A 75-year-old patient was transferred to the oncology department due to the discovery of a large pelvic tumor compressing the femoral neurovascular bundle suspected to be of malignant origin. Further investigation revealed a rare complication related to a 27-year-old total hip arthroplasty (THA). The final diagnosis was a severe adverse local tissue reaction (ALTR) resulting from excessive implant wear—first from a metal-on-metal (MoM) bearing and later exacerbated by a revision to a metal-on-polyethylene (MoP) articulation. The clinical course was further complicated by periprosthetic joint infection (PJI). The patient underwent extensive tumor-like mass resection followed by two-stage revision arthroplasty. Despite these interventions, infection persisted, ultimately necessitating joint resection. This case highlights the rare but serious convergence of dreaded orthopedic complications (ALTR and PJI). It underscores the diagnostic challenge posed by wear-induced pseudotumors, which are rare even among arthroplasty specialists and are often unfamiliar to oncologists. This case illustrates the importance of early orthopedic evaluation, maintaining a high index of suspicion in atypical presentations, and invites further discussion about the interplay between ALTRs and infection risk in arthroplasty patients.

Infections after joint arthroplasties represent a devastating and progressively escalating complication with increased morbidity and mortality. The eradication of biofilms from infected implants is still an unsolved challenge. The erbium-doped yttrium aluminum garnet (Er:YAG) laser, which delivers high-energy light for rapid tissue ablation, may offer an advancement. This study aimed to evaluate the effectiveness of this laser in removing biofilms from infected implant surfaces. In this prospective study, 31 patients with 33 early postoperative or acute hematogenous periprosthetic joint infections (PJIs) were treated with our modified procedure of debridement, antibiotics, laser irradiation and implant retention (DALIR). Biofilm removal was compared between mechanical cleansing alone and the additional use of Er:YAG laser light. Therefore, swab cultures from the implants were taken at three distinct occasions: post-arthrotomy, after mechanical cleansing with a fluid disinfectant (LavaSurge), and after additional Er:YAG laser irradiation. The success rate of the DALIR procedure was compared with a prior group (n = 34) that underwent DAIR procedures without the Er:YAG laser at our clinic. The implementation of the laser system in our DAIR procedure was uncomplicated. The additional Er:YAG laser therapy significantly reduced viable microorganisms on implant surfaces (9.1%) compared to mechanical cleaning alone (42.4%; p < 0.01). The healing rate in our cohort was 78.1%, a substantial improvement over the previous rate of 44.1% (p < 0.01). Therefore, we recommend the use of Er:YAG laser irradiation as an additional tool for surface disinfection of metal implants in PJIs whenever a DAIR procedure seems to be beneficial. Trial Registration: ClinicalTrials.gov identifier: NCT06440564. LEVEL OF EVIDENCE: 2B.

Background: Cranio-maxillofacial (CMF) injuries represent a significant challenge in low- and middle-income countries (LMICs), exacerbated by inadequate infrastructure, resources, and training. This systematic review aims to evaluate the current strategies and solutions proposed in the literature to improve CMF fracture care in LMICs, focusing on education, patient transfer, and off-label solutions. Methods: A comprehensive literature search was conducted using PubMed/Medline from January 2000 to June 2023. Studies were selected based on the Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA). Solutions were categorized into three main areas: education (digital and on-site teaching, fellowships abroad), patient transfer to specialized clinics, and off-label/non-operative solutions. Results: Twenty-three articles were included in the review, revealing a consensus on the necessity for enhanced education and training for local surgeons as the cornerstone for sustainable improvements in CMF care in LMICs. Digital platforms and on-site teaching were identified as key methods for delivering educational content. Furthermore, patient transfer to specialized national clinics and innovative off-label techniques were discussed as immediate solutions to provide quality care despite resource constraints. Conclusions: Effective CMF fracture care in LMICs requires a multifaceted approach, prioritizing the education and training of local healthcare professionals, facilitated patient transfer to specialized centers, and the adoption of off-label solutions to leverage available resources. Collaborative efforts between international organizations, local healthcare providers, and educational institutions are essential to implement these solutions effectively and improve patient outcomes in LMICs.

The generation of harmful reactive oxygen species (ROS), including hydrogen peroxide, in out-of-hospital cardiac arrest (OHCA) survivors causes systemic ischemia/reperfusion injury that may lead to multiple organ dysfunction and mortality. We hypothesized that the antioxidant enzyme catalase may attenuate these pathophysiological processes after cardiac arrest. Therefore, we aimed to analyze the predictive value of catalase levels for mortality in OHCA survivors. In a prospective, single-center study, catalase levels were determined in OHCA survivors 48 h after the return of spontaneous circulation. Thirty-day mortality was defined as the study end point. A total of 96 OHCA survivors were enrolled, of whom 26% (n = 25) died within the first 30 days after OHCA. The median plasma intensity levels (log2) of catalase were 8.25 (IQR 7.64–8.81). Plasma levels of catalase were found to be associated with mortality, with an adjusted HR of 2.13 (95% CI 1.07–4.23, p = 0.032). A Kaplan–Meier analysis showed a significant increase in 30-day mortality in patients with high catalase plasma levels compared to patients with low catalase levels (p = 0.012). High plasma levels of catalase are a strong and independent predictor for 30-day mortality in OHCA survivors. This indicates that ROS-dependent tissue damage is playing a crucial role in fatal outcomes of post-cardiac syndrome patients.

Hypoxic-ischemic brain injury can affect and disturb the autonomous nervous system (ANS), which regulates various visceral systems including the gastro-intestinal and emetic system. The present study aimed to analyze the predictive value of gastric regurgitation (GReg) for neurological outcome in out-of-hospital cardiac arrest (OHCA) survivors. In this prospective, single-center study, 79 OHCA survivors treated at a university-affiliated tertiary care centre were included and GReg was measured at the first day after successful cardiopulmonary resuscitation. Neurological outcome was assessed by the Cerebral Performance Categories score at discharge. Seventy-six percent of the study population had a poor neurological outcome. GReg was found to be associated with poor neurological outcome with an adjusted OR of 5.37 (95% CI 1.41-20.46; p = 0.01). The area under the ROC curve for GReg was 0.69 (95% CI, 0.56-0.81) for poor neurological outcome. GReg on the first day after OHCA is an early, strong and independent predictor for poor neurological outcome in comatose OHCA survivors. These results are particularly compelling because measurement of GReg is inexpensive and routinely performed in critical care units.

Infections related to orthopedic procedures are considered particularly severe when implantation materials are used, because effective treatments for biofilm removal are lacking. In this study, the relatively new approach for infection control by using an erbium:yttrium-aluminum-garnet (Er:YAG) laser was tested. This laser vaporizes all water containing cells in a very effective, precise, and predictable manner and results in only minimal thermal damage. For preliminary testing, 42 steel plates and 42 pins were seeded with mixed cultures. First, the minimally necessary laser energy for biofilm removal was determined. Subsequently, the effectiveness of biofilm removal with the Er:YAG laser and the cleansing of the metal implants with octenidine-soaked gauze was compared. Then, we compared the effectiveness of biofilm removal on 207 steel pins from 41 patients directly after explantation. Sonication and scanning electron microscopy were used for analysis. Laser fluences exceeding 2.8 J/cm(2)caused a complete extinction of all living cells by a single-laser impulse. Cleansing with octenidine-soaked gauze and irradiation with the Er:YAG laser are both thoroughly effective when applied to seeded pins. In contrast, when explanted pins with fully developed biofilms were analyzed, we found a significant advantage of the laser procedure. The Er:YAG laser offers a secure, complete, and nontoxic eradication of all kinds of pathogens from metal implants without damaging the implant and without the possible development of resistance. The precise noncontact removal of adjacent tissue is a decisive advantage over conventional disinfectants. Therefore, laser irradiation could become a valuable method in every debridement, antibiotics, and implant retention procedure.

Background Extracorporeal membrane oxygenation (ECMO) represents a valuable and rapidly evolving therapeutic option in patients with severe heart or lung failure following cardiovascular surgery. However, despite significant advances in ECMO techniques and management, prognosis remains poor and accurate risk stratification challenging. We therefore evaluated the predictive value of liver function variables on all-cause mortality in patients undergoing venoarterial ECMO support after cardiovascular surgery. Methods We included into our single-center registry a total of 240 patients undergoing venoarterial ECMO therapy following cardiovascular surgery at a university-affiliated tertiary care center. Results The median follow-up was 37 months (interquartile range 19–67 months), and a total of 156 patients (65 %) died. Alkaline phosphatase and total bilirubin were the strongest predictors for 30-day mortality, with adjusted hazard ratios (HRs) per 1–standard deviation increase of 1.36 (95 % confidence interval [CI] 1.10–1.68; P = 0.004) and 1.22 (95 % CI 1.07–1.40; P = 0.004), respectively. The observed associations persisted for long-term mortality, with adjusted HRs of 1.27 (95 % CI 1.03–1.56; P = 0.023) for alkaline phosphatase and 1.22 (95 % CI 1.07–1.39; P = 0.003) for total bilirubin. Conclusions The present study demonstrates that elevated values of alkaline phosphatase and total bilirubin are sensitive parameters for predicting the short-term and long-term outcomes of ECMO patients.

With a prevalence of 1 in 3,000 births, neurofibromatosis type 1 (NF1) is one of the most common genetic disorders and is characterized by an uninhibited expansion of neural tissue. Occasionally, severe deformities occur, but frequently considerable cosmetic disfigurement is caused by the development of hundreds of benign cutaneous neurofibromas. The objective of this study was to evaluate the erbium:yttrium-aluminium-garnet (Er:YAG) laser as a therapeutic option for the removal of multiple cutaneous neurofibromas. In this prospective, comparative, in vivo study, 15,580 neurofibromas (44 operations on 21 patients) were removed via electrosurgery, CO2- or Er:YAG laser ablation. In 12 adjacent test areas, we compared the zone of thermal necrosis, the postoperative pain, the time to reepithelialization, the duration of postoperative erythema and the cosmetic outcome of these surgical methods. When compared to electrosurgery and CO2 laser ablation, the Er:YAG laser ablation outperformed the other methods of tumor removal. Rapid healing by second intention as well as the minimal discomfort and scar formation following Er:YAG laser ablation were noted. After 36 months of follow-up, permanent dyspigmentation was rare and hypertrophic scarring was not observed. Er:YAG laser vaporization of multiple cutaneous neurofibromas is a simple and rapid procedure that results in significantly better cosmetic results than CO2 laser treatment or electrosurgery.

Sir:FigureNeurofibromatosis type I is one of the most common genetic disorders and leads to cosmetic disfigurement because of the development of hundreds of cutaneous neurofibromas over the entire body. Excision (scalpel or electrocautery) and carbon dioxide laser vaporization (currently the criterion standard1–4) are established as standard treatment, but the removal is time consuming and/or results in unattractive scars. Because the erbium:yttrium-aluminum-garnet laser causes only minimal collateral thermal damage, it has a positive influence on wound healing and scar formation. This significant positive effect can be anticipated in tissues with high water content and low bleeding tendency. Cutaneous neurofibromas meet these criteria. In this prospective, comparative, in vivo study, 126 neurofibromas (12 patients) were analyzed. We compared the histopathologic effects of the established treatment modalities with the effects of erbium:yttrium-aluminum-garnet laser vaporization. Therefore, 78 skin specimens were excised after tumor removal by means of electrosurgery or carbon dioxide or erbium:yttrium-aluminum-garnet laser vaporization. Ex vivo, another eight neurofibromas were vaporized completely. and agarose cell blocks of the remnants were prepared. We also assessed the adequacy of tumor removal and measured the water content of neurofibromas, skin, and subcutaneous fatty tissue. Our use of an erbium:yttrium-aluminum-garnet laser corresponds widely to the descriptions given by other authors for carbon dioxide lasers,1,4 with the exception that, because of the minor thermal damage, there is no coagulation of the wound. Histologic analysis revealed dermal thermal damage ranging from 430 to 920 μm in the carbon dioxide laser–treated specimens and from 70 to 230 μm in the erbium:yttrium-aluminum-garnet laser–treated samples (Figs. 1 and 2). This difference was highly significant (p < 0.001).Fig. 1: Zone of thermal necrosis (eosinophilic homogenization of collagen fibers and pyknosis of cell nuclei) after erbium:yttrium-aluminum-garnet treatment (hematoxylin and eosin; original magnification, ×40).Fig. 2: Zone of thermal necrosis (eosinophilic homogenization of collagen fibers and pyknosis of cell nuclei) after carbon dioxide laser treatment (hematoxylin and eosin; original magnification, ×40).With regard to the adequacy of tumor removal, we did not observe any difference because the neurofibromas were eliminated entirely by both lasers. In addition, the high content of water in neurofibromas (86.1 ± 3 percent) allowed for residue-free elimination without any carbonization using the erbium:yttrium-aluminum-garnet laser. Electrocautery was used only for pedunculated neurofibromas where the skin stalk was cut at the base. The thermal necrosis produced when using the wire loop was 290 to 780 μm compared with 410 to 970 μm when using the Colorado needle (Fig. 3).Fig. 3: Thermal damage after electrosurgery, carbon dioxide, and erbium:yttrium-aluminum-garnet laser vaporization. Vertical I bars show the standard deviation. “1/2” indicates that half of the neurofibroma was vaporized and then excised in order to assess the thermal necrosis within the neurofibroma itself. “Total” indicates that the whole neurofibroma was vaporized and then excised.It is difficult to say how much residual thermal damage can be tolerated by the skin without scarring, but according to Ross et al. it is not more than 300 μm in the perioral area.5 This amount is clearly exceeded when the carbon dioxide laser is used. In the treatment of cutaneous neurofibromas, hemostasis is of minor importance, as the neurofibromas are usually located just beneath or inside the dermis, show low bleeding tendency, and can be vaporized within a few seconds, even if situated in deep subcutaneous layers. The photothermal selectivity of the erbium:yttrium-aluminum-garnet laser decreases the amount of heat damage and thereby decreases scarring and other unwanted side effects. Thus, the overall recovery period will be shorter, the cosmetic results will be superior to all known treatment alternatives, and the patient's quality of life can be improved. Based on our results, we propose the clinical use of erbium:yttrium-aluminum-garnet laser therapy in patients suffering from disfigurement caused by neurofibromatosis. Lukas K. Kriechbaumer, M.D. University Clinic of Trauma Surgery Martin Susani, M.D. Clinical Institute of Pathology Susanne G. Kircher, M.D., M.B.A. Department of Medical Chemistry Wolfgang Happak, M.D. Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. ACKNOWLEDGMENTS The authors thank Dr. Karen Eiler (VCA West Los Angeles Animal Hospital) and Dr. Katharina Klien (Department of Occupational Medicine, Medical University of Vienna, Austria) for their helpful comments on an early version and for their final review of this communication. STUDY AND CLINICAL TRIAL INFORMATION This study was approved by the Ethics Committee of the Medical University of Vienna on May 23, 2006; EK Nr.: 128/2006; Treatment of cutaneous neurofibromas with an Erbium- YAG laser in comparison to conventional surgery and CO2 laser vaporization (German original: Behandlung von kutanen Neurofibromen mit dem Erbium-YAG Laser im Vergleich mit klassischer Chirurgie und CO2 Laser). Registration at: http://www.clinicaltrials.gov; Trial registry name: First Clinical Study of Erbium - Yttrium Aluminium Garnet (YAG) Laser Vaporization of Cutaneous Neurofibromas, URL: http://clinicaltrials.gov/ct2/show/NCT00921037, ClinicalTrials.gov Identifier: NCT00921037, Date: 15. 06. 2009.

BACKGROUND The effectiveness of a new surgical technique for the treatment of severe chronic pain stages was evaluated. For the last 140 years, the treatment of complex regional pain syndrome type II (CRPS II) has been an unsolved problem. Therapeutic approaches have included conventional pain medication, physical therapy, sympathetic blocks, transcutaneous or spinal cord stimulation, injections or infusion therapies, and sympathectomy. When used alone or in combination, these therapies often yield unfavorable results. The majority of physicians who treat patients with CRPS are convinced that a surgical treatment of the affected extremity only exacerbates the symptoms, especially its hallmark excruciating pain. METHODS Sixteen patients with a CRPS type II of the upper or lower limb were included in the study after ineffective pain therapy for more than 6 months. The most proximal region of pain associated with CRPS was localized, and 2% lidocaine was injected into that area. Once the sympathetic, deep, burning pain had been blocked, the subcutaneous veins in the previously determined area were surgically removed. A visual analog scale, the Nottingham Health Profile, and physical examinations were used to evaluate the outcome of the operation. RESULTS Twelve (75%) surgically treated patients showed significant improvement in limb function, the visual analog scale, and the Nottingham Health Profile. CONCLUSIONS These data and recent findings in animal models conclude that CRPS type II is maintained by a coupling of newly sprouted sympathetic and sensible fibers. These fibers can be resected with a regional subcutaneous venous sympathectomy. LEVEL OF EVIDENCE Therapeutic study, level III.