Clinical Efficacy Of Surgical Treatment Research Articles

Posterior endoscopic decompression combined with anterior cervical discectomy and fusion versus posterior laminectomy and fusion for multilevel cervical spondylotic myelopathy: a retrospective case-control study

ObjectiveTo compare the clinical efficacy of surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) between the hybrid procedure, posterior endoscopic decompression (PED) combined with anterior cervical discectomy fusion (ACDF), and posterior cervical laminectomy and fusion (PCLF).MethodsA retrospective analysis was performed on 38 patients who received surgical treatment for MCSM from January 2018 to December 2021, including 19 cases in hybrid procedure group (13 males and 6 females), followed up for 10 to 22 (12.8 ± 10.3) months, and 19 cases in PCLF group (15 males and 4 females), followed up for 10 to 21 (11.7 ± 8.9) months. Perioperative information, including operation time, intraoperative blood loss, length of hospitalization, and complications, were compared between two groups. Visual analogue scale (VAS) of pain, neck disability index (NDI) and Japanese Orthopaedic Association (JOA) score were recorded to evaluate clinical efficacy. Cervical lordosis was calculated by radiographic examination.ResultsIntraoperative blood loss, length of hospital stay were less in hybrid group than PCLF group, while operation time is longer in hybrid group, with a statistically significant difference (p < 0.05). Increased lordosis was better in hybrid group. There was no significant difference in preoperative VAS, JOA and NDI at pre-operation and final follow-up between two groups. But at post-operation and final follow-up, VAS was less in hybrid group than PCLF group (p < 0.05). There were 2 cases of neurostimulation symptoms in hybrid group, 2 cases of C5 nerve root palsy, 2 cases of subcutaneous fat necrosis and 1 case of dural tear in PCLF group, and all patients relieved with symptomatic treatment.ConclusionThe hybrid procedure of PED combined with ACDF showed satisfied clinical outcome, with less intraoperative blood loss, shorter length of hospitalization and lower post-operative neck pain than PCLF. It is an effective surgical treatment for MCSM.

Анализ результатов хирургического лечения пациентов с облитерацией слезоотводящих путей вследствие терапии радиоактивным йодом

Relevance. Nasolacrimal duct obstruction occurs in 9% of patients after radioiodine therapy for thyroid cancer. The surgical interventions used in this case have not been studied enough; indications for certain operations have not been developed. Purpose. To evaluate clinical efficacy of surgical treatment in patients with nasolacrimal duct obstruction due to radioactive iodine therapy. Material and methods. The outcomes of 47 surgeries in patients with secondary acquired nasolacrimal duct obstruction due to radioiodine therapy were analyzed, among them 30 cases of dacryocystorinostomy and 17 cases of recanalization of the tear ducts. In 15 cases, dacryocystorinostomy was supplemented by the formation of an anastomosis in the area of the Hasner's valve. A comparative analysis of the effectiveness of surgical intervention depending on the localization of obstruction was carried out. Results. Dacryocystorinostomy was effective in 90% of cases, recanalization of the tear ducts – in 13% of cases. The analysis revealed that in cases of obstruction at the level of the lacrimal sac, the success of dacryocystorinostomy was 100% (5 observations), with obstruction at the level of the middle part of the nasolacrimal duct – 85.7% (12 observations), with obstruction at the level of the Hasner's valve – 100% (6 observations). Recanalization of the tear ducts was characterized by success in 100% of cases (1 observation) with obstruction of the middle part of the nasolacrimal duct and in 6.3% of cases (1 observation) with obstruction at the level of Hasner's valve. Conclusion. Dacryocystorinostomy is an effective intervention in patients with secondary acquired nasolacrimal duct obstruction due to radioiodine therapy. Recanalization of the tear ducts is characterized by low efficiency. The analysis of the effectiveness of these interventions, considering the localization of obstruction of the tear ducts, showed that the effectiveness of surgical treatment may vary depending on the level of obstruction. In cases of anatomically low obstruction of the tear ducts, dacryocystorinostomy was supplemented by the formation of an anastomosis in the area of the Hasner's valve. Recanalization of the tear ducts was characterized by greater efficiency in cases where the level of obstruction of the tear ducts was higher than the Hasner's valve than directly at Hasner's valve. The choice of treatment tactics for patients with secondary acquired nasolacrimal duct obstruction due to radioiodine therapy should be differentiated depending on the localization of the tear duct obstruction. Key words: tear ducts, radioiodine, dacryocystorhinostomy, nasolacrimal duct intubation

CLINICAL RESULTS OF BALLOON PLASTY OF PULMONARY ARTERY VALVE IN BULLDOG DOGS

The paper presents the results of a clinical and experimental study to determine the clinical efficacy of surgical treatment of animals with pulmonary artery valve stenosis using balloon plasty. The study was retrospective, animals were evaluated from 2018 to 2020, and the morphofunctional state of the cardiovascular system was assessed before and after surgery. The total sample consisted of 15 animals. Diagnosis of this defect was performed auscultatively and by echocardiography [ultrasound]. On auscultation systolic murmur was heard in all animals. Echocardiography evaluated the geometry and function of the right heart, as well as velocity and gradient on the pulmonary artery valve. All animals were diagnosed with congenital heart defect: pulmonary artery valve stenosis. After diagnosis, each dog underwent balloon plasty of the pulmonary artery valve. No animal died during and after surgical intervention. All animals were discharged on the day of surgery for outpatient treatment. There were no postoperative complications. Maintenance and feeding remained unchanged at all times. All animals became more active after the operation, clinical signs of the disease, if any, were resolved or reduced markedly. One month later, repeated echocardiography was performed to evaluate the pulmonary artery valve velocity and gradient. In one animal we observed increased flow velocity on the pulmonary artery valve, which was associated with increased systolic function after surgery. In the remaining dogs, a decrease in velocity and pressure gradient at the pulmonary artery valve was noted. -

Новый подход к хирургическому лечению первичного прогрессирующего птеригиума

Purpose. To evaluate effectiveness of new method of barrier amnioplasty in surgical treatment of primary progressive pterygium. Material and methods. The study included 64 patients (64 eyes) with primary progressive pterygium. All patients were divided into two groups depending on method of barrier amnioplasty. The main group consisted of 32 people (32 eyes) who underwent barrier amnioplasty in the area of initial growth of pterygium. The control group consisted of 32 patients (32 eyes) who underwent barrier amnioplasty in the limbus area. The main criterions for clinical efficacy of surgical treatment of pterygium was dynamics of the wound process, the Ocular Surface Disease Index (OSDI) and the osmolarity of the tear fluid in the compared groups. Also, after 1 year, the frequency of pterygium recurrence was assessed. In addition to standard ophthalmological examinations, special methods were used in the work: determination of the osmolarity of the tear fluid, pH of tears, cytological assessment of the wound process, and also assessed the OSDI. Results. The results of pH-metric, osmometric, cytological studies have provided evidence of the ability of the anatomical and topographic approach described by us to positively influence the course of inflammatory and reparative processes in the operation area, preventing the development of recurrent pterygium and cicatricial deformities. Conclusion. A new effective method of surgical treatment of primary progressive pterygium, including moving the area of the barrier amnioplasty from the limbus area to the area of initial growth of blood vessels of pterygium - the area of the lunate fold, has been developed and introduced into clinical practice. Key words: pterygium, inflammatory and reparative processes, recurrence.

Clinical Efficacy of Surgical Treatment in 40 Patients with Acute Hematogenous Osteomyelitis

Objective: This study aimed to evaluate the diagnostic methods of acute hematogenous osteomyelitis and the clinical efficacy of fenestration decompression, focus debridement, and convective flushing. Methods: A retrospective analysis was performed on 40 patients with acute hematogenous osteomyelitis admitted to the Department of Orthopedics of our hospital from January 2011 to December 2018. There were 21 males and 19 females, aged 1–70 years, with an average age of 21.45 ± 15.23 years, including 27 children and adolescents. The pathogenic sites were as follows: femur 20 cases, tibia 16 cases, humerus 2 cases, ulna 1 case, and radius 1 case. The systemic and local symptoms of patients before and after surgery were evaluated. The results of white blood cell count (WBC), NEUT%, hs-CRP, erythrocyte sedimentation rate (ESR), imaging examination, bacteriology, and pathological examination were analyzed. Fenestration decompression, focus debridement, and convective flushing were used at the site of lesion in the surgery.

Clinical efficacy of surgical treatment for Pipkin fracture in 17 cases

To investigate the clinical effect of surgical treatment for femoral head fracture-dislocation (Pipkin fracture). Methods: A total of 17 patients with femoral head fracture-dislocation were retrospectively analyzed. The duration from injury to surgery was 1-30 (average 9.5) days. According to the classification of Pipkin criteria, there were 4, 6, 1, and 6 cases in Type I, Type II, Type III, and Type IV, respectively. Thirteen patients were treated with skin traction or bone traction after admission, and the postoperative traction lasted for 4 weeks. Results: All patients got a mean follow-up of 43(8-84) months. No patient suffered from infection and skin flap necrosis. X ray showed no implants loose or breakage. According to the Thompson-Epstein evaluation system, among the cases of Type I, 3 cases were excellent and 1 case was fair; among the cases of Type II, 3 cases were excellent, 2 cases were good, and 1 case was poor. The case of Type III was good. Among the cases of Type IV, 2 cases were excellent, 2 cases were good, and 2 cases were fair. The excellent and good rate was 76.47%. Conclusion: Early diagnosis of Pipkin fracture, reasonable selection of surgical approach and internal fixation according to Pipkin classification can help patients to obtain satisfactory hip function and improve their prognosis.

Surgical treatment of radial head fractures with elbow dislocation

Objective To explore the clinical efficacy of surgical treatment for radial head fractures with elbow dislocation. Methods From October 2013 to October 2016, 22 cases of Mason-Johnston typeIVradial head fractures were performed surgical treatment. There were 14 cases of Mason typeIIfracture and 8 cases of typeIIIfracture. The patients were followed up clinically and radiographically until the fracture healing and elbow function entering the plateau stage. The Mayo Elbow Performance Score (MEPS) was used for the functional assessment. Results Nineteen cases of radial head fractures underwent internal fixation, and 3 cases underwent radial head replacement. The postoperative follow-up period ranged from 13 to 36 months with an average of 20 months. The elbow flexion and extension arc averaged (106±17)°, and the forearm rotation arc averaged (140±18)°. The X-ray films of all the patients showed that the concentric reduction of the elbow was maintained. No instability of the joint was found, and the reduction and fixation of the radial head fracture were satisfactory. The healing time of radial head fracture was 11 to 17 weeks with an average of 12. 5 weeks. No complications such as prosthesis dislocation were found after operation in the 3 cases of prosthetic replacement. At the last follow-up, MEPS was 60 to 100 points with an average of (91±7) points. The function was rated as excellent in 8 cases, good in 13 cases and poor in 1 case. There were 5 cases of elbow heterotopic ossification, 4 cases without further surgical treatment. And 1 case underwent surgical release. Conclusion Open reduction and internal fixation or radial head replacement combined with collateral ligament repair for the treatment of radial head fractures with elbow dislocation can obtain satisfactory clinical efficacy. Key words: Fractures, bone; Treatment outcome; Radial head; Elbow dislocation

Posterolateral decompression, bone graft fusion, posterior instrumentation, and local continuous chemotherapy in the surgical treatment of thoracic spinal tuberculosis.

To investigate the clinical efficacy of surgical treatment for thoracic spinal tuberculosis with kyphosis deformity via posterolateral debridement, fusion, posterior instrumentation and local continuous chemotherapy. A total of 25 patients with thoracic tuberculosis received surgery by posterolateral decompression, fusion, posterior instrumentation, and postural drainage with local continuous chemotherapy between June 2009 and October 2011. The clinical outcomes was evaluated using statistical analysis about deformity correction, bone fusion, neurologic status, and the visual analog score (VAS) and erythrocyte sedimentation rate (ESR). All of 25 patients were followed up for 39.0 ± 10.7 months (range, 24–60 months) postoperatively. There was no recurrence of tuberculosis, breakage and looseness of internal fixation. Bony fusion was achieved in all cases with 6.7 ± 1.9 months. The values of ESR recovered to normal within 6 months postoperatively. All patients with neurological deficit had significant improvement at the final follow-up. The average preoperative Cobb angles were significantly decreased to 12.2 ± 2.9° (range, 8–17°) postoperatively, and at final follow-up were 12.9 ± 2.7°. Our results showed that single-stage posterolateral debridement fusion, posterior instrumentation and local continuous chemotherapy can be expected to yield satisfactory clinical and radiographic outcomes in patients with thoracic spinal tuberculosis.

Clinical analysis of surgical treatment for subungual glomus tumor

Objective To explore the clinical efficacy of surgical treatment for subungual glomus tumor. Methods From February 2006 to July 2015, 35 patients with subungual glomus tumor were performed surgical treatment. Transungual approach was used in 29 patients and Lateral Subperiosteal approach was used in 4 patients under the microscope. 2 cases of glomus tumor were located at the depth of the finger, and the finger pulp incision was adopted. The pain, recurrence and nail deformity of the fingers were evaluated before and 6 months after the operation. Results After 6 months of follow-up, 34 cases (97.0%) relieved of subjective pain, and 3 cases (8.6%) recurred after operation. 10 cases (28.5%) performed by Transungual occurred nail deformities, but no cases occurred by Lateral Subperiosteal and abdominal incision. Conclusion Surgical treatment of subungual glomus tumor has significant improvement in pain and low recurrence rate. The occurrence of nail deformity may be related to the surgical methods. Key words: Glomus tumor; Pain; Recurrence; Nail deformity

Surgical treatment of patients with compressive complications of chronic pancreatitis

Background. Treatment of patients with chronic pancreatitis complications remains one of the complex problems in modern gastroenterology. Surgical treatment of these patients is not always effective, the risk of postoperative complications is significant. Surgical treatment of such patients has special features, since the use of traditional resective organ preservation techniques has certain limitations. Material and methods. The experience of surgical treatment of 185 patients with complicated chronic pancreatitis has been analyzed for the last 7 years. The clinical efficacy of surgical treatment of 31 patients with compressive complications of chronic pancreatitis was studies. Results. The main types of interventions performed in compression forms of chronic pancreatitis were drainage operations (in 12 patients) and pancreatic resections (in 8 patients), as well as surgeries with the formation of various cystodigestive anastomoses (5 patients). When radical interventions are impossible (6 episodes), the formation of bypass gastroenteroanastomosis, biliodigestive anastomosis or bile ducts external drainage were performed. The indications to the operations, their efficacy and complications were considered. Conclusions. Standard pancreatic organ preservation surgeries in most cases can eliminate the phenomena of subcompensated forms of biliary and portal hypertension, as well as duodenal obstruction. The obtained results proved the reasonability of pancreatic duct drainages in all types of resection that ensures the aggressive compounds removal from the place of anastomosis during its healing and reduces hydrostatic pressure in the pancreatic duct system.

Clinical efficacy of surgical treatment for stage IV gastric cancer after conversion therapy

Clinical efficacy of surgical treatment for stage IV gastric cancer after conversion therapy

Analysis on the effect of surgical cleaning combined with external fixator for the treatment of post-traumatic heterotopic ossification of elbow joint

To evaluate the clinical efficacy of surgical treatment using a combined medial and lateral approach combined with an external fixator for the treatment of post-traumatic heterotopic ossification(HO) in patients with stiff elbow joints. Surgical release using the combined medial and lateral approach combined with external fixation for the treatment of HO and elbow stiffness in 26 patients from July 2010 to December 2013. The study group included 18 males and 8 females, with an average age 38.7 years (ranged 14 to 60 years). The time from injury to surgery averaged 9.3 (ranged 7 to 18) months. Before and after operation, the elbow range of motion and forearm rotation angle were measured, and the Mayo Elbow Performance Score (MEPS) was evaluated. The wound of all patients was well healed during the first period, except one patient who had chronic infection at the external fixation pin 3 weeks after operation. Then the external fixator was removed. All 26 patients were followed up, and the during ranged from 24 to 40 months, with an average of 34 months. HO recurrence occurred in 1 patient 8 months after operation. The range of motion, forearm rotation angle, and Mayo Elbow Performance Score of elbow joint in patients was significantly improved compared with that before surgery(P<0.05). Surgical release using the combined medial and lateral approach combined with an external fixator for the treatment of traumatic HO and elbow stiffness can effectively improve elbow function, resulting in a satisfactory effect.

Сравнительный анализ отдаленных результатов хирургического лечения первичной регматогенной отслойки сетчатки с использованием экстра- и интраокулярных подходов

Purpose . Analysis of clinical efficacy of surgical treatment of primary rhegmatogenous retinal detachment (PRRD) using extra- and intra-scleral approaches, depending on the stage of proliferative vitreoretinopathy (PVR). Material and methods . The analysis of long-term results in surgical treatment of 116 eyes (112 patients) with PRRD was carried out. Duration of retinal detachment ranged from 7 days to 5 months (average 4.5 weeks). The structure of PVR stages: A – 31 eyes, B – 31 eye, C – 54 eyes. Macular detachment occurred in 47 eyes. Visual acuity preoperatively varied from 0.005 to 1.0 (average 0.25). Extra-scleral approaches were used in 49 eyes of 45 patients. Endovitreal 20G surgery was performed in 67 eyes of 67 patients. Evaluation of the clinical efficacy of treatment in all eyes was carried out in the follow-up period of 3-7 postoperative days and 3-4 years later. Results and discussion . After the extraocular surgery the retinal anatomic reattachment was achieved at 2-3 day of postoperative period in 45 eyes (91.8%). Partial retinal reattachment was revealed in 4 eyes. After reoperation a complete retinal reattachment was achieved in all eyes. After endovitreal surgery it was noted at 2-3 day that the retina attached in 64 eyes (95.5%), in 3 eyes the retinal attachment was failed (4.5%), where a repeated silicone tamponade was performed. Relapses of PRRD occurred in 11 eyes (12.2%), in their structure: 6 eyes after extra-scleral approach – in the period from 2.5 to 12 months; 5 eyes (7.4%) after the intraocular approach – in the period from 4 to 18.5 months. After a repeated endovitreal surgery the anatomic reattachment of retina was achieved in all cases. Conclusions . The main reason of PRRD relapses was the progression of vitreo-proliferative process. Intraocular surgery with the use of plugging fluids (silicone, gas, air) allows more reliably reduce the risk of postoperative complications, occurrence of PRRD relapses. Episcleral approaches in PRRD treatment continue to be the method of choice in the initial PVR stages.

The clinical efficacy of pathologic vertebral surgery for thoracic and lumbar tuberculosis

Objective To discuss the clinical efficacy of surgical treatment of pathologic vertebral surgery for thoracic and lumbar tuberculosis. Methods All of 322 cases of thoracic and lumbar spinal tuberculosis patients from December 2003 to June 2014 were retrospectively analyzed in our department. All patients were underwent debridement, fusion and nerve decompression surgery. According to different fixed methods, patients were divided into pathologic vertebral surgery group (fixation completed within lesions invaded motion unit) including 91 males and 100 females, with an average age of 41.53 years, and non-pathologic vertebral surgery group (long segments or short segment fixation) including 61 males and 70 females, with an average age of 42.72 years. We observed the tuberculosis cure rate, degrees of deformity, pain and neurological recovery, operative time, blood loss and complications by follow-up. Results The average follow-up time was 75.52 months in pathologic vertebral surgery group and 76.21 months in non-pathologic vertebral surgery group. The total number of pathologic vertebras in pathologic vertebral surgery group and non-pathologic vertebral surgery group were 277 and 218 respectively, and the average was 1.45 and 1.66. The total number of fixed segments was 277 in pathologic vertebral surgery group and 485 in non-pathologic vertebral surgery group, and the average fixed segments was 1.45 and 3.70. The cure rate was 85.86% in pathologic vertebral surgery group and 85.49% in non-pathologic vertebral surgery group at 6 months postoperatively, and 98.95% and 98.47% at the last follow-up time, with no significant difference between groups. Graft fusion rate was 89.00% in pathologic vertebral surgery group and 89.31% in non-pathologic vertebral surgery group 6 months postoperatively, 98.38% and 98.47% at the last follow-up time, without significant difference. In lumbar spine, the average correction of Cobb's angle was 12.4° in pathologic vertebral surgery group and 13.1° in non-pathologic vertebral surgery group, and the average angle loss was 1.3 and 1.4°, with no significant difference. In thoracolumbar, the average correction of Cobb's angle was 10.9°in pathologic vertebral surgery group and 11.1°in non-pathologic vertebral surgery group, and the average angle loss was 1.7°and 1.5° respectively, without significant difference. However, in thoracic, the average correction of Cobb's angle was 10.2° in pathologic vertebral surgery group and 12.7° in non-pathologic vertebral surgery group, and the average angle loss was 3.6° and 2.5°respectively, with significant difference. The mean operation time was 210.45 min in pathologic vertebral surgery group and 210.45 min in non-pathologic vertebral surgery group, with significant difference. The average blood loss was 726.12 ml in pathologic vertebral surgery group and 726.12 ml in non-pathologic vertebral surgery group, with significant difference. The complication rate was 11.51% in pathologic vertebral surgery group and 11.45% in non-pathologic vertebral surgery group, with no significant difference. Conclusion Pathologic vertebral surgery surgery is a safe, effective and feasible method of operation for treatment of thoracic and lumbar tuberculosis, which can effectively preserve adjacent normal vertebral motion unit features. The thoracic surgery was less satisfactory than the lumbar and thoracolumbar surgery. Key words: Thoracic vertebrae; Lumbar vertebrae; Tuberculosis, spinal; Bone transplantation; Treatment outcome

Clinical efficacy of surgical treatment for chronic pancreatitis with mass in the head of the pancreas

Objective To investigate the clinical efficacy of treatment for chronic pancreatitis and mass in the head of the pancreas.Methods The clinical data of 19 patients with chronic pancreatitis with mass in the head of the pancreas who were admitted to the China-Japan Union Hospital of Jilin University from May 2008 to May 2013 were retrospectively analyzed,including 2 patients with gallstone.Methods of treatment were selected by in traoperative pathological results.All the patients were followed up by outpatient examination and telephone interview till January 2014.Results The operations of the 19 patients were successfully done,including 11 with pancreaticoduodenectomy,5 with exploratory laparotomy and 3 with the laparoscopic cholecystectomy and choledochojejunostomy.The operation time and intraoperative blood loss were (249± 140)minutes (50-390 minutes) and (320 ± 260)mL (50-900 mL).The postoperative mean time of recovery of gastrointestinal function and duration of postoperative hospital stay were 3.0 days (2.0-6.0 days) and 22.6 days (8.0-30.0 days) after the operation.The mean casein-IgG4 of 12 patients was higher (2.64 g/L) after operation.Five patients with operation-related complication were cured after symptomatic treatment,among 2 patients with leakage of the pancreatic fluid,2 with operative incision fat necrosis and liquefaction and 1 with bile leakage.No patients died perioperatively.Nineteen patients were followed up for 11.0 months to 36.0 months with the median time of 28.2 months.The pancreatic head mass of 8 patients with non-pancreaticoduodenectomy were reduced or disappeared by a computed tomography (CT) or magnetic resonance imaging (MRI) rescan,who were treated by the oral prednisone.No complications were detected in the other 11 patients with pancreaticoduodenectomy.Conclusion Method of surgery or medicine treatment for atypical mass in the head of the pancreas is selected according to the pathology results by effective communication with patients and family members,exploratory laparotomy and interpretative aspiration biopsy. Key words: Autoimmune pancreatitis; Mass in the head of the pancreas; Surgical operation

Using Decision Analysis to Assess Comparative Clinical Efficacy of Surgical Treatment of Unstable Ankle Fractures

The development of a robust treatment algorithm for ankle fractures based on well-established stability criteria has been shown to be prognostic with respect to treatment and outcomes. In parallel with the development of improved understanding of the biomechanical rationale of ankle fracture treatment has been an increased emphasis on assessing the effectiveness of medical and surgical interventions. The purpose of this study was to investigate the use of using decision analysis in the assessment of the cost effectiveness of operative treatment of ankle fractures based on the existing clinical data in the literature. Using the data obtained from a previous structured review of the ankle fracture literature, decision analysis trees were constructed using standard software. The decision nodes for the trees were based on ankle fracture stability criteria previously published. The outcomes were assessed by calculated Quality-Adjusted Life Years (QALYs) assigned to achieving normal ankle function, developing posttraumatic arthritis, or sustaining a postoperative infection. Sensitivity analysis was undertaken by varying the patient's age, incidence of arthritis, and incidence or infection. Decision analysis trees captured the essential aspects of clinical decision making in ankle fracture treatment in a clinically useful manner. In general, stable fractures yielded better outcomes with nonoperative treatment, whereas unstable fractures had better outcomes with surgery. These were consistent results over a wide range of postoperative infection rates. Varying the age of the patient did not qualitatively change the results. Between the ages of 30 and 80 years, surgery yielded higher expected QALYs than nonoperative care for unstable fractures, and generated lower QALYs than nonoperative care for stable fractures. Using local cost estimates for operative and nonoperative treatment, the incremental cost of surgery for unstable fractures was less than $40,000 per QALY (the usual cutoff for the determination of cost effectiveness) for patients aged up to 90 years. Decision analysis is a useful methodology in developing treatment guidelines. Numerous previous studies have indicated superior clinical outcomes when unstable ankle fractures underwent operative reduction and stabilization. What has been lacking was an examination of the cost effectiveness of such an approach, particularly in older patients who have fewer expected years of life. In light of the evidence for satisfactory outcomes for surgery of severe ankle fractures in older people, the justification for operative intervention is an obvious question that can be asked in the current increasingly cost-conscious environment. Using a decision-tree decision analysis structured around the stability-based ankle fracture classification system, in conjunction with a relatively simple cost effectiveness analysis, this study was able to demonstrate that surgical treatment of unstable ankle fractures in elderly patients is in fact cost effective. The clinical implication of the present analysis is that these existing treatment protocols for ankle fracture treatment are also cost effective when quality of life outcome measures are taken into account. Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Clinical efficacy of surgical treatment for hilar cholangiocarcinoma: a report of 207 cases

Objective To investigate the efficacy of different radical surgical procedures for the treatment of hilar cholangiocarcinoma.Methods The clinical data of 207 patients with hilar cholangiocarcinoma who were treated at the Southwest Hospital from June 2007 to June 2012 were retrospectively analyzed.Local resection or hemihepatectomy combined with caudate lobectomy was applied to patients with Bismuth type Ⅰ hilar cholangiocarcinoma; dumbbell type radical resection was applied to patients with Bismuth type Ⅱ hilar cholangiocarcinoma or some patients with type Ⅲ a,Ⅲ b and Ⅳ hilar cholangiocarcinoma; hemihepatectomy or extended hemihepatectomy combined with caudate lobectomy was applied to patients with Bismuth type Ⅲ a,Ⅲ b and Ⅳ hilar cholangiocarcinoma.The patients were followed up every 3 months postoperatively till December 2012.All data were analyzed using the chi-square test or Fisher exact probability test,the survival curve was drawn by Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results Of the 207 patients,124 received radical resection,including 14 received local resection,23 received dumbbell type resection,87 received lobectomy + caudate lobectomy,49 received palliative resection; 34 received biliary drainage.Four patients died perioperatively.The incidences of complications of dumbbell type radical resection,left hemihepatectomy + caudate lobectomy,right hemihepatectomy + caudate lobectomy were 21.7％ (5/23),46.6％ (27/58) and 48.3％ (14/29),respectively.The incidence of complications after dumbbell type radical resection was significantly lower than left hemihepatectomy + caudate lobectomy and right hemihepatectomy + caudate lobectomy (x2 =4.42,3.90,P ＜ 0.05).One hundred and seventy patients were followed up.The median survival time of the 112 patients who received radical radical resection was 26.5 months,and the 1-,3-,5-year survival rates were 75.9％ (85/112),42.9％ (24/56) and 28.9％ (11/38),respectively.The median survival time of the 38 patients who received palliative resection was 8.5 months,and the 1-,3-year survival rates were 31.6％ (12/38) and 0.The survival time of 20 patients who received biliary drainage was 4.0 months,and the l-year survival rate was 0.The survival rate of patients who received radical resection was significantly higher than those who received palliative resection (x2=65.32,P ＜ 0.05).There was a significant difference in the survival rate between patients who received surgical treatment and those who received biliary drainage (x2=99.97,P ＜ 0.05).Of the 112 patients who received radical resection,the median survival time of 10 patients who received local resection of tumor was 47.0 months,the 1-year survival rate was 10/10,and 4 patients survived at the end of the follow-up; the median survival time of 23 patients who received dumbbell type radical resection was 32.0 months,and the 1-,3-year survival rates were 95.7％ (22/23) and 7/15,and the survival time of 6 patients was longer than 5 years; the median survival time of 54 patients who received left hemihepatectomy or extended left hemihepatectomy + caudate lobectomy was 27.6 months,and the 1-,3-year survival rates were 42.1％ (24/57) and 38.7％ (12/32),and the survival time of 9 patients was longer than 5 years,3 patients survived at the end of the follow-up ; the median survival time of 25 patients who received right hemihepatectomy or extended right hemihepatectomy + caudate lobectomy was 28.3 months,and the 1-,3-year survival rates were 45.8％ (11/24) and 6/15,and the survival time of 6 patients was longer than 5 years,2 patients survived at the end of follow-up.The median survival time of 35 patients (patients with Bismuth type Ⅰ,Ⅱ hilar cholangiocarcinoma and Bismuth Ⅲ a and Ⅲ b hilar cholangiocarcinoma which did not invade the secondary bile duct) who received hemihepatectomy + caudate lobectomy was 32.0 months,and the 1-,3-,5-year survival rates were 91.4％ (32/35),45.8％ (11/24) and 5/16,which were not different from the survival rate of patients who received dumbbell type radical resection (x2 =0.17,P ＞ 0.05).The 5-year survival rate of patients with lymph node metastasis was 4/19,which was significantly lower than 30.4％ (7/23) of patients without lymph node metastasis (x2 =23.40,P ＜ 0.05).Conclusion Joint lobectomy and standardized lymph node dissection could help to improve the efficacy of surgical treatment for patients with hilar cholangiocarcinoma. Key words: Biliary neoplasms, hilar; Radical resection ; Efficacy

Surgical treatment of severe cervical dystrophic kyphosis due to neurofibromatosis Type 1: a review of 8 cases

the goal in this study was to retrospectively investigate the clinical efficacy of surgical treatment for cervical dystrophic kyphotic deformity due to neurofibromatosis Type 1. between January 1998 and July 2008, 8 patients with cervical dystrophic kyphotic deformity due to neurofibromatosis Type 1 (mean Cobb angle of 58.5°) were surgically treated in the authors' department. The mean age at surgery was 19 years (range 12-38 years). Among these patients, 1 with a Cobb angle of 52° and good flexibility underwent single anterior correction, whereas the other 7 patients with severe deformity and poor flexibility received combined anterior and posterior cervical osteotomy. Motor-evoked potential studies were used intraoperatively for spinal cord monitoring. Radiographic assessment and Japanese Orthopaedic Association scoring were used to evaluate the clinical outcome. no severe neurological complications were noted. Two patients complained of persistent neck and shoulder pain after combined anterior and posterior correction, which alleviated after conservative treatment half a year later. All patients were followed up for a mean of 21.1 months (range 6-36 months). All patients had a solid bone fusion at the latest follow-up, with Japanese Orthopaedic Association scoring improving from 11.5 preoperatively to 14.1 postoperatively (p < 0.01) at the final follow-up. The kyphotic deformities improved significantly, with average Cobb angles of 2.5° postoperatively and 4.1° at final follow-up. the deformity of neurofibromatosis with cervical kyphosis is severe, and surgery carries a high risk of failure. Although premature fusion may be performed, the deformity may still progress, and this situation may lead to failure of surgery. The successful management of this disease requires early recognition and a more aggressive and reliable intervention to prevent disastrous worsening of the deformity. Meticulous preoperative evaluation, appropriate surgical strategy, and skilled technique were essential for successful surgical treatment and good clinical results.

Metastases to the Upper Cervical Spine

A retrospective study of 13 patients with metastases to the upper cervical spine was designed to examine the clinical efficacy of surgical treatment. All patients had severe neck pain and two had quadriplegia. Eleven patients underwent operative posterior stabilization, and two patients were treated with a brace and radiotherapy. Pain relief after surgery was significant so that 10 of the 11 patients could leave bed and resume their normal activities. The other two patients who were treated nonoperatively had severe dementia and sudden death from a respiratory arrest after a fall, despite temporary relief from pain. Surgery may be very successful in improving the quality of life of patients who have pain and/or paralysis caused by metastases to the upper cervical spine.