Adnexal torsion with paraovarian cysts in pediatric and adolescent populations: A retrospective study

BackgroundDetermination of the clinical characteristics associated with adnexal torsion involving paraovarian cysts in pediatric and adolescent populations.MethodsRetrospective review of all cases of paraovarian cysts operated on in our department between 2007 and 2019. Demographic characteristics, clinical and sonographic findings were reviewed.ResultsThe cohort was composed of 39 pediatric and adolescent patients with an operative diagnosis of adnexal masses located in the paraovarian area. The patients were classified into two groups: 19 girls (48.7%) with a confirmed operative diagnosis of adnexal torsion and 20 girls (51.3%) without torsion. The preoperative diagnosis of adnexal torsion was correct in ≈ 70% of the cases. The mean BMI were similar in both groups. The preoperative sonographic detection rate of paraovarian cysts was also similar (11/19 [57.9%] vs. 14/20 [70.0%]; P = 0.514). The mean cyst diameter did not differ between groups, nor did the classification into cyst size groups (≤ 50 mm, 51–99 mm and ≥ 100 mm).ConclusionAdnexal torsion is a common complication diagnosed in girls undergoing surgery for paraovarian cysts, and is not associated with sonographic appearance or cyst diameter. In order to prevent torsion, surgical removal of paraovarian cysts should thus be considered in young girls undergoing surgery for paraovarian cysts.Type of studyRetrospective case series.Level of evidenceIV     

Pullout strength of pedicle screws augmented with particulate calcium phosphate: An experimental study

Background contextPressure-injected and in situ curing bone cements have been studied as alternatives in augmenting lumbar pedicle screw fixation but are frequently found to leak outside the confines of the target vertebra.PurposeThe objective is set to determine the mechanical efficacy of a porous granular/particulate calcium phosphate (CP) bone augmentation product (Skelite) applied manually without pressurized injection in this application.Study design/settingThe biomechanical analysis compared the axial pullout strength and insertional torque of augmented and nonaugmented pedicle screws in cellular polyurethane foams.MethodsThe insertion torque and pullout strength of 6.5-mm pedicle screws inserted (via 3.5-mm pilot holes) into polyurethane blocks mimicking the porosity of cancellous bone were measured. New pilot holes were then packed with granular particles of Skelite and retested. Last, those blocks initially tested to failure without augmentation were packed with Skelite and retested. Measurements were performed for polyurethane densities of 0.16 and 0.32 g/cc (corresponding to the porosity of osteoporotic and normal bone) and strain rates of 0.5 and 5 mm/min.ResultsPeak pullout force averaged 2132.5 ± 119.3 N and 1840.1 ± 216.7 N in high density samples without and with augmentation and 688.2 ± 91.4 N and 861.6 ± 74.5 N in low density samples without and with augmentation. After failure, approximately 50% and 77% of the peak pullout force of original high and low density samples was regained by augmentation. Statistical analysis revealed significant (p < .0001) correlation between the addition of CP, peak pullout resistance, and insertion torque.ConclusionGranular CP augmentation improved the pullout strength in both failed (pulledout) samples and low density (porosity of osteoporotic cancellous bone) polyurethane blocks.     

Bloqueio PECS I para analgesia pós‐operatória em pacientes submetidos a mamoplastia de aumento: estudo randomizado,duplo‐cego,controlado por placebo

Background and objectivesPECS I block was first described for surgery involving the pectoralis muscles. No randomized clinical trial has been conducted on surgeries that directly involve these muscles, such as subpectoral breast augmentation. We hypothesized that PECS I block would decrease pain in the postoperative period in this population.MethodsThis was a randomized, double‐blind, placebo‐controlled trial in women undergoing subpectoral breast augmentation surgery. PECS I block was performed using 0.4 mL.kg^‐1 of 0.9% saline on one side and bupivacaine (0.25%) on the other side, each patient being her own control. Numeric Rating Scale (NRS) pain scores (0 − 10) were measured at rest and during movement. The primary outcome was pain score at rest 30 minutes after arrival in the PACU. To detect a clinically significant difference of 50% in pain reduction, 14 volunteers were enrolled (power of 90% and alpha < 0.05).ResultsIn the PACU, three patients had no difference in pain between sides, five had reduced pain on the placebo side, and six had reduced pain on the bupivacaine side. In the bupivacaine group, pain scores at rest at 5, 30 and 60 minutes and 24 hours were 4.89 (4.23 − 5.56; mean 95% CI), 3.75 (3.13 − 4.37), 3.79 (2.93 − 4.64), and 2.29 (1.56 − 3.01), respectively, whereas in the placebo group, they were 4.96 (4.32 − 5.60), 4.00 (3.50 − 4.49), 3.93 (3.12 − 4.73), and 2.29 (1.56 − 3.01), respectively.ConclusionsPECS I block in patients undergoing breast augmentation surgery does not provide better pain relief than placebo. Therefore, the indications for PECS I block in breast augmentation surgery should be reconsidered.     

Modified Limberg flap technique in the treatment of pilonidal sinus disease in teenagers

BackgroundPilonidal sinus disease (PSD) is most common in young adults but can also affect teenagers. Although many techniques have been used to treat pilonidal sinus disease in adults, few studies have compared treatment methods for the condition in teenagers. In this study, we aimed to compare the modified Limberg flap technique with the excision and primary closure technique, both of which are used routinely in adults and teenage patients.Materials and methodsThis study was a retrospective review of 40 teenaged patients who underwent surgery in a single pediatric surgery center over ~ 2 years. The patients' age, gender, body mass index (BMI), number of sinuses, surgery technique and any complications were recorded. The patients underwent excision and primary repair or rhomboid excision and a modified Limberg flap.ResultsOf the 40 patients, 22 (55%) were female, and 18 (45%) were male. The mean age of all the patients was 15.20 ± 1.31 (12–17) years. The average number of sinuses was 3.18 ± 0.90 (1–5). Of the patients, 52.5% (n = 21) had a high body mass index. These patients were obese (n = 4) and overweight(n = 17). Pilonidal sinus excision and primary repair were performed in 8 (20%) of the patients, while the remaining 32 (80%) underwent the modified Limberg flap technique. Complications were observed in 87.5% of the patients undergoing excision and primary repair, and in 15.6% of those who underwent the modified Limberg flap technique. Recurrence was observed with only the primary repair technique (37.5%).DiscussionWhen compared with adults, teenage pilonidal sinus disease occurs more frequently in females. In this study, no correlation existed between the number of sinuses, symptoms, BMI and postoperative complications. Based on the results of this study, the modified Limberg flap technique has a low complication rate when used to treat pilonidal sinus disease in teenagers.     

Intraoperative ketorolac dose of 15 mg versus the standard 30 mg on early postoperative pain after spine surgery: A randomized,blinded, non-inferiority trial

Study objectiveThe primary aim of this study is to show the non-inferiority of 15 mg intraoperative dose of ketorolac as compared to the standard 30 mg ketorolac by looking at the visual analog scale pain (VAS) scores 4 h after an adult spine surgery.DesignThe study design is a prospective randomized non-inferiority clinical trial looking at non-inferiority of intraoperative 15 mg ketorolac from the standard 30 mg dose.SettingQuaternary care center.Patients50 adult (18–65 years of age) undergoing lumbar decompression spine surgery.InterventionsGroup A received a single intraoperative dose of 15 mg ketorolac at the end of surgery and group B received single intraoperative dose of 30 mg ketorolac.MeasurementsThe primary outcome was the visual analog scale (VAS) pain scores 4 h after an adult spine surgery. Secondary measures were morphine usage in the first 8 and 24 h postoperatively, numeric rating scores (NRS) up to 24 h, sedation, nausea, vomiting, respiratory depression, pruritus and bleeding complications.Main resultsIntention to treat analysis showed a mean increase in 4 h VAS pain score of 7.9 mm (95% CI: − 4.5 mm to 20.4 mm) in patients administered 15 mg ketorolac. This difference was neither statistically (P = 0.207) nor clinically significant (< 18 mm on VAS scale). A similar increase in the 15 mg group was noted through a per protocol analysis, 6.9 mm (95% CI: − 6.6 mm to 20.5 mm, P = 0.307) greater in the 15 mg group. Non-inferiority of 15 mg was not confirmed. No significant difference was found in secondary endpoints.ConclusionsKetorolac 30 mg intravenous was not superior to 15 mg intravenous for post-operative pain management after spine surgery. However, 15 mg failed to meet the pre-specified criteria for non-inferiority to the 30 mg dose.     

Endoscopic removal of large orbito-ethmoidal osteoma in pediatric patient: Case report

INTRODUCTIONOsteoma is a benign slow growing bone tumor with a prevalence of 3% of all benign paranasal sinuses tumors, with a peak incidence between the fourth and sixth decades, mostly involving frontal sinuses.¹PRESENTATION OF CASEWe present a case of a large right ethmoidal sinus osteoma in a 12-year-old boy, complaining of frontal headaches and excessive lacrimation of the right eye. CT scan showed a very large tumor in the right anterior ethmoidal sinus (30 mm × 25 mm × 15 mm).DISCUSSIONLarge osteomas of the paranasal sinuses are usually resected by external approaches. However, the minimally invasive endonasal approach, which minimizes external facial scarring, is challenging for such large lesions in pediatrics. In the presented case, the osteoma was successfully resected exclusively by endoscopy-guided endonasal approach assisted by neuronavigation, with no peri or postoperative complications.CONCLUSIONAn endoscopic approach assisted with neuronavigation may be a minimally invasive and safe procedure for managing large osteoma of the ethmoidal sinus in pediatrics patients.     

New methods for determination of the keyhole position in the lateral suboccipital approach to avoid transverse-sigmoid sinus injury: Proposition of the groove line as a new surgical landmark

PurposeThe asterion is frequently used as an anatomical landmark to determine the location of a keyhole in the lateral suboccipital approach used in craniotomies. However, the asterion may not be ideal because of large individual differences among patients. We examined a simple and safe method for determining an optimal keyhole position (KP) using the digastric groove as a new landmark in the lateral suboccipital approach.MethodsThirty-three patients with trigeminal neuralgia who underwent surgery in our institute between April 2014 and December 2018 were included. The groove line (GL) was designed accurately, extending the digastric groove on the surface of the occipital bone, as the x-axis. The y-axis was depicted from the posterior edge of the digastric groove (the groove point: GP) vertical to the GL. The x–y coordinates represented the distances from GP on each axis. The x–y coordinates of median edge of the transverse-sigmoid sinus (TSJ point), asterion, and the intersection of the GL and transverse sinus (the transverse point: TP) were investigated, based on intraoperative findings and recorded videos.ResultsThe x–y coordinated of the TSJ point were (23.9 ± 3.9, 7.2 ± 3.6). In all patients, the TSJ point was located superior to the GL. The x–y coordinates of the asterion were (27.3 ± 6.0, 8.9 ± 4.1), and in 28 of the 33 patients, their coordinates exceeded the TSJ points. The x-coordinate of the TP was 29.5 ± 4.5, and was located behind the TSJ point on the GL in all patients. The shortest distance between the TSJ points and TP was approximately 3 mm. According to these measurements, we decided that the optimal KP would be at 20 mm from the GP, subjacent to the GL.ConclusionsOur methods of using the GL as a new surgical landmark for setting the optimal KP is simple, safe, and useful.     

Comparação dos efeitos de sulfato de magnésio e da dexmedetomidina sobre a qualidade da visibilidade em cirurgia endoscópica sinusal: estudo clínico randomizado

Background and objectivesEven a small amount of bleeding during endoscopic sinus surgery can corrupt the endoscopic field and complicate the procedure. Various techniques, including induced hypotension, can minimize bleeding during endoscopic sinus surgery. The aim of this study was to compare the surgical vision quality, haemodynamic parameters, postoperative pain, and other effects of magnesium, a hypotensive agent, with that of dexmedetomidine, which was initially developed for short‐term sedation in the intensive care unit but also is an alpha 2 agonist sedative.Method60 patients between the ages of 18 and 45 years were divided into either the magnesium group (Group M) or the dexmedetomidine group (Group D). In Group M, magnesium sulphate was given at a pre‐induction loading dose of 50 mg kg⁻¹ over 10 min and maintained at 15 mg kg⁻¹ h⁻¹; in Group D, dexmedetomidine was given at 1 mcg kg⁻¹ 10 min before induction and maintained at 0.6 mcg kg⁻¹ h⁻¹. Intraoperatively, the haemodynamic and respiratory parameters and 6‐point intraoperative surgical field evaluation scale were recorded. During the postoperative period, an 11‐point numerical pain scale, the Ramsay sedation scale, the nausea/vomiting scale, the adverse effects profile, and itching parameters were noted.ResultsGroup D showed a significant decrease in intraoperative surgical field evaluation scale scale score and heart rate. The average operation time was 50 min, and Group M had a higher number of prolonged surgeries. No significant difference was found in the other parameters.ConclusionsDue to its reduction of bleeding and heart rate in endoscopic sinus surgery and its positive impacts on the duration of surgery, we consider dexmedetomidine to be a good alternative to magnesium.     

Vertebral augmentation via the rib approach: Surgical essentials and therapeutic effects

ObjectiveThe rib approach is a new extrapedicular approach for vertebral augmentation in the thoracic spine. This article discusses the surgical essentials and therapeutic effect.MethodsComputed tomography (CT) imagings were obtained from 100 subjects to stimulate a Φ 4-mm puncture needle via the rib approach to determine the anatomical parameters of the channel and the position of the needle inserted in the vertebral body. Application results for 26 patients with T5–10 lesions were observed, four patients were treated under general anesthesia and 22 were treated under local anesthesia.ResultsThe channel diameter was 5.9–7.0 mm. In T5–10, the puncture needle could reach the middle of the midsagittal line of vertebral bodies in the transverse plane and only reached the middle and upper parts of the vertebral body in the sagittal plane. One week after surgery, the visual analog scale (VAS) sores decreased to 2.4 ± 0.8, the ODI decreased to 13.4 ± 5.9, and the anterior and posterior vertebral body height ratios recovered to 82.2 ± 13.7% and 86.3 ± 13.2%, respectively (all, P < 0.05). No intraspinal cement leakage or nerve injury was noted.ConclusionsVertebral augmentation via the rib approach is suitable only for patients with T5-10 lesions located in the middle and upper parts of the vertebral body. The puncture needle should be inclined inward and downward. This method is characterized by simple execution and low risks of intraspinal cement leakage and nerve injury.     

Changes in the syndesmotic reduction after syndesmotic screw fixation for ankle malleolar fractures: One-year longitudinal evaluations using computer tomography

IntroductionTo evaluate time-dependent changes in the syndesmotic reduction after syndesmotic screw fixation and one year after screw removal for ankle malleolar fractures, and to assess whether the incidence of syndesmotic malreduction changes depending on the measurement method.MethodsWe assessed twenty patients who underwent syndesmotic screw fixation for ankle fractures. The syndesmotic screws were removed after six weeks of the fracture surgery. Syndesmotic reduction was assessed within two weeks of the fracture surgery and one year after the screw removal using the axial computer tomographic images. Side-to-side differences in the anterior and posterior tibiofibular distances, anteroposterior fibular translation, and fibular rotation were measured.ResultsThe mean anterior tibiofibular distance was 0.7 mm after syndesmotic fixation. It increased to 1.9 mm at one year after screw removal (p = 0.002). After syndesmotic fixation, four ankles had malreduction of the anterior tibiofibular distance, including three ankles with widening and one with overtightening. At one year, eight ankles had malreduction, all of whom had widening. The other measurement values did not change over time (0.1 mm vs. 0.6 mm for the posterior tibiofibular distance, 0.2 mm vs. 0.3 mm for the anteroposterior fibular translation, and 0.7 ° vs. 0 ° for the fibular rotation). The incidences of malreduction were significantly different depending on the definition of malreduction, ranging from 10% to 50% after syndesmotic fixation (p = 0.01) and from 20% to 60% at one year after screw removal (p = 0.02).ConclusionsThe anterior tibiofibular distance widened after one year of syndesmotic screw removal. The incidence of malreduction varied depending on the measurement method.     

Enhanced cephalomedullary nail lag screw placement and intraoperative tip-apex distance measurement with a novel computer assisted surgery system

ObjectiveThe goal of this study was to evaluate the ability of a novel computer assisted surgery system to guide ideal placement of a lag screw during cephalomedullary nailing and then accurately measure the tip-apex distance (TAD) measurement intraoperatively.DesignRetrospective case review.SettingLevel II trauma hospital.PatientsThe initial 98 consecutive clinical cases treated with a cephalomedullary nail in conjunction with a novel computer assisted surgery system were retrospectively reviewed.InterventionA novel computer assisted surgery system was utilized to enhance lag screw placement during cephalomedullary nailing procedures. The computer assisted surgery system calculates the TAD intraoperatively after final lag screw placement.Main outcome measuresThe ideal TAD was considered to be within a range of 5 mm–20 mm. The ability of the computer assisted surgery system (CASS) to assist in placement of a lag screw within the ideal TAD was evaluated. Intraoperative TAD measurements provided by the computer assisted surgery system were then compared to standard postoperative TAD measurements on PACS (picture archiving and communication system) images to determine whether these measurements are equivalent.Results79 cases (80.6%) were available with complete information for a retrospective review. All cases had CASS TAD and PACS TAD measurements >5 mm and < 20 mm. In addition, no significant difference could be detected between the intraoperative CASS TAD and the postoperative PACS TAD (p = 0.374, Wilcoxon Test; p = 0.174, paired T-Test). A cut-out rate of 0% was observed in all patients who were treated with CASS in this case series (95% CI: 0 − 3.01%).ConclusionsThe novel computer assisted surgery system tested here is an effective and reliable adjunct that can be utilized for optimal lag screw placement in cephalomedullary nailing procedures. The computer assisted surgery system provides an accurate intraoperative TAD measurement that is equivalent to the standard postoperative measurement utilizing PACS images.Level of evidenceTherapeutic Level IV.     

Anatomical characterisation of the cricothyroid membrane in females of childbearing age using computed tomography

BackgroundIn the event of failure to secure the airway by conventional means, it may be necessary to perform invasive airway access via the cricothyroid membrane. No studies have addressed anatomy of this structure in the obstetric population. We aimed to review the anatomical variation of this structure in a population of childbearing age.MethodsWe searched the radiology database for computed tomography studies of the neck performed in a 13-month period in consecutive patients aged 15–55 years. Studies on 18 females and 22 males were reviewed. Male patients were included for comparison. Data were reconstructed using a high spatial frequency algorithm to optimise spatial resolution. Five parameters were measured: distance from the skin to the membrane, maximum midline height of the membrane in the vertical plane, maximum transverse diameter of the membrane, neck diameter and cartilaginous calcification.ResultsThe distance (mean range) from skin to the membrane was similar in females and males (16.2 [3–33] vs. 13.9 [3–37] mm, P = 0.42). The vertical height (9.9 [7–17] vs. 11.4 [8–15] mm, P = 0.04) and maximum width of the membrane (14.5 [10–17] mm vs. 12.5 [10–15] mm, P < 0.01) were greater in males. Cartilaginous calcification was low and did not differ between genders.ConclusionsThe cricothyroid membrane is not necessarily a superficial structure and consequently may be difficult to palpate. The smallest dimensions of the membrane indicate that smaller than recommended cricothyroidotomy devices may be required in some patients as the external diameter of commercial trocar devices and tracheal tubes may exceed 7 mm.     

The relationship of Interleukin-6 -174 G > C gene polymorphism in type 2 diabetic patients with and without diabetic foot ulcers in Turkish population

ObjectiveWe aims investigate Turkish type 2 diabetic patients with/without diabetic foot ulcers and healthy group and examined the contribution of Interleukin (IL)-6 -174 G > C gene polymorphism to the development of diabetic foot ulcers.Design and patientsThe Interleukin (IL)-6 -174 G > C genotypes were determined prospectively in 50 patients with diabetic foot ulcers and 35 without diabetic foot ulcers and a control group of 119 healthy individuals. Genotyping of the Interleukin (IL)-6 -174 G > C gene polymorphisms for all individuals was performed by PCR-RFLP method.ResultsThe genotype IL6 distribution did differ between the control group (CC 13.3%, GC 66.7%, GG 20%) and type 2 diabetic patients (CC 2.4%, GC 47.1%, GG 50.6%) (P < 0.001). The genotype IL6 distribution did not differ between type 2 diabetic patients group (CC 0%, GC 45.7%, GG 54.3%) and diabetic foot ulcers (CC 4%, GC 48%, 48%) (P > 0.05). The frequency of the polymorphic G allele in between the control group and type 2 diabetic patients was no similar for the groups (58.4% and 74.1%, respectively) (p < 0.05). The frequency of the polymorphic G allele in between the type 2 diabetic patients and diabetic foot ulcers was similar for the groups (77.1% and 72%, respectively) (p > 0.05).ConclusionThe gene polymorphism of Interleukin-6 -174 G > C and G allele are an risk factor for diabetes, but gene polymorphism of Interleukin-6 -174 G > C is not an independent risk factor for diabetic foot. Genetic factors in the pathogenesis of diabetic foot may also show any changes in different populations.     

The outcomes of transanal endorectal pull-through for Hirschsprung’s disease according to the mucosectomy-commencing points: A study based on the results of a nationwide survey in Japan

Background/AimAlthough the mucosectomy-commencing points on transanal endorectal pull-through (TAEPT) differ among reports, the optimal point is unclear. This study assessed the outcomes among different mucosectomy-commencing points.MethodsWe conducted a nationwide survey from 2008 to 2012. The data of 1,087 Hirschsprung’s disease patients were collected, and data on those who underwent TAEPT were extracted. The patients were divided according to the mucosectomy-commencing points into two groups: in Group A, mucosectomy was started ≥ 5 mm from the dentate line (DL), and in Group B, mucosectomy was started < 5 mm from the DL. The extent of the aganglionic segment and postoperative complications in the month after TAEPT were compared.ResultsThe data of 327 patients were extracted (Group A, n = 155; B, n = 172). Aganglionosis extending to the sigmoid colon was the most frequent in both groups. Regarding postoperative complications, the patients of each group experienced enterocolitis (Group A: 8.4%; B: 7.6%) and incontinence (A: 3.9%; B: 2.9%). The incidence of rectal mucosal prolapse was significantly greater in Group B (4.1%); (A: 0%, p = 0.02).ConclusionsAlthough the outcomes of TAEPT were comparable in both groups, rectal mucosal prolapse was significantly frequent in patients in whom the commencing point was < 5 mm from the DL.Type of studyRetrospective studyLevel of evidenceLevel III     

Effect of parecoxib sodium pretreatment combined with dexmedetomidine on early postoperative cognitive dysfunction in elderly patients after shoulder arthroscopy: A randomized double blinded controlled trial

Study objectiveTo evaluate effect of parecoxib sodium pretreatment combined with dexmedetomidine on early postoperative cognitive dysfunction in elderly patients after shoulder arthroscopy.DesignRandomized, double-blind study.SettingUniversity-affiliated teaching hospital.PatientsOne hundred and fifty-two elderly patients scheduled for shoulder arthroscopy.InterventionsAt 15 min before the induction of anesthesia, 152 patients received intravenously parecoxib sodium 40 mg and dexmedetomidine at a dose of 0.5 μg/kg over 15 min, followed by a continuous infusion at a rate of 0.5 μg/kg/h until the end of surgery. Then all patients who received postoperative patient-controlled intravenous analgesia were divided 2 groups: sufentanil(0.04μg/kg/h, S group), sufentanil (0.04μg/kg/h) plus dexmedetomidine(0.06μg/kg/h) (SD group).MeasurementsThe mini–mental status examination score in SD group was significantly higher than S group at 1, 2 and 7 days after surgery. The incidence of postoperative cognitive dysfunction during 7 days after surgery in S and SD groups was respectively 17.1% and 6.7%. Compared with the S group, the visual analogue scale scores at rest and upon movement were significantly lower at 6, 14, 24, 36 and 48 h after surgery in SD group; analgesia pump liquid amount during 24 h after surgery and number of rescue analgesia during 48 h after surgery were significantly lower in SD group. Jugular venous oxygen partial pressure and jugular venous oxygen saturation values in SD group were significantly higher than S group at postoperative 24 h. The occurrence of nausea and vomiting within 48 h after surgery in SD group were significantly lower than S group. We found no complications including respiratory depression and sinus bradycardia within 48 h after surgery in all patients.ConclusionsParecoxib sodium pretreatment combined with dexmedetomidine could reduce the incidence of early postoperative cognitive dysfunction in elderly patients. This might be related to the improvement of postoperative analgesia effect and cerebral oxygen metabolism in patients.     

Effect of vitamin C on prevention of complex regional pain syndrome type I in foot and ankle surgery

BackgroundThe public health cost impact of complex regional pain syndrome type I (CRPS I) is considerable in both emergency and scheduled orthopaedic surgery. We proposed to assess the effectiveness of vitamin C in prevention of CRPS I in foot and ankle surgery.MethodsWe carried out a “before–after” quasi-experimental study comparing two chronologically successive groups without (Group I: July 2002–June 2003) and with (Group II: July 2003–June 2004) preventive 1 g daily vitamin C treatment. All patients having surgery on the foot or ankle were enrolled, with the exception of diabetic foot cases. Several factors were analysed: sex, age, type of pathology, history of CRPS I, psychological context, tourniquet time, and cast immobilisation time.Results420 feet (392 patients) were included in the study: 185 in Group I, 235 in Group II. CRPS I occurred in 18 cases in Group I (9.6%) and 4 cases in Group II (1.7%) (p < 10^?4), with history of CRPS I as a significantly correlated factor (relative risk = 10.4). The psychological context (anxio-depressive state) showed a (sub-significant) tendency to increase the risk of CRPS I (relative risk = 2.6).ConclusionVitamin C has been shown to be effective in preventing CRPS I secondary to wrist fracture, but few data are available with respect to foot and ankle cases. The present study demonstrates the effectiveness of vitamin C in preventing CRPS I of the foot and ankle—a frequent complication in our control group (9.6%). The authors recommend preventive management by vitamin C.     

Middle cerebral artery blood flow velocity during beach chair position for shoulder surgery under general anesthesia

ObjectivesThe goal of the present study was to examine changes of middle cerebral artery (V_MCA) blood flow velocity in patients scheduled for shoulder surgery in beach chair position.DesignProspective observational study.SettingOperating room, shoulder surgery.PatientsFifty-three consecutive patients scheduled for shoulder surgery in beach chair position.InterventionsTranscranial Doppler performed after induction of general anesthesia (baseline), after beach chair positioning (BC1), during surgery 20 minutes (BC2), and after back to supine position before stopping anesthesia (supine).MeasurementsMean arterial pressure (MAP), end-tidal CO₂, and volatile anesthetic concentration and V_MCA were recorded at baseline, BC1, BC2, and supine. Postoperative neurologic complications were searched.Main ResultsBeach chair position induced decrease in MAP (baseline: 73 ± 10 mm Hg vs lower MAP recorded: 61 ± 10 mm Hg; P < .0001) requiring vasopressors and fluid challenge in 44 patients (83%). There was a significant decrease in V_MCA after beach chair positioning (BC1: 33 ± 10 cm/s vs baseline: 39 ± 14 cm/s; P = .001). The V_MCA at baseline (39 ± 2 cm/s), BC2 (35 ± 14 cm/s), and supine (39 ± 14 cm/s) were not different. The minimal alveolar concentration of volatile anesthetics, end-tidal CO₂, SpO₂, and MAP were not different at baseline, BC1, BC2, and supine.ConclusionBeach chair position resulted in transient decrease in MAP requiring fluid challenge and vasopressors and a moderate decrease in V_MCA.     

Primary hydatid cyst of pancreas: Case report and review of literature

IntroductionHydatid disease is caused by the larval stage of Echinococcus granulosus. It most commonly affects the liver and lung. Pancreatic hydatid cyst (PHC) is very rare with incidence of 0.14%–2%.Presentation of caseA 40 year old lady presented with epigastric pain for last 3 months. A 5 × 5 cm abdominal lump occupying the epigastric and left hypochondrial region was noted on physical examination. Ultrasonography (USG) and Contrast enhanced Computed Tomogrpahy (CT) revealed a 55 × 57 mm cystic structure in the pancreatic body. Endoscopic ultrasound guided fluid aspiration cytology revealed normal Carcinoembryonic antigen and Amylase levels. Cytological examination was noncontributory. During open surgical exploration, it was found to be a hydatid cyst. After irrigation with scolicidal agent and evacuation of cystic contents, Partial cystectomy with external drainage was done. Histopathological biopsy revealed Hydatid cyst. Post-operative ELISA (Enzyme linked immunosorbent assay) for Echinococcal antigen was positive.DiscussionPHC is a rare entity. Most common mode of spread is hematogenous. Cysts in pancreatic head can present as obstructive jaundice. Cysts in body and tail are usually asymptomatic. USG, CT and Hydaitd serology can help in diagnosis and monitoring recurrence. Surgical exploration is treatment of choice. Options include pericystectomy, partial cystectomy +/− external drainage/omentopexy, marsupialization or cysto-enterostomy. Preoperative and Post-operative anti helminthic (Albendazole) is recommended.ConclusionPHC can masquerade as pseudocyst or cystic neoplasm of pancreas. It should always be considered in the differential diagnosis of cystic pancreatic lesion in patients from endemic regions.     

Study on the foot shape characteristics of the elderly in China

BackgroundWith aging, the feet of the elderly above 60 years old in China present degenerative changes, deformities, and diseases, which significantly affect their daily activities.ObjectivesThe authors aimed to study the morphological characteristics of the feet and identify the foot type according to size (length and width) and defect characteristics of elderly feet in China.MethodsA convenient sample of 1000 subjects above 60 years old was recruited mainly in the regions of Shanghai, Shaanxi, Henan, Hebei, and Sichuan in China. Foot images were collected, and 800 (male 398, female 402) valid questionnaires were recovered. A total of 800 elderly subjects as the test group were invited to measure their foot sizes by means of a Footprint Collector (Tong Yuan Tang Health Management Limited, Qingdao in Shandong province). The foot type of the elderly was compared with that of the general adult Chinese population as the control group using the t-test for independent samples.ResultsHallux valgus (46.9%) and flat foot (50.0%) were the most common foot shape deformities. The most frequent foot diseases were foot scaling (91.2%) and calluses (96.3%). The medial width of the first metatarsal-toe joint of the elderly was significantly higher (elderly female, 44.95 ± 4.86 mm; elderly male, 48.55 ± 4.94 mm) than that of the general adult population (adult female, 40.18 ± 3.43 mm; adult male, 43.22 ± 3.20 mm) (p < 0.01).ConclusionThe foot length of the elderly was not significantly different from that of the general adult Chinese population. The width of the first metatarsal-toe joint in the forefoot of the elderly was significantly higher than that of the general adult Chinese population, which was consistent with the result that a high proportion of elderly subjects presented hallux valgus.