Incision For Insertion Research Articles

A clinical study on robot navigationassisted intramedullary nail treatment for humeral shaft fractures

BackgroundThe purpose of this study was to evaluate the advantages of robot navigation system-assisted intramedullary nail treatment for humeral shaft fractures and compare it’s efficacy with that of traditional surgical intramedullary nail treatment.Materials and methodsThis was a retrospective analysis of patients with humeral shaft fractures who received intramedullary nail treatment at our centre from March 2020 to September 2022. The analysis was divided into a robot group and a traditional surgical group on the basis of whether the surgery involved a robot navigation system. We compared the baseline data (age, sex, cause of injury, fracture AO classification, and time of injury-induced surgery), intraoperative conditions (surgery time, length of main nail insertion incision, postoperative fluoroscopy frequency, intraoperative bleeding), fracture healing time, and shoulder joint function at 1 year postsurgery (ASES score and Constant–Murley score) between the two groups of patients.ResultsThere was no statistically significant difference in the baseline data or average fracture healing time between the two groups of patients. However, the robotic group had significantly shorter surgical times, longer main nail incisions, fewer intraoperative fluoroscopies, and less intraoperative blood loss than did the traditional surgery group (P < 0.001).ConclusionRobot navigation system-assisted intramedullary nail fixation for humeral shaft fractures is a reasonable and effective surgical plan. It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes.

Intraoperative and Postoperative Outcomes of Modified Bidirectional Intra-Umbilical Incision versus Infra-Umbilical Incision for Direct Trocar Insertion in Gynaecological Laparoscopy

Objectives: This study aimed to describe a modified, curved, deep, bidirectional, intra-umbilical, vertical incision for primary trocar insertion and prospectively compare its intraoperative and postoperative outcomes with an infra-umbilical incision in gynaecologic laparoscopy. Methods: Between August 2019 and March 2021, 110 patients subjected to the direct trocar insertion technique for laparoscopic intervention were classified into two groups. Group A comprised 55 cases of infra-umbilical incision, whereas group B comprised 55 cases of a modified, curved, longitudinal, deep, bidirectional, intra-umbilical incision. Afterwards, intraoperative and postoperative assessments were performed. Results: The increase in the numbers of parity, gravidity and previous caesarean sections was found to be statistically significant; a smaller number of infertility complaints were observed in group B. Similarly, group B expressed a statistically significant less peri-trocar CO2 leakage (46 [83.6%] patients versus 28 [50.9%] patients) and more tightness of the primary portal entry (45 [81.8%] patients versus 30 [54.5%] patients) when compared to group A throughout the whole operation. After a one-month follow-up, a statistically significant (P = 0.029) decrease in the Observer Scar Assessment Scale and Patient Scar Assessment Scale scores in group B (10.4 ± 4.2 and 11.8 ± 4.3, respectively), demonstrating better cosmoses when compared to group A (13.3 ± 5.7 and 16.0 ± 6.8, respectively). Conclusion: Performing a modified, curved, deep, bidirectional, intra-umbilical, vertical incision for the insertion of a primary laparoscopic trocar (i.e. Darwish laparoscopic entry) is a simple and fast step that results in the elimination of intraoperative gas leakage and trocar slippage without the need for any additional sutures. Aesthetically, it results in a better scar with satisfactory cosmoses when compared to an infra-umbilical incision. Keywords: Laparoscopy; Trocar; Egypt.

Subcutaneous emphysema and pneumocephalus following Ventriculoperitoneal Shunt (VPS) surgery for hydrocephalus: a case report

Link Video Abstract: https://youtu.be/vfAwOXSjbCE Background: Hydrocephalus is still commonly found in pediatric neurosurgery managed by endoscopic third ventriculostomy (ETV) and Ventriculoperitoneal Shunt (VPS). Subcutaneous emphysema and pneumocephalus as a complication of VPS surgery is rare. Subcutaneous emphysema is the presence of air in the skin, while pneumocephalus is the presence of air in the intracranial space. This case study aims to evaluate subcutaneous emphysema and pneumocephalus following ventriculoperitoneal shunt surgery for hydrocephalus. Case Presentation: We report an 11-month-old girl with hydrocephalus due to aqueductal stenosis who postoperatively had subcutaneous emphysema and pneumocephalus. 1 week after VPS insertion, there was a crepitation under the skin of the neck and chest. The patient occasionally appeared breathless and had a fever. The respiratory rate increased with rales on the right lung, along with the gradually decreased consciousness, and the abdominal wound slowly became dehiscent. There was subcutaneous emphysema along the shunt track and pneumocephalus. Conclusion: The interest, in this case, could be that of the patient’s other morbid conditions, including pneumonia and the dehiscent abdominal wound on the post-VP shunt insertion incision that may have also contributed to causing the subcutaneous emphysema and pneumocephalus.

Transabdominal self-expandable metal stent placement as a rescue therapy for drainage of walled-off necrosis.

Video 1CT scan of a walled-off necrosis in the right pararenal space extended to the iliac area.

Clinical and radiographic evaluation ofminimally invasive plate osteosynthesis (MIPO) indogs with tibial fractures.

The aim ofthis study was aclinical and radiographic evaluation ofthe minimally invasive plate osteosynthesis (MIPO) method for treatment indogs with tibial fractures. Ten dogs ofdifferent breeds, ages, and sex with tibial fractures were used asthe subjects. Amedial approach tothe tibia was used inall the cases. The tibial tuberosity was palpated proximally and ashort incision was made along the midline. After reduction ofthe fracture, proximal and distal insertion incisions were made toapproach the tibia. The mean times for the MIPO operations were 21minutes. The patients were able tostand and walk postoperatively onthe first day and recovery was rapid for all ofthe dogs. The fracture healing was completed onday45 based onthe radiographic evaluations ofthese cases. Dogs with tibia fractures treated byMIPO healed rapidly without any complications (90%). Correct fracture selection isimportant for the use ofMIPO tobe successful. Further studies with alarger group ofdogs should beconsidered tocompare the efficacy ofMIPO and other fixation techniques and for the long-term evaluation ofthe repaired tibial fractures.

Minimally invasive (Titanium elastic nailing system) operative technique in pediatric both bone forearm fractures

Background: Both bone forearm fracture in paediatric population is one of the most common fractures encountered. Here we present a prospective study conducted to evaluate radiographic & functional outcome of paediatric both bone forearm fractures treated with titanium elastic nailing systems. Methods: In our prospective study we included 18 patients who were between 6 – 15 years, admitted during October 2019 to June 2020 in Chamarajanagar institute of medical sciences & Karwar institute of medical sciences, patients were included according to inclusion & exclusion criteria. All patients were operated under appropriate anaesthesia. Outcome was evaluated using price et al. criteria. All the patients were operated using minimally invasive system (titanium elastic nailing). Results: we included 18 patients, out of which 13 (72.2%) were male & 5(27.7%) were female with male predominance, 10 (55.5%) patients had displaced fracture, 8 (44.4%) had loss of reduction due to unstable & irreducible fracture. 15 (83.3%) patients had right side involvement & 3(16.7%) had left side involvement, closed reduction & internal fixation done in 14 (77.7%) patients were as 4 (22.2%) patients were treated with minimal open reduction & internal fixation, due to irreducibility. Depending on location of fracture 16(88.8%) were in middle 1/3rd, 2(11.1%) were in distal 1/3rd. patients were analysed depending on Price et al. criteria in whom 15 had excellent, 2 had good, 1 had fair result due to local infection & implant prominence. Patients were regularly evaluated at 4, 8 & 12 weeks, finally at 6 months. Union was seen in an average around 4 – 6 weeks. Conclusions: Minimally invasive technique (Titanium elastic nails) for paediatric forearm fractures revealed several advantages, a small incision for insertion, a low rate of complications, good bone healing, and good clinical and radiological results thus achieving maximum range of motion at the earliest.

Robot-assisted renal transplantation using the retroperitoneal approach (RART) with more than one year follow up: Description of the technique and results

To describe the technique and report our first experience of robotic-assisted renal transplantation (RART) with more than one year follow up. In our center the first case of RART was realized in October 2013 with a cadaveric graft. We used the combined extra- and intraperitoneal robot assisted laparoscopic route with extraperitoneal positioning of the graft and intraperitoneal transplantation. The patient was placed in the supine position with arms along the body; the robot came from the right inferior part of the patient. Access to the retroperitoneal space was obtained using an Alexis trocar that permitted the insertion of the kidney with ice without losing the pneumoperitoneum. Ports included a 12-mm camera port (placed under the ombilicus), two 8-mm robotic ports (placed 6cms laterally from the previous port) and a 12-mm assistant port (placed between the upper port and the ombilic). All the pre-, per- and postoperative data were prospectively included in a database. We report the results of the initial experience of RART, performed with more than one year follow-up. This technique is the first described using the retroperitoneal approach that is the routine approach for conventional open renal transplantation. This approach permitted to perform excellent arterial, veinous and ureteral anastomosis. Eight cases of RART were conducted between October 2013 and November 2015 (five men and three women). The average age was 58 years (range 39-75years). The average body mass index was 28 (range 22-38). Five patients had history of abdominal surgery and were dialyzed for 30 months on average (range 3-63months). Three left and five right cadavers kidneys were transplanted in the right iliac fossa. The mean graft size was 109mm (range 90-130). The mean length of the incision for insertion of the graft was 60 mms (40-100mms). Mean warm ischemia time was 63minutes (range 46-84). The total operative time was 200minutes (149-245). No patient was transfused during surgery and two were transfused postoperatively. Median length of hospital stay was 14 days (range 10-30 days). Only one patient needed postoperative morphine, the pain visual analogic scale 12hours postoperatively was 2 (0-5). Mean serum creatinine at seven days, at three months and at one year was 400 (98-639micromol/L), 151 (80-235micromol/L) and 129 (86-194micromol/L) respectively. At one year follow-up, no patient had a wound infection or incisional hernia. One patient was re-operated for ureteral anastomosis stricture. The retroperitoneal approach for RART permits the kidney to be cooled and a direct access to the iliac vessels and bladder. This initial series with more than a year of post-monitoring RART shows promising results despite some initial technical difficulties. The procedure can still be improved and hoped to see an improvement in the results. A comparison to the results of the conventional route is necessary before diffusing the robot-assisted technique. 3.

Pediatric forearm fractures with tens: freedom of movements

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; A prospective analysis of a case series of diaphyseal forearm fractures in children treated with titanium elastic nails is presented. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Between 2012 and 2014, 30 children aged 5-15 years with displaced diaphyseal forearm fractures underwent titanium elastic nailing. Both bones were fractured in 25 patients, four fractured only the radius, and one experienced ulna fracture. Eleven candidates had unstable irreducible fractures, 13 had loss of reduction, and six had open fractures. Titanium elastic nails were used to stabilize the fractures. All fractures were immobilized postoperatively with an above-elbow plaster slab for 2 weeks till the swelling is completely resolved followed by encouraging range of motion exercises.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Closed reduction and TENS was successful in 20 cases, including 15 double-bone fractures and five single-bone fractures. Open reduction was completed in four fractures of both bones, and in six single-bone open fractures. Bone union was achieved in all patients at an average of 7 weeks. The ROM of the forearms was evaluated using the Daruwalla grading criteria. Excellent results were reported in 96% without significant complications after a mean follow-up of 20 months.&lt;/p&gt;&lt;p class="Default"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Titanium elastic nails fixation of pediatric forearm fractures revealed several advantages, a small incision for insertion, a low rate of complications, unhindered bone healing, and good clinical and radiological results thus achieving maximum range of motion at the earliest.&lt;/p&gt;

Minimal Invasive Internal Liver Retractor in Conventional and Trans-umbilical Single-Incision Laparoscopic Sleeve Gastrectomy: Video Report

Sleeve gastrectomy (SG) is a safe and efficient procedure with comparable results between conventional and single-incision approach in selected patients. However, the critical point in both approaches is the retraction of the hypertrophic and fatty left lobe of the liver which increases technical difficulties and limit the exposure of the hiatus. Traditional liver retractors require an additional sub-xiphoid incision for insertion and cause post-operative pain as well as iatrogenic liver injuries. Various techniques have been described to allow adequate liver retraction through smaller incisions or fewer ports without compromising patient safety. However, some disadvantages of these methods are the need for incision of the liver ligament or diaphragmatic crura puncture rendering the device difficult to reposition. Two morbidly obese patients underwent a SG by conventional laparoscopy and by trans-umbilical single-incision using a novel minimal invasive internal liver retractor: the Versa Lifter Band®. This soft and flexible internal retractor was fully repositionable and adjustable intraoperatively. The time required to complete the liver retraction was 4 min 12 s in conventional surgery and 5 min 23 s in single-incision approach. Liver retraction was always satisfying resulting in limited intra-operative difficulties without the need of additional retractors/ports or conversion in both patients. No adverse outcomes occurred during the intra and post-operative periods without rise in aspartate aminotransferase and alanine-aminotransferase serum levels. In our preliminary experience, this internal liver retractor was easy to handle and provided an effective and safe retraction with good exposure of the surgical field and improved ergonomy in single incision as well as reduced port laparoscopic SG.

Tracking Method of Adaptive For Inserting an Artificial Lens

We marked with a pen directly to the incision for insertion into the patient's eye of the intraocular lens insertion in cataract surgery, and insertion point. However, it can delete or blur the display due to such factors as foreign material coming out of the eye during surgery. Therefore, in recent years, a method of tracking the image processing by receiving the camera images in real time display method such extended. There are many ways to estimate the object in the video in, but in the method has been applied widely used typically have optical flow and template matching. The template matching, while indicating the tracking performance with excellent background simple from complex background, its performance is reduced, while indicating the tracking excellent performance in a complex background, simple background, optical flow, the performance fall. In this paper, there is provided a method adaptive tracking don't give a significant effect on the change in the background template region. Therefore, by using to suit the circumstances the optical flow indicating the tracking excellent performance in a complex background template matching showing a tracking superior performance with a simple background, when inserting an intraocular lens in cataract surgery, and a knife in it was possible to improve the accuracy of tracking a region of the incision.

Treatment of Paediadric Forearm Fractures with Titanium Elastic Nails

Background: A prospective analysis of a case series of diaphyseal forearm fractures in children treated with titanium elastic nails is presented. Methods: Between 2012 and 2014, 45 children aged 5-15 years with displaced diaphyseal forearm fractures underwent titanium elastic nailing. Both bones were fractured in 32 patients, ten fractured only the radius, and three experienced ulna fracture. Eighteen children had unstable irreducible fractures, twenty had loss of reduction, and seven had open fractures. Titanium elastic nails were used to stabilize the fractures. All fractures were immobilized postoperatively with an above-elbow plaster slab for 2 weeks till the swelling is completely resolved followed by encouraging range of motion exercises. Results: Closed reduction and TENS was successful in 33 cases, including 25 double-bone fractures and eight single-bone fractures. Open reduction was unavoidable in seven fractures of both bones, and in five single-bone open fractures. Bone union was achieved in all patients at an average of 7 weeks. Conclusion:Titanium elastic nails fixation of pediatric forearm fractures revealed several advantages, a small incision for insertion, a low rate of complications, unhindered bone healing, and good clinical and radiological results. Key words: Diaphyseal; Radius and ulna; Pediatric; Forearm fractures; Fracture fixation; TENS

A Simple Method to Inset and Position Polyurethane-Covered Breast Implants

Polyurethane-covered breast implants have been used increasingly for cosmetic and revision breast surgery. The incision for insertion should be of minimal length and the placement of these implants in the pocket can be more difficult than that of conventional implants because of the highly adherent textured surface of the polyurethane external layer that grasps the surrounding tissues. The use of a sterile plastic insertion sleeve that is open on both sides is suggested by the manufacturer to overcome the friction between the polyurethane implant and the skin and surrounding tissues. A new method to facilitate polyurethane implant insertion and adjustment in all cases of primary breast augmentation and revision surgery is presented. After the implant, which is in the sleeve, is located in the pocket, the plastic sleeve is filled with saline and antibiotics so the solution lubricates the surface around the implant. The sleeve is then twisted so that the solution is squeezed inside the pocket while the sleeve itself is pulled back and removed. Between 2010 and 2013, this method was used in 73 cases of primary augmentation and revision breast surgery without any complications. The method described here allows for easier removal of the plastic sleeve during polyurethane implant insertion without any complications or evidence of implant migration or rotation at follow-up. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Laparoscopic Oviductal Embryo Transfer and Artificial Insemination in Felids – Challenges, Strategies and Successes

Embryo transfer (ET) and artificial insemination (AI) are potentially invaluable techniques for the propagation and management of genetically valuable domestic cat and endangered nondomestic cat populations. Many of the challenges that impair the effective application of ET and AI in felids may be overcome by using laparoscopic oviductal (LO) approaches. LO-ET and LO-AI are minimally-invasive procedures, requiring only two small skin incisions for insertion of a laparoscope and grasping forceps into the abdominal cavity to permit visualization and catheterization of the oviduct for embryo or semen deposition. With concurrent improvements in embryo culture systems and ovarian synchronization protocols, LO-ET has proven effective over the past decade for propagation of laboratory cats, cat models of hereditary disease and nondomestic cats. To date, viable offspring have been produced following LO-ET of non-frozen and frozen-thawed IVF-derived embryos in eight cat hereditary disease models and two nondomestic cat species, the ocelot and sand cat. LO-AI with low sperm numbers (c. 2-8 million motile) has shown similar efficacy to LO-ET, resulting in high pregnancy percentages (50-70%) following insemination of gonadotropin-treated domestic cats. Multiple kittens also have been produced in two hereditary disease models following LO-AI with frozen semen, and both ocelot and Pallas' cat kittens have been born after LO-AI with freshly-collected semen. The application of LO-ET and LO-AI to felids has resulted in substantial improvement in the efficiency of assisted reproduction for genetic management of these invaluable domestic cat and wild cat populations.

Descemet's Stripping Automated Endothelial Keratoplasty: Three-Year Graft and Endothelial Cell Survival Compared with Penetrating Keratoplasty

To assess 3-year outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) in comparison with penetrating keratoplasty (PKP) from the Cornea Donor Study (CDS). Prospective, multicenter, nonrandomized clinical trial. A total of 173 subjects undergoing DSAEK for a moderate risk condition (principally Fuchs' dystrophy or pseudophakic corneal edema) compared with 1101 subjects undergoing PKP from the CDS. The DSAEK procedures were performed by 2 experienced surgeons using the same donor and similar recipient criteria as for the CDS PKP procedures, performed by 68 surgeons. Graft success was assessed by Kaplan-Meier survival analysis. Central endothelial cell density (ECD) was determined from baseline donor and postoperative central endothelial images by the reading center used in the CDS Specular Microscopy Ancillary Study. Graft clarity and ECD. The donor and recipient demographics were comparable in the DSAEK and PKP groups, except that the proportion of Fuchs' dystrophy cases was higher in the DSAEK cohort. The 3-year survival rate did not differ significantly between DSAEK and PKP procedures performed for either Fuchs' dystrophy (96% for both; P = 0.81) or non-Fuchs' cases (86% vs. 84%, respectively; P = 0.41). Principal causes of graft failure or regraft within 3 years after DSAEK and PKP were immunologic graft rejection (0.6% vs. 3.1%), endothelial decompensation in the absence of documented rejection (1.7% vs 2.1%), unsatisfactory visual or refractive outcome (1.7% vs. 0.5%), and infection (0% vs. 1.1%), respectively. The 3-year predicted probability of a rejection episode was 9% with DSAEK versus 20% with PKP (P = 0.0005). The median 3-year cell loss for DSAEK and PKP was 46% and 51%, respectively (P = 0.33), in Fuchs' dystrophy cases and 59% and 61%, respectively (P = 0.70), in the non-Fuchs' cases. At 3 years, use of a smaller DSAEK insertion incision was associated with significantly higher cell loss (60% vs. 33% for 3.2- and 5.0-mm incisions, respectively; P = 0.0007), but not with a significant difference in graft survival (P = 0.45). The graft success rate and endothelial cell loss were comparable at 3 years for DSAEK and PKP procedures. A 5-mm DSAEK incision width was associated with significantly less cell loss than a 3.2-mm incision.

Risk of Injury to the Superior Gluteal Nerve When Using a Proximal Incision for Insertion of a Piriformis-Entry Reamed Femoral Intramedullary Nail

This cadaveric study evaluated the risk of injury to the superior gluteal nerve when a proximal incision site is used for insertion of an antegrade, reamed femoral intramedullary nail into the piriformis fossa. Based on prior anatomical studies, our hypothesis is that the use of a proximal incision site for intramedullary nail insertion will consistently injure the superior gluteal nerve. A reamed femoral intramedullary nail was inserted through a piriformis fossa entry site in six pairs of fresh-frozen cadaver femora. The specimens were randomized to two groups: reaming of the femoral canal with or without a protective sleeve. Damage to the superior gluteal nerve was evaluated by means of layered dissection of specimens. Damage to any part(s) of the superior gluteal nerve was recorded, and the distances between the path of the instrumentation and nail and the branches of the superior gluteal nerve were measured. A "spray" nerve pattern of the superior gluteal nerve was present in all twelve specimens. The average distance and standard deviation between the most superior branch of the superior gluteal nerve and the instrumentation and nail path was 17.75 ± 8.58 mm. The average distance between the most inferior branch of the superior gluteal nerve and the instrumentation and nail path was 22.39 ± 10.52 mm. There were no significant differences between the two groups. There were no injuries to any part of the superior gluteal nerve regardless of whether or not a protective sleeve was used. This anatomic study demonstrated that the superior gluteal nerve is not at risk for injury when a proximal incision site is used to place a reamed intramedullary nail into the piriformis fossa.

Comparison of Breast Augmentation Incisions and Common Complications

Incisions for insertion of breast implants are most commonly placed in the inframammary fold, areola, or axilla. Previous studies have evaluated selection of incision location preoperatively and for nipple-areola complex sensation retention after primary augmentation mammaplasty. This study compares the most common postoperative complications for each incision location in patients who underwent primary breast augmentation. A retrospective chart review was performed on 619 patients who underwent primary breast augmentation, excluding simultaneous mastopexy, within a single group practice from July 1994 to June 2009. Incision location, postoperative complications (capsular contracture, hematoma formation, rippling, infection, and rupture), and total reoperation rates were recorded. Incision locations were also compared with respect to implant fill type (saline or silicone gel) and pocket location (subglandular or submuscular). A statistically significant association was identified between total reoperation and incision location (p = 0.0054). The highest rate of total reoperation occurred when using an inframammary fold incision compared to either the transaxillary or periareolar. This relationship with total reoperation was not attributed to the five complications analyzed, but rather with patient desire for size/style change, asymmetry, or ptosis. No statistically significant association was observed between incision location and specific complications such as capsular contracture, rippling, implant rupture, hematoma, or infection. None of the five complications analyzed correlated with incision location. The data generated from this study will assure the surgeon that all three incision locations are safe. Preoperative examination, patient preference, and surgeon comfort should remain the mainstays of incision planning in augmentation mammaplasty. This journal requires that authors assign a level of evidence to each article.

A Survey of Attitudes of Ontario Plastic Surgeons Leading up to the Return of Silicone Implants

Sir: The government of Canada introduced round silicone gel implants to the Canadian market through the Special Access Program in 1999. Anatomical silicone gel implants became available through the Special Access Program in 2000. There has been a large increase in the use of silicone implants by Canadian plastic surgeons since the Special Access Program reintroduced them into the Canadian market in 2000. This increase is consistent across all provinces in Canada. The most dramatic increase in use has been for breast augmentation (Fig. 1).Fig. 1.: Silicone implant use in Ontario from 2000 to 2005 according to type of surgery.Health Canada lifted the restricted use label in October of 2006, granting licenses to Allergan, Inc. (Irvine, Calif.) and Mentor Medical Systems (Santa Barbara, Calif.) to market their silicone gel implants in Canada.1 The U.S. Food and Drug Administration quickly followed suit in November of 2006, also approving the marketing of silicone gel implants made by Allergan and Mentor for breast reconstruction and augmentation.2 A survey tailored to practicing plastic surgeons in Ontario was designed to evaluate surgeons’ attitudes toward the use of silicone implants for breast reconstruction and augmentation procedures. There was a 64 percent (89 of 140) response rate to the survey. Although silicone implants were the most common preference for reconstruction patients (46 percent), saline implants (21 percent) and autologous tissue (30 percent) were also commonly indicated as preferences. Surgeon preferences were more evenly divided for their augmentation patients, as 45 percent preferred silicone implants, 45 percent preferred saline implants, and 10 percent indicated they made their choice based on the patient’s preference. Many surgeons felt that shape (54 percent), consistency (78 percent), and durability (41 percent) were benefits of silicone implants. Few surgeons (<3 percent) rated these qualities as advantages of saline implants. However, 75 percent of surgeons listed other advantages of saline implants, including a smaller incision for insertion, less patient anxiety, and less expense for the patient. Surgeons were asked to consider the following earlier controversies surrounding silicone implants: Increased cancer risk Increased risk of connective tissue diseases Increased incidence of fibromyalgia Existence of systemic silicone syndrome The majority of surgeons currently feel that all of these issues are likely either false or will be proven to be false. Surgeons were then asked how much these issues currently influence their decision to recommend silicone implants to either reconstruction or augmentation patients. With regard to the reconstruction patients, 38 percent feel these issues do not at all influence their decision to recommend silicone implants. However, 17 percent feel these issues affect their decision to recommend silicone implants greatly, and 33 percent feel they affect their decision moderately. With regard to augmentation patients, 36 percent feel these issues do not at all influence their decision to recommend silicone implants. However, 20 percent feel these issues affect their decision to recommend silicone implants greatly, and 39 percent feel they affect their decision moderately. Leading up to the release of silicone breast implants in Canada, plastic surgeons in Ontario had been using increasing numbers of silicone implants. This seems to reflect increased confidence in the safety of silicone implants. Many plastic surgeons feel that silicone implants have advantages over saline implants, including shape, consistency, and durability, which also may in part account for the resurgence of silicone implant use. We recognize that since Health Canada and the U.S. Food and Drug Administration have made silicone implants more accessible, some of the concerns noted in our survey may no longer be present. Laura Snell, M.D. Nancy Baxter, M.D. John L. Semple, M.D. Sunnybrook Women’s College Health Center Toronto, Ontario, Canada DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned or implied in this article.

Percutaneous Transphyseal Intramedullary Pinning for Displaced Diaphyseal Forearm Fractures in Children

Background: A prospective analysis of a case series of diaphyseal forearm fractures in children treated with percutaneous transphyseal intramedullary pinning is presented. Methods: Between 2004 and 2006, 30 children aged 9-15 years with displaced diaphyseal forearm fractures underwent percutaneous transphyseal intramedullary pinning. Both bones were fractured in 25 patients, four fractured only the radius, and one experienced ulna fracture. Eleven candidates had irreducible fractures, 13 had loss of reduction, and six had open fractures. Contoured Kirschner wires or Steinmann pins were introduced proximal to distal into the ulna and distal to proximal into the radius. All fractures were immobilized postoperatively with an above-elbow plaster cast for 4 weeks followed by a short-arm plaster cast for 2-4 weeks. Results: Closed reduction and pinning was successful in 20 cases, including 15 double-bone fractures and five single-bone fractures. Open reduction was completed in four fractures of both bones, and in six single-bone open fractures. Bone union was achieved in all patients at an average of 7 weeks. The ROM of the forearms was evaluated using the Daruwalla grading criteria. Excellent results were reported in 96% without significant complications after a mean follow-up of 20 months. Conclusion: Percutaneous transphyseal intramedullary pinning of pediatric forearm fractures revealed several advantages, including ease of application, a small incision for insertion and removal of instrumentation, a low rate of complications, unhindered bone healing, and good clinical and radiological results. This method is convenient, effective, and safe without any deleterious effects on subsequent growth of the radius and ulna.

Breast augmentation using silicone gel–filled implants

The author provides pointers for using silicone gel-filled breast implants. Technical differences between the use of silicone gel-filled and saline implants include the need for a longer incision for insertion of gel implants. The author discusses patient selection, noting the variety of patients for whom gel implants may provide significant benefit including those with implant rippling, minimal breast tissue, minimal ptosis, and breast deformities such as tubular breast. The need for proper size selection considering breast base diameter is emphasized. The author provides his views on smooth versus textured gel implants and the role of hemostasis in avoiding capsular contracture.

Selected best demonstrated practices in peritoneal dialysis access

Many burdensome interventions that adversely affect the utilization of peritoneal dialysis as renal replacement therapy and patient satisfaction with this treatment modality can be avoided by early peritoneal access placement with embedded catheters, implantation techniques that preempt common catheter complications, and the use of access devices that provide flexibility in exit site location. Catheter embedding consists of subcutaneously burying the external limb of the catheter tubing at the time of the insertion procedure. Interval exteriorization of the catheter is performed when dialysis is needed. Earlier commitment by patients to peritoneal dialysis can be achieved by elimination of catheter maintenance until dialysis is necessary. Catheter embedding is a practical strategy to avoid temporary hemodialysis with vascular catheters and reduces stress on operating room access by allowing more efficient scheduling as non-urgent procedures. Laparoscopic catheter placement enables proactive techniques not available to other conventional insertion methods. These techniques include rectus sheath tunneling to prevent catheter tip migration, selective prophylactic omentopexy to prevent omental entrapment, selective resection of epiploic appendages to prevent catheter obstruction, adhesiolysis to eliminate compartmentalization, and diagnosis and simultaneous repair of previously undiagnosed abdominal wall hernias. Both standard and extended 2-piece catheter systems are necessary to customize the peritoneal access to a variety of body configurations. Catheters should be able to produce lower abdominal, mid-abdominal, upper abdominal, and upper chest exit site locations that facilitate management by the patient without sacrificing deep pelvic position of the catheter tip or resulting in excessive tubing stress during passage through the abdominal wall.