Is the laparoscopic approach reasonable in cases of splenomegaly?

Laparoscopic splenectomy in cases of splenomegaly has been shown to be feasible in experienced hands, even though the size of the spleen increases the operative time and difficulty. Laparoscopic splenectomy for splenomegaly offers the same advantages as for patients with smaller spleens: a shorter hospital stay and a faster recovery. Recent experience has shown that hand-assisted laparoscopic surgery makes the surgical maneuvers during laparoscopic splenectomy in cases of splenomegaly considerably easier while preserving the advantages of a purely laparoscopic approach. This technique may facilitate and broaden the application of laparoscopy for splenectomy in patients with enlarged spleens.     

Are antibiotic nails effective in the treatment of infected tibial fractures?

BackgroundAntibiotic-impregnated cement nails are used to treat postoperative deep infections after primary intramedullary nail insertion for the treatment of tibial fractures. Few data exist regarding the efficacy of this treatment strategy. We hypothesized that such treatment with antibiotic nails results in a high rate of infection clearance at intermediate follow-up.MethodsWe conducted a retrospective review at our Level I trauma center. Patients who received intramedullary nails to stabilize tibial fractures (from 2000 to 2011) and subsequently required antibiotic nails to treat deep postoperative infection (n = 55) were considered for study inclusion. Patients with less than 6 months of follow-up were excluded, leaving 41 patients in the study group (average age, 41 years; average follow-up, 20 months).ResultsThirty-one patients (76%) had no evidence of infection after treatment. The 10 patients for whom treatment failed were shown to have infection within the first 6 months. Two experienced persistent infection after antibiotic nail removal, necessitating massive débridement and ring fixator placement. Four patients underwent repeat antibiotic nail insertion after persistent infection. Three infections resulted in eventual above-knee amputations, and one chronic infection resulted in the need for multiple débridement and saucerization procedures. No complications associated with use of the antibiotic nails were observed.ConclusionThe use of antibiotic nails for treatment of tibial infections seems to be a reasonable option, clearing 76% of infections at the 6-month time frame. Further investigation is needed to compare this treatment algorithm with other strategies, such as antibiotic treatment without nail removal and massive débridement with ring fixator placement.     

Superior pubic ramus fractures fixed with percutaneous screws: what predicts fixation failure?

OBJECTIVE: The purpose of this study is to present the early complications of percutaneous screw fixation of superior pubic ramus fractures and to present a new classification scheme for superior pubic ramus fractures. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS: One hundred and twelve patients with pelvic fracture between the ages of 14 to 89 years underwent percutaneous screw fixation of 145 pubic ramus fractures. Eighty-one patients with 107 surgically repaired fractures were followed to fracture union. Follow-up averaged 9 months (range 2-52 months). One additional patient who sustained fixation failure 4 days after surgery was included to yield a study group of 82 patients with 108 surgically repaired ramus fractures. INTERVENTION: Patients underwent percutaneous screw fixation of a superior pubic ramus fracture. MAIN OUTCOME MEASUREMENTS: Superior pubic ramus fractures were classified according to a new scheme, the Nakatani system, which categorizes superior ramus fractures according to location with respect to the obturator foramen. Patient radiographs were examined for evidence of loss of reduction, defined as any motion at the ramus fracture site or hardware motion, after fracture surgery. RESULTS: Of the 82 patients followed to union or fixation failure, 12 (15%) had loss of reduction on follow-up radiographs. The average age of patients who lost reduction was 55 years. The most common mechanism of reduction loss was a collapse of the pubic ramus over the screw, with recurrence of an internal rotation deformity of the injured hemipelvis. Ten patients who lost reduction were women, and 11 had undergone ramus screw placement in retrograde fashion. No loss of reduction was seen in Zone III ramus fractures (those that involve the bone lateral to the obturator foramen). No patient sustained recognized neurologic, vascular, or urologic injury as a result of percutaneous screw fixation of a superior pubic ramus fracture. CONCLUSIONS: The prevalence of loss of reduction after percutaneous screw fixation of pubic ramus fractures is 15%. Loss of reduction is more common in elderly and female patients and in patients whose ramus screws are placed in a retrograde fashion. Also, loss of reduction appears to be more common in fractures medial to the lateral border of the obturator foramen.     

Is folate a promising agent in the prevention and treatment of cardiovascular disease in patients with renal failure?

Management of the conventional cardiovascular risk factors is insufficient to prevent the dramatic increase in atherosclerotic cardiovascular morbidity and mortality in patients with renal failure. Folate recently received attention as a potential alternative treatment option to decrease the excess cardiovascular risk in the uremic population. Folate administration is the principal treatment modality for hyperhomocysteinemia. Hyperhomocysteinemia is prevalent in more than 85% of patients with end-stage renal disease (ESRD) and is independently associated with increased odds for atherosclerotic cardiovascular disease. Several attempts have been made to normalize homocysteine levels in uremic patients with folate-based vitamin regimens. Although supraphysiologic doses of folic acid afford greater reductions in homocysteine levels than standard doses, the response to treatment is generally only partial and the large majority of ESRD patients have residual hyperhomocysteinemia. Several defects in folate metabolism have been described in uremia, which may explain the relative folate resistance in patients with renal failure, but their clinical relevance remains uncertain. It appears unlikely that the hyperhomocysteinemia in ESRD can be cured solely with folic acid supplements, since folate does not affect the prolonged plasma elimination of homocysteine, which is the primary defect in homocysteine metabolism in uremia. Folate restores endothelial dysfunction, associated with hyperlipidemia, diabetes and hyperhomocysteinemia. The beneficial effect appears to be independent of its homocysteine-lowering capacity and is possibly related to an improved bioavailability of nitric oxide. However, folate has failed to improve endothelial dysfunction in uremic patients. In the ESRD population, multiple metabolic and hemodynamic abnormalities adversely affect endothelial function. In addition, irreversible structural vascular disease already may be present. Folate should, therefore, probably be an integral part of an "endothelial protective regimen," consisting of lipid-lowering agents, antihypertensives and antioxidant vitamins and started very early in patients with renal failure. Before large-scale folate administration can be recommended, effects on hard endpoints of cardiovascular disease need to be demonstrated in randomized trials. Such trials are currently underway in patients with normal renal function at high risk for cardiovascular disease, and one trial has recently been initiated in stable renal transplant recipients.     

Cephalomedullary nails in the management of ipsilateral neck and shaft fractures of the femur—One or two femoral neck screws?

This was a prospective study of 43 consecutive cases of combined ipsilateral femoral neck and shaft fractures treated with cephalomedullary nails. Sequential clinicoradiological evaluation of all high-energy femoral shaft fractures to detect associated ipsilateral neck fracture improved diagnosis. All but 1 of 35 cases included in the study achieved union of both fractures and excellent or good functional outcome. Mean Harris Hip Score at the last follow-up was 92 ± 4 in single-neck screw configurations, and 94 ± 3 for two-neck screw cephalomedullary nails which had better tip-apex distance. Mean sliding of the neck screw was 5 ± 2 mm with single-neck and 3 ± 2 mm with two-neck screw constructs. In six cases shortening was <1 cm; 22 had delayed union of the shaft fracture, but only four of these needed additional surgery. Early aggressive fixation of both fractures using a cephalomedullary nail with the least possible surgical trauma is the key to success in these polytrauma cases.     

The importance of biomechanics and the kinetic chains of human movement in the development and treatment of burn scars – A narrative review with illustrative cases

BackgroundBurn scars are a major clinical sequelae of severe burn wound healing. To effectively establish a successful treatment plan and achieve durable results, understanding the pathophysiology of scar development is of utmost importance.MethodsA narrative review of the principles of the kinematic chain of movement and the hypothesised effect on burn scar development based on properties of burn scars was performed. An examination of the literature supporting these concepts is presented in conjunction with illustrative cases, with a particular focus on the effect of combination treatments that include ablative fractional resurfacing with surgical contracture releases.DiscussionAblative fractional resurfacing combined with the surgical release of contractures are an effective treatment modality for burn scar reconstruction. This treatment approach seems particularly effective because it is one of the only approaches where the principles of functional kinematics can be addressed when tailoring a reconstructive approach to an individual burn patient. The presented cases illustrate the importance of recognising and including the principles of functional kinematic chains in any reconstructive treatment approach for burn scars. Further, epifascial contracture bands are cord like structures which can be found underneath the subcutaneous fat of scar contractures which follow the principles of functional kinematics. Contractures can be more efficiently released if these structures are divided as well.ConclusionAblative fractional resurfacing combined with local tissue re-arrangements is a promising approach to address the underlying forces leading to hypertrophic burn scarring. To achieve an optimal outcome, it is essential to recognise and address the origin of the pathology when treating burn scars. Ablative fractional laser resurfacing allows a different scar approach as it is not limited to one surgical site and thus enables for effective treatment at the cause of the pathology.     

Is ultrasound really helpful in the detection of rib fractures?

OBJECTIVE: To determine the usefulness of ultrasound in the detection of rib fractures. PATIENTS AND METHODS: A prospective study was performed over a 3-month period. Patients presenting with a high clinical suspicion of rib fracture(s) to the Accident and Emergency Department were referred for radiological work-up with a PA chest radiograph, an oblique rib view and a chest ultrasound. Associated lesions, e.g. pleural effusion, splenic laceration and pneumothorax were recorded. RESULTS: Fourteen patients were radiologically assessed. The mean patient age was 31 years (range 16-55 years) and the M:F ratio 3.7:1 (11 men and 3 women). Ten patients displayed a total of 15 broken ribs. Chest radiography detected 11, oblique rib views 13 and ultrasound 14 broken ribs. Ultrasound findings included discontinuity of cortical alignment in 12 fractures, an acoustic linear edge shadow in nine and a reverberation artifact in six. Concordance with plain film findings, and especially oblique rib views, was good, though better when the rib fractures fragments were markedly displaced. One splenic laceration was detected with an associated small pleural effusion. There were no pneumothoraces. The average time of ultrasound examination was 13 min. CONCLUSION: Ultrasound does not significantly increase the detection rate of rib fractures, may be uncomfortable for the patient and is too time-consuming to justify its routine use to detect rib fractures.     

Is laparoscopic enucleation the gold standard in selected cases with insulinoma?

We present the case of a 49-year-old male with the diagnosis of pancreatic insulinoma who underwent laparoscopic enucleation. The surgical procedure was completed successfully. The patient suffered from postoperative low-volume pancreatic fistula, which was self-limited. This was the first laparoscopic enucleation of an insulinoma in Turkey. The laparoscopic enucleation procedure is an appropriate method for superficially located pancreatic corpus and tail insulinomas.     

Is distal locking of long nails for intertrochanteric fractures necessary? A clinical study

Background

Few clinical studies have examined the utility of distal interlocking nails when fixing intertrochanteric fractures with intramedullary devices. In this study we performed a retrospective analysis comparing fixation method of intertrochanteric fractures with either a long unlocked cephalomedullary nail versus a long locked cephalomedullary nail. Our hypothesis was there would be no difference in device related failures or complications in stable intertrochanteric fractures treated with long locked or long unlocked cephalomedullary nails.

Methods

A retrospective chart review was performed of all stable intertrochanteric fractures treated with a long cephalomedullary nail between 2006 and 2012 at our institution. Clinical history as well as perioperative radiography was carefully reviewed for all subjects. AO classification, the use of locked or unlocked technique, and failure status was recorded.

Results

Overall, a device related failure rate of 1.8% (2/107) was observed for stable intertrochanteric fractures treated with long cephalomedullary nails. No statistical difference in failure rate was found between locked and unlocked nails within our studied population (0% long locked (0/56) versus 3.9% long unlocked (2/51), p = 0.224).

Conclusion

This clinical study supports our hypothesis that long cephalomedullary nails do not need to be locked for stable intertrochanteric fractures. We found no difference in failure rates between the two approaches across 107 patients.     

Lezius nailing under controversy? Experiences with Lezius-Herzer curved nailing in 1,062 pertrochanteric femoral fractures

Curved nailing according to Lezius and Herzer was applied to 700 of 1,062 cases of pertrochanteric fractures of the femur at the Surgical Department of the "Carl Gustav Carus" Medical Academy, Dresden, between 1964 and 1985. Complications are described, and results are generally compared with other surgical techniques used to handle pertrochanteric fractures of the femur. Lezius nailing, when compared to other methods, has proved to be a simple and reliable approach, primarily under the aspect of geriatric traumatology, and should be used on a much wider scale.     

How to determine the surgical approach in Hoffa fractures?

Surgical approach selection and fixation of Hoffa fractures is difficult and remains controversial. Evolving trends emphasize the importance of fracture morphology, fracture location, and comminution, all of which guide decisions regarding surgical approach and implant selection. This focused review highlights factors affecting Hoffa fracture available surgical approaches, treatment outcomes, and recommendations for selecting an optimal approach.     

Is obesity related with periprosthetic fractures around the knee?

Purpose

Periprosthetic fracture (PPF) is a devastating complication following primary total knee arthroplasty. Obesity is currently considered a risk factor for many complications in orthopaedics, but there is no evidence in literature about the relationship between obesity and PPF around the knee. The objective of this study was to determine whether obesity is associated with a higher incidence of PPF.

Methods

All patients diagnosed of a PPF around the knee from January 2010 to December 2013 were enrolled. Forty-nine PPF (47 women and 2 men) were included, and a total of 97 patients (80 women and 17 men) were randomly obtained as a control group. Body mass index (BMI) was obtained in both groups and classified as <25 (normal), overweight (25–29.9), obese (30–34.9), very obese (35–39.9), or morbid obesity (≥40). Both groups, were also divided into subpopulations depending on the age as follows: <70, 70–75, 75–80 and ≥80. Statistical analysis was performed to determine any difference in BMI ≥30 kg/m² distribution between groups.

Results

In the PPF group 61.22 % of the patients had a BMI over 30 kg/m² and likewise 62.88 % of the patients in the control group. No association was found between obesity and a higher risk of PPF (p?<?0.05).

Conclusion

As a conclusion, obesity (BMI ≥30 kg/m²) does not have any clinical relationship with the appearance of a periprosthetic fracture around the knee (相似文献   

Diaphyseal femoral fractures in children: should we change the present mode of treatment?

Three hundred thirty-nine diaphyseal fractures of the femur in 327 children were studied retrospectively. There were 196 boys and 131 girls, with a mean age of 5.59 years (range, 1 day-14 years). The majority of the children were < 6 years of age. In 67.8% of the children, the fracture was caused by a road traffic accident. Seventy-seven of the children had associated injuries. The minimum hospital stay was 15 days, and the maximum was 42 days (mean, 32.6 days). The most common site of fracture was at the middle third (N = 206), and 133 were the transverse type. The mode of treatment was balance skin traction in 146, skeletal traction in 72, hip spica in 22, internal fixation in 16, and external fixators in 5. The average follow up was 7.8 years. Complications were few. Our experience indicates that with a conservative mode of treatment, there is no risk of overgrowth, and a rotational malalignment of up to 20 degrees corrects during growth. We believe that diaphyseal fractures of the femur in children can be safely managed nonoperatively and economically, contrary to the present advocacy of operative treatment. The operative mode of treatment should be used in selected cases.     

Distal locking in short hip nails: Cause or prevention of peri-implant fractures?

ObjectivesThe most common cause of femoral fractures after osteosynthesis of trochanteric fractures with short nails is weakening of the femoral cortex via distal locking and stress concentrations at the tip of the nail. The aim of the study was to verify whether the incidence of peri-implant fractures is dependent upon the distal locking technique.MethodsWe prospectively analysed a group of 849 pertrochanteric fractures (AO/ASIF 31-A1 + 2) managed with short nails from 2009 to 2013. Unlocked nailing was performed in 70.1% and distal dynamic locking was performed in 29.9%. The mean age was 82.0 years. Peri-implant fractures were divided into 3 groups according to the height of the fracture in relation to the tip of the nail.ResultsIn total 17 fractures (2.0%) were detected. One peri-implant fracture occurred after locked nailing, whereas 16 cases occurred after unlocked nailing (p = 0.037). Patients without distal locking had an 85.7% greater risk of peri-implant fracture. Fractures of the proximal femur (Type I) occurred significantly earlier than fractures at the tip of the nail (Type II) (p = 0.028).ConclusionUnlocked nails do not guarantee sufficient stability. Distal locking serves to prevent postoperative femoral fractures. We recommend the routine use of distal locking when utilizing short nails.     

Is the fracture pattern in periprosthetic fractures around the knee related with the anterior femoral notch?

Introduction

Periprosthetic fractures around the knee (PPF) are a devastating complication of total knee arthroplasty (TKA). Anterior femoral notching during TKA is considered a risk factor for PPF. The aim of this paper is to determine if an anterior femoral notch after total knee arthroplasty may affect the fracture pattern when a PPF appears postoperatively.