Treatment of stiff-knee gait in cerebral palsy: a comparison by gait analysis of distal rectus femoris transfer versus proximal rectus release

Two groups of patients with cerebral palsy (CP) were studied pre- and postoperatively by gait analysis after proximal release or distal transfer of the rectus femoris for treatment of knee stiffness in swing phase. In the first group studied, 12 patients underwent proximal rectus femoris muscle release. In the second group, 10 patients underwent distal rectus femoris transfer. After surgery, peak knee flexion was increased 9.1 degrees in swing phase by proximal rectus release and 16.2 degrees by distal rectus transfer. Hip motion throughout the gait cycle was not significantly affected by either operation, and no tendency for a crouch gait was observed after either procedure.     

Comparison of rectus femoris transposition with traditional transfer for treatment of stiff knee gait in patients with cerebral palsy

Purpose To assess the outcome of children with cerebral palsy following reposition of the distal rectus femoris tendon for treatment of stiff knee gait. Methods Children with cerebral palsy with stiff knee gait who underwent rectus femoris transfer were studied retrospectively. Inclusion criteria were cerebral palsy of diplegic or quadriplegic type, preoperative and 1 year postoperative three-dimensional motion analysis, and no other surgery except rectus femoris transfer at the time of study. The patients were separated into two groups: in group I, the rectus femoris was transferred to the distal medial hamstring tendons, either the gracilis or the semitendinosus; in group II, the distal tendon of the rectus femoris was transposed laterally and attached to the iliotibial band/intermuscular septum. Results Peak knee flexion during swing phase, total dynamic knee range of motion, knee range of motion during swing phase, and time to peak knee flexion during swing phase were all improved in both groups. Hip and pelvic kinematics were not influenced by the surgery. Velocity, stride length, and cadence were all improved following the surgery. There was no difference between the transfer group and the transposition group. Conclusion These findings suggest that distal transfer of the rectus femoris is effective in improving swing phase knee function by diminishing the mechanical effect of the dysphasic swing phase activity of the rectus femoris, not by converting the rectus femoris to an active knee flexor. No financial support was received for this study.     

Psychological Profile and Outcome in Patients Undergoing Gastroplasty for Morbid Obesity

Eighteen out of 22 consecutive patients undergoing vertical banded gastroplasty were reviewed with regard to preoperative psychological assessment and postoperative outcome. Each patient was initially evaluated by a consultant liaison psychiatrist with regard to previous or ongoing psychological disturbance, and suitability for bariatric surgery. Patients could be grouped into three broad categories: Group A (seven patients) those with no psychiatric abnormality; Group B (six patients) those with minor psychiatric disorders such as sociopathic teenage behaviour, outpatient treatment for depression; and Group C (five patients) those with a history of major psychiatric disturbance such as depressive psychosis and drug dependency. Psychiatric morbidity had no adverse effect in terms of postoperative outcome or weight loss. Mean weight loss of 26%, 30% and 33% was recorded in groups A, B and C respectively after a mean follow-up period of 33 months following gastroplasty. The occurrence of postoperative psychiatric problems correlated closely with preoperative psychological assessment, with none of seven patients in group A but four of the five patients in group C requiring psychiatric management. Our findings indicate that psychiatric illness is not associated with poor outcome following surgery for morbid obesity and such patients should not be excluded if psychiatric support is available before and after surgery.     

Proximal rectus femoris release surgery is not effective in normalizing hip and pelvic variables during gait in children with cerebral palsy

The purpose of this study was to determine the efficacy of the proximal rectus femoris release to treat hip flexor contractures and hip and pelvic gait deviations in children with spastic cerebral palsy. This study was a retrospective repeated-measures analysis of data collected on two matched groups of patients, those with and without proximal rectus femoris release surgery, seen in our Motion Analysis Laboratory. Proximal rectus release surgery did not improve hip extension, did not decrease anterior pelvic tilt, and did not improve temporal-distance measures of gait in children with cerebral palsy. A multivariate measure, the Hip Flexor Index, was also unchanged. The group of patients without any hip flexor surgery was not different from the rectus femoris release group on hip or pelvic variables before or after surgery. The findings of this study offer no evidence that the proximal rectus femoris release is successful in achieving desired gait outcomes at the hip and pelvis in children with cerebral palsy.     

酗酒老年患者全麻术后早期认知功能的改变

目的通过临床对照试验,评价酗酒老年患者下腹部或四肢手术全麻术后早期认知功能的改变。方法选择择期行下腹部或四肢手术的患者60例,均为男性,年龄65~80岁,ASAⅠ或Ⅱ级,符合酗酒史条件的患者30例,作为酗酒组(A组);根据病种、术式选择匹配的无酗酒史患者30例,作为对照组(C组),所有患者均接受全凭静脉麻醉。记录患者术前、术中一般情况及术后7d内主要并发症的发生情况,采用简易精神状态量表(MMSE)测定两组患者术前1d、术后1、7d的认知功能。结果两组麻醉时间、拔管时间、主要麻醉药用量、血管活性药用量、术中出血量等差异均无统计学意义。与术前1d比较,术后1、7d两组MMSE评分均明显降低(P0.05);与术后1d比较,术后7dA组MMSE评分明显升高(P0.05);术后1、7dA组MMSE评分明显低于C组(P0.05)。术后1、7dA组POCD发生率明显高于C组(P0.05)。术后7d内A组主要并发症的发生率均高于C组,但差异无统计学意义。结论酗酒可增加老年患者全麻术后早期认知功能障碍的发生率。     

The effect of quadriceps excision on functional results after distal femoral resection and prosthetic replacement of bone tumors

Although resection and reconstruction with a prosthesis is an accepted form of treatment for tumors of the distal femur, minimal effort has been made to correlate the functional result with the degree of adjacent muscle excision. From 1983 to 1986, 65 patients had distal femoral resection and prosthetic reconstruction. Ten patients had only the vastus intermedius excised (Group A), 30 patients had excision of the vastus intermedius plus either the vastus medialis or lateralis (Group B), nine patients had only the rectus femoris spared (Group C), and 16 patients had the entire quadriceps excised or conversion of the previous arthrodesis (Group D). Based on the rating system of the Musculoskeletal Tumor Society, satisfactory results were obtained in 70% of Group A patients (30% excellent and 40% good), with no poor results. In group B, 80% had good or excellent results and 7% poor results. In Group C, 78% of the patients had good results but no excellent results, whereas Group D had only 50% satisfactory results. The parameters that most often led to functional impairment were restricted motion and inadequate extensor powers. Muscle transfers, however, (flexors to extensors) were effective only in Group C patients. With proper technique and prosthetic design, satisfactory results can be achieved after distal femoral resection and prosthetic reconstruction, even after extensive quadriceps excision.     

Cerebral hemodynamic parameters for patients with neurological improvements after extracranial-intracranial arterial bypass surgery: evaluation using positron emission tomography

OBJECTIVE: The purpose of this study was to clarify the hemodynamic features of patients who experienced improved neurological function after extracranial-intracranial arterial bypass surgery. With this aim, we retrospectively analyzed the results of their pre- and postoperative positron emission tomographic studies. METHODS: This study included 16 patients who exhibited stable neurological dysfunction just before extracranial-intracranial bypass surgery. All underwent pre- and postoperative positron emission tomographic studies. They were divided into groups, i.e., patients who did (Group 1, n = 6) or did not (Group 2, n = 10) manifest postoperative improvements in neurological functions. Positron emission tomographic parameters obtained in the middle cerebral artery territories were compared between the two groups. RESULTS: Comparison of the preoperative hemodynamic values on the affected side and the contralateral side demonstrated that the mean regional cerebral blood flow values were significantly lower on the affected side in both groups (Group 1, P < 0.005; Group 2, P < 0.05). For Group 1 patients, the mean regional oxygen extraction fraction (rOEF) and regional cerebral blood volume values were significantly higher on the affected side than on the contralateral side (P < 0.01 and P < 0.05, respectively). For Group 2 patients, the mean regional cerebral metabolic rate of oxygen (rCMRO2) value was significantly lower on the affected side than on the contralateral side (P < 0.05). The mean rOEF and rCMRO2 values on the affected side were significantly higher for Group 1 patients, compared with Group 2 patients, before surgery (P < 0.05 and P < 0.05, respectively). The preoperative regional cerebral blood flow and regional cerebral blood volume values on the affected side were similar for the two groups. Postoperative changes in mean regional cerebral blood flow and mean rOEF on the affected side were statistically significant for both groups. The mean rCMRO2 on the affected side for Group 2 was significantly lower than that for Group 1, even after bypass surgery (P < 0.05). CONCLUSION: Bypass surgery may improve neurological function for patients with significantly elevated rOEF values and rCMRO2 values near the normal level. These hemodynamic parameters may be useful for the identification of candidates for extracranial-intracranial bypass surgery.     

Effects of altered portal hemodynamics after distal splenorenal shunts

Patients with cirrhosis who had undergone the distal splenorenal shunt were grouped based on preoperative to early postoperative changes in hepatic portal perfusion and corrected sinusoidal pressure. Early and late postoperative morbidity and mortality rates were determined for each hemodynamic group. Morbidity was least when both hepatic portal perfusion and sinusoidal pressure were maintained near preoperative levels (Group 1). Survival for this group was significantly better than for patients who lost portal flow to the liver during the early postoperative interval (Group 4). Patients with absent hepatic portal perfusion had the worst survival and greatest morbidity. Intermediate results were achieved for the two groups of patients that had postoperative preservation of portal perfusion but significant preoperative to postoperative alterations in sinusoidal pressure. Although survival curves for these two groups were not significantly different from Group 1, morbidity was greater, especially for patients with an increase in sinusoidal pressure (Group 2).     

The efficacy of blood culture in postoperative patients

Blood cultures are often obtained in postoperative patients to rule out bloodstream infections. Our study objectives were to determine the efficacy of blood cultures in postoperative patients with suspected sepsis and to determine variables predisposing patients to positive cultures. This was a retrospective study including patients with blood cultures drawn from January to March 2009 at our institution. We recorded demographics, presence of fever (temperature 101.5 degrees F or higher), elevated white blood cell count (12,000/microL or greater), central line, diabetes, intensive care unit admission, postoperative day of blood draw, National Research Council surgical wound classification, and pre- or postoperative antibiotics. Blood cultures were drawn from 150 patients undergoing surgery within 30 days prior. Sixteen had positive cultures and nine were true-positives (6.3%). There was no statistical difference (P > 0.05) between patients with positive and negative cultures except that those with negative cultures were more likely to have received preoperative antibiotics (P = 0.0186). Blood cultures are invasive, expensive tests with low yield. We recommend that blood cultures be drawn in patients not receiving preoperative antibiotics who have undergone surgery more than 4 days before culture.     

术前,术后放疗的直肠癌治疗中作用的评估和比较

目的：评估和比较辅助性术前、术后放疗在直肠癌治疗中的作用。方法：１９８８年２月～１９９５年２月收治经病理证实的直肠癌１７６例,配合手术分别采用术前单次放疗、术前常规放疗和术后放疗。术前单次放疗组３８例,剂量为５Ｇｙ,并于放疗后４８ｈ内手术;术前４０Ｇｙ常规放疗组４３例,多为临床晚期（Ｔ３～４占６０．５％）,中位剂量４０Ｇｙ,放疗后休４周再行手术;术后放疗组９５例,以病变晚期和淋巴结阳性为主（Ｔ３～４占６２．１％,Ｔ２～４Ｎ＋占８１．１％）,采用中位剂量５４Ｇｙ常规分割,疗程约６周,手术后３～４周开始接受放疗。结果：全部病例平均随访８４个月,Ｋａｐｌａｎ－Ｍｅｉｅｒ法计算生存率。术前单次放疗组３年、５年局部复发率分别为７８．９％和５０．０％,常规术前４０Ｇｙ放疗组为６７．４％和５１．１％;术后放疗组为５８．９％和     

Pre- or postoperative radiotherapy in rectal and rectosigmoid carcinoma. Report from a randomized multicenter trial.

Between October 1980 and December 1985, 471 patients with a resectable rectal carcinoma entered a randomized multicenter trial for comparison of pre- and postoperative irradiation. Two hundred thirty-six patients were allocated to receive high-dose fractionated preoperative irradiation (total dosage, 25.5 Gy in five to seven days) and 235 patients to receive postoperative irradiation to a very high dosage level with conventional fractionation (60 Gy in a total 8 weeks). The postoperative treatment was delivered only to a high-risk group of patients (Astler-Coller stages B2, C1, and C2). The preoperative irradiation was well tolerated, with no immediate irradiation-related complications and no increased postoperative mortality (3%, 7 of 217 patients, compared to 5%, 10 of 215 patients in the postoperatively irradiated group). More patients in the preoperative irradiation group had perineal wound sepsis after abdominoperineal resection and this prolonged the stay in hospital after surgery. In 50% of the patients the postoperative treatment could not be commenced until more than 6 weeks after surgery. The postoperative treatment was not as well tolerated as the preoperative one. The local recurrence rate was statistically significantly lower after preoperative than after postoperative radiotherapy (12% versus 21%; p = 0.02). In both groups more patients developed a local recurrence if the bowel was perforated at surgery or if the resection line was microscopically close to the tumor. To date, with a minimum follow-up of 3 years and a mean follow-up of 6 years, there is no difference in survival rates between the two groups.     

帕洛诺司琼在加速康复外科中的作用

目的探讨帕洛诺司琼在加速康复外科中的作用,为临床患者的围手术期康复提供更优质的服务。 方法采用前瞻性、随机的研究方法,选择2015年9月至2016年2月拟行结直肠腹腔镜手术者120例,随机分为3组,各40例,各组术后行同配方的静脉镇痛。A组手术结束前1 h静推托烷司琼6 mg;B组手术结束前1 h静推帕洛诺司琼0.25 mg;C组手术结束前1 h静推帕洛诺司琼0.25 mg,静脉镇痛泵中静脉泵注帕洛诺司琼0.25 mg/72 h。记录并比较各组患者术后恶心、呕吐（PONV）等并发症发生率以及下床天数、出院时间。 结果B组和A组术后恶心、呕吐发生率差异无统计学意义,C组较之A组、B组在术后24 h后PONV发生率差异有统计学意义（χ²=5.165、5.165,P=0.023、0.023）;C组、B组较之A组术后镇痛24 h内除PONV外其余并发症发生率差异无统计学意义,24 h后除PONV外其余并发症发生率差异有统计学意义（χ²=4.500、6.275,P=0.033、0.012）;C组较之A组、B组术后下床天数（t=3.718、2.975,P<0.001、0.004）、出院时间（t=6.650、5.440,均P<0.001）差异有统计学意义。 结论帕洛诺司琼持续用药效果更稳定,可降低术后恶心、呕吐发生率,加速患者术后康复。     

Parenteral nutrition in carcinoma of the oesophagus treated by surgery: nitrogen balance and clinical studies.

Nitrogen balance studies and clinical observations were made on two groups of patients suffering from obstructive carcinoma of the oesophagus. In 10 patients (group A) parenteral nutrition with a high calorie and nitrogen content was given pre- and early postoperatively. Five patients (group B) received intravenous dextrose/saline solution pre- and postoperatively with no nitrogen supply. Patients in group A had a positive nitrogen balance before and after operation and had a satisfactory postoperative progress. The patients in group B had a negative nitrogen balance until the resumption of oral feeding and their postoperative progress was not as satisfactory as that of patients in group A.     

Heparin reversal in off-pump coronary artery bypass surgery: complete,partial, or no reversal?

Several clinical studies have reported that avoiding cardiopulmonary bypass reduces postoperative bleeding. The purpose of this study is to verify that protamine during off-pump coronary artery bypass surgery produces significant reduction of postoperative bleeding.Sixty consecutive patients undergoing off-pump coronary artery bypass surgery were prospectively randomized in three groups: Group A received 1 mg of protamine every 100 IU of heparin, Group B 0.5 mg of protamine every 100 IU of heparin, and Group C none. The three groups were analyzed for differences in preoperative cardiac function, pre-, intra-, and postoperative coagulation profile, intraoperative variables, and postoperative bleeding.In the three study groups, no statistically significant difference was found in preoperative cardiac function, pre- and intraoperative coagulation profile, and prothrombin time, activated partial thromboplastin time, platelet count in the first postoperative day. In Group A, total postoperative bleeding, use of packed red blood cells, and mild pericardial effusion prevalence at discharge were significantly lower only when compared to Group C, but they were not significantly different when compared to Group B.In off-pump coronary artery bypass surgery, heparin should be reverted with protamine, otherwise the postoperative bleeding risk might increase. Partial heparin reversal might not increase postoperative bleeding risk, but it may reduce dose-dependent protamine adverse effects.     

Nocturnal hypoxaemia and respiratory function after endovascular and conventional abdominal aortic aneurysm repair

Respiratory function, assessed by pre- and postoperative spirometry, and overnight pulse oximetry recordings, was compared prospectively in patients undergoing infrarenal abdominal aortic aneurysm repair by endovascular or conventional surgery. Episodic hypoxaemia was common in both groups before operation and up to the fifth night after operation. The frequency and severity of hypoxaemia were greater in the conventional group (P < 0.05). FEV1 and FVC decreased significantly on the third and fifth days after operation in both groups (P < 0.05); decreases in FVC were greater in patients undergoing conventional surgery. On the fifth day after operation, FVC had recovered to 86% and 64% of preoperative values in the endovascular and conventional groups, respectively (P < 0.05). Duration of surgery was greater (P < 0.05) and duration of postoperative artificial ventilation significantly less (P < 0.05) after endovascular repair. Postoperative PCA morphine consumption and duration of use were significantly greater (P < 0.05) in patients undergoing conventional abdominal aortic aneurysm surgery.      

Effects of surgical lengthening of the hamstrings without a concomitant distal rectus femoris transfer in ambulant patients with cerebral palsy

Eighteen ambulant patients (32 legs) who had undergone fractional lengthening of the medial and lateral hamstrings without rectus femoris transfer underwent pre- and postoperative gait analysis. A significant increase in the amount of knee extension and a decrease in the amount of peak knee flexion in swing were observed. This decrease in knee flexion signified a change towards more normal speed-related values. Dorsiflexion at initial contact decreased significantly for patients who did not undergo a gastrocnemius lengthening (n = 24). Absolute cadence was significantly lower after surgery, but the change in dimensionless cadence was not significantly different. This difference in the outcome between dimensionless and absolute stride parameters can be attributed to the increase in body height after surgery. The clinical significance of these findings is that it is important to recognize that postoperative effects of surgery on gait in children may, in part, be explained by changes in height and not surgery alone.     

Perioperative red blood cell salvage in spine surgery. A prospective analysis.

Reinfusion of perioperative blood loss was studied in 150 spinal surgery patients to evaluate its efficacy in reducing transfusion requirements. Three groups of 50 consecutive patients were observed. Group A had no blood salvage and served as a control group, Group B used Cell Saver for intraoperative blood salvage, and Group C used Cell Saver intraoperatively and Solcotrans postoperatively for salvage of postoperative drainage. The three groups had similar demographics, preoperative hematocrits (HCT), operative blood loss, and postoperative drainage. Serial HCTs through the fifth postoperative day showed no significant difference between groups. Total transfusion requirements of homologous and prebanked autologous blood were reduced 35% in Group B and 68% in Group C when compared to control group A. These differences are statistically significant. The combination of intraoperative and postoperative blood salvage was highly effective in reducing the need for transfused blood.     

Significance of the Preoperative Intravesical Instillation of Doxorubicin and the Oral Administration of 5-Fluorouracil in Preventing Recurrence After a Transurethral Resection of Superficial Bladder Cancer

Background : The postoperative intravesical instillation of doxorubicin (ADM) has a preventative effect on recurrence after a transurethral resection (TUR) of superficial bladder cancer. However, the significance of preoperative ADM instillation remains unclear. Although the oral administration of 5-fluorouracil (5-FU) has been observed to show some clinical response against bladder cancer, its preventative effect on the recurrence of superficial bladder cancer after TUR is unknown. Methods: Patients were randomized into 4 groups. All 4 groups received postoperative ADM instillation. In addition, patients in groups C and D received preoperative ADM instillation, whereas patients in groups B and D additionally received oral 5-FU postoperatively. The nonrecurrence rate and side effects were both compared among the 4 groups.
Results : Of the 282 patients registered, 200 were evaluable, with a median follow-up period of 21.4 months. There were no significant differences in the characteristics of the patients among the 4 groups. Group C (pre- and postoperative ADM) showed a significantly longer disease-free interval than group A (postoperative ADM alone). However, there was no significant difference in the disease-free interval between groups A and B (postoperative ADM plus 5-FU), or between groups C and D (pre- and postoperative ADM plus 5-FU). Bladder irritation symptoms were the most frequently noted side effect encountered in all groups, but the severity was generally mild.
Conclusions : Preoperative ADM instillation was found to prevent recurrence to a greater extent than the usual postoperative instillation alone, whereas oral 5-FU was found to have no additional beneficial effect on the disease-free interval in patients with superficial bladder cancer.     

低潮气量联合不同阶段呼气末正压通气对老年患者开腹术后肺功能的影响

目的观察术中低潮气量联合不同阶段呼气末正压通气(positive end expiratory pressure,PEEP)对老年患者开腹术后肺功能及并发症的影响。方法选择择期全麻下行开腹手术的老年患者60例,男21例,女39例,年龄≥65岁,ASAⅠ或Ⅱ级,随机分为三组,每组20例。A组手术开始后1h联合PEEP 10cm H_2O持续1h,B组术毕拔除气管导管前1h联合PEEP 10cm H_2O持续1h,C组手术全程联合PEEP 10cm H_2O。分别于术前、术后1、24h行血气分析测PaCO_2、PaO_2和A-aDO_2,计算氧合指数。记录术前、术后24、72h的气道分泌物评分。结果与术前比较,术后1h三组PaCO_2明显升高,B组PaO_2明显下降,A组A-aDO_2明显升高(P0.05);术后24hB组、C组PaCO_2明显升高,B组氧合指数明显下降(P0.05)。与术后1h比较,术后24hA组PaCO_2明显下降,A组A-aDO_2明显下降(P0.05)。术后三组气道分泌物评分差异无统计学意义。结论术中低潮气量联合不同阶段PEEP能够改善术后肺的氧合功能,但对术后肺部并发症无明显影响。