Epidural hemostasis by autologous fat graft in minimally invasive surgery for lumbar spinal stenosis: In vivo experimental study

BackgroundEpidural hemostasis needs to use small, adapted material in minimally invasive surgery, including bilateral decompression via a unilateral approach for lumbar spinal stenosis. Most surgeons avoid external material for hemostasis because of possible neural tissue damage or complications. We compared epidural hemostasis in minimally invasive surgery by fat graft versus gelatin sponge.MethodsThe design was a prospective randomized controlled in-vivo human experimental study. The 24 levels operated on for lumbar spinal stenosis were evaluated in two groups: Group A (control group: gelatin sponge) and Group B (experimental group: fat graft). International Normalized Ratio and Prothrombin Time were assessed preoperatively. Number of cotton hemostats and systolic and diastolic blood pressure were assessed intraoperatively. Epidural hemorrhage area, spinal cord size and ratio of epidural hemorrhage area to spinal cord size were evaluated on early postoperative lumbar MRI.ResultsMean epidural hemorrhage area in groups A and B was respectively 1.3 ± 0.5 and 1.2 ± 0.6 cm², and mean spinal cord size 1.2 ± 0.6 and 1.8 ± 0.6 cm² on early postoperative axial lumbar MRI. The two groups did not significantly differ in ratio of epidural hemorrhage/spinal cord size or number of intraoperative hemostats (P = 0.36, and P = 0.71).ConclusionsThe autologous fat graft ensured sufficient and safe epidural hemostasis without serious adverse events in minimally invasive spinal surgery, and is preferable as autologous tissue is easily and quickly harvested. The surgeon feels safe with this technique and does not need external hemostatic agents.     

Joint debridement and microfracture for treatment late-stage Freiberg-Kohler’s disease: Long-term follow-up study

BackgroundFreiberg-Kohler’s disease is not a common disease and although various reports have been described since 1914, treatment methods are not completely established. The purpose of the present retrospective study was to evaluate the long-term outcomes following joint debridement and microfracture procedures for the treatment of Freiberg-Kohler’s disease.MethodsFifteen consecutive patients (16 feet) with Freiberg-Kohler’s disease (Smillie’s classification grade III–V) were operated between May 1996 to December 2011. All patients followed the same post-operative protocol. The objective and subjective evaluations were taken at the initial examination and at final follow-up.ResultsMean follow-up was 11 years ±5.5 (range 4.2–19.7 years). The AOFAS score, VAS score and ROM of the MTP joint improved significantly after surgery (p value <0.05).The AOFAS score improved from a preoperative value of 46.7 ± 15.5 points to 83.2 ± 9.4 points postoperative (p < 0.05). The mean preoperative joint ROM was 28° ± 8° and 49° ± 13° postoperative (p < 0.05). VAS score improved from a preoperative value of 5.5 ± 1.2 points to 1.2 ± 1 points at last follow-up (p < 0.05). At the end of follow-up 13 patients (81%) declared they were very satisfied, 3 patients (19%) satisfied and nobody unsatisfied.ConclusionsOur results suggest that joint debridement and microfracture procedure is an effective surgical treatment for late-stage Freiberg-Kohler’s disease with decrease of daily pain, improved ROM, and high patient satisfaction.     

Biphasic bioresorbable scaffold (TruFit Plug®) for the treatment of osteochondral lesions of talus: 6- to 8-year follow-up

BackgroundThe ideal treatment of osteochondral lesions of the talus (OLT) is debatable. The TruFit plug has been investigated as a potential treatment method for osteochondral defects. This is a biphasic scaffold designed to stimulate cartilage and subchondral bone formation. The purpose of this retrospective study was to investigate the long-term functional and MRI outcomes of the TruFit Plug for the treatment of OLT.MethodsTwelve consecutive patients treated from March 2007 to April 2009 for OLT were evaluated. Clinical examination included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and the visual analog scale (VAS) for pain. MRI scans were optained pre-treatment and at last follow-up. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used to assess cartilage incorporation.ResultsMean follow-up was 7.5 years (range, 6.5–8.7 years). The average age was of 38.6 years (range, 22–57 years). The sex ratio between males and females was 3:1 (9 males, 3 females). The mean AOFAS score improved from a preoperative score of 47.2 ± 10.7 to 84.4 ± 8 (p < 0.05). According to the postoperative AOFAS scores 1 case obtained excellent results, 9 were classified as good, and 2 were fair. VAS score improved from a preoperative value of 6.9 ± 1.4 points to 1.2 ± 1.1 points at last follow-up (p < 0.05). The MOCART score for cartilage repair tissue on postoperative MRI averaged 61.1 points (range, 25–85 points).ConclusionsThe long-term results suggest that the technique of Trufit Plug for OLT is safe and demonstrates good post-operative scores including improvement of pain and function, with discordant MRI results. However, randomized controlled clinical trials comparing TruFit Plug with an established treatment method are needed to improve synthetic biphasic implants as therapy for osteochondral lesions.Level of evidence: Retrospective case series, Level IV.     

Progrip self-gripping mesh in Rives-Stoppa repair: Are there any differences in outcomes versus a retromuscular polypropylene mesh fixed with sutures? A “case series” study

BackgroundRives-Stoppa repair is widely accepted technique in large midline IH, and appears to be advantageous compared to other surgical techniques concerning complications and recurrence rates. The aim of this case series study was to analyze 1-year outcomes in patients with IH treated with Progrip self-gripping mesh compared to polypropylene (PPL) mesh fixed with sutures during the Rives-Stoppa technique.MethodsBetween June 2014 and June 2015, we performed a prospective comparative non-randomized (case series) analysis between 25 patients with IH using retromuscular Progrip self-gripping mesh and 25 patients with retromuscular PPL mesh fixed with sutures, under Rives-Stoppa repair. All intraoperative and perioperative morbidities were reported with particular attention to wound infection, seroma or hematoma formation, duration of hospital stay, presence of abdominal wall pain (VAS) and recurrence during long-term follow-up.ResultsMean operative time in Progrip group was shorter than Non-Progrip group (101 ± 29.5 versus 121 ± 39.8 min). In Progrip group, the only postoperative complication was seroma in two patients; however, in Non-Progrip group, we reported seroma in three patients, and hematoma in 4 patients (p = 0.03). The median hospital stay was shorter in Progrip group (5.8 ± 2.2 days versus 6.6 ± 2.9 days). Mean VAS score in the first 48 h was higher in Non-Progrip group than Progrip group (4.9 ± 2.1 versus 8.1 ± 2)(p = 0.01). The median follow-up was 13 months (range 12–20 months) and none of the 50 patients had a hernia recurrence.ConclusionsIn Rives-Stoppa repair, retromuscular Progrip mesh causes less postoperative pain in the first 48 h and lower rate of hematoma than PPL mesh fixed with sutures in the short term follow-up.     

Long-term follow-up evaluation of autologous chondrocyte implantation for symptomatic cartilage lesions of the knee: A single-centre prospective study

IntroductionAutologous Chondrocyte Implantation (ACI) has been the first technique in reconstruction of a valid articular surface. The aim of this study was to evaluate clinical results of this technique at an average follow up of 162 ± 27 months (range 88–208) in a group of patients who underwent ACI.Materials and methods32 patients were operated between 1997 and 2007 for chondral lesions or osteochondritis dissecans of the knee. Mean size of the defect was 5.48 cm² ± 1.53 (range 2–9). Nine patients were treated with I generation technique and 23 with II generation. All patients were evaluated with Subjective IKDC and Tegner Activity Scales for clinical outcomes and with EQ-VAS for a quantitative measure of health after intervention, starting from pre-operative period and at regular follow up (minimum 88 months-maximum 208 months).ResultsA significant increment of all scores was noticed comparing preoperative and postoperative results. In particular medium IKDC score increased from 40.3 ± 9.6 in preoperative evaluation to 74.2 ± 11.6 at one year (p < 0.00001) and to 83.9 ± 10.4 at 5 years follow up (p < 0.001). Mean IKDC values at the last follow-up were 80.3 ± 14.2, showing no statistical differences with those obtained at five-year follow-up. Tegner Activity Scale values increased from 2.8 ± 1.1 preoperatively to 4.1 ± 1.1 (p < 0.0001) after one year and to 6 ± 1.1 at five years (p < 0.0001). Mean Tegner Activity Scale values decreased to 4.8 ± 1.4 at the last follow-up. EQ-VAS evaluation showed superposable results comparing the 5 years evaluation with the ones at a medium follow up of 162 ± 27 months.DiscussionThe most important finding is the reliability at long-term of ACI technique, which in our series gave excellent clinical results. No statistical differences were observed between first- and second-generation. Clinical outcomes were significantly better for defects in the femoral condyles, influenced by age (worse results over 30 years old).ConclusionsACI represents a valid technique for chondral and osteochondral lesions of the knee in a population heterogeneous for age, sex and activity level with good results even at a long term follow up.     

Early results of minimally invasive,reverse-oblique,distal metaphyseal metatarsal osteotomy (R-DMMO) for arthritis of the lesser tarsometatarsal joints — A retrospective case series

BackgroundArthrodesis is the gold standard for operative management of osteoarthritis of the lesser tarsometatarsal joints (TMTJs) but is not without complications. Our early results of a minimally invasive alternative treatment – the reverse-oblique distal metaphyseal metatarsal osteotomy (R-DMMO) are described.MethodsThis is a single-centre, single-surgeon, retrospective series of patients with isolated, symptomatic lesser TMTJ arthrosis who underwent R-DMMO.ResultsSixteen feet in 15 patients were included. The mean age was 64.7 ± 9.7 years and mean duration of follow-up was 109.4 ± 27.4 weeks. There were no non-unions, infections or wound complications. Two patients developed transfer symptoms to their first metatarsal, one of these patients improved after three months. There was one delayed union which united at 12 months. Two patients developed recurrence of symptoms but felt that they were still improved compared to preoperatively and no patient has required arthrodesis thus far. The mean preoperative VAS was 8.3 ± 1.3 and the mean postoperative VAS was 2.4 ± 2.2 (P < 0.001). The mean postoperative MOxFQ-Walking was 25.2 ± 25.6, MOxFQ-Pain was 24.8 ± 20.5, MOxFQ-Social was 18.4 ± 19.1, and MOxFQ-Index was 23.4 ± 20.6. Eight patients were ‘very satisfied’ and seven were ‘satisfied’ with the procedure.ConclusionsR-DMMO is a minimally invasive and safe procedure for lesser TMTJ arthrosis which can produce good results and prevent, or at least delay, the need for arthrodesis without compromising future operative options. Good to excellent outcomes have been shown with few significant complications in the short term in selected patients.     

Ultrasound to identify the lumbar space in women with impalpable bony landmarks presenting for elective caesarean delivery under spinal anaesthesia: a randomised trial

BackgroundUltrasound can facilitate neuraxial blockade in patients with poorly defined anatomical surface landmarks, but there are no studies comparing an ultrasound-guided technique with landmark palpation for spinal anaesthesia. The objective of this study was to compare pre-procedural lumbar ultrasonography with landmark palpation to locate the needle insertion point in women with impalpable lumbar spinous processes presenting for caesarean delivery.MethodsAfter institutional ethics committee approval, 20 women with impalpable lumbar spinous processes presenting for elective caesarean delivery were recruited. Patients were randomised to palpation or ultrasound. The primary outcome of the study was the number of needle passes to achieve lumbar puncture. Secondary outcomes were the overall procedural time and patient satisfaction score.ResultsThere was no difference in mean (±SD) body mass index of both groups (ultrasound 39.1 ± 5.02 kg/m² vs. palpation 38.3 ± 3.77 kg/m²). There were significantly fewer needle passes in the ultrasound group (median 3 [IQR 1.8–3.2]) compared to the palpation group (median 5.5 [IQR 3.2–7.2] (P=0.03)). More time was required to locate the needle insertion point in the ultrasound group (ultrasound 91.8 ± 30.8 s vs. palpation 32.6 ± 11.4 s, P <0.001). There was no difference in the total procedural time between groups (ultrasound 191.8 ± 49.4 s vs. palpation 192 ± 110.9 s, P=0.99).ConclusionThe use of ultrasonography to locate the needle insertion point reduced the number of needle passes in women with impalpable lumbar spinous processes undergoing elective caesarean delivery under spinal anaesthesia. Its use did not prolong overall procedural time.     

Percutaneous Zadek osteotomy for the treatment of insertional Achilles tendinopathy

BackgroundInsertional Achilles tendinopathy (IAT) is a challenging common lower extremity disorder, despite several treatment options described in literature. Open dorsal closing wedge calcaneal osteotomy or Zadek Osteotomy (ZO), for the treatment of the IAT has good clinical results but a high rate of postoperative complications. The purpose of this study is to describe percutaneous ZO for the treatment of the IAT and to evaluate its impact on the clinical and functional postoperative outcomes.MethodsTwenty-six consecutive patients presenting with unilateral IAT refractory to nonoperative measures were treated with percutaneous ZO. Visual Analogue Scale (VAS) and Foot Function Index Score (FFI) were recorded preoperatively and at final follow-up visit (12 ± 3) months. Postoperative complications, satisfaction, and relief of the pain were also recorded.ResultsThe percutaneous ZO showed a significant improvement (p < 0.0001) in preoperative to postoperative FFI (from 65 ± 9 to 8 ± 12) and VAS (from 9 ± 1 to 1 ± 2). Two postoperative complications (8%) were observed: a case of symptomatic non-union and hardware pain, both in healthy patients. The overall rate of satisfaction after surgery was (92%). The relief from pain was achieved after an average period of 12 weeks.ConclusionsZO is a safe and effective procedure for the treatment of IAT. The use of a minimally invasive surgical approach is associated with excellent pain reduction (VAS score) and improved clinical function (FFI score). When compared to the open surgical approach, the percutaneous ZO may decrease recovery time and postoperative complications.Level of evidence: III, retrospective case series.     

Treatment of Trigger finger by ultrasound-guided needle release of a1 pulley: A series of 105 cases

IntroductionWe aimed to evaluate the efficacy and tolerance of A1 pulley release using the needle technique, under ultrasound guidance, in patients with symptomatic trigger finger.MethodsAll patients with symptomatic trigger finger underwent A1 pulley release using an intramuscular 21 gauge (G) needle. Quinnell grade (I-IV), Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score (0–100) and pain score on a visual analog scale (VAS: 0–10 mm) were recorded at inclusion. The primary endpoint was complete resolution of the trigger finger at 6 months.ResultsEighty-four patients totaling 105 treated digits were included. Mean age was 63.3 ± 10.7 years. Prior to treatment, mean VAS pain score was 5.8 ± 2.6 mm, and mean QuickDASH score was 44.3 ± 19.1. At 6 months, disappearance of symptoms was achieved in 85 of 91 digits with follow-up (93.4%), and in 85.7% at 12 months. The absolute reduction in VAS pain and QuickDASH scores at 6 months was respectively 4.1 ± 3.1 (P < 0.001) and 36.1 ± 20.7 (P < 0.001), and 90% of patients reported being satisfied or very satisfied at 6 months. Long duration of symptoms was significantly associated with persistent trigger finger at 6 months after intervention. Complications were rare and minor. Tenosynovitis occurred in 5.7% of cases, for which a corticosteroid injection into the tendon sheath rapidly led to favorable resolution.ConclusionTreatment of trigger finger by release of the A1 pulley under ultrasound guidance using the needle technique is a mildly invasive technique that yields rapid and effective symptom resolution with good tolerance up to 12 months.     

Spinal metastases treated with bipolar radiofrequency ablation with increased (> 70 °C) target temperature: Pain management and local tumor control

PurposeTo investigate the safety and clinical efficacy of bipolar radiofrequency ablation (b-RFA) with increased (> 70 °C) target temperature for the treatment of spine metastases with the intent of achieving pain relief or local tumor control.Materials and methodsThirty-one patients with a total of 37 metastases who were treated with b-RFA with increased temperature and vertebroplasty from January 2016 to May 2019 were retrospectively included. There were 20 women and 11 men with a mean age of 62.4 ± 10.5 (SD) years (range: 40–78 years). Patients and metastases characteristics, procedure details and clinical outcomes were analyzed.ResultsMetastases were predominantly located in lumbar (22/37; 59.5%) or thoracic spine (13/37; 35.1%). Mean target temperature was 88.4 ± 3.5 (SD) °C (range: 70–90 °C). Technical success was 100% (37/37 metastases). One (1/37; 2.7%) major complication unrelated to b-RFA was reported. One (1/37; 2.7%) metastasis was lost to follow-up. Favorable outcome was noted in patients receiving b-RFA for pain management (16/20 metastases; 80%; mean follow-up, 3.4 ± 2.9 [SD] months) or with oligometastatic/oligoprogressive disease (6/6 metastases; 100%; mean follow-up, 5.0 ± 4.6 [SD] months). In patients receiving b-RFA to prevent complications, favorable outcome was noted in 6/10 metastases (60%; mean follow-up, 3.8 ± 4.8 [SD] months).ConclusionsB-RFA with increased target temperature has an excellent safety profile and results in high rates of pain relief and local metastasis control in patients with oligometastatic/oligoprogressive disease. Suboptimal results are achieved in patients receiving b-RFA to prevent complications related to the growth of the index tumor.     

Initial experience with extraperitoneal laparoscopic radical prostatectomy after 20 procedures by a single surgeon

ObjectiveExtraperitoneal laparoscopic radical prostatectomy (ELRP) has been established as a minimally invasive and viable alternative to the open procedure. Herein, we summarize the initial experience of single surgeon who performed 20 procedures for clinically localized prostate cancer.Materials and MethodsBetween February 2006 and June 2009, 20 patients underwent an ELRP. Demographic data, including age, preoperative prostate-specific antigen (PSA), prostate volume, Gleason score, and ASA score were collected. A five-trocar extraperitoneal technique was used. Surgical parameters, pathological staging, postoperative complications, hospital stay, continence state, and oncological control during follow-up were retrospectively reviewed.ResultsThe mean age was 67.5 (54–81) years. Mean preoperative PSA was 24.6 ± 15.8 ng/mL and prostate volume was 47.8 ± 22.5 (17–92) mL. The mean operative time was 325 ± 58 (220–465) min. Mean blood loss was 450 ± 300 (250–3000) mL. The mean postoperative hospitalization was 10.4 ± 4.9 (5–25) days. The one major complication that occurred was deep-venous thrombosis, and venous filter implantation was applied. In addition, one had anastomosis disruption, and three had bladder neck contracture. All patients had transient stress urinary incontinence but almost 80% were continent 9 months later. Biochemical failure was noted in five patients, and they received adjuvant hormone or radiation therapy. All patients are alive except one who had pelvic lymph node involvement (N1) with bony metastasis; that patient died 34 months postoperatively.ConclusionA major benefit of ELRP compared to the transperitoneal approach is avoiding potential risks of intraperitoneal injury. In addition, it can also isolate urine leakage due to a negligent interrupted suture at anastomosis. From our 5-year short-term follow-up, it provides equal efficacy in tumor control as does a radical prostatectomy. We think that as experience accumulates, better postoperative oncological and functional outcomes are expected.     

Minimally invasive distal metaphyseal metatarsal osteotomy (DMMO) for symptomatic forefoot pathology – Short to medium term outcomes from a retrospective case series

BackgroundMinimally invasive distal metaphyseal metatarsal osteotomy (DMMO) may be used to treat metatarsalgia and forefoot pathology. Few large series report its results or examine the degree of metatarsal shortening with this technique. The clinical and radiographic results of a cohort of patients treated with DMMOs at our unit are reported.MethodsThis was a single-centre retrospective study looking at the outcome of consecutive patients undergoing DMMOs. Demographics, radiological and clinical outcomes, complications and patient reported outcome measures (PROMs) were analysed.ResultsDMMOs on 106 toes in 43 feet were included. Mean age was 60.2 ± 10.2 years and median follow-up was 38 months. Concurrent procedures were performed in 26 cases (60%). DMMO was performed on multiple toes in 42 cases (97%). Mean shortening achieved was 3.6 ± 2.2 mm, 4.1 ± 1.6 mm, and 3.6 ± 1.6 mm for the second, third and fourth metatarsals respectively. Mean time to fusion was 11.4 ± 7.8 weeks and union occurred in 105 toes (99%). The single non-union was asymptomatic at 12 months. Two patients required a subsequent additional DMMO for transfer metatarsalgia. Minor complications were seen in 11 patients (26%). At final follow-up PROMs data was available for 42 cases: mean MOxFQ was 28.8 ± 27.6, mean EQ-5D was 0.789 ± 0.225, mean EQ-VAS was 68.5 ± 20.3, mean VAS-Pain score was 3.1 ± 2.8, and patients were satisfied overall in 40 cases (95%).ConclusionsThe authors demonstrate excellent radiological and clinical outcomes in the short to medium term with DMMOs and present data on metatarsal shortening achieved with this technique.     

Moore I postero-medial articular tibial fracture in alpine skiers: Surgical management and return to sports activity

PurposeOver the past 10 years, like many authors, we observed an increasing number of Moore I tibial plateau fractures related to alpine skiing for which the surgeon may face difficult choices regarding surgical approach and fixation means. Some authors have recently been suggesting a posterior approach associated to open reduction and osteosynthesis by a buttress plate. But in our knowledge there is no specific study on sports activity recovery after Moore I tibial fractures. The aim of this work was to assess sports activities and clinical outcomes after surgically treated Moore I tibial plateau fractures in an athletic population of skiers.MethodsWe conducted a prospective case series between 2012 and 2014. This included fifteen patients aged 39.6 ± 7 years whom presented with a Moore I tibial plateau fracture during a skiing accident. 12 cases (80%) presented with an associated tibial spine fracture. Treatment consisted of a standard antero-medial approach, with a medial para patellar arthrotomy to allow direct visualisation of articular reduction and spinal fixation. Two or three 6.5 mm long cancellous bone screws were placed antero-posteriorly so as to ensure perfect compression of the fracture site. Radiological and functional results were assessed by an independent observer (Lysholm-Tegner, UCLA, KOOS scores) at the longest follow-up.ResultsMean follow-up was 18.2 ± 6 months (12–28). An immediate postoperative anatomical reduction was achieved in all cases and remained stable in time. At last follow-up Lysholm mean score was 85 ± 14 points (59–100), UCLA score was 7.3 ± 1.6 (4–10) and Tegner score was 4.6 ± 1.3 (3–6). Mean KOOS score was 77 ± 15 (54–97). 87% of patients had resumed their skiing activity and 93% were satisfied or very satisfied from their post-operative surgical outcome. We observed no pseudarthrosis or secondary varus displacement.ConclusionIn our series 87% of patients had resumed back to their sporting activities. Surgical management of Moore I tibial plateau fractures by isolated antero-posterior screwing provides excellent clinical and radiological results. The anteromedial incision has a dual advantage of anatomical reduction, tibial spine fixation (in 80% of our cases) and posteromedial fragment reduction.     

经皮显微内窥镜下责任节段减压治疗多节段腰椎椎管狭窄症

目的探讨经皮显微内窥镜下责任节段减压治疗多节段腰椎椎管狭窄症的临床疗效。方法回顾性分析2014年9月—2016年10月收治的40例多节段腰椎椎管狭窄症患者的临床资料,所有患者均接受经皮显微内窥镜下责任节段减压治疗,记录手术时间、术中出血量、住院时间,术前及术后疼痛视觉模拟量表(VAS)评分和日本骨科学会(JOA)评分,术后并发症发生情况。采用VAS评分评估患者腰腿疼痛程度,采用JOA评分评估临床疗效。结果所有手术顺利完成,随访12～36(21±3)个月。手术时间50～150(70±15)min,术中出血量50～400(60±5)mL,住院时间3～7(4±1)d。末次随访时,腰痛VAS评分由术前(5.7±1.4)分改善至(1.8±1.7)分,腿痛VAS评分由术前(7.2±2.3)分改善至(1.7±0.9)分;JOA评分由术前(11.0±2.8)分改善至(23.0±2.2)分;差异均有统计学意义(P 0.05)。临床疗效优23例(57.5%),良12例(30.0%),可5例(12.5%),优良率为87.5%。结论采用经皮显微内窥镜下责任节段减压治疗多节段腰椎椎管狭窄症可获得椎管的完全减压,缓解症状,疗效确切。     

Pharmacokinetics of bupivacaine after bilateral ultrasound-guided transversus abdominis plane block following cesarean delivery under spinal anesthesia

BackgroundTransversus abdominis plane block is an effective method of post-cesarean analgesia. There are no data available about plasma bupivacaine levels after this block in adults. This study aimed to assess bupivacaine pharmacokinetic parameters after ultrasound-guided transversus abdominis plane blocks following cesarean delivery under spinal anesthesia.MethodsA prospective observational study in parturients undergoing elective cesarean delivery under hyperbaric bupivacaine spinal anesthesia was conducted. After surgery, patients received bilateral transversus abdominis plane block (50 mg bupivacaine each side). Venous blood samples were collected immediately before performing the block and at 10, 20, 30, 45, 60, 90, 120, 180, 240, 720 and 1440 minutes. High performance liquid chromatography was used to measure total plasma bupivacaine concentrations. Mean bupivacaine area under the curve (AUC) was calculated from 0 to 24 hours.ResultsData were collected from 17 parturients. Mean age and body mass index were 31 ± 6 y and 30 ± 4 kg/m² respectively. Mean plasma bupivacaine concentration before the block was 171 ng/mL. Mean peak concentration was 802.36 ng/mL (range 231.8 to 3504.5 ng/mL). Mean time to peak concentration was 30 min and mean area-under-the-curve (0–24 h) was 4505.4 h.ng/mL. Mean elimination half-life was 8.75 h. Three subjects had concentrations above the quoted toxic threshold and mild symptoms suggestive of neurotoxicity were reported by two subjects, but no treatment was required.ConclusionSingle-dose bilateral transversus abdominis plane block using 100 mg of bupivacaine, after spinal anesthesia for cesarean delivery, can result in toxic plasma bupivacaine concentrations.     

Surgery for spinal deformity in Parkinson's disease patients: What are we missing?

IntroductionDeformity associating coronal and sagittal malalignment can severely impair quality of life in Parkinson's disease (PD). Realignment using patient-specific rods (PSRs) is useful for achieving alignment goals.MethodsThis was a retrospective single-center analysis of a prospectively maintained database of all PD patients who underwent surgery between January 2013 and January 2017. Clinical evaluation, preoperatively and at 1 year's follow-up, used the Oswestry Disability Index (ODI). Radiological evaluation used systematic preoperative and 1-year postoperative full-spine radiographs.ResultsTwelve patients were included: 6 female, 6 male; mean age, 68.4 years. Mean follow-up was 40.8 months [range 12–70]. On average, 14 levels were fused [range 10–18]. Unplanned revision surgery was necessary for 8 patients at a mean 15.625 months after index surgery. Mean preoperative ODI score was 64% preoperatively [range 56–70] versus 52% [range 28–64] at 1 year's follow-up (P = 0.004). Lumbar lordosis improved significantly, from ?16.7° preoperatively to ?41.4° at 1 year (P = 0.006). Pelvic tilt was the least effectively corrected parameter, with a mean preoperative value of 31.6° vs. 27.8° at 1 year (P = 0.19). Mean preoperative sagittal vertical axis was 149.7 mm versus 73.6 mm at 1 year (P = 0.013). Mean preoperative coronal tilt was 68.2 mm versus 22.9 mm at 1 year (P = 0.007).ConclusionParkinson's disease is a degenerative disease frequently associated with major spine malalignment. The severity of the postural disorders in these patients needs special precautions to avoid complications.     

Callus distraction with external fixator for the treatment of congenital brachymetatarsia of the fourth ray

BackgroundBrachymetatarsia is a rare abnormality of the foot which occurs most frequently in the first and fourth metatarsals. The aim of this study was to evaluate the efficacy of gradual metatarsal lengthening by external fixator for treatment of brachymetatarsia of the fourth ray. The hypothesis was that with external fixation it would be possible to achieve the desired length of the metatarsal with a low rate of complications. Secondarily, in cases requiring a greater amount of correction, it was hypothesized that an opportune rate of bone consolidation would be achievable using a traditional oscillating saw without predrilling or use of a cold osteotome.MethodsBetween 2013 and 2016, 12 eligible patients and 13 feet underwent gradual metatarsal lengthening by an external fixator (MiniRail System M103, Orthofix) due to brachymetatarsia of the fourth ray. Mean age at surgery was 24.5 ± 5.3 years (range 19–36), with mean follow-up of 22.3 ± 8.3 months. Clinical evaluation was performed with the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score. Radiographic assessment was performed on follow-up using non-weightbearing dorsoplantar foot radiographs.ResultsThe mean AOFAS lesser MTP-IP score improved from a preoperative score of 76.6 ± 7.1 points (range 62–85 points) to a postoperative score of 90.3 ± 3.0 points (range 86–95 points). The average amount of lengthening was 16.8 ± 3.9 mm (range 8–22 mm). Mean shortening, final lengthening, Healing Index, period of treatment, and complications are also reported. The operative technique is described.ConclusionsGradual metatarsal lengthening with external fixator is an effective treatment for brachymetatarsia and can restore forefoot anatomy with good clinical outcomes, a low rate of morbidity and complications in selected cases. Particular attention should be given when treating patients with shortening >20 mm.     

Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal

IntroductionLaparoscopic adrenalectomy is currently the gold standard in surgical management of adrenal pathology.ObjectivesTo analyze our results after 12 years of experience in this surgery and to compare with the main published series.Material & methodswe describe retrospectively 100 adrenalectomies performed between 1997–2009. Analized variables: age, size, side, preoperative diagnosis, operative time, blood loss, reconversion, hospital stay and histopathologic report. We utilized Fisher test and chi square test to compare categoric data. We utilized t-Student test to compare means from independents groups with normal distribution. We considered statistical significance when p<0.05.Resultsmean age was 53,1 years (±14,4). Mean size was 3,7 cm (±2,2). In 51% of cases it was the left side. Mean follow-up was 15 months (±11,9). Preoperative diagnosis was: functional mass (44%), pheocromocytome (17%), incedentaloma >4 cm (20%), metastasis (10%) and adrenal carcinoma (5%). Mean operative time was 145,1 min (±55,6). Mean hematocrite loss was 6,26 points (±3,3). Reconversion rate was 9,6%. 2 cases of prolonged postoperative ileus. 2 patients required transfusion. 1 patient death because of an descompensation of liver cirrhosis. 80% of complications were on right side. Mean hospital stay was 6 days (±5,6). In last 30 procedures we realized statistical differences with first group, in terms of operative time (119,1 min vs 171,2 min) and hospital stay (4,1 days vs 6,1) (p<0,05).ConclusionsTransperitoneal laparoscopic adrenalectomy is a surgical feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar with the published series and confirm the efficacy, security and reproducibility of this technique.     

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

IntroductionThe number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.AimTo investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.Patients and methodsIn this randomised controlled trial involving patients aged ≥70 years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.ResultsThe study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9) years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12 h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12 h compared with controls (p < 0.001 and p = 0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3 ± 4.0 vs. 5.7 ± 5.2 mg, p < 0.001) and in the subgroup with dementia (2.1 ± 3.3 vs. 5.8 ± 5.0 mg, p < 0.001).ConclusionPatients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.     

Perioperative axial loading computed tomography findings in varus ankle osteoarthritis: Effect of supramalleolar osteotomy on abnormal internal rotation of the talus

BackgroundWe used axial loading computed tomography (AL CT) to evaluate preoperative and postoperative talocrural joints of patients who underwent supramalleolar osteotomy (SMO) to treat varus ankle osteoarthritis.MethodsWe performed retrospective analyses of 16 patients (18 feet) who underwent SMO including fibular osteotomy. Radiographic assessment was performed with weightbearing radiographs and AL CT. Clinical outcomes were assessed based on American Orthopedic Foot & Ankle Society (AOFAS) scale, visual analog scale (VAS) for pain, and Foot and Ankle Ability Measure (FAAM).ResultsThe mean 2-year follow-up tibial-ankle surface angle, talar tilt angle, Takakura stage, and tibial-lateral surface angle were all significantly different relative to preoperative parameters (P < .05). The mean 6-month follow-up talus rotation ratio was significantly corrected compared to the preoperative value (P = .001). The mean 2-year follow-up AOFAS, VAS at gait, and FAAM scores were all significantly improved relative to preoperative measurements (P = .001).ConclusionsAbnormal internal rotation of the talus in mild to moderate varus ankle osteoarthritis found on AL CT was significantly corrected after SMO.Level of evidenceTherapeutic Level IV