前循环TIA患者血清总胆红素水平与ABCD2评分

目的探讨动脉粥样硬化(AS)性前循环短暂性脑缺血发作(TIA)患者血清总胆红素(T.Bil)水平与其ABCD2评分的相关性。方法收集前循环TIA患者133例进行ABCD2评分,根据评分分为低危亚组、中危亚组和高危亚组,收集其血清T.Bil水平资料,比较三组间血清T.Bil平均水平,分析血清T.Bil水平与ABCD2评分的相关程度及其临床意义。结果 TIA患者血清T.Bil水平较对照组显著降低,差异有统计学意义(P<0.05)。Kruskal-Wallis H检验显示,三组间血清T.Bil平均水平差异有统计学意义(P=0.004),高危亚组[(7.59±2.05)μmol/L]低于中危亚组[(9.45±3.08)μmol/L],中危亚组低于低危亚组[(11.53±2.26)μmol/L](均P<0.05)。经Spearman秩相关系数检验,血清T.Bil水平与ABCD2评分呈负相关(r=-0.269,P=0.002)。结论 TIA患者血清T.Bil水平随ABCD2评分的增高而降低,并与ABCD2评分呈负相关。     

颅脑损伤大鼠下丘脑前部、延髓内脏带突触膨体素和突触蛋白Ⅰ的表达变化

目的探讨颅脑损伤大鼠伤后不同时间下丘脑前部和延髓内脏带脑组织突触膨体素（SYN）和突触蛋白I（SYN-I）表达的变化,以及致应激性胃溃疡的变化。方法将40只成年SD大鼠按随机数字表法随机分为四组：对照组（C组,n=10）、颅脑损伤后1 h组（T1组,n=10）、颅脑损伤后6 h组（T1组,n=10）、颅脑损伤后12 h组（T1组,n=10）。利用液压装置以1.8个标准大气压的压力打击致大鼠颅脑损伤。应用胃溃疡指数评估应激性胃溃疡,利用免疫印迹法观察各组下丘脑前部和延髓内脏带脑组织SYN和SYN-I的表达变化。结果 C组、T1组、T6组、T12组胃溃疡指数分别为0、7.2±0.6、13.8±1.4、29.1±3.0,两两比较均有统计学差异（P〈0.05）。与C组相比,下丘脑前部脑组织SYN和SYN-Ia伤后6 h内无明显变化（P〉0.05）,伤后12 h SYN和SYN-Ia明显升高（P〈0.05）;SYN-Ib伤后1 h即明显升高（P〈0.05）。与C组相比,延髓内脏带脑组织SYN伤后1 h即明显升高（P〈0.05）,而SYN-Ⅰb明显降低（P〈0.05）;SYN-Ⅰa伤后1 h显著增高（P〈0.05）,伤后6 h达高峰,伤后12 h逐渐降低,但仍显著高于C组（P〈0.05）。结论颅脑损伤导致的应激性胃溃疡随时间延长逐渐加重;还可导致下丘脑前部和延髓内脏中枢发生突触可塑性的改变,其引起的突触传递效率的改变可能与应激性胃溃疡有关。     

Foot and Ankle Function after Tibial Overlengthening

Lengthening the tibia more than 25% of its original length can be indicated for proximal femoral deficiency, poliomyelitis, or femoral infected nonunion. Such lengthening of the tibia can adversely affect the ankle or foot shape and function. The present study aimed to assess the effect of tibial lengthening of more than 25% of its original length on the foot and ankle shape and function compared with the preoperative condition. This was a retrospective study of 13 children with severe proximal focal femoral deficiency, Aitken classification type D, who had undergone limb lengthening from June 2000 to June 2008 using Ilizarov external fixators. The techniques used in tibial lengthening included lengthening without intramedullary rodding and lengthening over a nail. The foot assessment was done preoperatively, at fixator removal, and then annually for 3 years, documenting the range of motion and deformity of the ankle and subtalar joints and big toe and the navicular height, calcaneal pitch angle, and talo-first metatarsal angle. At fixator removal, all cases showed equinocavovarus deformity, with decreased ankle, subtalar, and big toe motion. The mean American Orthopedic Foot and Ankle Society score was significantly reduced. During follow-up, the range of motion, foot deformity, and American Orthopedic Foot and Ankle Society score improved, reaching nearly to the preoperative condition by 2 years of follow-up. The results of our study have shown that tibial overlengthening has an adverse effect on foot and ankle function. This effect was reversible in the patients included in the present study. Lengthening of more than 25% can be safely done after careful discussion with the patients and their families about the probable effects of lengthening on foot and ankle function.     

End-Stage Hindfoot Arthrosis: Outcomes of Tibiocalcaneal Fusion Using Internal and Ilizarov Fixation

End-stage post-traumatic pantalar arthrosis from ankle, pilon, and talus fractures has often been complicated by infection, bone loss, and a soft tissue deficit. Patients can present with neuropathy, diabetes, tobacco use, and previously failed arthrodesis. Fusion in this population has been challenging, with nonunion rates up to 30%, often leading to amputation. We reviewed the results of a standardized protocol that combined simultaneous internal fixation with the Ilizarov technique to achieve fusion in high-risk patients. With institutional review board approval, a retrospective review of the patients treated with simultaneous internal fixation and an Ilizarov frame was undertaken. The records and radiographs allowed identification of the comorbidities and the presence or absence of successful fusion. Complications were acknowledged and treated. Fifteen patients had undergone the procedure. The mean follow-up period was 27.9 (range 9 to 67) months. Thirteen patients (86.67%) had had previous fusion failure. Twelve patients (80%) had developed post-traumatic arthrosis, 5 (33.33%) of whom had open injuries. All patients had 1 comorbidity, and 10 (66.67%) had multiple, including rheumatoid arthritis, diabetes (types 1 and 2), and smoking. Four patients (26.67%) presented with deep infection and bone loss. Union was achieved in 11 (73.33%), with 12 (80%) patients experiencing profound pain relief. Seven patients (46.67%) required symptomatic hardware removal. Three patients (20%) eventually underwent below-the-knee amputation for recalcitrant nonunion. Statistically significant correlations were found between smoking and wound infection and revision and between nonunion and amputation. Our results have indicated that combined internal fixation with Ilizarov application can provide a strong surgical option for the management of end-stage, pantalar arthritis. More studies are needed to compare the cohort outcomes and gait analysis in these patients with those who have chosen below-the-knee amputation.     

Complications,outcomes, and need for fusion after minimally invasive posterior cervical foraminotomy and microdiscectomy

Background context

Posterior cervical foraminotomy (PCF) with or without microdiscectomy (posterior cervical discectomy [PCD]) is a frequently used surgical technique for cervical radiculopathy secondary to foraminal stenosis or a laterally located herniated disc. Currently, these procedures are being performed with increasing frequency using advanced minimally invasive techniques. Although the safety and efficacy of minimally invasive PCF/PCD (MI-PCF/PCD) have been established, reports on long-term outcome and need for secondary surgical intervention at the index or adjacent level are lacking.

Purpose

To determine the rates of complications, long-term outcomes, and need for secondary surgical intervention at the index or adjacent level after MI-PCF and microdiscectomy.

Study design

Retrospective analysis of a prospective cohort.

Patient sample

Seventy patients treated with MI-PCF and/or MI-PCD for cervical radiculopathy.

Outcome measures

Visual Analog Scale for neck/arm (VAS_N/A) pain and Neck Disability Index (NDI).

Methods

Ninety-seven patients underwent MI-PCF with or without MI-PCD between 2002 and 2011. Adequate prospective follow-up was available for 70 patients (95 cervical levels). The primary outcome assessed was need for secondary surgical intervention at the index or adjacent level. The secondary outcomes assessed included complications and improvements in NDI and VAS_N/A scores. All complications were reviewed. Mixed-model analyses of variance with random subject effects and autoregressive first-order correlation structures were used to test for differences among NDI, VAS_A, and VAS_N measurements made over time while accounting for the correlation among repeated observations within a patient. All statistical hypothesis tests were conducted at the 5% level of significance.

Results

Patients were followed for a mean of 32.1 months. Of 70 patients operated, there were 3 (4.3%) complications (1 cerebrospinal fluid leak, 1 postoperative wound hematoma, and 1 radiculitis), none of which required a secondary operative intervention. Five patients required an anterior cervical discectomy and fusion (eight total levels fused) on average 44.4 months after the index surgery. Of those, five (5.3%) were at the index level and three (2.1%) were at adjacent levels. Neck Disability Index scores improved significantly (p<.0001) immediately postoperatively and continued to decrease gradually with time. Visual Analog Scale for neck/arm scores improved significantly (p<.0001) from baseline immediately postoperatively but tended to plateau with time.

Conclusions

Minimally invasive PCF with or without MI-PCD is an excellent alternative for cervical radiculopathy secondary to foraminal stenosis or a laterally located herniated disc. There is a low rate (1.1% per index level per year) of future index site fusion and a very low rate (0.9% per adjacent level per year) of adjacent-level disease requiring surgery.     

Comparison of complications,costs, and length of stay of three different lumbar interbody fusion techniques: an analysis of the Nationwide Inpatient Sample database

Background contextLumbar interbody fusion (LIF) techniques have been used for years to treat a number of pathologies of the lower back. These procedures may use an anterior, posterior, or combined surgical approach. Each approach is associated with a unique set of complications, but the exact prevalence of complications associated with each approach remains unclear.PurposeTo investigate the rates of perioperative complications of anterior lumbar interbody fusion (ALIF), posterior/transforaminal lumbar interbody fusion (P/TLIF), and LIF with a combined anterior-posterior interbody fusion (APF).Study design/settingRetrospective review of national data from a large administrative database.Patient samplePatients undergoing ALIF, P/TLIF, or APF.Outcome measuresPerioperative complications, length of stay (LOS), total costs, and mortality.MethodsThe Nationwide Inpatient Sample database was queried for patients undergoing ALIF, P/TLIF, or APF between 2001 and 2010 as identified via International Classification of Diseases, ninth revision codes. Univariate analyses were carried out comparing the three cohorts in terms of the outcomes of interest. Multivariate analysis for primary outcomes was carried out adjusting for overall comorbidity burden, race, gender, age, and length of fusion. National estimates of annual total number of procedures were calculated based on the provided discharge weights. Geographic distribution of the three cohorts was also investigated.ResultsAn estimated total of 923,038 LIFs were performed between 2001 and 2010 in the United States. Posterior/transforaminal lumbar interbody fusions accounted for 79% to 86% of total LIFs between 2001 and 2010, ALIFs for 10% to 15%, and APF decreased from 10% in 2002 to less than 1% in 2010. On average, P/TLIF patients were oldest (54.55 years), followed by combined approach (47.23 years) and ALIF (46.94 years) patients (p<.0001). Anterior lumbar interbody fusion, P/TLIF, and combined surgical costs were $75,872, $65,894, and $92,249, respectively (p<.0001). Patients in the P/TLIF cohort had the greatest number of comorbidities, having the highest prevalence for 10 of 17 comorbidities investigated. Anterior-posterior interbody fusion group was associated with the greatest number of complications, having the highest incidence of 12 of the 16 complications investigated.ConclusionsThese data help to define the perioperative risks for several LIF approaches. Comparison of outcomes showed that a combined approach is more expensive and associated with greater LOS, whereas ALIF is associated with the highest postoperative mortality. These trends should be taken into consideration during surgical planning to improve clinical outcomes.     

A case report on the usefulness of early endoscopic ultrasound (EUS)-guided transgastric internal stenting for severe blunt pancreatic trauma

IntroductionTherapeutic strategies for pancreatic trauma vary greatly depending on its severity. Surgical intervention is recommended in cases of severe pancreatic injuries for which standard therapy is not advised. We present a two-step treatment method for severe pancreatic injury using an endoscopic ultrasound (EUS)-guided transgastric internal stent.Clinical caseA 50 year-old male with blunt abdominal trauma sustained in a traffic accident was transported with vital signs indicating shock and CT findings of complete transection of the proximal pancreas and a huge haematoma. A life-saving primary emergency damage control operation was performed. A secondary EUS-guided transgastric internal stent was placed into the pancreatic fluid collection on post-operative day 8 (POD 8). The pancreatic juice secreted from the transected pancreatic tail eventually flowed along the internal stent and emptied completely into the stomach. The patient did not display prognostic symptoms at discharge.DiscussionEUS-guided transgastric internal stenting is currently considered the first line of therapy for pancreatic pseudocysts. It is recommended that pseudocyst drainage occur at least four weeks or more after its formation. In this severe case of blunt pancreatic trauma, the primary damage control operation saved the patient's life. Following primary surgery, a secondary early operation involved insertion of an EUS-guided transgastric internal stent into the collection of pancreatic juice secreted from the transected pancreatic tail, which allowed complete recovery without surgical extraction or reconstruction of the pancreatic tail.ConclusionIn cases of severe pancreatic trauma, practitioners should consider the value of early EUS-guided transgastric internal stenting.     

上臂内侧切口钢板内固定治疗肱骨干骨折

目的探讨肱骨干骨折采用切开复位钢板内固定治疗的效果。方法回顾性分析自2010-01—2012—01收治的肱骨干骨折165例,其中105例获得随访纳入本研究,根据手术入路的不同将其分为3组：A组上臂内侧切口39例;B组后侧切1：334例：C组前外侧切口32例。结果随访时间均超过12个月,3组骨折均愈合良好,A组愈合时间短于B、C组,差异有统计学意义（P〈0．05）,A、B组皮肤感觉优良率与C组比较差异有统计学意义（P〈0．05）,A、B、C3组间肩、肘功能比较差异无统计学意义（P〉0．05）。结论上臂内侧切口人路钢板内固定治疗肱骨干骨折是可行且安全的。