Summary

Background Acute appendicitis is the most common surgical emergency worldwide. Concern that delayed treatment might increase perforation can lead to unnecessary surgery and high rates of negative appendicectomy, where a normal, non-inflamed appendix is removed. However, whether perforation is related to pre-hospital time (symptom onset to first surgical assessment) has not been explored in contemporary global data. Methods We conducted an international, multicentre, prospective, observational cohort study (AlliGatOr) of patients undergoing emergency appendicectomy for suspected acute appendicitis in 1377 hospitals across 112 countries. We included all consecutive eligible patients and excluded patients undergoing appendicectomy for indications other than suspected acute appendicitis. Each participating hospital entered data from medical records prospectively into the Research Electronic Data Capture platform. The primary outcome was perforation and the primary exposure was pre-hospital time (categorised as <12 h, 12–23 h, 24–47 h, 48–71 h, and ≥72 h). Follow-up was for 30 days after surgery to assess postoperative outcomes. In-hospital time (first surgical assessment to skin incision) was a key secondary exposure. We estimated adjusted risk ratios (aRRs) using multilevel Poisson regression. Multivariable analyses used complete cases; missing data were not imputed. The study is registered with ClinicalTrials.gov (NCT06774001) and is completed. Findings Between Feb 3 and May 25, 2025, we enrolled 45 218 patients with a median age of 27 years (IQR 18–41); 25 218 (55⋅8%) were male and 19 996 (44⋅2%) were female. 42 317 patients were included in the primary analysis, of whom 13 560 (32⋅0%) had perforation. The adjusted primary model included 41 740 patients with complete covariate data. Access to CT imaging varied across income groups: 12 232 (58⋅6%) of 20 861 patients in high-income countries, 4597 (37⋅1%) of 12 388 in upper-middle-income countries, 1769 (19⋅2%) of 9192 in lower-middle-income countries, and 156 (5⋅6%) of 2769 in low-income countries. Minimally invasive surgery was used in 19 985 (95⋅8%) of 20 861 patients, 6817 (55⋅0%) of 12 390, 2613 (28⋅4%) of 9195, and 203 (7⋅3%) of 2770, respectively. Perforation increased with pre-hospital times, from 2629 (22⋅9%) of 11 487 patients at less than 12 h (reference) to 2671 (25⋅8%) of 10 371 at 12–23 h (aRR 1⋅07 [95% CI 1⋅01–1⋅13]; p=0⋅021), 2969 (33⋅6%) of 8826 at 24–47 h (1⋅36 [1⋅28–1⋅44]; p<0⋅0001), 1933 (41⋅7%) of 4640 at 48–71 h (1⋅62 [1⋅52–1⋅72]; p<0⋅0001), and 3350 (48⋅0%) of 6974 at pre-hospital times of at least 72 h (1⋅85 [1⋅75–1⋅95]; p<0⋅0001). Longer in-hospital time was associated with lower perforation risk: versus less than 12 h, aRRs were 0⋅95 (95% CI 0⋅91–1⋅00; p=0⋅034) for 12–23 h, 0⋅87 (0⋅82–0⋅93; p<0⋅0001) for 24–47 h, and 0⋅82 (0⋅75–0⋅90; p<0⋅0001) for at least 48 h. Perforation was associated with higher complication risk at 30 days (2⋅36 [2⋅24–2⋅48]; p<0⋅0001). Complications were also higher after open surgery than for minimally invasive surgery (1⋅30 [1⋅20–1⋅41]; p<0⋅0001). Negative appendicectomy occurred in 2365 (5⋅2%) of 45 218 patients and was lower among those who had preoperative CT than among those who did not (0⋅69 [0⋅62–0⋅77]; p<0⋅0001). Interpretation These findings support prioritising surgical assessment within 24 h as a target to reduce the burden of perforated appendicitis. Preoperative CT imaging was associated with lower rates of unnecessary operations; access to CT and minimally invasive surgery varied markedly by country income group. Funding National Institute for Health and Care Research.

ABSTRACT

Background: Incisional hernia is a common complication following abdominal surgery, and mesh reinforcement has become

the standard of care. This study aimed to compare the clinical outcomes of sublay versus onlay mesh repair in patients with

incisional her

nia.

Methods: This prospective randomized controlled clinical trial was conducted at the General Surgery Department, Faculty

of Medicine, ..... Hospitals. A total of 60 patients diagnosed with incisional hernia and scheduled for elective surgical repai

r

were recr

uited from general surgery outpatient clinics and the emergency department. Patients were randomly assigned into

two equal groups: Group A (Onlay Group, n=30) underwent onlay mesh repair, and Group B (Sublay Group, n=30)

underwent sublay (retrorectus) mesh

repair. Baseline demographic, clinical, laboratory, and radiological characteristics were

recorded. Operative parameters, postoperative pain scores (Visual Analogue Scale), hospital stay, return to normal activity,

postoperative complications (seroma, hem

atoma, surgical site infection), and hernia recurrence at 12 months were compared

between the two groups.

Results: Operative time was significantly shorter in the onlay group (88.93 ± 7.93 minutes) compared to the sublay group

(99.67 ± 7.74 minutes) (p < 0.001). Postoperative pain scores were significantly lower in the sublay group at day 1 (4.70 ±

0.76 vs. 6.

10 ± 0.79), 1 week (2.39 ± 0.75 vs. 3.99 ± 0.82), 1 month (0.85 ± 0.74 vs. 2.41 ± 0.88), 3 months (0.30 ± 0.49 vs.

1.41 ± 0.86), 6 months (0.16 ± 0.36 vs. 1.02 ± 0.82), and 12 months (0.14 ± 0.48 vs. 0.82 ± 0.86) (p < 0.001 for all). Hospit

al

stay was sign

ificantly shorter in the sublay group (3.47 ± 1.11 days vs. 4.40 ± 0.93 days, p < 0.001), and return to normal

activity was significantly earlier (21.53 ± 3.41 days vs. 26.07 ± 4.73 days, p < 0.001). No significant difference was found

in drain removal day

(p = 0.257). Postoperative complications including seroma (10.0% vs. 23.3%, p = 0.299), hematoma

(3.3% vs. 6.7%, p = 1.000), and surgical site infection (6.7% vs. 16.7%, p = 0.424) were directionally lower in the sublay

group but did not reach statistical

significance. Hernia recurrence at 12 months was 3.3% in the sublay group versus 10.0%

in the onlay group (p = 0.612). All patients completed the 12

-

month follow

-

up.

Conclusion: Sublay (retrorectus) mesh repair offers significant clinical advantages over onlay mesh repair for incisional

hernia, including superior postoperative pain control, shorter hospital stay, and earlier return to normal activity. Postoper

ative

com

plications and recurrence showed consistent trends favoring sublay repair. These findings support sublay mesh repair as

the preferred technique for elective incisional hernia repair in appropriately selected patients.

.

Keywords

: Incisional hernia, mesh repair, sublay, retrorectus, onlay, postoperative pain, randomized controlled trial.

Medical education is being reshaped by two major technological disruptions: the rapid expansion of online learning since the COVID-19 pandemic and the equally rapid adoption of artificial intelligence (AI) in teaching, assessment, and clinical training. These developments are often treated as distinct phases of change. In reality, they are part of the same broader challenge: educational institutions have repeatedly adopted new technologies faster than they have developed the pedagogic, ethical, and regulatory frameworks needed to use them well. 1-3

Dysfunctions and pain in the shoulder are a prevalent musculoskeletal condition and a key area for clinical research. This paper investigates the etiology, epidemiology, and risk factors associated with shoulder pathologies based on a data set from the Sydney Shoulder Research Institute (SSRI) that spans a cohort between the years 2015 and 2024. A cohort was retrospectively designed to analyze the demography of patients, their injury mechanisms, symptom durations, and the symptoms of joints that are associated with it. The findings pointed out that the male gender was more likely to encounter traumatic injuries when compared to the females, who reported degenerative conditions of the shoulder such as rotator cuff tendinitis. The age and symptom duration of the patients pointed to a significant correlation to chronic shoulder disorders, where above 42% experienced the symptoms for more than a year. Injury causes vary from trauma due to sports to degenerated conditions. The study pinpoints the role that hand dominance plays and the impact of contralateral shoulder and knee pathologies. Results highlighted the need for early diagnosis and

implementing of ideal management measures to handle the long-term healthcare impacts.

One of the most common problems seen in the office of a primary care physician is low back pain. Backache can have a variety of causes. The aim of this study is to assess the various etiological, occupational, and risk factors for low back pain, as well as its correlation with the patient's age, sex, and lifestyle. Materials and methods: This study collected patients from private clinics and hospitals in Libya between September and November 2024, admitted them, and treated them in the orthopedic department. Many people suffer from low back discomfort, which can be challenging to diagnose. In conclusion, orthopedists must acknowledge the diagnostic uncertainty that often accompanies this illness. The occurrence of incapacitating back pain can be significantly reduced by identifying the etiological and risk factors, the type of occupation, the origin of the pain, implementing preventive measures, and assisting patients in their recovery.

Ankle fracture-dislocations are complex injuries that pose significant challenges due to their association with severe functional impairments. Representing 9% of all fractures, these injuries predominantly affect young individuals experiencing high-energy trauma and elderly patients with conditions such as diabetes and osteoporosis. Younger patients are at risk of post-traumatic osteoarthritis and functional limitations, whereas older individuals often face complications such as wound infections, fixation failure, and, in severe cases, amputation. Classification systems provide a framework for categorizing fractures based on the mechanism of injury, guiding treatment decisions. Precise anatomical reduction of the talus within the ankle mortise and fibular length restoration are critical for maintaining joint congruity and preventing long-term complications.

Management strategies vary by fracture type. Posterior malleolus fractures typically benefit from surgical fixation, improving stability and reducing syndesmosis fixation requirements, while stable fractures are often managed conservatively. This review highlights the need for individualized treatment approaches to optimize recovery and minimize complications. Continued research is essential to refine fixation techniques and enhance the prognosis for patients with these challenging injuries.

Total Hip Replacement Outcomes in Alkhadra Hospital: A Retrospective Descriptive Epidemiological Study. We reviewed the outcomes of 77 total hip replacements done in Alkhadra Hospital from 1/9/1993 to 1/9/1997 using different types of prostheses and techniques. The mean age of the patients was 55 years, and the mean follow-up was four years. The most common complications were cup loosening (8%), hip dislocation (4%), and femoral neck fracture (3%). The mean hospital stay was 29 days. Our results suggest that total hip replacement is a safe and effective procedure for patients with hip arthritis in our setting. The aim of the study was to evaluate the clinical and radiological results, the complications, and the revision rates of the THR. Conclusions: The study shows that primary total hip replacement can be performed successfully in Libyan hospitals despite challenges. The complication rate and results were low, but careful patient selection, surgical technique, and follow-up are important to reduce complications and improve outcomes. Recommendation: Surgeons need proper training and resources for primary THR. A DVT prophylaxis protocol should be developed based on local risks. Further research is needed to investigate complications, risk factors, outcomes, and patient satisfaction in Libyan patients who undergo THR.

Teachers have also begun to take note of the new technology and investigate how it affects student performance and conduct. High smartphone penetration has sparked an increase in the usage of apps by groups of teachers and their students to help the learning process by granting direct access to many online resources. In addition, engagement and satisfaction with online learning are important factors in encouraging effective educational processes Aim: In this study, we try to access students’ acceptance of free apps and social media that can be used to launch a respectable kind of distance learning for students and teachers during a pandemic or crisis. Methodology: we took 68 students registered, divided into 4 groups and the course planned to teach orthopedic surgery. The electronic questionnaire was distributed to students using the SurveyMonkey application to assess their acceptance of distance learning As a result, the students showed acceptance of the course as well as the time, material, and clarity of the course. In addition, they found the supportive materials such as videos that were delivered during the course were very useful. Conclusion: Programs for education that are less expensive than customary education programs. This technology made schooling possible. Technology is cost-effective, which is significant in nations with inadequate infrastructure.

FRACTURES OF THE PROXIMAL HUMERUS: MANAGEMENT AND EVALUATION (GENERAL OVERVIEW)

Abstract:

Fractures of the proximal humerus are a common phenomenon, while low-energy injuries occur in the elderly, and less frequent fractures with higher energy affect young people. The decision to perform surgical or nonsurgical treatment is determined by the functional goals and the degree of displacement of the proximal anatomical parts of the humerus. Surgical treatment is based on the ability to achieve and maintain the reduction, the vascularity of the articular segment, the quality of attachment of soft tissues and bone porosity. Despite numerous studies, the optimal treatment of significantly displaced fractures remains controversial. Keywords: fracture, humerus, fracture treatment.

Medical students have been shown to be more susceptible to stress and depression than the rest of the population. Libyan students specifically have to undergo the challenges of becoming a doctor while living with the stressful outcomes of the Libyan civil war. And the spread of COVID-19 has added to these stressors. This study aimed to determine prevalence of depression and anxiety among Libyan medical students and analyze the

causing factors. A cross-sectional study was conducted using an online survey. We used the Kessler psychological distress scale to measure the level of distress. A total of 1348 students from 16 Libyan medical schools across the 5 years of study completed the survey. The number of females was 992 (73.6%), and males were 356 (26.4%). The mean age (SD) was 22.09 (2.56). Out of the 1348 participants, 638 (47.3%) scored for severe mental disorder. A moderate mental disorder was presented by 213 (15.8%), and 200 (14.8%) presented with a mild one. Students are likely to be well according to the K-10 scale, which is 297 (22%). Out of the students whose houses have been displaced. In the war, 66.3% have presented with moderate to severe mental disorders. Students that have reported having suicidal thoughts throughout their time in medical school are 235 (17.4%). In comparison to similar studies done in other countries, Libyan students scored a higher prevalence of depression. The current political state of the country and the COVID-19 pandemic were shown to be contributing factors.