Endoscopic retrieval of retracted flexor tendons: An atraumatic technique

Background

The repair of retracted flexor tendons is a challenging problem for hand surgeons. The tendon stump should be handled in an atraumatic manner because any microtrauma to the sheath and tendon can lead to poor functional outcomes.

Limberg flap procedure for pilonidal sinus disease: results of 353 patients

Purpose Pilonidal sinus disease is common especially in young adult males. Many surgical and nonsurgical methods have been described. Some surgical techniques for the treatment still have high recurrence rate. The aim of this study was to evaluate advantages and long term results of Limberg flap surgical technique. Methods From November 2001 to December 2004, 353 patients [335 male, 18 female; average age = 24.65 ± 4.2 (range, 15–53) years] with primary or recurrent pilonidal sinus disease were operated on under spinal anesthesia by rhomboid excision and Limberg flap. Follow-up examinations were made at the end of the 4 weeks and 3, 6, 12, 18, and 24 months after surgery. Results The mean duration of symptoms was 23.28 ± 16.09 (range, 2–140) months. The mean duration of hospital stay was 4.51 ± 2.85 (range, 2–19) days. Thirty nine patients (11%) had recurrent disease. Total wound dehiscence and flap necrosis did not occur in any patient. Recurrences were observed in 11 patients (3.1%) at the end of the follow up period. Conclusion Quick healing time, short hospital stay, early return to daily life, low complication and recurrence rate are the important advantages of the Limberg flap procedure. We think using closed suction drain in Limberg flap operation is not necessary. In the light of this study results, Limberg flap surgical technique may be an ideal operation for pilonidal sinus disease.     

A demineralized calf vertebra model as an alternative to classic osteoporotic vertebra models for pedicle screw pullout studies

Screws, clamps and other spinal instrumentation materials are tested using healthy animal and healthy human vertebrae, but the application of similar tests to an osteoporotic vertebra is generally neglected because of high costs and limited availability of high quality and consistent osteoporotic vertebrae. The objective of this study is to develop an in-vitro method to decrease the mineral content of an animal vertebra utilizing decalcifying chemical agents that alters the bone mineral density and some biomechanical properties to such an extent that they biomechanically mimic the osteoporotic spine. This study was performed on 24 fresh calf lumbar vertebrae. Twelve out of these 24 vertebrae were demineralized and the others served as control. A hole was opened in the pedicles of each vertebrae and the bone mineral density was measured. Each vertebra was then placed into a beher-glass filled with hydrochloric acid decalcifier solution. The decalcifier solution was introduced through the holes in the pedicles with an infusion pump. The vertebrae were then subjected to DEXA to measure post process BMD. Pedicle screws were introduced into both pedicles of each vertebrae and pullout testing was performed at a rate of 5 mm/min. The difference of BMD measurements between pre- and post-demineralizing process were also statistically significant (p < 0.001). The difference of pullout loads between pre- and post-demineralizing process were also statistically significant (p < 0.001). The acid demineralizing process may be useful for producing a vertebra that has some biomechanical properties that are consistent with osteopenia or osteoporosis in humans.     

Percent positive axillary involvement predicts for the development of brain metastasis in high-risk patients with nonmetastatic breast cancer receiving post-mastectomy radiotherapy

Abstract:  We retrospectively assessed the predictive factors for brain metastasis in high-risk breast cancer patients receiving radiotherapy after mastectomy. Between January 1994 and 2002, the medical charts of nonmetastatic breast cancer patients receiving post-mastectomy radiotherapy were evaluated. The clinical and pathologic features of patients who developed brain metastasis as the first site metastatic disease were compared with nonmetastatic patients treated at the same time period. All eligible patients in this study were treated with postoperative radiotherapy ± chemotherapy. Age, stage, percent positive lymph node involvement, number of lymph node metastasis, primary tumor size, grade, surgical margin status, estrogen receptor status, and perinodal fat tissue invasion were analyzed as predictive factors for brain metastasis. Statistical analyses were performed by using Log-rank test and Cox's regression analysis. Median follow-up-time was 61 months. In this period, 32 out of 957 patients (3.3%) developed brain metastasis. In univariate analysis percent positive axillary lymph node involvement (p < 0.001), primary tumor size (p < 0.001), number of lymph node metastasis (p = 0.01), and American Joint Committee on Cancer 2002 stage (p < 0.001) were found to be predictive for brain metastasis. Multivariate analysis revealed that only the primary tumor size and percent positive lymph node involvement were significant predictive factors for the development of brain metastasis. The primary tumor size and percent positive lymph node involvement increases the risk of brain metastasis in patients with nonmetastatic breast cancer receiving postoperative radiotherapy and chemotherapy.     

A Useful Method for Planning Hump Resection of Deviated Nose

The deviated nose is a particular challenge because both functional and aesthetic problems must be addressed. A most important challenge is resection of the hump. The nasal bones often are asymmetric in deviated noses. Several methods have been used for resection of the hump. Using the authors’ method, it is possible to calculate the extent of hump resection. Clinical analysis of the nasal deviation is performed preoperatively. Digital photographs are taken, and all the landmarks are marked on the life-size photo prints. Planning begins on the deviated side. The ideal dorsal line is drawn, and the extent of hump resection is planned according to the preoperative measurements. Measurements on the deviated side are applied to the other side using the medial canthi and the most prominent part of the alar creases as landmarks. Classical methods emphasize the importance of the chisel position during hump removal. According to the classical approach, the chisel should be positioned lower on the deviated side to resect more bone. However, there is no method for calculating how the chisel should be positioned exactly during hump resection. Therefore, a precise plan has been devised to leave symmetric nasal bones after hump resection. The authors have applied this method in eight cases, achieving satisfactory results.     

The effect of pedicle screw insertion at a young age on pedicle and canal development

STUDY DESIGN.: A longitudinal case study. OBJECTIVE.: To determine whether pedicle screws placed in an immature spine exert effect on the continued growth of the vertebral body. SUMMARY OF BACKGROUND DATA.: Pedicle screws have revolutionized surgical treatment of spinal deformities by allowing a mode of secure fixation that provides consistently better correction rates in adults and adolescents. In the young child, however, the trajectory of pedicle screws takes them through an open physis: the neurocentral cartilage. There exists little information regarding the possible effect of pedicle screws inserted at a young age on further development of the spine and the spinal canal. METHODS.: Patients undergoing pedicle screw instrumentation of at least 2 levels before the age of 5 years (60 mo) for the first time for any diagnosis and who had been followed for at least 24 months were included. Measurements were performed in instrumented and adjacent noninstrumented levels without visible deformity in pre- and postoperative cross-sectional images and compared using statistical methods. RESULTS.: Ninety segments in 15 patients met the inclusion criteria (average age at instrumentation 46.3 mo [range, 29-60 mo]). Forty segments had no screws and 50 had at least 1 screw. Pedicle length and vertebral body diameter had significantly increased in both groups, whereas spinal canal parameters did not change significantly. No significant difference was observed between the growth rates in levels with or without screws in pedicle length, vertebral body diameter, or spinal canal parameters (anterior-posterior and interpedicular diameters, and area). CONCLUSION.: Pedicle screw instrumentation performed before the age of 5 years does not cause a negative effect on the growth of pedicles, the transverse plane of the vertebral body, or the spinal canal. It can be safely performed in the treatment of deformity in this age group.     

Surgery for chronic total occlusion of the left main coronary artery--myocardial preservation

We report seven patients with chronic total occlusion of the left main coronary artery that were operated in our institution and discuss the myocardial preservation options in these patients. In addition to total occlusion of the left main coronary artery, three patients also had severe lesions of right coronary artery. Prior myocardial infarction history and significantly depressed left ventricle functions were detected in all three patients with right coronary artery lesions. Five patients were operated on cardiopulmonary bypass while two patients were operated off pump. All patients received alternating antegrade/retrograde cardioplegia for myocardial preservation. In patients with simultaneous right coronary artery disease we first established the origin of the collaterals to the left coronary system. For patients with collaterals arising from the right coronary artery segment distal to the right coronary artery lesion, the antegrade component was administered through the saphenous vein graft bypassed to a distal part of right coronary artery segment. Thus we have achieved a more effective distribution of the antegrade cardioplegia. In off-pump-operated patients the left coronary system was revascularized before the right coronary system. Postoperative low cardiac output syndrome occurred in only one patient who was operated off pump. There was no operative and early mortality. Mean follow-up was 32 +/- 21.42 (range, 4 to 60) months. Alternating antegrade/retrograde cardioplegia was used with acceptable results in patients with total occlusion of the left main coronary artery. In patients with simultaneous RCA lesion we recommend regulation of the antegrade component based on the origin of collaterals that supplies the left coronary system. In off-pump-operated patients we suggest avoiding of clamping of right coronary artery at the beginning of the operation while it still supplies all the coronary circulation.     

An evaluation of low molecular weight heparin and hyperbaric oxygen treatment in the prevention of intra-abdominal adhesions and wound healing

BACKGROUND: Abdominal surgery can lead to intra-abdominal adhesions with significant morbidity and mortality. To prevent adhesions, an experimental study was planned to designate the effects of low molecular weight (LMW) heparins and hyperbaric oxygen (HBO) therapy both on the formation of adhesions and wound healing. METHODS: Thirty-eight Wistar albino rats underwent laparotomy to cause intra-abdominal adhesions by mechanical abrasion of the cecum and ethanol application. The rats were divided into 4 groups. In the control group (group 1) no further management was undertaken. Group 2 was treated by Enoxaparine Na, group 3 received HBO therapy, and group 4 was given both enoxaparine Na and HBO treatment. RESULTS: There was a statistically significant difference between the control and enoxaparine Na groups regarding adhesions. Statistically significant differences were observed between groups 1 and 4 and between groups 1 and 3 regarding the hydroxyproline content of the abdominal wounds. In the pathologic analysis of the abdominal wounds, there was no statistically significant difference between any of the groups, including the control group, regarding inflammation. Statistically significant differences were observed regarding angiogenesis between the control group and groups 3 and 4. There was also a statistically significant difference regarding fibrosis between groups 1 and 4. CONCLUSIONS: Enoxaparine Na decreased intra-abdominal adhesions, and HBO therapy had no beneficial effect on adhesions. Enoxaparine Na had no harmful effects on wound healing, and HBO therapy increased the process of wound healing.     

PSA bouncing after short term androgen deprivation and 3D-conformal radiotherapy for localized prostate adenocarcinoma and the relationship with the kinetics of testosterone

OBJECTIVES: To assess the factors effecting PSA bounce and to identify any possible relationship with biochemical control after 3-D conformal radiotherapy (3D-CRT) and total androgen deprivation (TAD) for prostate cancer by evaluating four previously described PSA bounce definitions. METHODS: Between January 1998 and January 2001, 83 consecutive patients with clinically localized prostate cancer were treated by 3D-CRT with neoadjuvant 3 months and/or 6 months adjuvant TAD. All patients had a pretreatment PSA level, at least eight post-external beam radiotherapy (EBRT) PSA and testosterone levels and minimum two years of follow-up. Total radiotherapy dose was 73.6 Gy at ICRU reference point. Four previous definitions of PSA bounce were used: Critz definition (>or=0.1 ng/mL), Cavanagh definition (>or=0.2 ng/mL), Hanlon definition (>or=0.4 ng/mL) and Rosser definition (>or=0.5 ng/mL) according to original methodology performed to report PSA bounce. Biochemical failure was defined in accordance with the ASTRO consensus guidelines. RESULTS: The median follow-up time was 40 months. PSA bounce was recorded as follows: Critz definition, 33 patients (40%); Cavanagh definition, 21 patients (25%); Hanlon definition, 11 patients (13%); and Rosser definition, 7 patients (8%). In multivariate analysis, pre-EBRT PSA level and the duration of TAD for Critz definition; age, pre-EBRT PSA and the duration of TAD for Cavanagh definition; age and duration of TAD for Hanlon definition; age and pre-biopsy PSA for Rosser definition were significant independent prognostic factors determining PSA bounce. A significant increase of mean testosterone level in bouncers was detected at the 6th-9th and 18th-21st months. PSA bounce did not predict for PSA failure in multivariate analysis. CONCLUSIONS: We observed no correlation between biochemical failure and PSA bounce. The longer duration of TAD and older age were found to be inversely proportional with PSA bouncing in this cohort. Notably, recovery of testosterone might cause PSA bouncing.