Locating the Sural Nerve during Calcaneal (Achilles) Tendon Repair with Confidence: A Cadaveric Study with Clinical Applications

The sural nerve is at risk of iatrogenic injury even during minimally invasive operative procedures to repair the calcaneal (Achilles) tendon. Through 107 cadaveric leg dissections, the data derived from the present study was used to develop a regression equation that will enable surgeons to estimate the intersection point at which the sural nerve crosses the lateral border of the Achilles tendon, an important surgical landmark. In most cases, the sural nerve crossed the lateral border of the Achilles tendon 8 to 10 cm proximal to the superior border of the calcaneal tuberosity. By simply measuring the leg length of the patient (from the base of the heel to the flexor crease of the popliteal fossa), surgeons can approximate the location of this intersection point with an interval length of 0.68 to 1.80 cm, with 90% confidence, or 0.82 to 2.15 cm, with 95% confidence. For example, for a patient with a lower leg length of 47.0 cm, the mean measurement in the present study, a surgeon can be 90% confident that the sural nerve will cross the lateral border of the Achilles tendon 8.28 to 8.96 cm (interval width of 0.68 cm) proximal to the calcaneal tuberosity. Currently, ultrasound and clinical techniques have been implemented to approximate the location of the sural nerve. The results of the present study offer surgeons another method, that is less intensive, to locate reliably and subsequently avoid damage to the sural nerve during calcaneal (Achilles) tendon repair and other procedures of the posterolateral leg and ankle.     

Wound infection,dressings and pain,is there a relationship in the chronic wound?

The focus on quality of life issues in wound care has justly taken a far greater importance. With the acceptance that pain can be a major factor to the patient, and in particular, pain at dressing change comes the opportunity for avoidance and/or reduction strategies. Whilst pain has been associated with wound infection for millennia, it is only much more recently that this has received due attention from research and clinical practice. In this study, the nature of pain, changes in pain and pain associated with infection are the focal points. A Delphi approach, now a frequently used tool in wound care research, has been used to obtain expert opinion on these aspects of management.     

The cross‐pin retained implant supported restoration: a study of gasket placement and leakage

Background: Advantages of cross‐pin retained implant supported restorations (ISRs) include predictable retrieval and predictable retention. Unlike direct to fixture (DTF) or cement retained restorations, the prosthetic design of a cross‐pinned restoration retains gaps at the interfaces between the crown, abutment and cross‐pin screw. These spaces permit leakage into the suprastructure and gasket placement has been recommended to prevent this leakage. Methods: Five different gaskets were assessed for their ability to prevent leakage into a cross‐pinned ISR. The gaskets tested were: cement admixture on the cross‐pin screw; cement admixture on the inner surface of the coping and the cross‐pin screw; cement admixture on the inner surface of the coping only; cement admixture placed 1 mm from the margin of the coping and a filler placed in the abutment chimney. Results: Only gaskets which sealed both the cross‐pin screw interface and the abutment‐crown interface prevented leakage. A filler placed in the abutment chimney prevented leakage into this space but did not prevent fluid accumulating between the coping and abutment. Conservative placement of cement at the margin of the coping failed to prevent leakage. Conclusions: Cement gaskets may effectively prevent leakage into a cross‐pinned ISR. However, the use of a cement as a gasket has to be weighed against the issue of predictable retrieval, cement extrusion and incomplete seating.     

Two-temperature PCR and heteroduplex detection: application to rapid cystic fibrosis screening.

We describe a rapid two-temperature PCR protocol for amplification of genomic DNA applied to the region of the most common mutation (delta F508) of the cystic fibrosis gene. Amplification products are detected as homo- or heteroduplexes on polyacrylamide gels as previously described. Data using two-temperature PCR show complete concordance with allele-specific hybridization after classical three-temperature PCR in 105 normal, carrier and affected individuals. Clinical application is demonstrated in a family which was uninformative by traditional RFLP linkage analysis. Two-temperature PCR may offer advantages of speed and specificity over three-temperature PCR in many clinical and research applications.     

Paracetamol is an effective drug to use for pain following oral surgery

DATA SOURCE: Studies were identified using the Cochrane trials registers of the Oral Health Group and of the Pain, Palliative and Supportive Care Group, along with the Cochrane Central Register of Controlled Trials, Medline, Embase and the Current Controlled Trials Register. Handsearching included several dental journals as well as the bibliographies of relevant clinical trials and review articles for studies outside the journals searched by hand. Authors of the randomised controlled trials (RCT) identified and manufacturers of analgesic pharmaceuticals were contacted in an attempt to identify unpublished or ongoing RCT. No language restriction was applied. STUDY SELECTION: Randomised, parallel-group, placebo-controlled, double-blind clinical trials of paracetamol (acetaminophen) for acute pain following third molar surgery were included. DATA EXTRACTION AND SYNTHESIS: All trials identified were scanned independently and in duplicate by two review authors. Any disagreements were resolved by discussion or, if necessary, a third review author was consulted. The proportion of patients who recorded at least 50% pain relief was calculated for both paracetamol and placebo. The number of patients experiencing adverse events, and/ or the total number of adverse events reported were analysed. RESULTS: Twenty-one trials met the inclusion criteria. A total of 2048 people were initially enrolled in the trials (1148 took paracetamol and 892 the placebo) and of these 1968 (96%) were included in the meta-analysis (1133 took paracetamol, and 835 the placebo). Paracetamol provided a statistically significant benefit when compared with placebo for pain relief and for pain intensity at both 4 and 6 h. Most studies were found to have moderate risk of bias, with poorly reported allocation concealment being the main problem. The risk ratio for pain relief at 4 h was 2.85 (95% confidence interval, 1.89-4.29), and at 6 h was 3.32 (95% confidence interval, 1.88-5.87). A statistically significant benefit was also found between doses of <1000 mg and of 1000 mg, the higher dose giving greater benefit for pain relief and intensity at both timepoints. There was no statistically significant difference between the number of patients who reported adverse events: this was 19% in the paracetamol group and 16% in the placebo group. CONCLUSIONS: Paracetamol is an effective drug to use for postoperative pain following oral surgery, and the reporting of adverse events shows it to be a safe drug: the number-needed-to-treat (NNT) to benefit is three for 1000 mg of paracetamol at 6 h and the NNT to harm is 33. It is most effective at a 1000 mg dose, and can be taken at 6-hourly intervals without compromising safety. It could be considered more readily by dentist and patients both as a first-choice analgesic, or to be taken alternately with other analgesics such as nonsteroidal anti-inflammatory drugs.     

Is There a Role for Reconstructive Techniques to Prevent Periodontal Defects After Third Molar Surgery?

The purpose of this article is to address the following clinical question: Among subjects undergoing mandibular third molar (M3) removal, does an intervention at the time of tooth removal, when compared with no intervention, improve the long-term periodontal health on the distal aspect of the adjacent second molar (M2)? Routine application of interventions to improve the periodontal parameters on the distal of the M2 at the time of M3 removal is not indicated for most subjects. There seems to be a subpopulation of subjects having M3s removed who are at increased risk for periodontal defects after M3 removal, pre-existing periodontal defects, and a horizontal or mesioangular impaction. In the clinical setting of all three risk factors being present, there seems to be a predictable benefit to treating the dentoalveolar defect at the time of extraction.     

Open Versus Minimally Invasive Resection of Gastric GIST: A Multi-Institutional Analysis of Short- and Long-Term Outcomes

Background

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences.

Methods

A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection.

Results

There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05).

Conclusions

An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.