[Research progression and application of Laennec capsule in liver].

The Laennec capsule of liver was first discovered and reported by French doctor Rene Theophile Hyacinthe Laennec in 1802.However, it has not received enough attention for more than 200 years since then. In recent years, with the rapid development of liver surgery represented by laparoscopic technology, and the deepening of the theory of precise liver surgery, the fine anatomical structure of liver Laennec capsule has returned to the vision of liver surgeons.Recent studies have demonstrated the presence of Laennec capsule in liver histology, covering the whole liver surface, and lining the surface of liver parenchyma around the Glisson pedicle and the main hepatic vein along the inflow and outflow channels of the liver. Based on the Laennec capsule approach, it is expected to unify the current approach of Glisson pedicle and the approach of hepatic vein, and provide a new theoretical basis for the liver surgery, and guide us in the standardization of liver surgeries.

Independent Risk Factors for Postoperative Seizures in Chronic Subdural Hematoma Identified by Multiple Logistic Regression Analysis.

BACKGROUND: Postoperative seizures are potential complications of chronic subdural hematoma (cSDH). Knowledge of risk factors may help to identify patients that may benefit from antiepileptic prophylaxis. METHODS: A total of 101 patients (mean age, 70.1 ± 32.1 years) with surgical evacuation of cSDH were enrolled. We retrospectively collected patient characteristics, hematoma specifics, and procedural aspects and evaluated their impact on postoperative seizures within a 14-day follow-up period by means of bivariate logistic regression analysis. RESULTS: Postoperative seizures occurred in 14 patients (13.9%). At discharge, the mean Markwalder grading scale score was 1.1 ± 1.1 and 0.5 ± 0.8 in patients with and without seizures, respectively (P = 0.04). In the univariate analysis, preoperative midline shift (8.3 vs. 4.5 mm, P = 0.045), open craniotomy (85.7% vs. 55.2%, P = 0.031), and membranectomy (57.1% vs. 20.7%, P = 0.004) were significantly associated with postoperative seizures, respectively. In the multivariate analysis, preoperative midline shift (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.01-1.26; P = 0.029) and membranectomy (OR, 3.9; 95% CI, 1.0-15.0; P = 0.048) remained as independent risk factors for seizures. CONCLUSIONS: Perioperative antiepileptic prophylaxis may be recommended in patients with preoperative midline shift. Membranectomy may not be routinely applied during surgery.

A Novel Algorithmic Approach to Chronic Forearm Longitudinal Instability.

Essex-Lopresti Lesions are rare injuries that are often missed in the acute setting. Delayed intervention may lead to chronic wrist and elbow pain and overall poor outcomes. The literature currently supports treatments that involve shortening of the ulna to reduce the relative degree of ulnar impaction, followed by attempted reduction of the distal radioulnar joint. Although such techniques may help to temporarily reduce wrist pain secondary to ulnar impaction, they do not address the proximal migration of the radius and ipsilateral radial head dislocation at the elbow. Subsequent procedures are often needed to replace or resect the radial head. We present a novel approach to chronic Essex-Lopresti lesions resulting in anatomic restoration of forearm length with return of elbow and wrist flexion/extension as well as improved forearm pronation/supination.

Single- versus double-bundle suture button reconstruction of the forearm interosseous membrane for the chronic Essex-Lopresti lesion.

PURPOSE: Reconstruction of the ruptured interosseous membrane (IOM) is critical to restore forearm stability for the chronic Essex-Lopresti injury. Positive outcomes have been reported following IOM reconstruction with a single-bundle suture button (Mini-Tightrope) construct, although recent work suggests that double-bundle Mini-TightRope® IOM reconstruction is biomechanically superior. The purpose of this study was to determine whether double-bundle Mini-TightRope® reconstruction of the forearm IOM results in superior clinical outcomes to the single-bundle technique. METHODS: Five patients with chronic Essex-Lopresti injuries treated with double-bundle Mini-TightRope® IOM reconstruction were matched to five patients treated with single-bundle Mini-TightRope® reconstruction. Improvement in clinical examination measures and patient-reported outcomes was compared between the groups. RESULTS: Results were good to excellent in all 10 patients. At final follow-up, forearm rotation was significantly better in the single-bundle group, while maintenance of ulnar variance was better in the double-bundle group. No significant differences were noted between the two groups for any other numerical outcomes, and no complications occurred. CONCLUSION: These findings suggest that while IOM reconstruction with a double-bundle Mini-TightRope® construct results in greater resistance to proximal migration of the radius in the intermediate term, there is a modest concomitant loss of forearm rotation when compared to single-bundle reconstruction. LEVEL OF EVIDENCE: Therapeutic Level IV.

Forearm Instability: Anatomy, Biomechanics, and Treatment Options.

The forearm unit consists of the radius and ulna, a complex and interrelated set of joints (distal radioulnar joint, proximal radioulnar joint) and the soft tissue stabilizers between the 3 bones. Distally, this is represented by the triangular fibrocartilage complex at the wrist, proximally by the annular ligament at the elbow, and in the forearm by the interosseous membrane. Disruptions in any of these structures may lead to forearm instability, with consequences at each of the remaining structures.

Formação de membrana fibrótica cicatricial em paciente submetido à ceratoplastia penetrante / Fibrotic scar membrane formation in patients undergoing penetrating keratoplasty

RESUMO O surgimento de uma membrana fibrótica opacificada na córnea transplantada é pouco descrito nas literaturas nacional e mundial. O objetivo é relatar o caso de um paciente com leucoma total de olho esquerdo que foi submetido à ceratoplastia penetrante levando a formação de dupla câmara anterior devido ao surgimento de uma membrana fibrótica cicatricial. Paciente do sexo masculino, 54 anos, com leucoma total secundário a ceratite herpética, diabético há 20 anos, em uso de insulina, com retinopatia diabética não proliferativa. Realizou-se cirurgia de membranectomia com complicações pós-operatória.

ABSTRACT The emergence of opaque fibrotic membrane in transplanted cornea is little described in national and world literature. The goal is to report the case of a patient with leucoma total of left eye that was submitted to the penetrating keratoplasty leading to formation of double anterior chamber due to the emergence of a fibrotic scar membrane. Male patient, 54 years, with total herpetic keratitis secondary leucoma, diabetic for 20 years, using insulin, with non-proliferative diabetic retinopathy. Held membranectomia surgery with postoperative complications.

Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability.

BACKGROUND: The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability. METHODS: We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded. RESULTS: Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall. CONCLUSION: IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.

Antegrade Peroneal Flap through the Interosseous Membrane for Knee and Distal Femur Coverage.

BACKGROUND: Antegrade peroneal flaps can be rotated around the fibula to cover defects in the lower leg and lateral knee. However, these flaps cannot reliably cover the distal femur and anterior and medial knee. In the present article, the authors describe a novel technical modification that involves creating a tunnel through the interosseous membrane, through which the flap can be passed, circumventing the need to rotate around the fibula, allowing it to reach the entire knee and distal femur. METHODS: An anatomical study was performed in five cadaveric specimens to measure the gain in pedicle reaching distance when the flap is tunneled compared to transferred around the fibula. A clinical study in 12 patients was also performed to measure the gain in pedicle reaching distance and the long-term viability of the tunneled interosseous flap. RESULTS: In the anatomical study, the mean reaching distance was 7.4 ± 0.9 cm for the flaps rotated around the fibula and 17.0 ± 1.6 for the tunneled interosseous flaps (p < 0.001). In the clinical study, the mean reaching distance was 2.6 ± 1.4 cm for the flaps rotated around the fibula and 11.4 ± 2.4 for the tunneled interosseous flaps (p < 0.0000000001). Patients were followed for up to 4 years (mean, 2.5 years). All flaps survived completely, and there were no complications. CONCLUSION: By passing the antegrade peroneal flap through the interosseous membrane, instead of around the fibula, the flap reaching distance can be increased by approximately 8 cm, allowing for effective coverage of distal femur and knee defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Effect of Limited Tenon Capsule and Intermuscular Membranes Dissection on the Outcome of Surgery in Patients with Horizontal Strabismus.

PURPOSE: The aim of the study was to evaluate the effect of limited dissection of Tenon capsule on the outcome of strabismus surgery. METHODS: Patients between the ages of 2 and 50 years with pure horizontal strabismus were enrolled in a prospective study. Patients were divided into two groups: case and control as a non-randomized study. The method of operation was similar in both groups except for the amount of sheath Tenon dissection. In the control group the intermuscular connections and Tenon capsule were cut as much as possible. In the study group, Tenon capsule, 3-4 mm posterior to the location of the sutures over the muscle (recessed or resected), were cut and intermuscular connections remained intact. RESULTS: The study enrolled 54 patients with 27 patients in each group. In both groups, after operation, regardless of the type of surgery, the angle of strabismus was reduced (P< 0.05). For patients who had undergone bimedial recession, the angle of strabismus was corrected to 2.6 ± 0.4 prism diopters per mm (PD/mm) of muscle recession in the case group, and 2.2 ± 0.9 in the control group (P=0.2). For patients who had undergone monocular recession and resection (R&R) for esotropia, the angle of strabismus was corrected 3.4 ± 0.3 PD/mm of muscle recession or resection in the case group, and 3.2 ± 0.2 in the control group (P=0.05). For patients who had undergone bilateral recession, the angle of strabismus was corrected 2.3 ± 0.2 PD/mm of muscle recession in the case group, and 2.2 ± 0.2 in the control group (P=0.03). For patients who had undergone R&R for exotropia, the angle of strabismus was corrected 3.1 ± 0.5 PD/mm of muscle recession or resection in the case group, and 2.7 ± 0.3 in the control group (P=0.02). CONCLUSION: Connective tissue ensheathments, whether disturbed or removed, do not ultimately affect the success of the strabismus surgery.

A prospective outcome study of membranous and solid distal common canalicular obstructions.

PURPOSE: To prospectively evaluate the surgical outcomes of membranous and solid distal common canalicular obstructions (CCOs) following endoscopic dacryocystorhinostomy (EnDCR) and lacrimal intubation combined with either membranotomy or trephination. METHODS: This was a prospective, non-randomized, consecutive interventional case series. Inclusion criteria included patients undergoing EnDCR with evidence of a membranous block or more solid obstruction of the distal common canaliculus, treated with membranotomy or canalicular trephination. Complete CCO was confirmed pre-operatively using dacryocystography and dacryoscintigraphy. All patients received bicanalicular intubation for 3 months with a minimum follow-up of 12 months. Functional and anatomical success was assessed at 4 weeks, 3 months, and 12 months following surgery. Functional success was defined as subjective improvement of epiphora and anatomical success as the presence of a patent ostium and a positive dye test on nasal endoscopy. RESULTS: Twenty-nine patients were included in the study with a mean age of 58 years. Twenty-one patients (72%) received a membranotomy and eight (28%) required trephination. At 12 months, the functional and anatomical success rate in the membranotomy group was 90% (19/21) and 100% (21/21), respectively, and in trephination group the functional and anatomical success rate was 63% (5/8). There were no intra-operative or lacrimal stent-related complications. CONCLUSIONS: Identifying and excising distal CCOs in association with EnDCR and lacrimal intubation is associated with a high degree of functional (83%) and anatomical (90%) success. The success of membranous obstructions appear be superior to outcomes for solid obstructions of the distal common canaliculus that require trephination.

Epilens membrane simulating cataract in children with uveitis: a report of three cases / Membrana epicristaliniana simulando catarata em crianças com uveíte: relato de três casos

ABSTRACTHere we present the cases of three female children, of whom two were aged 6 years and one was aged 11 years. Two of the three children had bilateral uveitis and suspected cataract and Vogt-Koyanagi-Harada (VKH) disease. The third one had uveitis and suspected cataract in one eye and sympathetic ophthalmia (SO), and had undergone penetrating keratoplasty in the fellow eye following a trauma. After controlling the inflammation, we planned to perform phacoemulsification without intraocular lens implantation. However, intraoperatively, after removing the epilens membranes, the lenses appeared clear, and therefore phacoemulsification was not performed. During follow-up, the patients did not develop cataract, and visual acuity levels ranged from 20/30 to 20/100. Fundoscopy revealed VKH disease and SO. Ophthalmologists should not always assume that patients with uveitis have cataract; a transparent lens may exist behind the epilens membrane, allowing a less aggressive therapeutic approach.

RESUMOApresentamos os casos de três meninas (duas de seis anos e uma de onze anos), com uveíte bilateral e suspeita de catarata em ambos os olhos e doença de Vogt-Koyanagi-Harada (VKH) em dois casos. No terceiro caso, oftalmia simpática e suspeita de catarata em um olho e trauma com ceratoplastia penetrante no outro olho. Após controle da inflamação, indicou-se facoemulsificação sem LIO. No per-operatório, após retirada da membrana epicristaliniana, a transparência do cristalino foi percebida, não sendo realizada a facoemulsificação. No período de acompanhamento as pacientes não desenvolveram catarata e a acuidade visual variou de 20/30 a 20/100. O exame de fundoscopia reforçou o diagnóstico de VKH e oftalmia simpática. Portanto, é muito importante que o oftalmologista esteja sempre atento quando se deparar com um caso de uveíte com suspeita de catarata, porque, por trás da membrana epicristaliniana pode existir um cristalino transparente, o que leva a uma conduta terapêutica menos agressiva.

Sequential argon-YAG laser membranotomy of extensive persistent pupillary membrane with visual loss.

A 20-year-old woman, a registered nurse, presented with best-corrected visual acuity of 6/15 (20/50) due to bilateral extensive persistent pupillary membrane. Sequential argon laser photocoagulation of the iris strands at the pupillary membrane iris collarette followed by neodymium:YAG laser lysis resulted in partial clearing of the central visual axis without bleeding. Best-corrected visual acuity improved to 6/9 (20/30) bilaterally without complications noted 1 year after combined laser therapy.

Waterjet cutting of periprosthetic interface tissue in loosened hip prostheses: an in vitro feasibility study.

Waterjet cutting technology is considered a promising technology to be used for minimally invasive removal of interface tissue surrounding aseptically loose hip prostheses. The goal of this study was to investigate the feasibility of waterjet cutting of interface tissue membrane. Waterjets with 0.2 mm and 0.6 mm diameter, a stand-off distance of 5 mm, and a traverse speed of 0.5 mm/s were used to cut interface tissue samples in half. The water flow through the nozzle was controlled by means of a valve. By changing the flow, the resulting waterjet pressure was regulated. Tissue sample thickness and the required waterjet pressures were measured. Mean thickness of the samples tested within the 0.2 mm nozzle group was 2.3 mm (SD 0.7 mm) and within the 0.6 mm nozzle group 2.6 mm (SD 0.9 mm). The required waterjet pressure to cut samples was between 10 and 12 MPa for the 0.2 mm nozzle and between 5 and 10 MPa for the 0.6 mm nozzle. Cutting bone or bone cement requires about 3 times higher waterjet pressure (30-50 MPa, depending on used nozzle diameter) and therefore we consider waterjet cutting as a safe technique to be used for minimally invasive interface tissue removal.

PERSISTENT PUPILLARY MEMBRANE OR ACCESSORY IRIS MEMBRANE?.

Frequently, in literature and curent practice, accessory iris membrane (AIM) and persistant pupillary membrane (PPM) are confused. Both AIM and PPM are congenital iris anomalies in which fine or thick iris strands arrise form the collarette and obscure the pupil. AIM, which is also called iris duplication, closely resembles the normal iris tissue in color and thickness and presents a virtual second pseudopupil aperture in the centre while PPM even in its extreme forms presents as a translucent or opaque membranous structure that extends across the pupil and has no pseudopupil. Mydriatiscs, laser treatment or surgery is used to clear the visual axis and optimize visual development. Surgical intervention is reserved for large, dense AIMs and PPMs. Our patient, a 29 year old male, has come with bilateral dense AIM, bilateral compound hyperopic astigmatism, BCVA OD = 0.6, BCVA OS = 0.4, IOP OU = 17 mmHg. To improve the visual acuity of the patient we decided to do a bilateral membranectomy, restoring in this way transparency of the visual axis. After surgery, the visual acuity improved to BCVA OD= 0.8, BCVA OS=0.8.

Risk factors in chronic subdural hematoma: comparison of irrigation with artificial cerebrospinal fluid and normal saline in a cohort analysis.

BACKGROUND: Chronic subdural hematoma (CSDH) is known to have a substantial recurrence rate. Artificial cerebrospinal fluid (ACF) is an effective irrigation solution in general open craniotomy and endoneurosurgery, but no evidence of its use in burr-hole surgery exists. OBJECTIVE: To identify the potential of ACF irrigation to prevent CSDH recurrence. More specifically, to investigate the perioperative and intraoperative prognostic factors, and to identify controllable ones. METHODS: To examine various prognostic factors, 120 consecutive patients with unilateral CSDH treated with burr-hole drainage between September 2007 and March 2013 were analyzed. Intraoperative irrigation was performed with one of two irrigation solutions: normal saline (NS; n = 60) or ACF (n = 60). All patients were followed-up for at least 6 months postoperatively. We also examined the morphological alternations of the hematoma outer membranes after incubation with different solutions. RESULTS: Eleven patients (9.2%) had recurrence. Nine patients (15%) required additional surgery in the NS group, whereas only 2 patients (3.3%) in the ACF group required additional surgery. Among preoperative and intraoperative data, age (<80 years old, P = .044), thrombocyte (>22.0, P = .037), laterality (right, P = .03), and irrigation solution (ACF, P = .027) were related to smaller recurrence rates by log-rank tests. Only the type of irrigation solution used significantly correlated with recurrence in favor of ACF in both Cox proportional hazards (relative hazard: 0.20, 95% confidence interval (CI): 0.04-0.99; P = .049) and logistic regression models (odds ratio, 0.17, 95% CI: 0.03-0.92; P = .04) using these factors. Histological examinations of the hematoma membranes showed that the membranes incubated with NS were loose and infiltrated by inflammatory cells compared with those incubated with ACF. CONCLUSION: Irrigation with ACF decreased the rate of CSDH recurrence.

Treating acute Essex-Lopresti injury with the TightRope device: a case study.

Essex-Lopresti injury consists of a fracture or dislocation of the radial head, rupture of the interosseous membrane (IOM), which is the main pathology, and a dislocated distal radio-ulnar joint. There are several reports in the literature, including cadaveric studies, which suggest an operative solution for this complicated injury. The torn IOM is not treated during the traditional operative repair. In the following paper, we suggest a treatment for the IOM by unloading it with the TightRope device. This device temporarily takes the tension off the torn IOM and assists in reduction and maintenance of the longitudinal ratios between the radius and the ulna, while allowing its healing. Recently, we have treated one patient with this system. The application of the TightRope technique in this acute injury and the follow-up are described in this case report.