Clinical and instrumental (magnetic resonance imaging [MRI] and multimodal evoked potentials) follow-up of brain lesions in three young patients with neurofibromatosis 1

Diagnosis of neurofibromatosis 1 is based on clinical criteria. In a large number of children with neurofibromatosis 1, magnetic resonance imaging (MRI) reveals high-signal T(2)-weighted intensities in different brain regions, defined as unidentified bright objects. These lesions are asymptomatic; most of them regress spontaneously with age, but the presence of contrast enhancement or mass effect in them usually strongly suggests an increased risk of proliferative changes. To date, few studies have focused on evoked potentials in patients with neurofibromatosis 1, and the reported abnormalities did not have significant clinical correlations. We describe the clinical and instrumental (MRI and evoked potentials) follow-up of three patients with neurofibromatosis 1. MRI and evoked potentials showed subclinical involvement of the central nervous system. Some MRI T(2)-weighted hyperintensities showed enhancement and mass effect of uncertain significance. During follow-up, the MRI lesions spontaneously decreased in size or enhancement, allowing us to exclude the hypothesis of proliferative lesions; in the same way, some asymptomatic evoked potential abnormalities disappeared. These findings suggest that both MRI and evoked potentials could be useful in the detection and monitoring of cerebral complications of neurofibromatosis 1.     

Video-Assisted Thyroidectomy Significantly Reduces the Risk of Early Postthyroidectomy Voice and Swallowing Symptoms

Background Voice and swallowing symptoms are frequently reported after thyroidectomy even in absence of objective voice alterations. We evaluated the influence of the video-assisted approach on voice and swallowing outcome of thyroidectomy. Methods Sixty-five patients undergoing total thyroidectomy (TT) were recruited. Eligibility criteria were: nodule size ≤30 mm, thyroid volume ≤30 ml, no previous neck surgery. Exclusion criteria were: younger than aged 18 years and older than aged 75 years, vocal fold paralysis, history of voice, laryngeal or pulmonary diseases, malignancy other than papillary thyroid carcinoma. Patients were randomized for video-assisted (VAT) or conventional (CT) thyroidectomy. Videostrobolaryngoscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) evaluation were performed preoperatively and 3 months after TT. Subjective evaluation of voice (voice impairment score = VIS) and swallowing (swallowing impairment score = SIS) were obtained preoperatively, 1 week, 1 month, and 3 months after TT. Results Fifty-three patients completed the postoperative evaluation: 29 in the VAT group, and 24 in the CT group. No laryngeal nerves injury was shown at postoperative VSL. Mean postoperative MPT, F ₀, F _low, F _high, and the number of semitones were significantly reduced in the CT group but not in the VAT group. Mean VIS 3 months after surgery was significantly higher than preoperatively in CT group but not in the VAT group. Mean SIS was significantly decreased 1 and 3 months after VAT but not after CT. Conclusions The incidence and the severity of early voice and swallowing postthyroidectomy symptoms are significantly reduced in patients who undergo VAT compared with conventional surgery. Presented at the ISW2007—IAES free paper session, Montreal, Canada, August 26–30, 2007.     

Malignant pleural mesothelioma: utility of 18 F-FDG PET

Malignant Pleural Mesothelioma is a rare tumour that arise from the mesothelial cells of the pleura and in recent time the incidence of this disease is rising. Because of the implications for management and therapy, it is important to assess the accurate staging. 18F-fluorodeoxiglucose Positron Emission Tomography (18F-FDG PET) is become a useful tool in the diagnosis of many neoplasms, such as Malignant Pleural Mesothelioma. In particular it has been shown to be useful in the evaluation of the extent of pleural disease, in the establishment of lymph node involvement, in the evaluation of tumour invasion into the lung and thoracic wall, in the diagnosis of extrathoracic metastases, in the assessment of the response to treatment, and in planning radiotherapy. Developments in system technology, like improvements in hybrid system (integrated Positron Emission Tomography/Computed Tomography) and the discovery of new radiopharmaceuticals, promise to make PET much more useful and versatile in the future.     

Excursion and strain of the superficial peroneal nerve during inversion ankle sprain

BACKGROUND: Traction is presumed to be the mechanism of injury to the superficial peroneal nerve in an inversion ankle sprain, but it is not known whether the amount of strain caused by nerve traction is sufficient to cause nerve injury. We hypothesized that the superficial peroneal nerve would experience significant excursion and strain during a simulated inversion sprain, that sectioning of the anterior talofibular ligament would increase excursion and strain, and that an impact force would produce strain in a range that can structurally alter the nerve. METHODS: Differential reluctance transducers were placed in the superficial peroneal nerve in sixteen lower-extremity cadaver specimens to measure excursion and strain in situ. Static weight was applied to the foot in increments starting at 0.454 kg and ending at 4.54 kg. The anterior talofibular ligament was sectioned, and the measurements were repeated. A final impact force of 4.54 kg was applied to each specimen. Two-way repeated-measures analysis of variance was used to evaluate differences in excursion and strain. RESULTS: The mean excursion and strain of the superficial peroneal nerve increased with increases in the applied weight in both the group with the intact anterior talofibular ligament and the group in which it had been sectioned. Nerve excursion was greater in the sectioned-ligament group than in the intact-ligament group with all applied weights (p < 0.05). The mean nerve strain was greater in the sectioned-ligament group (range, 5.5% to 12.9%) than in the intact-ligament group (range, 3.0% to 11.6%) with application of the 0.454, 0.908, 1.362, and 1.816-kg weights (p < 0.05). With the ligament sectioned, the 4.54-kg impact force produced significantly higher mean nerve excursion and strain than did the 4.54-kg static weight (p < 0.05). CONCLUSIONS: The magnitude of strain with the impact force was in the lower range of values that have been shown to structurally alter peripheral nerves. The superficial peroneal nerve is at risk for traction injury during an ankle inversion sprain and is at additional risk with more severe sprains or with an insufficient anterior talofibular ligament.     

Biomechanical analysis of screw-augmented intramedullary fixation for tibiotalocalcaneal arthrodesis

BACKGROUND: This study compared intramedullary (IM) fixation for tibiotalocalcaneal arthrodesis with and without a tibiotalocalcaneal augmentation screw. METHODS: Each specimen in six matched pairs of fresh frozen cadavers underwent tibiotalocalcaneal arthrodesis with an IM nail. One specimen from each pair also received a tibiotalocalcaneal augmentation screw. Initial and final stiffness, load to failure, and construct deformation at failure were calculated with dorsiflexion loading. Bone mineral density of each pair was determined. Statistical analysis was done using a paired Student t-test and a Pearson correlation. RESULTS: Initial and final stiffness and load to failure were significantly higher for the tibiotalocalcaneal screw augmented fixation group as compared with the specimens with no additional screw (initial stiffness, 128.0 versus 78.4 N/mm, p = 0.04; final stiffness, 230.9 versus 164.7 N/mm, p = 0.04; load to failure, 875.5 versus 660.2 N, p = 0.03). There was a significant negative correlation between bone mineral density and average construct deformation in the samples without the added tibiotalocalcaneal screw (r = -0.90, p = 0.02). CONCLUSIONS: In tibiotalocalcaneal arthrodesis with intramedullary nail fixation, a tibiotalocalcaneal augmentation screw provides more stable fixation. CLINICAL RELEVANCE: Use of an augmentation screw as described in this study may lead to lower complication rates, particularly in patients with osteopenic bone.     

Living donor liver transplantation in children: Should the adult donor be operated on by an adult or pediatric surgeon? Experience of a single pediatric center

Background/Purpose

Living donor liver transplantation has become a cornerstone for the treatment of children with end-stage hepatic dysfunction, especially within populations or countries with low rates of organ utilization from deceased donors. The objective is to report our experience with 185 living donors operated on by a team pediatric surgeons in a tertiary center for pediatric liver transplantation.

Methods

Retrospective analysis of medical records of donors of hepatic grafts for transplant undergoing surgery between June 1998 and March 2013.

Results

Over the last 14 years, 185 liver transplants were performed in pediatric recipients of grafts from living donors. Among the donors, 166 left lateral segments (89.7%), 18 left lobes without the caudate lobe (9.7%) and 1 right lobe (0.5%) were harvested. The donor age ranged from 16 to 53 years, and the weight ranged from 47 to 106 kg. In 10 donors, an additional graft of the donor inferior mesenteric vein was harvested to substitute for a hypoplastic recipient portal vein. The transfusion of blood products was required in 15 donors (8.1%). The mean hospital stay was 5 days. No deaths occurred, but complications were identified in 23 patients (12.4%): 9 patients experienced abdominal pain and severe gastrointestinal symptoms and 3 patients required reoperations. Eight donors presented with minor bile leaks that were treated conservatively, and 3 patients developed extra-peritoneal infections (1 wound collection, 1 phlebitis and 1 pneumonia). Eight grafts (4.3%) showed primary dysfunction resulting in recipient death (3 cases of fulminant hepatitis, 1 patient with metabolic disease, 1 patient with Alagille syndrome and 3 cases of biliary atresia in infants under 1 year old). There was no relation between donor complications and primary graft dysfunction (P = 0.6).

Conclusions

Living donor transplantation is safe for the donor and presents a low morbidity. The donor surgery may be performed by a team of trained pediatric surgeons.     

Results of resurfacing a native patella in patients with a painful total knee arthroplasty

Between 1990 and 2003, 24 patients (28 knees) who had a total knee arthroplasty (TKA) and underwent subsequent patella resurfacing without revision of the tibial or femoral components to alleviate pain were identified. Patient charts were reviewed retrospectively and patients were interviewed after average 2.9-year follow-up (range: 1-12 years) to assess function, pain, and satisfaction with the procedure. Average patient age at revision surgery was 68 years, and the average time from the index TKA was 9.8 years. Mean Knee Society function and pain scores were 68+/-28 and 45+/-16, respectively. Average preoperative range of motion was 102 degrees (range: 65 degrees-130 degrees), and average postoperative range of motion was 106 degrees (range: 65 degrees-130 degrees). Only 52% of patients would undergo revision surgery again given their current levels of pain and function. Revision of only the patella for patients with a painful TKA who did not undergo patella resurfacing at the initial surgery provides 52% satisfactory results. Surgeons should look for other causes of pain in this patient population and reconsider their indications for not resurfacing the patella in TKA.