Modified Technique of Mesh Hepatorrhaphy for Management of Juxtahepatic Venous Injury in a Case of Blunt Liver Trauma: A Case Report

The liver is the most frequently injured organ in cases of blunt abdominal trauma. Injuries to the caudate lobe are rarely isolated and usually associated with retrohepatic caval injury or hepatic vein injury. The management of the associated vascular injuries is usually difficult owing to the short courses of the hepatic veins and the difficulty in obtaining proximal and distal control of the suprarenal and suprahepatic inferior vena cava – hence the frequency of perihepatic packing in the management of caudate lobe and hepatic venous injuries. We present here a rare case of the failure of perihepatic packing to effectively control hemorrhage from blunt injury to the caudate lobe and retrohepatic vena cava. A case of blunt abdominal trauma with injury to the caudate lobe and retrohepatic venous injury was initially managed with perihepatic packing. The patient developed hemorrhage 48 h after pack removal, which was then successfully managed with mesh hepatorrhaphy of the caudate lobe.     

Improving Functional Performance and Muscle Power 4-to-6 Months After Anterior Cruciate Ligament Reconstruction

The purpose of this study was to examine the effects of 8-week retraining programs, with either two or three training sessions per week, on measures of functional performance and muscular power in athletes with anterior cruciate ligament reconstruction (ACLR). Sixteen male athletes were randomly assigned to two groups after ACLR: a functional training group (FTG, n = 8) training 2 intense sessions per week (4hrs/week), and a control group (CG, n = 8) training 3 sessions per week with moderate intensity (6hrs/week). The two groups were assessed at four and six months post-ACLR and the effects of retraining were measured using the following assessments: the functional and the muscular power tests, and the agility T-test. After retraining, the FTG had improved more than the CG in the operated leg in the single leg hop test (+34.64% vs. +10.92%; large effect), the five jump test (+8.87% vs. +5.03%; medium effect), and single leg triple jump (+32.15% vs. +16.05%; medium effect). For the agility T-test, the FTG had larger improvements (+17.26% vs. +13.03%, medium effect) as compared to the CG. For the bilateral power tests, no significant training effects were shown for the two groups in the squat jump (SJ), the counter movement jump (CMJ) and the free arms CMJ (Arm CMJ). On the other hand, the unilateral CMJ test with the injured and the uninjured legs showed a significant increase for the FTG with respect to CG (p < 0.05). The present study introduces a new training modality in rehabilitation after ACLR that results in good recovery of the operated limb along with the contra-lateral leg. This may allow the athletes to reach good functional and strength performance with only two physical training sessions per week, better preparing them for a return to sport activity at 6 months post- ACLR and eventually sparing time for a possible progressive introduction of the sport specific technical training.

Key points

• Functional training (plyometrics, neuromuscular, proprioceptive and agility exercises) in athletes during 4th to 6th months post-ACLR further improved functional outcomes, compared to a conventional rehabilitation program.
• The former program was more time-efficient compared to the latter one as indicated by the weekly training duration (4hrs/week vs. 6hrs/week).
• This study provides evidence of the functional training in knee rehabilitation and provides important information that is highly relevant to clinicians, physiotherapists, coaches and trainers who are in charge of the injured athletes during the later phase of the rehabilitation after ACLR.

Key words: ACL reconstruction, knee injury, retraining, agility, strength testing, power testing     

Image-guided laser ablation of osteoid osteoma in pediatric patients

BACKGROUND: We aimed to evaluate the effectiveness of image-guided laser ablation for the treatment of osteoid osteomas in pediatric patients. METHODS: From June 1994 to June 2006, 68 patients aged 3 to 18 years (mean age, 12.1 +/- 4.2 years) with a diagnosis of osteoid osteoma underwent laser ablation in our department. Among them, 3 patients had prior unsuccessful attempt of surgical resection. Procedures were performed under spinal or general anesthesia with combined computed tomographic and fluoroscopic guidance. An 18-gauge needle was placed in the nidus after bone drilling when required, and an optical fiber was inserted through it. An average energy of 1200 J was delivered using an infrared diode laser generator. Patients were discharged the next day and followed up with assessment of pain, medication intakes, and potential complications. Clinical success was defined by complete pain relief without need for medication intake. RESULTS: Technical success was achieved in all but 1 of our first patients, which was subsequently treated by percutaneous resection. Overall clinical success was 98%. Primary clinical success was obtained in 60 patients (88%). In 7 patients, recurrence of symptoms at 4 to 27 months from the initial procedure was managed by repeat laser ablation, resulting in secondary success (10%). No complications related to the procedure were observed. Follow-up ranged 16 to 146 months (mean, 83 months). CONCLUSIONS: Currently, image-guided laser ablation is a safe and effective procedure that can be proposed as the mainstay treatment of osteoid osteomas in pediatrics. LEVEL OF EVIDENCE: Therapeutic case series study level IV.     

Beneficial effects of ethyl pyruvate in septic shock from peritonitis

HYPOTHESIS: Infusion of ethyl pyruvate (EP) solution can improve outcome in a clinically relevant, large- animal model of septic shock resulting from fecal peritonitis. DESIGN: Prospective randomized animal study. SETTING: University hospital animal research laboratory. SUBJECTS: Fourteen female sheep. INTERVENTIONS: Fourteen fasted, anesthetized, invasively monitored, mechanically ventilated female sheep weighing (mean +/- SD) 30.4 +/- 3.8 kg received 0.5 g/kg of feces intraperitoneally to induce peritonitis, without administration of antibiotic agents or vasoactive drugs. After surgical preparation, the ewes were randomized to receive a continuous intravenous infusion at 15 mg/kg per hour of either EP combined with Ringer lactate solution or Ringer lactate solution only. Fluid resuscitation was titrated to maintain the pulmonary artery occlusion pressure at baseline levels throughout the experiment. All animals were monitored until they died spontaneously or for a maximum of 30 hours. RESULTS: Compared with Ringer lactate solution alone, EP administration resulted in less tachycardia, longer time to development of arterial hypotension and oliguria (median, 27 vs 15 hours and 24 vs 16 hours, respectively; both P<.01), and prolonged survival time (median, 29.5 vs 17.0 hours; P<.001). Animals who received EP also had a smaller decrease in colloid osmotic pressure (P<.05) and a tendency for lower serum interleukin 6 concentrations (P = .08). CONCLUSIONS: In this clinically relevant model of septic shock in ewes, continuous EP infusion prolonged time to development of organ dysfunction and markedly prolonged survival. These findings suggest a potential use for EP in the treatment of severe sepsis and septic shock.     

Acute hyperglycemia induces a global downregulation of gene expression in adipose tissue and skeletal muscle of healthy subjects

To define the effects of acute hyperglycemia per se (i.e., without the confounding effect of hyperinsulinemia) in human tissues in vivo, we performed global gene expression analysis using microarrays in vastus lateralis muscle and subcutaneous abdominal adipose tissue of seven healthy men during a hyperglycemic-euinsulinemic clamp with infusion of somatostatin to inhibit endogenous insulin release. We found that doubling fasting blood glucose values while maintaining plasma insulin in the fasting range modifies the expression of 316 genes in skeletal muscle and 336 genes in adipose tissue. More than 80% of them were downregulated during the clamp, indicating a drastic effect of acute high glucose, in the absence of insulin, on mRNA levels in human fat and muscle tissues. Almost all the biological pathways were affected, suggesting a generalized effect of hyperglycemia. The induction of genes from the metallothionein family, related to detoxification and free radical scavenging, indicated that hyperglycemia-induced oxidative stress could be involved in the observed modifications. Because the duration and the concentration of the experimental hyperglycemia were close to what is observed during a postprandial glucose excursion in diabetic patients, these data suggest that modifications of gene expression could be an additional effect of glucose toxicity in vivo.     

Detection of the center of the hip joint in computer-assisted surgery: an evaluation study of the Surgetics algorithm.

OBJECTIVE: The aim of this paper is to assess the accuracy of an algorithm implemented by PRAXIM in the SURGETICS navigation station for detection of the hip center. This study will assess the robustness and accuracy of the algorithm in various clinical situations such as those involving non-sphericity of the femoral head, motion of the pelvis during hip center detection, and restricted range of motion. MATERIALS AND METHODS: The localization of the hip center, based on kinematics, relies on the recording of n successive positions of the femoral rigid body in the localizer reference system during a passive circumduction motion of the hip joint. Therefore, the shape of the clouds of points acquired may vary from one acquisition to the next. To allow a comprehensive study of the consequences of these variations for hip center detection, we developed a simulator to generate numerous clouds of points. Results given subsequently for each test are the values of the difference between the femoral mechanical axis computed with C(c), the computed hip center, and the same axis computed with C(o), the reference hip center. RESULTS: Test 1: Sensitivity to noise. The errors ranged from 3.33 E - 12 (SD 3.29E - 12) for a noise of 0 mm to 8.18E - 1 (SD - 7.05E - 1) for a noise of 15 mm. Test 2: Sensitivity to the shape of the acquisition motion. All trajectories gave an error < 1 degrees . Test 3: Sensitivity to restricted range of motion. No value > 1 degrees was found during this test. Test 4: Sensitivity to the distance between two points of the cloud. No value > 0.5 degrees was found during this test. Test 5: Sensitivity to the number of points included in the cloud. No value > 1 degrees was found during this test. CONCLUSIONS: The Surgetics algorithm is robust to noise, can compensate for pelvic motion, and can be used even in the case of restricted range of motion.     

Psychological impact and cosmetic outcome of surgical breast cancer strategies

BACKGROUND: Current surgical treatment modalities for breast cancer include breast conserving surgery, mastectomy alone and mastectomy with breast reconstruction. There are recognized benefits of breast conservation and breast reconstruction over mastectomy but there are few studies assessing this area in Australia. The aim of the present study was to compare the various surgical strategies for breast cancer treatment in terms of quality of life, cosmesis and patient satisfaction. METHODS: A chart analysis was conducted of all patients who underwent Breast Cancer Reconstruction at the Royal Adelaide Hospital Breast Unit between 1990 and 2002. Patients were then traced and asked to take part in an interview. Mastectomy and breast conservation patients who attended outpatient clinic for follow up were also approached. All three groups were interviewed and self-assessment quality of life questionnaires (Functional Assessment of Cancer Therapy-Breast, body image) were administered. The breast conservation and reconstruction groups also underwent assessment of satisfaction and cosmesis. RESULTS: A total of 78 mastectomy, 109 breast conservation and 123 breast reconstruction patients were interviewed. Quality of life assessment was similar between the three groups but the breast conservation and reconstruction patients' body image scores were superior to the mastectomy group. Patient satisfaction was higher in the reconstruction group than the breast conservation group of patients, while cosmesis was similar. CONCLUSION: While little difference was seen on quality of life assessment, body image is improved with the use of breast conservation and reconstruction. The high satisfaction and cosmesis scores in the breast reconstruction group are an indication of the superior results that can be achieved with breast reconstruction.