Preoperative Clinical Manifestations Research Articles

Clinical research of popliteal cyst excision combined with debridement of the knee under arthroscopy with local anesthesia

To evaluate the clinical effects of popliteal cyst excision combined with debridement of the knee under arthroscopy with local anesthesia. From February 2009 to August 2014, 52 patients with popliteal cysts were treated in our hospital, including 34 males and 18 females with an average age of 43.6 years old ranging from 14 to 62 years old; 29 cases were on the right knee and 23 on the left knee. Preoperative diagnosis was performed according to MRI findings and to determine whether other knee disorders were associated with the disease, 52 patients were diagnosed as popliteal cyst before operation; 23 cases of simple meniscus injury or cartilage injury, 18 cases of osteoarthritis, 7 cases of cruciate ligament injury, 2 cases of gouty arthritis, 1 case of rheumatoid arthritis, 1 case of pigmented villonodular arthritis. The preoperative clinical manifestations involved knee swelling in 21 cases, knee joint pain in 16 cases, joint lock in 8 cases, leg weakness in 4 cases, and knee joint snapping in 4 cases. Cyst size was 4.0 cm× 3.3 cm to 6.2 cm× 5.3 cm. According to the Rauschning and Lindgren standards, 1 case was grade I, 9 cases were grade II, 42 cases were class III. The rehabilitation plan should be made according to the patient's specific injuries and intraoperative management. During the postoperative follow-up, the postoperative curative effect was evaluated by the standard grading of Rauschning and Lindgren of popliteal cyst. All the incisions healed by first intention, and no complications occurred. All the cases were followed up from 25 to 64 months (averaged 39.6 months). For the Rauschning and Lindgren grading, 43 cases were grade 0, 8 cases were grade I, 1 case were grade II. Local anesthesia under arthroscopy and popliteal cyst removal knee joint cavity debridement is effective, less trauma, quick recovery, short term effect is good. The recurrence rate is also low because of the primary disease of the knee joint is also treated. After the operation, the rehabilitation plan should be made according to the intraoperative treatment and actively trained so as to recover at an early date.

Clinical Interrogation for Unveiling an Isolated Hypophysitis Mimicking Pituitary Adenoma

Hypophysitis is a rare disease entity mimicking a pituitary adenoma. Despite crucial disease involving a pituitary gland which is a main component of the hormonal axis, there have been minimal researches regarding the hypophysitis. In this study, we described the constellation of the preoperative findings including clinical, radiologic, and endocrinologic features, as well as postoperative outcomes of the hypophysitis. The authors reviewed the data retrospectively of a total of 2814 patients who underwent microsurgery at our institution to treat a pituitary mass lesion. Among them, the patients proven as hypophysitis in histologic examination were enrolled, followed by stratification into tumor-associated hypophysitis and isolated hypophysitis depending on the existence of associated tumor lesion. As a result, a total 21 cases were enrolled consisting of the 13 cases of tumor-associated and the 8 cases of isolated hypophysitis. In this study, the isolated hypophysitis was focused on the analysis. All patients with isolated hypophysitis were evaluated the clinical, radiologic, and endocrinologic tests preoperatively. After microsurgery, all patients had a minimum follow up of 6 months (6∼72 months). The clinical symptoms, endocrinologic tests, and brain MRI were checked at every 6 months during first 2 year, since then, at every 12 months. Among 2814 cases of pituitary mass lesion underwent microsurgery, the hypophysitis were found 21 cases (0.74 %). The 13 cases were the tumor-associated hypophysitis, consisting of rathke's cleft cyst (7 cases), craniopharyngioma (3 cases), pituitary adenoma (2 cases), and germinoma (1 case). The 8 cases were the isolated hypophysitis including lymphocytic (4 cases), granulomatous (3 cases), and IgG4-related (1 case) hypophysitis. The patients presented a wide range of clinical symptoms from general weakness to panhypopituitarism. In addition, the most remarkable radiologic features of the isolated hypophysitis were infundibular thickening and the low signal intensity in T1WI and T2WI. All 8 patients with isolated hypophysitis presented endocrinologic deficiency with various extent in a preoperative biochemistry. After surgery, the hormonal status were not changed in 4 patients (50%), however, aggravated in 4 patients (50%). The 3 patients (37.5%) complained visual field defects in preoperative ophthalmologic test, but improved all after surgery. In this study, the preoperative clinical manifestations, radiologic and endocrinologic features of hypophysitis were described comprehensively. In addition, we also revealed the long-term outcomes of hypophysitis in the aspect of visual function and endocrinologic outcomes. Preexisting visual field defects were improved in all patients (3 cases). However, all patients presented endocrinologic deficiency in preoperative biochemistry, among them, the 4 patients (50 %) were unchanged and the 4 patients (50 %) were exacerbated after surgery. In conclusion, the visual outcomes were satisfactory, however, the endocrinologic outcomes were vice versa, because the preoperative endocrinologic deterioration was unchanged or even aggravated after surgery in some cases.

Efficacy of Combined Laparoscopic and Hysteroscopic Repair of Post-Cesarean Section Uterine Diverticulum: A Retrospective Analysis.

Background. Diverticulum, one of the long-term sequelae of cesarean section, can cause abnormal uterine bleeding and increase the risk of uterine scar rupture. In this study, we aimed to evaluate the efficacy of combined laparoscopic and hysteroscopic repair, a newly occurring method, treating post-cesarean section uterine scar diverticulum. Methods. Data relating to 40 patients with post-cesarean section uterine diverticulum who underwent combined laparoscopic and hysteroscopic repair were retrospectively analyzed. Preoperative clinical manifestations, size of uterine defects, thickness of the lower uterine segment (LUS), and duration of menstruation were compared with follow-up findings at 1, 3, and 6 months after surgery. Results. The average preoperative length and width of uterine diverticula and thickness of the lower uterine segment were recorded and analyzed. The average durations of menstruations at 1, 3, and 6 months after surgery were significantly shorter than the preoperative one (p < 0.05), respectively. At 6 months after surgery, the overall success improvement rate of surgery was 90% (36/40). Three patients (3/40 = 7.5%) developed partial improvement, and 1/40 (2.5%) was lost to follow-up. Conclusions. Our findings showed that combined treatment with laparoscopy and hysteroscopy was an effective method for the repair of post-cesarean section uterine diverticulum.

A rare case of synovial chondromatosis of the inferior TMJ compartment. Diagnosis and treatment aspect.

Synovial Chondromatosis (SC) is a rare, benign non neoplastic arthopathy characterized by the metaplastic development of cartilaginous nodules within the synovial membrane. In only 3% of all cases does it affect the temporomandibular joint (TMJ) and cases that arise from the lower compartment are rarely found in literature. The aim of this paper is to report a new case of SC of the inferior TMJ compartment with the description of the clinical, therapeutic and histopathological findings. This article presents a 68-year-old woman with preauricular swelling on the right side, pain, crepitus and limited joint motion. This patient was evaluated by preoperative clinical manifestation, CT scan and MR images. Both showed multiple, calcified loose bodies in the inferior compartment. Based on these images as well as the patient's signs and symptoms, a surgical intervention was performed. A good functional recovery with no signs of recurrence at 36 months of follow up was obtained. Among cases of synovial chondromatosis in literature, only twelve originating in the lower compartment have been reported, this one included. In all the cases treated for SC in the lower compartment, both in literature and in our case report, surgical treatment led to healing.

Diagnosis and treatment of the medial-extension type of posterior malleolar fractures

Objective o evaluate the characteristics and treatments of the medial-extension type of posterior malleolar fractures.Methods Data of 75 patients with posterior malleolar fractures from May 2007 to December 2010were retrospectively analyzed.13 patients whose X-ray showed Cotton fracture while CT scan showed medial-extension type of posterior malleolar fractures were involved in this study.There were 8 males and 5 females,with an average age of 40.3 years old (range,15-75 years).The mechanisms of injuries were as follow:6 patients with falling injury,4 patients from motor vehicle accidents and 3 patients from severe sprain.All the patients combined with distal fibular fracture.The preoperative clinical manifestations included foot and ankle swelling,deformity and restricted movement.The fracture line could be found on coronary X-ray.10 of those patients had double lines sign in medial malleolus.According to Haraguchi CT scan classification system,8 patients were Type Ⅰ fractures (61.6％,8/13),3 with Type Ⅱ fractures (23％,3/13),and 2 with Type Ⅲ fractures (15.4％,2/13).Posterior medial incision,cannulared screws after reduction were conducted.Wound and fracture healing were recorded postoperatively.Function was evaluated according to Baird-Jackson criterion.Results All 13 cases had been followed up for 8-45 months (mean 16 months).Post-operation X-ray showed articular surface displacement was less than 1mm; widening of the medial ankle mortise was no more than lmm; anatomy reduction was achieved or approximately achieved.All cases got union and the union period was 12-20 weeks with an average of 15.1 weeks.The incisions were primary healed in all patients.According to Baird-Jackson criterion,10 cases were excellent and 3 were good.76.9％(10/13) patients got excellent results.No instrument failure,fracture displacement,and infection were found.All patients could walk without accessory appliance.Conclusion Most of medial-extension type of posterior malleolar fractures have articular cartilage damage.It may be caused by rotational force combined with axial load.It needs open reduction and internal fixation early.The posterior medial incision has certain superiority. Key words: Ankle joint; Fractures, bone; Fracture fixation, internal

Preoperative evaluation of children with anomalous origin of left coronary artery from the pulmonary artery and the follow-up after surgery

Objective To retrospectively study 50 children with anomalous origin of the left coronary artery from the pulmonary artery(ALCAPA) and find the simple and practical indexes that may predict myocardial viability and the possible risk factors that may affect the choice of operation and the recovery after surgery. Methods A retrospective study was performed in 50 children with ALCAPA[29 male, 21 female, aged from 4 months to 18 years, average (4.49±4.30) years] between Apr.1999 and Mar. 2013. The preoperative examination included electrocardiogram(ECG), echocardiography, chest X-ray, mutislice spiral computerized tomography(MSCT), angiocardiography et al. Follow-up data were obtained by reviewing the records made in out-patient and recent telephone call. According to myocardial 18F-FDG imaging, the extent of myocardial viability of 15 patients with ALCAPA was classified into 4 grades.0 normal myocardial; 1 viable myocardial; 2 partial viable myocardial; 3 myocardial infarction. Meanwhile, the global clinical scores were calculated and divided into 10 levels according to the deviations of clinical manifestations which included abnormal Q waves, left ventricular ejection fraction(LVEF), left ventricular end-diastolic dimension(LVED), cardiothoracic ratio(CTR), intercoronary collaterals(ICC), mitral regurgitation(MR) and aneurysm. The relationship of the extent of myocardial viability and clinical features were studied. All patients with ALCAPA were classified into groups by the global clinical scores and the preoperative, perioperative and post operative clinical manifestations were compared among groups. Results The extent of myocardial viability was related well to the global clinical scores(r=0.936, P 0.05). The results showed that grade 0-1 equaled scores 0-3, grade 2 equaled scores 3-5, grade 3 equaled scores>5. Children with less viable myocardium had more severe clinical symptoms. Among abnormal Q waves, LVEF 0.65, ICC dysplasia, median to severe MR and the global clinical scores>3, the global clinical scores>3 and LVEF 3) in all patients. More infants and toddlers, abnormal Q waves, ICC dysplasia, RCA/AO<0.2, larger CTR and lower LVEF were found in group B than those in group A. The time of cross-clamp and CPB was not different between the 2 groups, but the postoperative ventilation time and postoperative ICU stay were longer in group B than in group A. Forty-seven patients underwent operation and there were no operative deaths. One infant with scores 9 died while waiting heart transplantation. Follow-ups from 1 to 168 months were conducted in 38 patients(80.9%, 38/47 cases) and 1 patient with ligation of the left coronary artery(LCA) had a sudden death after 8 months of surgery. All patients had gotten smaller LVED after surgery. Nineteen patients had mild MR and 3 patients had mild supravalvular pulmonary stenosis in following-up. Of the 16 patients with LVEF<50%, 14 had a recovery of LVEF, 2 patients still had LVEF<50%. Conclusions In children with ALCAPA, the extent of myocardial viability evaluated by myocardial 18F-FDG imaging is related closely to the preoperative clinical manifestations. The global clinical scores>3 and LVEF<50% have a good predict of myocardial infarction. Even in young children with severely depressed left ventricular function, higher global clinical scores and more myocardial infarction, median and long-term follow-ups showed satisfactory recovery of cardiac function after successful restoration of a dual coronary arterial system. Key words: Anomalous origin of the left coronary artery from the pulmonary artery; Preoperative evaluation; Follow-up; Myocardial viability

Clinical analysis of 73 cases of intraspinal nerve sheath tumor

Seventy-three patients with spinal nerve sheath tumor who were surgically treated in our hospital during the years 2004-2010 were retrospectively reviewed with respect to recovery of neurological function, recurrence of the tumor and occurrence of kyphotic deformities. Preoperative clinical manifestations, imaging data, surgical records and follow-up results were comprehensively analyzed. The follow-up duration was 12-60 months with an average of 32.0 months. Out of the 73 cases enrolled, 69 had gradual recovery of sensation, motor and sphincter functions 1 week to 3 months after operation. Forty-six cases had incomplete paralysis, whose American Spinal Injury Association (ASIA) grades, however, were gradually increased during the follow-up period, 4 cases had no significant improvement of the clinical symptoms and no change in ASIA grades during the follow-up period. Two cases had postoperative recurrence of the tumor. There were no deaths, no spinal instability, and no kyphotic malformations found in any cases. Our study indicated that complete removal of the tumor is important for good recovery, and an ideal surgical method may reduce the recurrence of the tumor or the occurrence of complications.

Clinical typing of lumbosacral plexus nerve root injury caused by trauma

Objective To classify the type of lumbosacral plexus nerve root injury. Methods From November 2004 to August 2011, 36 patients suffered with lumbarsacral plexus nerve root injury underwent surgical exploration in our department. There were 24 males and 12 females, aged from 7 to 49 years（average, 29.5 years）. By inductively analyzing the location and amount of nerve root injury, preoperative clinical manifestations and results of physical examination, the clinical typing of lumbarsacral plexus nerve root injury was made. Results Lumbosacral plexus nerve root injury was classified into 6 types： total lumbosacral plexus nerve root injury （4 cases）, lumbar plexus and upper sacral plexus nerve root injury （6 cases）, sacral plexus nerve root injury （9 cases）, upper sacral plexus nerve root injury （11 cases）, lower sacral plexus nerve root injury（4 cases） and lumbar plexus injury（2 cases）. There were 19 patients with total lumbosacral plexus nerve root injury, lumbar plexus and upper sacral plexus nerve root injury or sacral plexus nerve root injury, among which 73.7%（14/19） nerve root injury located in the spinal canal and all of them were nerve root avulsion or rupture. There were 17 patients with upper sacral plexus nerve root injury, lower sacral plexus nerve root injury or lumbar plexus nerve root injury, among which 64.7% （11/17） nerve root injury located in intro-pelvic or pelvic sacral foramina, and all of them were distraction injury. Conclusion This clinical typ- ing is useful for the accurate diagnosis of lumbosacral plexus nerve root injury. In addition, it is also beneficial for judging the location and characteristics of nerve root injury. Key words: Lumbosacral plexus; Pelvis; Wounds and injuries; Classification

Symptomatic Rathke cleft cyst

Rathke cleft cysts (RCC) are uncommon intrasellar lesions. Although their clinical manifestations, radiological features and treatment are frequently reported, controversy remains as a result of their rarity. We reviewed the preoperative clinical manifestations, neurological examination findings, visual acuity and fields, endocrinological function, radiographic study findings, surgical and pathological records, and prognosis of 45 patients with RCC (21 males, 24 females, average age: 47years) admitted to our department between January 2002 and January 2011. The most common clinical manifestations included headaches, and visual and hormonal disturbances. Most RCC were intrasellar with a suprasellar extension. The most common MRI patterns were hypointense on T1-weighted and hyperintense on T2-weighted images, isointense on T1-weighted and hyperintense on T2-weighted images, and hyperintense on T1-weighted and hyperintense on T2-weighted images. Aspiration and biopsy of the cyst wall were performed in most patients. Most patients experienced improved headaches and visual disturbance, but the hormonal disturbance rarely returned to normal, especially in those patients with a serious preoperative hormonal disturbance. The recurrence rate was 14%, which was associated with the extent of cyst removal, inflammation and rim enhancement, as well as the surgical approach. Aspiration and biopsy of the cyst wall still seems to be an effective treatment for most RCC for its low morbidity and good prognosis. Conservative treatment and close follow-up may be suitable for small cysts with subtle clinical manifestations.

The Role of Myocardial Viability Assessed by Perfusion/F-18 FDG Imaging in Children With Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery

Although surgical treatments evolved, the short-term postoperative mortality is still high in children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), and long-term survivors may suffer from restrained functional recovery. Therefore, an optimal means in predicting postoperative reversal is demanded. In this study, we assess the utility of myocardial perfusion/F-18 fluorodeoxyglucose (FDG) imaging in the evaluation of myocardial viability and postsurgery functional recovery in children with ALCAPA. A retrospective study was performed in 7 children with diagnosed ALCAPA who underwent myocardial perfusion/F-18 FDG imaging preoperatively. Global viability index was used to evaluate myocardial viability and was compared with the preoperative deviations of left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDD) from age-matched healthy children and with the postoperative durations of intensive care. Children with more viable myocardium had less severe clinical symptoms. The viability index was correlated well with the preoperative deviations of LVEF (r = -0.98, P = 0.001) and LVEDD (r = 0.87, P = 0.02) and postoperative durations of intensive care hospitalization (r = 0.77, P = 0.04) and mechanical ventilation (r = 0.83, P = 0.02). LVEF and LVEDD reached normal range within 5 months in viable children, whereas incomplete reversal was observed in partial- and nonviable children. In children with ALCAPA, myocardial viability evaluated by perfusion/F-18 FDG imaging is related to the preoperative clinical manifestations and cardiac function. Additionally, it may predict functional recovery after surgical repair.

Arthroscopically assisted treatment of adolescent knee joint tuberculosis

To evaluate the role of knee arthroscopy in diagnosis and treatment of knee joint synovitis and total joint tuberculosis (TB) of adolescence. Forty-one patients with knee TB, aged 7-16 years, were treated using knee arthroscopy from June 2002 to December 2006. Clinical data were reviewed at followed up and evaluated using the Lysholm score. Among the 41 patients, 36 were diagnosed as having TB on the basis of preoperative clinical manifestations and laboratory results, and the remaining 5 as synovitis preoperatively, TB being confirmed postoperatively by arthroscopy and pathological examination. Specimens from 37 patients were confirmed as tuberculosis by pathological examination, while the other 4 were reported as chronic synovitis and necrotic tissue. Patients were followed-up for 6-58 months postoperatively (average, 43.5 months). All patients were treated with knee arthroscopy surgery and postoperative medication and no relapses occurred over the duration of follow-up. The mean Lysholm score was 91.4 points. The range of movement of the knee joint in 6 patients remained at 70°-110°. Two patients retained an extension lag of 10° and 25°, respectively. Diagnosis and treatment of adolescent TB is different from that of other TB patients. Arthroscopically assisted treatment of adolescent knee joint TB has the advantages of early diagnosis, minimization of trauma, thorough clearance and rapid recovery. Early treatment with arthroscopically assisted debridement, early rehabilitation and postoperative medication can preserve maximal function of knee joint and avoid arthrodesis. This is an ideal method for the treatment of adolescent knee TB.

The clinical features and surgical treatment of degenerative lumbar scoliosis: A review of 112 patients

To investigate the clinical features, radiological characteristics and surgical results of degenerative lumbar scoliosis (DLS). One hundred and twelve cases of DLS treated surgically from June 2001 to February 2006 were retrospectively reviewed for clinical features, characteristics of nerve root compression and imaging presentations. According to the preoperative clinical manifestations and imaging findings, different surgical modalities were performed, including simple nerve decompression and decompression with short or long posterior fusion (less or more than three segments, respectively). The mean age of 47 male and 65 female patients was 54.7 years. Clinical manifestations included lower back pain (76.8%), radiculopathy (79.5%) and claudication (48.2%). Plain lumbar radiograph showed right scoliosis in 87 and left scoliosis in the other 25 cases; the Cobb angle was 10°-46°; the apex of scoliosis mostly located at L3 (48.2%); L3 and L4 nerve roots were usually compressed on the concave side and L5 and S1 nerve roots on the convex side. The Cobb angle and physiologic lordosis angle of patients who underwent multi-segment (>3 segments) fusion improved to a greater extent than did that of patients who had simple decompression without fusion. A mean 5.7-year follow-up showed that the average improvement in Oswestry disability index (ODI) scores was 32.6, 26.3 and 13.5 for long segment fusion, short segment fusion and simple decompression without fusion, respectively. Decompression surgery with or without fusion, the main purpose of which is to relieve nerve root compression and stabilize the spinal column, is an effective treatment for chronic DLS. The treatment should be individualized according to the patient's age, general and economic factors, severity of deformity and other coexisting lumbar degenerative disorders.

Long-term results of scaphoid nonunion treated by intercalated bone grafting and Herbert’s screw fixation—a study of 49 patients for at least five years

The objective of this article is to report our clinical experience in the treatment of patients with scaphoid nonunion using intercalated bone graft and Herbert's screw and the long-term postoperative results with a minimum of five years of follow-up. We retrospectively reviewed 49 patients treated with carved intercalated bone graft and Herbert's screw fixation from September 1987 to June 2001. Preoperative clinical manifestations and postoperative results were assessed by radiography, and functional results, including grip force, range of motion of the wrist joint, and Cooney's scoring chart, were evaluated. The union rate was 93.9%. The average grip power, as well as wrist flexion and extension were significantly improved. Using Cooney's scoring system, 29 patients were rated excellent and 17 good. For successful union, anatomical reduction with carved intercalated bone grafting and Herbert's screw fixation is definitely a reliable option. This method leads to a satisfactory long-term functional outcome.

The discussion of standards for clinical functional gradation and preoperative preparation of pheochromocytoma

To discuss the standards for clinical functional gradation and preoperative preparation of pheochromocytoma. According to the preoperative clinical manifestations and 24 hr urine catecholamine, 172 cases of pheochromocytomas were divided into 4 grades. Functionary grade 0 including 22 patients was given no volume expansion. Functionary Grade 1 consisted of 17 cases, 10 of which were given phenoxybenzamine orally 5 - 10 mg/d for 1 week (therapeutic group), the rest were control group; the results were analyzed by the chi(2) test. Functionary Grade 2 including 120 patients had phenoxybenzamine orally 30 - 240 mg/d for 4 weeks, hemodynamics and microcirculation image were standards for evaluating volume expansion. Functionary Grade 3 consisted of 13 patients including 1 with acute heart failure, 2 and 10 patients with past history of cerebral hemorrhage and hypertensive crisis respectively, they were treated with enough phenoxybenzamine and other emergent measures. The perioperative blood pressure of Functionary Grade 0 had no fluctuation. The blood pressure of therapeutic group of Functionary Grade 1 had small range fluctuation (< 20 mm Hg), that of the control group was large (> 40 mm Hg). Chi(2) = 13.12, P < 0.01. The hemodynamics of Functionary Grade 2 and Grade 3 recovered within 24 hours postoperatively and no complications occurred. According to the function of pheochromocytoma, it is safe and efficient to use different preoperative preparations. Hemodynamics and microcirculation image are golden standards for evaluating preoperative preparations.

Discoid Lateral Meniscus in Children: Clinical Manifestations and Morphology

The authors investigated the correlation between the clinical manifestations and the morphology of discoid lateral meniscus. Thirty-eight children, age 5 to 17 years, with 39 cases of discoid lateral meniscus underwent an arthroscopic procedure and magnetic resonance imaging. The two most frequent preoperative clinical manifestations were pain and extension block. In 19 cases without surface tear, the most frequent clinical manifestation was extension block. In the sagittal magnetic resonance images, the mean thickness of the anterior portion of the discoid lateral meniscus (7.77 mm) in the group with extension block exceeded that (4.02 mm) in the group without extension block. Extension block was significantly more common in patients with the anterior hypertrophy type and the slab (anterior-posterior diffusely hypertrophic) type than in the posterior hypertrophy type by the modified Hall classification. As a result, extension block was significantly correlated with the morphology of the menisci. Also, the thickened anterior portion of the discoid lateral meniscus may be considered one of the mechanical factors that limit knee extension.