The impact of Creutzfeldt-Jakob disease on surgical practice

Creutzfeldt-Jakob disease (CJD) is characterised by abnormal prion protein that can replicate and replace nervous tissue, with rapid lethal neurodegenerative consequences. The transmissible nature of CJD has been known for half a century and transmission has occurred through neurosurgical procedures. Variant Creutzfeldt-Jakob disease (vCJD) emerged in 1996, and the presence of abnormal prion in lymphatic tissue extended the number of surgical specialties dealing with infected material; transmission through blood transfusion raised the possibilities of a large carrier pool and spread of epidemic proportion. The abnormal prion is difficult to remove and this could influence future decontamination programmes. Contaminated instruments must be withdrawn from surgical practice, and this can interfere with the efficient running of a surgical unit and optimal patient care. There is an urgent need for reliable methods for the detection of abnormal prion, within and outside the body. These will help to clarify the epidemiology of CJD, and to reduce its transmission via blood and tissue. They will also allow determination of the efficacy of new decontamination products in surgical practice, and the value of any treatment of sufferers and carriers of CJD. In the meantime, continued vigilance and informed regulation of all aspects of CJD must remain.     

Unusual juvenile ankle fracture: explanation and surgical repair

Juvenile ankle fractures are reasonably common, comprising approximately 11% of all epiphyseal injuries. They are more common in males and occur most frequently in the age distribution of 11 to 15 years. They characteristically fall into one of the Salter-Harris classification patterns; however, atypical cases do occur that present classification problems and treatment consideration questions. An illustrative case is presented with an explanation, to alert the clinician to these situations and provide a basis for care.     

Radiographic instability of the ankle joint after Evans' repair

Forty-two unstable ankle joints were treated surgically by Evans' operation. The clinical postoperative results were correlated with the objective radiological stress examinations. The mean age of the patients was 29 years (15-60 years). The clinical and radiological follow-up examinations were performed 6 months after the operation. In the stress X-ray examinations a modified stress frame was used. Clinical instability was noted in four patients. In the radiological examination one patient had a pathological finding in the talar tilt test and 18 patients in the anterior drawer sign test. The radiological instability correlated poorly with the subjective end results. Six patients were estimated to have a poor result of the operation. Five of these patients had a positive anterior drawer sign in the stress X-ray examination and one had degenerative changes in the ankle. Although Evans' repair is a simple and reliable method of reconstructing ruptures of the lateral ligaments of the ankle joint, it is associated with a relatively high frequency of positive anterior subluxation on radiological stress examination. This finding can be explained by the anatomical and geometrical factors on the lateral side of the ankle joint.     

Blood-induced cartilage damage alters the ankle joint load during walking

Ankle cartilage damage due to repeated joint bleeds often leads to altered gait in adult patients with hemophilia. It is therefore of clinical importance to develop an understanding of the biomechanical gait features in hemophilia patients with and without blood-induced cartilage damage and age-matched control subjects. We recruited a control group (n = 17), patients with hemophilia (PwH) without blood-induced ankle cartilage damage (PwH__NoCartDam, n = 5) and PwH with severe blood-induced ankle cartilage damage (PwH__CartDam, n = 19). We collected three-dimensional gait analysis data with following outcome variables in the ankle, Chopart and the first metatarsophalangeal (MTP 1) joints: range of motion (ROM) during stance phase, peak joint moment and powers. Biomechanical loading (BW) was quantified as the joint reaction forces using inverse dynamic analysis. Loading rate (BW/s) and impulse (BW*s) were calculated between 50% and 70% of stance phase. All biomechanical variables of the ankle joint were significantly lowered in the PwH__CartDam group compared with both the control subjects and the PwH__NoCartDam group. No compensatory biomechanical function was observed in other foot joints. An ankle loading rate of 2.64 ± 0.83 BW/s was observed in the control group, which was significantly higher than 1.75 ± 0.43 BW/s (P = .049) and 1.22 ± 0.59 BW/s (P < .001) in respectively the PwH__NoCartDam group and PwH__CartDam group. Patients with severe blood-induced cartilage damage demonstrated a (mal)adaptive gait strategy as they experience difficulties to properly unload the ankle cartilage during walking.     

Results of the surgical treatment of ankle joint fractures

Surgical treatment was applied to 74 cases of ankle joint fractures at the author's hospital, between 1979 and 1984. Follow-up checks were made on 59 patients, within one to seven years from surgery. Luxation fractures accounted for 39 per cent. The rates of wound edge necrosis and bone infection were three per cent each. Results were evaluated by stringent and precisely defined criteria. The worst findings, according to expectation, were recorded from the cases of luxation fractures. Sixty-four per cent of all results were rated good to very good, and 17 per cent were rated poor. The patients' individual assessment was much better, since only three per cent felt that results were inadequate.     

The impact of low health literacy on surgical practice

BACKGROUND: We sought to determine the prevalence of low health literacy (LHL) among patients in a preoperative clinic, the characteristics associated with LHL, and the association between LHL and adherence to preoperative instructions. METHODS: We conducted a cohort study and interviewed patients at a VA preoperative clinic. We administered a health literacy test and collected sociodemographic information. When patients returned for their scheduled surgical procedures, adherence to preoperative instructions was assessed. RESULTS: Of 332 participants, 12% (n = 40) had LHL. Low health literacy was more prevalent among older adults (more than 65 years) compared with those under age 65. Patients with LHL were more likely to be nonadherent to preoperative medication instructions (odds ratio = 1.9; 95% confidence interval: 0.8 to 4.8), but this was of borderline statistical significance. CONCLUSIONS: Low health literacy was common among older patients and appeared to be associated with lower adherence to preoperative medication instructions.     

膝关节软骨缺损的修复方法与策略

关节软骨缺损十分常见,是导致关节退变的重要因素之一.由于缺乏血供,自身再生能力有限,因此,临床尝试多种方法来修复这些缺损.具体采用何种方法,应根据软骨缺损的病理类型来制定最优策略.     

膝关节牵伸术修复膝关节软骨的研究进展

膝关节牵伸术是近年来治疗膝骨关节炎的新技术,它能减轻膝关节疼痛和改善膝关节功能,这与其修复软骨的作用密不可分。膝关节牵伸术修复软骨的作用机制和影响因素作为当前研究的热点,本文通过回顾文献发现,膝关节牵伸术能减轻膝关节负荷为软骨修复提供适宜的力学环境,引起的膝关节流体静水压波动不仅能帮助软骨吸收营养,还能促进软骨形成基因和抑制软骨基质降解酶基因表达。此外,膝关节牵伸术为滑液间充质干细胞募集到软骨损伤处创造了条件,并提升了滑液间充质干细胞增殖、分化为成软骨谱系的能力。膝关节牵伸术还能通过减少膝关节内部炎性因子含量和抑制炎性基因表达,减轻膝关节炎症反应和软骨损伤。目前已知的影响膝关节牵伸术修复软骨的因素包括适当增加膝关节负重活动、牵伸高度和牵伸时间有助于软骨修复,男性患者、膝关节炎严重程度更高的患者膝关节牵伸术后软骨修复效果更好。而膝关节牵伸术后第1年软骨修复疗效越好,预示着膝关节牵伸术保留膝关节的远期生存率越高。但目前对上述热点的研究只停留在初期阶段,仍需进行更深入的探索,才能对膝关节牵伸术的临床应用起到更好的指导。     

治疗关节软骨缺损手术方法的比较

目的对比研究骨膜移植术,软骨细胞移植术和骨软骨钻孔术对关节软骨损伤的修复。方法 纯种青紫蓝兔４４只,随机分为Ａ、Ｂ、Ｃ、Ｄ４组,在膝关节作全层软骨缺损模型,Ａ、Ｂ、Ｃ组分别选择行上述一种操作,Ｄ组不作处理。术后４、８、１２周取材作大体,光镜和电镜观察。结果 各组缺损均有不同程度修复,但修复优势组织性质有所差别。结论 自体游离骨膜移植术的钻孔术修复关节节软骨缺损效果明显优于未处理组,其中以钻孔术为简     

The surgical treatment of postburn deformities of the foot and ankle joint]

The results of surgical treatment of 82 patients with postburn deformity of a foot and an ankle joint are presented. For elimination of the deformity and contracture, the tightening scars were excised, autodermoplasty of a defect was used, in severe contracture of the ankle joint, the Ilizarov's apparatus was applied, trophic ulcers of a stump of the foot were closed by means of a migrating Filatov's graft. In 80.5% of the patients, a contracture was eliminated, the weight-bearing function of a foot improved.     

The impact of intra-operative transoesophageal echocardiography on cardiac surgical practice

The use of transoesophageal echocardiography during cardiac surgery has increased dramatically and it is now widely accepted as a routine monitoring and diagnostic tool. A prospective study was carried out between September 2004 and September 2007, and included all patients in whom intra-operative echocardiography was performed, 2 473 (44%) out of a total of 5 591 cases. Changes to surgery were subdivided into predictable (where echocardiographic examination was planned specifically to guide surgery) and unpredictable (new pathology not diagnosed pre-operatively). A change in the planned surgical procedure was documented in 312 (15%) cases. In 216 (69%) patients the changes were predictable and in 96 (31%) they were unpredictable. The number of predictable changes increased between 2004–5 and 2006–7 (8% vs 13%, p = 0.025). In these cases, intra-operative echocardiography was specifically requested by the surgeon to help determine the operative intervention. This has implications for consent and operative risk, which have yet to be fully determined.