2021年ACOG关于产后阶梯式多模式药物镇痛的建议及要点解读

产后疼痛是困扰产妇的常见问题,如治疗不当可能会导致阿片类药物滥用、产后抑郁和疼痛长期存在等不良后果。因此,美国妇产科医师学会（American College of Obstetricians and Gynecologists,ACOG）于2021年9月提出了针对产后疼痛的临床共识,专门对产后疼痛的一般管理、阴道分娩、剖宫产术后、母乳喂养时及出院后疼痛的处置给出了治疗建议与指导,强调了阶梯式多模式药物镇痛方法与个体化用药原则。推荐临床用药可遵循“非阿片类镇痛药（如对乙酰氨基酚和非甾体抗炎药）—弱阿片类药物—强阿片类药物（必要时）”阶梯式给药原则,并可合理联合用药。对此进行简要介绍与要点解读。     

夏商周断代工程的研究途径与阶段性成果

国家“九五”期间重点科技攻关计划项目“夏商周断代工程” ,经过200位专家学者前后5年的集体努力 ,已于2000年9月通过验收 ,同年11月公布了《夏商周断代工程1996-2000年阶段成果报告 (简本 )》。这一项目采取自然科学与人文社会科学多学科结合的研究途径 ,制定了《夏商周年表》 ,为我国古代夏商周这一重要历史时期的年代学提供了科学依据 ,使进一步探索中国古代文明起源及其早期发展有了可靠的基础。     

无胸壁缺损的心外胸骨旁小切口的可行性研究

目的研究以带蒂复合组织瓣修复胸骨旁小切口术后胸壁缺损的可行性。方法观察尸体前胸壁深层结构的血供 规律,测量胸骨外侧缘与胸廊内动脉之间的距离,并在此基础之上设计出以胸阔内动脉为蒂的肋软骨助间肌瓣。结果 前胸壁深层各结构均由胸廓内动脉及其分支供血,胸廊内动脉里胸骨外侧缘的距离为１ｃｍ左右。紧挨胸骨外侧缘切开 肋软骨,可以避免胸廓内动脉的损伤。以该动脉为帮,可以保证数种肋软骨肋间肌瓣有良好的血供。结论用以胸廊内动 脉为蒂的肋软骨助间肌瓣修复心脏外科术后的胸壁缺损具有良好的可行性。     

Retrosigmoid Approach in the Supine Position Using ORBEYE: A Consecutive Series of 14 Cases

One of the merits of recently introduced exoscopes, including ORBEYE, is that they are superior to a conventional microscope in terms of ergonomic features. Taking advantage of it, the retrosigmoid approach can be performed in the supine position using ORBEYE. We report a consecutive series of 14 operations through the retrosigmoid approach in the supine position using ORBEYE. Fourteen consecutive patients who underwent surgery through the retrosigmoid approach for cerebellopontine (CP) angle lesions in the supine position using ORBEYE were targeted, and surgical outcomes and complications were examined. We evaluated the posture of the operator and the surgical field during this approach compared with those using a conventional microscope. In all 14 cases, all operative procedures were accomplished only using the ORBEYE. There were no operative complications due to this approach. Using ORBEYE, even when the angle of the operative visual axis was horizontal, the operators could manipulate in a comfortable posture. They were not forced to be in an uncomfortable posture that extended their arms, as is often the case with a conventional microscope. Therefore, they could use shorter surgical instruments. As the cerebellum shifted downward with gravity even using slight retraction during this approach, the working space of the surgical field was easily secured. Through this approach, the operators can perform stable microsurgery of CP angle lesions in a comfortable posture. This approach can reduce the burden on the operator and the patient, leading to a refined surgical procedure.     

Capsular Management in Direct Anterior Total Hip Arthroplasty: A Randomized,Single-Blind,Controlled Trial

BackgroundThe direct anterior approach (DAA) is a popular approach to total hip arthroplasty (THA). Unlike the posterior approach, the importance of anterior capsular management is unknown. This randomized controlled trial compares capsular repair versus capsulectomy.MethodsThis single-surgeon, single-blinded, parallel-group randomized controlled trial occurred between 2013 and 2016. Patients undergoing unilateral, primary THA for osteoarthritis consented to undergo blinded, simple randomization to anterior capsulotomy with repair or anterior capsulectomy. Primary outcome measures included hip range of motion, hip flexion strength, and pain with seated hip flexion. Secondary outcome measures included surgical time, estimated blood loss, postoperative complications, and hip disability and osteoarthritis outcome score. Data were prospectively collected intraoperatively, six weeks, six months, an average of over 5 years postoperatively.ResultsNinety-eight patients were ultimately enrolled in the trial; 50 received capsulectomy and 48 received capsulotomy. No significant differences were seen in preoperative demographics or in primary or secondary outcomes during this study. No difference was seen in pain at final follow-up at average > 5 years postoperatively.ConclusionThis study demonstrates that capsular management in DAA THA does not affect postoperative pain or range of motion. The anterior capsule’s role in prosthetic stability after DAA THA remains uncertain, but it does not currently appear that repair provides benefit and may lead to increased surgical time and blood loss. As such, capsular management in DAA THA is at surgeon discretion.     

Magnetic Resonance Imaging Assessment of Abductor Muscles Shortly After Curved Periacetabular Osteotomy

BackgroundCurved periacetabular osteotomy (CPO) is performed via an anterior approach without detachment of the hip abductor muscles. This study aimed to evaluate the abductor muscle status shortly after CPO on magnetic resonance imaging (MRI).MethodsWe prospectively evaluated 38 hips in 38 patients 1 week and 3 months after CPO between October 2017 and July 2019. The status of the abductor muscles was assessed on MRI using the following criteria: grade 0, normal; grade I, strain/edema; grade II, partial tear; and grade III, complete tear. We also evaluated associations between muscle status and patients’ characteristics.ResultsOne week after CPO, the gluteus maximus was classified as grade 0 in all patients. The gluteus medius was grade 0 in 84.2% of patients and grade I in 15.8%. The gluteus minimus was grade I in 55.3% of patients and grade II in 44.7%. Three months after CPO, both the gluteus maximus and gluteus medius were grade 0 in all patients, while the gluteus minimus was still grade I in 47.4%. There were no significant differences between patients with a grade 0 and grade I gluteus minimus at 3 months after CPO in patients’ characteristics (age and body mass index) or clinical scores (Harris Hip Score and Japanese Orthopedics Association score).ConclusionBoth the gluteus minimus and medius showed abnormal appearances on MRI 1 week after CPO, whereas only the gluteus minimus showed abnormalities 3 months after CPO. This abductor muscle status did not affect the postoperative Harris Hip Score or Japanese Orthopedics Association score.     

Minimally invasive neurectomy for Morton’s neuroma with interdigital approach. Long term results

Background“Morton’s Neuroma” is a frequent cause of chronic forefoot pain. It can affect general population, including athletes, and can lead to progressive foot pain and discomfort for daily life activities and sports.Hypothesis/purposeOur objective is to evaluate the long-term results in a series of 85 feet, operatively treated with minimally invasive interdigital approach for neurectomy.Study designCase series.Method83 patients (85 feet) were treated between January 2003 and December 2019. The AOFAS score and VAS scale were used to evaluate the patients pre and postoperatively. Results were analyzed using the JASP software.ResultsMean age was 50.58 years (range 23–77). Eleven (11) were men, and seventy-four (74) women, with two bilateral cases. Mean follow up was 49 months. Our series was evaluated with AOFAS and VAS scores, both showing statistically significant improvement posterior to the operative procedure.ConclusionsA series of 85 feet operatively treated for Morton’s neuroma with minimally invasive interdigital approach for neurectomy is presented. Long term results were similar to other published series with different approaches, with the advantage of minimal incision, minimum soft tissue dissection and no need to release intermetatarsal ligament, immediate weightbearing and quick return to daily activities and sports. It is concluded that minimally invasive neurectomy with interdigital approach is a safe procedure for Morton’s neuroma treatment with similar results that other operative procedures.Level evidenceLevel IV.     

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.