3D打印技术辅助成人脊柱侧后凸畸形的术前规划及应用价值

目的:探讨3D打印技术在成人脊柱侧后凸畸形的术前规划及术中辅助操作的应用价值。方法 :回顾性分析2017年9月至2019年1月收治的12例成人脊柱侧后凸畸形患者,其中男3例,女9例;年龄21~63(47.67±13.32)岁;先天性脊柱侧后凸畸形4例,脊柱陈旧性结核伴后凸畸形2例,特发性脊柱侧后凸畸形2例,退变性脊柱侧后凸畸形4例。将患者脊柱CT断层扫描数据导入Mimics17.0软件中,建立脊柱三维模型,通过3D打印机制作脊柱模型,然后进行术前规划及模拟手术操作,分析其术后影像学参数的改善情况。所有患者随访时间1年以上,于手术前后及末次随访时测量侧凸Cobb角,最大后凸Cobb角,冠状面平衡(distance between C7plumbline and center sacral vertical line,C7PL-CSVL)和矢状面平衡(sagittal vertical axis,SVA),骨盆参数等相关影像学参数,进一步评估其矫形效果。结果:12例脊柱侧后凸畸形患者的脊柱矫形术在1∶1脊柱模型的指导下,采用不同的截骨矫形内固定融合方式(其中4例畸形较重的患者采用椎弓根螺钉置钉导板辅助椎弓根螺钉置入)置钉及截骨矫形,效果良好,术中、术后无血管、神经、脊髓等重要组织结构损伤,无脑脊液漏、感染等并发症发生。术前侧凸Cobb角为(56.5±22.5)°,后凸Cobb角为(65.2±19.5)°,C7PL-CSVL为(45.8±16.9) mm,SVA为(48.7±25.4) mm。术后4周侧凸Cobb角为(20.8±11.5)°,后凸Cobb角为(22.0±6.6)°,矫正率分别为(65.1±9.7)%和(64.6±10.6)%;C7PL-CSVL为(22.3±8.9) mm,SVA为(23.3±13.1)mm,均较术前明显改善。12例患者均随访1年以上,平均(18.5±7.9)个月,末次随访时侧、后凸Cobb角分别为(22.2±10.8)°和(23.6±7.7)°,C7PL-CSVL为(23.5±10.8) mm,SVA为(24.7±12.5) mm,较术前差异均有统计学意义(P0.05),末次随访较术后差异无统计学意义(P0.05)。结论:3D打印模型可直观清晰地显示成人脊柱侧后凸畸形的椎体形态结构以及其与邻近椎体、血管、神经的空间关系,为手术方案个体化制定提供了良好、直观的立体解剖结构观察。术前预模拟手术操作,确定手术内固定、融合节段及截骨矫形方式,可以为实际临床手术提供参考,并能提高手术的精确性及安全性。     

脊柱截骨矫形技术治疗成人复杂脊柱侧后凸畸形的疗效及安全性的前瞻性观察

目的:探讨应用脊柱截骨矫形技术治疗成人复杂脊柱侧后凸矫形术的安全性,并评估其临床应用价值。方法:选择2011年9月~2012年9月期间应用截骨技术治疗的成人复杂脊柱侧后凸畸形患者进行前瞻性研究。所有入选患者均于手术前后及末次随访时测量侧凸Cobb角、最大后凸Cobb角、冠状面平衡(distance between C7 plumbline and center sacral vertical line C7PL-CSVL)和矢状面平衡(sagittal vertical axis,SVA)等影像学相关参数。同时采用SF-36量表、疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、SRS-22量表等评估其临床疗效,并使用AISA评分法评价患者手术前后及末次随访时神经功能情况。结果:共17例患者最终纳入本次研究,其中男7例,女10例;年龄18~55岁(34.6±10.9)岁,术前侧凸Cobb角51°~97°(78.5°±13.1°),后凸Cobb角50°~112°(71.8°±19.8°),C7PL-CSVL为58.4±21.3mm,SVA为56.4±51.2mm。手术时间200~540min(406.1±82.2min);术中出血量1000~12000ml(4088.9±2546.9ml)。术后侧凸Cobb角为37.7°±17.7°,后凸Cobb角为25.0°±16.4°,矫正率分别为51.9%±18.7%和67.2%±20.3%;C7PL-CSVL为18.0±9.4mm,SVA为27.6±16.9mm,均较术前明显改善。随访24.3±1.8个月,末次随访时侧、后凸Cobb角分别为39.5°±16.6°和26.2°±17.6°,C7PL-CSVL为22.1±15.4mm,SVA为30.4±17.1mm,随访期间无明显矫正丢失。术中监测均无诱发电位异常改变,无死亡、瘫痪等严重并发症,术后5例患者出现肢体远端一过性感觉功能减退,1例患者椎体前壁骨折,1例患者螺钉置钉不良,2例患者随访期间发生内固定并发症,总体并发症发生率为52.9%。术后和末次随访时的SF-36、VAS、ODI、SRS-22与术前比较均有明显改善,术后和末次随访时无显著性差异,ASIA运动和感觉评分与术前比较无显著性差异。结论:经后路脊柱截骨术治疗成人复杂脊柱侧后凸畸形矫正角度大,术后三维矫形效果满意,可显著改善患者临床症状和生活质量,但存在手术时间长、出血量大、并发症多等风险。     

全脊椎截骨梯次矫形治疗重度脊柱角状后凸畸形

目的评价后路全脊椎截骨梯次矫形治疗重度脊柱角状后凸畸形的安全性和有效性。方法 2015年1月至2016年12月,前瞻性采取后路全脊椎截骨梯次矫形技术治疗重度脊柱角状后凸畸形患者37例,男16例,女21例;年龄11~58岁,平均28.6岁。所有入选患者均于手术前、后及末次随访时测量后凸Cobb角、侧凸Cobb角、冠状位躯干偏移(trunk shift,TS)和矢状面平衡(sagittal vertical axis,SVA)等影像学相关参数。同时采用疼痛视觉模拟评分(visual analogue scale,VAS)、SF-36评分,Oswestry功能障碍指数((The oswestry disability index,ODI)评估其临床疗效,使用Frankel分级法评价患者手术前后及末次随访时神经功能情况,并对围手术期并发症进行分析。结果手术时间平均(468.9±108.3)min(312~723min),术中出血量平均(2 173.7±1 226.6)mL(800~5 100mL),随访时间平均22.5个月(12~40个月),术前后凸Cobb角平均(124±20.4)°(91°~160°),侧凸Cobb角平均(87.2±45.2)°(0°~156°);术后后凸角平均(46.8±21.5)°(10°~120°),侧凸角平均(49.1±26.9)°(0°~109°),矫正率分别为62.3%和45.2%;末次随访时后凸、侧凸Cobb角有轻度丢失,但与术后比较,差异无统计学意义。TS由术前的(38.6±17.2)mm减少至(11.5±11.2)mm,SVA由术前(33.5±11.4)mm减少到术后(9.6±7.2)mm,差异有统计学意义。术后和末次随访时的SF-36、VAS、ODI与术前比较均有明显改善。14例次(37.8%)患者发生围手术期并发症,其中发生神经系统并发症4例(10.8%),包括完全性脊髓损伤1例,一过性神经功能障碍3例;非神经系统并发症10例次(27%),包括胸腔积液2例,切口愈合不良3例,消化系统并发症3例;螺钉松动拔出1例,螺帽脱落1例。结论后路全脊椎截骨梯次矫形是治疗重度脊柱角状后凸畸形的有效手术方法,但手术时间长,出血量多,应充分重视围手术期并发症。     

儿童及青少年颈胸段/上胸段先天性脊柱侧后凸畸形手术治疗的疗效与并发症

目的:评估儿童及青少年颈胸段/上胸段先天性脊柱侧后凸畸形手术治疗的疗效和并发症。方法:回顾性研究2005年4月～2018年1月于我科接受手术治疗的颈胸段及上胸段先天性脊柱侧后凸畸形患者45例,男27例,女18例;年龄10.9±3.1岁(5～15)岁。术前所有患者均存在双肩不等高以及斜颈,2例患者存在脊髓受压及神经功能障碍(均为ASIA D级)。术前均行全脊柱CT平扫及三维重建,畸形顶点位于颈椎12例,位于胸椎33例;形成障碍型24例,分节障碍型5例,混合型16例;28例患者存在代偿性胸弯/胸腰弯;23例患者伴发其他部位的脊柱畸形。所有患者术前均行全脊柱MRI明确椎管内病变情况。对于计划进行颈胸段(C7/T1)截骨或颈椎固定的患者,行双侧椎动脉CT造影(CTA)检查。所有患者均行三柱截骨侧后凸矫形内固定植骨融合术,其中44例患者为单纯后路手术,1例接受C6-7半椎体切除患者行前后路联合手术。截骨水平位于颈椎12例,位于胸椎33例;半椎体切除术32例,全脊椎切除术10例,经椎弓根截骨术3例。6例患者代偿弯行手术治疗,其中4例接受后路融合术,2例接受双生长棒手术。于术后3个月、6个月及1年随访,此后每年进行随访。术前、术后及随访时均摄站立位全脊柱正侧位X线片,对原发侧凸、代偿侧凸及节段性后凸Cobb角与锁骨角、斜颈角度及矢状面平衡(sagittal vertical axis,SVA)进行测量。统计手术时间、术中出血量和手术并发症情况。结果:手术时间为269.1±65.3min(150～310min),术中出血量为987±157ml(500～2700ml)。45例患者均获1年以上随访,随访时间2.8±0.6(1～13)年。原发侧凸Cobb角术前为51.3°±13.9°,术后10.3°±6.4°,末次随访时12.4°±7.5°;代偿侧凸术前为32.1°±23.0°,术后11.1°±21.0°,末次随访时16.3°±23.1°;节段性后凸Cobb角术前为24.2°±15.2°,术后9.2°±8.7°,末次随访时10.4°±9.4°;斜颈术前为19.3°±5.0°,术后4.6°±3.0°,末次随访时5.7°±4.1°;锁骨角术前为7.5°±3.1°,术后2.7°±1.9°,末次随访时2.1°±1.2°;SVA术前为-9.1±16.1mm,术后-12.3±11.2mm,末次随访时-7.5±15.2mm。术后的原发侧凸Cobb角、代偿性侧凸Cobb角、斜颈角度、锁骨角及节段性后凸Cobb角与术前比较均有统计学差异(P0.05),末次随访时的原发侧凸、代偿性侧凸及节段性后凸Cobb角与术后比较有统计学差异(P0.05);SVA术前、术后及末次随访时均在正常范围内,无统计学差异(P0.05)。2例术前存在神经功能障碍者术后完全恢复正常。22例患者发生24例次并发症,其中一过性脊髓损伤伴C8神经根损伤1例,一过性神经根损伤14例,Horner综合征1例,内固定失败2例,血胸3例,切口延迟愈合1例,肺不张1例。结论:三柱截骨术治疗颈胸段及上胸段先天性脊柱侧后凸畸形矫形效果良好,但手术相关并发症风险较高,一过性神经根损伤较为常见,需引起外科医生充分的重视。     

伴无症状性椎管内异常的先天性脊柱侧凸患儿半椎体切除术疗效及安全性评估

目的 :分析伴无症状性椎管内异常的先天性脊柱侧凸患儿行半椎体切除术的临床疗效,评估半椎体切除术治疗该类患儿的有效性及安全性。方法:回顾性分析2012年1月～2017年4月在我院行半椎体切除手术的先天性脊柱侧凸患儿的病例资料,共纳入36例(男15例,女21例),平均年龄6.6±2.7(2～9)岁。患儿术前全脊柱MRI发现椎管内脊髓拴系、脊髓纵裂及脊髓空洞,经详细的神经查体无神经系统异常。于术前、术后1周和末次随访时的站立位全脊柱正侧位X线片上测量侧凸Cobb角、冠状面平衡(C7PL-CSVL)、后凸Cobb角和矢状面平衡(SVA)等参数;记录患儿术中、术后及随访过程中的并发症。结果:患儿侧凸Cobb角术前为37.7°±16.4°,术后1周为10.4°±9.2°,手术平均矫正率为(72.4±27.9)%,有统计学差异(P0.001);后凸Cobb角术前为20.3°±5.4°,术后1周为1.6°±3.4°,有统计学差异(P0.001)。术前、术后C7PL-CSVL分别为10.6±5.4mm、7.9±5.3mm,SVA分别为-6.4±19.8mm、1.2±14.1mm,无统计学差异(P0.05)。术后平均随访46.1±20.3(12～72)个月,末次随访时侧凸Cobb角、后凸Cobb角、C7PL-CSVL和SVA分别为11.3°±13.7°、3.1°±7.2°、9.1±4.8mm和8.7±22.4mm,无明显矫正丢失(P0.05)。1例患儿术中出现硬脊膜破裂、脑脊液漏,修补后愈合良好。1例患儿术后出现继发弯加重5°,3例患儿出现近端交界性后凸,均经过支具保守治疗后控制良好。所有患儿术后及随访中均未见神经系统相关并发症及内固定失败并发症。结论:无神经损害表现的伴椎管内异常的先天性脊柱侧凸患儿行半椎体切除术可以有效地矫正脊柱畸形,不明显增加术中及术后发生神经并发症的风险。     

后路楔形截骨治疗僵硬性脊柱侧弯

目的总结经后路顶椎区楔形截骨矫形内固定治疗僵硬性脊柱侧弯的手术方法 ,探讨其融合固定范围及手术适应证的选择。方法 1999年7月-2009年1月,对23例僵硬性脊柱侧弯采用后路顶椎区楔形截骨矫形内固定术。男11例,女12例;年龄8～29岁,中位年龄15岁。先天性脊柱侧弯16例,特发性脊柱侧弯5例,神经纤维瘤病2例。既往有脊柱矫正手术史2例。脊柱侧凸主弯Cobb角(85.39±13.51)°;后凸Cobb角(56.78±17.69)°;躯干偏移(15.61±4.89)mm。CT或MRI检查显示2例合并骨性纵裂畸形。结果手术时间平均241min,术中出血平均1452mL。术中固定融合节段8～14个椎体,平均10.7个。术后23例均获随访,随访时间1～4年,平均2年6个月。术后即刻脊柱侧凸主弯Cobb角为(38.70±6.51)°,后凸Cobb角为(27.78±6.01)°,躯干偏移(4.69±1.87)mm,身高增加平均5.2cm。末次随访时脊柱侧凸主弯Cobb角为(41.57±6.80)°,后凸Cobb角为(30.39±5.94)°,躯干偏移(4.78±2.00)mm。术前主弯Cobb角、后凸Cobb角和躯干偏移与术后即刻及末次随访比较,差异均有统计学意义(P0.05);术后即刻与末次随访比较,差异无统计学意义(P0.05)。手术并发症包括术中椎弓根骨折4例,L1神经根损伤1例,肠系膜上动脉综合征2例,术后切口渗液1例,切口积液2例,一过性双侧下肢神经功能障碍2例,经对症处理后均治愈。结论采用后路顶椎区楔形截骨矫形内固定术治疗僵硬性脊柱侧弯是一种安全、可靠的方法 ,通过椎弓根螺钉的应用,可以达到良好的矫形效果。     

改良单侧后路椎体截骨术治疗先天性重度脊柱角状后凸畸形

[目的]探讨改良单侧后路椎体截骨术(MU-PVCR)治疗先天性重度脊柱角状后凸畸形的临床疗效。[方法]回顾性分析本院采用MU-PVCR和后路钉棒矫形固定治疗的22例先天性重度脊柱角状后凸畸形患者的临床资料,记录患者围手术期资料,采用Frankel分级评估手术前后神经功能,VAS评分、Oswestry功能障碍指数(ODI)、日本骨科协会(JOA)评分评价临床疗效。影像测量后凸Cobb角、脊柱矢状位平衡(SVA)。[结果] 22例患者手术顺利,手术时间(125.31±34.25) min,出血量(750.10±114.67) ml。2例患者术中硬脊膜撕裂,给予缝合硬脊膜,无不良后果。随访(26.75±1.25)个月。术前6例有神经症状的患者Frankel分级由术前D级提高到术后E级。术后3个月VAS评分和ODI指数均较术前显著减少(P<0.05),术后3个月JOA评分均较术前显著增加(P<0.05)。末次随访时VAS、ODI和JOA评分较术后3个月无显著改变(P>0.05)。影像评估方面,术后3个月Cobb角和SVA测量结果均较术前显著减少(P<0.05),末次随访时Cobb角和SVA测量结果较术后3个月无显著改变(P>0.05)。[结论]对于先天性重度脊柱角状后凸畸形的患者,行改良单侧后路全脊椎截骨矫形固定融合术获得良好的临床疗效。     

陈旧性胸腰椎骨折伴后凸畸形的截骨矫形术式选择

目的:观测经椎弓根截骨(PSO)与Smith-Petersen截骨(SPO)两种术式治疗胸腰椎陈旧骨折伴后凸畸形的矫形效果和临床疗效,探讨截骨矫形术式选择。方法:2006年3月~2014年12月,对47例创伤性后凸畸形患者进行了截骨矫形手术。其中男30例,女17,年龄22~69岁,平均42.5±15.5岁。均为陈旧性胸腰椎骨折导致的创伤性后凸畸形。47例患者主诉均为腰背部疼痛。针对不同病理特征和畸形程度,32例行PSO矫形,15例行SPO矫形。PSO手术在病椎行经椎弓根楔形截骨矫形,SPO手术在病椎上下及相邻间隙做2~3节段SPO截骨矫形。通过术前、术后和末次随访全脊柱正侧位X线片,测量后凸畸形Cobb角及矢状面平衡(SVA),分析两种方法矫形效果,采用疼痛视觉模拟评分(VAS)评估疼痛情况,应用Oswestry功能障碍指数(ODI)分析两种方法临床疗效。结果:47例中有42例获得随访,其中PSO手术29例,SPO手术13例。随访时间8~48个月,平均29.4±7.8个月。42例均获得骨性融合。后凸畸形Cobb角PSO组术前为41.8°±10.5°,术后为2.6°±1.2°,末次随访时为3.2°±1.3°,矫正率92.3%;SPO组术前为40.2°±9.6°,术后为4.9°±2.3°,末次随访时为5.3°±3.5°,矫正率86.8%。两组术后、末次随访时Cobb角与术前相比均有显著性差异(P0.05)。PSO组SVA术前为5.0±4.1cm,术后为-0.6±2.2cm,末次随访时为1.2±1.5cm;SPO组SVA术前为3.5±2.2cm,术后为0.8±0.6㎝,末次随访时为1.3±1.1cm。两组术后、末次随访时SVA与术前相比均有显著性差异(P0.05)。PSO组VAS术前为6.46±1.72,末次随访时为0.91±0.59,ODI术前为(69.4±12.1)%,末次随访时为(23.7±11.5)%;SPO组VAS术前为6.51±1.87,末次随访时为2.08±0.75,ODI术前为(68.1±16.3)%,末次随访时为(33.1±12.5)%,两组随访VAS和ODI与术前相比有显著性差异(P0.05)。结论:针对不同病理特征和畸形程度的胸腰椎陈旧骨折伴后凸畸形患者,选用PSO或SPO矫治均可取得良好矫形效果及临床疗效。     

后路截骨矫形固定治疗老年骨质疏松性陈旧胸腰椎骨折伴后凸畸形

目的探讨后路截骨矫形固定治疗老年骨质疏松性陈旧性胸腰椎骨折伴后凸畸形的临床疗效。方法 2007-04-2012-12采用后路Ponte截骨矫形手术治疗11例老年骨质疏松性多节段陈旧胸腰骨折伴后凸畸形的患者。术前、术后2周及末次随访时采用X线片观察Cobb角、SVA间距改善情况,应用VAS评分评价患者疼痛情况以及观察神经功能和术后并发症。结果末次随访VAS评分为0~5分,平均3.3分;矢状位后凸Cobb角11°~23°,平均17°,丢失2.2%;SVA间距为-1.6~2.0 cm,平均1.1 cm。术前术后比较差异均有统计学意义(P0.05)。结论后路截骨矫形固定治疗老年骨质疏松性多节段陈旧性胸腰椎骨折伴后凸畸形,矢状面平衡恢复好,可取得良好的近期疗效。     

后路选择性双侧交替置钉钉棒矫形内固定治疗青少年脊柱侧凸

目的 探讨青少年脊柱侧凸的最佳手术治疗方法.方法 分析2008年4月～2012年3月本院收治的11例青少年脊柱侧凸病例临床资料,11例患者均采用后路选择性双侧交替置钉或椎板钩、钉棒系统矫形内固定术进行手术治疗,对术前、术后脊柱侧凸、胸椎后凸、腰椎前凸Cobb角进行统计学分析.结果 侧凸Cobb角术前、术后及末次随访时分别为58.36°±14.34.、23.27.±8.47°及28.82.±12.34°,侧凸Cobb角术前与术后及末次随访比较,差异均具有统计学意义(P＜0.01);胸椎后凸、腰椎前凸Cobb角术前与术后、术前与末次随访、术后与末次随访相比,差异均无统计学意义(P＞0.05).结论 单纯后路选择性双侧交替置钉、钉棒系统矫形内固定治疗青少年脊柱侧凸安全、经济,适合于普通医院开展.     

Fundamentals of laparoscopic surgery: a surgical skills assessment tool in gynecology

Objective:

To describe our experience with the Fundamentals of Laparoscopic Surgery (FLS) program as a teaching and assessment tool for basic laparoscopic competency among gynecology residents.

Methods:

A prospective observational study was conducted at a single academic institution. Before the FLS program was introduced, baseline FLS testing was offered to residents and gynecology division directors. Test scores were analyzed by training level and self-reported surgical experience. After implementing a minimally invasive gynecologic surgical curriculum, third-year residents were retested.

Results:

The pass rates for baseline FLS skills testing were 0% for first-year residents, 50% for second-year residents, and 75% for third- and fourth-year residents. The pass rates for baseline cognitive testing were 60% for first- and second-year residents, 67% for third-year residents, and 40% for fourth-year residents. When comparing junior and senior residents, there was a significant difference in pass rates for the skills test (P=.007) but not the cognitive test (P=.068). Self-reported surgical experience strongly correlated with skills scores (r-value=0.97, P=.0048), but not cognitive scores (r-value=0.20, P=.6265). After implementing a curriculum, 100% of the third-year residents passed the skills test, and 92% passed the cognitive examination.

Conclusions:

The FLS skills test may be a valuable assessment tool for gynecology residents. The cognitive test may need further adaptation for applicability to gynecologists.     

腓肠神经营养血管皮瓣修复跟部小腿下段软组织缺损

自1999年,应用带腓肠神经营养血管蒂逆行岛状皮瓣修复足跟小腿下段软组织缺损6例,取得良好效果,介绍如下.……     

Transfer of microsurgical flaps without an anoxic period at the time of vascular anastomoses

Summary Technical advances in microsurgery have made frequent use of free flaps possible. One of the concerns of the microsurgeons has been the role of ischemia in flap failure. In five patients, the rectus abdominis myocutaneous flap and the radial forearm flap each having with two dominant pedicles were used employing microsurgical vascular anastomoses before section of the second pedicle. This procedure eliminates the ischemic period of the flap and consequent accumulation of free radicals and development of microthrombi, ensuring vascular perfusion during the entire operation.     

COVID-19 and surgery: A thematic analysis of unintended consequences on performance,practice and surgical training

PurposeThe shift in the national focus and allocation of resources to the management of COVID19 has led to significant changes to surgical practice including the delay of elective surgery. The aim of this study was to explore the implications of such changes on surgeons.MethodUsing a qualitative study design, semi-structured interviews were conducted with general surgery consultants and non-consultant hospital doctors from a major tertiary hospital in the Dublin region between March–May 2020. Data collection proceeded iteratively using a thematic analysis approach with quality controls such as memoing and collaborative analysis.ResultsFourteen surgeons (8 male, 6 female) were interviewed. The majority (n = 11, 78.6%) were NCHDs. Significant themes determined included ‘impacts’ on a variety of constructs such as performance, self-reported fatigue and wellbeing. Training themes elucidated included the effects of the cancellation of elective admissions on reduced operative exposure for trainees. Senior surgical staff were particularly focused on increased complexity in patient management. New policy requirements such as personal protective equipment use and novel rotas have had implications for aspects of work engagement. The pandemic and subsequent national restrictions imposed has afforded opportunities for improved well-being but also resulted in greater solitude in surgeons.ConclusionsRhetoric surrounding fatigue management and virus control dominates the conversation on the relationship between COVID-19 and surgery. Tipping the balance back to parity of fatigue management with service delivery in surgery will be key for sustainability of the surgical workforce.     

The opportunity cost of arthroplasty training in orthopaedic surgery

IntroductionTraining the next generation of surgeons is a crucial role fulfilled by consultant orthopaedic surgeons. However we are increasingly constrained by limited time and resources. We sought to compare operative time and length of stay (LOS) for total hip and total knee arthroplasties (THA, TKA) performed by a consultant orthopaedic surgeon with those performed by supervised trainees.Materials and methodsA prospective database of arthroplasty procedures performed from 2015 to 2018 was collated. Primary surgeon grade was recorded. Patient demographics, ASA grade, LOS and operative time were recorded. For THA both cemented and uncemented arthroplasties were used. SPSS version 23 was used for statistical analysis.Results394 arthroplasty procedures were carried out during the study period. Trainee surgeons performed a high proportion of both THA (53.2%, n = 123) and TKA (44.8%, n = 73) surgeries. Trainees performed 57% of cemented THA procedures. LOS did not differ between consultant and trainee surgeons for THA (5.9 ± 4.8 days) or TKA (5.6 ± 4.1 days). Age had a significant effect on LOS (p < 0.001). For THA the mean operative time for trainees was 90.3 ± 19.23 min, 18.2 min longer than the consultant group. For TKA the mean operative time was 89.06 ± 18.87 min for trainees, 24.4 min longer than the consultant group.DiscussionAt our institution trainee surgeons can be expected to take between 18 and 24 min longer to perform arthroplasty procedures. This should be factored into resource planning, as the training of orthopaedic surgeons is crucial to sustaining and improving health service provision.     

医用胶水在急诊外科颜面部伤口处理中的应用

【摘要】〓目的〓观察医用胶水在急诊外科颜面部伤口处理中的疗效。方法〓对2012~2013年急诊外科收治的50例颜面部外伤应用医用胶水进行粘合,与周期另外50例使用常规清创缝合的患者进行比较。结果〓与常规清创缝合的处理方法相比,应用医用胶水进行创面的粘合处理,减少了创口周围红斑、硬结及瘢痕增生;术后创面更加平整,美观;不增加感染机会减少,且免去拆线。使用医用胶水同时减少了清创时间,患者对该方法的满意度增加。结论〓在急诊外科颜面部伤口处理应用医用胶水进行粘合处理较传统的清创术效果更好,但应正确选择适应症。     

Determinants of surgical decision making: a national survey

Background

We conducted a national survey of general surgeons to address the association between surgeon characteristics and the tendency to recommend surgery.

Methods

We used a web-based survey with 25 hypothetical clinical scenarios with clinical equipoise regarding the decision to operate. The respondent-level tendency to operate (TTO) score was calculated as the average score over the 25 scenarios. Surgical volume was based on self-report. Linear regression models were used to evaluate the associations between TTO, other covariates of interest, and surgical volume.

Results

There were 907 respondents. The mean surgical TTO was 3.05 ± .43. Surgeons had significantly lower TTO scores when responding to questions within their area of practice (P < .0001). There was no association between TTO and malpractice concerns, financial incentives, or compensation structure.

Conclusions

Surgeons recommend intervention far less frequently within their area of specialization. Malpractice concerns, volume, and financial compensation do not significantly affect surgical decision making.     

Lessons learned at sea--ocean sailing as a metaphor for surgical training

Surgical education is in the process of tumultuous change. Mastering this change will require a new set of competencies and a new understanding of the medical education process. While accreditation agencies are rapidly working to define the new criteria and benchmarks, training programs are quickly pulling together curricula, objectives, and evaluation tools. Yet much has already been learned in other complex, high-risk activities. Blue water sailing, ocean racing, and trans-Atlantic crossing are all activities that require a renewed form of leadership and an understanding of how knowledge, skill, and behavior come together to define the competent sailor. Ideas learned in such endeavors may assist the surgical educator in defining the horizons and the hazards of this uncharted voyage.     

Needs Assessment for Electrosurgery Training of Residents and Faculty in Obstetrics and Gynecology

Background and Objectives:

Effective application of electrosurgical techniques requires knowledge of energy sources and electric circuits to produce desired tissue effects. A lack of electrosurgery knowledge may negatively affect patient outcomes and safety. Our objective was to survey obstetrics-gynecology trainees and faculty to assess their basic knowledge of electrosurgery concepts as a needs assessment for formal electrosurgery training.

Methods:

We performed an observational study with a sample of convenience at 2 academic hospitals (Beth Israel Deaconess Medical Center and Mount Auburn Hospital). Grand rounds dedicated to electrosurgery teaching were conducted at each department of obstetrics and gynecology, where a short electrosurgery multiple-choice examination was administered to attendees.

Results:

The face validity of the test content was obtained from a gynecologic electrosurgery specialist. Forty-four individuals completed the examination. Test scores were analyzed by level of training to investigate whether scores positively correlated with more advanced career stages. The median test score was 45.5% among all participants (interquartile range, 36.4%–54.5%). Senior residents scored the highest (median score, 54.5%), followed by attendings (median score, 45.5%), junior residents and fellows (median score in both groups, 36.4%), and medical students (median score, 27.3%).

Conclusion:

Although surgeons have used electrosurgery for nearly a century, it remains poorly understood by most obstetrician-gynecologists. Senior residents, attendings, junior residents, and medical students all show a general deficiency in electrosurgery comprehension. This study suggests that there is a need for formal electrosurgery training. A standardized electrosurgery curriculum with a workshop component demonstrating clinically useful concepts essential for safe surgical practice is advised.     

第2趾胫侧皮瓣修复手指中末节指腹皮肤软组织缺损

目的探讨以跖底动脉为蒂的第2趾胫侧游离皮瓣移植修复手指中末节指腹软组织缺损或指尖皮肤缺损的临床效果。方法1998年1月一2012年3月,对29例因外伤造成手指中末节指腹软组织缺损或指尖皮肤缺损患者,采用第2趾胫侧皮瓣游离移植修复。结果本组29例均恢复原手指的外形与功能,且保留了第2趾的长度、外形与功能。结论第2趾胫侧游离皮瓣是修复手指中末节指腹软组织缺损或指尖皮肤缺损的良好方法。