Background: Ankyloglossia, or tongue-tie, is characterized by a short or thickened lingual frenulum; this can be associated with impaired breastfeeding, speech, and dentofacial growth. The indications for performing frenotomy, frenuloplasty, or other operative interventions are unclear. Methods: A meta-analysis was performed to identify the extent of the benefit from frenotomy in breastfeeding measures, degree of tongue-tie, and maternal pain during feeding in randomized controlled trials. A structured literature review analyzed the optimal type and timing of repair. An algorithm was developed to incorporate this evidence into a management pathway. Results: Among 424 studies reviewed, 5 randomized controlled trials met inclusion criteria for meta-analysis. Frenotomy significantly improved the degree of tongue-tie, with a 4.5-point decrease in Hazelbaker Assessment Tool for Lingual Frenulum Function score compared with a decrease of 0 in those who did not undergo frenotomy ( P < 0.00001). This was associated with improved self-reported breastfeeding (relative risk [RR] = 3.48, P < 0.00001) and decreased pain (Short-Form McGill Pain Questionnaire, P < 0.00001); however, Breastfeeding Self-Efficacy–Short Form and Latch, Audible Swallowing, Type of Nipple, Comfort, Hold scores did not significantly improve. Multiple studies demonstrated significant improvements following frenuloplasty when compared with frenotomy but demonstrated mixed results as to the effect of timing of tongue-tie division. Conclusions: Frenotomy is associated with breastfeeding improvements that vary individually but trend toward significance collectively during a critical time in infant development. Among patients with a severe Hazelbaker Assessment Tool for Lingual Frenulum Function score or difficulty breastfeeding, we conclude that simple frenotomy without anesthetic is generally indicated in infancy and frenuloplasty under general anesthesia for older children.
Soft tissue sarcoma represents approximately 1% of all cancers, and up to 20% of soft tissue sarcoma occurs in the retroperitoneum. 1 Locoregional failure occurs in up to 50% of cases. 2 Although a 2019 prospective trial 3 suggested no survival benefit with preoperative radiation, the National Comprehensive Cancer Network (NCCN) guidelines on neoadjuvant treatments for nonmetastatic, resectable retroperitoneal sarcoma are heterogeneous and are at the discretion of clinicians. 4 Given a paucity of large prospective data, clinical benefit of neoadjuvant interventions remains unclear. We performed a retrospective cohort study using a nationwide oncology database to compare surgical treatment alone vs surgical treatment and preoperative therapy regimens. MethodsThe Roswell Park Comprehensive Cancer Center institutional review board approved this cohort study and determined that informed consent was not required because the database was deidentified and publicly available to those who applied through the American College of Surgeons website. Our study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The National Cancer Database (NCDB) was queried for patients diagnosed between 2006 and 2015 with nonmetastatic, resectable retroperitoneal sarcoma.We searched for individuals treated with surgical procedure alone or surgical procedure following preoperative chemotherapy or radiation. Primary end point was overall survival, evaluated by Kaplan-Meier method, log-rank test, and Cox multivariable analysis. To reduce selection bias, propensity score matching was performed (using treatment facility type, treatment facility volume, and patient age, sex, Charlson/Deyo comorbidity score, income level, insurance type, histological characteristics, tumor grade, year of diagnosis, T and N staging, surgical procedure type, surgical margin, postoperative readmission, and duration of postoperative inpatient admission). To address immortal time bias, individuals who survived less than 6 months after diagnosis were excluded as a conditional landmark (eAppendix in the Supplement). Analyses were performed March 2020 to May 2020 using R statistical software version 3.6.1 (R Project for Statistical Computing). All P values were evaluated using 2-sided Cox proportional hazard multivariable analysis, and P values less than .05 were considered statistically significant. ResultsOf 7857 patients who met our inclusion criteria, with median (interquartile range [IQR]) age 63 (53-72) years, 4003 (50.9%) were men; 6814 patients (86.7%) underwent surgical treatment alone, 850 patients (10.8%) had preoperative radiation, and 193 patients (2.5%) received preoperative chemotherapy (Table ). The median (IQR) follow-up was 48.7 (27.6-76.8) months. Most patients with preoperative therapies were treated at academic, high-volume facilities and had simple or radical resections with negative margins and a longer postoperative inpatient admission compared with patients with no preoperative therapies (...
BACKGROUND Pseudoarthrosis, or failure to achieve bony union, is a well-known complication of spinal fusion operations. Rates range from 5% to 40% and are influenced by both patient and technical factors. Patients who do not achieve complete fusion may experience a return or worsening of their preoperative pain. For patients with complicated pathologies, vascularized bone grafts (VBGs) have been shown to provide better outcomes than nonvascularized bone grafts (N-VBGs). OBJECTIVE To enhance an instrumented spinal fusion by the innovative technique presented herein that utilizes a rotated, pedicled VBG from the left eighth rib under the paraspinous musculature into the midlumbar posterolateral gutter. METHODS For posterior approaches, the rib can be easily accessed and rotated into the appropriate strut position. The rib is dissected out, identifying and preserving the neurovascular bundle medially. The rib is then tunneled medially and appropriately positioned as the spinal graft, with the curve providing anatomic kyphosis or lordosis, depending on the surgical location. It is then successfully fixated with plates and spinal screws. RESULTS In our limited experience to date, vascularized rib grafting procedures augment fusion and reduce operating room time and bleeding compared to free flap procedures. No patients have experienced complications related to these grafts. CONCLUSION Pedicled vascularized rib grafts can be utilized to provide the advantages of a vascularized bone flap in complicated pathologies requiring spinal fusion as far as the L2-L3 level, without the morbidity associated with free tissue transfer.
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