Minimally invasive plate osteosynthesis for metastatic pathologic humeral fractures

Because patients with metastatic bone disease may survive only 3 to 12 months, the goal of surgery for pathologic fractures is to attain rigid and durable internal fixation and immediate postoperative use of the upper extremity. Surgical options such as intramedullary nailing, plating, and insertion of prosthesis usually reinforced with bone cement have been proposed for pathological humeral fractures. We describe a 42-year-old man with a pathologic distal humeral fracture. The fracture location and lack of distal bone stock precluded the use of intramedullary nails. We performed minimally invasive plating by using a locking plate for bridging and stabilization of fracture. Minimally invasive plate osteosynthesis of the humeral shaft was developed to allow anterior plate and screw stabilization involving less soft tissue disruption and to theoretically improve healing rates and reduce complications, such as infection and iatrogenic radial nerve palsy. Plain radiographs showed stable consolidation of the fracture without screw loosening at the 7-month follow-up. Elbow range of motion was 120°, and the arm was stable without pain. Minimally invasive plate using a locking plate can provide stable fixation and allow early arm mobilization without protection and decrease the risk of operation-related complications, making it a useful surgical alternative in the treatment of pathologic humeral fractures.     

Status of hypertension and coronary stenosis in asymptomatic type 2 diabetic patients: Analysis from Coronary Computed Tomographic Angiography Registry

Background

Limited data exist regarding the prevalence of coronary artery disease (CAD) as well as clinical outcomes in asymptomatic diabetic patients with normotension, controlled hypertension, and uncontrolled hypertension.

Methods

We enrolled 935 consecutive asymptomatic type 2 diabetic patients without known CAD. Coronary computed tomography angiography was used to evaluate the prevalence and severity of CAD. Blood pressure was measured at baseline. Patients were assigned to one of the three groups: normotension (n = 314), controlled hypertension (systolic blood pressure (SBP) < 140 mmHg with treatment, n = 458), or uncontrolled hypertension (SBP ≥ 140 mmHg with or without treatment, n = 163).

Results

Obstructive CAD (≥ 50% stenosis) increased from the prevalence in normotensive patients (33%) to that in patients with controlled (40%) or uncontrolled hypertension (52%) (p = 0.003). The incidence of obstructive CAD in multivessel or left main CAD also increased across the three groups (13%, 21%, 32%, respectively, p < 0.001). A multivariate logistic regression analysis showed that uncontrolled hypertension was an independent predictor of obstructive CAD (adjusted odds ratio, 2.13; 95% confidence interval (CI), 1.42 to 3.21, p < 0.001). During a median follow-up of 3.1 years, uncontrolled hypertension was associated with increased risk of cardiac death or myocardial infarction compared to the risk in normotensive patients (hazard ratio, 6.11; 95% CI, 1.65 to 22.6, p = 0.007).

Conclusion

In asymptomatic type 2 diabetic patients, uncontrolled hypertension was associated with increased risk of CAD and poor clinical outcomes.     

Mid-Term Follow Up Results of Subtalar Distraction Arthrodesis Using a Double Bone-Block for Calcaneal Malunion

Purpose

This study was designed to evaluate the mid-term results and efficacy of subtalar distraction double bone-block arthrodesis for calcaneal malunion.

Materials and Methods

From January 2004 to June 2007, we operated on 6 patients (10 cases). There were 5 males (9 cases) and 1 female (1 case), four of which presented with bilateral calcaneal malunion. Seven cases were operated on initially. The period between initial injury and arthrodesis was 23 months, and the average follow up period was 58 months. In operation, we applied an extensile lateral approach and arthrodesis was performed through a tricortical double bone-block and cannulated screws. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale was used for clinical evaluation. In radiologic analysis, plain X-ray and CT were examined to assess union and various parameters.

Results

The mean age of the patients was 41 years. All cases achieved radiologic union at the final follow-up. The mean AOFAS Ankle-Hindfoot scale (maximum of 94 points) increased from 43.3 points preoperatively to 85.4 points at the final follow-up. The radiologic analysis of the pre- and postoperative standing lateral radiographs showed improvements of 5.6 mm in talo-calcaneal height, 1.8° in talocalcaneal angle, 5.1° in talar declination angle and 5.3° in talo-first metatarsal angle.

Conclusion

Subtalar distraction two bone-block arthrodesis provides overall good results not only in the short term but also the mid-term with significant improvement in clinical and radiologic outcomes. This procedure warrants consideration for managing calcaneal malunion with loss of height and subtalar arthritis.     

A randomised controlled trial comparing two insertion techniques for the Laryngeal Mask Airway Flexible™ in patients undergoing dental surgery

The Laryngeal Mask Airway Flexible^TM (LMA Flexible) has been widely utilised for dental, ophthalmology and otorhinolaryngology‐related procedures. Our study evaluates two different techniques of inserting the LMA Flexible for patients undergoing day‐case dental surgery. One hundred and eight patients were randomly assigned into two groups based on the LMA Flexible insertion technique – either laryngoscopy‐guided (n = 54) or digital manipulation (standard technique; n = 54). Patient and airway characteristics were recorded before induction of anaesthesia. The primary outcome was success rate at first insertion. Other outcomes assessed included fibreoptic assessment of laryngeal mask airway placement, haemodynamic changes, need for airway adjustment during surgery and sore throat. The success rate of insertion on the first attempt was higher for the laryngoscopy‐assisted technique compared with the standard technique (96.3% vs 81.5%, respectively, p < 0.05). Fibreoptic assessment showed that the former group had better placement of the laryngeal mask airway than the latter (59.3% vs 37% p < 0.05). There were no significant differences between the two groups for haemodynamic changes. Sore throat was more common in the group with the standard technique (35.2% vs 16.7%, p < 0.05). Our study suggests the use of the laryngoscope to guide insertion of the LMA Flexible for dental surgery is a better option compared with the standard technique of digital manipulation.     

Maximum principal strain correlates with spinal cord tissue damage in contusion and dislocation injuries in the rat cervical spine

The heterogeneity of the primary mechanical mechanism of spinal cord injury (SCI) is not currently used to tailor treatment strategies because the effects of these distinct patterns of acute mechanical damage on long-term neuropathology have not been fully investigated. A computational model of SCI enables the dynamic analysis of mechanical forces and deformations within the spinal cord tissue that would otherwise not be visible from histological tissue sections. We created a dynamic, three-dimensional finite element (FE) model of the rat cervical spine and simulated contusion and dislocation SCI mechanisms. We investigated the relationship between maximum principal strain and tissue damage, and compared primary injury patterns between mechanisms. The model incorporated the spinal cord white and gray matter, the dura mater, cerebrospinal fluid, spinal ligaments, intervertebral discs, a rigid indenter and vertebrae, and failure criteria for ligaments and vertebral endplates. High-speed (～ 1 m/sec) contusion and dislocation injuries were simulated between vertebral levels C3 and C6 to match previous animal experiments, and average peak maximum principal strains were calculated for several regions at the injury epicenter and at 1-mm intervals from +5 mm rostral to -5 mm caudal to the lesion. Average peak principal strains were compared to tissue damage measured previously in the same regions via axonal permeability to 10-kD fluorescein-dextran. Linear regression of tissue damage against peak maximum principal strain for pooled data within all white matter regions yielded similar and significant (p<0.0001) correlations for both contusion (R(2)=0.86) and dislocation (R(2)=0.52). The model enhances our understanding of the differences in injury patterns between SCI mechanisms, and provides further evidence for the link between principal strain and tissue damage.     

Pilot Testing of a Population-based Surgical Survey Tool in Sierra Leone

Background  

The prevalence of surgical diseases in low income countries is thought to be very large, but to date no population-based survey has documented the need. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) is a survey tool programmed for use with iPads to measure the prevalence of surgical conditions.