4th Postoperative Week Research Articles

Prevention of para-articular ossifications by radiotherapy after cementless total hip endoprosthesis implantation

By means of a prospective study, concerning the postoperative rate of ossification after cementless total hip replacement, it was due to prove the efficacy of radiotherapy in preventing periarticular ossification. In 1992 arthroplasty was followed by radiotherapy of 50 hip joints as regular therapy. The radiation was performed with a focal dose of 8 Gy. Patients with bilateral cementless total hip replacement and radiotherapy only at one side were of special interest in this study. Within the 24th postoperative week in 28 (56%) of the radiated hip joins no periarticular ossifications were found. In 20 (40%) we found ossifications grade 1, in 1 case ossification grade II and in 1 further case ossification grade III following the classification of Arcq. By 8 patients with former cementless total hip replacement without postoperative radiotherapy, a significant reduction of the ossification rate was found in the contralateral hip joint treated by postoperative radiotherapy. The rate of ossification was reduced by 28%. In correlation to reduction of periarticular ossification the increase on the overall range of motion in the radiated hip joins was 10.9%. By none of the patients treated by radiotherapy we found a disturbed healing process, a deep infection or an early loosening of the endoprosthesis. Postoperative radiotherapy as regular therapy for prophylaxis of periarticular ossification after Cementless total hip replacement can subsequently be recommended.

The Effect of Platelet Gels on Lumbar Intertransverse Process Spinal Fusion in a Rabbit Model

Objectives: Platelets contain many growth factors which enhance new bone formation. Platelet-rich plasma however has little adhesive strength. This limits its application to some situations in orthopedic surgery such as fracture or spinal fusion. In this study, platelet gels were used in spinal fusion surgery to provide new bone formation and adhesive strength and prolong the effective period of time. Methods: Sixteen adult rabbits received posterolateral intertransverse process fusion at L5-L6 with the use of autogenous bone grafts. Rabbits were randomly divided into experimental and control groups. Two groups of animals received similar surgical procedures. The experimental group received an autogenous bone graft mixed with platelet gels. The control group received an autogenous bone graft only. Posteroanterior radiographs of the spine were taken pre-operatively and then post-operatively every week for 6 weeks. Rabbits were euthanized at 6 weeks after surgery. The spinal fusion was assessed by radiographic analysis and by manual palpation at the level of arthrodesis and at the adjacent proximal and distal levels. Histopathological examination was performed by a biopsy of the bilateral fusion mass and evaluating fusion quality using the Emery grading scales. Results: One rabbit died on the fifth day after the operation for an unknown reason, while the other 15 rabbits (7 in the experimental group and 8 in the control group) survived until the 6th postoperative weeks. Each side of the spine was graded separately, and 11 of the 14 fusion masses (78.6%) in the experimental group and 10 of the 16 fusion masses (62.5%) in the control group had radiographic evidence of fusion. With gross manual palpation, 6 of the 7 motion segments (87.7%) in the experimental group versus 4 of the 8 motion segments (50%) in the control group were determined to have solid fusion. The difference was not statistically significant (p＞0.05) for either the radiographic analysis or manual palpation. Histologically, however, the experimental group had a higher mean score (with a mean of 6.21 vs. 5.06, p=0.03) and a higher fusion rate (85.7% vs. 31.3%, p=0.002), which were both statistically significant. Conclusion: Platelet gels can enhance new bone formation, thus increasing the fusion rate of posterolateral spinal fusion in a rabbit model.

First clinical study of a new virus-inhibiting surgical glove.

Prospective clinical study to evaluate the tolerance, ergonomics and glove barrier value (mechanical resistance to breach) of a new surgical glove sandwiching droplets of a disinfecting agent between two layers of a synthetic elastomer (G-VIR) able to inactivate viruses when breached. 100 surgical procedures were performed by six surgeons wearing G-VIR on 100 patients included after informed consent. Procedures were classified into laparoscopic (n = 28) or open surgery (n = 72); open surgery being subdivided either into superficial (n = 33) and deep (n = 39) or into hernia (n = 32) and non hernia (n = 40). The ergonomics and tolerance of the glove were evaluated by the surgeons using a questionnaire. Patients were clinically evaluated daily during hospitalization and once between the 4th to 6th postoperative week. All used gloves underwent a water leak test to detect any breach. 834 G-VIR gloves were used, 456 by the first surgeon and 378 by the assistant surgeon, resulting in 195 exposures, lasting 288 operator-hours (OH). No adverse effect on patients and/or surgeons linked to G-VIR could be observed. Ergonomics of G-VIR has been evaluated as equivalent as standard double gloving, excepted for donning which was more difficult (P <0.05). The breach rate per glove (BRpG) amounted to 1.8%. According to breach rate per operator-hour (BRpOH), surgical procedures could be categorized in low (laparoscopy), middle (non hernia and hernia superficial) and high (hernia deep) risk procedures. G-VIR gloving offers an excellent mechanical protection, is suitable for daily surgical practice and maybe recommended in high risk surgical procedures.

First clinical study of a new virus-inhibiting surgical glove.

Prospective clinical study to evaluate the tolerance, ergonomics and glove barrier value (mechanical resistance to breach) of a new surgical glove sandwiching droplets of a disinfecting agent between two layers of a synthetic elastomer (G-VIR) able to inactivate viruses when breached. 100 surgical procedures were performed by six surgeons wearing G-VIR on 100 patients included after informed consent. Procedures were classified into laparoscopic (n = 28) or open surgery (n = 72); open surgery being subdivided either into superficial (n = 33) and deep (n = 39) or into hernia (n = 32) and non hernia (n = 40). The ergonomics and tolerance of the glove were evaluated by the surgeons using a questionnaire. Patients were clinically evaluated daily during hospitalization and once between the 4th to 6th postoperative week. All used gloves underwent a water leak test to detect any breach. 834 G-VIR gloves were used, 456 by the first surgeon and 378 by the assistant surgeon, resulting in 195 exposures, lasting 288 operator-hours (OH). No adverse effect on patients and/or surgeons linked to G-VIR could be observed. Ergonomics of G-VIR has been evaluated as equivalent as standard double gloving, excepted for donning which was more difficult (P <0.05). The breach rate per glove (BRpG) amounted to 1.8%. According to breach rate per operator-hour (BRpOH), surgical procedures could be categorized in low (laparoscopy), middle (non hernia and hernia superficial) and high (hernia deep) risk procedures. G-VIR gloving offers an excellent mechanical protection, is suitable for daily surgical practice and maybe recommended in high risk surgical procedures.

Stability and morbidity of Le Fort I osteotomy with bioresorbable fixation: a randomized controlled trial

A randomized controlled clinical trial was conducted to compare the use of bioresorbable and titanium mini-plates and screws in Le Fort I maxillary osteotomies for evaluation of clinical morbidity and stability. Forty patients requiring Le Fort I osteotomies were randomly assigned to two groups. One group underwent bioresorbable mini-plate fixation and the other titanium mini-plate fixation. Stability of the maxilla was determined by serial cephalometric analysis at 2 and 6 weeks and at 3, 6 and 12 months postoperatively. Subjective and objective assessment of clinical morbidity was made prospectively. There were no differences in complications between the two fixation materials. Maxillae with bioresorbable fixation were significantly more mobile at the second postoperative week. Bioresorbable plates were initially more easily palpable, but their palpability decreased with time. Titanium plates became significantly more palpable at the 1-year follow-up. There was no difference in neurosensory disturbance between groups. Patients with bioresorbable plate fixation showed significantly more upward displacement in anterior maxilla following impaction and posterior maxilla following downgrafting from the 2nd to 6th postoperative week. The horizontal and angular relapses in the two groups were comparable. Le Fort I osteotomy with bioresorbable fixation results in no greater morbidity than with titanium fixation up to 1 postoperative year.

Primary loading of palatal implants for orthodontic anchorage – A pilot animal study

This study aimed at evaluating the clinical performance and osseointegration of short orthodontic implants immediately loaded with orthodontic forces. The investigation was designed as an experimental animal study. Eight palatal implants of the Ortho-system were immediately loaded with 100 cN after palatal insertion in 4 female German shepherd dogs. Xylene orange and calcein green were used for polychrome sequential labelling. Histological preparation utilized the cutting and grinding technique. Outcome variables were clinical implant success, histological osseointegration and bone-to-implant contact rates. All (8/8) implants were clinically successful and stable when the animals were sacrificed. One implant showed fibrous encapsulation and was histologically classified as "failed" for "osseointegration". Upon morphometrical analysis, bone to implant contact rates for newly formed or remodelled bone were 19% at 4 weeks and 26% at 6 months. The fluorochrome labelling indicated substantial mineral apposition on the surface of the implants at the end of the first and the second postoperative months. This study revealed borderline reliability of osseointegration for immediately loaded palatal implants but reasonable bone formation at the 4th postoperative week. Thus, two clinical concepts are both supported: early orthodontic loading after 4 weeks as well as improvement of primary stability to provide a biomechanical basis for immediate orthodontic loading.

Effect of strontium ranelate on fracture healing in rat tibia

ObjectivesVarious anti-osteoporotic agents are available for clinical use. In contrast to other anti-osteoporotic drugs, strontium ranelate has anti-resorptive and bone-forming effects (dual action). Our objective in the present study is to investigate the efficacy of strontium ranelate (SR) on fracture healing in rat tibia. MethodsForty-two male Wistar rats randomized into two groups (groups 1 and 2, n=21 for each). Left tibiae of all animals were broken in a closed manner using a manual three-point bending technique through mid-tibia following deep anesthesia with ketamine. The animals in group 1 were fed 25g/day specially produced food containing 450mg/kg SR starting from the first post-operative day. Group 2 were given 25g/day normal food. The animals were sacrificed on the 2nd, 3rd and 4th post-operative weeks (each week 7 animals were sacrificed from each group) and the broken tibiae were removed. The tibiae were examined first radiographically and second, histopathologically. ResultsRadiologically, callus maturity and bone union increased with time in both groups. But no significant differences were found regarding callus maturity and bone union in weekly comparisons (p=0.52, p=0.19, p=0.74). ConclusionsHistopathologically, it was seen that the fractures remarkably healed steadily in both groups on the 2nd, 3rd and 4th post-operative weeks. But no significant differences were found regarding the progression of fracture callus in weekly comparison (p=1.0, p=0.52, p=1.0).In the present study, we were unable to find any beneficial or harmful effects of strontium ranelate on fracture healing.

Long-term results of endoscopic treatment of vesicoureteral reflux with the sub-ureteric injection of calcium hydroxyapatite

To review our long-term results of the sub-ureteric injection of calcium hydroxyapatite in the endoscopic management of vesicoureteral reflux (VUR) in children. A sub-ureteric injection of calcium hydroxyapatite was given to 14 children (23 ureteral units) affected by VUR grades I-V. All children were followed-up with monthly urine cultures, and a renal ultrasound was done on the postoperative 4th week, while the first voiding cysto-urethrogram (VCUG) control was performed on postoperative week 12. The children were followed-up with yearly renal ultrasound and monthly urine cultures, thereafter. Data from the patients' charts were retrospectively analyzed regarding the outcome of the procedures. Mean follow-up time was 52 months (47-60 months). VUR was cured in 47.4% of cases after a single injection. After the second injection the global success rate was 52.1%. Ureteroneocystostomy was performed on seven refluxing ureters of five children unresponsive to sub-ureteric injection therapy. One patient underwent nephroureterectomy because of a non-functioning kidney secondary to ureteral obstruction due to migration of material at the 23rd month postoperatively. Although favorable short-term success rates have been reported with the sub-ureteric injection of calcium hydroxyapatite without any side effects, our long-term results showed a low success rate, with the only reported serious morbidity.

Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study

The purpose of the present investigation was to evaluate physical outcome after anterior cruciate ligament (ACL) reconstruction with early versus late initiation of open kinetic chain (OKC) exercises for the quadriceps in patients operated on either patellar tendon or hamstring grafts. Sixty-eight patients, 36 males and 32 females, with either patellar tendon graft (34 patients) or hamstring graft (34 patients) were enrolled in this study. All patients were randomly allocated to either early (the 4th postoperative week) or late (the 12th postoperative week) start of OKC exercises for the quadriceps, resulting in four subgroups: patellar tendon reconstruction, early start (P4) or late start (P12) of OKC quadriceps exercises, hamstring tendon reconstruction, early start (H4) or late start (H12) of quadriceps OKC exercises. Prior to surgery and 3, 5 and 7 months later, assessments of range of motion (goniometer), anterior knee laxity (KT-1000), postural sway (KAT 2000), thigh muscle torques (Kin-Com dynamometer) and anterior knee pain (anterior knee pain score) were evaluated. No significant group differences were found in terms of range of motion 3, 5 and 7 months postoperatively. The H4 group showed a significantly higher mean difference of laxity over time of 1.0 mm (CI: 0.18-1.86) than the P4 group (P=0.04). Within the same type of surgery, the H4 against the H12, the mean difference over time was 1.2 mm (0.37-2.1) higher in the H4 group than in the H12 group (P=0.01). There were no significant group differences in terms of postural sway or anterior knee pain at the different test occasions. Significant differences in trends (changes over time) were found when comparing the four groups, for both quadriceps muscle torques (P<0.001) and hamstring muscle torques (P<0.001). All groups, except the P4 group, reached preoperative values of quadriceps muscle torques at the 7 months follow-up. In the H4 and the H12 groups, significantly lower hamstring muscle torques at the 7 months follow-up compared with preoperative values were found. In conclusion, early start of OKC quadriceps exercises after hamstring ACL reconstruction resulted in significantly increased anterior knee laxity in comparison with both late start and with early and late start after bone-patellar tendon-bone ACL reconstruction. Furthermore, the early introduction of OKC exercises for quadriceps did not influence quadriceps muscle torques neither in patients operated on patellar tendon nor hamstring tendon grafts. On the contrary, it appears as if the choice of graft affected the strength of the specific muscle more than the type of exercises performed. Our results could not determine the appropriate time for starting OKC quadriceps exercises for patients who have undergone ACL reconstruction with hamstring tendon graft. Future studies of long-term results of anterior knee laxity and functional outcome are needed.

A novel model of portal vein transplantation in mice using two‐cuff technique

Allogeneic portal vein (PV) grafts have been widely used for vascular reconstruction in the aggressive biliary-pancreatic surgery and partial liver transplantation. We developed a novel PV transplantation model aimed at studying the pathologic alteration of the grafts and further managements. The PV graft was implanted orthotopically into the recipient using two-cuff technique. A total of 80 PV transplants have been performed, and the overall survival rate for the recipients was 91.3% (73/80). Mice were randomly separated into isografts group, allografts group, and allografts group treated with CTLA4-Ig. PV grafts were harvested on the 1st, 2nd, 4th, and 8th postoperative week. The isografts remained intact vascular structure, and the allografts developed marked rejection with significant increase in wall thickness (95 +/- 19 microm vs. 49 +/- 7 microm; P < 0.01) and decrease in lumen area (1.9 +/- 1.1 x 10(4) microm(2) vs. 7.7 +/- 3.1 x 10(4) microm(2); P < 0.01) on the 4th week. In the CTLA4-Ig treated group, the vascular thickness and lumen area were significantly improved when compared with the untreated allografts (wall-thickness: 53 +/- 3 microm vs. 95 +/- 19 microm, P < 0.01; lumen area: 8.8 +/- 2.4 x 10(4) microm(2) vs. 1.9 +/- 1.1 x 10(4) microm(2), P < 0.01) on the 4th week. In conclusion, the PV transplantation model in mice using two-cuff technique is a feasible procedure with a high survival rate. The PV allografts responded well to the CTLA4-Ig therapy in our preliminary research by the model.

Iron Deficiency in the Acute-Phase Reaction After Open Aortic Surgery

The objective of this study was to quantify the magnitude of iron deficiency in the postoperative period after open aortic surgery. This was a prospective observational study in 55 consecutive patients. Blood samples were obtained on postoperative days 1, 2, 4, 30, and 45, and the parameters determined were the following: iron, transferrin, transferrin saturation index, transferrin-soluble receptor, ferritin, red cell count, hemoglobin, hematocrit, serum C-reactive protein, fibrinogen, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and number of blood units transfused. We performed statistical ANOVA test for repetitive measurements (lower bound) in regard to its basal level. Iron deficiency and its parameters reached the maximum at 48 hours postoperatively (iron: 18.92 g/dL and transferrin saturation index: 11.1%) (P <.05). There was not a complete recovery after 45 days (iron: 51.23 g/dL and transferrin saturation index: 18.0%) (P <.05). A similar evolution was observed in the other measured parameters (red cell count: 3.5 x 106/L.; hemoglobin: 10.4 g/dL; hematocrit: 30.7%) (P <.005), none affecting the values of concentration or volume (P <.05). Transferrin-soluble receptors, normal at first, were increased at postoperative days 30 and 45 (2.7 and 2.4 mg/dL respectively, P <.005). After open aortic surgery there is an important acute-phase reaction, a dramatic iron deficiency, and a lack of its transporters until the 45th analyzed day. The elevation of transferrin-soluble receptors in the 4th and 6th weeks denotes a necessity of iron supplementation for a correct development of the immature hematic cells since blood parameters do not reach normal levels in the 6th postoperative week.

Possible involvement of opioidergic systems in the antinociceptive effect of the selective serotonin reuptake inhibitors in sciatic nerve-injured mice

The involvement of opioid receptor activation in the antinociceptive effect of either fluvoxamine, a selective serotonin reuptake inhibitor, or serotonin (5-HT) on thermal hyperalgesia and mechanical allodynia in a model of neuropathic pain in mice induced by sciatic nerve ligation was examined. The experiments were conducted 2 or 6 weeks after unilateral sciatic nerve ligation. Ipsilateral thermal hyperalgesia and mechanical allodynia were observed both 2 and 6 weeks after sciatic nerve ligation. Neither s.c. fluvoxamine nor i.t. 5-HT affected sciatic nerve ligation-induced thermal hyperalgesia or mechanical allodynia in mice 2 weeks after sciatic nerve ligation. However, the same dose of either fluvoxamine or 5-HT significantly reduced mechanical allodynia but not thermal hyperalgesia in sciatic nerve ligated mice 6 weeks after surgery. The antinociceptive effect of fluvoxamine on sciatic nerve ligation-induced mechanical allodynia in mice 6 weeks after surgery was completely abolished by pretreatment with either naloxone, a nonselective opioid receptor antagonist, or β-funaltrexamine, a selective μ-opioid receptor antagonist. Furthermore, pretreatment with naltrindole, a selective δ-opioid receptor antagonist, partially but significantly inhibited the antinociceptive effect of fluvoxamine in sciatic nerve ligated mice at the 6th postoperative week. The antinociceptive effect induced by i.t. 5-HT was also completely antagonized by either naloxone or β-funaltrexamine, and partially inhibited by naltrindole. However, pretreatment with nor-binaltorphimine, a selective κ-opioid receptor antagonist, had no effect against either s.c. fluvoxamine- or i.t. 5-HT-induced antinociception. These results suggest that the antinociceptive effect of s.c. fluvoxamine or i.t. 5-HT in the chronic state of sciatic nerve ligation-induced neuropathic pain may be related to opioidergic activity, mainly through the activation of spinal μ- and δ-opioid receptors.

QT dispersion in non-apneic simple snoring patients and the effect of surgical therapy on QT dispersion

Aim: Increased QT dispersion in cases of obstructive sleep apnea, which may induce serious arrhythmias, is a well-known process. However, there is little information about the QT dispersion in patients with simple snoring without apnea. We investigated QT dispersion in snoring and the effect of surgical therapy on QT dispersion. Methods: One hundred and sixty two patients with simple snoring without apnea were included in this study. Patients had polysomnography and surface electrocardiography (ECG) on the pre-operative 1st week and post-operative 4th week. The patients underwent one of the three surgical procedures, which include uvulopalatopharyngoplasty, laser assisted uvulopalatoplasty, and cautery assisted uvulopalatoplasty. QT dispersion was calculated in each patient from pre-operative and post-operative surface ECG. Pre-operative and post-operative values were compared using the student’s t test. P < 0.05 was considered statistically significant. Results: One hundred and fourteen of the patients were male, 48 were female, and the mean age was 35.2 ± 14.1 years (range: 21–51). No improvements were observed in 9 of the patients. Surgical interventions were successful in 153 patients (94%). Post-operative QTc max and QTc dispersion values were significantly shortened, and QTc min was increased compared to the pre-operative values (449.6 ± 6.2 vs. 440.9 ± 20.8, and 68.2 ± 8.4 vs. 43.8 ± 6.2, and 381.3 ± 7.8 vs. 397.0 ± 5.9 respectively; P = 0.001). Conclusion: This study shows that QT dispersion is increased in simple snoring patients without apnea and that QT dispersion decreases after surgical interventions.

The DuraHeart VAD, a Magnetically Levitated Centrifugal Pump The University of Vienna Bridge-to-Transplant Experience

The clinical application of the DuraHeart (Terumo Heart Inc, USA) has begun in Europe as a clinical trial of a third-generation implantable centrifugal blood pump. Four successful clinical implants are presented. Four male patients had end-stage left heart failure and received a DuraHeart VAD as a left ventricular assist device for bridge-to-transplantation. The pump showed good performance with flow rates of 4.9+/-0.5 L/min after gradual weaning of extracorporeal circulation. The pump flow was then maintained at 6.1+/-0.5, 5.5+/-0.3, 5.5+/-0.1, 5.7+/-0.1, 5.5, 6.4 and 6.5 L/min at the 1st, 4th, 8th, 12th, 16th, 20th and 24th postoperative week, respectively. No significant elevation of mean plasma-free hemoglobin was detected. The patients were discharged on the 18th, 42nd, 41st and 31st postoperative day, respectively, and all were successfully transplanted on the 202nd, 84th, 128th and 96th postoperative day, respectively. At the time of transplant surfaces of the removed pumps were free from thrombus formation, although intraventricular pannus growth was observed around the inflow cannulae in all patients. The DuraHeart VAD showed stable and sufficient circulatory support for the bridge-to-transplant procedure in this cohort of 4 patients.

Dual treatment of albendazole in hepatic hydatidosis: New therapeutic modality in 52 cases

Hepatic hydatidosis still remains as a serious problem in general surgery. Recurrence and/or secondary hydatidosis rates are up to 25% in the cases treated with surgery alone. Albendazole is the most commonly used drug in the medical treatment of echinococcosis. The aim of the present study was to evaluate the effect of albendazole using the intraoperative and perioperative periods as dual therapy. Fifty-two cases of hepatic hydatidosis were evaluated and treated by dual treatment of albendazole together with surgery. Perioperative albendazole treatment was given in a dose of 12-15 mg/kg per day in four divided doses. The treatment started 2-28 days before the surgery when the diagnosis was established and continued for 2-24 months (4.76 +/- 3.25) postoperatively in a cyclic monthly form. A total of 1.7 microg/mL albendazole solution was used as a protoscolicidal agent in the cystic cavity intraoperatively. In the postoperative period serology, ultrasonography and computed tomography evaluations were done. The follow-up period was 5-92 months (mean: 62.48 months). There was no recurrence in the present study. One patient died in the 6th postoperative week due to cerebral hydatidosis and multiple organ failure. Early and late morbidity rates were 7.69 and 9.61%, respectively. Dual albendazole treatment is effective in the prevention of recurrences and/or secondary hydatidosis.

First human transplantation of a bioengineered airway tissue

First human transplantation of a bioengineered airway tissue

Patterns and predictors of sleep pattern disturbance after cardiac surgery.

The purposes of this study were to examine changes in sleep patterns after cardiac surgery and the contributions of preoperative sleep to postoperative sleep. Seventy-two cardiac surgery patients wore wrist actigraphs for 3 days during the preoperative period (T1) and the 1st (T2), 4th (T3), and 8th (T4) postoperative weeks. They completed the Pittsburgh Sleep Quality Index at T1, T3, and T4. Sleep was most disturbed during the 1st postoperative week and improved at T3 and T4. Overall, sleep pattern disturbance was higher at T3 and T4 than at T1. Age, gender, preoperative New York Heart Association Functional Class, and preoperative sleep variables explained 20%-50% of the variance in sleep at T2, T3, and T4. Sleep disturbance is present preoperatively and continues during the postoperative period.

Intraoperative subcortical stimulation mapping for hemispheric perirolandic gliomas located within or adjacent to the descending motor pathways: evaluation of morbidity and assessment of functional outcome in 294 patients

Intraoperative stimulation mapping of subcortical white matter tracts during the resection of gliomas has become a valuable surgical adjunct that is used to reduce morbidity associated with tumor removal. The purpose of this retrospective analysis was to assess the morbidity and functional outcome associated with this method, thus allowing the surgeon to predict the likelihood of causing a temporary or permanent motor deficit. In this study, the authors report their experience with intraoperative stimulation mapping to locate subcortical motor pathways in 294 patients who underwent surgery for hemispheric gliomas within or adjacent to the rolandic cortex. Data were collected regarding intraoperative cortical and subcortical stimulation mapping results, along with the patient's neurological status pre- and postoperatively. For patients in whom an additional motor deficit occurred postoperatively, its evolution was examined. Of 294 patients, an additional postoperative motor deficit occurred in 60 (20.4%). Of those 60, 23 (38%) recovered to their preoperative baseline status within the 1st postoperative week. Another 12 (20%) recovered from their postoperative motor deficit by the end of the 4th postoperative week, and 11 more recovered to their baseline status by the end of the 3rd postoperative month. Thus, 46 (76.7%) of 60 patients with postoperative motor deficits regained their baseline function within the first 90 days after surgery. The remaining 14 patients (4.8% of the entire study population of 294) had a persistent motor deficit after 3 months. Patients whose subcortical pathways were identified with stimulation mapping were more prone to develop an additional (temporary or permanent) motor deficit than those in whom subcortical pathways could not be identified (27.5% compared with 13.1%, p = 0.003). This was also true when additional (permanent) motor deficits lasted more than 3 months (7.4% when subcortical pathways were found, compared with 2.1% when they were not found; p = 0.041). In patients with gliomas that are located within or adjacent to the rolandic cortex and, thus, the descending motor tracts, stimulation mapping of subcortical pathways enables the surgeon to identify these descending motor pathways during tumor removal and to achieve an acceptable rate of permanent morbidity in these high-risk functional areas.

Antegrade Intramedullary Nailing in Humeral Shaft Fractures

Purpose: To evaluate union time and functional recovery of the shoulder joint in humeral shaft fractures treated with intramedullary nailing. Material and Methods: During the period 1990-2001, 43 patients with humeral shaft fractures were treated with intramedullary nailing. 38 patients (21 males and 17 females, mean age 48 years) were available at the final follow-up evaluation after 21 months on average. In 25 patients the entry point was below the greater tuberosity to avoid rotator cuff injury and in the other 18 patients the entry point was intra-articular. Passive shoulder and elbow motion was allowed from the second postoperative day followed by active assisted exercises from the second postoperative week. Union progress was assessed radiologically at 2nd, 4th, 8th, and 16th postoperative week whereas final shoulder function was evaluated using the parameters of the Constant-Murley scoring system. Results: Solid callus formation was noted in all fractures, except one, between the 8th and 35th postoperative week. Patients with extra-articular application of the nail had full passive shoulder motion between the 2nd and the 4th postoperative week whereas patients with intra-articular application had delayed passive shoulder motion and final functional limitation. Seven patients had painful shoulder motion 3 months postoperatively. There were 4 patients with transient radial nerve palsy, who demonstrated full functional recovery after 3 to 6 months and 3 patients with proximally migration of the nail underwent reoperation. Conclusions: Intramedullary nailing in humeral shaft fractures seems to be a reliable method of treatment regarding union and functional recovery. Advantages are shorter operative time, minor blood loss, small incision with shorter soft tissue detachment and early mobilization of the shoulder, especially in the patients with extra-articular nail application without rotator cuff injury.

Chronic cerebral hypoperfusion induces striatal alterations due to the transient increase of NO production and the depression of glutathione content.

We examined the effects of chronic cerebral hypoperfusion on the endogenous oxidative stress-related indices, nitrite and nitrate (NOx) concentration, glutathione (GSH) content, superoxide dismutase and catalase activities, and thiobarbituric acid-reactive substances level in the rat striatum, to clarify the participation of oxidative stress in the chronic cerebral hypoperfusion-induced alterations. Our present results indicate that chronic cerebral hypoperfusion produces oxidative stress and disturbs intracellular redox regulation in two distinct phases: at 1 day, "acute" and at 6 weeks, "chronic" alterations after the operation. Therefore, striatal neural cell damage may be mainly attributed to the transient increase of NOx production at 1 day after, and the delayed reduction of muscarinic acetylcholine receptor binding in the striatum may be mostly attributed to the continuous depression of GSH content from the 1st to the 6th postoperative week. In particular, the continuous GSH depression may be considered to accompany the pathophysiology of chronic cerebral hypoperfusion.