Arthroscopic Latissimus Dorsi Transfer

The patient is placed in lateral decubitus. A 6-cm incision made in the axilla allows access to the latissimus dorsi tendon and its neurovascular pedicle. Holding the arm in internal rotation, the surgeon detaches sharply the tendon off the humeral shaft and then reinforces it with wrapping sutures. Pulling the free limbs of the sutures exposes the under surface of the muscle and helps to identify the neurovascular pedicle. Special lighting retractors suited for a large diameter scope are helpful. Mobilization is completed when 2 cm of the tendon crosses the posterior edge of the acromion. The standard lateral portal is used for visualization. A silicon drain tube stiffened by a Wissinger rod is advanced from the posterior portal under direct visualization in the space between teres minor and deltoid, exiting in the auxiliary incision. A suture loop passed down the tube retrieves the tendon sutures out the posterior portal. These are then moved out the anterior portal, thus pulling the tendon over the tuberosity. The first anchor is inserted at the anterior aspect of the greater tuberosity, close to the articular cartilage and long head of the biceps tendon. Two to 3 anchors are inserted fixing the tendon to the tuberosity until it is stable.     

Reconstruction of the foot with microvascular free flaps

Reconstruction of the foot using microvascular flaps has been widely performed in the last 15 years but the choice of flap to repair some areas in the foot remains controversial. We present a series of 128 free flaps to the foot performed during the period of 1975–1990. One hundred and seventeen had a successful outcome (91%). The etiology of the problem was traumatic in 94, congenital in 10, tumor in 9, and chronic ulcerations due to vascular problems in 15. The indications for a specific flap depended on the site and extension of the foot problem, and were divided into four groups:

• 1 Dorsum of the foot. Cutaneous parascapular flap was the best choice.
• 2 The sole-weight-bearing area. We favored the use of the latissimus dorsi muscle flap covered with a split thickness skin graft, done immediately. A proper tailoring of the flap and postoperative care by the patient are very important to maintain the result without ulceration. Tactile sensation does not seem to be essential.
• 3 The area over the calcaneus tendon. We have used cutaneous flaps such as the parascapular and lateral arm flap or fascial flaps covered by split thickness skin grafts (STSG). The fascia used were the serratus or the parascapular.
• 4 Complex trauma problems with extensive skin loss or chronic ulcerations due to vascular diseases: the latissimus dorsi musculocutaneous or muscle plus STSG was mostly used.

The overall number of donor areas were 5 groins, 48 parascapular, 2 gluteal fold flaps, 4 lateral arm, 61 latissimus dorsi, and 8 fascial flaps. © 1994 Wiley-Liss, Inc.     

Prospects and advantages in the use of cartilage cell cultures for in vivo transplants

The authors present a critical analysis of the literature in order to evaluate the current prospects and advantages of cartilage cell cultures for in vivo transplants. The analysis is relative to their use or to the treatment of isolated osteochondral lesions of the knee, and it is preceded by an analysis of the methods used in the treatment of this pathology, such as: 1) debridement, 2) abrasion of the subchondral bone, 3) perforations and decortication of the subchondral bone, 4) perichondral transplants. The most significant results obtained for cartilage cell transplants for the repair of focal osteochondral defects in experiments conducted on animals and in successive clinical trials in man, also revealing the complex problems that may lead to a variability in chondrocytary activity, going from an in vitro to an in vivo environment, are presented.     

Favorable outcome with bivalirudin anticoagulation during cardiopulmonary bypass

An 81-year-old man with previous syncopal episodes, progressive shortness of breath, pulmonary edema, severe calcific aortic stenosis, and a history of heparin-induced thrombocytopenia required aortic valve replacement. Bivalirudin, a thrombin-specific anticoagulant, was used in place of heparin. The patient received a 50 mg bivalirudin bolus followed by an infusion between 1.5 mg x kg(-1) x h(-1) and 1.75 mg x kg(-1) x h(-1). Adequate anticoagulation was readily obtained resulting in an uneventful cardiopulmonary bypass. Activated clotting time (ACT) values steadily declined after discontinuation of the bivalirudin infusion. Bivalirudin is a practical alternative to heparin during cardiac surgical procedures.     

The locomotory index: a new proposal for evaluating walking impairments

The energy cost of walking per unit of body mass and of distance (Cw) was determined before total hip (n = 17) or total knee (n = 16) arthroplasty and ten days, two, six or twelve months after surgery. The ratio of Cw observed on patients (at the self selected speed) relative to that observed in healthy subjects of the same age at the same speed was defined Locomotory Index (Index Locomotorius, IL). So, IL is a quantitative measure of the economy of walking; for both groups of patients IL amounted to about 1.40 before surgery; it increased significantly 10 days after the operation to 1.86 or to 1.58, for hip or knee patients, respectively. Two, six and twelve months after the operation IL had decreased significantly below presurgery values (1.29, 1.30 and 1.30) for knee replacement, whereas it was still larger, albeit not significantly so, after hip replacement (IL = 1.61; 1.56 and 1.50). It was also observed that the self selected speed increased and the traditional clinical scores (Harris for hip and B.O.A. for knee) improved, with decreasing IL. It is suggested that IL is a useful quantitative tool, in addition to the more traditional clinical scores, for evaluating ambulatory disability in patients.     

Nursing Students’ Knowledge of Patient Safety and Development of Competences Over their Academic Years: Findings from a Longitudinal Study

IntroductionFuture nurses should possess the knowledge and competences necessary to ensure patient safety. However, little evidence is available on the way in which students learn patient safety-related principles over time. This study explored the progress of a cohort of Italian undergraduate nursing students as they acquired patient safety knowledge and competences from time of enrolment to graduation.MethodsA longitudinal study carried out between 2015 and 2018 enrolled a cohort of 90 nursing students from two Italian Bachelor of Nursing Science Degree Courses at the Udine University, Italy. The students were followed-up on an annual basis and data collection was performed three times: at the end of the 1st, 2nd and 3rd years. The validated Italian version of the Professional Education in Patient Safety Survey tool was used to collect data.ResultsAt the end of the 1st year, students reported an average 4.19 out of 5 patient safety knowledge acquired in classrooms (CI 95%, 4.11–4.28), which was stable at the end of the 2nd (4.16; CI 95%, 4.06–4.26) and 3rd years (4.26; CI 95%, 4.16–4.32) and no statistical differences emerged over the years. With regard to the competences acquired in clinical settings, at the end of the 1st year the students reported an average 4.28 out of 5 (CI 95%, 4.20–4.37), which decreased significantly at the end of the 2nd year (4.15; CI 95%, 4.07–4.23; p=0.02) and increased at the end of the 3rd year (4.37; CI 95%, 4.27–4.47; p<0.01).ConclusionsNursing students’ competences in patient safety issues increases over time, while their knowledge remains stable. Students are more vulnerable at the end of the 1st year, when they seem to be overconfident about patient-safety issues.     

Mycobacterium marinum: a case of skin granuloma complicated by tenosynovitis of the extensors

The authors report the case of a male patient who owned a tropical aquarium and who developed a M. marinum skin infection of the wrist. The clinical findings and microbiological features of the case are described, as are the difficulty in providing a prompt diagnosis, and the need for surgical treatment and the use of antibiotics to treat the infection.     

The Ilizarov technique in the treatment of osteoarthritic genu varum

The authors report their experience in the treatment of 200 patients affected with osteoarthritic genu varum by proximal tibial osteotomy in valgus according to the Ilizarov technique. The criteria used to select patients is emphasized as the results of surgery depends on it. The surgical technique is described and several important steps are revealed. In conclusion, the advantages and the disadvantages of surgery and the importance of correct indications are discussed.