Reduction strategies through the anterolateral exposure for fixation of type B and C pilon fractures

The surgical management of pilon fractures has evolved over the last several years with treatment shifting from acute definitive fixation to delayed fixation. One of the driving forces behind this change was the high incidence of soft tissue complications in those patients with high-energy pilon fractures (Orthopaedic Trauma Association 43B and 43C) managed with acute stabilization. Meticulous soft tissue handling along with delayed definitive fixation based on the soft tissue envelope has decreased the short-term complications associated with treatment of these injuries. Anterolateral exposure to the distal tibial articular surface allows for adequate visualization of most fracture patterns, novel reduction strategies, and successful implant placements. This exposure is useful in certain Type C pilon fractures, anterior and anterolateral Type B pilon fractures, and some extra-articular distal tibial fractures. The anterolateral exposure is not suitable in fractures with medial comminution, medial crush, impaction at the medial shoulder of the joint, segmental medial malleolar injuries, or varus deformity at the time of injury. The exposure has the advantage of excellent visualization of the articular surface up to the medial shoulder of the plafond while avoiding dissection of the anteromedial tibial surface.     

Acute kidney injury in congenital diaphragmatic hernia requiring extracorporeal life support: an insidious problem

Purpose

Patients with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS) are at increased risk for acute kidney injury (AKI). We hypothesized that AKI would be associated with increased mortality. We further hypothesized that vasopressor requirement, nephrotoxic medications, and infections would be associated with AKI.

Methods

We performed a retrospective chart review in all patients with CDH requiring ECLS from 1999 to 2009 (n = 68). Patient variables that could potentiate renal failure were collected. We used a rise in creatinine from baseline by the RIFLE (risk, 1.5×; injury, 2×; failure, 3×; loss; and end-stage renal disease) criteria to define AKI. Statistical analysis was performed via SPSS (SPSS, Chicago, IL) using Student t test and χ² analysis, with P < .05 being considered significant.

Results

Survival to hospital discharge was 37 (54.4%) of 68. Acute kidney injury was identified in 48 (71%) of 68 patients, with 15 (22% of all patients) qualifying as injury and 33 (49% of all patients) qualifying as failure by the RIFLE criteria. Patients who qualified as failure by the RIFLE criteria had a significant decrease in survival (27.3% with failure vs 80% without failure; P = .001). Patients who qualified as failure also had increased length of ECLS (314 ± 145 vs 197 ± 115 hours; P = .001) and decreased ventilator-free days in the first 60 days (1.39 ± 5.3 vs 20.17 ± 17.4 days; P = .001). There was no significant difference in survival when patients qualified as risk or injury.

Conclusions

This is the first report using a systematic definition of AKI in patients with CDH on ECLS. There is a high incidence of AKI in these patients, and when it progresses to failure, it is associated with higher mortality, increased ECLS duration, and increased ventilator days. This highlights the importance of recognizing AKI in patients with CDH requiring ECLS and the potential benefit of preventing progression of AKI or early intervention.     

Vertical expandable prosthetic titanium rib device insertion: does it improve pulmonary function?

Purpose

Vertical expandable prosthetic titanium rib (VEPTR) insertion and expansion has been advocated to increase thoracic volume and pulmonary function in patients with thoracic insufficiency syndrome. We reviewed our experience with VEPTR implantation to determine if lung function and growth is augmented, to determine the children's functional status, and if the scoliosis is controlled.

Methods

From 2006 to 2010, 29 insertions and 57 expansions were performed in 26 patients at our institution. Demographic data were reviewed in conjunction with complications, scoliosis angles, pulmonary function tests (PFTs), and computed tomography-guided 3D reconstructions to determine lung volumes; and quality of life scores were determined using a modified Scoliosis Research Society (SRS) questionnaire preoperatively and postoperatively. The groups were also stratified by age (because of lung growth potential), disease (congenital or infantile scoliosis, Jeune syndrome, neuromuscular, other structural thoracic disorders), and sex. Analyses using SPSS (SPSS, Chicago, Ill) were performed with P < .05 considered significant.

Results

Each patient underwent 3.03 ± 1.8 surgeries, spending 0.97 ± 1.8 days in the intensive care unit and 4.41 ± 6 days in the hospital for each procedure. Mean age was 90.7 ± 41 months. Of the 36 complications, most were because of infection (12), half requiring operative repair (hardware removal). The average PFT percent predicted values for forced expiratory volume in 1 second, forced vital capacity, and RV were 54.6 ± 22, 58.1 ± 24, and 145.3 ± 112, respectively, preoperatively and 51.8 ± 20, 55.9 ± 20, and 105.6 ± 31, respectively, postoperatively. The lung volumes measured by computed tomography when corrected for age do not increase significantly postoperatively. The mean Cobb measurement for the preoperative major curves was 64.7° and postoperatively was 46.1° for those curves measured preoperatively, for a 29% curve improvement. All postoperative curves had a mean of 56.4° and 58.1° at final follow-up, a 3% curve increase. The SRS scores for patients remained unchanged and no statistical difference was seen from preoperative to postoperative values. No statistically significant difference was seen in complications, PFT (forced expiratory volume in 1 second, forced vital capacity, RV), lung volumes, scoliosis angles, and SRS scores between sex, age, and disease categories.

Conclusion

There was mild improvement in scoliosis angles but no improvement in lung function and volume. Scoliosis Research Society scores indicate that the children have near normal function both before and after VEPTR placement. Pulmonary function, lung volume, and patient subjective assessments did not increase dramatically after VEPTR placement, although scoliosis angles improved.     

Impact of a novel education curriculum on surgical training within an academic training program

BACKGROUND: The training of the 21st century surgeon has become increasingly complex with the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements and work-hour restrictions. Herein we report the two-year results of a novel problem-based learning education module at a large academic surgery program. METHODS: All data were prospectively collected from 2004 to 2006 on all categorical residents in the department of surgery (n = 42). Analysis was performed to identify any correlation between class attendance and American Board of Surgery In-Service Training Exam (ABSITE) score performance (percentile change). All data were reported as a mean with a standard error of the mean. Categorical variables were analyzed using a paired Student's t-test. A bivariate correlation was calculated using Spearman's rho correlation. RESULTS: When comparing the 2004 scores (pre-program) to 2006 scores, there was significant score improvement (P 相似文献   

Radiofrequency capsular shrinkage for voluntary shoulder instability

We report a prospective study of 13 consecutive shoulders treated exclusively with radiofrequency capsular shrinkage for voluntary instability. Before surgery, voluntary instability had ceased in all patients with physiotherapy, but involuntary shoulder instability continued. The mean follow-up was 45 months (range, 32-57 months). According to the system of Rowe et al, the results were excellent in 3 shoulders (23.1%), fair in 1 (7.7%), and poor in 9 (69.2%). All 4 shoulders that had previous stabilization surgery had a recurrence of instability. Of the 6 shoulders with fair and poor Rowe ratings that had no previous stabilization surgery, 4 had a repeat capsular shrinkage. Two of these four shoulders had an excellent Rowe rating at final review. Overall, 5 of 9 patients (55.6%) with no previous surgery achieved stability by radiofrequency stabilization. In conclusion, results of radiofrequency capsular shrinkage in voluntary shoulder instability are poor. Results are improved with repeat capsular shrinkage. Radiofrequency capsular shrinkage is not recommended for patients who have had previous stabilization surgery.     

Endoclip Closure of Jejunal Perforation after Balloon Dilatation

Endoscopy is commonly used in patients undergoing Roux-en-Y gastric bypass (RYGBP) for diagnosis and intervention. Stomal stricture at the gastrojejunostomy occurs in approximately 3% to 17% of patients after laparoscopic RYGBP. The incidence of iatrogenic perforation during stomal balloon dilatation is reported to be 3% to 12% among these patients. Surgery has typically been required for iatrogenic perforation. With the availability of the endoclip, endoscopists are able to manage iatrogenic perforation non-operatively. We report a patient who had jejunal perforation during balloon dilatation after RYBGP, who was successfully closed with endoclip applications and managed non-operatively.     

Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum

PURPOSE: Intravaginal or extravaginal spermatic cord torsion is a diagnostic challenge for the surgeon and radiologist. Color Doppler sonography can be inaccurate, leading to dangerous false-negative results. To date, no single reliable test has been able to provide 100% diagnostic accuracy. The direct visualization of the twisted cord during emergency high resolution ultrasonography has been proposed to avoid systematic and abusive surgical exploration. The aim of this multicenter study was to assess the validity and reproducibility of high resolution ultrasonography based management of acute scrotum in children. MATERIALS AND METHODS: A total of 919 patients from 11 European university hospitals underwent color Doppler sonography and high resolution ultrasonography for acute scrotum between 1992 and 2005. The spermatic cord was studied along its complete length to detect a spiral twist. The surgical findings were correlated with the preoperative results. RESULTS: A total of 208 patients had spermatic cord torsion proved at surgery. Intratesticular vascularization was absent in the affected testis in only 158 cases (76%). In contrast, high resolution ultrasonography detected the twist as a snail shell-shaped mass, measuring 7 to 33 mm, in 199 patients (96%). High resolution ultrasonography revealed a linear cord for all other causes of acute scrotum (711 patients) with a specificity of 99%. The radiologist training level was the best predictive factor of high resolution ultrasonography reliability (p <0.05). CONCLUSIONS: High resolution ultrasonography based management of acute scrotum is reliable and reproducible. Thanks to its high sensitivity and specificity for the diagnosis of spermatic cord torsion, high resolution ultrasonography can significantly improve the management of acute scrotum in children.     

Perioperative beta-blocker therapy and heart rate control during noncardiac surgery

BACKGROUND: Perioperative treatment with beta-blockade is a widely advocated practice. We assessed the preoperative, intraoperative, and postoperative control of heart rate (HR) in patients who received beta-blockade as recommended during preoperative medicine clearance. METHODS: We conducted a retrospective review of patients who underwent noncardiac surgery from 2002 to 2004 at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, with recommendations of beta-blockade as part of their risk stratification. Demographic data and comorbid risk factors were collected on patients undergoing general anesthesia. All data were presented as mean +/- SEM. The chi-square test and analysis of variance were used for statistical analysis. RESULTS: A total of 130 patients referred for preoperative medicine clearance, who were risk-stratified based on comorbid conditions and risk of procedure, had beta-blockade started before elective surgery. Sixty percent (78 of 130) of the patients underwent high-/intermediate-risk surgery. The mean preoperative HR was 74 +/- 1 beat per minute (bpm). The mean intraoperative HR was 69 +/- 1 bpm. The mean postoperative HR was 84 +/- 1 bpm. There was a significant difference in the preoperative and intraoperative HR when compared with the postoperative HR (P < .003). There were no deaths at 30 days postoperatively. Perioperative cardiac morbidity occurred in 5.4% (7 of 130) of all patients (high patient risk, 71%; low patient risk, 29%; P < .05), and did not correlate with procedure risk. CONCLUSIONS: Beta-blockade is achieved sufficiently in the preoperative and intraoperative settings. However, attention to postoperative HR may be warranted to maintain the benefits of beta-blockade.     

Association of methylenetetrahydrofolate reductase genetic polymorphisms with atlantoaxial dislocation

OBJECT: Genetic mechanisms of atlantoaxial dislocation (AAD) have not previously been elucidated. The authors studied association of polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene, which encodes enzymes of the folate pathway (implicated in causation of neural tube defects [NTDs]), in patients with AAD. METHODS: Molecular analysis of MTHFR polymorphisms (677C-->T, cytosine to thymine and, 1298A-->C, adenine to cytosine, substitutions) was carried out using polymerase chain reaction and restriction enzyme digestion in 75 consecutive patients with AAD and in their reducible (nine patients, 12%) and irreducible (66 patients, 88%) subgroups. Controls were 60 age- and sex-matched patients of the same ethnicity. Comparisons of genotype and allele frequencies were performed using a chi-square test (with significance at p < 0.05). RESULTS: The CT genotype frequency of MTHFR 677C-->T polymorphism was significantly increased in the full group of patients with AAD (odds ratio [OR] 3.00, 95% confidence interval [CI] 1.28-7.14, p = 0.005) as well as in the irreducible subgroup (OR 2.81, 95% CI 1.17-6.86, p = 0.01). The frequency of T alleles was also higher in the AAD group (25.3%) than in controls (15%). The comparison of the combined frequency of CT and TT genotypes with the frequency of the CC genotype again showed significant association in AAD (OR 2.63, 95% CI 1.98-5.90, p = 0.009) and the irreducible (OR 2.5, 95% CI 1.1-5.74, p = 0.016) subgroup. There was, however, no significant association of MTHFR 1298A-->C polymorphism with AAD. CONCLUSIONS: Both MTHFR 677C-->T polymorphism and higher T allele frequency have significant associations with AAD, especially the irreducible variety. Perhaps adequate supplementation of periconceptional folic acid to circumvent effects of this missense mutation (as is done for prevention of NTDs) would reduce the incidence of AAD.