Evaluation of the treatment of clubfeet with the Diméglio score

Between January 1994 and November 1997, 17 children with 25 clubfeet were treated and evaluated. This group was divided into a group of only conservatively treated feet (group A, n=13) and a group of feet which had conservative treatment and complementary operative treatment (group B, n=12). Both groups were evaluated according to the Diméglio classification method in which the objective clinical evaluation is scored only. This was performed for the starting-point (at presentation until 2 weeks after birth), with the necessary information received from the patient's files where all the passive limitations were recorded in a standardized way and also for the end-point (at the time of the follow-up). After comparing these results to each other, all 25 feet had improved after treatment and the operative group had improved more than the conservative group, however the end result was equal, because the operated feet were more severely deformed before the treatment. After treatment, the results were considered acceptable in 92% of the feet, comparable to 93%, 75-85%, 88%, 77%, and 96% in other studies. Moreover, the forefoot adduction was the most common residual sign in the treated feet, confirmed by results in other studies. We conclude that the Diméglio method is an appropriate tool for the follow-up of clubfeet from birth to the end of treatment.     

Does the vascular development of the femoral head correlate with the incidence of avascular necrosis of the proximal femoral epiphysis in children with developmental dysplasia of the hip treated by closed reduction?

PurposeThe purpose of this study was to identify the correlation between the vascular development of the femoral head and avascular necrosis (AVN) in patients with developmental dysplasia of the hip (DDH) treated by closed reduction (CR).MethodsWe retrospectively reviewed 78 patients with DDH treated by CR (83 hips). The vascular maturity, number of vessels and perfusion changes of the femoral head were assessed on perfusion MRI (pMRI) before and after CR.ResultsThe number of vessels (mean 4.2 sd 1.4) of the femoral head and the ratio (36.1%) of mature vessels (type III) on the dislocated side were significantly less than those at contralateral side (mean 6.0 sd 1.2; 82.2%) (p < 0.001). Of the included 83 hips, 39 hips (61.5%) showed decreased perfusion of the femoral head, including partial decreased (Class B, 47.0%) and global decreased (Class C, 14.5%), at the dislocated side, which was significantly more than those at contralateral side (0.0%) (p < 0.001). In total, 32 out of 83 hips (38.5%) developed AVN. The rate of AVN with Class A (18.8%) which perfusion of the femoral head was normal (unchanged or enhanced) was significantly less than those with Class C (66.7%) (p = 0.006).ConclusionThe vascular development and perfusion changes of the femoral head on the dislocated side are significantly worse than those at contralateral side. Immature vascularity of the femoral head before CR and poor perfusion of the femoral head after CR may be risk factors for AVN in patients with DDH.Level of evidenceIII     

Does cystoscopy correlate with the histology of recurrent papillary tumours of the bladder?

OBJECTIVE: To correlate the cystoscopic appearance of recurrent papillary bladder tumours with the histology after transurethral resection, and thus ascertain whether cystoscopy can reliably identify low-grade, noninvasive papillary tumours suitable for outpatient fulguration. PATIENTS AND METHODS: In all, 150 recurrent papillary tumours of the bladder identified at outpatient flexible cystoscopy were classified as either low-grade and noninvasive (TaG1), high-grade and noninvasive (TaG3), or invasive (TIG3) tumours, and correlated with urine cytology and histology of tumour stage and tumour grade after transurethral resection. RESULTS: Cystoscopy classified 84 of the 150 papillary tumours as TaG1 and 66 as either TaG3 or T1G3. Cystoscopy correctly predicted the histology of 78 of 84 (93%) TaG1 tumours, 71 of 72 (98%) TaG1 tumours associated with a negative urine cytology, and 92% of TaG3 or T1G3 tumours. CONCLUSIONS: A skilled urologist can identify noninvasive, low-grade recurrent papillary bladder tumours on follow-up cystoscopy that do not require biopsy and that may be treated by outpatient fulguration alone.     

Treatment of the rupture of the distal tibiofibular syndesmosis with “Engelbrechts syndesmosis hook”

Summary After completing the osteosynthesis of the lateral malleolus, the hook is positioned 3–5 cm cranial of the syndesmosis and fixed to the tibia with a screw. It is expected to allow undisturbed ligament healing of the syndesmosis with early formation or fibres under limited motion. No immobilisation is necessary and no early removing of the implant. Results: Of 62 patients questioned, 53 were examined, after an average of 50 months (2–6 years p. o.). Using the Weber score, 51 had excellent or good results. Twelve patients reported discomfort while jumping, in five cases the ROM concerned dorsal extension, and in three cases plantar flection was reduced. Four patients showed distinct radiologic signs of osteoarthrosis, and two patients slight signs.      

Does the iliolumbar ligament prevent anterior displacement of the fifth lumbar vertebra with defects of the pars?

We studied 23 patients with spondylolysis of the fifth lumbar vertebra (L5) and 20 with spondylolytic spondylolisthesis at this level. All were more than 40 years of age. The transverse processes at L5 were significantly wider in the former group than in the latter. We also dissected 56 cadavers to study the morphological relationship between the transverse process of L5 and the iliolumbar ligament, and found that the wider transverse process is associated with increased width of the posterior band of the iliolumbar ligament. If a patient with pars defects has wide transverse processes at L5, the lumbosacral junction may be stabilised by wide posterior bands of the iliolumbar ligament and the fifth lumbar vertebra by the ligament, preventing anterior displacement.     

Low conjunction of the cystic duct with the common bile duct: does it correlate with the formation of common bile duct stones?

Background This study aimed to evaluate the accuracy of magnetic resonance cholangiography (MRC) in detecting variants of low cystic duct conjunction, which can be a source of confusion during surgery when unrecognized. Methods All cases with both MRC and endoscopic retrograde cholangiography (ERC) indicating suspected common bile duct stones between January 1999 and January 2004 were retrospectively reviewed by investigators blinded to the final diagnosis. Assessment with ERC was regarded as the gold standard. The aim was to find a low conjunction of the cystic duct with the bile duct. The sensitivity and specificity of MRC were calculated in comparison with those for ERC. The cystic junction radial orientation was defined as lateral (insertion diagonally from the right), medial (insertion into the left side of the common hepatic duct), or posteroanterior (overlap of the junction with the bile duct in the posteroanterior view). A spiral cystic duct and a long parallel course were evaluated separately. Results Low insertion of the cystic duct was found on ERC in 66 of 622 patients (11%; 28 men and 38 women; mean age, 64.5 years). The sensitivity and specificity of MRC for detecting low cystic entrance were 100% (90.4% on an intention-to-diagnose basis and 100%, respectively). In 11 patients (16.6%), the radial orientation of the cysticohepatic junction could not be defined with MRC. The rate of correct MRC delineation was 95% for lateral (n = 21), 77% for medial (n = 26), and 74% for posteroanterior (n = 19) insertion of the cystic duct. Conclusion The findings showed that MRC has good correlation with ERC with regard to the location and anatomic details of cystic duct insertion. Although this does not generate a separate indication for MRC before laparoscopic cholecystectomy, the anatomic information can be of additional use when MRC is clinically indicated in this setting.     

Osteosynthesis of distal radius fractures with the Micronail®

Introduction

The Micronail^® is a minimally invasive intramedullar titanium locking screw fixation for two-part dislocated extra-articular fractures and average displaced intra-articular fractures.

Patients and methods

In a retrospective study we analyzed the outcome of 20 distal radius fractures in 18 patients (17 female, mean age 78 years), which were treated by Micronail^®. Average follow-up time was 4 months. We describe the operative technique. All fractures were classified according to AO guidelines. We studied the radiologic and clinical outcome.

Results

According to the AO classification there were 12 A2, 3 A3, 1 B1, and 1 B3 fracture. Three patients had an antebrachii fracture. Mean American Society of Anesthesiologists (ASA) score was 2.4. Eight patients had associated lesions. Average operative time was 58 min. All fractures healed without major loss of alignment. There were two major complications: one patient developed a carpal tunnel syndrome and one device secondary dislocated. With the use of the Micronail^®, we found no infections or complications due to the insertion of the osteosynthesis materials. Patients experienced good to excellent results, on an analogue scale, in function of their wrist from the procedure. All patients had a good range of motion of the operated wrist; the difference between their two wrists was maximal 10° in all directions.

Conclusion

This intramedullary implant intends to minimize some of the disadvantages of other surgical options in the treatment of distal radius fracture; the Micronail^® causes less tissue damage and has early load-carrying capacity. This minimally invasive technique seems suitable in selected, two-part dislocated extra-articular and average displaced intra-articular, distal radius fractures.     

Insertion of the ProSeal™ laryngeal mask airway is more successful with the Flexi-Slip™ stylet than with the introducer

Purpose

The ProSeal? laryngeal mask airway (PLMA?) may be difficult to insert because of its large soft cuff, even when using a dedicated introducer tool. The purpose of this study was to investigate whether introduction of a stylet (Flexi-Slip?) in the drainage tube improved insertion characteristics compared with the standard introducer.

Methods

In this randomized controlled trial, 160 adults were allocated randomly to either the Introducer group (n = 80) or to the Flexi-Slip stylet group (n = 80). In the Introducer group, the PLMA was inserted with an introducer as described in the manufacturer’s instructions. In the Flexi-Slip stylet group, a Flexi-Slip stylet was inserted into the drainage tube of the PLMA and bent to form a near 90° angle at the junction of the cuff and the airway tube. The primary outcome measurement was the success rate at first attempt. Insertion time, visible blood staining, and complications were also noted.

Results

Success at first attempt was more frequent with the Flexi-Slip stylet than with the introducer (100% vs 86%, respectively; P = 0.001). Overall time (mean ± standard deviation) taken for successful placement was shorter with the Flexi-Slip stylet than with the introducer (19.9 ± 5.6 sec vs 28.4 ± 15.2 sec, respectively; P < 0.001). The incidences of blood staining and postoperative sore throat were lower in the Flexi-Slip stylet group than in the Introducer group (4% vs 15%, respectively; P = 0.015 and 8% vs 23%, respectively; P = 0.008).

Conclusion

Insertion of the PLMA with a Flexi-Slip stylet has a higher success rate at first attempt, requires less time, and results in fewer airway complications than the introducer technique.     

Introduction of the Microdroplet Technique with Incobotulinumtoxin A for the Treatment of Crow’s Feet

To investigate the efficacy and safety of the addition of the microdroplet technique to conventional injections for the treatment of crow’s feet with incobotulinumtoxin A, four women with moderate-to-severe crow’s feet at maximum expression received three standard intradermal injections of incobotulinumtoxin A on both sides of the face (4U [0.1mL] at each injection point) plus six microdroplet injections of incobotulinumtoxin A (0.5U [0.025mL] per point) into the lateral canthal area on the left side of the face and an equal quantity of saline at the same injection points on the right side of the face. Investigators and subjects independently evaluated the degree of rhytide improvement both at rest and maximum expression after 28 and 84 days. Investigator and subject ratings for wrinkle severity at maximum expression were improved to a greater degree on the side of the face treated with additional microdroplet incobotulinumtoxin A in all subjects, except one who was over 65 years old. All women preferred the results on the left side of their face. Treatment was well tolerated. The addition of the microdroplet technique to standard practice for injecting incobotulinumtoxin A is a promising procedure for the treatment of crow’s feet in women with moderate-to-severe wrinkles.The microdroplet technique for injection of botulinum neurotoxin has been developed to Thesupplement traditional injection procedures. It microdroplet technique for injection oftargets only the superficial muscle fibers where they insert into the dermis (Figure 1) with a series of small, highly diluted microdroplet injections. In this manner, a smooth transition between treated and nontreated areas is achieved for a more harmonious effect. The more precise placement of small amounts of neurotoxin into superficial fibers is also less likely to lead to diffusion of neurotoxin into untargeted muscle and unwanted side effects. The microdroplet technique may therefore allow areas of the face to be treated that are generally avoided with conventional injection techniques. Open in a separate windowFigure 1Histology slide demonstrating superficial facial muscle fibers inserting into the dermisIn a preliminary assessment of this technique, the authors present a case report of four subjects in whom the microdroplet technique in addition to standard injections was compared with a standard injection technique alone. Incobotulinumtoxin A (Xeomin®/Xeomeen®/Bocouture®/XEOMIN Cosmetic™; botulinum toxin type A free from complexing proteins [150 kDa]/NT 201, Merz Pharmaceuticals GmbH, Frankfurt, Germany) was chosen as the neurotoxin for injection because of its comparable efficacy to other botulinum toxins and reduced likelihood of neutralizing antibody development.1-4     

Can the manipulation of urinary pH by beverages assist with the prevention of stone recurrence?

The formation of various types of stones in the urinary tract is strongly influenced by urinary pH. An acidic urinary pH promotes the crystallization of uric acid and cystine, respectively. Moreover, changes in systemic acid–base homeostasis alter urinary excretion of citrate, an important inhibitor of calcium oxalate stone formation. The effect of beverages on urinary pH and citrate excretion is mainly determined by the presence of bicarbonate and citrate. The bicarbonate content of mineral water can replace alkalization therapy with potassium citrate and contribute to urine inhibitory power by increasing urinary pH and citrate excretion. Citrus juices are rich sources of citrate. Oral citrate is absorbed in the intestine and nearly completely metabolized to bicarbonate, providing an alkali load, which in turn increases urinary pH and citrate excretion. However, data from observational and interventional studies on the effect of different types of citrus juices on the risk of urinary stone formation are conflicting. In conclusion, favourable changes in urinary pH and citrate excretion can be attained by various beverages. However, the long-term efficacy of certain beverages for the recurrence prevention of different types of stones has yet to be determined.     

The prospective study of the relationship between perimesencephalic cistern of CT scanning and the outcome of the patients with acute craniocerebral injury

Objective: To explore prospectively the relationship between the state of perimesencephalic cistern and the degree of deformation of the midbrain on CT scanning and the outcome of the patients with acute craniocerebral injury.Methods: The CT scan features including the states of perimesencephalic cisterns, the deformations of the midbrain and the ratios of the occipitofrontal diameter and the transverse diameter of the midbrain of 132 cases were measured. The GOS of the patients 3 months after trauma were regarded as outcome.Results: The rate of unfavorable outcome ( dead, vegetative status, severe disability ) was significantly correlated with perimesencephalic cistern narrower than 1mm (P < 0.05), especially narrower than 0.5 mm (P < 0.005), deformed midbrain (P< 0.005) or abnormal ratio ( < 0.9 or > 1.1) of the occipitofrontal diameter and transverse diameter of the midbrain (P < 0.01). But the patient's perimesencephalic cistern wider than 1mm and the patients without deformed midbrain got favorable     

Effect of pretreatment with compound cyproterone acetate-metformin combination on the outcome of ovulation induction in the infertility women with polycystic ovarian syndrome

Objective: To observe the effects of compound cyproterone acetate (Daine-35) in combination with metformin on the endocrinologic, metabolic changes and the outcomes of ovulation induction in the infertility women with polycystic ovarian syndrome (PCOS). Methods: A prospective study recruited 65 PCOS patients and 30 non-PCOS infertility women. The body mass index (BMI), waist: hip ratio (WHR), Ferriman-Gallwey score, gonadotrophin, testosterone (T), fasting glucose, fasting insulin, triglyceride, total cholesterol, apoA, apoB and HDL-cholesterol were determined in all patients before the treatment and served as the baseline. At the end of 12-week therapy, these parameters were re-measured. 50 PCOS infertile patients as study group were treated with combination of Daine-35 with metformin for three months. Clomiphene citrate (CC) and human menopause gonadotrophin (hMG) were added for three cycles to induce ovulation. Other 15 PCOS cases as control group directly underwent ovulation induction with CC and hMG for three cycles. Results: The PCOS patients had higher levels of LH, T, E2, fasting insulin, FG/FI, total cholesterol and triglyceride, and lower levels of HDL-cholesterol when compared with the non-PCOS women (P<0.001-P<0.05). After treatment, the levels of LH, T, E2 were significantly decreased (58.9%, 38% and 30.1%, respectively) and the levels of apoB and HDL-C were significantly increased (17.2% and 20%, respectively) in the study group (P<0.001-P<0.05). FI and FG/FI showed a slight change in the study group, but no significant difference was found. The rates of ovulation and pregnancy were higher than those in control group (71% vs 60.5% and 38% vs 13.3%, respectively).Conclusions: Metformin in combination with compound cyproterone acetate (Daine-35) therapy may normalize the endocrine and metabolic abnormalities, and improve the ovarian response to ovulation induction drugs and increase the pregnancy rate of infertility patients with PCOS.     

Screening with ultrasound of the heel may contribute to the prevention in osteoporosis

<正> Objective:To calibrate a Quantitative Ultrasonography(QUS)system against densitometryby defining the sensitivity and specificity of the method,and to propose a series of QUS interpre-tation thresholds to classify the individual risk with regards to the risk of developing osteoporosisin later life.Methods:Subjects were recruited in New York City over a 1-year period.Women with amen-orrhea for at least 12 months were defined as postmenopausal,and all other women as premeno-pausal.Bone mineral density(BMD)was measured with a dual energy X-ray absorptiometer(DXA)and QUS performed with the calcaneus of broadband ultrasound attenuation(BUA)andspeed of sound(SOS)using the Lunar Achilles system.Statistical analysis was performed usingSPSS software Version 10.0.Results:Two hundred twenty-eight premenopausal and menopausal women were recruited.Most of the participants were Hispanic,Caucasian and African-American in this study.All thesubjects had DXA and QUS examined and T-score was got from both.The statistical resultsshowed that the T-score of QUS has a significant relationship with that of DXA(spine:r=0.557,P<0.0001;femur:r=0.611,P<0.0001).Both QUS and DXA T-score has a significant andnegative relationship with age(QUS:r=-0.241,P<0.0001;Spine:r=-0.277,P<0.0001;femur:-0.296,P<0.0001).When T-score of heel ultrasound -1.5 was set as the interpreta-tion threshold,the osteoporosis patients with T-score of DXA-femur scan(100%)and DXA-spine(77.10%)less than -2.5 were detected.As well,the specificities of T-score -1.5 ofQUS for DXA-femur and DXA-spine were 67.5% and 72.8%,respectively.In addition,if we set-1.0 of T-score of QUS as the cutoff,74.80% and 79.60% of the osteopenia based on DXA ofspine and femur were identified.The specificities were 59.4% and 57.7%.Conclusions:QUS of the calcaneus may be an effective method for providing risk stratifica-tion for osteoporosis,and for the closely associated future risk for fragility-fracture.