Neurosurgeons and ideas before their time.

As a complementary inquiry to previous studies on citation analysis in neurosurgery, a group of ideas before their time has been arbitrarily selected by the author from 3792 first-authored papers written between 1897 and 1980 by 50 of the first American neurosurgeons. There were eight neurosurgeons who proposed 12 original theories or procedures whose importance was not recognized at the time of publication. Although the value of these ideas was not initially judged to be significant, these concepts became a part of the intellectual consensus of neurosurgery or related disciplines after varying periods of time. Technical constraints constituted the most important reason for delayed recognition of these innovative and creative ideas. Other factors were an unsuitable medium of communication, fixed scientific attitudes, prestige of previous authors, incomplete literature review by later authors, and a failure to verify observations by other investigators. The question is raised as to whether these factors might continue to affect present and future clinical investigation and laboratory research in neurosurgery.     

Changing concepts of surgical treatment for haemorrhoids: From excision to reduction fixation

A diversity of surgical procedures has been described for treating haemorrhoidal disease. The current article attempts to give an account of these procedures, based on different concepts about pathogenesis and aetiology of haemorrhoids. Surgical excision, that is, haemorrhoidectomy, has stood the challenge of time and currently remains to be the most definitive way for treating the disorder. More recently, stapled haemorrhoidopexy has emerged as a potential less painful alternative. Different from conventional excision, this is basically a mucosal reduction procedure rather similar to the Délorme's operation. The concept is exciting and initial results from different studies look promising. However, the published trials so far are limited in the following aspects – insufficient data on fourth‐degree and thrombosed haemorrhoids, complete lack of data on external haemorrhoids, unknown long‐term recurrence rate, as well as insufficient information on feasibility as a day‐case procedure. Further studies with longer follow‐up should be conducted in order to determine whether stapled haemorrhoidopexy will become the ultimate procedure in treating haemorrhoidal disease in the nearest future.      

The insurance carrier's viewpoint. Practicing brinksmanship

The author presents a guide to the most common elements of the insurance industry. A working familiarity of the provisions of one's policy would prevent the frequent quarrels between the insurance carrier and the insured. Thus, the author attempts to clear up the misconceptions many physicians have about the industry. Finally, he offers a word of advice to physicians when choosing an insurance carrier.     

Anwendung der Klingen- und der dynamischen Schraubplattenosteosynthese

Osteosynthesis in fracture treatment and in some reconstructive procedures with blade plates or dynamic screw systems was the standard procedure for several decades. In this review, the current options and concepts using blade plate osteosynthesis, stabilization of proximal and distal femur fractures and reconstructive procedures with the dynamic hip screw or the dynamic condylar blade are discussed. On the basis of a literature review, the present indications, results and region-specific complications are reported and discussed. Blade plates are used mainly in the context of reconstructive procedures, as well as in the treatment of pseudoarthroses. The Pauwel procedure in femoral neck non-unions is one of the best known indications. In contrast, the dynamic hip screw is the gold standard for stabilization of femoral neck and most pertrochanteric fractures, whereas the dynamic condylar screw is still an alternative to internal fixators for proximal and distal femoral fracture fixations.     

Result of 310 consecutive patients undergoing laparoscopic Nissen fundoplication as hospital outpatients or at a free-standing surgery center

Recently, several studies were published regarding the safety and feasibility of laparoscopic Nissen fundoplication as an outpatient procedure. However, in these studies the patients were discharged within 24 h and considered to be outpatients. In our study, the author performed 310 procedures on an outpatient basis at a hospital or free-standing surgery center. The study analyzed intraoperative complications, readmission after discharge, length of dysphagia, resumption of regular diet, effectiveness, and the use of antireflux medications after the procedure. The study concluded that with the outpatient procedure, there is no increase in morbidity, mortality, readmission, or long-term effectiveness, as compared with inpatient procedures. Outpatient laparoscopic Nissen fundoplication makes the procedure much more attractive to most patients.     

Surgical treatment of forehead and glabellar wrinkles]

Many surgeons concerned with aging in the jowl and neck often overlook more objectionable changes in the upper face. These changes produce not only an old or aged appearance but inappropriate expressions as well. This paper outlines the elements of aging in the upper face and details the planning and execution of the foreheadplasty. Topics discussed include inappropriate facial expressions, upper facial aesthetics, incisions for bald or balding men and techniques for minimizing scars. For many years the evolution and application of techniques for rejuvenation of the upper face lagged behind that of procedures used to correct aging in the cheek and neck. Men were generally overlooked as candidates for foreheadplasties by surgeons who believed these procedures not to be possible on bald or balding scalps. In addition, patients were frequently disappointed after surgery due to objectionable secondary deformities. These include bizarre expressions from over-resection of forehead muscles, contour irregularities following imprecise muscle sculpturing, inappropriate appearances due to eyebrow malpositioning and aesthetic imbalances resulting from hairline shifting. For these and other reasons some surgeons deemed the procedure to be of questionable value. The author would like to share current concepts and new techniques which have overcome these problems and delivered satisfaction and happiness to many patients.     

Zementfreie Endoprothetik des Hüftgelenks

Prognosis of cemented total hip replacement seems to be excellent for elderly patients. In younger age the outcome is less favourable and early revision is more common. Thus, different concepts with better prognosis and preservation of bone stock for possible revisions were needed. After more than 30 years of application with excellent short-term and long-term results, uncemented total hip arthroplasty is nowadays generally regarded as the standard procedure for younger patients. New bone-preserving implants, such as surface replacement or short-stemmed femoral shaft prostheses, have been introduced especially for younger patients. Some of these new procedures are still under development, and the long-term results of new implant concepts have to be evaluated over the next decades. Regarding recently published scientific studies an overview about non-cemented total hip arthroplasty is given and current concepts and developments are presented.     

Präklinik, Schockraum und Intensivstation

Within the treatment algorithm for accident victims there is an additional risk potential beyond those associated with the complex treatment procedures in primary medical care, and it is inherent in the interfaces between the different treatment sectors. Besides the substantial loss of time and information, such factors as technical incompatibilities between items of equipment, differing treatment concepts and responsibilities and difficulties in transfer and positioning can put the patient at risk. The entire process involves multiple interfaces both between preclinical and clinical medical care and within the various treatment sectors, e.g. when a preclinical patient is transferred from ground medical staff to the air rescue team. The goal of an efficient treatment algorithm should be the reduction of multiple interfaces in order to optimize the various procedures. Future concepts directed at optimizing trauma management should therefore make some contribution to interface reduction.     

Rhinometry: An Important Clinical Index for Evaluation of the Nose Before and After Rhinoplasty

Background Preoperative planning and postoperative outcome assessment in rhinoplasty are important. For preoperative planning, some standard relationships are defined and evaluated primarily with standard photographs, but photographs do not necessarily reflect reality. Outcome assessment, on the other hand, is mostly subjective, and again, even photographic analyses may not address real changes after rhinoplasty. Methods “Rhinometry” is introduced as a clinical method for preoperative evaluations and postoperative judgments, and rhinometric parameters are defined. Measurements of these parameters were performed for 300 patients before rhinoplasty and in the follow-up visits 3 months postoperatively. Results Preoperatively, the nasal length and tip projection for most patients were more than ideal. There was moderate reduction in nasal length (mean, 9.21 mm) and a decrease in tip projection (mean, 3.34 mm) for the majority of the patients after rhinoplasty. Reductions in nasal length, tip projection, bony base width, alar base width, and alar base width during a smile were statistically significant. Patients who underwent surgery using the closed approach had significantly more reduction in nasal length and less reduction in tip projection. All the patients were satisfied with these pre- and postoperative data. Rhinometry changed the ideas of the authors about some changes that their operative approaches produce. Conclusions Rhinometry can change the ideas of plastic surgeons about the changes their operative approaches accomplish and can be a very useful guide for patients. It is recommended as a part of the pre- and postoperative physical examination of patients undergoing rhinoplasty.     

An Evaluation System to Enhance Patient Selection for Alopecia-Reducing Surgery

BACKGROUND: The author presents an evaluation system that helps optimize the chances of achieving good results with alopecia-reducing procedures. OBJECTIVE: To help hair restoration surgeons select patients properly for alopecia-reducing procedures. METHODS: Twenty criteria are scrutinized by the hair restoration surgeon during the initial consultation and given a score of one to five. The scores are added together and divided by 20. A patient with a score greater than four is considered a good candidate for alopecia reduction in most cases. RESULTS: This evaluation method has significantly decreased the number of patients undergoing alopecia-reducing procedures while helping the author achieve consistently good results. CONCLUSION: An evaluation system is presented that helps determine who is a good candidate for alopecia reduction and who is a poor candidate. This selection technique has helped the author achieve more consistently good results by eliminating poor and borderline candidates.     

Operative treatment of extremely large bilateral subdural effusions in infancy

Summary In some cases of subdural effusions the common methods of treatment (subdural punctures, burr holes, shunting procedures and standard craniotomy) are ineffective. Usually in these cases a marked craniocerebral disproportion causes the persistence of the hygroma. In 14 of these cases with bilateral effusions the authors have used effectively an operative procedure, in which not only the inner membrane is removed but also the dural sac and the cranium is resected down to a size, where an optimal adaptation to the brain volume is achieved. The operative technique is illustrated and the long term results are presented. No major operative and postoperative complications occurred. The indication for this operative procedure is discussed with special regard to the current concepts in the literature.     

Preliminary report: endoscopic laser-microsurgical removal of human gallbladder.

An alternative surgical instrumentation and technique to laser laparoscopic cholecystectomy (LLC) with a case report is presented. Thousands of patients have benefited from the conceptual and practical revolution brought about through LLC (i.e., minimal surgical trauma). The minimal invasiveness of this procedure also can help make surgical treatment more acceptable by the public. The instruments and technique presented are redesigns of ones used in laryngology for 30 years. Utilizing them would provide major cost reduction. Most hospitals around the world already have operating microscopes, electrocoagulation equipment, and CO2 lasers. Some of these are underutilized. The presented patient case shows that the procedure can have similar benefits to LLC, in some respects even more. This open endoscopic technique and instrumentation may be suitable to other abdominal or thoracic procedures.     

Doxorubicin in experimental and clinical heart failure.

Doxorubicin-induced heart failure is a rare but serious illness due to the well-known treatment difficulties. Prevention strategies have not demonstrated the expected success and unfortunately, this specific type of heart failure does not respond to the usual medical therapy as other kinds of heart failure. Therefore, surgical procedures may be necessary in some patients. Cardiac transplantation is performed in most cases but it requires the cure of the neoplastic disease. This usually requires a recurrence-free interval of several years which is associated with a high attrition rate in these patients due to their cardiac disease. Therefore, other conservative and surgical treatment concepts were developed during the last years. This review presents the most common procedures and discusses their efficacy as well as their clinical applicability.     

Nerve blocks in palliative care

Although between 85% and 90% of patients with advanced cancer can have their pain well controlled with the use of analgesic drugs and adjuvants, there are some patients who will benefit from an interventional procedure. This includes a variety of nerve blocks and also some neurosurgical procedures. Approximately 8-10% of patients may benefit from a peripheral nerve block and around 2% from a central neuraxial block. The most common indication is because opioid dose escalation is limited by signs of opioid toxicity but some patients will benefit from one component of their pain being relieved by a simple peripheral block. Most patients about to undergo these procedures are already taking high doses of opiods and obtaining valid consent may pose problems. The use of peripheral nerve blocks, epidural and intrathecal infusions, and plexus blocks is discussed.     

The role of stabilization in the treatment of cervical spine injuries

This presentation started with the assumption that our patient needs a cervical spine operation. Attention has been focused on the questions of which operation is needed and why. Most operations substitute one abnormal situation for another. The second abnormal situation must be beneficial to the patient. It was suggested that we think about the concept of immediate postoperative stability and the methods of achieving it when needed. When decompressions are indicated, we should determine as precisely as possible where the pressure is and what surgical procedure is the best to relieve it. We have suggested that allographs may be as good or in some ways better than autographs. The validity of the statement that bone grafts under tension will be absorbed has been questioned. We have suggested that the maturation of a bone graft can be staged and the patient managed accordingly. The discussion included an analysis of the advantages and disadvantages of some of the surgical constructions that are employed into the occipital-atalantoaxial complex. The importance of preserving motion in this joint as much as is compatible with a solution of the clinical problem was indicated. We suggested the use of the halo applied preoperatively and maintained through surgery in order to have safe, thorough control for the highly unstable situations in the upper cervical spine. In the lower cervical spine the selection of procedures that do not add to already existing instability was emphasized. Opinion was submitted about the relative immediate postoperative stability of the various anterior and posterior procedures in the lower cervical spine. We submitted some ideas about the principles of the use of methylmethacrylate in cervical spine surgery. Specific details of the surgical procedures were discussed when needed and illustrative case reports were included, when they were thought to be helpful.     

骨盆新月形骨折的研究进展

骨盆新月形骨折是Young-Burgess骨盆骨折分型中侧方挤压型Ⅱ型中典型的后环损伤表现。近年来许多学者就其受伤机制、影像学表现、分型、骨盆稳定性及手术方式提出了一些新的观点。微创复位经皮螺钉内固定在骨盆新月形骨折的治疗中应用越来越广泛。本文就骨盆新月形骨折的临床特征、分型、治疗等方面作一综述,以期使读者对骨盆新月形骨折有一个更加全面的认识,从而选择更合理的治疗方式。     

The functional significance of the oblique retinacular ligament of Landsmeer. A review and new proposals

The author presents a review of the current ideas of the function of the oblique retinacular ligament, first introduced by Landsmeer. It was suggested that the oblique ligament plays an important role in synchronizing the movements of the two distal phalanges and that it initiates extension of the maximally flexed distal phalanx. The author raises some objections to these ideas, referring partly to experiments performed by Harris and partly to some experiments reported in the present paper. These experiments disclosed that extension of the maximally flexed distal phalanges was actively initiated by motor forces. The author proposes another function of the oblique retinacular ligament, i.e. as a restraining and thus stabilizing force of the flexed terminal phalanx when the fingertip is used for pressure while the proximal interphalangeal joint is forced into full extension.     

Liposuktion

Liposuction is one of the most commonly performed procedures in aesthetic surgery. The primary aim is body contouring and not weight reduction. The vast amount of available methods for suctioning subcutaneous fat allows an optimal individual treatment plan, keeping in mind the correct indications. Although liposuction is often offered as a minor and harmless surgery, it is a complex procedure. A thorough training of the surgeon and in-depth knowledge about possible complications is essential. In addition to aesthetic indications liposuction is also a valuable tool in reconstructive surgery. For optimal patient selection the skin elasticity has to be considered during the preoperative assessment. Besides pure volume reduction through liposuction, the regenerative possibilities of adipose tissue are of great interest for basic research and clinical applications. Lipofilling or autologous fat transfer is used for a wide variety of aesthetic and reconstructive procedures. Of special interest is the regenerative and reconstructive potential of adipose-derived stem cells (ADSC).     

Urethroplasty using a pedicled skin graft in one-stage treatment of urethral stenosis. Review of 87 cases

118 cases of urethral stenosis treated by the same surgeon from September, 1984, to December, 1989, have led the author to describing a one-stage technique for the surgical treatment of urethral stenosis using a widening implant or a pedicled penoscrotal tube. This technique is patterned on ORANDI's and BLANDY's procedures and utilizes a pedicled skin graft taken from a remote, therefore unaffected, site. 87 patients were treated with this procedure for urethral stenosis, often complicated by infection and fistulae, 34 after the failure of previous treatment. With a distance in time exceeding 2 years for most operated cases, the percentage of satisfied patients is of about 95%. The results were estimated according to the quality of urination, to the strength of the urine flow, to micturating and retrograde pyelography and to a fiberendoscopic checkup. In 71 cases (81.6%), the result was rated as good, immediately in 66 cases, after a second operation in 4 and after 3 operations in 1 case. The results were regarded as average in 12 cases (13.5%) and poor in 4 cases (4.6%). Cutaneous urethroplasty using a pedicled skin flap is relatively easy and represents an excellent procedure for the treatment of urethral stenosis owing to the low rate of failure and to the quality of the results obtained. The author stresses the advantages of grafting a well-vascularized skin flap, which is particularly indicated, whatever the site and extent, in cases of urethral stenosis with infection, fistulae or following several operations, the pedicled skin graft being a procedure of choice for all these aggravating factors.     

The treatment of hemangiomas: with special reference to the role of steroid therapy.

Hemangiomas are the most common of all human birth defects. The author has reviewed a 25-year personal experience with treatment of over 1000 patients with a variety of common and rare developmental vascular anomalies. Attention is given to a more useful clinical classification of these disorders. The classification is intended to be helpful in estimating prognosis of the lesions and as a guide to the choice of therapy. Many treatment modalities are evaluated--some successful and some quite disappointing. Surgical excision, irradiation, CO2 freezing, sclerosing agents, cauterization, steroid therapy and watchful waiting are among the treatment methods evaluated. High dose--short course Prednisone therapy has proved to be a major new addition to the treatment of massive juvenile capillary hemangiomas. Numerous misconceptions have appeared in the medical literature. These are noted and a philosophic basis for present day management is suggested for each type angioma. The roles of growth, resolution, histologic picture and sense of deformity are considered in viewing the surgeon''s approach to these difficult and challenging problems. Some evidence and speculations are offered as to the etiology, neurogenic influences and physiological dynamics of the various hemangiomas.