Sparing Surgical Approach Research Articles

Current Concepts in Management of Distal Femur Fractures

Recent studies report the overall incidence of distal femur fractures as 8.7/100,000/year. This incidence is expected to rise with high energy motor vehicle collisions and elderly osteoporotic fractures in native and prosthetic knees keep increasing. These fractures are more common in males in the younger age spectrum while females predominate for elderly osteoporotic fractures. Surgical treatment is recommended for these fractures to maintain articular congruity, enable early joint motion and assisted ambulation. Over the last two decades, development of minimally invasive and quadriceps sparing surgical approaches, availability of angle stable implants have helped achieve predictable healing and early return to function in these patients. Currently, laterally positioned locked plate is the implant of choice across all fracture patterns. Retrograde with capital implantation of intramedullary nails with provision for multiplanar distal locking is preferred for extra-articular and partial articular fractures. Even with these advancements, nonunion after distal femur fracture fixation can be as high as 19%. Further recent research has helped us understand the biomechanical limitations and healing problems with lateral locked plate fixation and intramedullary nails. This has lead to development of more robust constructs such as nail-plate and double plate constructs aiming for improved construct strength and to minimise failures. Early results with these combination constructs have shown promise in high risk situations such as fractures with extensive metaphyseal fragmentation, osteoporosis and periprosthetic fractures. These constructs however, run the risk of being over stiff and can inhibit healing if not kept balanced. The ideal stiffness that is needed for fracture healing is not clearly known and current research in this domain has lead to the development of smart implants which are expected to evolve and may help improve clinical results in future.

Update on Diagnosis and Treatment of Uveitic Glaucoma.

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

Minimally invasive nerve and artery sparing surgical approach for temporal migraines

Temporal migraines (TM) present with throbbing, pulsating headaches in the temporal area. Different surgical techniques ranging from resecting the auriculotemporal nerve (ATN) and or ligating the superficial temporal artery (STA) have shown similar good results to decrease TM symptoms. No conclusive data supports a specific disease of the STA in TM patients. A minimally invasive technique is proposed to preserve both vascular and nerve structures. Patients with drug resistant TM were selected and treated with two techniques: nerve sparing and nerve and artery sparing. The study included 57 patients with TM, with an average age of 47.5 years. TM improvement was quantified after at least one year of follow up time. STA biopsies were sent for histological analysis. Forty-two patients underwent nerve-sparing decompression, with a therapeutic success rate of 78.6%, corresponding to 22.1 days with migraine per month decreasing to 6.2. Histological analysis of the STA showed varying degrees of endofibrosis in 75% of the samples. Histological results do not correlate with the intensity of symptoms before or after surgery. Fifteen patients underwent nerve and artery sparing arteriolysis, with an overall therapeutic success rate of 86.6% of which 80% had >90% improvement. The average migraine days dropped from 24 to 2.5 days per month in this group. Minimally invasive nerve sparing approaches are an effective and safe treatment to improve drug resistant TM symptoms. Endofibrosis of the STA was present in 75% of the cases, but it was found to be unrelated to pre-operative symptoms and outcome. Results are promising, but the limited numbers of patients treated with artery and nerve sparing technique needs further investigations.

Anatomical evaluation of the transpubic screw corridor based on a 3D statistical model of the pelvic ring

Retrograde transpubic screw fixation is a common procedure for the treatment of anterior pelvic ring fractures. With its sparing surgical approach and significant pain relief after screw fixations allowing early mobilisation, it has gained importance especially in the treatment of insufficiency fractures in elderly patients. However, positioning of transpubic screw osteosynthesis is not always possible due to narrowness and curvature of the screw corridor. The aim of the present study was to evaluate availability and length of the screw corridor using a 3D statistical model of the pelvic ring consisting out of 150 uninjured pelves. Virtual bore probes with a diameter of 7.5 mm were analysed as to accessibility, length and grey value distribution in Hounsfield Unit (HU). A transpubic corridor with a diameter of ≥ 7.5 mm was available in 185 of 300 investigated superior pubic rami with mean screw length of 131.7 mm. Accessibility of the screw corridor was higher in males than in females. However, screw length showed no systematic differences between the sexes or ethnicities. Analysis of the grey value distribution demonstrated the strongest bone to be located at the lateral ilium and the supraacetabular region.

SURGERY OF BRAIN STEM CAVERNOUSES MALFORMATION

Cavernous malformations (CM), also known as cavernous angiomas or cavernomas, are benign vascular hamartomas having a sinusoidal type of wall structure.CM occurs in the brain stem with a frequency of 9–35 % of cases. They are most often localized in the brain stem, have a higher risk of hemorrhage compared to supratentorial. After the primary hemorrhage, the risks of recurrent hemorrhages are very high. CM located in the brain stem has not always been subjected to surgical treatment. Conservative treatment was recommended for most patients. At the same time, according to the literature data, mortality reached 20 %, and during radiosurgery up to 8.3 % with recurrence of hemorrhage up to 59 %. The aim of the study was to evaluate the results of surgical treatment of patients with cavernomas of the brain stem. Materials and methods. the study included 16 patients who had hemorrhages in different parts of the brain stem. There were 12 males (75 %) and 4 females (25 %). Indications for surgical treatment were: presence of subacute hematoma, recurrent hemorrhage and progressive symptoms of brain stem damage. All patients were operated using modern methods of microsurgery. Neurophysiological monitoring was performed intraoperatively. Statistical processing was carried out with the program Statistica (version 10). Results. There was no operational mortality. At discharge, patients were assessed on the Rankin scale. Good functional outcomes were achieved in 87.8 % of cases (Rankin 1 – 43.8 %, Rankin 2 – 31.5 %, Rankin 3 – 12.5 %). Summary . Symptomatic malformations of the brain stem are subject to surgical removal when they are anatomically accessible. The use of modern methods of neuroimaging, adequate, sparing surgical approaches, microsurgical techniques for removing the cavernous brain stem, allows us to achieve good functional results in the operated patients, in the absence of postoperative mortality.

Functional Outcomes and Clinical Strength Assessment After Infraspinatus Sparing Surgical Approach to Scapular Fracture. Does it Really Make a Difference?

Background Surgical treatment of scapular fractures with posterior approach is frequently associated with postoperative infraspinatus hypotrophy and weakness. The aim of this retrospective study is to compare infraspinatus strength and functional outcomes in patients treated with the classic Judet versus modified Judet approach for scapular fracture.

Is fertility sparing surgery a treatment option for young patients with yolk sac tumor?

Yolk sac tumor (YST) is the third most frequent ovarian germ cell type ovarian tumor. YST occurs primarily in young girls and in women at reproductive age and thus, the preservation of fertility is considered to be a crucial option if possible for these patients. Compared to previous years, the use of innovative chemotherapeutic regimens in the treatment of YSTs improved significantly the prognosis and outcomes of this rare type of neoplasia. As YSTs are chemosensitive, this fact favors fertility sparing surgical approach and less aggressive type of operations. We present a narrative review of the multispecialty fertility sparing surgical and medical approach of women with YST.

Multiplex Partial Nephrectomy, Repeat Partial Nephrectomy, and Salvage Partial Nephrectomy Remain the Primary Treatment in Multifocal and Hereditary Kidney Cancer

The standard of care treatment for solitary renal cell carcinoma (RCC) tumors 4 cm or less is partial nephrectomy (PNx). However, multifocal kidney cancer presents unique challenges for treating physicians. Historically, total nephrectomy and hemodialysis with possible renal transplant later was the primary therapeutic strategy for these patients. Later, as nephron sparing surgical approaches improved, PNx became the standard of care for patients presenting with multifocal and hereditary RCC. Surgeries to remove multiple renal tumors simultaneously produce different perioperative outcomes and increased risk of complications. Due to these differences in technique and outcomes, the term multiplex partial nephrectomy (MxPNx) has been coined to designate these differences. Here, we discuss the role that MxPNx continues to play in multifocal RCC.

Penile sparing surgical approaches for primary penile tumors: preserving function and appearance.

Penile cancer is a rare and potentially disfiguring disease. There are multiple treatment options for primary penile lesions. Penile sparing approaches offer an attractive option as they can provide several quality of life benefits without detrimental oncologic outcomes. With appropriate diagnostic evaluation and staging, penile sparing techniques provide proper cancer control with improved cosmetic and functional results. Regardless of the chosen treatment modality, a commitment to close follow-up remains a critical component of all treatment considerations. The goal of this review is to provide an overview of the multiple treatment strategies for primary penile tumors with a focus on penile sparing surgical approaches.

Testicular tumors of adrenogenital syndrome: From physiopathology to therapy

Testicular tumor of adrenogenital syndrome is a rare and benign anomaly usually presenting as bilateral testicular masses. It is the most important cause of infertility in adult male congenital adrenal hyperplasia. Distinction between testicular tumors of adrenogenital syndrome and Leydig cell tumors can be problematic; it is based on clinical, histopathologic, immunohistochemical and endocrine features. Biopsy is advised in cases of longstanding tumors in infertile patients and when surgery is indicated. Fertility preservation is a key management goal in testicular tumor of adrenogenital syndrome. In stages2 and 3, intensified glucocorticoid treatment is recommended as a first step treatment. Sparing surgical approach is preferred for tumors of stage4 and steroid unresponsive masses. Magnetic resonance imaging is recommended before surgery. The only indication of surgery in stage5 is testicular pain.

Swing Mandibulotomy Access to Deep Lobe Parotid Tumors Case Reviews

To utilize Swing mandibulotomy approach for gaining access to the deep lobe parotid tumors and to evaluate the functional and esthetic results. 1.1 Case Series In the present case series, two patients were selected on standard criterion based on histological type, site, age, sex, clinical features, radiological evaluation, recurrence of the parotid tumors and surgical access to these tumors. Patients selected on eligibility criteria were evaluated and underwent, further, radiological evaluation and were surgically managed. Thereafter, long term follow-up was done clinically as well as radiologically. Successful surgical outcome was determined on the basis of functional and clinical recovery. 1.2 Conclusion Selecting the best approach to maximize visibility, ensure complete removal of the tumor and to reduce morbidity is an important decision to be made. Mandibulotomy provides an excellent mandible sparing surgical approach to gain access to deep lobe parotid tumors which are otherwise not accessible without procedures which leave significant morbidity.

Clinical Vignettes/Case Reports - Biliary/Pancreas.

Groove pancreatitis is a rare type of segmental pancreatitis that can mimic the effects of a mass leading to gastric outlet obstruction. The clinical manifestations as well as the radiographic appearance make this entity a diagnostic challenge. A 61 year old male with a history of heavy alcohol use and multiple admissions for chronic pancreatitis presented with a four day history of nausea and vomiting. Nine months earlier he had been evaluated by his primary care doctor for a one month history of progressive jaundice. Initial workup was notable for a cholestatic elevation in liver enzymes and a direct bilirubinemia. MRCP suggested distal common bile duct stricture. ERCP confirmed this finding and suggested possible cholangiocarcinoma or pancreatic adenocarcinoma. Tumor markers including CA 19-9 and CEA were normal. A biliary stent was placed and jaundice resolved. Subsequent ERCP to exchange the stent revealed chronic calcified pancreatitis and adenopathy in the peripancreatic and porta-hepatis areas with persistent distal common bile duct stricture. Biopsies were taken from the pancreatic head which were suggestive of chronic pancreatitis but were negative for malignant cells. On admission, lab values were consistent with a severe metabolic alkalosis and a cholestatic pattern of hepatic enzyme elevations. Abdominal CT with oral contrast revealed partial gastric outlet obstruction. A nasogastric tube was placed to decompress the stomach. Repeat MRCP was notable for gastric outlet obstruction and a pancreatic head mass involving the second portion of the duodenum. Repeat ERCP showed partial obstruction in the duodenal cap with edematous folds. Biopsies were again taken from the pancreatic head, which were negative for malignancy. The patient underwent PEJ placement for nutrition and placement of a venting PEG tube for oral liquid intake. The patient was started on prednisone 40mg daily to reduce pancreatic inflammation and discharged. He was readmitted five days later with biliary sepsis, and severe gastric outlet obstruction. He was medically managed with antibiotics and hydration and subsequently transferred to the surgical service where he underwent gastrojejunostomy. At three month follow up he reported feeling well, resolved nasuea, and weight gain. A rare condition in the US, groove pancreatitis is associated with male gender and alcohol abuse. Pathogenesis likely involves increased viscocity of pancreatic secretions from alcohol use in susceptible patients, leading to stasis. inflammation, and obstruction of the minor papilla. Case series describing this condition suggest that definitive treatment is pancreatoduodenectomy, however this case demonstrates that pancreatic sparing surgical approaches may be feasible.Figure 1Figure 2Figure 2

Surgical Management of an Optic Nerve Glioma with Perineural Arachnoidal Gliomatosis Growth Pattern

We describe a vision sparing surgical approach for optic nerve glioma. A 7-year-old girl experienced declining academic performance and social withdrawal attributed to progressive disfiguring proptosis. Three years earlier, she had undergone a limited biopsy, a course of chemotherapy, and orbital radiation therapy for a right optic nerve glioma with perineural arachnoidal gliomatosis (PAG). Because of marked proptosis, another surgery was performed via a lateral orbitotomy. After cutting a window in the thickened dura of the optic nerve, rouge colored spongy tissue was suctioned from the subarachnoid space. Small, more solidified areas were excised with unipolar cautery. Care was taken to avoid identifiable blood vessels and the optic nerve, and approximately 60%-70% of the tumor was removed. The dural window was approximated with interrupted sutures. Postoperatively, there was 9 mm reduction in right proptosis and visual acuity improved to from 20/70 to 20/60. This case illustrates the possibility of debulking optic nerve gliomas without sacrificing vision. It should be stressed that this technique is only applicable to gliomas with PAG and the durability of the surgical benefit is unknown.

Does the anterior approach for total hip arthroplasty better restore stair climbing gait mechanics?

While total hip arthroplasty (THA) provides pain relief and restores mobility, gait anomalies persist even years after surgery. A muscle sparing surgical approach could result in better postoperative gait mechanics. Our purpose was to compare both the anterior muscle sparing approach and the direct lateral approach (LAT) to a matched control group by using three-dimensional motion analysis while performing stair ascent and descent tasks. Lower-limb kinematics and kinetics were recorded for 20 patients that had an anterior approach (ANT), 20 that had a LAT, and 20 age- and weight-matched control participants. Patients were assessed on average 10 months after surgery. Compared to the control group, during stair ascent, the anterior group had reduced peak hip extension, peak hip flexion moment, and peak hip power. The lateral group had reduced peak hip abduction, hip frontal plane range of motion, and peak hip internal rotation. In stair descent, the anterior group had reduced peak hip flexion, peak hip abduction moment and internal rotation, as well as peak hip power. The lateral group had reduced peak hip flexion, peak knee extension moment, and peak hip power. Therefore, gait anomalies persist after THA for both approaches, which could be due to other factors such as preoperative gait adaptations.

Effect of a Collateral Ligament Sparing Surgical Approach on Mechanical Properties of Equine Proximal Interphalangeal Joint Arthrodesis Constructs

To (1) compare the effect of a collateral ligament sparing surgical approach with an open surgical approach on mechanical properties of proximal interphalangeal joint (PIPJ) arthrodesis, and (2) to determine the percentage of articular cartilage surface removed by transarticular (TA) drilling with different diameter drill bits. Randomized paired limb design. Cadaveric equine limbs (n=76). Cadaveric PIPJ were drilled using a 3.5, 4.5, or 5.5 mm drill bit at 80-84° to the dorsal plane to remove articular cartilage and subchondral bone from the distal articular surface of the proximal phalanx (P1) and the proximal articular surface of the middle phalanx (P2). Bone ends were photographed and the percentage of the projected surface area that was denuded of cartilage was measured. PIPJ arthrodesis constructs (3-hole dynamic compression plate [DCP], two 5.5 mm TA screws inserted in lag fashion, medial and lateral to the DCP; DCP-TA) were created using 2 surgical approaches in paired limbs. A conventional open approach was used in 1 limb and a collateral ligament sparing approach used in the other limb. Constructs were tested to failure in single-cycle 3-point dorsopalmar/plantar or lateromedial bending. Maximum load, yield load, and composite stiffness were compared between techniques. The 3.5, 4.5, and 5.5 mm drill bits removed 24±4%, 35±5%, and 45±7% of total PIPJ articular cartilage surface, respectively. Constructs with the collateral ligament sparing approach had significantly greater mean yield load (11.3±2.8 versus 7.68±1.1 kN, P=.008) and mean maximum load (13.5±3.1 versus 10.1±1.94 kN, P=.02) under lateromedial bending. Under dorsopalmar/plantar bending there was no significant difference between surgical approaches. The collateral ligament sparing arthrodesis technique had a shorter surgical time (19±3 minutes) compared with the open technique (31±3 minutes). A collateral ligament sparing surgical approach to the PIPJ with removal of articular cartilage by TA drilling and arthrodesis by DCP-TA was faster and stronger in mediolateral bending than arthrodesis constructs created with an open surgical approach. Preservation of the collateral ligaments and TA drilling for cartilage removal during PIPJ arthrodesis may be a superior approach to the conventional open approach and warrants clinical evaluation.

Accuracy of side-cutting implantation instruments for total knee arthroplasty

A new generation of implantation instruments were developed for quadriceps sparing surgical approaches during total knee arthroplasty (TKA). There is little information on the accuracy of the bone cuts performed with the side-cutting technique. A total of 100 patients were randomized to undergo computer-assisted TKA or non-navigated TKA using a mini-subvastus surgical approach and side-cutting implant instrumentation. The radiographic parameters, clinical outcomes and knee scores were evaluated 3 months postoperative. The mechanical axis of the limb was within 3 degrees varus/valgus in 76% of the patients who had navigated procedures versus 66% of patients who had conventional surgery. The tibial slope showed a rate of inaccuracy of 3 degrees or less for 78% of the patients in the navigated total knee arthroplasty group versus 66% of the patients in the conventional group. Clinical outcomes and knee scores were similar in both groups. The navigation technique could not compensate for shortcomings of the implantation instruments.

EVALUATION AND MANAGEMENT OF RENAL TUMORS IN THE BIRT-HOGG-DUBÉ SYNDROME

Herein we describe the evaluation and management of renal tumors in Birt-Hogg-Dubé (BHD), an autosomal dominant disorder predisposing to cutaneous fibrofolliculomas, pulmonary cysts, spontaneous pneumothorax and renal tumors. A total of 124 affected individuals underwent comprehensive clinical evaluation, including body computerized tomography, to determine cutaneous, pulmonary and renal manifestations of BHD. Of these individuals 14 had their renal tumors managed at our institution. Of the 124 BHD affected individuals 34 (27%) had renal tumors of various histologies, most commonly hybrid oncocytic tumor and chromophobe renal carcinoma. Average age at renal tumor detection was 50.4 years and multiple tumors were found in a majority of patients. Some patients with renal tumors were identified that did not have the characteristic cutaneous hallmarks of BHD. In 4 of the 14 patients treated at our institution small (less than 3 cm) renal tumors were observed, while 10 others underwent a total of 12 renal procedures, including 4 radical and 8 partial nephrectomies. At a median of 38 months of followup 5 of these 10 patients remained free of disease, 3 had small renal tumors and 2 died of metastatic renal cancer. Patients with BHD are at risk for multiple renal tumors that are often malignant and can metastasize. Individuals at risk or affected by BHD should be radiographically screened for renal tumors at periodic intervals and they are best treated with nephron sparing surgical approaches. Genetic testing for this syndrome is now available.

Periacetabular osteotomy without abductor dissection using direct anterior exposure.

The direct anterior exposure is a new abductor sparing surgical approach to perform periacetabular osteotomy, developed in an effort to eliminate the postoperative abductor morbidity associated with the classic Smith-Petersen approach. The direct anterior exposure also allows anterior arthrotomy of the hip joint, necessary to deal with intraarticular disease of the acetabular rim that is common in adult patients who require periacetabular osteotomy. The direct anterior exposure combines the medial portion of the classic Smith-Petersen iliofemoral exposure with or without the second window of the ilioinguinal exposure. An osteotomy of the anterior superior spine is done routinely to facilitate the approach by relaxing the attached sartorius and inguinal ligament origins. The authors' experience with the direct anterior exposure involves 195 consecutive periacetabular osteotomies done since 1992, with 60 operations done using the full approach through two windows and 135 operations done using the limited approach through one window. There was no difference in functional or radiographic results, with both approaches allowing rapid functional recovery, excellent radiographic corrections, rapid bony healing, and minimal formation of heterotopic bone. No osteonecrosis or vascular injuries were seen. In nearly all patients, abductor function had returned to preoperative levels by 3 months after surgery, in distinct contrast to the authors' previous experience with the Smith-Petersen approach. The authors consider the direct anterior exposure to be the surgical approach of choice for periacetabular osteotomy, with the more limited version proving satisfactory in all patients except the largest and most muscular patients. The full version is useful in large male patients.

Evaluation of Color Doppler Intraoperative Ultrasound in Parenchymal Sparing Renal Surgery

A renal parenchymal sparing surgical approach may be recommended in select patients with von Hippel-Lindau disease and renal cancer or in those with sporadic renal cancer and limited normal renal function. We performed 27 partial nephrectomies or enucleations in 17 patients with the use of intraoperative ultrasound to examine a subset of all renal lesions identified on preoperative examination.Of 24 lesions deep in the renal parenchyma that were examined, localized or identified with intraoperative ultrasound 18 were characterized as cystic and 6 as solid. The deep cystic lesions were characterized with ultrasound as benign simple cysts. Intraoperative ultrasound was used to locate and mark the line of incision over 2 impalpable solid renal cell carcinomas. Four solid renal cell tumors extended deep into the renal parenchyma where color Doppler intraoperative ultrasound helped to define the plane of dissection adjacent to vital vascular structures. Renal hypothermia was not used in 3 renal operations based on intraoperative ultrasound findings.