crisis in America, there is also an increasing focus on minimizing perioperative narcotic use. The purpose of this review is to compare ERAS protocols across surgical subspecialties, focusing on quantified metrics of improvement, and to provide a clear and concise summary of the literature in regards to current ERAS practices and success rates.
Asrafi Rizki Gatam,1– 3 Luthfi Gatam,1– 3 Ajiantoro Ajiantoro,3 Omar Luthfi,3 Phedy Phedy,1,2 Harmantya Mahadhipta,1 Syafrudin Husin,1 Ilham Suryo Wibowo Antono,4 Erwin Ardian Noor,2 Karina Sylvana Gani,1 Mitchel Mitchel,1 Erica Kholinne1,5 1Department of Orthopedic and Traumatology, Gatam Institute Eka Hospital, Jakarta, Indonesia; 2Department of Orthopedic and Traumatology department, Fatmawati Hospital, Jakarta, Indonesia; 3Department of Orthopedic and Traumatology Department, Premier Bintaro Hospital, Jakarta, Indonesia; 4Orthopaedi dan Traumatologi Department, Faculty of Medicine Universitas Indonesia– Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia; 5Department of Surgery, Faculty of Medicine, Universitas Trisakti, Jakarta, IndonesiaCorrespondence: Erica Kholinne, Department of Surgery, Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia, Tel +628118682265, Email erica@trisakti.ac.idIntroduction: Facet cysts are degenerative lesions near the facet joints, often seen in older adults with lumbar or radicular pain. They can compress nerves and cause significant morbidity. Treatment options range from conservative care to surgery. This article outlines the Biportal Endoscopic Spine Surgery (BESS) technique using interlaminar ipsilateral or contralateral approaches for symptom relief.Methods: This paper outlines the surgical techniques of Biportal Endoscopic Spine Surgery (BESS), utilizing both ipsilateral and contralateral interlaminar approaches. The choice of approach was determined by the location and characteristics of the synovial cyst. It details the surgical process, including portal placement, visualization, trajectory differences between approaches, and steps for cyst removal.Results: Biportal endoscopic spine surgery is a safe and effective minimally invasive treatment for symptomatic lumbar facet cysts, especially in elderly patients. The contralateral approach offers better visualization, improved dural dissection, and greater facet joint preservation, making it ideal for medial or adherent cysts. It also reduces nerve root manipulation and postoperative instability. In contrast, the ipsilateral approach is more suitable for lateral cysts.Conclusion: The choice between contralateral and ipsilateral approaches in biportal endoscopic facet cyst removal depends on cyst location and anatomical considerations. The contralateral approach is better suited for medial or adherent cysts, offering improved access with less facet disruption. Meanwhile, the ipsilateral approach provides a direct path for lateral cysts but may require more nerve manipulation and facet joint resection. A personalized surgical strategy is essential to optimize access, ensure nerve safety, and maintain spinal stability.Keywords: biportal endoscopic, contralateral, ipsilateral, interlaminar approach, facet cyst, lumbar
Orthopedic surgery, Diseases of the musculoskeletal system
Abstract Purpose The poor prognosis of adult patients with spinal deformity following long-segment spinal fusion surgery remains a major concern. Our study aims to investigate the impact of an Enhanced Recovery After Surgery (ERAS) protocol on the prognosis of adult patients with spinal deformity. Methods This study focused on a retrospective review of a database of previous adult spinal deformity. Adult patients with spinal deformity who underwent long-segment fusion surgery from July 2016 to July 2022 were evaluated, from July 2016 to July 2019 for the pre-ERAS patient group and from July 2019 to July 2022 for the ERAS group. Demographic data, radiological sagittal parameters, and intraoperative data were collected from all patients. The length of hospital stay, postoperative complications, and 90-day readmission rates were compared between the two groups. Additionally, multivariate regression models were used to analyze the predictors of postoperative length of stay, postoperative complications, and 90-day readmission rates. Results A total of 215 patients were included in this study, 102 patients in the pre-ERAS group and 113 patients in the ERAS group. Postoperative outcomes in the ERAS group included significantly lower postoperative length of stay (LOS) (13.09 ± 4.57 vs. 11.13 ± 4.16, P = 0.001); significantly lower rate of postoperative complications (52.0% vs. 29.2%, P < 0.001) and significantly lower 90-day readmission rates (14.7% vs. 6.19%, P = 0.040). Multivariate linear regression showed that fewer ERAS (P = 0.022), later drain placement (P = 0.027), and more complications (P = 0.002) were significantly associated with longer postoperative LOS. Multivariate logistic regression showed that fewer ERAS (P = 0.015) and later drain removal (P = 0.041) were significantly associated with more complications, and more ERAS (P = 0.009), earlier postoperative LOS (P = 0.020), and earlier urinary catheter removal (P = 0.034) were significantly associated with the 90-day readmission rates. Conclusions According to the results of our study, it is necessary to implement an ERAS protocol for adult patients with spinal deformity undergoing long-segment fusion surgery. The ERAS protocol is effective in reducing postoperative hospital length of stay, incidence of surgical complications, and 90-day readmission rates.
Orthopedic surgery, Diseases of the musculoskeletal system
Abstract Background PMMA bone cement is known to induce tissue inflammation around implants. A previous research group developed a novel material, enoxaparin sodium bone cement (ES-PMMA), which combines 40 g of PMMA bone cement with 8000 AxaIU of enoxaparin sodium. This innovative bone cement has demonstrated anti-inflammatory and immunomodulatory properties within the local tissue microenvironment. This study aimed to explore the underlying molecular mechanisms. Methods RAW264.7 cells were treated with different bone cement extract mediums to observe macrophage polarization and the expression of inflammatory factors. RAW264.7 cells treated with different bone cement extract mediums were collected for lncRNA sequencing, and the sequencing results were analyzed using bioinformatics. The lncRNA NONMMUT104330.1-miR-709-DDX58 regulatory axis was constructed based on the competing endogenous RNA mechanism. Subsequently, lncRNA NONMMUT104330.1 in RAW264.7 cells was either knocked down or overexpressed to observe the inflammatory response of the cells. Results ES-PMMA bone cement induces M2 polarization of macrophages and increases the expression of anti-inflammatory factors. A bioinformatics analysis was conducted on the sequencing results to construct the lncRNA NONMMUT104330.1-miR-709-DDX58 regulatory axis. A dual-luciferase reporter gene assay was employed to verify the binding feasibility of the axis, and the results demonstrated that miR-709 could bind to the molecular sites of lncRNA NONMMUT104330.1 and DDX58, respectively. Knockout and overexpression experiments of lncRNA NONMMUT104330.1 demonstrated that the knockdown of lncRNA NONMMUT104330.1 induced M2 polarization in RAW264.7 cells, leading to a reduction in pro-inflammatory factor expression and an increase in anti-inflammatory factor expression. Conversely, upon overexpression of lncRNA NONMMUT104330.1, RAW264.7 cells were polarized to M1, resulting in elevated levels of pro-inflammatory factors. Conclusion Enoxaparin sodium bone cement can induce M2 polarization of macrophages, thereby playing an anti-inflammatory immunomodulatory role. The lncRNA NONMMUT104330.1-miR-709-DDX58 axis may significantly contribute to this process. Clinical trial number Not applicable.
Orthopedic surgery, Diseases of the musculoskeletal system
Introduction:
Neonatal Obstetric fractures are rare birth injuries that newborns sustained from trauma during delivery and birth process. Long bone fractures are common in vaginal breech deliveries. A cesarean section is considered a relatively safe and preferred mode of delivery of breech fetuses to prevent birth trauma and decrease the risk of fetal head entrapment; nevertheless, it can lead to femur fracture in newborn rarely.
Case Report:
A 3915 g male child born at 38 weeks and 4 days of gestation to a primigravida aged 31 years by emergency Lower Segment Cesarean Section for Premature Rupture of Membrane with breech presentation. During extraction, the newborn sustained a fracture to his right femur shaft. X-rays confirmed the diagnosis. The fracture was treated successfully with a toe-groin cast for 25 days with complete healing.
Conclusion:
As compared to vaginal breech delivery, cesarean section reduces the risk of traumatic birth injuries; however, it does not completely eliminate the possibility of birth injuries and long bone fractures in newborns. Orthopedic opinion must be sought, if the obstetrician and neonatologist suspect any birth trauma in difficult deliveries. Immobilization of the limb leads to complete healing of the fracture without any sequel.
Orthopedic surgery, Diseases of the musculoskeletal system
Laura S. Herzog, Lucas Berent, Aleksander Kubica
et al.
Lattice surgery with two-dimensional quantum error correcting codes is among the leading schemes for fault-tolerant quantum computation, motivated by superconducting hardware architectures. In conventional lattice surgery compilation schemes, logical circuits are compiled following a place-and-route paradigm, where logical qubits remain statically fixed in space throughout the computation. In this work, we introduce a paradigm shift by exploiting movable logical qubits via teleportation during the logical lattice surgery CNOT gate. Focusing on lattice surgery with the color code, we propose a proof-of-concept compilation scheme that leverages this capability. Numerical simulations show that the proposed approach can substantially reduce the routed circuit depth compared to standard place-and-route compilation techniques. Our results demonstrate that optimizations based on movable logical qubits are not limited to architectures with physically movable qubits, such as neutral atoms or trapped ions - they are also readily applicable to superconducting quantum hardware. An open-source implementation of our method is available on GitHub https://github.com/munich-quantum-toolkit/qecc.
Netanja I. Harlianto, BSc, Solaiman Ezzafzafi, BSc, Wouter Foppen, MD, PhD
et al.
Background: Subjects with ankylosing spinal disorders, including diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) are more prone to vertebral fractures and frequently present with neurological deficit compared to the patients without an ankylosed spine. Moreover, prevalent vertebral fractures are an important predictor for subsequent fracture risk. However, the pooled fracture prevalence for DISH is unknown and less recent for AS. We aimed to systematically investigate the prevalence and risk of vertebral fractures in DISH and AS populations. Methods: Publications in Medline and EMBASE were searched from January 1980 until July 2023 for cohort studies reporting vertebral fractures in AS and DISH. Data on prevalence were pooled with random effects modeling after double arcsine transformation. Heterogeneity was assessed with I2 statistics and we performed subgroup analysis and meta-regression to explore sources of heterogeneity. Results: We included 7 studies on DISH (n = 1,193, total fractures = 231) with a pooled vertebral fracture prevalence of 22.6% (95%CI: 13.4%–33.4%). For AS, 26 studies were included (n = 2,875, total fractures = 460) with a pooled vertebral fracture prevalence of 15.2% (95%CI: 11.6%–19.1%). In general, fracture prevalence for AS remained similar for several study-level and clinically relevant characteristics, including study design, diagnostic criteria, spine level, and patient characteristics in subgroup analysis. AS publications from 2010 to 2020 showed higher fracture prevalence compared to 1990 to 2010 (18.6% vs. 11.6%). Fractures in DISH were most common at the thoracolumbar junction, whereas for AS, the most common location was the mid-thoracic spine. Conclusions: Vertebral fractures are prevalent in AS and DISH populations. Differences in fracture distribution along the spinal axis exist between the 2 disorders. Additional longitudinal studies are needed for incident fracture assessment in patients with ankylosing spinal disorders.
Orthopedic surgery, Neurology. Diseases of the nervous system
Hanna Pihlman, Jere Linden, Kaarlo Paakinaho
et al.
Improving bone-graft substitutes and expanding their use in orthopedic and spinal surgery leads to shorter surgical times, fewer complications, and less pain among patients both in human and veterinary medicine. This study compared an elastic porous β-tricalcium phosphate/poly(L-lactide-co-ε-caprolactone) (β-TCP/PLCL) copolymer scaffold (composite scaffold) and a commercially available β-TCP/PLCL bone-graft substitute (chronOS Strip) in a rabbit calvarial defect. A bilateral, 12-mm circular defect was created in the parietal bones of 12 rabbits. Both graft materials were soaked in bone marrow aspirate before implantation, and the usability of the material was recorded during surgery. After a follow-up time of 24 ( n = 5) and 48 ( n = 7) weeks, artificial intelligence- (AI-) assisted micro-CT imaging was used to evaluate the bone formation and β-TCP distribution. Bone formation, implant material decomposition, and tissue reactions were further investigated through histopathology and AI-assisted histomorphometric analyses. Both materials supported tissue ingrowth and vascularization and modest 10%–16% new bone formation through the implant. In both materials the degradation advanced during the follow-up time, but there was implant material visible 48 weeks after implantation. Typical long term foreign body reaction with histiocytes, giant cells and lymphocytes, was seen in both materials being more pronounced in composite scaffold. The benefit of the new composite scaffold was its superior usability during surgery.
Background/Objectives: Cataract surgery, a very common and critical procedure for restoring vision, has outcomes that can vary based on patient demographics. This study aimed to elucidate the effects of age and sex on the risk factors, intraoperative complications, and postoperative outcomes of cataract surgery. Subjects/Methods: Conducted as a single-center retrospective cohort study, it analyzed 691 eyes from 589 individuals who underwent surgery at a tertiary referral center, utilizing data from electronic medical records to assess preoperative risk factors, intraoperative complications, and pre- and post-operative best corrected visual acuity (BCVA) along with demographic data. Results: The main results highlighted that males aged 65-75 years exhibited significantly higher rates of functional postoperative BCVA (91% for males vs. 79% for females, p=0.007), a disparity that is not explained by differences in surgical complications or risk factor prevalence. Furthermore, the study identified age-specific thresholds where BCVA improvements significantly declined beyond 65 years for females and 75 years for males. The likelihood of worsened BCVA post-surgery increased with age for both sexes, with a significant decline in BCVA improvement transitioning from 55-65 years to 65-75 years age groups. Conclusions: The findings underscore the critical influence of both sex and age on cataract surgery outcomes, revealing significant sex-specific age thresholds that signal lesser improvements in postoperative BCVA. These insights advocate for the integration of patient age and sex into preoperative evaluations to better tailor the timing and planning of cataract surgery, ultimately aiming to optimize clinical outcomes.
We provide an exposition of a `horizontal' generalization of Goodman's surgery operation on (pseudo-)Anosov flows. This operation is performed by cutting along a specific kind of annulus that is transverse to the flow and regluing with a Dehn twist of the appropriate sign. We then show that performing horizontal Goodman surgery on a transitive pseudo-Anosov flow yields an almost equivalent flow, i.e. the original flow and the surgered flow are orbit equivalent after drilling out a finite collection of closed orbits. We obtain some almost equivalence results by applying this theorem on examples of the surgery operation. Along the way, we also show a structural stability result for pseudo-Anosov flows.
Orthognathic surgery consultation is essential to help patients understand the changes to their facial appearance after surgery. However, current visualization methods are often inefficient and inaccurate due to limited pre- and post-treatment data and the complexity of the treatment. To overcome these challenges, this study aims to develop a fully automated pipeline that generates accurate and efficient 3D previews of postsurgical facial appearances for patients with orthognathic treatment without requiring additional medical images. The study introduces novel aesthetic losses, such as mouth-convexity and asymmetry losses, to improve the accuracy of facial surgery prediction. Additionally, it proposes a specialized parametric model for 3D reconstruction of the patient, medical-related losses to guide latent code prediction network optimization, and a data augmentation scheme to address insufficient data. The study additionally employs FLAME, a parametric model, to enhance the quality of facial appearance previews by extracting facial latent codes and establishing dense correspondences between pre- and post-surgery geometries. Quantitative comparisons showed the algorithm's effectiveness, and qualitative results highlighted accurate facial contour and detail predictions. A user study confirmed that doctors and the public could not distinguish between machine learning predictions and actual postoperative results. This study aims to offer a practical, effective solution for orthognathic surgery consultations, benefiting doctors and patients.
In Japan, the first endoscopic surgery, a laparoscopic cholecystectomy, was performed in 1990. Since then, operative procedures have been standardized, and the safety and efficacy of endoscopic surgery have been evaluated. In accordance with the social acceptance of endoscopic surgery as a less invasive type of surgery, the number of endoscopic procedures performed has increased in all surgical domains. The Japan Society for Endoscopic Surgery (JSES) has played an important role in the development of endoscopic surgery in Japan. Notably, a technical skills certification system for surgeons was established by the JSES to train instructors on how to teach safe endoscopic surgery. Furthermore, the JSES has conducted a national survey every 2 years. In 2019, 291,792 patients underwent endoscopic surgery in all surgical domains, such as abdominal, thoracic, mammary and thyroid gland, cardiovascular, obstetrics and gynecology, urologic, orthopedic, and plastic surgery. The 15th National Survey of Endoscopic Surgery conducted by the JSES demonstrated the status of laparoscopic surgery in Japan in 2018–2019.
Negin Ghamsarian, Yosuf El-Shabrawi, Sahar Nasirihaghighi
et al.
In recent years, the landscape of computer-assisted interventions and post-operative surgical video analysis has been dramatically reshaped by deep-learning techniques, resulting in significant advancements in surgeons' skills, operation room management, and overall surgical outcomes. However, the progression of deep-learning-powered surgical technologies is profoundly reliant on large-scale datasets and annotations. Particularly, surgical scene understanding and phase recognition stand as pivotal pillars within the realm of computer-assisted surgery and post-operative assessment of cataract surgery videos. In this context, we present the largest cataract surgery video dataset that addresses diverse requisites for constructing computerized surgical workflow analysis and detecting post-operative irregularities in cataract surgery. We validate the quality of annotations by benchmarking the performance of several state-of-the-art neural network architectures for phase recognition and surgical scene segmentation. Besides, we initiate the research on domain adaptation for instrument segmentation in cataract surgery by evaluating cross-domain instrument segmentation performance in cataract surgery videos. The dataset and annotations will be publicly available upon acceptance of the paper.
We show an infinite family of hyperbolic knots that have an exceptional surgery producing a graph manifold containing five disjoint, and non parallel incompressible tori.
Opioid use and abuse has become a national crisis in the United States. Many opioid abusers become addicted through an initial course of legal, physician-prescribed medications. Consequently, there has been increased pressure on medical care providers to be better stewards of these medications. In orthopedic surgery and total joint arthroplasty, pain control after surgery is critical for restoring mobility and maintaining patient satisfaction in the early postoperative period. Before the opioid misuse epidemic, orthopedic surgeons were frequently influenced to "treat pain with pain medications." Long-acting opioids, such as OxyContin were used commonly. In the past decade, there has been a paradigm shift in favor of multimodal pain control with limited opioid use. This review will discuss 4 major topics. First, we will describe the pressures on orthopedic surgeons to prescribe narcotic pain medications. We will then discuss the major and minor complications and side effects associated with these prescriptions. Second, we will review how these factors motivated the development of alternative pain management strategies and a multimodal approach. Third, we will look at perioperative interventions that can reduce postoperative opioid consumption, including wound injections and peripheral nerve blocks, which have shown superb clinical results. Finally, we will recommend an evidence-based program that avoids parenteral narcotics and facilitates rapid discharge home without readmissions for pain-related complaints.
Orthopedic implant failure is the most common complication of orthopedic surgery, causing serious trauma and resulting in a tremendous economic burden for patients. There are many reasons for implant failure, among which peri-implant infection (or implant-related infection) and aseptic loosening are the most important. At present, orthopedic doctors have many methods to treat these complications, such as revision surgery, which have shown good results. However, if peri-implant infection can be prevented, this will bring about significant social benefits. Many studies have focused on adding antibacterial substances to the implant coating, and with a deeper understanding of the mechanism of implant failure, adding such substances by different modification methods has become a research hot spot. This review aims to summarize the antibacterial and anti-inflammatory substances that can be used as coating materials in orthopedic implants and to provide a reference for the prevention and treatment of implant failure caused by implant-related infection and excessive inflammation.