Rectus abdominis myocutaneous flap in radical oncopelvic surgery: A safe and useful procedure

AIMS: The aim of this retrospective study was to evaluate the usefulness of rectus abdominis myocutaneous (RAM) flaps to treat locally advanced pelvic gynaecological or digestive tumours. METHODS: We reviewed 46 patients, who received RAM flaps after radical oncopelvic surgery, including: (a) total vaginal reconstruction (TVR); (b) partial vaginal reconstruction (PVR); (c) perineal reconstruction (PR). RESULTS: Between 1989 and 1998, 46 patients underwent pelvi-perineal reconstruction with RAM flaps after radical pelvic surgery for carcinoma of the cervix (n=22), anal carcinoma (n=11), rectal carcinoma (n=7), or other pelvic tumours types (n=6). There were two post-operative deaths. Overall surgical morbidity was 45, 6% (n=21). Specific morbidity of the RAM flap was 21, 7% (n=10). Global re-intervention rate was 13% (n=6). CONCLUSION: Rectus abdominis myocutaneous flap in radical oncopelvic surgery is useful for vaginal or perineal reconstruction and prevention of pelvic collections after extended resections with a low rate of associated morbidity.     

经会阴四维盆底超声动态成像对初产妇膀胱膨出疾病分级与分型的临床价值

目的 探讨经会阴四维盆底超声动态成像对初产妇膀胱膨出疾病分级与分型的临床价值。方法 选取西安市第三医院2018年1月~2018年6月收治的盆底功能障碍性疾病（膀胱膨出）初产妇92例为研究对象,根据产妇的分娩方式分为经阴道分娩组（n=46）及剖宫产组（n=46）。在静息、屏气向下用力动作（Valaslva）及缩肛状态下观察两组患者膀胱尿道及盆膈裂孔的超声成像变化,测量膀胱相关参数数值并进行膀胱膨出Green分型。 结果 两组产妇经会阴盆底超声参数比较中,静止期BSD、尿道膀胱后角比较,差异均无统计学意义（均 P＞0.05）;剖宫产组产妇张力期BSD、尿道膀胱后角及膀胱颈移动度、尿道旋转角均明显小于经阴道分娩组产妇（均 P＜0.05）。 经阴道分娩组产妇膀胱膨出Green分型中,Ⅰ型6例（13.04%）,Ⅱ型26例（56.52%）,Ⅲ型14例（30.43%）;剖宫产组产妇膀胱膨出Green分型中,Ⅰ型14例（30.43%）,Ⅱ型23例（50.00%）,Ⅲ型9例（19.56%）。经阴道分娩组Ⅰ型膀胱膨出者明显少于剖宫产组,差异有统计学意义（P＜0.05）;而两组产妇Ⅱ型、Ⅲ型膀胱膨出例数比较,差异无统计学意义（P＞0.05）。结论 经会阴四维盆底超声检查可清楚显示盆底解剖结构,有效区分不同分娩方式产妇的盆底Green类型,为临床制定治疗方案提供可靠的影像学资料。     

Multiple tumors due to mosaic genome‐wide paternal uniparental disomy

Mosaic genome‐wide paternal uniparental disomy is an infrequently described disorder in which affected individuals have signs and symptoms that may resemble Beckwith–Wiedemann syndrome. In addition, they can develop multiple benign and malignant tumors throughout life. Routine molecular diagnostics may not detect the (characteristic) low level of mosaicism, and the diagnosis is likely to be missed. Genetic counseling and a life‐long alertness for the development of tumors is indicated. We describe the long diagnostic process of a patient who already had a tumor at birth and developed multiple tumors in childhood and adulthood. Furthermore, we offer clues to recognize the entity.     

骨科损伤控制治疗不稳定骨盆骨折合并四肢多发骨折的临床疗效观察

目的:分析研究骨科损伤控制(DCO)治疗不稳定骨盆骨折合并四肢多发骨折的临床效果。方法:回顾性分析我院收治的42例不稳定骨盆骨折合并四肢多发骨折患者采用骨科损伤控制治疗的效果。结果:42例患者救治成功39例,痊愈率92.9%,死亡3例,所占比例为7.1%。术后5个月观察可见4例患者因患肢功能异常,其余35例患者可自理生活;术后10个月随访观察可见,骨折愈合效果良好。结论:不稳定骨盆骨折合并四肢多发骨折实施连续性骨科控制,疗效显著。     

Tubo-ovarian Abscess in Virginal Adolescent Females: A Case Report and Review of the Literature

BackgroundA tubo-ovarian abscess (TOA) is a serious complication of pelvic inflammatory disease (PID), predominantly polymicrobial and present in sexually active women. TOA in virginal adolescent females are extremely rare but have serious and lifelong consequences.CaseA 13 y.o. virginal female presented to the Emergency Room of a tertiary care pediatric hospital with abdominal pain and vomiting. Imaging suggested bowel compromise with potential perforation. An exploratory laparotomy revealed TOA which grew Escherichia Coli. This is the first reported case of Escherichia Coli TOA due to suspected bowel translocation.ConclusionReview of the literature identified 8 cases of TOA in virginal adolescents. Given the severity of outcomes following TOA, this pathology should be considered in the differential diagnosis of virginal adolescents who present with fever and abdominal pain. If suspected, a prompt gynecology consult should be initiated, followed by a first line antibiotic therapy and when indicated, surgical drainage.     

Operative treatment for spinal deformities in cerebral palsy

The higher the functional impairment, the more likely patients with cerebral palsy (cP) are to develop a scoliotic deformity. This is usually long-sweeping, C-shaped, and progressive in nature, since the causes of the deformity, such as muscular weakness, imbalance, and osteoporosis, persist through adulthood. In contrast to idiopathic scoliosis, not only is the spine deformed, the patient is also sick. This multimorbidity warrants a multidisciplinary approach with close involvement of the caregivers from the beginning. Brace treatment is usually ineffective or intolerable in light of the mostly stiff and severe deformities and the poor nutritional status. The pros and cons of surgical correction need to weighed up when pelvic obliquity, subsequent loss of sitting balance, pressure sores, and pain due to impingement of the rib cage on the ileum become issues. General risks of, for example, pulmonary or urogenital infections, pulmonary failure, the need for a tracheostoma, permanent home ventilation, and death add to the particular surgery-related hazards, such as excessive bleeding, surgical site infections, pseudarthrosis, implant failure, and dural tears with leakage of cerebrospinal fluid. The overall complication rate averages around 25 %. From an orthopedic perspective, stiffness, marked deformities including sagittal profile disturbances and pelvic obliquity, as well as osteoporosis are the main challenges. In nonambulatory patients, long fusions from T2/T3 with forces distributed over all segments, low-profile anchors in areas of poor soft tissue coverage (sublaminar bands, wires), and strong lumbosacropelvic modern screw fixation in combination with meticulous fusion techniques (facetectomies, laminar decortication, use of local autologous bone) and hemostasis can be employed to keep the rate of surgical and implant-related complications at an acceptably low level. Excessive posterior release techniques, osteotomies, or even vertebrectomies in cases of very severe short-angled deformity mostly prevent anterior one- or two-stage releases. Despite improved operative techniques and implants with predictable and satisfactory deformity corrections, the comorbidities and quality-of-life related issues demand a thorough preoperative, multidisciplinary decision-making process that takes ethical and economic aspects into consideration.     

Risk factors for complications and in-hospital mortality: An analysis of 19,834 open pelvic ring fractures

BackgroundOpen pelvic fractures are rare injuries, associated with high patient morbidity and mortality. Few studies have investigated the impact of patient demographics, comorbidities, and injury related factors on complication and mortality rates. The purpose of this study was to: (1) identify the overall incidence of complications and mortality after open pelvic fractures, (2) compare patient factors between those who did and did not develop complications, (3) identify perioperative independent risk factors for complications and mortality.MethodsA query was performed for patients with open pelvic fractures between 2007 and 2017 using the American College of Surgeons National Trauma Data Bank. Patient and injury specific variables were collected and complications were identified using International Classification of Disease Ninth and Tenth edition Codes. Patient demographic and perioperative data was compared using Fisher’s exact test and chi-square test for categorical variables, and Welch’s t-test for continuous variables. Using pooled data from multiple imputations, logistic regressions were used to calculate odds ratios and confidence intervals of independent risk factors for complications.ResultsA total of 19,834 open pelvic fracture cases were identified, with 9622 patients (48.5%) developing at least one complication. Patients who developed complications were older (35.0 vs 38.1 years), and had higher Injury Severity Scores (17.7 vs 26.5), lower Glasgow Coma Scores (14.2 vs 11.7), and a larger proportion presenting with hypotension (21% vs 6.9%). After pooled regression involving 19 factors, these were the strongest independent predictors of inpatient complication and mortality.ConclusionWe report a mortality rate of 14%, with an inclusive complication rate of 48.5%. Evaluating risk factors for morbidity and mortality for this devastating orthopaedic injury provides knowledge of an inherently sparse population.Level of EvidenceLevel II, Retrospective study.     

Total hip arthroplasty in acetabular fractures

Total Hip Arthroplasty (THA) is a well-accepted treatment for established hip arthritis following acetabular fractures. If a conservatively managed or operated case progresses to non-union/mal-union failing to restore the joint integrity, it may eventually develop secondary arthritis warranting a total hip arthroplasty. Also, in recent years, acute total hip arthroplasty is gaining importance in conditions where the fracture presents with pre-existing hip arthritis, is not amenable to salvage by open reduction and internal fixation, or, a poor prognosis is anticipated following fixation.There are several surgical challenges in performing total hip arthroplasty for acetabular fractures whether acute or delayed. As a separate entity elderly patients pose a distinct challenge due to osteoporosis and need stable fixation for early weight bearing alleviating the risk of any thromboembolic event, pulmonary complications and decubitus ulcer. The aim of surgery is to restore the columns for acetabular component implantation rather than anatomic fixation. Meticulous preoperative planning with radiographs and Computed Tomography (CT) scans, adequate exposure to delineate the fracture pattern, and, availability of an array of all instruments and possible implants as backup are the key points for success. Previous implants if any should be removed only if they are in the way of cup implantation or infected. Press fit uncemented modern porous metal acetabular component with multiple screw options is the preferred implant for majority of cases. However, complex fractures may require major reconstruction with revision THA implants especially when a pelvic discontinuity is present.