Robotic pyeloplasty: Technological global panacea or geo-surgical nightmare?

To the Editor, Pelvi-ureteric junction obstruction (PUJO) is a well-recognised clinical entity characterised by functionally significant impairment of drainage of urine at the level of the pelvi-ureteric junction due to extrinsic or intrinsic obstruction and is encountered both by adult and paediatric urologists alike. Management of PUJO has been surgical historically, and the gold standard has been an open Anderson-Hynes dismembered pyeloplasty [...].

Safe zones in dorsal portals for wrist arthroscopy: a cadaveric study

The standard dorsal portals are the most commonly used in wrist arthroscopy. This cadaveric study aims to determine safe zones, by quantitatively describing the neurovascular relationships of the dorsal wrist arthroscopy portals: 1-2, 3-4, midcarpal radial, midcarpal ulnar, 4-5, 6-radial and 6-ulnar. The neurovascular structures of twenty-one fresh frozen human cadaveric upper limbs were exposed, while the aforementioned portals were established with needles through portal sites. The minimum distance between portals and: dorsal carpal branch of radial artery, superficial branch of radial nerve, posterior interosseous nerve and dorsal branch of ulnar nerve, were measured accordingly with a digital caliper, followed by statistical analysis of the data. The median and interquartile range for each portal to structures at risk were determined and a safe zone around each portal was established. Free of any neurovascular structure safe zones surrounding 1-2, 3-4, midcarpal radial, midcarpal ulnar, 4-5, 6-radial and 6-ulnar portals were found at 0.46mm, 2.33mm, 10.73mm, 11.01mm, 10.38mm, 5.95mm and 0.64mm respectively. Results of statistical analysis from comparisons between 1-2, 3-4 and midcarpal radial portals, indicated that 1-2 was the least safe. The same analysis among 3-4, midcarpal radial, midcarpal ulnar and 4-5 portals indicated that midcarpal portals were safer, while 3-4 was the least safe. Results among midcarpal ulnar, 4-5, 6-radial and 6-ulnar portals indicated that 6-radial and specifically 6-ulnar were the least safe. This study provides a safe approach to the dorsal aspect of the wrist, enhancing established measurements and further examining safety of the posterior interosseous nerve.

The Risk of Injury in Wrist Arthroscopy Portals: A Cadaveric Study

During wrist arthroscopy, the wrist joint can be visualized from almost every perspective through a combination of standard dorsal and volar arthroscopic portals. This cadaveric study aims to compare all wrist portals described in terms of their safety in order to rank them according to the distance from the nearest structure at risk for arthroscopic wrist procedures. Twenty-nine cadaveric formalin-embellished upper limbs were examined. Needles were inserted at dorsal and volar portal sites to perform the measurements. During the subsequent dissection, distances were measured as the shortest possible distance from the nearest structure at risk for each portal. Safe zones were determined for all portals, and the safety classification of arthroscopic wrist portals was proposed, ranking them from the safest to the most perilous. Applying the proposed safety classification to arthroscopic practice, wrist arthroscopy can be performed with a lower risk of iatrogenic complications arising from the implementation of the wrist portals.

Prevalence of stable and successfully treated periodontitis subjects and incidence of subsequent tooth loss within supportive periodontal care: A systematic review with meta-analyses

AIM

To identify (i) the prevalence of meeting the endpoints of 'stable periodontitis' (probing pocket depth [PPD] ≤ 4 mm, bleeding on probing [BoP] < 10%, no BoP at 4 mm sites), 'endpoints of therapy' (no PPD > 4 mm with BoP, no PPD ≥ 6 mm), 'controlled periodontitis' (≤4 sites with PPD ≥ 5 mm), 'PPD < 5 mm' and 'PPD < 6 mm' at the start of supportive periodontal care [SPC]) and (ii) the incidence of tooth loss in relation to not meeting these endpoints within a minimum of 5 years of SPC.

MATERIALS AND METHODS

Systematic electronic and manual searches were conducted to identify studies where subjects, upon completion of active periodontal therapy, entered into SPC. Duplicate screening was performed to find relevant articles. Corresponding authors were contacted to confirm inclusion and retrieve required clinical data for further analyses to assess the prevalence of reaching endpoints and incidence of subsequent tooth loss, if available, within at least 5 years of SPC. Meta-analyses were carried out to evaluate risk ratios for tooth loss in relation to not reaching the various endpoints.

RESULTS

Fifteen studies including 12,884 patients and 323,111 teeth were retrieved. Achievement of endpoints at baseline SPC was rare (1.35%, 11.00% and 34.62%, respectively, for 'stable periodontitis', 'endpoints of therapy' and 'controlled periodontitis'). Less than a third of the 1190 subjects with 5 years of SPC data lost teeth-a total of 3.14% of all teeth were lost. Statistically significant associations with tooth loss, at the subject-level, were found for not achieving 'controlled periodontitis' (relative risk [RR] = 2.57), PPD < 5 mm (RR = 1.59) and PPD < 6 mm (RR = 1.98).

CONCLUSIONS

An overwhelming majority of subjects and teeth do not achieve the proposed endpoints for periodontal stability, yet most periodontal patients preserve most of their teeth during an average of 10-13 years in SPC.

Lateral Ankle Instability after Rotational Injury: A Case Report

Introduction

One of the most common orthopedic injury injuries seen in patients at the emergency department is that of the ankle. There are some efficient protocols for their treatment, but more often the clinician is fo-cused in finding and treating possible fractures and disregards ligamentous lesions that lead to instabil-ity, if they become chronic.

Case Report

A patient that suffered an ankle sprain was improperly handled, developed lateral instability of the ankle, and was treated surgically using an autologous semitendinosus graft. A 42-year year-old Caucasian male that after an ankle sprain was examined in various primary health -care centers, four times within six 6 months, with persistent symptoms of his left ankle. After all these months, he was eventually diagnosed with post-traumatic lateral instability of the ankle that was resistant to con-servative treatment. In stress view X-rays, the talar tilt angle was 21°ο and the anterior drawer was measured at 13 mm. The patient was treated surgically with reconstruction of the anterior talofibular and the calcaneofibular ligament using an autologous semitendinosus graft from the left knee. The graft was pinned in the anatomical insertion sites of the ligaments with absorbable screws. A post-surgical physiotherapy regimen was applied for two 2 months. In the post-surgical dynamic stress view X-rays, the talar tilt angle and the anterior drawer were markedly improved, measured at 3°ο and 4 mm, respec-tively. In 11 months post-surgical follow-up, the patient's American Foot and Ankle Score was 85, from the 60 evaluated before treatment.

Conclusion

The use of guidelines, regular follow-ups, and functional rehabilitation are key factors to treating ankle injuries. The reconstruction of lateral collateral ligament complex with a semitendinosus graft is one of the surgical options for restoring lateral ankle instability.

The brain in oral clefting: preliminary results of a systematic review with meta-analyses

Introduction

Previous neuroimaging studies of individuals with nonsyndromic oral clefts have revealed subtle brain structural differences compared to matched controls. Additional studies strongly suggest that the higher incidence of neuropsychiatric issues observed in these individuals may be explained by these neuroanatomical differences. Currently there are no studies that have assessed the overall empirical evidence of the effect of oral clefts on the brain.

Objectives

Our aim was to summarize available evidence on potential brain structure differences in individuals with nonsyndromic oral clefts and their matched controls. In the current presentation, we discuss the results of regional brain structural differences.

Methods

Five databases were systematically searched in September 2020 for case-control studies that reported neuroimaging in healthy individuals and individuals with nonsyndromic oral clefts. Duplicate study selection, data extraction, random effects meta-analyses of mean differences (MDs) and their 95% confidence intervals were performed in order to compare regional brain MRI volumes.

Results

We have identified 245 records following the database searches, from which 12 records met the inclusion criteria. Quantitative data on brain structure were available in three studies.The cerebellum, occipital and temporal lobes were significantly smaller in the cleft group compared to controls (MD: -12.46, 95% CI: -18.26, -6.67, n=3 studies; MD:-7.39, 95% CI: -12.80, -1.99, n=2 studies; MD: -10.53, 95% CI: -18.23, -2.82, n=2 studies, respectively).

Conclusions

There may be structural brain differences between individuals with nonsyndromic oral clefts and their controls based on the available evidence.

Disclosure

No significant relationships.

Effectiveness of soft tissue augmentation procedures for coverage of buccal soft tissue dehiscence around dental implants. A systematic review

OBJECTIVE

This systematic review evaluated the effectiveness of soft tissue augmentation procedures for complete coverage and mean coverage of buccal soft tissue dehiscence (BSTD) in patients with implant-supported restorations.

METHODS

Three databases were surveyed for randomized (RCTs), non-randomized controlled clinical trials (CCTs), cohort studies, case-control studies, and case series with a minimum of five patients per control or test group. Studies dealing with soft tissue augmentation procedures to cover BSTD-occurring during implant function and not due to the result of peri-implantitis-were included. Risk of bias was evaluated with RoB 2 or the National Institutes of Health's Quality Assessment. Whenever possible exploratory meta-analyses were performed to evaluate weighted mean effects (WME) for the different outcomes. The primary outcomes were percentage of complete coverage and mean coverage of BSTD.

RESULTS

Seven articles were included. Only one study was a RCT, with a high risk of bias. Meta-analyses showed that after 1 year (2 studies, n = 36 patients; WME = 70; 95% confidence interval [CI] = 50; 90; p = 0.23) as well as after 5 years (3 studies, n = 54 patients; WME = 70; 95%; CI = 60; 80; p = 0.44), complete coverage of BSTD could be achieved in 70% of the cases.

CONCLUSION

Based on limited evidence it can be concluded that BSTD can be substantially reduced with the use of soft tissue augmentation procedures. Further research with comparative trials using larger samples and longer follow-up periods is needed to study the stability of soft tissues in the long term.

Bioresorbable Magnesium-Based Alloys as Novel Biomaterials in Oral Bone Regeneration: General Review and Clinical Perspectives

Bone preservation and primary regeneration is a daily challenge in the field of dental medicine. In recent years, bioresorbable metals based on magnesium (Mg) have been widely investigated due to their bone-like modulus of elasticity, their high biocompatibility, antimicrobial, and osteoconductive properties. Synthetic Mg-based biomaterials are promising candidates for bone regeneration in comparison with other currently available pure synthetic materials. Different alloys based on Mg were developed to fit clinical requirements. In parallel, advances in additive manufacturing offer the possibility to fabricate experimentally bioresorbable metallic porous scaffolds. This review describes the promising clinical results of resorbable Mg-based biomaterials for bone repair in osteosynthetic application and discusses the perspectives of use in oral bone regeneration.

Periodontitis, Edentulism, and Risk of Mortality: A Systematic Review with Meta-analyses

Periodontitis has been independently associated with the chronic noncommunicable diseases that most frequently lead to death worldwide. The aim of the present systematic review was to study whether people with periodontitis/edentulism are at increased risk of all-cause and cause-specific mortality as compared with those without periodontitis/edentulism. Cohort studies were included that 1) evaluated periodontitis or edentulism as exposures in relation to all-cause or cause-specific mortality as an outcome and 2) reported effect estimates as hazard ratios, risk ratios, or odds ratios with 95% CIs or crude numbers. Two review authors independently searched for eligible studies, screened the titles and abstracts, did full-text analysis, extracted the data from the published reports, and performed the risk-of-bias assessment. In case of disagreement, a third review author was consulted. Study results were summarized through random effects meta-analyses. A total of 57 studies were included, involving 48 cohorts and 5.71 million participants. Periodontitis was associated with increased risk of all-cause mortality (risk ratio, 1.46 [95% CI, 1.15 to 1.85]) and mortality due to cardiovascular diseases (1.47 [1.14 to 1.90]), cancer (1.38 [1.24 to 1.53]), coronary heart disease (2.58 [2.20 to 3.03]), cerebrovascular diseases (3.11 [2.42 to 3.98]), but not pneumonia (0.98 [0.69 to 1.38]). Edentulism (all types) was associated with increased risk of all-cause mortality (1.66 [1.46 to 1.88]) and mortality due to cardiovascular diseases (2.03 [1.50 to 2.74]), cancer (1.55 [1.24 to 1.94]), pneumonia (1.72 [1.07 to 2.78]), coronary heart disease (2.98 [2.43 to 3.65]), and cerebrovascular diseases (3.18 [2.24 to 4.51]). Periodontitis and its ultimate sequela (edentulism) are associated with an increased risk of all-cause and cause-specific mortality (PROSPERO CRD42018100095).

Safe zones in volar portals for wrist arthroscopy, evaluation of central portal : a cadaveric study

The purpose of this cadaveric study is to determine safe zones utilizing volar portals for wrist arthroscopy, by quantitatively describing the neurovascular relationships of a volar radial and a volar ulnar wrist arthroscopy portals in comparison with those of a newly described volar central portal (7) , considering the advantages in visualization of volar portals for wrist arthroscopy over the standard dorsal (19) . The neurovascular structures and the tendons of nine frozen human cadaveric upper limbs were exposed, while the aforementioned volar portal sites were pointed out with pins. The horizontal distance between the portals and the closest neurovascular branch or tendon was measured with a digital caliper, followed by statistical analysis of the data. The median interquartile range distances from portals to structures at risk were measured and safe zones around each portal were established. This study provides a safe approach to the volar radial and ulnar aspects of the radiocarpal and midcarpal joints, while volar radial and ulnar portals should be considered for inclusion in the arthroscopic examination of any patient with radial and ulnar sided wrist pain respectively (17,18) . Regarding the volar central portal, it is reproducible, safe and both the above joints can be inspected through one single incision (7) .

Closed Rupture of Anterior Tibialis Tendon after Minor Injury without Medical History: A Surgical Repair

Introduction

Closed rupture of the anterior tibial tendon is uncommon, with only a few cases being documented in literature. It usually happens in the forceful plantar flexion of the foot while in eversion and the simultaneous contraction of the anterior tibialis muscle.

Care Report

We present the case of a 65-year-old man with closed rupture of the tibialis anterior tendon after injury who was treated by primary surgical repair. The surgical technique as well as the rehabilitation protocol are described in detail.

Conclusion

Primary surgical reconstruction repair is indicated in younger, active individuals. It appears that early diagnosis and treatment provides the best clinical results, while delayed treatment usually requires the use of a tendon graft in combination with tendon transfers, giving inferior results compared to primary tendon repair.

Serum 1,25(OH)D level increases after elimination of periodontal inflammation in T1DM subjects

OBJECTIVES

The aim of the present study was to investigate associations between serum concentrations of vitamin D metabolites, 25-hydroxyvitamin D [25(OH)D], and its active form, 1,25-dihydroxyvitamin D [1,25(OH)D], and the severity of chronic periodontitis.

SUBJECTS AND DESIGN

Presence of dental plaque, probing pocket depth (PD), and attachment level in 80 type 1 diabetes mellitus subjects were recorded. The serum levels of 25(OH)D, 1,25(OH)D, ultrasensitive C-reactive protein, IL-6, TNF-α, high-density lipoprotein cholesterol, and glycosylated hemoglobin (percentage) were determined. Multivariate regression models were used to explore the associations between serum 25(OH)D (nanomoles per liter) and 1,25(OH)D (picomoles per liter) levels and periodontal health status.

INTERVENTION

Antiinfective periodontal therapies were delivered and the clinical examination and laboratory analyses were repeated 8 weeks after the therapies.

RESULTS

A statistically significant association was found between the serum level of 1,25(OH)D (odds ratio 1.06, 95% confidence interval 1.02-1.11) and periodontal health at the baseline; subjects with a high level were more likely to belong to the group of no or mild periodontitis. The serum level of 1,25(OH)D showed a statistically significant increase after antiinfective periodontal therapy in both no or mild (P = .001) and moderate or severe periodontitis (P < .001) subjects. The association between serum 25(OH)D level and periodontal health was negligible.

CONCLUSION

This study has shown a significant positive association between the serum 1,25(OH)D level and periodontal health status. To what extent this association is causal in nature remains to be confirmed.

Cytolethal distending toxin in isolates of Aggregatibacter actinomycetemcomitans from Ghanaian adolescents and association with serotype and disease progression

BACKGROUND AND OBJECTIVES

The cytolethal distending toxin (Cdt) is a highly conserved exotoxin that are produced by a number of Gram negative bacteria, including Aggregatibacter actinomycetemcomitans, and affects mammalian cells by inhibiting cell division and causing apoptosis. A complete cdt-operon is present in the majority of A. actinomycetemcomitans, but the proportion of isolates that lack cdt-encoding genes (A, B and C) varies according to the population studied. The objectives of this study were to examine serotype, Cdt-genotype, and Cdt-activity in isolates of A. actinomycetemcomitans collected from an adolescent West African population and to examine the association between the carrier status of A. actinomycetemcomitans and the progression of attachment loss (AL).

MATERIALS AND METHODS

A total of 249 A. actinomycetemcomitans isolates from 200 Ghanaian adolescents were examined for serotype and cdt-genotype by PCR. The activity of the Cdt-toxin was examined by DNA-staining of exposed cultured cells and documented with flow cytometry. The periodontal status of the participants was examined at baseline and at a two-year follow-up.

RESULTS

Presence of all three cdt-encoding genes was detected in 79% of the examined A. actinomycetemcomitans isolates. All these isolates showed a substantial Cdt-activity. The two different cdt-genotypes (with and without presence of all three cdt-encoding genes) showed a serotype-dependent distribution pattern. Presence of A. actinomycetemcomitans was significantly associated with progression of AL (OR = 5.126; 95% CI = [2.994-8.779], p<0.001).

CONCLUSION

A. actinomycetemcomitans isolated from the Ghanaian adolescents showed a distribution of serotype and cdt-genotype in line with results based on other previously studied populations. Presence of A. actinomycetemcomitans was significantly associated with disease progression, in particular the b serotype, whereas the association with disease progression was not particularly related to cdt-genotype, and Cdt-activity.