The midvastus approach for total knee arthroplasty

Objective  Approach to the knee for total knee arthroplasty with the goal to avoid tendency to lateralization and extension lag. Indications  Implantation of total knee components. Revision surgery after total knee arthroplasty. Contraindications  Morbid obesity. For revision surgery: preoperative knee flexion of <60°. Surgical Technique  Anterior midline incision, blunt separation of the distal part of the obliquely running fibers of the vastus medialis over an extent of at least 5 cm. The muscle incision ends at the proximal and medial corner of the patella and is continued distally along the medial patellar border ending at the tibial tuberosity. After opening of the joint, the patella is dislocated laterally thus exposing the articular surfaces. After insertion of the components, superficial adaptation of the muscle fibers and wound closure in layers. Results  Of 297 total knee implants 276 knees (92.9%) could be followed up for an average of 36.2 (19–56) months. 153 knees were in women and 123 in men with an average age of 66.3 (33–81) years. In none of the operations a lateral release became necessary. The results were based on the score of the American Knee Society. The score showed 52.3 points preoperatively and 90.6 at follow-up. 95% of the patients had an excellent or good functional result. Tangential radiographs of the patella with the knee in 30° of flexion showed in 91% a central position in the patellar groove.     

Correction of pterygium colli deformity in Ullrich-Noonan syndrome

A case of Ullrich-Noonan syndrome with the typical marked webbed neck deformity is presented. The posterior approach is preferred for the correction of the webbed neck deformity. Bilaterally localized excess skin and the underlying fibrotic bands were excised in an elliptical shape. The webbed neck was corrected by a large classical z-plasty. After the transposition of z-plasty flaps, the final appearance of the neck was cosmetically satisfactory.     

Trans‐vitreal endoresection for vasoproliferative retinal tumours

We present an interventional consecutive case series to describe our experience of transvitreal endoresection (TVE) for vasoproliferative retinal tumours (VPRTs). Three patients with VPRTs refractory to conventional treatment modalities of cryotherapy, plaque radiotherapy and anti‐VEGF presented with macular exudative changes and were offered TVE. Complete ophthalmic examination with colour fundal photographs was performed before and during the follow‐up period. All patients were followed up for 6 months following silicone oil removal. At the last follow up, resolution of macular and retinal exudative changes with parallel improvement in vision was observed. No recurrences were detected during the follow‐up period. Two of three patients had simultaneous cataract surgery and developed fibrinous uveitis, requiring management with intensive topical steroids. After 3 months, these patients had a fibrotic pupillary membrane enveloping the intraocular lens (IOL) with posterior synechiae. These two patients underwent SO removal, IOL explantation and artisan IOL (iris clipped) insertion, resulting in visual improvement. We did not observe any PVR complications in our cases. TVE represents an effective and safe option for the treatment of VPRTs refractory to other treatment modalities. Further studies with a larger sample size and long‐term follow up are indicated to evaluate the role of TVE in the management of VPRTs.     

A novel surgical approach for complex destructive acetabular malignancies

Current treatment of acetabular defects created by metastatic disease involve extensile approaches removing the abductors from the greater trochanter or greater trochanteric osteotomy. We have developed a technique which does not involve removal of the muscle from the greater trochanter or trochanteric osteotomy. We remove the gluteus medius muscle from its anterior origin along several inches of the anterior iliac wing and the gluteus maximus from its insertion (the conjoined tendon) along the posterior proximal femur. The entire hip joint capsule is removed from anterior and posterior to the gluteus medius and minimus taking care to leave the insertion of these muscles intact. We have performed this approach in 13 patients with known metastatic disease and our preliminary results indicate that their limp and immediate weight bearing are improvements from the current standard of care involving removal of either the insertion of the gluteus medius and minimus from the greater trochanter or greater trochanteric osteotomy. J. Surg. Oncol. 2009;99:379–381. © 2009 Wiley‐Liss, Inc.     

Comparison of methods for transcatheter fragmentation of gallstones

Summary Alternative methods have been considered for treating cholelithiasis. Compared to extracorporeal shockwave lithotripsy (ESWL), a percutaneous endoscopic approach would be more invasive, but would offer the advantage of immediate stone removal without the need for subsequent drug therapy. We performed an in vitro comparison of three methods of transcatheter cholecystolithotripsy with regard to effectiveness of stone fragmentation, damage to the gallbladder mucosa, and compatibility with percutaneous delivery systems. The three devices used for cholecystolithotripsy were the ultrasonic lithotriptor (UL), the electrohydraulic lithotriptor (EHL), and the thulium-holmium-chromium: YAG laser (THC:YAG). The UL effectively fragmented all types of stones studied, although it is necessary to hold the stone against the tip of the probe. The EHL quickly fragmented noncalcified and pigment stones simply by placing the tip in the vicinity of the stone, but calcified stones had to be held in position near the electrode. The THC:YAG was effective at fragmenting each type of stone, but the number of pulses required was quite large, corresponding to 7 min for some stones. The EHL had the most capacity for mucosal damage, followed by the THC:YAG laser. The UL produced no mucosal damage at the exposure times tested. The UL is not compatible with flexible endoscopes while the EHL and the THC:YAG are. Because of the specific advantages and disadvantages of each device, a combination of devices may be required for successful clinical cholecystolithotripsy.     

经眉弓眶上锁孔入路切除鞍区病变

目的探讨经眉弓眶上锁孔入路治疗鞍区病变的显微手术技术。方法采用经眉弓皮肤切口,做2.0cm×2.5cm包分眶板在内的额下骨窗;应用显微手术技术处理鞍区病变20例。结果20例鞍区病变采用经眉弓眶上锁孔入路愈,包括垂体瘤9例,颅咽管瘤4例,后交通动脉瘤1例,鞍膈脑膜瘤1例,鞍结节脑膜瘤1例,嗅沟脑膜瘤1例,脊神经损伤2例,1例出现一过性尿崩症,3例出现电解质紊乱,所有20例均经随访,到目前为止,无一例复发。结上锁孔入路可明显减少手术创伤,同时能提供鞍区足够的手术空间,并能有效地处理病变。     

椎间孔镜BEIS技术治疗老年腰椎侧隐窝狭窄症

目的 :探讨经皮椎间孔镜BEIS(broad easy immediate surgery)技术治疗老年腰椎侧隐窝狭窄症的安全性及有效性。方法:2014年2月至2016年5月,采用经皮椎间孔镜BEIS技术治疗21例老年腰椎侧隐窝狭窄症患者,其中男13例,女8例,年龄70~85岁,平均74.3岁。记录术前、术后1、12个月腿痛视觉模拟评分(visual analogue scale,VAS)及Oswestry功能障碍指数(Oswestry Disability Index,ODI),统计分析术前及术后各时间点的差异。用改良MacNab标准评价疗效。结果 :21例患者均顺利完成手术,手术时间90~130 min,平均110 min。所有病例获得随访,时间12~38个月,平均18个月。术前、术后1、12个月的VAS评分分别为8.47±1.23、1.78±0.72、0.68±0.32,术前、术后1、12个月的ODI评分分别为32.48±10.03、19.53±3.55、5.15±1.02,术后2个时间点随访的VAS评分及ODI评分,均较术前明显改善(P0.05)。术后12个月采用改良Mac Nab标准评定疗效,优14例,良5例,可2例。术后出现下肢感觉异常1例,给予保守治疗,术后3周恢复。1例肺气肿患者术后出现肺部感染,经抗感染治疗后控制。无椎体或椎间隙感染、血管及神经根损伤、硬脊膜撕裂脑脊液漏等并发症发生。结论:经皮椎间孔镜BEIS技术治疗老年腰椎侧隐窝狭窄症是一种安全、有效、微创的手术方法,但技术难度较大,特别是对于严重的椎间孔狭窄,经椎间孔入路操作困难,应严格把握手术适应证。术后可能并发神经激惹及术后感觉异常。     

Attention-Deficit/Hyperactivity Disorder: A Neurodevelopmental Approach

TOPIC. Attention-deficitlhyperactivity disorder is frequently overdiagnosed when a complete evaluation by a knowledgeable clinician is not undertaken. Because of the recent negative media campaign regarding psychos t im ulan t medication, it becomes more imperative that a thorough and accurate evaluation be completed before starting children and adolescents on psychostimulant medications.
PURPOSE. To describe the neurodevelopmental perspective in the assessment and treatment of ADHD.
SOURCES. Published literature and clinical experience.
CONCLUSION. It is useful in practice to conceptualize the dmelopmental path of children with ADHD not as disordered but as delayed, and to build on each child's strengths. The neurodmeloprnental approach provides the child psychiatric nurse a child-focused framework for assessment and development of individualized interventions.     

天幕裂孔后内方病变手术入路显微解剖研究

目的：比较天幕裂孔后内方病变常用的手术入路，特别对经枕经天幕入路作深入研究。方法：应用经乳胶灌注成人福尔马林固定头颅湿标本，共10具，模拟幕下小脑上入路和经枕经天幕入路，体会两种入路暴露的范围、经过的重要结构。结果：行经枕经天幕入路Galen静脉显露满意；幕下小脑上入路Galen静脉及其主要属支大脑内静脉显露差。经枕经天幕入路能良好暴露天幕游离缘水平以上的结构；幕下小脑上入路能良好暴露天幕裂孔后方空闰的下半部分。经枕经天幕入路当体位放在3／4俯卧位术侧朝下时，枕极牵开较易，暴露松果体区、中脑和接近三脑室后部都较方便。坐位时处理小脑上表面时比较方便。枕内侧静脉以及距状沟、顶枕沟的交汇点可以作为定位大脑后动脉、脉络膜后内侧动脉以及Galen静脉的标志。结论：经枕经天幕入路可用于主体主要位于天幕裂孔后内方空间上半部的病变，同时也适用于部分延伸至下半部分的病变，对于累及小脑前上部和四叠体的病变也适用。幕下小脑上入路主要适用于那些位于中线且完全位于天幕裂孔后内方空间下半部分、侵及四叠体和小脑前上部的病变。对于两种入路均可选择的病变，我们更倾向于选择经枕经天幕入路。3／4俯卧位术侧朝下体位是适合经枕经天幕入路的较好体位；坐位仍有一定的应用价值。枕内侧静脉以及距状沟、顶枕沟的交汇点可以作为定位大脑后动脉、脉络膜后内侧动脉以及Galen静脉的标志。