Single-stage medial plateau elevation and metaphyseal osteotomies in advanced-stage Blount’s disease: a new technique

PurposeSurgical treatment in advanced-stage infantile Blount’s disease with medial plateau (MP) depression is challenging. Several osteotomies and fixation methods have been described with no established benchmark. We conducted this study to evaluate the efficacy and safety of a new single-stage technique for acute medial condyle elevation and metaphyseal osteotomies with internal fixation.MethodsA prospective case series of 19 consecutive patients (21 knees) with severe infantile Blount’s disease underwent a single-stage MP elevation and metaphyseal osteotomies, with internal fixation. The mean age was 10.3 years (8.2 to 13.6) and the mean follow-up was 5.1 years (3.2 to 8.3). The outcome measures included clinical and radiological parameters and patient-reported pediatric outcomes data collection instrument (PODCI) score.ResultsThe mean PODCI score improved significantly from 50% to 88%. The mean internal tibial torsion improved from -27° to 11°. All cases maintained full knee extension, no limitation in flexion range of movement and no signs of instability or lateral thrust gait. All the radiographic parameters improved significantly; the mean tibiofemoral angle improved from -29° to 7°, the metaphyseal-diaphyseal angle improved from 33.4° to 4.7° and the angle of depressed MP improved from 38.3° to 2.4° (p < 0.001). At the latest follow-up, no cases of deformity recurrence were identified, the final limb-length discrepancy was < 1 cm in all patients.ConclusionSingle-stage MP elevation and metaphyseal osteotomies with internal fixation significantly improved the clinical and radiographic parameters and PODCI score in advanced infantile Blount’s disease and precluded the use of external immobilization, with no evidence of deformity recurrence.Level of evidenceIV     

The extent of hearing impairment amongst Australian Indigenous prisoners in Victoria,and implications for the correctional system

An association between congenital hearing impairmentand deprivation has been suggested, but evidence is limited.We studied children born in Greater Glasgow,1985-94, with bilateral congenital hearing impairment.The children were divided into seven deprivation categoriesusing the Carstairs Deprivation Index. One hundredand twenty-four hearing-impaired children wereborn over the study period, an incidence of 1.18/1000 livebirths. There was a clear association between deprivationcategory and incidence, ranging from 0.47/1000 to1.72/1000. An association with deprivation was seen forchildren with a family history and perinatal problems(such as prematurity and low birth weight). No associationwas found for other aetiological groups such ascraniofacial syndromes or early postnatal infection.Deprivation had no effect on age of diagnosis or hearingaid provision. Deprivation is associated with congenitalhearing impairment, due to more prematurity and lowbirth weight in deprived families, and the fact that familieswith many hearing-impaired members are economicallydisadvantaged. There should be a strong emphasison the needs of the socio-economically disadvantagedwhen planning services for hearing-impaired children.     

“Holes-in-one”: A case of concurrent windsock mitral valve,root abscess,and Gerbode defect

Infective endocarditis is a heterogeneous disease with a wide array of pathological lesions. We present a 55-year-old man with severe mitral and aortic regurgitation on transthoracic echocardiography. Transesophageal echocardiogram characterized the mechanisms detecting a windsock mitral valve perforation, aortic root abscess, and Gerbode ventricular septal defect, with the deep transgastric view showing all three pathologies concurrently. The etiologies of mitral valve perforation and Gerbode defects are discussed. Transesophageal echocardiography remains a critical imaging modality to diagnose and evaluate the extent of infective endocarditis with superior sensitivity to transthoracic echocardiography.     

Patterns and management of vascular injuries in intravenous drug users: A literature review

BackgroundIntravenous drug use is becoming an increasing problem in today’s society causing an enormous socio-economic burden. Any intravenous injection will carry a risk of vascular injury. However, this risk will be significantly increased with repeated injections. With ongoing injection drug misuse, individuals are at risk of serious complex vascular injuries that can masquerade as simple illnesses.MethodsA comprehensive Medline search was conducted to identify key articles related to vascular injuries in intravenous drug users (IVDUs).ResultsNumerous arterial and venous injuries have been described as a result of intravenous drug use. This article reviews the literature to identify appropriate management of the peripheral vascular injuries encountered more and more often in this group of patients. Recommendations for investigation and treatment are made.ConclusionIntravenous drug users are notoriously difficult to treat and present late in the course of their illnesses. Despite management problems, it is important to have a high index of suspicion for serious vascular problems. Education and awareness of both patients and health care professionals may lead to earlier diagnosis and treatment of these conditions which carry significant morbidity and mortality.     

Proteomics applied to the clinical follow-up of patients after allogeneic hematopoietic stem cell transplantation

A phase 1 diagnostic study was performed to evaluate a novel technology for clinical proteomic research based on capillary electrophoresis and mass spectrometry. Urine from 40 patients after hematopoietic stem cell transplantation (HSCT; 35 allogeneic, 5 autologous) and 5 patients with sepsis was collected for a period of 100 days and analyzed. More than 1000 different polypeptides could be detected in individual samples. Polypeptide patterns excreted in the urine of patients were significantly different from those of healthy volunteers. No significant differences were detected comparing different conditioning regimens. The aim of this study was to identify polypeptide patterns functioning as early indicators of graft-versus-host disease (GVHD). Eighteen patients developed GVHD after allogeneic HSCT. Sixteen differentially excreted polypeptides formed a pattern of early GVHD markers, allowing discrimination of GVHD from patients without complications with 82% specificity and 100% sensitivity, cross-validated. Inclusion of 13 sepsis-specific polypeptides allowed us to distinguish sepsis from GVHD with a specificity of 97% and a sensitivity of 100%. Sequencing 2 prominent GVHD-indicative polypeptides led to the identification of a peptide from leukotriene A4 hydrolase and a peptide from serum albumin. The data reveal that capillary electrophoresis and mass spectrometry allow identification of biomarkers for a variety of diseases or related complications.     

Skeletonization and Isolation of the Glissonean and Venous Branches in Liver Surgery With an Ultrasonic Scalpel Technology

This study describes a novel technique for skeletonization and isolation of Glissonean and venous branches during liver surgery using a harmonic scalpel (HS). Hepatic resections with HS were performed with the skeletonization and isolation technique in 50 patients (HS group). Variables evaluated were blood loss, operative time, biliary leak, and morbidity. The results were compared with 50 hepatic resections that were performed using a previously established technique: Cavitron ultrasonic surgical aspirator with electric cautery, ligatures, and hemoclips (NHS group). The HS group had shorter total operative times (285 versus 358 minutes; P = 0.01), less blood loss (389 versus 871 mL; P = 0.034), and less crystalloid infusion (2744 versus 3299 mL; P = 0.027) compared with the NHS group. Postoperative liver function and complication rates were similar when comparing the two groups. These data demonstrate that HS is a simple, easy, and effective instrument for the skeletonization and isolation of vessels during liver transection.Key words: Liver resection, Ultrasonic scalpel, Skeletonization, Cavitation effectVarious devices are available for liver transection, but the availability of comparative data for transection techniques is limited by the diversity of operative procedures. Clamp crushing (CC) and a Cavitron ultrasonic surgical aspirator are widely used for splitting the liver parenchyma,^1,2 and hemostasis is achieved by bipolar coagulation, ligatures, or hemoclips. Various coagulating devices, such as Ligasure,³ Tissuelink,⁴ and the Harmonic Scalpel (HS),^5–7 have recently been developed to aid in liver splitting. The choice of instrument is often based on individual surgeon preference. Higami et al^8,9 described a novel technique to skeletonize and harvest the internal thoracic artery with the HS, and the present study capitalizes on their experience to describe a unique method to skeletonize and isolate the Glissonean and venous branches using an HS.