Conservative surgery for chronic diabetic foot osteomyelitis: Procedures and recommendations

Osteomyelitis (OM) is the most frequent infection associated with diabetic foot ulcers (DFU) that typically involve the forefoot, the most common location of DFU.Conservative surgical procedures could be attractive alternative that reduces minor and major amputations and avoid future recurrence thus preserving the functionally of the foot. This review aimed to analyze and describe the current evidence on conservative diabetic foot osteomyelitis (DFO) surgical procedures depending on DFU location and indications.A narrative revision of the evidence was carried out by searching Medline through PubMed databases from inception to late July 2020 to identify retrospective, prospective, and randomized controlled trials pertaining to conservative DFO procedures on the forefoot.Seven types of conservative surgical procedures for DFO treatment in the forefoot are described in this review: (1) partial or total distal phalangectomy, (2) arthroplasty of the proximal or distal interphalangeal joint, (3) distal Syme amputation, (4) percutaneous flexor tenotomy, (5) sesamoidectomy, (6) arthroplasty of the metatarsophalangeal joint, and (7) metatarsal head resection.When indicated, conservative surgery for DFUs in patients with chronic forefoot OM is a safe and effective option that increases the chances of healing and reduces the possibility of limb loss and death compared with radical amputation procedures.Since a lack of sufficient evidence supporting this procedure exists, future investigations should be focused on the random clinical trial (RCT) design. The results of prospective trials could help surgeons select the appropriate procedure in each case in order to minimize complications.     

Multidisciplinary Approach to the Management of Extensive Dermato-fibro-sarcomas Involving the Chest Wall

Dermato-fibro-sarcomas are known for high-recurrence rates. The gold standard of management is surgical excision with clear margins. Such margins on the chest results in large defects which require complex reconstructive procedures. We report a case series of patients managed by a multidisciplinary team with good outcomes. A total of 12 patients with extensive dermato-fibro-sarcoma of the anterior chest wall were treated over a period of 5 years in our setting. The age range was 25 to 54 years. Skeletal defects were reconstructed with Prolene mesh and methyl acrylate cement in 10 of the 12 patients. Pedicle flaps were used in nine patients. All margins were clear of tumors, with the nearest margin being 1.5 cm. One patient had a recurrence. No donor-site morbidity was recorded in any of the patients.In conclusion, a multidisciplinary approach provides improved outcomes in the management of large dermato-fibro-sarcomas of the chest wall. With this approach, extensive dissection of the tumor is achieved, and reconstruction is performed with minimal complication.     

Comprehensive review of surgical approaches to the elbow

The choice of the most suitable surgical approach to the elbow forms the foundation of any successful elbow surgery. The surgical approach is based on the injury or pathology to be addressed and therefore specific anatomical details need to be considered. The surgeon must be comfortable with the bony, ligamentous and neurovascular anatomy of the elbow to consider and execute the best approach for each problem. This is an imperative to avoid iatrogenic injury.This article provides a detailed analysis, valuable technical tips, advantages and disadvantages of the most common approaches to the elbow. The lateral approaches include the Kocher, Kaplan and Extensor Digitorum Communis (EDC) Split approaches, the medial approaches include the Hotchkiss, Flexor carpi ulnaris (FCU) splitting approach, the Taylor and Scham approach. The anterior approach includes the anterior neurovascular interval approach and the posterior approaches include the Olecranon osteotomy, triceps sparing, triceps reflecting approach and finally the Boyd interval approach. The text and illustrations will provide a structured overview for the practicing surgeon.     

完全神经内镜下经Poppen锁孔入路松果体区手术的应用解剖学研究

目的 解剖观察完全神经内镜下经Poppen锁孔入路开颅松果体区手术的相关解剖结构及其特征,并探讨该术式的可行性。方法 选取12具经10%甲醛固定、红蓝乳胶灌注的成人尸头湿标本进行实验观察,其中男7例、女5例,年龄34~71岁。应用随机数字表法将12具标本随机分为内镜组和显微组,每组6具,分别采用完全神经内镜Poppen锁孔入路和显微镜常规Poppen入路进行模拟开颅手术松果体区手术。模拟手术中,利用神经导航对松果体区以及手术间隙进行观察测量：（1）观察2组松果体区重要解剖结构;（2）内镜组术中,于剪开小脑幕前后,分别测量松果体区暴露面积,并采用配对t检验进行比较;（3）内镜组与显微镜组术中,分别测量第1、2、3手术间隙的暴露面积,并采用独立样本t检验进行组间比较;（4）其他重要解剖结构间距的神经内镜测量。结果 （1）2种入路均可观察到双侧基底静脉、小脑中脑裂静脉、大脑内静脉、大脑后动脉、小脑上动脉等重要血管,以及滑车神经、四叠体、胼胝体压部和松果体等重要解剖结构,但显微镜常规Poppen入路的手术通道狭窄、倾斜,视野局限。（2）内镜组模拟手术中,剪开小脑幕前后松果体区显露面积分别为（73.14±3.38）mm²和（127.77±7.90）mm²,剪开后明显大于剪开前,差异有统计学意义（t=28.84,P<0.001）。（3）内镜组和显微镜组模拟手术中,第1、2、3手术间隙的暴露面积分别为（20.93±2.49）mm²、（72.55±4.18）mm²、（208.57±11.79）mm²和（9.12±1.12）mm²、（53.45±3.17）mm²、（175.29±9.98）mm²,内镜组均大于显微镜组,差异均有统计学意义（t=14.92、12.61、7.41,P值均<0.001）。（4）神经内镜测量显示：双侧基底静脉最大距离为（14.41±0.94）mm,双侧小脑中脑裂静脉最大距离为（8.23±0.84）mm,双侧大脑内静脉最大距离为（8.41±0.96）mm,双侧大脑内静脉最小距离（第1间隙最窄长度）为（2.58±0.22）mm,松果体中心点至丘脑枕部中心点距离为（16.83±1.16）mm。结论 完全神经内镜下经Poppen锁孔入路模拟手术中间隙恒定,可安全到达松果体区;与显微镜常规Poppen入路相比,完全神经内镜Poppen锁孔入路的手术操作空间更大,松果体区显露得更充分。     

结肠系膜入路与后腹腔入路腹腔镜肾盂成形术治疗小儿肾积水的疗效对比研究

目的:探讨经结肠系膜入路腹腔镜离断性肾盂成形术治疗小儿肾盂输尿管连接部梗阻的临床效果。方法:回顾分析2014年1月至2018年4月为96例左侧肾盂输尿管连接部梗阻患儿行腹腔镜离断性肾盂成形术的临床资料,其中经腹腔结肠系膜途径46例(观察组),经腹膜后途径50例(对照组),对比分析两组手术时间、术中出血量、引流管留置时间、术后进食时间、术后住院时间、并发症、肾脏恢复情况等。结果:手术均一次性完成。观察组与对照组手术时间[75(70,90)min vs.100(83,106)min]差异有统计学意义(P<0.001);两组术中出血量、引流管留置时间、术后进食时间、术后住院时间差异无统计学意义(P>0.05)。对照组术后1例出现漏尿,引流管术后9 d拔除,导致术后住院时间延长至11 d,余者均无并发症发生。术后随访24个月,两组肾积水、分肾功能恢复方面差异无统计学意义(P>0.05)。结论:经结肠系膜入路腹腔镜离断性肾盂成形术治疗小儿肾盂输尿管连接部梗阻具有操作空间大、手术时间短、不增加肠道干扰的优点,值得推广。     

A mini-incision carpal tunnel release technique to prevent pillar pain: A technical note

Pillar pain represents one of the most common complications of classic open carpal tunnel release (CTR). This complication causes a sense of discomfort worse than the compression syndrome itself. We, herein, introduce a new treatment method for CTR through a mini-incision, which allows subcutaneously cutting the transverse carpal ligament (TCL) and releasing the median nerve without neurovascular complications. This mini-incision approach can allow the direct visualization and preservation of the thenar motor branch in those rare cases where it has an aberrant origin. For the past 10 years, we have consecutively performed this technique in the surgical treatment of 318 patients with the diagnosis of primary CTS, without developing any neurovascular and tendon injuries as well as pillar pain.     

Comparison of extreme lateral approach with posterior approach in the treatment of lumbar degenerative diseases: A meta-analysis of clinical and imaging findings

ObjectiveTo compare clinical and imaging findings between extreme lateral lumbar interbody fusion (XLIF) and posterior fusion (PF) via meta-analysis for the treatment of lumbar degenerative diseases.MethodsEnglish papers reporting clinical and imaging findings for the treatment of lumbar degenerative diseases with XLIF and PF published electronically in the PubMed, Embase, Cochrane Library, and Web of Science databases from January 2006 to August 2019 were retrieved. Two authors independently extracted data and evaluated the quality of the included literature. Meta-analysis of outcome measures was performed using Stata 14 and RevMan 5.3 software.ResultsThis meta-analysis included 744 patients from nine studies, two of which were prospective studies, while the others were retrospective studies. The quality of each study was determined to be high. The meta-analysis showed no significant differences in the operative time, length of hospital stay, clinical effectiveness, and improvement in postoperative global sagittal alignment between two approaches (P > 0.05). However, XLIF was significantly better than PF in reducing intraoperative blood loss and recovery of local sagittal alignment (P < 0.05). Moreover, the high incidence of postoperative complications were detected in XLIF group (P < 0.05).ConclusionsBoth surgical approaches have equally promising clinical effectiveness for the treatment of lumbar degenerative diseases. Although XLIF can reduce intraoperative blood loss and obtain better postoperative local sagittal alignment than PF, the high incidence of postoperative complications should prompt us to consider why XLIF procedure is still being offered to our patients and how we can reduce these complications. In addition, any conclusions should be taken with caution because of the mix of prospective and retrospective studies, and the high heterogeneity and bias.     

Anatomical study of the human sacral hiatus and implications for successful caudal epidural injection

BackgroundCaudal epidural injection (CEI) is a commonly used procedure to treat back and leg pain secondary to nerve root irritation, predominantly in the context of spinal canal stenosis. Key to a successful outcome is correct needle placement. Although fluoroscopic guidance confirms accurate needle placement, it does not help in determining the starting point, which can lead to multiple needle insertions.ObjectiveThis study aimed to determine the variability in size and position of the sacral hiatus and to identify reproducible surface landmarks to locate its position.Methods and study design250 human sacral bones were examined, measuring morphology and structure. Vernier callipers accurate to 0.1 mm were used for measurements. Results were analysed using SPSS statistical software.ResultsTwo specimens were excluded due to agenesis of the hiatus (0.8%). Of the remaining 248 specimens, it was found that the mean internal diameter of the sacral hiatus was 5.12 mm (SD 1.61). The position of the hiatus was variable but was most commonly found at the level of the fourth sacral vertebrae (62.9%, n = 156). Mean distance between the two superolateral sacral prominences was 64.15 mm (SD 6.5) and between superolateral sacral prominences (left and right) and apex of the hiatus were 63.21 mm (SD 10.9) and 63.34 mm (SD 10.87) respectively.ConclusionAlthough there is a clear anatomical variance in the position and size of the sacral hiatus, this study suggests that surface anatomy landmarks can be used to form an equilateral triangle of which the inferior apex should correspond to the sacral hiatus. Knowledge of this surface anatomy may assist the correct location of the sacral hiatus and hence subsequently improve the efficacy of CEI.     

腹膜外入路腹腔镜下膀胱颈悬吊术治疗压力性尿失禁TVT-O术后失败或复发患者的初步经验

目的报道6例经腹膜外途径腹腔镜下膀胱颈Cooper韧带悬吊术(Burch手术)治疗女性压力性尿失禁行经阴道经闭孔尿道中段无张力悬吊术(TVT-O)术后失败或复发患者的初步经验。方法回顾分析2015年6月至2019年9月我们采用经腹腔镜下腹膜外途径Burch手术治疗的6例女性压力性尿失禁TVT-O术后失败或复发患者。自脐下2 cm处切开皮肤并制造腹膜外空间,用2#0薇荞线将尿道旁侧的阴道壁肌层“8字”缝合后再缝合到同侧Cooper韧带上。观察患者手术时间、出血量、住院时间等。结果所有手术均成功,手术时间(37±6)min,术中出血量(17±7)ml,术后住院时间(4.5±0.5)d。6例随访时间3~45个月,所有病例尿失禁症状均消失,均无感染、膀胱损伤、排尿困难、复发等并发症。结论女性压力性尿失禁患者行TVT-O术失败或复发后,选择腹腔镜下经腹膜外途径Burch术安全、有效,可以获得完全尿控,为临床可选方案。