Application of pedicled supraclavicular flaps in hypopharyngectomy with preservation of laryngeal function.

To evaluate the efficacy of pedicled supraclavicular flaps in hypopharyngectomy reconstruction, with a focus on preserving laryngeal function. From August 2019 to June 2022, 14 patients with primary hypopharyngeal carcinoma who met the inclusion and exclusion criteria and underwent the repair of hypopharyngeal defects using pedicled supraclavicular flaps were included retrospectively. Relevant clinical evaluation indicators include patient characteristics, defect sizes, flap sizes, flap harvesting time, postoperative hospital stay, postoperative complications, recurrence, and survival outcomes. Among the 14 patients, pyriform sinus carcinoma (n = 10) and posterior hypopharyngeal wall carcinoma (n = 4) were present, with stages T2 (n = 7), T3 (n = 4), T4 (n = 3), N0 (n = 3), N1 (n = 1), and N2 (n = 10). The average defect size was 7.0 (4.0-12.6) cm in the longitudinal diameter and 4.1 (2.8-7.5) cm in the transverse diameter. The mean flap size was 8.4 (5.0-14.0) cm in length and 6.5 (4.0-9.0) cm in width. The mean time for flap harvesting was 37.0 (29.0-51.0) min. The mean postoperative hospital stay was 24.0 (12.0-48.0) days. The mean follow-up period was 20.3 (4.0-47.0) months, and one of the 14 patients was lost during follow-up. Short-term postoperative complications included partial flap necrosis (n = 1), subcutaneous hematoma at the donor site (n = 1), and pharyngeal fistula (n = 4). Long-term complications encompassed pharyngoesophageal anastomotic stenosis (n = 2) and shoulder elevation dysfunction (n = 2). Tumor recurrence occurred in 3 patients. 1 patient succumbed to massive hemorrhage resulting from neck infection due to pharyngeal fistula during chemoradiotherapy. 2 patients succumbed to tumor-related causes. The gastric tube was removed in 13 patients, and the tracheal tube was extracted in 10 patients. The supraclavicular flap offers a promising alternative for reconstruction during hypopharyngectomy with preservation of laryngeal function. It can be utilized to reshape the morphology of the pyriform fossa, aryepiglottic wall, and laryngeal cavity, thereby restoring the functionality of the laryngopharynx.

Zhou W ，Li J ，Feng H ，Xu S ，Liu T ，Wang D ，Qin G ... -  《BMC Surgery》

[Anatomical investigation of the venous system in pedicled nasal septal mucosal flap and its application in nasal skull base reconstruction].

Xue K ，Peng B ，Zhang HK ，Liu Q ，Zheng SX ，Li WP ，Song XL ，Gu Y ，Sun XC ，Yu HM ... -  《-》

[Application of nasal pedicle mucosal flap based on nasal blood supply in reconstruction of nasal skull base defects].

Zhang H ，Gao KL ，Zhang CX ，Fan RH ，Xie ZH ，Zhang JY ，Xie SM ，Jiang WH ... -  《-》

Comparison of Two Modern Survival Prediction Tools, SORG-MLA and METSSS, in Patients With Symptomatic Long-bone Metastases Who Underwent Local Treatment With Surgery Followed by Radiotherapy and With Radiotherapy Alone.

Survival estimation for patients with symptomatic skeletal metastases ideally should be made before a type of local treatment has already been determined. Currently available survival prediction tools, however, were generated using data from patients treated either operatively or with local radiation alone, raising concerns about whether they would generalize well to all patients presenting for assessment. The Skeletal Oncology Research Group machine-learning algorithm (SORG-MLA), trained with institution-based data of surgically treated patients, and the Metastases location, Elderly, Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy model (METSSS), trained with registry-based data of patients treated with radiotherapy alone, are two of the most recently developed survival prediction models, but they have not been tested on patients whose local treatment strategy is not yet decided. (1) Which of these two survival prediction models performed better in a mixed cohort made up both of patients who received local treatment with surgery followed by radiotherapy and who had radiation alone for symptomatic bone metastases? (2) Which model performed better among patients whose local treatment consisted of only palliative radiotherapy? (3) Are laboratory values used by SORG-MLA, which are not included in METSSS, independently associated with survival after controlling for predictions made by METSSS? Between 2010 and 2018, we provided local treatment for 2113 adult patients with skeletal metastases in the extremities at an urban tertiary referral academic medical center using one of two strategies: (1) surgery followed by postoperative radiotherapy or (2) palliative radiotherapy alone. Every patient's survivorship status was ascertained either by their medical records or the national death registry from the Taiwanese National Health Insurance Administration. After applying a priori designated exclusion criteria, 91% (1920) were analyzed here. Among them, 48% (920) of the patients were female, and the median (IQR) age was 62 years (53 to 70 years). Lung was the most common primary tumor site (41% [782]), and 59% (1128) of patients had other skeletal metastases in addition to the treated lesion(s). In general, the indications for surgery were the presence of a complete pathologic fracture or an impending pathologic fracture, defined as having a Mirels score of ≥ 9, in patients with an American Society of Anesthesiologists (ASA) classification of less than or equal to IV and who were considered fit for surgery. The indications for radiotherapy were relief of pain, local tumor control, prevention of skeletal-related events, and any combination of the above. In all, 84% (1610) of the patients received palliative radiotherapy alone as local treatment for the target lesion(s), and 16% (310) underwent surgery followed by postoperative radiotherapy. Neither METSSS nor SORG-MLA was used at the point of care to aid clinical decision-making during the treatment period. Survival was retrospectively estimated by these two models to test their potential for providing survival probabilities. We first compared SORG to METSSS in the entire population. Then, we repeated the comparison in patients who received local treatment with palliative radiation alone. We assessed model performance by area under the receiver operating characteristic curve (AUROC), calibration analysis, Brier score, and decision curve analysis (DCA). The AUROC measures discrimination, which is the ability to distinguish patients with the event of interest (such as death at a particular time point) from those without. AUROC typically ranges from 0.5 to 1.0, with 0.5 indicating random guessing and 1.0 a perfect prediction, and in general, an AUROC of ≥ 0.7 indicates adequate discrimination for clinical use. Calibration refers to the agreement between the predicted outcomes (in this case, survival probabilities) and the actual outcomes, with a perfect calibration curve having an intercept of 0 and a slope of 1. A positive intercept indicates that the actual survival is generally underestimated by the prediction model, and a negative intercept suggests the opposite (overestimation). When comparing models, an intercept closer to 0 typically indicates better calibration. Calibration can also be summarized as log(O:E), the logarithm scale of the ratio of observed (O) to expected (E) survivors. A log(O:E) > 0 signals an underestimation (the observed survival is greater than the predicted survival); and a log(O:E) < 0 indicates the opposite (the observed survival is lower than the predicted survival). A model with a log(O:E) closer to 0 is generally considered better calibrated. The Brier score is the mean squared difference between the model predictions and the observed outcomes, and it ranges from 0 (best prediction) to 1 (worst prediction). The Brier score captures both discrimination and calibration, and it is considered a measure of overall model performance. In Brier score analysis, the "null model" assigns a predicted probability equal to the prevalence of the outcome and represents a model that adds no new information. A prediction model should achieve a Brier score at least lower than the null-model Brier score to be considered as useful. The DCA was developed as a method to determine whether using a model to inform treatment decisions would do more good than harm. It plots the net benefit of making decisions based on the model's predictions across all possible risk thresholds (or cost-to-benefit ratios) in relation to the two default strategies of treating all or no patients. The care provider can decide on an acceptable risk threshold for the proposed treatment in an individual and assess the corresponding net benefit to determine whether consulting with the model is superior to adopting the default strategies. Finally, we examined whether laboratory data, which were not included in the METSSS model, would have been independently associated with survival after controlling for the METSSS model's predictions by using the multivariable logistic and Cox proportional hazards regression analyses. Between the two models, only SORG-MLA achieved adequate discrimination (an AUROC of > 0.7) in the entire cohort (of patients treated operatively or with radiation alone) and in the subgroup of patients treated with palliative radiotherapy alone. SORG-MLA outperformed METSSS by a wide margin on discrimination, calibration, and Brier score analyses in not only the entire cohort but also the subgroup of patients whose local treatment consisted of radiotherapy alone. In both the entire cohort and the subgroup, DCA demonstrated that SORG-MLA provided more net benefit compared with the two default strategies (of treating all or no patients) and compared with METSSS when risk thresholds ranged from 0.2 to 0.9 at both 90 days and 1 year, indicating that using SORG-MLA as a decision-making aid was beneficial when a patient's individualized risk threshold for opting for treatment was 0.2 to 0.9. Higher albumin, lower alkaline phosphatase, lower calcium, higher hemoglobin, lower international normalized ratio, higher lymphocytes, lower neutrophils, lower neutrophil-to-lymphocyte ratio, lower platelet-to-lymphocyte ratio, higher sodium, and lower white blood cells were independently associated with better 1-year and overall survival after adjusting for the predictions made by METSSS. Based on these discoveries, clinicians might choose to consult SORG-MLA instead of METSSS for survival estimation in patients with long-bone metastases presenting for evaluation of local treatment. Basing a treatment decision on the predictions of SORG-MLA could be beneficial when a patient's individualized risk threshold for opting to undergo a particular treatment strategy ranged from 0.2 to 0.9. Future studies might investigate relevant laboratory items when constructing or refining a survival estimation model because these data demonstrated prognostic value independent of the predictions of the METSSS model, and future studies might also seek to keep these models up to date using data from diverse, contemporary patients undergoing both modern operative and nonoperative treatments. Level III, diagnostic study.

Lee CC ，Chen CW ，Yen HK ，Lin YP ，Lai CY ，Wang JL ，Groot OQ ，Janssen SJ ，Schwab JH ，Hsu FM ，Lin WH ... -  《-》

What Are the Functional, Radiographic, and Survivorship Outcomes of a Modified Cup-cage Technique for Pelvic Discontinuity?

Pelvic discontinuity (PD) presents a complex challenge in revision hip arthroplasty. The traditional cup-cage construct, which involves a screw-secured porous metal cup and an overlying antiprotrusio cage, has shown promising mid- to long-term results. However, there is limited information on the outcomes of modifications to the original technique. Our study aims to evaluate a modified technique in which the cup position is determined by the placement of the overlying cage, allowing for adjustments to achieve optimal orientation. Among patients treated for PD with a cup-cage construct in which the cup position was dictated by the position of the cage: (1) What are Harris hip scores achieved at a minimum of 2 years of follow-up? (2) What is the Kaplan-Meier survivorship free from aseptic loosening or component migration? (3) What is the Kaplan-Meier survivorship free from revision for any reason? (4) What surgical complications are associated with the procedure? Between October 2013 and January 2022, we performed 805 acetabular revisions. Among these, 33 patients with PD confirmed intraoperatively were considered potentially eligible for a cup-cage construct; no other method of surgical management was used. We performed 64% (21 of 33) of these procedures from October 2013 to January 2018, with 6% (2 of 33) of patients lost to follow-up before the minimum study follow-up of 2 years; these 19 patients were monitored over a period ranging from 70 to 115 months. A further 12 patients underwent this procedure from January 2018 to January 2022, with one lost to follow-up before the minimum study follow-up of 2 years; the other patients met the minimum 2-year follow-up requirement. The remaining 30 patients with data analyzed here (10 men, 20 women) had a mean ± SD age of 61 ± 12 years and a median BMI of 29 kg/m 2 (range 20 to 33 kg/m 2 ) at the time of revision surgery. Twenty-one patients underwent revision due to aseptic loosening, and nine due to periprosthetic joint infection (PJI). The causes of PD in our patients were as follows: cup aseptic loosening without significant osteolysis in 20% (6 of 30), where the loose cup caused erosion of the host bone, leading to PD; PJI in 30% (9 of 30); intraoperative iatrogenic PD in 3% (1 of 30); and osteolysis in 47% (14 of 30), which also resulted in aseptic loosening. The median follow-up time was 79 months (range 25 to 115 months). The Harris hip score was used to evaluate clinical outcomes, with preoperative values compared with the most recent follow-up. Radiographs were reviewed by two experienced surgeons at each follow-up visit to assess component loosening (defined as migration > 5 mm or the presence of circumferential radiolucent lines) or clear migration. PD was considered healed if bridging callus or trabecular bone was visible across the site of the discontinuity. Complications were assessed through a comprehensive review of electronic medical records. Kaplan-Meier analysis was used to estimate implant survivorship and radiographic loosening, with aseptic loosening or component migration as the endpoint, as well as survivorship free from any reoperation. The Harris hip score improved from a median of 39 (range 30 to 66) preoperatively to a median of 76 (range 30 to 90) postoperatively (median difference 33 [range 2 to 48]; p < 0.01). Within the limitations of two-dimensional (2D) radiographic imaging, successful bone graft integration and the healing of PD were noted in 83% (25 of 30) of patients. Kaplan-Meier survivorship free from radiographic signs of aseptic loosening or component migration was 100% (95% CI 100% to 100%) at 115 months. When any revision related to the acetabular component was considered the endpoint, survivorship free from acetabular component revision at 115 months after revision surgery was 100% (95% CI 100% to 100%). When the need for any reoperation was considered the endpoint, survivorship free from needing reoperation at 115 months after revision surgery was 85% for all patients (95% CI 73% to 100%). When including only patients with a follow-up time of > 4 years (20 of 30), survivorship free from needing reoperation at 115 months after revision surgery was 90% (95% CI 78% to 100%). Postoperative complications during the follow-up period included one early dislocation on the fifth day after surgery, treated with closed reduction and 6 weeks of abduction bracing. One femoral stem loosening occurred at 56 months postoperatively, although the acetabular component remained securely fixed; this patient declined revision surgery. One patient experienced a dislocation 5 months after surgery but refused treatment and opted for prolonged bed rest. Additionally, one patient underwent a debridement, antibiotics, and implant retention procedure 1 week after the revision surgery and subsequently showed no signs of infection at the latest follow-up, 38 months postoperatively. Our study highlights the effectiveness of a modified cup-cage technique in complex hip revisions, showing promising results in terms of construct survivorship and low complication rates. Surgeons could consider delaying screw fixation until after positioning the cage within the porous cup to allow for optimal adjustment and using metal augments for severe bone defects to achieve better alignment. Surgeon experience with the cup-cage technique is crucial for achieving optimal outcomes. Future studies should focus on long-term follow-up visits to assess the durability and effectiveness of these modifications and explore the comparative effectiveness versus other methods, such as custom triflange components and jumbo cups with distraction. Level III, therapeutic study.

Mu W ，Xu B ，Wahafu T ，Wang F ，Guo W ，Zou C ，Cao L ... -  《-》