A history of meniscal surgery: from ancient times to the twenty-first century.

The science and surgery of the meniscus have evolved significantly over time. Surgeons and scientists always enjoy looking forward to novel therapies. However, as part of the ongoing effort at optimizing interventions and outcomes, it may also be useful to reflect on important milestones from the past. The aim of the present manuscript was to explore the history of meniscal surgery across the ages, from ancient times to the twenty-first century. Herein, some of the investigations of the pioneers in orthopaedics are described, to underline how their work has influenced the management of the injured meniscus in modern times. Level of evidence V.

Patient-reported outcomes after Silastic replacement of the trapezium for osteoarthritis.

This retrospective study evaluated 69 Swanson trapezium replacements performed between 1990 and 2009 for trapeziometacarpal osteoarthritis in 58 patients. Pain and function were assessed using the Michigan Hand Questionnaire and the Disability of the Arm, Shoulder and Hand questionnaire. Patients had a mean age of 62 years at the time of surgery, with a mean time of 7.7 years (range 9 months to 19 years) from surgery to follow-up interview. There was no association between outcome scores and the length of follow-up, suggesting that the results are maintained over time (Spearman's rank correlation test < ±0.2). Scores for activities of daily living and work-related activities were higher when surgery was on the dominant hand (p < 0.05). Silicone trapezium replacement remains a good option for patients with painful trapeziometacarpal osteoarthritis that has not responded to nonoperative management.

Society of NeuroInterventional Surgery Standards of Practice: general considerations.

This is the first in a set of documents intended to standardize techniques, procedures, and practices in the field of endovascular surgical neuroradiology. Standards are meant to define core practices for peer review, comparison, and improvement. Standards and guidelines also form the basic dialogue, reporting, and recommendations for ongoing practices and future development.

Translation of science to surgery: linking emerging concepts in biological cartilage repair to surgical intervention.

Orthopaedic surgery is in an exciting transitional period as modern surgical interventions, implants and scientific developments are providing new therapeutic options. As advances in basic science and technology improve our understanding of the pathology and repair of musculoskeletal tissue, traditional operations may be replaced by newer, less invasive procedures which are more appropriately targeted at the underlying pathophysiology. However, evidence-based practice will remain a basic requirement of care. Orthopaedic surgeons can and should remain at the forefront of the development of novel therapeutic interventions and their application. Progression of the potential of bench research into an improved array of orthopaedic treatments in an effective yet safe manner will require the development of a subgroup of specialists with extended training in research to play an important role in bridging the gap between laboratory science and clinical practice. International regulations regarding the introduction of new biological treatments will place an additional burden on the mechanisms of this translational process, and orthopaedic surgeons who are trained in science, surgery and the regulatory environment will be essential. Training and supporting individuals with these skills requires special consideration and discussion by the orthopaedic community. In this paper we review some traditional approaches to the integration of orthopaedic science and surgery, the therapeutic potential of current regenerative biomedical science for cartilage repair and ways in which we may develop surgeons with the skills required to translate scientific discovery into effective and properly assessed orthopaedic treatments.

Performance and training standards for endovascular ischemic stroke treatment.

Stroke is the third leading cause of death in the USA, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, there are now 750,000 new strokes that occur each year, resulting in 200,000 deaths, or 1 of every 16 deaths, per year in the USA alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intra-arterial thrombolysis in selected patients. Intra-arterial thrombolysis has been studied in two randomized trials and numerous case series. Although two devices have been granted FDA approval with an indication for mechanical stroke thrombectomy, none of these thrombectomy devices has demonstrated efficacy for the improvement of patient outcomes. The purpose of the present document is to define what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and what performance standards should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies which historically have been directly involved in the medical, surgical and endovascular care of patients with acute stroke. The participating member organizations of the Neurovascular Coalition involved in the writing and endorsement of this document are the Society of NeuroInterventional Surgery, the American Academy of Neurology, the American Association of Neurological Surgeons/Congress of Neurological Surgeons Cerebrovascular Section, and the Society of Vascular & Interventional Neurology.

Performance and training standards for endovascular ischemic stroke treatment.

Stroke is the third leading cause of death in the USA, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, there are now 750,000 new strokes that occur each year, resulting in 200,000 deaths, or 1 of every 16 deaths, per year in the USA alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intra-arterial thrombolysis in selected patients. Intra-arterial thrombolysis has been studied in two randomized trials and numerous case series. Although two devices have been granted FDA approval with an indication for mechanical stroke thrombectomy, none of these thrombectomy devices has demonstrated efficacy for the improvement of patient outcomes. The purpose of the present document is to define what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and what performance standards should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies which historically have been directly involved in the medical, surgical and endovascular care of patients with acute stroke. The participating member organizations of the Neurovascular Coalition involved in the writing and endorsement of this document are the Society of NeuroInterventional Surgery, the American Academy of Neurology, the American Association of Neurological Surgeons/Congress of Neurological Surgeons Cerebrovascular Section, and the Society of Vascular & Interventional Neurology.

Three Tesla MRI for the diagnosis of meniscal and anterior cruciate ligament pathology: a comparison to arthroscopic findings.

AIM: To assess the accuracy of 3T magnetic resonance imaging (MRI) in the evaluation of meniscal and anterior cruciate ligament (ACL) injury. MATERIALS AND METHODS: Sixty-one consecutive patients were identified who were referred for evaluation of suspected intra-articular pathology with a 3T MRI and who, subsequently, underwent an arthroscopic procedure of the knee were included for the study. Two musculoskeletal radiologists interpreted the images. The sensitivity, specificity, positive predictive value, and negative predictive value were then calculated for the MRI versus the arthroscopic findings as a reference standard. RESULTS: The sensitivity and specificity for the overall detection of meniscal tears in this study was 84 and 93%, respectively. The results for the medial meniscus separately were 91 and 93% and for the lateral 77 and 93%. The evaluation of ACL integrity was 100% sensitive and specific. The meniscal tear type was correctly identified in 75% of cases and its location in 94%. CONCLUSION: This study demonstrates good results of 3T MRI in the evaluation of the injured knee. Caution should still be given to the interpretation on MRI of a lateral meniscus tear, and it is suggested that the standard diagnostic criteria of high signal reaching the articular surface on two consecutive image sections be adhered to even at these higher field strengths.

The role of sentinel lymph node biopsy in ductal carcinoma in situ.

AIM: To review the role of sentinel lymph node (SLN) biopsy in the surgical management of patients with ductal carcinoma in situ (DCIS). METHODS: A search was conducted of Medline and the National Library of Medicine to identify key articles concerning DCIS, SLN biopsy (SLNB) and axillary dissection. Further relevant articles were obtained from the references cited in the literature. RESULTS: Up to 20% of patients with a core biopsy diagnosis of DCIS will be later up-staged based on an invasive component identified on the excision specimen. Quality assurance in breast screening programmes requires minimally invasive pre-operative diagnosis and also axillary sampling in the case of documented invasive disease. As an effective and validated procedure, SLNB represents a paradigm shift in the surgical management of the axilla for patients with invasive breast cancer. It remains undefined which, if any, subgroups of patients with DCIS should undergo SLNB. CONCLUSION: Axillary lymphadenectomy is an overtreatment for patients with DCIS. Performing a SLNB during the initial procedure may avoid a second operation in some DCIS patients who are diagnosed with occult invasive disease at their definitive operation. When predictors of hidden invasive disease are clarified by further study, SLNB may be used in the management of selected high-risk DCIS patients.

CDH1 associated gastric cancer: a report of a family and review of the literature.

AIMS: Hereditary diffuse gastric cancer (HDGC) is an autosomal-dominant inherited form of gastric cancer associated with inactivating germline mutations in the CDH1 gene. We set out to outline the role of CDH1 in HDGC. Investigation of a family suspected as having HDGC is discussed. The role of surgery in the management of affected individuals is then examined. METHODS: A search was conducted of Medline and the National Library of Medicine to identify key articles concerning CDH1 gene mutations, familial gastric cancer and gastrectomy. Further, relevant articles were obtained by manual scanning of the reference lists of identified papers. Mutation-specific CDH1 genetic testing was performed on six living family members and on gastric tissue obtained from two deceased members. RESULTS: CDH1 mutations cause inactivation of the cell adhesion protein E-cadherin. Carriers of the CDH1 germline gene mutation develop an aggressive, diffuse, submucosal gastric cancer at an early age. Current endoscopic screening is ineffective at detecting HDGC. The presence of a CDH1 germline gene mutation was confirmed in both deceased family members and also in four of the six living members tested. CONCLUSION: Genetic counselling and CDH1 gene mutation testing is indicated in families with suspected HDGC. In the absence of a satisfactory surveillance mechanism, prophylactic total gastrectomy would appear to be an appropriate therapeutic option in mutation carriers.

Minimally invasive parathyroidectomy with operative ultrasound localization of the adenoma.

BACKGROUND: Minimally invasive parathyroidectomy is the procedure of choice for primary hyperparathyroidism due to parathyroid adenoma. Adequate perioperative adenoma localization is essential for this operation. We describe a technique using ultrasound to perform minimally invasive parathyroidectomy. METHODS: 99mTc sestamibi scanning was performed on patients with primary hyperparathyroidism to localize parathyroid adenomas; no intraoperative gamma probe was used. We also performed pre- and intraoperative ultrasound scanning to localize these adenomas. RESULTS: All patients underwent successful localization and removal of their parathyroid adenomas. At follow-up, all patients were well, with calcium within normal limits. CONCLUSION: The use of intraoperative ultrasound facilitates minimally invasive parathyroidectomy and may obviate the need for intraoperative 99mTc sestamibi scanning.

Prepontine lesions with chiari II malformation. Report of two cases.

In 2 cases of infants with the Chiari II malformation, a prepontine cyst presented in association with the hindbrain abnormalities characteristic of the Chiari II syndrome. Both infants presented with bulbar dysfunction and had poor outcome despite decompression of the cerebellar tonsillar herniation and drainage of the prepontine cysts. No such association between prepontine lesions and Chiari II has been described previously.

Sagittal sinus occlusion by intraluminal dural cysts. Report of two cases.

Lesions involving the sagittal sinus typically present as masses compressing the sinus externally. The authors describe two cases of lesions entirely within the lumen of the sagittal sinus. In one of the cases, syncope was the presenting symptom and surgical resection of the cyst was performed. An entirely intraluminal cyst, consistent with a dural cyst, was resected, followed by reconstruction of the sinus and resolution of symptoms. Entirely intraluminal lesions of the sagittal sinus have rarely been reported as incidental findings. This represents the first report of symptomatic occlusion of a venous sinus by an intraluminal cyst.

Radiation dose to patients and personnel during intraoperative digital subtraction angiography.

BACKGROUND AND PURPOSE: The use of intraoperative angiography to assess the results of neurovascular surgery is increasing. The purpose of this study was to measure the radiation dose to patients and personnel during intraoperative angiography and to determine the effect of experience. METHODS: Fifty consecutive intraoperative angiographic studies were performed during aneurysmal clipping or arteriovenous malformation resection from June 1993 to December 1993 and another 50 from December 1994 to June 1995. Data collected prospectively included fluoroscopy time, digital angiography time, number of views, and amount of time the radiologist spent in the room. Student's t-test was used to assess statistical significance. Effective doses were calculated from radiation exposure measurements using adult thoracic and head phantoms. RESULTS: The overall median examination required 5.2 minutes of fluoroscopy, 55 minutes of operating room use, 40 seconds of digital angiographic series time, and four views and runs. The mean room time and the number of views and runs increased in the second group of patients. A trend toward reduced fluoroscopy time was noted. Calculated effective doses for median values were as follows: patient, 76.7 millirems (mrems); radiologist, 0.028 mrems; radiology technologist, 0.044 mrems; and anesthesiologist, 0.016 mrems. CONCLUSION: Intraoperative angiography is performed with a reasonable radiation dose to the patient and personnel. The number of angiographic views and the radiologist's time in the room increase with experience.

Intracranial tumor in children: MR imaging findings within 24 hours of craniotomy.

PURPOSE: To evaluate whether very early magnetic resonance (MR) imaging enables distinction of residual tumor from benign postoperative change in children. MATERIALS AND METHODS: Forty-six postoperative MR examinations were performed in 43 children with intracranial tumors within 24 hours of the completion of surgery during a 2-year period. These examinations were categorized according to whether residual tumor could be definitely identified or excluded, or whether the diagnosis was uncertain. RESULTS: Contrast enhancement occurred in 33 of 46 MR examinations performed within 24 hours of surgery. In 18 instances, this was associated with obvious residual tumor. In 15 patients, only small amounts of linear or patchy enhancement were seen. Of these, seven patients (46%) were disease-free for an average of 4.5 years. Assessment for postoperative enhancement was hampered in seven patients because of the presence of methemoglobin in the tumor bed. Contrast enhancement was not observed in two patients before surgery. CONCLUSION: Surgically induced, MR-detectable contrast enhancement and extracellular methemoglobin formation occurs within 24 hours of the completion of intracranial surgery. This can interfere with the detection of small amounts of residual tumor.

Patterns of facial nerve synkinesis.

Facial nerve synkinesis is an extremely distressing sequela of facial paralysis, and its prevention and treatment are less than adequate. Improved therapeutic interventions await better understanding of its pathogenesis. In this study, 11 patients with synkinesis and 11 normal control subjects were quantitatively assessed using a new computer-assisted, motion-sensitive system. Two additional, informative cases presenting at the completion of the study are also briefly reported. The observed synkinetic patterns appear predictable and nonrandom. In addition, these observations tend to raise doubts that the aberrant fiber regeneration hypothesis is the sole explanation of synkinesis. They further implicate facial nuclear hyperexcitability as an explanation in at least some cases of synkinesis. Understanding these patterns enhances clinical detection and evaluation and may lead to a better knowledge of the fundamental pathophysiology of synkinesis and its prevention.

Early postoperative magnetic resonance imaging following nonneoplastic cortical resection.

Postcraniotomy residual tumor is often determined by magnetic resonance (MR) imaging. Magnetic resonance changes that occur in the postoperative setting must be defined to ensure both the optimum timing of postoperative image acquisition and the accurate assessment of images for residual tumor. Postoperative changes in nontumor parenchyma have previously been described for computerized tomography but not for MR imaging. In the present study, 11 patients without intracranial neoplastic disease (six females and five males with a median age of 36 years) submitted to MR imaging 17 to 28 hours after undergoing temporal lobectomies for epilepsy. Four of the operations were performed with the patients under general anesthesia and seven under local anesthesia. Postoperative MR images (T1-weighted, T1-weighted gadolinium enhanced, and T2-weighted) were reviewed. Extraaxial fluid, air, or blood was present in all cases. Enhancement of the resection bed parenchyma occurred in seven (64%) of 11 patients. In three of the remaining four patients, assessment of parenchymal enhancement was obscured by extraaxial fluid collections. Dural enhancement occurred adjacent to the resection site in all of the cases and remotely in 73%. Eight (73%) of 11 patients displayed enhancement of the pia-arachnoid of the ipsilateral cerebral convexity, two (18%) of the contralateral convexity, and four (36%) of the pia-arachnoid overlying the cerebellum. Contrary to previous reports, contrast enhancement of nonneoplastic human brain parenchyma can occur postoperatively within 17 hours. Benign parenchymal contrast enhancement is usually linear in appearance; nonneoplastic dural and leptomeningeal enhancement can occur both adjacent to and distant from the surgical site. Extraaxial fluid collections can hinder MR evaluation of the resection bed.

Intrasellar abscess following transsphenoidal surgery.

BACKGROUND: Intrasellar abscess following transsphenoidal surgery has been described only twice in the English language medical literature. Overall mortality associated with intrasellar abscesses is 51%, while mortality in reported cases not treated surgically is 100%. METHODS: Two cases of intrasellar abscess following uncomplicated transsphenoidal surgery for pituitary pathology are reported. The incidence, radiographic features, clinical presentations, and treatment of intrasellar abscesses are discussed. RESULTS: Both patients described underwent uncomplicated transsphenoidal procedures for treatment of a primary pituitary lesion. Neither developed postoperative CSF rhinorrhea, and initial recovery was uneventful. The first patient presented with new symptoms several weeks after transsphenoidal surgery; the second patient almost two years postoperatively. The first displayed signs of an expanding sellar mass, requiring transsphenoidal drainage and postoperative antibiotics. The second presented with recurrent meningitis without discernible CSF leak, and was treated with transnasal endoscopic drainage in conjunction with antibiotic therapy. CONCLUSIONS: The high mortality associated with intrasellar abscess mandates its inclusion in the differential diagnosis of patients presenting with symptoms of meningitis or an expanding sellar mass after transsphenoidal intervention. Although antibiotic therapy is an important adjunct, surgical drainage is required for definitive treatment.

Role of Doppler US in screening for carotid atherosclerotic disease.

PURPOSE: To evaluate Doppler ultrasound (US) as a screening modality before arteriography for extracranial carotid artery disease. MATERIALS AND METHODS: The net benefit in stroke reduction from screening with Doppler US was calculated on the basis of literature estimates of disease prevalence, risk reduction data, and locally validated sensitivities and specificities for detection of carotid artery stenosis and occlusion in 215 patients. RESULTS: Screening a symptomatic population demonstrated a net stroke reduction. Screening asymptomatic populations with a 20% prevalence of > or = 60% stenosis also yielded a net stroke reduction. Screening low-prevalence (5%) asymptomatic populations produced a small benefit, which was lost if arteriographic or surgical complications increased slightly. Arteriographic confirmation of the US diagnosis of occlusion produced a small benefit only in the symptomatic population. CONCLUSION: Screening symptomatic and high-prevalence asymptomatic populations with US reduces stroke. Increased arteriographic or surgical complication rates reduce the benefit of screening in any population.