Blood loss and operative duration using monopolar electrosurgery versus ultrasound scissors for surgical preparation during thoracoscopic ventral spondylodesis: results of a randomized, blinded, controlled trial.

PURPOSE: Monopolar electrosurgery is the gold standard for surgical preparation in thoracoscopic spine procedures. However, use of ultrasound scissors could decrease blood loss, accelerate the preparation time and improve patient safety, while minimizing operative costs. This trial compares both preparation techniques for ventral thoracoscopic spondylodesis. METHODS: The study design is an open, prospective, randomized, and double-blinded two-armed clinical trial performed in two centres. Forty-one patients with vertebral body fractures from T10 to L2 were included. Primary endpoint: preparation time. Secondary endpoints: blood loss, organ injuries, duration of hospitalization. RESULTS: Primary and secondary endpoints did not differ significantly between groups (p level 0.05). Increased blood loss (150 ml or more) was eliminated with ultrasound scissors (p = 0.0014). CONCLUSIONS: Primary and secondary endpoints did not differ significantly between the two preparation techniques. The use of either ultrasound scissors or electric scalpel offers safe and effective preparation for thoracoscopic spine surgery.

The relationship between the medial collateral ligament and the medial meniscus: a topographical and biomechanical study.

The functional influence of the medial collateral ligament on the medial meniscus is still discussed controversially. Commonly, a strong fixation of the meniscus by the collateral ligament is described. Injury to the medial meniscus is explained by its reduced mobility due to its strong adherence to the medial collateral ligament. The analysis of 10 plastinated series of the medial femorotibial compartment prove that only few fibres of the ligament radiate into the meniscus. To define the possible contribution of these fibers to the stability of the medial meniscus, experiments on two fresh frozen knee joints were performed. The distal femur was separated by cutting the capsule. The medial collateral ligament was detached carefully from its femoral insertion. The tibial head with both menisci was fixed in a clamping system. A translucent, exact acrylic glass copy of the femoral component to which the medial collateral ligament was reinserted, allowed studying the behaviour of the medial meniscus under axial compression (500 N). Firstly, stress was applied while the collateral ligament was proximally fixed and under tension; then the same experiment was performed after femoral detachment of collateral ligament. All plastinated series revealed only some deep and tender fibrous bundles of the medial collateral ligament radiating into the medial meniscus proximally and posteriorly. The behaviour of medial meniscus was exactly the same in both stress experiment series. The conclusion is that there is no relevant influence of the medial collateral ligament on the stability of the medial meniscus.

Manual stimulation, but not acute electrical stimulation prior to reconstructive surgery, improves functional recovery after facial nerve injury in rats.

UNLABELLED: The outcome of peripheral nerve injuries requiring surgical repair is poor. Recent work suggested that electrical stimulation (ES) of the proximal nerve stump to produce repeated discharges of the parent motoneurons for one hour could be a beneficial therapy if delivered immediately prior to reconstructive surgery of mixed peripheral nerves. PURPOSE: We tested whether ES has a positive influence on functional recovery after repair of a purely motor nerve, the facial nerve. METHODS: Electrical stimulation (20 Hz) was delivered to the proximal nerve stump of the transected facial nerve for 1 hour prior to nerve reconstruction by end-to-end suture (facial-facial anastomosis, FFA). For manual stimulation (MS), animals received daily rhythmic stroking of the whisker pads. Restoration of vibrissal motor performance following ES or MS was evaluated using video-based motion analysis. We also assessed the degree of collateral axonal branching at the lesion site, by counting motoneuronal perikarya after triple retrograde labeling, and estimated the quality of motor end-plate reinnervation in the target musculature. Outcomes at 4 months were compared to animals receiving sham stimulation (SS) or MS. RESULTS: Neither protocol reduced the degree of collateral sprouting. ES did not improve functional outcome and failed to reduce the proportion of polyinnervated motor end-plates. By contrast, MS restored normal whisking function and reduced polyinnervation. CONCLUSION: Whereas acute ES is not beneficial for facial nerve repair, MS provides long-term benefits.

The venous pump of the first metatarsophalangeal joint: clinical implications.

BACKGROUND: Although the anatomy and physiology of the venous circulation of the ankle and midfoot are well documented, the physiologic importance of forefoot mobility has not been reported in the literature. The question of this study was whether the first metatarsophalangeal (MTP) joint may operate, like the ankle, as a "pump" to encourage venous return. METHODS: Forty-nine cadaver foot specimens were examined using dissection, plastination, vessel infiltration, and maceration, and radiographic (including venography, MRI, and magnetic resonance angiography) techniques. The anatomy and physiology were described and compared to the ankle joint. Forty patients had biphasic Doppler flow studies. RESULTS: The major finding was the medial drainage of the plantar venous sinus, which is fibrotically bound to the joint capsule. Functional venous valves were evident distally and within fibrous vascular lumens. Mobilization of the first MTP joint led to compression and emptying of the veins. Passive mobilization of the first MTP joint led to an average flow increase of 55% +/- 7 (p < 0.0001), while active movement led to an average increase of 78% +/- 7 (p < 0.0001). CONCLUSIONS: Our described connection between the joint capsule and veins indicates a "toe-ankle pump" with a significant increase of venous blood flow during motion of the MTP joint. Possible clinical applications for an external MTP pump include anti-edema or thromboprophylactic therapy, especially in patients with foot or ankle injuries. A new toe-pump has been designed based on these results.

[Quality of Life and Functional Outcome after Microsurgical Decompression in Lumbar Spinal Stenosis: a Register Study]. / Lebensqualität und funktionelles Ergebnis nach mikrochirurgischer Dekompression bei lumbaler Spinalkanalstenose ­ eine Registerstudie.

Introduction Because of recent increases in life expectancy, lumbar spinal stenosis (LSS) has become one of the most common degenerative changes in the spine. In patients not responding to conservative therapy, microsurgical decompression is the gold standard of operative treatment for degenerative LSS. The goal of the current study is to evaluate quality of life after microsurgical decompression for LSS, using data from the DWG Register (previously Spine Tango). Methods 36 patients were included in this single-center, prospective, observational study from January 2013 to June 2014. Data were collected from the Spine Tango or DWG Register. The core outcome measure index (COMI), Oswestry Disability Index (ODI), and the quality of life questionnaire EuroQoL-5D were used. Data were collected prior to surgery as well as six weeks, six months, and twelve months after the operation. Results The patient cohort comprised 13 females and 23 males (36.1 and 63.9 %). Complete 12-month follow-up data on 21 patients were available for analysis. Compared to preoperative measures, the COMI score increased 8.1 ± 1.5 over the entire follow up, with 4.5 ± 3.1 at 6 weeks (p < 0.001), 4.8 ± 3.1 at 6 months, and 3.8 ± 3.2 at 12 months. ODI scores, measuring spinal function impairment, were significantly better than preoperative values overall (47.5 ± 17.3) and after 6 weeks (29.1 ± 22.4; p < 0.005), 6 months (30.0 ± 19.3), and 12 months (23.8 ± 18.2). Quality of life measures improved in a similar manner (preoperative: 0.36 ± 0.38; 6 weeks: 0.57 ± 0.34 (p < 0.019); 6 months: 0.62 ± 0.28; 12 months: 0.67 ± 0.31). Conclusion Our study shows that LSS patients without previous surgery and neurologic deficits can expect significant pain relief and improved quality of life already six weeks after undergoing stabilizing decompression. There was an increase in positive postoperative effects over 12 months. The DWG Register provides a standardized and validated means to compare non-operative and operative treatments of the spine over the long term.

Midclavicular fracture: not just a trivial injury: current treatment options.

BACKGROUND: Conservative treatment was long recommended for midclavicular fractures because of the excellent results that were reported in the 1960's and 70's. Recently, however, the rucksack bandage has received competition from surgical treatment. The spectrum of operations ranges from classic plate osteosynthesis to intramedullary techniques and angle-stable implants. METHODS: We present and evaluate the current treatment options on the basis of a selective review of the literature. RESULTS: Recent studies have confirmed some long-held concepts and refuted others. The risk of non-union after conservative treatment was previously reported as 1% to 2% but has turned out to be much higher in selected subgroups such as in patients with severe displacement, female patients, and patients of advanced age. Furthermore, new implants and techniques have made surgery safer and more likely to result in bony union. CONCLUSION: In any case of midclavicular fracture, the type of fracture should be precisely analyzed and an individual treatment strategy should be developed in view of the patient's particular situation. Current studies show with a high level of evidence (level 1) that patients with dislocated fractures benefit from surgery.

Transplantation of de novo scaffold-free cartilage implants into sheep knee chondral defects.

BACKGROUND: New cell-based treatments for articular cartilage repair are needed. As the optimal scaffold for cartilage repair has yet to be developed, scaffold-free cartilage implants may remove the complications caused by suboptimal scaffolds. HYPOTHESIS: The implantation of a scaffold-free, autologous de novo cartilage implant into standardized full-thickness cartilage defects of femoral condyles in sheep leads to a qualitatively better regenerative tissue than does periosteal flap alone or no treatment. STUDY DESIGN: Controlled laboratory study. METHODS: Chondral defects 4 mm in diameter (1 per sheep) were created in the center of 1 medial femoral condyle of 48 sheep. Twelve defects were allowed to heal spontaneously, 16 defects were covered with periosteal flaps alone, and 20 defects were filled with autologous de novo cartilage graft and overlaid with a periosteal flap. Differences were assessed macroscopically using the International Cartilage Repair Society score and microscopically using the International Cartilage Repair Society histological score and Mankin score at 26 and 52 weeks. RESULTS: The results of the International Cartilage Repair Society Cartilage repair assessment showed that the transplant group was better than was the untreated control at both time periods but not significantly different than was the periosteal flap group. Implanted groups demonstrated a marked improvement in grade of defect filling, cartilage stability, cell distribution, and matrix assessments in each method of assessment. In the transplant group, 2 defects were filled with hyaline cartilage, 5 with mixed hyaline and fibrocartilage, and 2 with fibrocartilage alone. CONCLUSION: Chondral defects treated with de novo cartilage transplantation show qualitatively better microscopic and macroscopic regeneration than do those treated with periosteal flaps alone. CLINICAL RELEVANCE: Results of the current study show that third-generation autologous chondrocyte transplantation is a promising development in the field of biologic cartilage regeneration. Future studies should compare this technique with the original Brittberg technique.

Complete talar dislocation without late osteonecrosis: clinical case and anatomic study.

Avascular necrosis is a well-known, severe complication postfracture or subluxation of the talus. Type and localization of injury often permit conclusions regarding the probability of bone necrosis. In the following case, talar neovascularization was demonstrated after severe trauma, resulting in an open pilon fracture of the right tibia and complete talar dislocation with consequent destruction of the most relevant blood supply. This example shows that even after apparently irreversible injury to the arterial circulation, immediate bony reconstruction with comprehensive soft tissue management is indicated and can lead to bony healing. The anatomy of intraosseus vascularization is reviewed and discussed.

Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail.

This study presents the results of a minimally invasive operative treatment for markedly displaced midclavicular fractures. In all patients a flexible titanium nail was inserted in an unreamed technique from the sternal end of the clavicle. The result of surgery was determined with clinical and radiographic controls. The clinical outcome was evaluated 12 months after hardware removal using the scoring system of Constant and Murley. Fifty-eight fractures in 55 patients were treated with intramedullary fixation. Postoperatively on Day 3, the mean subjective pain was significantly lower and range of motion was improved compared with the day before surgery. One nonunion occurred. There was no infection and no implant displacement or refracture. Intramedullary nailing of midclavicular fractures with a flexible titanium nail is a safe minimally invasive surgical technique with excellent functional and cosmetic results compared with plate fixation or conservative treatment. Marked pain reduction along with early restoration of shoulder function and early mobilization are advantageous for patients. This technique can be used as an alternative treatment to conservative procedures or plate fixation in patients with markedly displaced midclavicular fractures, multiple trauma, fractures of the lower extremities, or associated shoulder girdle injuries.