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Objective: The aim of this study was to evaluate the different phases of the learning curve for robotic distal pancreatectomy (RDP) in international expert centers., Summary Background Data: RDP is an emerging minimally invasive approach; however, only limited, mostly single center data are available on its safe implementation, including the learning curve., Methods: Consecutive patients undergoing elective RDP from 16 expert centers across three continents were included to assess the learning curve. Based on the first 100 RDPs at each center, three cutoffs were used to define the learning curve: operative time for competency, major complications (Clavien-Dindo grade ≥III) for proficiency, and textbook outcome for mastery. Clinical outcomes before and after the cutoffs were compared., Results: The learning curve analysis was conducted on 1109 of 2403 RDPs. Competency, proficiency, and mastery, respectively, were reached after 46, 63, and 73 RDP procedures. After competency, operative time decreased from 245 to 235 minutes (P=0.002). Attaining proficiency was reflected by a reduction in the rate of major complications from 20% to 15% (P=0.012), and mastery was associated with a higher proportion of patients with textbook outcome (71% vs. 63%; P=0.028). The postoperative pancreatic fistula rate remained stable along the learning curve, ranging between 18.5% and 21.5%. Previous laparoscopic experience accelerated the learning process by virtue of reduced operative time and an earlier decrease in major complications., Conclusion: Competency, proficiency, and mastery for RDP were reached after 46, 63, and 73 procedures, respectively, at international expert centers. The findings highlight that the learning curves for intraoperative parameters are completed earlier; however, extensive experience is needed to master RDP., Competing Interests: Conflict of interest: The authors declare that they have no conflict of interest. Conflict of interest: The authors declare that no conflict of interest exists. No grants and financial support were received for this study., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: There is increasing interest in applying artificial intelligence chatbots like generative pretrained transformer 4 (GPT-4) in the medical field. This study aimed to explore the universality of GPT-4 responses to simulated clinical scenarios of developmental dysplasia of the hip (DDH) across diverse global settings., Methods: Seventeen international experts with more than 15 years of experience in pediatric orthopaedics were selected for the evaluation panel. Eight simulated DDH clinical scenarios were created, covering 4 key areas: (1) initial evaluation and diagnosis, (2) initial examination and treatment, (3) nursing care and follow-up, and (4) prognosis and rehabilitation planning. Each scenario was completed independently in a new GPT-4 session. Interrater reliability was assessed using Fleiss kappa, and the quality, relevance, and applicability of GPT-4 responses were analyzed using median scores and interquartile ranges. Following scoring, experts met in ZOOM sessions to generate Regional Consensus Assessment Scores, which were intended to represent a consistent regional assessment of the use of the GPT-4 in pediatric orthopaedic care., Results: GPT-4's responses to the 8 clinical DDH scenarios received performance scores ranging from 44.3% to 98.9% of the 88-point maximum. The Fleiss kappa statistic of 0.113 ( P = 0.001) indicated low agreement among experts in their ratings. When assessing the responses' quality, relevance, and applicability, the median scores were 3, with interquartile ranges of 3 to 4, 3 to 4, and 2 to 3, respectively. Significant differences were noted in the prognosis and rehabilitation domain scores ( P < 0.05 for all). Regional consensus scores were 75 for Africa, 74 for Asia, 73 for India, 80 for Europe, and 65 for North America, with the Kruskal-Wallis test highlighting significant disparities between these regions ( P = 0.034)., Conclusions: This study demonstrates the promise of GPT-4 in pediatric orthopaedic care, particularly in supporting preliminary DDH assessments and guiding treatment strategies for specialist care. However, effective integration of GPT-4 into clinical practice will require adaptation to specific regional health care contexts, highlighting the importance of a nuanced approach to health technology adaptation., Level of Evidence: Level IV., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objective: Robotic distal pancreatectomy (DP) is an emerging attractive approach, but its role compared with laparoscopic or open surgery remains unclear. Benchmark values are novel and objective tools for such comparisons. The aim of this study was to identify benchmark cutoffs for many outcome parameters for DP with or without splenectomy beyond the learning curve., Methods: This study analyzed outcomes from international expert centers from patients undergoing robotic DP for malignant or benign lesions. After excluding the first 10 cases in each center to reduce the effect of the learning curve, consecutive patients were included from the start of robotic DP up to June 2020. Benchmark patients had no significant comorbidities. Benchmark cutoff values were derived from the 75th or the 25th percentile of the median values of all benchmark centers. Benchmark values were compared with a laparoscopic control group from 4 high-volume centers and published open DP landmark series., Results: Sixteen centers contributed 755 cases, whereof 345 benchmark patients (46%) were included the analysis. Benchmark cutoffs included: operation time ≤300 minutes, conversion rate ≤3%, clinically relevant postoperative pancreatic fistula ≤32%, 3 months major complication rate ≤26.7%, and lymph node retrieval ≥9. The comprehensive complication index at 3 months was ≤8.7 without deterioration thereafter. Compared with robotic DP, laparoscopy had significantly higher conversion rates (5×) and overall complications, while open DP was associated with more blood loss and longer hospital stay., Conclusion: This first benchmark study demonstrates that robotic DP provides superior postoperative outcomes compared with laparoscopic and open DP. Robotic DP may be expected to become the approach of choice in minimally invasive DP., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Fractures around the shoulder region in infants are treated by arm-chest bandaging, adhesive strapping, or sling application. These conventional treatment methods are associated with issues like skin irritation, excoriation, movement of bone fragments causing muscle spasm, and difficulty in nursing care. We describe the technique of modified Velpeau sling application and reviewed its efficacy at a long-term follow-up., Methods: A retrospective study was conducted with 19 infants who presented between 2009 and 2018 to a tertiary care center in western India with either clavicle or humerus fracture. Inclusion criteria was any infant with humerus or clavicle fracture that underwent modified Velpeau sling application and had a minimum follow-up of 2 years. Patients were followed at weekly intervals until sling discontinuation based on the fracture healing. At further follow-up, children were assessed for the presence of angular or rotational malalignment and limb length discrepancy. Functional outcome was measured by the Paediatric Adolescent Shoulder Survey at the final follow-up., Results: Seven clavicle and 12 humerus fractures were treated with this technique. The mean age at presentation was 50 days (range, 1 d to 7 mo). The average follow-up was 6 years (range, 2 to 10 y). Two infants had underlying osteogenesis imperfecta. Infants without underlying pathology had no angular/rotational malalignment or limb length discrepancy, while both infants with underlying osteogenesis imperfecta had a varus alignment and shortening of the humerus. Infants without underlying pathology demonstrated good functional outcomes measured by the Paediatric Adolescent Shoulder Survey questionnaire, while those with pathology had functional limitations., Conclusions: The modified Velpeau method is an effective way of treating fractures around the shoulder region in infants without underlying pathology. Several advantages such as accessibility of sling material, easy application, inexpensive material, and absence of skin-related complications make this an effective treatment., Level of Evidence: Level IV-therapeutic study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Pyomyositis is defined as a pyogenic infection of skeletal muscles principally caused by Staphylococcus aureus. It can present either primarily without any associated soft tissue or bone infection or secondary to any surrounding or distant infection focus. Hip pericapsular pyomyositis is one of the most common types of primary pyomyositis. Although many cases are increasingly being described both in tropical and temperate climates, there is no published study regarding the sequelae of untreated pericapsular pyomyositis around the hip joint. The purpose of this study is to describe the sequelae of unaddressed obturator internus abscesses in four adolescent patients and compare their outcome with patients where obturator abscess was also drained using Vanderbilt medial approach. A retrospective study was done with eight patients divided equally into two groups. All the patients were diagnosed as septic arthritis with pyomyositis of obturator internus. Group 1 includes patients treated in between 2012 and 2014 with only hip arthrotomy through anterior approach. Group 2 includes patients treated after 2014 with anterior hip arthrotomy along with drainage of obturator internus abscess. All patients in group 1 had frequent episodes of pain in the first postoperative year with persistent restriction of hip range of motion. Two patients required re-drainage of the hip joint within the first month of indexed surgery. Final follow-up (average 6 years) X-rays revealed grade 2 protrusio acetabuli in three cases and grade 3 in one case as per the Sotelo-Garza and Charnley classification. In contrast to the group 1, group 2 patients had an excellent outcome with an average Iowa Hip Score of 93 at average follow-up of 4.25 years with near normal range of motion, no radiological deterioration and residual pain. The possibility of pericapsular pyomyositis should always be kept in mind, in older children with acute hip pain. A high index of suspicion is required for its early diagnosis. MRI is the gold standard investigation for confirming diagnosis and planning the preferred early surgical treatment. Safe and effective surgical drainage of obturator internus abscess through a minimally invasive Vanderbilt medial approach may prevent long-term sequelae of chronic pain, protrusio acetabuli and secondary osteoarthritis., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The purpose of this study is to discuss the natural history and management of primary epiphyseal osteomyelitis (PEO), to differentiate clinico-radiologic features of PEO caused by Mycobacterium and other organisms, and to discuss their intermediate-term outcomes., Methods: Between 2006 and 2017, 18 patients of PEO were managed at our center. Blood investigations, x-rays, and magnetic resonance imaging of affected part were carried out. Surgical drainage of lesions was done to retrieve infective fluid and tissue for examination. Antibiotics were administered for 1 year in Mycobacterial PEO and for 6 weeks in bacterial PEO. Average follow-up of patients was 5.5 years (range, 2 to 11 y)., Results: Boys were more commonly affected (11/18). Distal femur was the most common site involved (12/18). Eleven patients had Mycobacterium tuberculosis as the causative organism, 6 were positive for Staphylococcus aureus, and 1 for Brucella. Swelling and limp were predominant in patients with Tubercular PEO, whereas pain was more common in bacterial PEO. Nine of 11 patients with Tubercular PEO had penetration into the joint, whereas none in bacterial PEO. All patients recovered completely without residual movement restriction or growth alteration. On follow-up magnetic resonance imaging, 4 patients with Tubercular PEO had thinning of articular cartilage., Conclusion: High index of suspicion is required for early diagnosis of PEO. It is important to differentiate Tubercular from other bacterial PEO as it has more subtle symptoms and poor prognosis if left untreated. Aggressive surgical treatment followed by antibiotic therapy of appropriate duration is required to avoid complications related to joint destruction. To our knowledge, this is the largest reported series with longest follow-up.

Background: Shoulder imbalance secondary to residual brachial plexus birth palsy requires release of internal rotation contracture and tendon transfer. Subscapularis is considered as the prime element of internal rotation contracture and various methods have been described for subscapularis lengthening. It includes open subscapularis slide or lengthening and arthroscopic release. We hypothesized that subscapularis can be released through minimally invasive approach from the medial border of scapula and thus avoiding formal open procedures and risk of weakening the internal rotation strength., Methods: Safety zones to avoid injury to important neurovascular structures while performing minimally invasive subscapularis release (MISR) were determined through cadaveric dissection. Between 2014 and 2016, 45 patients underwent MISR. A concomitant conjoined Latissimus Dorsi and Teres Major transfer was performed. Twenty patients with minimum 2-year follow-up were included in this study. Average age of patients was 6.4 years. A 5-point modified Mallet Score, degrees of active and passive rotations and abduction were used as outcome measures. Axial MRI imaging were available to classify the gleno-humeral deformity., Results: Mean improvement in passive external rotation was 80 degrees and in active external rotation was 43 degrees (P <0.001) at 3 months, which was maintained at final follow-up. Average shoulder abduction improved from preoperative-101 degrees to postoperative-142 degrees. Aggregate 5-point Mallet Score improved from 12.8 points (range, 11 to 16) preoperatively to 18.5 points (range, 16 to 21) postoperatively. None of the patients developed external rotation contracture. The results were comparable with other existing techniques of subscapularis release with conjoint tendon transfer., Conclusions: MISR with conjoined tendon transfer is an effective way of treating internal rotation contracture in children with congruent glenohumeral joints. This procedure has shown beneficial outcomes even in patients with noncongruous glenohumeral joints, when performed in children younger than 4 years. Advantages of MISR include less risk to neurovascular structures, minimal soft tissue trauma, directly addressing the medial tight subscapularis fibers, significantly less surgical time and minimum learning curve., Levels of Evidence: Level III-retrospective comparative study.

Objectives: The survival of patients with metastatic colorectal cancer (CRC) has been increasing over recent decades due to improvements in chemotherapy and surgery. There is a need to refine prognostic information to more accurately predict survival as patients survive for any given length of time to assist multidisciplinary cancer management teams in treatment decisions., Materials and Methods: We performed a single center retrospective analysis of patients treated with metastatic CRC (unresectable and resectable) who survived >24 months between 2005 and 2015 (N=155). Patient tumor and treatment related variables were collected. Overall survival (OS) estimates conditional on surviving >24 months were compared with actuarial survival estimates of a cohort of patients (33,104 resected, 39,382 unresected) from the National Cancer Database (NCDB)., Results: With a median follow-up of 44.2 months, the median OS of resected patients (n=86) was not reached. The median OS of unresected patients was 75.9 months. The conditional survival probabilities of living 1, 2, or 3 years longer after 24 months of survival are 92%, 72%, and 52%, respectively, in unresectable patients and 98%, 92%, and 89% in patients who were resected. The corresponding NCDB 1, 2, and 3 year actuarial survival was 38%, 20%, and 11% for unresected patients and 68%, 46%, and 32% for resected., Conclusions: These results indicate that CRC patients who survive 24 months with metastatic colorectal cancer have an excellent prognosis and surgery may be appropriate in a subset of patients initially deemed unresectable.

Background: Histoplasmosis is an infection caused by the dimorphic fungus Histoplasma capsulatum and primarily presents with pulmonary symptoms. Immunocompromised individuals are at high risk for contracting disseminated histoplasmosis, which can be fatal if left untreated., Case: We present a case involving a 50-year-old woman with acquired immunodeficiency syndrome with an ulcerated vulvar lesion concerning for carcinoma. Extensive workup revealed disseminated histoplasmosis without pulmonary manifestations. She was treated with an extended course of an antifungal agent. Her vulvar lesion resolved., Conclusion: Vulvar histoplasmosis is a rare etiology of vulvar pathology but one that should be considered in immunocompromised patients.

Objective: Alvimopan was approved by the Food and Drug Administration in May 2008 and has been shown to accelerate gastrointestinal recovery after colectomy. Our independent study evaluated alvimopan as it is used in actual hospital practice in the state of Michigan. We hypothesized that alvimopan significantly decreases incidence of prolonged ileus and reduces length of stay (LOS) in patients who have undergone colectomy., Methods: We identified 4749 patients from the Michigan Surgical Quality Collaborative (N = 28 hospitals) database between August 2007 and December 2010 who underwent elective colectomy operations. A total of 528 patients received alvimopan both pre- and postoperatively. We first selected a control group of patients from hospitals that had never administered alvimopan (n = 1833) and used propensity matching to manage differences in patient demographics and clinical characteristics. To control for hospital and surgeon characteristics, we then performed a sensitivity analysis, using a separate group of historical control patients treated before May 2008 in hospitals that would later administer alvimopan (n = 270). The Fisher exact test was used to compare complication rates, and the Student t test was used to compare LOS., Results: Patients who received alvimopan had significantly lower incidence of prolonged ileus (2.3% vs 7.9%; P < 0.001) and a significantly shorter LOS (4.84 ± 4.54 vs 6.40 ± 4.45 days; P < 0.001) than control patients in hospitals that had never administered alvimopan. No differences were noted in these outcomes using sensitivity analysis., Conclusion: This study suggests that the actual utilization of alvimopan leads to a reduction in prolonged ileus and LOS in patients who underwent colectomy. By accelerating postoperative recovery, alvimopan has the potential to benefit patients and health care systems by improving outcomes, ensuring patient comfort, and reducing cost.

Endometrial cancer is the most common gynecologic cancer and its incidence is rising among premenopausal women. Hysterectomy and bilateral salpingo-oophorectomy, traditional treatment for endometrial cancer, causes loss of fertility and ovarian function, both of which can significantly negatively impact a young woman's physical and mental well-being. Recently, conservative management with progestational agents has been reported with success from both oncologic and reproductive perspectives. However, there are no randomized trials comparing conservative versus surgical therapy. Patients who are candidates for conservative therapy must be extensively counseled regarding the risks and must comply with close surveillance.

Objective: To compare the effects of zidovudine (ZDV) on clonal maturation of hematopoietic progenitors obtained from the bone marrow of women of child-bearing age with its effects on progenitors obtained from the marrow, liver and blood of fetuses. We also sought to determine whether the adverse effects of ZDV on fetal hematopoiesis resulted exclusively from an action on progenitors, or also involved the inhibition of the production of hematopoietic growth factors., Participants: Hematopoietic progenitors were obtained from bone-marrow aspirates of seven women of child-bearing age, from the bone marrow and liver of seven mid-trimester abortuses, and from the umbilical cord blood of seven term infants., Methods: We added increasing concentrations of ZDV to clonal assays of hematopoietic progenitors, after which we assayed clonal maturation of progenitors, and counted the number of erythrocytes per erythroid clone and the number of neutrophils per granulocytic clone. Light-density cell fractions and enriched CD34+ progenitor fractions were studied. In other studies we determined the effect of increasing concentrations of ZDV on production of granulocyte colony-stimulating factor (G-CSF) protein [enzyme-linked immunosorbent assay (ELISA)] and mRNA by fetal and maternal monocytes, and on production of erythropoietin protein (ELISA) and mRNA by Hep3B cells., Results: Mature erythroid progenitors were the most sensitive to the adverse effects of ZDV on clonal maturation, and multipotent progenitors were the most resistant. Erythroid progenitors from all fetal and neonatal sources were more sensitive to the effect of ZDV than those from the bone marrow of adult women. The inhibitory effects were explained by an action on CD34+ cells; no effect was observed on production of G-CSF or erythropoietin., Conclusions: We speculate that the low hematocrits of neonates delivered after antenatal ZDV treatment are due to reduced clonal maturation of erythroid progenitors, and that fetal erythroid progenitors are inhibited to a greater extent than maternal progenitors.