Regional variation in orthopedic surgery in Switzerland

The study systematically describes the frequency and geographic variability of major surgical interventions for musculoskeletal disorders in Switzerland. Age- and sex-standardized rates for joint replacements, arthroscopies, spine surgery and hip fracture repair were calculated for hospital service regions. Various statistical analyses were used to measure the extent of variation. The authors argue that the surgery of hip fractures can be used as index surgery in the context of analyzing variations in orthopedic surgery. Temporal trends imply that patient demand and supply factors related to clinical ambiguity and non-medical incentives of providers are far more important components leading to increased use than the sole effect of an aging population.

[Periapical surgery with histologic examination of the periapical lesion. A case report]

Periapical surgery is required when periradicular pathosis associated with endodontically treated teeth cannot be resolved by nonsurgical root canal therapy (retreatment), or when retreatment was unsuccessful, not feasible or contraindicated. Endodontic failures can occur when irritants remain within the confines of the root canal, or when an extraradicular infection cannot be eradicated by orthograde root canal treatment. Foreign-body reponses towards filling materials, towards cholesterol crystals or radicular cysts might prevent complete periapical healing. Following enhanced microsurgical techniques in the last years the success rates of apical surgery have improved considerably. The aim of the current case report is to describe the therapeutical approach to a persistent periapical lesion and its histologic examination.

Gingival recession following apical surgery in the esthetic zone: a clinical study with 70 cases

The present study evaluated gingival recession 1 year following apical surgery of 70 maxillary anterior teeth (central and lateral incisors, canines, and first premolars). A visual assessment of the mid-facial aspect of the gingival level and of papillary heights of treated teeth was carried out using photographs taken at pre-treatment and 1-year follow-up appointments. In addition, changes in the gingival margin (GM) and clinical attachment levels (CAL) were calculated with the use of clinical measurements, that is, pre-treatment and 1-year follow-up pocket probing depth and level of gingival margin. Changes in GM and CAL were then correlated with patient-, tooth-, and surgery-related parameters. The following parameters were found to significantly influence changes in GM and CAL over time: gingival biotype (P < 0.05), with thin biotype exhibiting more gingival recession than thick biotype; pre-treatment pocket probing depth (PPD) (P < 0.03), with cases of pre-treatment PPD < 2.5 mm demonstrating more attachment loss than cases of PPD > or = 2.5 mm; and type of incision (P < 0.01), with the submarginal incision showing considerably less gingival recession compared with the intrasulcular incision, papilla-base incision or papilla-saving incision. The visual assessment using pre-treatment and 1-year follow-up photographs did not demonstrate significant changes in gingival level or papillary height after apical surgery. In conclusion, gingival biotype, pre-treatment PPD, and type of incision may significantly influence changes in GM and CAL following apical surgery in maxillary anterior teeth.

Histology of periapical lesions obtained during apical surgery

The aim of this was to evaluate the histology of periapical lesions in teeth treated with periapical surgery. After root-end resection, the root tip was removed together with the periapical pathological tissue. Histologic sectioning was performed on calcified specimens embedded in methylmethacrylate (MMA) and on demineralized specimens embedded in LR White (Fluka, Buchs, Switzerland). The samples were evaluated with light and transmission electron microscopy (TEM). The histologic findings were classified into periapical abscesses, granulomas, or cystic lesions (true or pocket cysts). The final material comprised 70% granulomas, 23% cysts and 5% abscesses, 1% scar tissues, and 1% keratocysts. Six of 125 samples could not be used. The cystic lesions could not be subdivided into pocket or true cysts. All cysts had an epithelium-lined cavity, two of them with cilia-lined epithelium. These results show the high incidence of periapical granulomas among periapical lesions obtained during apical surgery. Periapical abscesses were a rare occasion. The histologic findings from samples obtained during apical surgery may differ from findings obtained by teeth extractions. A determination between pocket and true apical cysts is hardly possible when collecting samples by apical surgery.

Stability after bilateral sagittal split osteotomy advancement surgery with rigid internal fixation: a systematic review

PURPOSE: The purpose of this systematic review was to evaluate horizontal relapse and its causes in bilateral sagittal split advancement osteotomy (BSSO) with rigid internal fixation of different types. MATERIALS AND METHODS: A search of the literature was performed in the databases PubMed, Ovid, Cochrane Library, and Google Scholar Beta. From 488 articles identified, 24 articles were finally included. Six studies were prospective, and 18 were retrospective. The range of postoperative study records was 6 months to 12.7 years. RESULTS: The short-term relapse for bicortical screws was between 1.5% and 32.7%, for miniplates between 1.5% and 18.0%, and for bioresorbable bicortical screws between 10.4% and 17.4%, at point B. The long-term relapse for bicortical screws was between 2.0% and 50.3%, and for miniplates between 1.5% and 8.9%, at point B. CONCLUSIONS: BSSO for mandibular advancement is a good treatment option for skeletal Class II, but seems less stable than BSSO setback in the short and long terms. Bicortical screws of titanium, stainless steel, or bioresorbable material show little difference regarding skeletal stability compared with miniplates in the short term. A greater number of studies with larger skeletal long-term relapse rates were evident in patients treated with bicortical screws instead of miniplates. The etiology of relapse is multifactorial, involving the proper seating of the condyles, the amount of advancement, the soft tissue and muscles, the mandibular plane angle, the remaining growth and remodeling, the skill of the surgeon, and preoperative age. Patients with a low mandibular plane angle have increased vertical relapse, whereas patients with a high mandibular plane angle have more horizontal relapse. Advancements in the range of 6 to 7 mm or more predispose to horizontal relapse. To obtain reliable scientific evidence, further short-term and long-term research into BSSO advancement with rigid internal fixation should exclude additional surgery, ie, genioplasty or maxillary surgery, and include a prospective study or randomized clinical trial design with correlation statistics.

[Preoperative preparation of patients with cardiovascular disease for noncardiac surgery]

Preoperative preparation of patients with cardiovascular disease is best initiated by the general practitioner. Updated Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery have been published by the American Heart Association und American College of Cardiology (2007). Individual cardiac evaluation must take into account active cardiac conditions, functional capacity, additional clinical risk factors and surgical risk. Stable, asymptomatic patients with normal functional capacity can proceed to elective anesthesia and surgery without further cardiac evaluation. Active cardiac conditions require evaluation and treatment by a cardiology service prior to elective surgery. In stable patients with poor (<4 metabolic equivalents, MET) or unknown functional capacity and clinical risk factors, who are scheduled for intermediate- or high-risk surgery, further cardiac evaluation and preparation is to be considered. Established indicated beta blocker and statin medication is to be continued; timely institution of beta blocker medication (target heart rate, <65 bpm) may be required depending on the risk of surgery, the presence of coronary heart disease, and the number of clinical risk factors present. Following percutaneous coronary intervention, specific waiting periods are required prior to elective surgery. In patients on antiplatelet therapy, the risk of stopping it should be weighed against the benefit of reduction in bleeding complications from the planned surgery.