Effect Of Different Surgical Approaches Research Articles

Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer

BackgroundNephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Compared to radical nephrectomy, kidney failure and cardiovascular events are less frequent with NSS. However, the effects of different surgical approaches and of zero ischaemia on the postoperative reduction in renal function remain controversial.We aimed to investigate the relative short- and long-term changes in estimated glomerular filtration rate (eGFR) after ischaemic or zero-ischaemic open (ONSS) and laparoscopic NSS (LNSS) for RCC, and to analyse prognostic factors for postoperative acute kidney injury (AKI) and chronic kidney disease (CKD) stage ≥3.MethodsData of 444 patients (211 LNSS, 233 ONSS), including 57 zero-ischaemic cases, were retrospectively analysed. Multiple regression models were used to predict relative changes in renal function. Natural cubic splines were used to demonstrate the association between ischaemia time (IT) and relative changes in renal function.ResultsIT was identified as significant risk factor for short-term relative changes in eGFR (ß = − 0.27) and development of AKI (OR, 1.02), but no effect was found on long-term relative changes in eGFR. Natural cubic splines revealed that IT had a greater effect on patients with baseline eGFR categories ≥G3 concerning short-term decrease in renal function and development of AKI. Unlike LNSS, ONSS was significantly associated with short-term decrease in renal function (ß = − 13.48) and development of AKI (OR, 3.87). Tumour diameter was associated with long-term decrease in renal function (ß = − 1.76), whereas baseline eGFR was a prognostic factor for both short- (ß = − 0.20) and long-term (ß = − 0.29) relative changes in eGFR and the development of CKD stage ≥3 (OR, 0.89).ConclusionsIT is a significant risk factor for AKI. The short-term effect of IT is not always linear, and the impact also depends on baseline eGFR. Unlike LNSS, ONSS is associated with the development of AKI. Our findings are helpful for surgical planning, and suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-time impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3.

Clinical characteristics, prognosis, and its risk factors of anorectal malformations: a retrospective study of 332 cases in Anhui Province of China

Objective: To analyze the clinical characteristics and prognosis of anorectal malformations (ARMs) and explore the influencing factors of postoperative anal function in Anhui Province of China.Methods: We performed a retrospective study of ARM patients diagnosed from 2013 to 2016 at Anhui Provincial Children’s Hospital. A total of 332 infants with ARM were enrolled in the survey. Demographic characteristic and clinical data were collected. Follow-up study was required to evaluate anal function after the operation and Logistic regression analysis was used for analyzing the influencing factors of prognosis.Results: A total of 253 males and 79 females were studied, with a ratio of 3.2:1. Abdominal distention was the most common presenting symptom, followed by vomiting. Of the cases, 53.0% (176/332) combined with other congenital malformations. The incidence of other malformations in intermediate and high ARM group was significantly higher than that in the low ARM group. Of the cases, 280 underwent anoplasty. 188, 73, 19 cases were treated with one-stage perineal anoplasty, posterior sagittal anorectoplasty, laparoscopically assisted anorectal pull-through, respectively. The result of follow-up study showed that the excellent and good rate of postoperative anal function was up to 83.3%. Type of ARM, combined with other malformations and the times of anoplasty were related to the anal function postoperatively.Conclusions: ARM occurs mainly in male infants. The incidence of associated abnormalities in ARM patients was high. Intermediate- and high-type, combined with other malformations and more times of anoplasty increased the risk of anal dysfunction postoperatively. Multicenter, prospective randomized-controlled studies were needed to clarify the curative effect of different surgical approaches.

Oncological Outcomes of Stage II Endometrial Cancer: A Retrospective Analysis of 250 Cases.

The aim of this study was to investigate the effect of different surgical approaches, adjuvant therapy, and pathological characteristics on oncological outcomes in patients with 2009 International Federation of Gynecology and Obstetrics (FIGO) stage II endometrial cancer (EC). A multicenter, retrospective department database review was performed to identify patients with FIGO 2009 stage II EC who underwent surgical staging between 2002 and 2015 at 5 gynecologic oncology centers in Turkey. Original pathology reports of 4867 patients who underwent surgical treatment for EC were analyzed. The study group consisted of 250 FIGO stage II patients. Of these patients, 203 (81.2%) had endometrioid and 47 (18.8%) had nonendometrioid histologic subtype of EC. Whereas 199 patients (79.6%) underwent type I hysterectomy, the remaining 51 patients (20.4%) underwent radical hysterectomy. Of the 250 patients, 208 patients (83.2%) had adjuvant therapy including radiotherapy (pelvic external beam radiotherapy and/or vaginal brachytherapy [VBT]) and/or platinum-based chemotherapy. Disease recurred in 29 patients (11.6%). The 5-year disease-free survival (DFS) and overall survival (OS) for the entire cohort were 82% and 85%, respectively. Multivariate analysis showed that only adjuvant treatment (P = 0.001; hazard ratio, 4.02; 95% confidence interval, 1.72-9.36) was significantly associated with DFS. According to multivariate analysis, only age older than 60 years (P = 0.01; hazard ratio, 3.03; 95% confidence interval, 1.3-7.04) was identified as an independent risk factor for OS. However, there were no differences in OS when evaluated by grade, histology, tumor size, type of hysterectomy, or adjuvant treatment. In stage II EC, adjuvant external beam radiotherapy ± VBT were associated with increased DFS but not OS. However, the benefit of VBT alone on DFS could not be demonstrated. Only age was an independent risk factor for OS. Type of hysterectomy and histologic subtype of the tumor for patients with uterus-confined disease improved neither DFS nor OS in our study group.

Neuropsychological outcome after subtemporal versus transsylvian approach for selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy: a randomised prospective clinical trial

ObjectiveTo compare the effects of different surgical approaches for selective amygdalohippocampectomy in patients with pharmacoresistant mesial temporal lobe epilepsy with regard to the neuropsychological outcome and to replicate an earlier...

Analysing the reasons of failure of surgical mitral repair approaches-do we need to better think in biomechanics?

The failure of mitral valve repair procedures revealed in the outcomes of the recent randomized studies is suggesting the necessity for a better understanding of the biomechanical mechanisms underlying the failure of the surgical approaches. Use of biomechanical modelling and finite element analysis (FEA) in cardiovascular research is an important aid in this context. In our group we developed a biomechanical model taking into account all the component of the mitral valve functional unit including the valve leaflets, the annulus, the papillary muscles, the chordae tendinea and the ventricular geometry. The two-dimensional mathematical model was capable to predict some of the actual geometrical and mechanical features of the valvular and subvalvular apparatuses in physiological and pathological conditions providing the engineering quantitative relations between closing and tethering forces and the mechanisms governing the mitral valve unit function. This model might further become patient-specific by means of 3D reconstruction of clinical imaging. Images are first converted in a standard vector format (DICOM, etc.), then automatically translated in a "structural" finite element model and finally implemented in a finite element code. This allows for in silico simulations to virtually explore the effects of different surgical approaches at an early stage after the procedure, to help the operative decision processes, or to optimize the design of surgical implants.

Different surgical approaches and their clinical efficacy in elderly patients with multi-level cervical spondylosis

Objective To investigate the clinical effect of different surgical approaches on multi-level cervical spondylosis in elderly patients. Methods A total of 53 aged patients with multi-level cervical spondylosis (≥70 years old) who received operation in our department during May 2007 to May 2014 were retrospectively studied, and divided into anterior cervical surgical group (n=22) and posterior cervical group (n=31), according to the surgical approach. The operation duration, intra-operative blood loss, hospitalization time, postoperative complications, Japanese orthopedics association (JOA) scores, Neck disability index (NDI), postoperative subjective improvement of clinical symptoms and spinal fusion of the two groups were evaluated and compared respectively. Results The mean operative time was longer in the anterior surgical group than in the posterior surgical group〔(2.7±0.5)h vs. (1.9±0.3) h, P 0.05〕. NDI score was lower in anterior surgical group than in posterior surgical group 3, 6, 12 months after operation and at the last follow-up. Among the 41 patients, radiographic outcomes showed that there were 16 cases of anterior surgical group with no bony fusion at the follow-up 3 months after operation, and all the 16 patients achieved bony fusion at the follow-up 1 year after operation, and there were 4 cases with titanium mesh subsidence (<3 mm). Conclusions Both anterior cervical decompression and fusion and posterior cervical single open-door laminoplasty have good efficacy in the treatment of multilevel cervical spondylosis in elderly patients, which have advantages on the limb functional recovery time and cervical function assessment. When anterior cervical surgical contraindications were excluded, the anterior cervical decompression and fusion may be a good choice for the treatment of multilevel cervical spondylosis in aged patients. Key words: Cervical spondylosis; Spinal fusion; Verterbroplasty

Difference in Stem Alignment Between the Direct Anterior Approach and the Posterolateral Approach in Total Hip Arthroplasty

The purpose of this study was to investigate the effects of different surgical approaches, the posterolateral approach (PLA) and the direct anterior approach (DAA), on postoperative femoral anteversion and stem coronal and sagittal alignment in total hip arthroplasty (THA), and to identify the factors related to postoperative femoral anteversion and stem alignment. A total of 209 hips of 181 patients were evaluated. THA was performed through the PLA in 80 hips and through the DAA in 129 hips. Femoral anteversion and stem alignment were measured on postoperative computed tomography images. The factor related to postoperative anteversion change was preoperative femoral anteversion, and the surgical approaches did not affect the postoperative anteversion change, while surgical approach did have an effect on stem sagittal alignment.

MP42-07 IMPACT OF SURGICAL APPROACH ON ERECTILE FUNCTION RECOVERY FOLLOWING BILATERAL NERVE SPARING-RADICAL PROSTATECTOMY: RESULTS FROM A RANDOMIZED CONTROLLED TRIAL OF TADALAFIL VERSUS PLACEBO (REACTT)

You have accessJournal of UrologyProstate Cancer: Localized I1 Apr 2015MP42-07 IMPACT OF SURGICAL APPROACH ON ERECTILE FUNCTION RECOVERY FOLLOWING BILATERAL NERVE SPARING-RADICAL PROSTATECTOMY: RESULTS FROM A RANDOMIZED CONTROLLED TRIAL OF TADALAFIL VERSUS PLACEBO (REACTT) Martin Schostak, Markus Graefen, Christian Kriegel, Uwe Michl, Antonio Martin Morales, Peter J. Pommerville, Martina Manning, Hartwig Büttner, Carsten Henneges, and Jens-Uwe Stolzenburg Martin SchostakMartin Schostak More articles by this author , Markus GraefenMarkus Graefen More articles by this author , Christian KriegelChristian Kriegel More articles by this author , Uwe MichlUwe Michl More articles by this author , Antonio Martin MoralesAntonio Martin Morales More articles by this author , Peter J. PommervillePeter J. Pommerville More articles by this author , Martina ManningMartina Manning More articles by this author , Hartwig BüttnerHartwig Büttner More articles by this author , Carsten HennegesCarsten Henneges More articles by this author , and Jens-Uwe StolzenburgJens-Uwe Stolzenburg More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1592AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) may be impacted by the type of surgical approach. We report pre-specified and exploratory analyses on the effect of different surgical approaches on recovery of EF obtained from the multicenter, randomized, double-blind, REACTT trial of tadalafil once a day (OaD) or on demand (pro re nata, PRN) versus placebo. METHODS Patients ≤(pts)68yrs with normal preoperative EF who underwent nsRP for localized prostate cancer were randomized post-nsRP 1:1:1 to 9 month double-blind, double-dummy treatment (DBT) with tadalafil 5mg OaD, tadalafil 20mg PRN, or placebo, followed by 6-week drug-free washout and 3-month open-label OaD treatment. EF-recovery was defined as an International Index of Erectile Function (IIEF)-EF domain score ≥22, and normal orgasmic function was defined as IIEF Question 10 item score ≥4. Both parameters were analyzed after washout using logistic regression including terms for: treatment, country, visit, visit-by-treatment interaction, age group, nerve-sparing score, and surgical approach. Time to EF-recovery was analyzed post-hoc with a Cox proportional-hazards model including terms for: treatment, age-group, country, nerve-sparing score, surgical approach, and surgery-by-treatment interaction. RESULTS Of 422 pts enrolled at 50 centers, 189 had open surgery, 115 robot-assisted laparoscopy (lap), 88 conventional lap, and 30 surgeries classified as “other” (endoscopic extraperitoneal nsRP). The odds of achieving EF-recovery at the end of drug-free washout were approximately twice as high for the robot-assisted laparoscopy group compared with the open surgery group (odds ratio: 2.42; 95%CI 1.24, 4.72; p=0.029). Pts who underwent robot-assisted laparoscopy were significantly more likely to recover during DBT compared with pts who had open surgery (hazard ratio: 1.9; 95%CI 1.18, 3.18; p=0.009). A favorable effect of conventional laparoscopy compared with open surgery could not be observed. CONCLUSIONS Although the trial was not primarily designed for these analyses, the results may provide further insights into the impact of surgery on EF-recovery post-nsRP. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e510-e511 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Martin Schostak More articles by this author Markus Graefen More articles by this author Christian Kriegel More articles by this author Uwe Michl More articles by this author Antonio Martin Morales More articles by this author Peter J. Pommerville More articles by this author Martina Manning More articles by this author Hartwig Büttner More articles by this author Carsten Henneges More articles by this author Jens-Uwe Stolzenburg More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopically assisted colorectal surgery provides better short-term clinical and inflammatory outcomes compared to open colorectal surgery.

IntroductionChanges in immune function after surgery may influence overall outcome, length of hospital stay, susceptibility to infection and perioperative tumour dissemination in cancer patients. Our aim was to elaborate on postoperative differences in the immune status and the intensity of the systemic inflammatory response between two groups of prospectively enrolled patients with colorectal cancer, namely patients undergoing laparoscopically assisted or open colorectal surgery.Material and methodsBlood samples from 77 patients were taken before surgery and then 3 h, 24 h and 4 days after surgery. The inflammatory response was determined by leukocyte counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and procalcitonin levels (PCT). Immune status was determined by phenotypic analysis of lymphocyte populations and the activation of mononuclear cells. CD64 expression and cytokine expression were also determined.ResultsPatients undergoing laparoscopically assisted surgery had less intraoperative blood loss (p = 0.002), earlier resumption of diet (p = 0.002) and shorter hospital stay (p = 0.02). Numbers of total leukocytes (p = 0.12), CRP (p = 0.002) and PCT (p = 0.23) were remarkably higher 4 days after surgery in patients who underwent an open colorectal procedure. There was an important decrease in monocyte HLA-DR expression 3 h after surgery in patients undergoing laparoscopically assisted surgery (p = 0.03).ConclusionsOur study suggests that minimally invasive surgery provides better short-term clinical outcomes for patients with resectable colorectal cancer. The acute inflammatory response is less pronounced. Post-surgical immunological disturbance in both groups is similar, but we observed a divergent effect of different surgical approaches on the expression of HLA-DR on monocytes. However, our results corroborate the results of previous studies.

Optimal surgical treatment and urological outcomes in boys with pelvic and urogenital rhabdomyosarcomas and soft tissue sarcomas

Soft tissue sarcomas (STS) of pelvic origin in boys often involve the urogenital organs. The optimal extensiveness of radical surgery has long been an issue of discussion, since exenterative surgeries result in severe urogenital adverse effects. We conducted a retrospective review of patients with pelvic STS treated in two regional center hospitals and assessed the radicality of surgery and the functional outcome of the bladder. Medical records and surgical reports of nine cases (embryonal rhabdomyosarcoma 6, malignant triton tumor 2, suspected rhabdomyosarcoma 1) treated within 1997-2012 were reviewed. Site of origin was prostate in seven, retroperitoneal in two. Average follow-up period was 96months. All cases were subjected to neoadjuvant chemotherapy. Response was PR in four, SD in two, and PD in two. Radical surgery resulted in gross total resection in eight, and partial resection in one. Three underwent cystoprostatectomy, two cases underwent prostatectomy, and bladder-preserving tumor resection was carried out in four cases. At the last follow-up, three retained a functional bladder. Two required augmentation cystoplasty with intestinal conduits. The majority of the on-going clinical trials recommend conservative surgery for bladder/prostate rhabdomyosarcoma, and to preserve the bladder function particularly in chemosensitive tumors. Some other groups, however, advocate the importance of radical surgery to prevent local relapse. These reports include heterogenous group of patients in the cohort, and therefore it is difficult to draw a conclusion of which approach truly contributes to the survival of the patients better. Future studies should evaluate bladder and sexual function objectively to establish reliable evidence regarding the benefit and adverse effects of different surgical approaches. These data would be informative to optimize the treatment balance for children with pelvic rhabdomyosarcomas.

Clinical analysis on effects of different surgical approaches in nasal inverted papilloma

Objective To evaluate the efficacy of different clinical criteria endoscopic surgical approaches for inverted papillomas of the nasal cavity and paranasal sinus.Methods 60 cases diagnosed as nasal inverted papilloma (NIP) were retrospectively analyzed.Among these patients,17 cases were treated by external approach surgery,27 cases by endoscopic surgery and 16 cases by endoscopy plus Caldwell-Luc approach resection.Comparison was made in three groups in respects of operation time,blood loss,hospitalization time and recovery.Results There were no obvious differences in operation time in three groups (P＞0.05).The blood loss and hospital time in external approach group were significantly higher than those in endoscopic group or endoscopy plus Caldwell-Luc group(P＜0.05).There was no statistical significant difference in the recurrence rate in three groups (P＞0.05).The recurrence rate was raised with the Krause stage increased.Conclusion For the cases of Krouse Ⅲ,the external approach is a good supplementary for the surgery under nasal endoscope.By using nasal endoscope united with external approach surgery,the tumor can be excised more thoroughly,with less residual and recurrence,and impairment can be cut down. Key words: Endoscopic surgery; External approach; Inverted; Papilloma

Treatment outcomes after surgical resection of midline anterior skull base meningiomas at a single center

Meningiomas of the midline anterior skull base (ASB) typically grow around the optic chiasm. These tumors can displace or adhere to the optic apparatus, resulting in visual abnormalities. For this reason, in most studies of surgically resected meningiomas, only surgical and visual outcomes have been evaluated. However, in this study, we assessed overall clinical outcomes and the effects of different surgical approaches on outcomes. Clinical data for 126 patients who were treated surgically for midline ASB meningiomas between 1994 and 2009 were collected and reviewed retrospectively. The mean follow-up duration was 39months (range: 0.5–146months). Most procedures were performed via a pterional approach and did not require an aggressive skull base approach. Clinical outcomes were evaluated using our own criteria, and potential predictive factors for visual and clinical outcomes were tested statistically. The tumor control rate was 83% (105/126). Immediate postoperative visual status and optic canal involvement were correlated with visual outcome. Of the patients who ultimately had improved visual status, only six were originally categorized as having severe visual impairment (all were only able to count fingers). In terms of clinical outcome, 41 patients were classified as “excellent”, 32 as “good”, 29 as “fair”, and 20 as “poor”. A symptom duration of less than six months, less severe preoperative visual symptoms of the affected eye, and the extent of resection were all correlated with improved clinical outcome. Involvement of the optic canal, adherence of the tumor to the optic nerve, and major arterial encasement by the tumor were associated with poor clinical outcome. We recommend that in patients with unilateral severe visual impairment, the focus should be on improving visual function in the contralateral eye. Preoperative and postoperative evaluation of several variables allows for the prediction of clinical and visual outcomes.

Impact of surgical approaches on the lumbar multifidus muscle: an experimental study using sheep as models

In this paper, the authors assessed the effects of different surgical approaches and reconstructive methods on the spinous process after lumbar surgery in sheep. A total of 41 healthy, adult sheep weighing 38-40 kg were used in this study. The animals were randomly divided into 4 groups (10 animals per group and 1 control). Animals in Group A underwent a spinous process-splitting procedure to expose the lamina. Animals in Group B had bilateral multifidus muscles stripped and the spinous process excised. All animals in Group C underwent unilateral stripping of the multifidus muscle from the spinous process (Group C1) as well as spinous process splitting at the bottom to expose the contralateral lamina attached to the multifidus muscle (Group C2). To mimic the laminoplasty procedure, the multifidus muscles were stripped bilaterally in Group D. For all groups, the surgical level (L-6), length of incision (4 cm), the retracting distance, and time (40 minutes) remained constant. Ten months after surgery, the atrophy rate of the cross-sectional areas (CSAs) of the multifidus muscle, MR imaging findings, and histological changes of the muscle tissue were evaluated. Normal multifidus muscles taken from a healthy sheep at the L-6 level and the preoperative data of MR imaging in experimental animals provided control data (Group E). The MR imaging and histological scores of multifidus muscles from sheep in Groups A, B, C1, C2, and D were significantly decreased, and the atrophy rates were significantly higher than those from sheep in Group E (p < 0.05). The postoperative MR imaging and histological scores obtained in Groups A and C2 were highest and the atrophy rates were lowest, while animals from Group B had the highest atrophy rate and lowest MR imaging and histological scores among all experimental groups (p < 0.05). The scores for animals in Groups A and C2, in which the muscles were not stripped from the spinous process, achieved lower atrophy rates and higher MR imaging and histological scores than those for sheep in Groups C1 and D, in which the muscles were stripped (p < 0.05). The groups in which the spinous process was reconstructed after detachment of the muscles (Groups C1 and D) had lower atrophy rates and higher MR imaging and histological scores than Group B (p < 0.05). The multifidus muscle can be effectively protected by reducing the extent of muscle detachment and reconstructing the posterior bone-ligament complex. A spinous process-splitting procedure is a useful method to reduce postoperative muscle atrophy.

Experimental study of the impact of different lumbar posterior approaches on multifidus muscle.

Objective To assess the effect of different surgical approaches on atrophy of multifidus muscle occurring after lumbar surgery. Methods Forty adult goats were randomly divided four groups.Group A underwent a spinous process-splitting procedure to expose the lamina; Group B did the bilateral multifidus muscles stripped and the spinous process excised; Group C underwent the cutting of the spinous process at the bottom, with unilateral multifidus muscle stripped (Group C1), and without stripped (Group C2); and Group D did the bilateral multifidus muscles stripped. Ten months after surgery, the atrophy rates of the cross-sectional areas, the subjective scores of fibrosis and fatty tissue infiltration of the bilateral multi-fidus muscles on MRI, and the histological assessment were evaluated. Normal multifidus muscles taken from healthy goats at L_6 level and the preoperative data of MRI in experimental animals provided control data.Results MRI and histological scores of multifidus muscles from Groups A, B, C1, C2, and D were signifi-cantly decreased, and the atrophy rate were significantly higher in comparison to control data. The postoper-ative MRI and histological scores of Group A and C2 were highest and the atrophy rate was lowest, while an-imals from Group B had highest atrophy rate and lowest MRI and histological scores among all experimental groups (P<0.05). The Groups A and C2 achieved lower atrophy rate, higher MRI and histological scores than those from Groups C1 and D which did have muscles stripped (P<0.05). The Groups C1 and D which recon-structed spinous process after detachment of muscles represented lower atrophy rate, higher MRI and histo-logical scores than Group B (P<0.05). The postoperative histological scores were positively correlated with MRI scores, but it had no correlation with atrophy rate of multifidus. Conclusion Multifidus muscle can be ef-fectively protected by reducing the extent of muscle detachment and reconstructing the posterior bone-ligament complex. The spinous process-splitting procedure is an effective method to avoid postoperative muscle atrophy. Key words: Lumbar vertebrae; Pathology; Magnetic Resonance Imaging; Goats

Variability in Surgical Technique for Brachioradialis Tendon Transfer&lt;sbt aid="1121202"&gt;Evidence and Implications&lt;/sbt&gt;

Transfer of the tendon of the brachioradialis muscle to the tendon of the flexor pollicis longus restores lateral pinch function after cervical spinal cord injury. However, the outcomes of the procedure are unpredictable, and the reasons for this are not understood. The purpose of this study was to document the degree of variability observed in the performance of this tendon transfer. The surgical technique used for the brachioradialis tendon transfer was assessed in two ways. First, the surgical attachment length of the brachioradialis was quantified, after transfer to the flexor pollicis longus, with use of intraoperative laser diffraction to measure muscle sarcomere length in eleven individuals (twelve limbs) with tetraplegia. Second, ten surgeons who regularly performed this procedure were surveyed regarding their tensioning preferences. Using a biomechanical model of the upper extremity, we investigated theoretically the effect of different surgical approaches on the active muscle-force-generating capacity of the transferred brachioradialis in functionally relevant elbow, wrist, and hand postures. The average sarcomere length (and standard deviation) of the transferred brachioradialis was 3.5 +/- 0.3 mum. That length was significantly correlated to the in situ sarcomere length (r(2) = 0.53, p < 0.05). Surgical tensioning preferences varied considerably; however, six of the ten surgeons positioned the patient's elbow between full extension (0 degrees of elbow flexion) and 50 degrees of flexion when selecting the attachment length, and six of the ten stated that their goal was to tension the transfer slightly tighter than its resting tension. The computer simulations suggested that a "tighter" brachioradialis transfer would produce its peak active force in an elbow position that is more flexed than the elbow position in which a "looser" transfer would produce its peak active force. This study provides evidence that experienced surgeons perform this tendon transfer differently from one another. Biomechanical simulations suggested that these differences could result in substantial variability in the active force that the transferred brachioradialis can produce in functionally relevant postures. The surgical attachment length and the position of the patient's limb at the time of tendon transfer are both controllable and measurable parameters. Understanding the relationship between surgical technique and postoperative muscle function may provide surgeons with more control of clinical outcomes.

VARIABILITY IN SURGICAL TECHNIQUE FOR BRACHIORADIALIS TENDON TRANSFER

Background: Transfer of the tendon of the brachioradialis muscle to the tendon of the flexor pollicis longus restores lateral pinch function after cervical spinal cord injury. However, the outcomes of the procedure are unpredictable, and the reasons for this are not understood. The purpose of this study was to document the degree of variability observed in the performance of this tendon transfer. Methods: The surgical technique used for the brachioradialis tendon transfer was assessed in two ways. First, the surgical attachment length of the brachioradialis was quantified, after transfer to the flexor pollicis longus, with use of intraoperative laser diffraction to measure muscle sarcomere length in eleven individuals (twelve limbs) with tetraplegia. Second, ten surgeons who regularly performed this procedure were surveyed regarding their tensioning preferences. Using a biomechanical model of the upper extremity, we investigated theoretically the effect of different surgical approaches on the active muscle-force-generating capacity of the transferred brachioradialis in functionally relevant elbow, wrist, and hand postures. Results: The average sarcomere length (and standard deviation) of the transferred brachioradialis was 3.5 ± 0.3 μm. That length was significantly correlated to the in situ sarcomere length (r2 = 0.53, p < 0.05). Surgical tensioning preferences varied considerably; however, six of the ten surgeons positioned the patient's elbow between full extension (0° of elbow flexion) and 50° of flexion when selecting the attachment length, and six of the ten stated that their goal was to tension the transfer slightly tighter than its resting tension. The computer simulations suggested that a “tighter” brachioradialis transfer would produce its peak active force in an elbow position that is more flexed than the elbow position in which a “looser” transfer would produce its peak active force. Conclusions: This study provides evidence that experienced surgeons perform this tendon transfer differently from one another. Biomechanical simulations suggested that these differences could result in substantial variability in the active force that the transferred brachioradialis can produce in functionally relevant postures. Clinical Relevance: The surgical attachment length and the position of the patient's limb at the time of tendon transfer are both controllable and measurable parameters. Understanding the relationship between surgical technique and postoperative muscle function may provide surgeons with more control of clinical outcomes.

Lesion therapy for Parkinson's disease and other movement disorders: update and controversies.

An analysis of the international literature on lesioning for movement disorders was undertaken to review lesion therapy for Parkinson's disease (PD) and other movement disorders and to highlight important controversies surrounding this surgical technique. Lesions have been placed throughout the neuraxis with varying approaches and success. Our understanding of the pathophysiological basis underlying the development of PD and other movement disorders has led to a better understanding of why lesioning certain portions of the nervous system should improve motor function. Advances in imaging technology and electrophysiological techniques used for localization of brain structures, such as microelectrode mapping, have improved the ability to accurately identify and lesion target structures deep in the brain. This improvement has led to an increase in the degree and consistency of clinical benefit. The major controversies in lesion therapy include: (1) which target for which disorder; (2) determination of the optimal lesion site and whether the external globus pallidus (GPe) should be included in the pallidotomy lesion for PD; (3) determination of the size of the lesion; (4) whether bilateral lesions can be placed without the high incidence of side effects reported by some investigators; (5) whether microelectrodes aid in the ability to improve clinical outcomes or increase the risk of side effects by making multiple microelectrode penetrations; (6) whether the subthalamic nucleus (STN) should be explored further as a lesioning target; and (7) whether lesioning should be abandoned entirely in favor of deep brain stimulation (DBS). Many important questions and controversies regarding lesion therapy remain unanswered. It is unlikely given the pro-DBS environment that these questions will be answered in the near future. We should, however, be careful not to abandon an effective therapy before fully exploring through randomized trials the relative effect of different surgical approaches for the treatment of patients with movement disorders.

Surgical approaches for inserting hemiarthroplasty of the hip

The operation of insertion of a hemiarthroplasty to the hip refers to replacement of the femoral head with a prosthesis, whilst retaining the natural acetabulum and acetabular cartilage. The main surgical approaches to the hip for insertion of the prosthesis can be broadly categorised as either 'anterior' via the anterior joint capsule, or 'posterior' through the posterior joint capsule. To evaluate, based on evidence from randomised controlled trials, the effects of different surgical approaches for the insertion of a hemiarthroplasty to the hip has on clinical outcomes. We searched the Cochrane Musculoskeletal Injuries Group specialised register (up to February 2002). Articles of all languages were considered. All randomised controlled trials comparing insertion of a hemiarthroplasty by different surgical approaches. Both reviewers independently assessed trial quality, using a 10 item scale, and extracted data. Wherever appropriate and possible, the data are presented graphically. One randomised trial was identified involving 114 patients. The trial had poor methodology (particularly in susceptibility to selection bias), inadequate follow-up of patients who withdrew, and there was limited reporting of results. Medical complications and mortality from six months to two years appeared greater in the posterior group; this difference in mortality, within the structure of the poor methodology, was statistically significant. No other differences were claimed to be significant. There is currently insufficient evidence from randomised trials to determine the optimum surgical approach for insertion of a hemiarthroplasty to the hip.

Surgical management of congenital nystagmus.

Forty-three patients with congenital nystagmus who underwent surgery in the Ocular Motility Clinic at The Royal Victorian Eye and Ear Hospital, Melbourne, are analysed to assess the effect of different surgical approaches on the abnormal head posture and binocular visual performance. There were 38 patients with a horizontal head turn, and five with a vertical abnormal head posture. In those undergoing horizontal nystagmus surgery the different surgical procedures have been classified as: Anderson procedure, which involves large bilateral augmented recessions only; Kestenbaum and augmented Kestenbaum bilateral recess/resect surgery in which the recess:resect ratio is less than 1; and a modified Anderson-Kestenbaum procedure with the emphasis on large recessions, so that the bilateral recess/resect ratio is greater than 1. In this series the augmented recessions of the Anderson and Anderson-Kestenbaum procedures appeared to produce a more favourable result of improved binocular vision. The five patients with vertical abnormal head posture with nystagmus had various surgical procedures with very encouraging results, both in terms of reduction of the abnormal head posture and an even greater improvement of binocular vision than with the horizontal cases. The surgical techniques in these cases are presented and discussed.

SURGICAL MANAGEMENT OF CONGENITAL NYSTAGMUS

AbstractForty‐three patients with congenital nystagmus who underwent surgery in the Ocular Motility Clinic at The Royal Victorian Eye and Ear Hospitar Melbourne, are analysed to assess the effect of different surgical approaches on the abnormal head posture and binocular visual performance. There were 38 patients with a horizontal head turn, and five with a vertical abnormal head posture.In those undergoing horizontal nystagmus surgery the different surgical procedures have been classified as(4 Anderson procedure, which involves large bilateral augmented recessions only; (ii) Kestenbaum and augmented Kestenbaum bilateral recess/resect surgery in which the recess:resect ratio is less than 1; and (iii) a modified Anderson‐Kestenbaum procedure with the emphasis on large recessions. so that the bilateral recess/resect ratio is greater than 1. In this series the augmented recessions of the Anderson and Anderson‐Kestenbaum procedures appeared to produce a more favourable result of improved binocular vision.The five patients with vertical abnormal head posture with nystagmus had various surgical procedures with very encouraging results, both in terms of reduction of the abnormal head posture and an even greater improvement of binocular vision than with the horizontal cases. The surgical techniques in these cases are presented and discussed.