经肛门内镜显微手术切除直肠肿瘤

目的评价经肛门内镜显微手术(TEM)切除直肠绒毛状腺瘤和早期直肠癌的应用效果。方法分析我院总结1995年11月至2001年12月27例TEM手术的临床资料。结果本组患者肿瘤直径中位值2.5cm,肿瘤下缘与齿状线距离(8.9±3.4)cm,肿瘤侵犯直肠周径范围(35.7±17.5)%。平均手术时间(109±46)min。平均住院日4.5d。无围手术期死亡。手术并发症有尿潴留、暂时性大便失禁和慢性阻塞性肺病(COPD)复发。术中2例切穿至腹腔,即刻内镜下修补成功。切缘100%瘤细胞阴性。病理示直肠绒毛状腺瘤14例、直肠腺癌13例,后者包括pTis2例,pT16例和pT25例。直肠癌腔内超声肿瘤T分期符合率为84.6%。5例pT2中2例中转前切除术,1例接受术后放疗,2例无附加任何治疗。平均随访18个月,所有病例无局部复发。死亡2例,但无复发迹象。结论TEM易行且安全,是直肠绒毛状腺瘤和部分T1直肠癌的治愈性手术,也可作为T2直肠癌的姑息性治疗手段。     

Patello-femoral joint in total knee replacement

Total knee arthroplasty (TKA) surgery is a widely used treatment and has a high success rate. Despite its success, the patello-femoral articulation has been overlooked as a contributor to the successful outcome of TKA. Patello-femoral complications remain the leading cause of failed knee replacement, accounting for up to 10% of complications. To understand the concept of patellar mal-tracking, we explore the normal anatomy and biomechanics of the patello-femoral articulation, and review the surgical factors and complications related to patellar tracking, with an aim to discussing the concepts on how to avoid such complications. Surgeons should be aware of the frequent occurrence of abnormal patellar tracking, and should pay particular attention to the patello-femoral component of knee replacement surgery.     

Arthroscopic double-pulley suture-bridge technique for rotator cuff repair

After preparation of the bone bed, two doubly loaded suture anchors with suture eyelets are inserted at the articular margin of the greater tuberosity. A retrograde suture-passing instrument penetrates the rotator cuff to retrieve the sutures through the modified Neviaser or subclavian portal. An ipsilateral pair of suture eyelets in the suture anchor is passed through the margins of the rotator cuff tear. The blue suture of the second and third pair is pulled out of the lateral cannula, and the threaded blue suture of the third pair in the needle is passed through the blue suture of the second pair. After retrieving the blue suture of the first pair through the anterior portal, it is pulled out to pass the blue suture of the third pair through the eyelet of the anteromedial anchor. The blue suture is linked between two anchors. The medial row of suture-bridge is repaired with a sliding knot, and the sutures are not cut. Once the rotator cuff repair using the suture-bridge technique has been performed, the two blue strands in the anterior portal are tied. We describe our technique that possesses the advantages of both the double-pulley and suture-bridge techniques, which improves the pressurized contact area and maximizes compression along the medial row.     

Combined CT venography and CT pulmonary angiography for the detection of deep venous thrombosis in injured patients

CT Venography (CTV) performed at the time of CT pulmonary angiography (CTPA) images the central, pelvic, and extremity venous circulation with minimal additional time, radiation, and no added contrast. CTV has been added to CTPA routinely at our Level I trauma center since 2000, and we sought to determine if this addition had increased the diagnostic yield of CTPA in trauma patients. The attending radiologist's interpretation of all CTPA-CTV studies performed over a 5-year period ending in August 2006 were retrospectively reviewed. CTPAs and CTVs were categorized as "positive", "negative", or "indeterminate" for pulmonary embolus (PE) and deep venous thrombosis (DVT). During the study period, 3798 patients underwent both a CTPA and CTV; 309 (8%) of these were trauma patients. Forty-four (14%) had a PE diagnosed on CTPA. Seventeen (6%) had a DVT diagnosed on CTV. In eight (3%), the CTV added clinically relevant data, diagnosing a DVT in a patient without PE. As the consequences of a missed pelvic DVT are high and the added time burden, radiation, and contrast required for a CTV are low, further investigation into optimizing the sensitivity of CTV performed at the time of CTPA is warranted.     

Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion

Humeral avulsion of the glenohumeral ligament (HAGL) is a rare lesion. The purpose of this study was to analyze the clinical manifestations of HAGL lesions in patients who underwent operative treatment for anterior shoulder instability. Six patients with HAGL lesions were studied. Four patients had an HAGL lesion associated with a Bankart lesion, and two had an isolated HAGL lesion. The range of motion at final follow-up showed a loss of 1 degree in forward flexion and of 15 degrees in external rotation. During an operation to treat anterior shoulder instability, a thorough examination for not only Bankart lesions but also other associated lesions, including an HAGL lesion, should be considered to lower the risk of redislocation. In repairing an HAGL lesion, the surgeon should keep in mind the possibility of a postoperative loss of external rotation and follow an active rehabilitation protocol to obtain successful results.     

The use of titanium mesh cages in the cervical spine.

Titanium mesh cages have been used widely for spinal reconstruction since 1986 when they first were introduced. Despite their popularity, relatively few studies have been published on their use in the cervical spine. These cages can be used as structural devices containing autologous local bone or iliac crest bone graft, obviating the need to harvest large structural bone grafts. The main disadvantages of their use are the increased costs and the difficulty of assessing fusion status. The authors review surgical techniques that can be used using titanium mesh cages in cervical spine applications and discuss some of their advantages and disadvantages.     

Can the Internal Iliac Artery Be Safely Covered during Endovascular Repair of Abdominal Aortic and Iliac Artery Aneurysms?

Aneurysmal involvement of the common iliac (CIA) or the internal iliac arteries (IIA) have been relative contraindications for safe endovascular aortic aneurysm (AAA) repair. Our goal was to review our experience in dealing with this problem by performing permanent coverage of one or both IIA during endoluminal repair of aneurysms of the aortoiliac region and to develop a safe, durable strategy. Of the 228 consecutive patients who had endoluminal repair of abdominal aortic (AAA) and iliac artery (IAA) aneurysms between 4/1999 and 4/2001 at our institution, 49 patients underwent coverage and/or coil embolization of one or both IIA during repair because of complex aortoiliac anatomy. These patients were evaluated prospectively for short-term adverse outcome. These results showed that CIA or IIA aneurysms can be managed safely during endoluminal repair of AAA. The IIA can be covered or embolized with minimum adverse consequences in patients who have inadequate CIA for deployment of the aortic or iliac endograft. Unilateral IIA occlusion is well tolerated. We advocate that whenever bilateral IIA occlusion is necessary during endovascular aneurysm repair, one of the IIAs should be revascularized if it is not aneurysmal.