膝关节伸直位僵硬松解手术入路探讨

目的探讨采用多种手术入路进行膝关节伸直位僵硬松解的可能性。方法对22例膝关节伸直位僵硬采用手术松解治疗,其中16例采用原手术切口,包括外侧1例,前外侧9例,前内侧3例和前正中入路3例,对6例无法利用原手术切口松解的病人,5例采用前外侧切口,另1例电击伤后膝内侧异位骨化病人采用前内侧切口。结果应用多种手术入路股四头肌成形术均完成松解手术,17例病人切断了纤维化和挛缩的股中间肌。术中完全松解后可以达到的被动屈曲角度,除1例僵硬时间25年的病例松解到130°外,其他病人均达到150°以上。出院时膝关节主动屈曲度为101.8°±12.9°,与术前比较有显著提高(P0.01)。平均随访时间11.8(5~21)个月,随访结束时膝关节主动屈曲度112.5°±18.4°,较手术前明显增加(P(0.01);膝关节功能平均(95.7±4.5)分,明显高于术前(P0.01)。结论采用外侧、前外侧、前内侧和前正中等多种手术入路进行股四头肌成形术均可有效解除导致膝关节伸直位僵硬的因素,恢复膝关节的屈曲功能,术后积极康复在关节功能的恢复过程中起着十分重要的作用。     

A New Experimental Model for Simultaneous Evaluation of Aortic and Pulmonary Allograft Performance in a Composite Graft

A model was developed in pigs for simultaneous evaluation of aortic and pulmonary allograft performance in a composite graft. The composite graft consisted of vascular prosthesis and aortic and pulmonary allografts. Following antibiotic preservation, it was anastomosed to the recipient's thoracic descending aorta by an extrapleural approach without using cardiopulmonary bypass. Aortic blood flow was completely diverted into the composite graft. All 12 recipient pigs recovered well, 4 of which were assigned for the initial study to design the suitable experimental schedule. Calcification readily occurred in the aortic allografts and aneurysmal dilatation without calcvication developed in the pulmonary allografts. These morphological findings were consistent with those of previous reports. This model has several benefits. First, aortic and pulmonary allograft conduits can be implanted and evaluated simultaneously under the same conditions by making a composite graft. Second, the magnitude of the operation is minimum, and postoperative circulatory and respiratory management is uncomplicated. Third, wound infection rarely occurs, because the skin incision is made on the back. These preliminary studies suggest that this model will allow future study concerning aortic and pulmonary allograft conduits under different conditions     

“Approaches and surgical results in the treatment of ventral thoracic meningiomas. Review of our experience with a postero-lateral combined transpedicular-transarticular approach.”

Summary ?Background. The surgical treatment of anterior thoracic meningiomas provides a set of technical difficulties: the access is obstructed by the spinal cord posteriorly, thoracic cage and musculature laterally, mediastinum and pleural cavity anteriorly. It is fundamental to avoid any manipulation of the compressed, but also undamaged spinal cord: this shows significant plastic capabilities. Any effort should be directed to maximizing the contribution of the plasticity in order to obtain a good functional recovery. Method. We have utilized a postero-lateral combined transpedicular-transarticular approach in order to obtain less invasiveness on the neural structures. Ten patients with ventral thoracic meningioma were operated in the last 5 years. The preoperative clinical evaluation, follow-up monitoring, timing of recovery, Clinical/Functional Grade change were analysed. Findings. 8 Patients had significant neurological improvement, 2 were unchanged. Magnetic Resonance Imaging (MRI) was useful in preoperative planning. Radical excision was possible in all patients and the late postoperative MRI did not reveal recurrence of the lesions at this time. To date, there has been no evidence of clinical or radiological instability. Interpretation. We found this surgical exposure very helpful in the treatment of anterior thoracic meningiomas. The related morbidity and risk of instability are minimal. The combined postero-lateral approach offers a good surgical access to ventral, lateral and dorsal aspects of the thoracic spinal canal without manipulation of the spinal cord. Exposure is obtained by avoiding damage to the pleura and manipulation of the lungs and mediastinum and may be a feasible alternative in elderly patients, too. Published online June 4, 2003     

Mathematical Model for a New Mode of Artificial Ventilation: Volume Assisted Pressure Supported Ventilation: A Comparative Study

Abstract: The patient submitted to artificial ventilation generally is connected to a high impedance flow source with controlled respiratory cycles to assure volume requirements or to a low impedance pressure source with spontaneous cycles to allow synchronization between his effort and system flow delivery. These two types of cycles represent the initial and final stages of artificial ventilation. The patient who needs a volume guarantee and at the same time presents unstable or insufficient inspiratory effort is difficult to manage with assisted cycles which are analogous to the controlled presence of a high impedance flow source. This paper presents a new approach where the respiratory cycles are obtained by the combination of flow and pressure sources using mathematical modeling. These cycles, named volume assisted pressure supported (VAPS) cycles, are compared with conventional assisted cycles showing a decrease in the patient work of breathing (WOB) during assisted ventilation. The theoretical results have been confirmed by clinical trials.     

Efficacy of Topical Hemostatic Agents: A Comparative Evaluation of Two Gelatin/Thrombin-Based Hemostatic Matrices in a Porcine Kidney Surgical Model

Abstract

Purpose: Topical hemostatic agents are an important means of controlling or preventing bleeding. This study was performed to compare gelatin–thrombin matrix with smooth particles (SmGM) versus gelatin–thrombin matrix with stellate particles (StGM) in a porcine kidney bleeding model. Materials and methods: In male pigs, reproducible lesions (diameter and depth ～10 mm) were created in the renal cortex. Each lesion was treated topically using either SmGM or StGM. Blood loss was quantified before and 2, 5 and 10 minutes after treatment. Dry mass, ultrastructural and histologic analyses were also performed. Results: Thirty-two lesions were treated with SmGM and 32 with StGM; median initial bleeding rates were 27.6 and 29.1 mL/min, respectively. Two minutes post-application, SmGM was associated with significantly less bleeding than StGM (0.574 vs 0.920 mL/min; p < .0001). This difference stemmed principally from lesions with initial blood loss >29 mL/min, where bleeding rates at 2 minutes were ～3-fold higher with StGM (1.636 vs 0.567 mL/min; p ≥ 0.040). Dry mass per unit volume of hemostatic agent was significantly higher with SmGM versus StGM. SmGM formed discrete, smooth particles, while StGM particles were stellate and tended to coalesce. Histologic analysis showed more solid mass, larger particles and less intervening space with SmGM versus StGM. Conclusions: In a severe, high-volume bleeding model, residual bleeding at 2 minutes was significantly lower with SmGM versus StGM, and SmGM showed greater consistency across bleeding intensities. These findings may be attributable to dry mass per unit volume and/or ultrastructural differences between the two agents.     

新型可调节支撑护具在阴茎再造术后早期运用的前瞻性研究

目的探讨游离前臂皮瓣移植阴茎再造术后,早期运用可调节支撑护具的效果。方法 2015年1月至2017年7月间,行阴茎再造术患者30例,分为试验组(n=15)和对照组(n=15)。试验组使用自主研制的可调节支撑护具对再造阴茎进行角度支撑固定保护,对照组仅使用传统棉垫予以保护。比较两组患者术后阴茎皮瓣存活情况、再造阴茎角度固定的精准度、伤口感染率以及感觉功能重建等情况。结果术后试验组在皮瓣存活、再造阴茎角度固定的精准度、伤口感染率以及感觉功能重建等方面均明显优于对照组(P<0.05)。结论可调节支撑护具对阴茎再造术后早期可进行有效保护,使用效果优于传统棉垫,有利于患者术后早期康复。     

A New Technique for the Surgical Creation of Aneurysms in an In Vivo Tortuous Vessel Model to Test Neurovascular Devices

The purpose of this study was to develop an aneurysm model that mimics the tortuous anatomy of the cerebrovasculature for the evaluation of endovascular devices. This model is an adaptation of the carotid siphon model of Georganos et al. The common carotid artery trunks in 10 swine were surgically elongated using an EXXCEL Soft ePTFE vascular graft and then sutured into position to form an S-curve, with each bend having a 5- to 10-mm radius. Following a 3- to 4-week healing period, aneurysms were surgically created from jugular vein grafts along or distal to the tortuous segment and immediately embolized with coils. In a subset (n = 6) of the arteries, a stent was also placed across the aneurysm neck. Animals were allowed to survive for 30 days. Clinical relevance and utility of the model were evaluated based on comparison to human angiographic images, physician feedback, and histopathological assessment. Tortuous anatomy was successfully created in all 10 animals, and aneurysms were added at various locations within or distal to the tortuous segment in a subset of 8 animals, creating 11 aneurysms in total. At 30 days, 18/20 vessels were patent and the bend radius was maintained. Endovascular access to aneurysms and placement of embolization coils and/or stents was successful in 10 of 11 attempts. Physician feedback indicated this tortuous model was more clinically relevant in terms of endovascular device delivery and deployment compared to established, nontortuous aneurysm models.     

Risk Factors for Surgical Site Infection Following Lower Limb Arthroplasty: A Retrospective Cohort Analysis of 3932 Lower Limb Arthroplasty Procedures in a High Volume Arthroplasty Unit

Background

Surgical site infection (SSI) is a debilitating complication of lower limb arthroplasty with significant morbidity and increased costs. Numerous risk factors are associated with SSI.

Evaluation of Models,Methodologies, Devices,and New Surgical Concepts: Catheterization of the Subarachnoid Space in Rabbits Using a Vascular Access Port

A surgical technique allowing chronic access to the subarachnoid space in unanesthetized rabbits was devised using the Vascular Access Port system. Instrumentation provides the investigator with a method of measuring intracranial pressure and sampling cerebrospinal fluid in awake rabbits. The catheter is introduced into the dorsal cervical subarachnoid space at the C4-C5 intervertebral space via dorsal laminectomy and passed cranially into the cisterna magna. The access port is subcutaneously implanted in the dorsal thoracic region between the scapulas. This system reduces the potential for infection, is not easily removed by the animal, and is relatively easy to access with minimal discomfort for the animal.     

Imaging Evaluation of Fat Infiltration in Paraspinal Muscles on MRI: A Systematic Review with a Focus on Methodology

PurposeNumerous studies have applied a variety of methods to assess paraspinal muscle degeneration. However, the methodological differences in imaging evaluation may lead to imprecise or inconsistent results. This article aimed to provide a pragmatic summary review of the current imaging modalities, measurement protocols, and imaging parameters in the evaluation of paraspinal muscle fat infiltration (FI) in MRI studies.MethodsWeb of Science, EMBASE, and PubMed were searched from January 2005 to March 2020 to identify studies that examined the FI of paraspinal muscles on MRI among patients with lumbar degenerative diseases.ResultsIntramyocellular lipids measured by magnetic resonance spectroscopy and FI measured by chemical‐shift MRI were both correlated to low back pain and several degenerative lumbar diseases, whereas results on the relationship between FI and degenerative lumbar pathologies using conventional MRI were conflicting. Multi‐segment measurement of FI at the lesion segment and adjacent segments could be a prognostic indicator for lumbar surgery. Most studies adopted the center of the intervertebral disc or endplate as the level of slice to evaluate the FI. Compared with visual semiquantitative assessment, quantitative parameters appeared to be precise for eliminating individual or modality differences. It has been demonstrated that fat CSA/total CSA (based on area) and muscle–fat index (based on signal intensity) as quantitative FI parameters are associated with multiple lumbar diseases and clinical outcomes after surgery.ConclusionHaving a good command of the methodology of paraspinal muscle FI on MRI was effective for diagnosis and prognosis in clinical practice.     

Successful Surgical Closure of an Esophagobronchial Fistula Caused by a Foreign Body in the Esophagus of a Female Octogenarian with a Delayed Diagnosis: A Case Report

Esophagobronchial fistula (EBF) caused by an esophageal foreign body is rare in adults. All surgical interventions in the reported cases were performed via right thoracotomy. We have successfully treated an 88-year-old woman with EBF caused by a thick 2 × 2 cm piece of cake decorating paper that was swallowed accidentally. There was a 2-month interval between ingestion of the foreign body and correct diagnosis. The bronchial opening of the EBF was on the cephalic wall of the proximal left main bronchus (LMB), so we planned a primary repair of the bronchial wall with sutures via left thoracotomy. We performed a division of the fistula and primary closure of the openings on the esophageal and bronchial walls and covered the suture sites with an intercostal muscle flap and pericardial fat, respectively. The patient resumed oral intake on postoperative day 11 and was subsequently transferred to other hospital for rehabilitation.     

Laparoscopic Sleeve Gastrectomy with Duodeno-Jejunal Bypass: A New Surgical Procedure for Weight Control. Feasibility and Safety Study in a Porcine Model

Background  One limit of the Roux-en-Y gastric bypass (GBP) is the preclusion of exploring the bypassed stomach with conventional endoscopy and radiological studies. In this study, we explored the feasibility, safety, and weight progression of a new bariatric procedure that eliminates this inconvenience. Methods  Eleven 40- to 50-kg Yorkshire pigs underwent laparoscopic sleeve gastrectomy and Roux-en-Y duodeno-jejunal bypass (SG-DJBP). Weight was monitored at postoperative days 15 and 30 and after 3 months; weight progression was compared with an identical group that underwent a sham procedure or GBP. At autopsy, surgical site was evaluated at microscopic and macroscopic level. Results  Mean operating time was 66 ± 5.76 min. All the survivors tolerated the procedure well, except one subject that experienced a gastric leak from the stapler line. The SG-DJBP had a had significantly slower weight gains than the sham group (P = 0.005). The absence of histological abnormalities in the duodenal wall was confirmed at autopsy. Conclusion  SG-DJBP is feasible and produces effects of weight progression comparable to those of GBP. Being a combination of previously standardized procedures, we are confident to propose this procedure as a bariatric alternative in humans. Long-term follow-up will be required to establish the efficacy on weight loss in humans. Funding/Grant support: None Conflicts of interest: None     

A New Surgical Technique for the Silicone Gastric Band in the Presence of a Large Hiatus Hernia

Background: The purpose of this study was to establish the efficacy of a new surgical technique for the placement of the silicone gastric band (LAP-Band) in the presence of a large (>5 cm) hiatus hernia. Method: Hiatus hernias >5 cm were identified by endoscopy and barium meal in 6 patients. Each patient underwent hiatal hernia repair and attempted gastrodesis with laparoscopic placement of a gastric band. Results: At 6 months, there were no complications. Mean weight loss was 16 kg. Conclusion: Repair of hiatus hernia with hiatal repair and gastrodesis of the posterior aspect of the stomach may allow some patients to undergo a procedure previously considered contraindicated.     

Lumbar Disc Surgery in a Fixed Compensation Population: A Model for Influence of Secondary Gain on Surgical Outcome

Background

Reported outcomes in patients undergoing surgical procedures for lumbar disc herniation are poorer in patients eligible for workers’ compensation or with pending litigation. In the civilian community, the amount of compensation for one’s disability is variable and thus its influence on surgical outcome is difficult to quantify. In the military, all members are covered by a standardized workers’ compensation system, and have generally standardized work requirements, a standard pay scale, and third party evaluation of disability based on the Veterans Affairs rating system. This made the military a good system in which to study the effect of potential compensation on surgical outcome.

Methods

The study population consisted of active duty military members who underwent sequential lumbar microdiscectomies over a 31-month period. Omitted were lumbar fusions, decompressive laminectomies, and far lateral discectomies. Clinical and demographic variables, along with financial data for each patient were derived from these data. A good result was defined as return to active military duty.

Results

Three hundred forty-nine lumbar discectomies were performed in 348 active duty military members. Overall, 75.3% (262) of the 348 patients were able to return to full military duty after surgery, and 24.7% (86) received disability compensation. Chi-square univariate analysis showed higher compensation incentive was a significant determinant of poor surgical outcome (p = 0.0021). The influence of compensation incentive was proportional to the amount of anticipated payout, and relative to a military service member’s usual income. In multivariate analysis, lower base pay (0.0005) and female gender (p = 0.038) were predictive of poor outcome.

Conclusions

Secondary gain in the form of disability pay has a proportionally adverse effect on outcome following lumbar disc surgery. Although studying this issue in the military system allowed standardization of secondary gain values, the influence of other factors could not be eliminated entirely. Potential disability pay is proportionally greater in lower ranked service members. Thus, other variables such as income level, education, and job satisfaction may contribute to the poorer results in this subgroup of military members.