The long-term outcome of revision microdiscectomy for recurrent sciatica

PURPOSE

To study the long-term outcome of revision microdiscectomy after classic microdiscectomy for lumbosacral radicular syndrome (LSRS).

METHODS

Eighty-eight of 216 patients (41%) who underwent a revision microdiscectomy between 2007 and 2010 for MRI disc-related LSRS participated in this study. Questionnaires included visual analogue scores (VAS) for leg pain, RDQ, OLBD, RAND-36, and seven-point Likert scores for recovery, leg pain, and back pain. Any further lumbar re-revision operation(s) were recorded.

RESULTS

Mean (SD) age was 59.8 (12.8), and median [IQR] time of follow-up was 10.0 years [9.0-11.0]. A favourable general perceived recovery was reported by 35 patients (40%). A favourable outcome with respect to perceived leg pain was present in 39 patients (45%), and 35 patients (41%) reported a favourable outcome concerning back pain. The median VAS for leg and back pain was worse in the unfavourable group (48.0/100 mm (IQR 16.0-71.0) vs. 3.0/100 mm (IQR 2.0-5.0) and 56.0/100 mm (IQR 27.0-74.0) vs. 4.0/100 mm (IQR 2.0-17.0), respectively; both p < 0.001). Re-revision operation occurred in 31 (35%) patients (24% same level same side); there was no significant difference in the rate of favourable outcome between patients with or without a re-revision operation.

CONCLUSION

The long-term results after revision microdiscectomy for LSRS show an unfavourable outcome in the majority of patients and a high risk of re-revision microdiscectomy, with similar results. Based on also the disappointing results of alternative treatments, revision microdiscectomy for recurrent LSRS seems to still be a valid treatment. The results of our study may be useful to counsel patients in making appropriate treatment choices.

Clinical and Radiologic Outcomes of Open Reduction and Internal Fixation without Capsular Incision for Inferior Glenoid Fossa Fractures

Background

Scapular surgery is usually undertaken via the posterior approach described by Judet. This approach allows access to the entire posterior scapular body; however, it results in severe soft-tissue injury and requires an incision in the deltoid muscle. To date, no clinical study has been reported on open reduction and internal fixation without capsular incision for displaced inferior glenoid fractures (Ideberg type II). The purpose of this study was to introduce an easy and less invasive approach to the inferior glenoid fossa and evaluate its clinical outcomes.

Methods

Ten patients with displaced inferior glenoid fractures underwent open reduction and internal fixation without capsular incision between January 2017 and July 2018. Postoperative computed tomography was performed to evaluate the reduction state within a week of the surgery. Clinical and radiological data from 7 patients who were followed up for more than 2 years were analyzed.

Results

The mean age of the patients was 61.7 years (range, 35-87 years). The mean follow-up period was 28.6 months (range, 24-42 months). The mean preoperative fracture gap and step-off values were 12.3 ± 4.4 mm and 6.8 ± 4.0 mm, respectively. Surgical stabilization was conducted 6.4 days (range, 4-13 days) after trauma. Mean postoperative-preoperative fracture gap and step-off values were 0.6 ± 0.6 mm and 0.6 ± 0.8 mm, respectively. At 24 months after surgery, the mean Constant score was 89.1 ± 10.6 points (range, 69-100) and the mean pain visual analog scale score was 1.4 ± 1.7 (range, 0-5). Bony union was observed in all patients. The mean time to bony union was 11 ± 1.7 weeks. The mean active range values for forward elevation, external rotation, and abduction were 162.9° ± 11.1° (range, 150°-180°), 55.7° ± 15.1° (range, 30°-70°), and 158.6° ± 10.7° (range, 150°-180°), respectively.

Conclusions

The presented posterior open reduction and internal fixation without capsular incision or extensive soft-tissue dissection may be an easy and less invasive surgical approach for inferior glenoid fossa fractures (Ideberg type II).

Life satisfaction and anxiety in women with urinary incontinence

BACKGROUND

This study aimed to examine satisfaction with life in patients with urinary incontinence and patients who underwent an operative procedure due to urinary incontinence.

METHODS

Women with a medical indication for surgery due to urinary incontinence problems but who had not yet had surgery (N = 110) and same-age women who had had a surgical procedure for urinary incontinence (N = 101) completed a set of questionnaires.

RESULTS

The results showed that women with urinary incontinence had significantly higher life satisfaction than women who underwent the operation. Contrary to expectations, women with urinary incontinence problems reported equal levels of life satisfaction to a comparable sample of postmenopausal normative women. Higher levels of life satisfaction were related to higher education level, employment, higher perceived socioeconomic level, and urban place of living.

CONCLUSION

It is important for physicians to address the problem of urinary incontinence with their patients and to examine the present anxiety symptoms, given that they may affect their subjective wellbeing.

Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study

OBJECTIVE

The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time.

METHODS

Patients who underwent primary repair of an iAAA by standard endovascular (EVAR) or open surgical repair (OSR) between 2014 and 2019 were selected from the DSAA for inclusion. The primary outcome was peri-operative mortality trend per year, stratified by OSR and EVAR. Secondary outcomes were trends per year in major complications, textbook outcome (TbO), and characteristics of treated patients. The trends per year were evaluated and reported in odds ratios per year.

RESULTS

In this study, 11 624 patients (74.8%) underwent EVAR and 3 908 patients (25.2%) underwent OSR. For EVAR, after adjustment for confounding factors, there was no improvement in peri-operative mortality (aOR [adjusted odds ratio] 1.06, 95% CI 0.94 - 1.20), while major complications decreased (2014: 10.1%, 2019: 7.0%; aOR 0.91, 95% CI 0.88 - 0.95) and the TbO rate increased (2014: 68.1%, 2019: 80.9%; aOR 1.13, 95% CI 1.10 - 1.16). For OSR, the peri-operative mortality decreased (2014: 6.1%, 2019: 4.6%; aOR 0.89, 95% CI 0.82 - 0.98), as well as major complications (2014: 28.6%, 2019: 23.3%; aOR 0.95, 95% CI 0.91 - 0.99). Furthermore, the proportion of TbO increased (2014: 49.1%, 2019: 58.3%; aOR 1.05, 95% CI 1.01 - 1.10). In both the EVAR and OSR group, the proportion of patients with cardiac comorbidity increased.

CONCLUSION

Since the establishment of this nationwide quality improvement initiative (DSAA), all outcomes of iAAA repair following EVAR and OSR have improved, except for peri-operative mortality following EVAR which remained unchanged.

A Modified Technique of Temporomandibular Joint Arthroscopic Operative Surgery of the Superior and Inferior Joint Spaces

PURPOSE

This paper describes in detail the first author's technique of performing arthroscopic surgery in both the superior and inferior joint spaces of the temporomandibular joint.

METHODS

The key is careful measurement of sagittal and coronal tomograms to determine the individual size and shape of the joint. The joint is then distracted to allow 3-port video arthroscopy.

RESULTS

The detailed steps in the procedure are described and illustrated.

CONCLUSION

This modified technique is safe and allows procedures in both joint spaces and surgical access to the fossa, condyle and disc.

An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer

When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as "artery-first" approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.

Three-dimensional computed tomography analysis and functional results of calcaneal fractures treated by an intramedullary nail

BACKGROUND

Intramedullary calcaneal nailing is used to treat displaced intra-articular calcaneal fractures. The main goal of the study was to assess the reduction of tomography and secondary goals were patient functional scores and complication rates.

METHODS

The functional outcome and restoration of the radiographic parameters were evaluated post-operatively, at three months, at one year, and at the last follow-up. The morphology of the posterior facet was evaluated post-operatively, at one year and at the last follow-up by CTs.

RESULTS

Twenty-six patients were included. The mean follow-up was 2.8 years. The mean AOFAS-AHS was 79 at the last follow-up. The mean calcaneal height index and length rose respectively from 0.44 to 0.86 and 83 to 87 mm, and the width decreased from 50 to 46 mm.

CONCLUSION

The radiographic parameters were restored. The AOFAS-AHS was comparable with other series. This study confirms the efficiency of this procedure with lower rate of complications.

[Diagnostics and treatment of posterior shoulder instability]

Posterior shoulder instability has a markedly lower incidence than anterior shoulder instability. It has a wide spectrum of clinical symptom manifestations and the overwhelming number of patients lack a traumatic primary dislocation. In addition to a detailed medical history, a specific clinical examination with the help of standardized provocation tests is essential for the diagnostics. For the detection of structural posterior capsule and labral lesions in cases of chronic courses, magnetic resonance imaging (MRI) should be used with an intra-articular contrast agent. Relevant bony defects of the humeral head (reverse Sachs-Hill lesion) are frequent, whereas critical posterior defects of glenoid cavity are relatively rare. Both lesions should be quantified using 3D computed tomography. The choice of therapeutic procedure should be based on the underlying pathology of the defect. Conservative therapy is useful in patients with scapular dyskinesis, voluntary dislocation and pathological muscle patterning. In isolated soft tissue pathologies, arthroscopic labrum fixation and capsule plication are the standard treatment. In the case of insufficient soft tissue relations or critical posterior glenoid defects, bony stabilization of the glenoid using an iliac crest bone graft is the recommended therapy.

Laparoscopic ultrasound procedure can reduce residual myomas in laparoscopic myomectomy for multiple myomas

PURPOSE

To clarify whether the use of laparoscopic ultrasound (LUS) during laparoscopic myomectomy could reduce the number of residual myomas after surgery.

METHODS

A cohort study was conducted. Subjects were women who underwent laparoscopic myomectomy for multiple uterine myomas for the first time. The subjects were assigned to one of two groups: LUS group or non-LUS group. All subjects underwent pelvic MRI 3 months before and 6 months after surgery, and the number of myomas on MRI was counted by radiodiagnosticians. The extraction rate and residual rate of uterine myomas were compared between the two groups.

RESULTS

Fourteen cases with and 30 cases without LUS were analyzed. Median operation times were 171 min (range 75-295) and 141 min (range 50-260) in cases with and without LUS, respectively (p = 0.077). Median extraction rates relative to the total number of myomas were 106 % (range 75-147 %) in subjects with LUS and 100 % (range 71-233 %) in subjects without LUS (p = 0.480). Numbers of residual myomas were 1 (range 0-3) in subjects with LUS and 2 (range 0-9) in subjects without LUS (p = 0.028). Median residual rates of myomas were 6.1 % (range 0-20 %) in subjects with LUS and 20.0 % (range 0-69 %) in subjects without LUS (p = 0.048). Myomas greater than 3 cm in diameter were not observed in either group.

CONCLUSIONS

The number and residual rate of myomas were significantly less in subjects with LUS as compared with those without LUS.

[Causes and management of patellar instability after total knee replacement : Lateralization, subluxation and luxation]

BACKGROUND

Patellofemoral complications after total knee arthroplasty are responsible for a variety of surgical revisions.

OBJECTIVE

The causes of the various types of instability of the patella are listed in a differentiated way and the importance of clinical and imaging diagnostics as well as preventive strategies are elaborated.

MATERIAL AND METHODS

This article is based on a selective literature search in the PubMed database and on the long-standing experience of the author.

RESULTS

Besides postoperative genu valgum with malalignment of the extensor mechanisms, other risk factors for patellar maltracking are insufficiency of the medial retinaculum, weakening of the vastus medialis muscle, contracture of the quadriceps femoris or tractus iliotibialis muscle, residual valgus deformity after total knee replacement, femoral or tibial malrotation as well as malpositioning of the patella, inappropriate design of the prosthesis and asymmetrical resection of the patella. The causes with respect to incorrect component positioning, faulty preparation of the patella, leg malalignment, inappropriate design of the prosthesis and soft tissue imbalance have to be recognized in order to address the problem in a targeted way. The preferred method of choice in the case of patellofemoral instability after total knee replacement is normally surgery; however, the cause for the instability has to be identified and consequently corrected before surgery. Without a clearly identified cause surgical measures are unrewarding and almost regularly lead to an unsatisfactory outcome.

CONCLUSION

Patella maltracking after total knee arthroplasty is multifactorial and requires an accurate clarification. A surgical revision is only recommended in cases of clearly defined causes of pain or a clearly defined reason for patella malpositioning.

Learning curve of septoplasty with radiofrequency volume reduction of the inferior turbinate

Objectives

Since few studies on surgical training and learning curves have been performed, majority of inexperienced surgeons are anxious about performing operations. We aimed to access the results and learning curve of septoplasty with radiofrequency volume reduction (RFVR) of the inferior turbinate.

Methods

We included 270 patients who underwent septoplasty with RFVR of the inferior turbinate by 6 inexperienced surgeons between January 2009 and July 2011. We analyzed success score, cases of revision, cases of complication, operation time, and acoustic rhinometry.

Results

Success score was relatively high and every surgeon had few cases of revision and complication. No significant difference was found in success score, revision, complication case, or acoustic rhinometry values between early cases and later cases. Operation time decreased according to increase in experience. However, there was no significant difference in the operation time after more than 30 cases.

Conclusion

We can conclude that 30 cases are needed to develop mature surgical skills for septoplasty with RFVR of the inferior turbinate and that training surgeons do not need to be anxious about performing this operation in the unskilled state.

Surgical treatment of hepatocellular carcinoma: Evidence-based outcomes

Surgeons may be severely criticized from the perspective of evidence-based medicine because the majority of surgical publications appear not to be convincing. In the top nine surgical journals in 1996, half of the 175 publications refer to pilot studies lacking a control group, 18% to animal experiments, and only 5% to randomized controlled trials (RCT). There are five levels of clinical evidence: level 1 (randomized controlled trial), level 2 (prospective concurrent cohort study), level 3 (retrospective historical cohort study), level 4 (pre-post study), and level 5 (case report). Recently, a Japanese evidence-based guideline for the surgical treatment of hepatocellular carcinoma (HCC) was made by a committee (Chairman, Professor Makuuchi and five members). We searched the literature using the Medline Dialog System with four keywords: HCC, surgery, English papers, in the last 20 years. A total of 915 publications were identified systematically reviewed. At the first selection (in which surgery-dominant papers were selected), 478 papers survived. In the second selection (clearly concluded papers), 181 papers survived. In the final selection (clinically significant papers), 100 papers survived. The evidence level of the 100 surviving papers is shown here: level-1 papers (13%), level-2 papers (11%), level-3 papers (52%), and level-4 papers (24%); therefore, there were 24% prospective papers and 76% retrospective papers. Here, we present a part of the guideline on the five main surgical issues: indication to operation, operative procedure, peri-operative care, prognostic factor, and post-operative adjuvant therapy.