Cost-effectiveness and cost-utility of the ball-and-socket trapeziometacarpal prosthesis compared to trapeziectomy and ligament reconstruction: study protocol for a randomized controlled clinical trial.

BACKGROUND: Trapeziometacarpal (TMC) osteoarthritis (OA) is a common cause of pain and weakness during thumb pinch leading to disability. There is no consensus about the best surgical treatment in unresponsive cases. The treatment is associated with costs and the recovery may take up to 1 year after surgery depending on the procedure. No randomized controlled trials have been conducted comparing ball and socket TMC prosthesis to trapeziectomy with ligament reconstruction. METHODS: A randomized, blinded, parallel-group superiority clinical trial comparing trapeziectomy with abductor pollicis longus (APL) arthroplasty and prosthetic replacement with Maïa® prosthesis. Patients, 18 years old and older, with a clinical diagnosis of unilateral or bilateral TMC OA who fulfill the trial's eligibility criteria will be invited to participate. The diagnosis will be made by experienced hand surgeons based on symptoms, clinical history, physical examination, and complementary imaging tests. A total of 106 patients who provide informed consent will be randomly assigned to treatment with APL arthroplasty and prosthetic replacement with Maïa® prosthesis. The participants will complete different questionnaires including EuroQuol 5D-5L (EQ-5D-5L), the Quick DASH, and the Patient Rated Wrist Evaluation (PRWE) at baseline, at 6 weeks, and 3, 6, 12, 24, 36, 48, and 60 months after surgical treatment. The participants will undergo physical examination, range of motion assessment, and strength measure every appointment. The trial's primary outcome variable is the change in the visual analog scale (VAS) from baseline to 12 months. A long-term follow-up analysis will be performed every year for 5 years to assess chronic changes and prosthesis survival rate. The costs will be calculated from the provider's and society perspective using direct and indirect medical costs. DISCUSSION: This is the first randomized study that investigates the effectiveness and cost-utility of trapeziectomy and ligament reconstruction arthroplasty and Maïa prosthesis. We expect the findings from this trial to lead to new insights into the surgical approach to TMC OA. TRIAL REGISTRATION: ClinicalTrials.gov NCT04562753. Registered on June 15, 2020.

MRI Assessment of Tendon Graft After Lateral Ankle Ligament Reconstruction: Does Ligamentization Exist?

BACKGROUND: No description exists in the literature about the normal evolution of tendon graft after a lateral ankle ligament (LAL) reconstruction. PURPOSE: To assess the magnetic resonance imaging (MRI) characteristics and the evolution of the tendon graft during different moments in the follow-up after an endoscopic reconstruction of the LAL. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This prospective study included 37 consecutive patients who underwent an endoscopic reconstruction of the LAL with an autograft using the gracilis tendon to treat chronic ankle instability (CAI) resistant to nonoperative treatment (CAI group) and 16 patients without ankle instability (control group). All patients in the CAI group underwent a postoperative assessment at 6, 12, and 24 months using the Karlsson score and MRI examination. Only patients with good and excellent results were included in the study. Graft assessment consisted of qualitative measurements and quantitative evaluations of the reconstructed anterior talofibular ligament (RATFL) and reconstructed calcaneofibular ligament (RCFL), including signal-to-noise quotient (SNQ) and contrast-to-noise quotient (CNQ) measurements in proton density-fat suppressed (PD-FS) and T1-weighted sequences. The analysis of variance test was used to compare the SNQ and the CNQ at different time points for each sequence. RESULTS: The MRI signal at 6 months was increased compared with that of the control group. Next, a significant signal decrease from 6 to 24 months was noted on PD-FS and T1-weighted images. SNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P = .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. Similarly, CNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P < .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. CONCLUSION: The present study demonstrated an evolution of the MRI characteristics, suggesting a process of graft maturation toward ligamentization. This is important for clinical practice, as it suggests an evolution in graft properties and supports the possibility of creating a viable ligament.

Intraoperative ultrasound assessment of ureteral patency after uterosacral ligaments apical suspension for prolapse surgical repair: A feasibility study.

OBJECTIVE: To prospectively compare power Doppler ultrasound diagnostic performance with reference standard cystoscopy in evaluating ureteral patency in a population at high risk of ureteral lesions. METHODS: We analyzed 100 women who underwent pelvic organ prolapse repair. All ultrasound scans were obtained, at the end of the procedures, before cystoscopic evaluation. Bilateral simultaneous ureteral jet evaluation with power Doppler was performed at the level of the ureterovesical junctions with a pulse repetition frequency set to detect low flow for a maximum of 3 min. RESULTS: According to the reference standard urethrocystoscopy, at least one ureter not ejaculating was observed in 6% of patients, for a total of seven ureters jets not visualized. No false-negative results were obtained. Ultrasound with power Doppler showed 100% sensitivity and 95.9% specificity in detecting the lack of ureteral jet. The negative predictive value was 100%, and the positive predictive value was 46.7%. CONCLUSIONS: Ultrasound with power Doppler represents an effective and reliable non-invasive screening test to exclude ureteral kinking and reduce the need for intraoperative cystoscopy.

Suspensory ligament size does not change after plantar fasciotomy and neurectomy of the deep branch of the lateral plantar nerve by ultrasonographic assessment.

OBJECTIVE: To determine the short-term effect of plantar fasciotomy and neurectomy (PFN) of the deep branch of the lateral plantar nerve on the proximal suspensory ligament (PSL) cross-sectional area (CSA) in horses with hindlimb proximal suspensory desmopathy (PSD). STUDY DESIGN: Analytical, observational, cohort study. SAMPLE POPULATION: Twenty-one horses. METHODS: Records of horses with chronic PSD treated by PFN were included if a preoperative ultrasonographic examination was available and at least one postoperative ultrasonographic examination. One masked observer measured the ultrasonographic cross-sectional area (CSA) of the PSL. Intraobserver reliability was determined by repeatedly measuring a subset of ultrasonographic images (n = 127). Two masked observers measured the cross-sectional area of the proximal suspensory ligament (PSL-CSA) on preoperative proton density (PD)-weighted transverse high field magnetic resonance images (n = 19 horses) . Agreements for PSL-CSA between preoperative ultrasonographic and MRI measures and between the two magnetic resonance imaging (MRI) observers were assessed. Follow up considered the horses' ability to return to exercise and their owners' satisfaction. RESULTS: The reliability of the ultrasonographic measurement of the PSL-CSA was excellent. Agreement between ultrasonographic assessment and MRI assessment of PSL-CSA was good. No difference was detected between preoperative (median, interquartile range; oblique-incidence, 2.07, 1.72-2.55; on-incidence, 2.23, 1.98-2.65) and postoperative (oblique-incidence, 2.08, 1.80-2.74; on-incidence, 2.28, 2.01-2.74) PSL-CSAs. At a median of 12 months (4-33 months), 16/20 (80%) owners reported the horse was "better" and 15/20 (75%) functioned at or above preoperative levels. CONCLUSION: Ultrasonographic measurement of the PSL-CSA was reproducible and in good agreement with MRI measurement. The PSL-CSA was not influenced by PFN. CLINICAL SIGNIFICANCE: The PSL-CSA cannot be used to guide return to function.

Cost Analysis and National Trends in the Treatment of Thumb Basal Arthritis: Comparing Ligament Reconstruction/Tendon Interposition and Trapeziectomy/Hematoma Distraction Arthroplasty.

BACKGROUND: Thumb basal arthritis (TBA) is a common form of arthritis characterized by wearing away of cartilage in the crarpometacarpal joint at the base of the thumb. The purpose of the study was to analyze cost trends of the 2 common surgical treatments options: ligament reconstruction/tendon interposition (LRTI) and trapeziectomy/hematoma distraction arthroplasty (THDA). METHODS: The Vizient Clinical Data/Resource Manager electronic database was reviewed for the 3 treatment procedures of TBA from January 1, 2016, to December 31, 2019. Cases were placed into 1 of 2 categories: LRTI or THDA. Total and direct costs were averaged and compared nationally and regionally. One-tailed t test and Pearson correlation analyses were performed (P < 0.05 and r > 0.9 or r < -0.9 was considered significant). RESULTS: A total of 28,887 total cases (26,405 LRTI, 2482 THDA) were analyzed. There was a 49% increase in number of surgical procedures to treat TBA between 2015 and 2018. Ligament reconstruction/tendon interposition (91%) had larger market share than THDA (9%). However, market share percentage of each procedure stayed the same over time. Trapeziectomy/hematoma distraction arthroplasty had lower average cost (US $4157) compared with that of LRTI (US $4446, P = 0.06) However, THDA had a significant positive trend in cost, increasing 14% in 4 years. In 2019, 30% of procedures performed were in the Midwestern United States, 27% Northeastern United States, 24% Southern United States, and 19% Western United States. CONCLUSIONS: Most patients with TBA seem to be treated with LRTI. The market share seems to be greatest for LRTI and lowest for THDA nationally and regionally. Although the average cost for THDA was less than that of LRTI, this difference was not significant.

Clinical outcomes and uroflowmetry assessment in patients with apical prolapse after laparoscopic uterosacral ligament suspension.

OBJECTIVE: The aim was to evaluate the voiding function and voiding dysfunction 3 months after laparoscopic uterosacral ligament suspension (LUSLS). We identified risk factors for postoperative voiding dysfunction. STUDY DESIGN: This retrospective study included 57 women with apical prolapse who underwent LUSLS with stage II or greater apical prolapse and without advanced anterior vaginal prolapse (stage III or IV). Data were collected from electronic medical records. Voiding function was assessed by uroflowmetry, PVR examination, and self-report questionnaires (the Pelvic Floor Distress Inventory-20 and the Urinary Impact Questionnaire) at baseline and 3 months after surgery. Voiding dysfunction was defined as an average flow rate (Qave)＜10 ml/s, a maximum flow rate (Qmax)＜15 ml/s, or a postvoid residual volume (PVR)＞50 ml. Statistical analyses were performed using paired-sample t tests, χ2 tests, and multivariate logistic regression. RESULTS: Thirty-five percent of women suffered from voiding dysfunction preoperatively. Uroflowmetry parameters and PVR, objective symptoms including voiding difficulties, incomplete empty, frequency and urinary incontinence didn't show significant improvement postoperatively (all p＞0.05). Low Qave was identified as an independent risk factor of post voiding dysfunction (odds ratio, 0.558; 95 % CI, 0.324-0.963). CONCLUSIONS: Approximately one-third of women suffering from apical prolapse without advanced anterior vaginal wall had evidence of voiding dysfunction preoperatively. LUSLS has no obvious effect on uroflowmetry parameters and clinical symptoms.

Simple assessment of the localization of posterior communicating artery aneurysms to the anterior petroclinoid ligament.

The microsurgical management of posterior communicating artery (PCoA) aneurysms can be modified depending on their localization, with respect to the tentorial edge consisting of the anterior petroclinoid ligament (APCL). However, the imaging of APCL has been impractical to date. In this study, we evaluated a simple method for assessing the relationship between PCoA aneurysms and APCL, using three-dimensional computed tomographic angiography (3D-CTA). We retrospectively reviewed all surgically treated cases of PCoA aneurysms via the pterional approach in our institute from May 2013 to August 2018. To predict the localization of the aneurysms, three anatomical lines were drawn on non-subtracted volumetric 3D-CTA as follows: 1. the apex of the anterior clinoid process to the posterior border of the trigeminal depression of the petrosal bone (AACP-PBTD); 2. AACP to the superior edge of the arcuate eminence (AACP-SEAE); 3. the base of the ACP to the superior edge of the arcuate eminence (BACP-SEAE). The relative location of each line to the PCoA aneurysms was compared with actual intraoperative findings. Fifty-six aneurysms were included. The sensitivity, specificity, and positive and negative predictive values of the superior localization of the aneurysm of the AACP-TDPB line were 93.8%, 40.0%, 38.5%, and 94.1%, respectively. Those of the AACP-SEAE line were 93.8%, 42.5%, 39.5, and 94.4%, respectively. In contrast, those of the BACP-SEAE line were 93.8%, 97.5%, 93.8%, and 97.5%, respectively. The BACP-SEAE line is a simple and practical landmark in predicting APCL.

Management of Diabetic Trigger Finger.

Diabetics have a much greater prevalence of trigger finger than nondiabetics and are more likely to have severe symptoms. Diabetic trigger finger may be more accurately described on a spectrum of diabetic hand pathology alongside carpal tunnel syndrome and cheiroarthropathy. Recent publications have called into question the current treatment algorithm for diabetic trigger finger. Although some evidence supports the use of corticosteroid injections, a recent cost analysis reported that immediate surgical release of the A1 pulley in the clinic is the most cost-effective management of diabetic trigger finger. In addition to traditional treatment with injection and open release, percutaneous release with or without simultaneous corticosteroid injection has shown promising results and may have a role in patient care. The appropriate treatment algorithm in terms of efficacy, safety, and cost remains controversial.

The unreimbursed costs of preventing revision surgery in adult spinal deformity: analysis of cost-effectiveness of proximal junctional failure prevention with ligament augmentation.

OBJECTIVE Proximal junctional kyphosis (PJK) is a well-recognized complication of surgery for adult spinal deformity and is characterized by increased kyphosis at the upper instrumented vertebra (UIV). PJK prevention strategies have the potential to decrease morbidity and cost by reducing rates of proximal junctional failure (PJF), which the authors define as radiographic PJK plus clinical sequelae requiring revision surgery. METHODS The authors performed an analysis of 195 consecutive patients with adult spinal deformity. Age, sex, levels fused, upper instrumented vertebra (UIV), use of 3-column osteotomy, pelvic fixation, and mean time to follow-up were collected. The authors also reviewed operative reports to assess for the use of surgical adjuncts targeted toward PJK prevention, including ligament augmentation, hook fixation, and vertebroplasty. The cost of surgery, including direct and total costs, was also assessed at index surgery and revision surgery. Only revision surgery for PJF was included. RESULTS The mean age of the cohort was 64 years (range 25-84 years); 135 (69%) patients were female. The mean number of levels fused was 10 (range 2-18) with the UIV as follows: 2 cervical (1%), 73 upper thoracic (37%), 108 lower thoracic (55%), and 12 lumbar (6%). Ligament augmentation was used in 99 cases (51%), hook fixation in 60 cases (31%), and vertebroplasty in 71 cases (36%). PJF occurred in 18 cases (9%). Univariate analysis found that ligament augmentation and hook fixation were associated with decreased rates of PJF. However, in a multivariate model that also incorporated age, sex, and UIV, only ligament augmentation maintained a significant association with PJF reduction (OR 0.196, 95% CI 0.050-0.774; p = 0.020). Patients with ligament augmentation, compared with those without, had a higher cost of index surgery, but ligament augmentation was overall cost effective and produced significant cost savings. In sensitivity analyses in which we independently varied the reduction in PJF, cost of ligament augmentation, and cost of reoperation by ± 50%, ligament augmentation remained a cost-effective strategy for PJF prevention. CONCLUSIONS Prevention strategies for PJK/PJF are limited, and their cost-effectiveness has yet to be established. The authors present the results of 195 patients with adult spinal deformity and show that ligament augmentation is associated with significant reductions in PJF in both univariate and multivariate analyses, and that this intervention is cost-effective. Future studies will need to determine if these clinical results are reproducible, but for high-risk cases, these data suggest an important role of ligament augmentation for PJF prevention and cost savings.

Evaluation of Sacrospinous Hysteropexy vs. Uterosacral Suspension for the Treatment of Uterine Prolapse: A Retrospective Assessment.

OBJECTIVE: This single-center retrospective study aimed to compare the outcomes of vaginal hysterectomy with utero-sacral suspension (VH/USS) versus sacro-spinous hysteropexy (SSHP) in the management of uterine prolapse at a tertiary care center specializing in Urogynecology. METHODS: The medical records of 50 women with stage 2 or more uterine prolapse treated with VH/USS (n = 26) or SSHP (n = 24) were assessed between January 2006 and December 2012. RESULTS: There were no significant differences between the two groups in terms of body mass index (BMI) and parity P = 0.881 and 0.304, respectively. VH/USS procedure was significantly more successful than SSHP procedure with regard to anatomical success (84.62 vs. 41.67%, P = 0.0028). There was a significantly higher anterior prolapse recurrence with SSHP procedure than with VH/USS (33.3 vs. 7.7%; P = 0.034). SSHP was associated with the lower likelihood of anatomical success and a higher risk of recurrent anterior prolapse in multivariate logistic regression analyzes adjusting for potential confounders. CONCLUSION: The findings of this retrospective study indicate that SSHP appears to be associated with less anatomical objective success and an increased risk of recurrent anterior prolapse in comparison to VH/USS. Further validation of our observations by independent investigators is required.

Abdominal sacral colpopexy versus sacrospinous ligament fixation: a cost-effectiveness analysis.

INTRODUCTION AND HYPOTHESIS: For the surgical correction of apical prolapse the abdominal approach is associated with better outcomes; however, it is more expensive than the transvaginal approach. This cost-effectiveness analysis compares abdominal sacral colpopexy (ASC) with sacrospinous ligament fixation (SSLF) to determine if the improved outcomes of ASC justify the increased expense. METHODS: A decision-analytic model was created comparing ASC with SSLF using data-modeling software, TreeAge Pro (2013), which included the following outcomes: post-operative stress urinary incontinence (SUI) with possible mid-urethral sling (MUS) placement, prolapse recurrence with possible re-operation, and post-operative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) of less than $50,000 per quality-associated life year (QALY). Base-case, threshold, and one-way sensitivity analyses were performed. RESULTS: At the baseline, ASC is more expensive than SSLF ($13,988 vs $11,950), but is more effective (QALY 1.53 vs 1.45) and is cost-effective (ICER $24,574/QALY) at 2 years. ASC was not cost-effective if the following four thresholds were met: the rate of post-operative SUI was above 36 % after ASC or below 28 % after SSLF; the rate of MUS placement for post-operative SUI was above 60 % after ASC or below 13 % after SSLF; the rate of recurrent prolapse was above 15 % after ASC or below 4 % after SSLF; the rate of post-operative dyspareunia was above 59 % after ASC or below 19 % after SSLF. CONCLUSIONS: Abdominal sacral colpopexy can be cost-effective compared with sacrospinous ligament fixation; however, as the post-operative outcomes of SSLF improve, SSLF can be considered a cost-effective alternative.

[Correlation of subjective and objective assessment of vaginal prolapse surgery - secondary analysis of randomized controlled study in patients with pelvic floor injury treated with vaginal mesh or with sacrospinous ligament fixation]. / Korelace subjektivního a objektivního hodnocení operace vaginálního prolapsu- sekundární analýza výsledku randomizované kontrolované studie pacientek s defektem pánevního dna a operovaných vaginální sítkou nebo závesem na sakrospinózní ligamentum.

OBJECTIVE: We had provided secondary analysis of our randomized controlled study comparing vaginal mesh with sacrospinous fixation for vaginal prolapse. We correlated data from subjective and objective assessment. Secondly we had provided correlations results of subjective and objective assessment between patient with anatomical failure and those without. The aim of this analysis was to provide correlation between objective and subjective outcome measures. DESIGN: Subanalysis of randomized controlled study. SETTING: Obstetric Gynecology Department, First Faculty of Medicine of Charles University and General University Hospital in Prague. METHODS: This is secondary analysis of single center randomized controlled study comparing two standard procedures for vaginal prolapse after hysterectomy in patients with levator avulsion injury. We had analyzed pre- and postoperative subjective POPDI score (Pelvic Organ Prolapse Distress Inventory) and correlated this score with most prolapsed portion of vaginal wall. We had compared all vaginal compartments using POPQ (Pelvic Organ Prolapse Quantification): anterior wall with point Ba, apical with point C, and posterior with point Bp. Subsequently we compared subjective POPDI score in group of patients with anatomical failure and those without. RESULTS: We had included in randomized study 70 women. Mean preoperative POPDI score was 65.25 (3.57-200). We didnt found any correlation between subjective score and objective assessment in preoperative data: POPDI vs. Ba (p = 0.75) POPDI vs. C (p = 0.57) a POPDI vs. Bp (p = 0.22) and no correlation in postoperative assessment. Postoperative POPDI score decreased to 26.1, but there was no difference in POPDI score in woman with anatomical failure and no failure - 17.4 vs. 23.3 (p = 0.64)CONCLUSION: Secondary analysis of randomized controlled study had shown that objective and subjective assessment have poor correlation. We didnt found any correlation between degree of prolapse and intensity of complains. The large inter-individual variability in symptoms and low sensitivity of subjective assessment to detect difference makes subjective assessment as an inappropriate tool as a primary outcome measure of pelvic floor surgery.

Ultrasound assessment of injury to the posterior ligamentous complex in patients with mild thoracolumbar fractures.

OBJECTIVE: To assess the value of ultrasonographic imaging of the posterior ligamentous complex (PLC) to diagnose ligamentous injuries, in patients with mild thoracolumbar fractures. METHODS: Patients with thoracolumbar fractures were included in this prospective study. Patients underwent palpation of the midline of the back, and ultrasonography was performed over the entire thoracolumbar region by an experienced sonographer. A team that included a musculoskeletal radiologist, an orthopaedic surgeon and a sonographer assessed the ultrasound results. Ultrasonographic and magnetic resonance imaging (MRI) findings were jointly evaluated in a subgroup of patients who were able to fund MRI analysis. Conflicts regarding the results were resolved by a majority vote. RESULTS: A total of 21 patients participated in the study, all of whom exhibited abnormal ultrasonographic echogenicity on the supraspinous or interspinous ligaments. Three patients were diagnosed with a rupture of the supraspinous ligament. In 15/17 (88.2%) patients, interspinous ligament injuries were detected caudally to the injured vertebrae. CONCLUSIONS: Ultrasound examination is a reliable complementary diagnostic tool to identify PLC injuries in patients with mild thoracolumbar fractures.

Transischioanal trans-sacrospinous ligament rectocele repair with polypropylene mesh: a prospective study with assessment of rectoanal function.

INTRODUCTION AND HYPOTHESIS: Despite good anatomical outcomes of pelvic organ prolapse (POP) repair by the vaginal route using synthetic mesh, complications limit their use. Clinical data are needed to generalize prolapse mesh repair by the vaginal route. The current study aims to evaluate midterm rectoanal function and clinical outcomes after transischioanal rectocele repair using a medium weight polypropylene mesh. METHODS: Between March 2003 and June 2004, 230 patients with stage II-IV anterior and/or posterior POP were included in a prospective multicenter study. The current study is based on the analysis of the 116 patients who underwent a rectocele repair via the infracoccygeal route through the sacrospinous ligament. Anatomical cure was defined when rectocele was at stage

Assessment of canine ovaries autografted to various body sites.

The influence of graft site on the survival of canine follicles and oocytes after autografting was investigated. Hemi-ovaries were autografted to three locations (quadriceps femoris muscle fascia, kidney capsule, and gastrosplenic ligament), and grafted ovaries were recovered (under anesthesia) 28 to 31 d after transplantation. The grafted hemi-ovaries were bisected: one-quarter ovary was used for histological assessment and another quarter for evaluation of oocyte viability. As controls, the remaining fresh hemi-ovaries were used to assess the viability of follicles and oocytes in non-transplanted ovaries. Most follicles in the histological sections of the grafts were classified as primordial or primary follicles. Antral follicles were not observed in the grafts, irrespective of the graft site. The percentages of viable follicles in the sections from control ovaries, and the ovaries grafted to the kidney capsule, the quadriceps femoris muscle fascia, and the gastrosplenic ligament were 17.4, 22.9, 18.3, and 32.4%, respectively. A total of 12 oocytes was recovered from the 15 hemi-ovaries grafted in five bitches, of which five (41.7%) oocytes from the ovaries grafted to the quadriceps femoris muscle fascia and the kidney capsule were cultured for assessment of meiotic competence. Three oocytes were viable but remained in the germinal vesicle stage after 72 h of maturation culture. The quadriceps femoris muscle fascia might be useful for grafting like the kidney capsule, but improvement of follicle survival and meiotic competence of oocytes in the grafts is necessary.

[Comparison outcomes of three surgical procedures in treatment of severe pelvic organ prolapse and analysis of risk factors for genital prolapse recurrence].

OBJECTIVE: To investigate clinical significance and application of modified pelvic floor reconstruction developed by Peking Union Medical College Hospital (MPFR) in treatment of severe pelvic organ prolapse (POP) by comparing the effectiveness, quality of postoperative sexual life, life satisfaction and risk factors for POP recurrence with the following two surgical procedures: traditional total vaginal hysterectomy with anterior-posterior colporrhaphy (TVH-APC) and total vaginal hysterectomy with lateral colporrhaphy and sacrospinous ligament fixation and vaginal bridge repair and episiotomy (TVH-LC-SSLF-VBR-EP). METHODS: Totally 173 patients with severe POP and at least two compartments defects of pelvic floor underwent surgeries in the study, 86 patients (group A) were treated by MPFR with polypropylene mesh application, 58 (group B) were treated by TVH-APC, and 29 patients (group C) were treated by TVH-LC-SSLF-VBR-EP. Peri-operative data and outcomes of postoperative courses at 6, 12, 18 months were collected and analyzed, in the meantime, the risk factors of recurrence were studied. RESULTS: (1) No statistical difference was observed among the above 3 groups in terms of length of operation, amount of blood loss, length of hospital stay, and morbidity after surgery (P > 0.05). (2) Cost hospitalization was (11 448 ± 3049) Yuan in group A, which was significantly higher than (7262 ± 1607) Yuan in group B and (7140 ± 1817) Yuan in group C (P < 0.05). (3) The length of vaginal cuff of (7.5 ± 1.4) cm in group A and (5.6 ± 1.1) cm in group C were significantly longer than (7.1 ± 0.6) cm in group B (P < 0.05). The width of vaginal cuff of (4.3 ± 0.3) cm in group A was larger than (3.4 ± 0.3) cm in group B and (3.3 ± 0.4) cm in group C (P < 0.05). (4) The recurrence rate at 12 months after surgery was 12.8% (11/86) in group A, which was similar with 17.2% (5/29) in group C (P > 0.05) and significantly less than 36.2% (21/58) in group B (P < 0.05). The rate of active sexual life of 16.3% (14/86) in group A was significantly higher than 1.7% (1/58) in group B and 0 in group C (P < 0.05). The index of life quality improvement at 12 months after surgery was 48 ± 12 in group A, which was no less than 53 ± 16 in group C (P > 0.05) and higher than 27 ± 9 in group B (P < 0.05). (5) Mesh rejection was observed in 6 patients in group A within 3 months after surgery, while the posterior vaginal wall was exclusively involved. No difference was found in urinary retention or urinary incontinence among three groups (P > 0.05). (6) The severe degree of POP, type of surgical procedure (TVT-APC), anterior compartment defect of pelvic floor, and early days of performing pelvic floor reconstruction surgeries were high risk factors for POP recurrence (P < 0.05). CONCLUSIONS: MPFR has a better curative effect and lower recurrence rate on patients with POP. It can help patients regain integrity of anatomical structure and functions of pelvic floor. TVH-LC-SSLF-VBR-EP is also effective.

Assessment of the posterior ligamentous complex following acute cervical spine trauma.

BACKGROUND: Magnetic resonance imaging is commonly used to assess the integrity of the posterior ligamentous complex following cervical trauma, but its accuracy and reliability have not been documented, to our knowledge. The purpose of this study was to determine the diagnostic accuracy of magnetic resonance imaging in detecting injury to specific components of the posterior ligamentous complex of the cervical spine. METHODS: Patients with an acute cervical spine injury that required posterior surgical treatment were prospectively studied. The six components of the posterior ligamentous complex were characterized as intact, incompletely disrupted, or disrupted on preoperative magnetic resonance imaging studies by a radiologist and intraoperatively by two surgeons. Correlation between the magnetic resonance imaging and intraoperative findings was determined. The percent agreement, sensitivity, specificity, negative predictive value, and positive predictive value of magnetic resonance imaging as a tool for characterizing the integrity of the posterior ligamentous complex were calculated. RESULTS: Forty-seven consecutive patients with a total of seventy levels of injury were studied. Overall, there was moderate agreement between the magnetic resonance imaging and intraoperative findings for the supraspinous and interspinous ligaments (kappa scores of 0.46 and 0.43, respectively) and fair agreement between those for the ligamentum flavum, left and right facet capsules, and cervical fascia (kappa scores of 0.32, 0.31, 0.26, and 0.39, respectively). The sensitivity of the magnetic resonance imaging was greatest for the cervical fascia (100%) and the lowest for the facet capsules (80%). Specificity ranged from 56% (for the facet capsules) to 67% (for the interspinous ligament). The positive predictive value ranged from 42% (for the cervical fascia) to 82% (for the interspinous ligament). CONCLUSIONS: Magnetic resonance imaging is sensitive for the evaluation of injury to the posterior ligamentous complex in the setting of acute cervical trauma. However, it has a lower positive predictive value and specificity, suggesting that injury to the posterior ligamentous complex may be "over-read" on magnetic resonance images. If magnetic resonance imaging is used in isolation to guide treatment, the high rate of false-positive findings may lead to unnecessary surgery. Other factors, including the morphology of the injury and the neurological status, should be considered as well when devising a treatment plan.

[Assessment of the urinary side effects after surgery for deep pelvic endometriosis]. / Evaluation des troubles urinaires après chirurgie de l'endométriose profonde.

OBJECTIVE: To evaluate the urinary side effects after laparoscopic surgery for deep endometriosis. PATIENTS AND METHOD: Longitudinal study including 86 patients operated for deep pelvic endometriosis : 58 (68%) with colorectal endometriosis, 21 (24%) with utero-sacral ligament endometriosis and 7 (8%) with recto-vaginal septum endometriosis. Assessment of the urinary side effects was permormed using the Bristole Female Lower Urinary Tract Symptom questionnaire. RESULTS: On postsurgical follow-up, almost all patients described: hesistancy (p = 0.02), strain to start (p = 0.04), stopping flow (p = 0.01), incomplete emptying (p = 0.008) and reduce stream (p=0.02). Only patients who had resection of both utero-sacral ligaments had significative postsurgical urinary dysfunction with stopping flow (p = 0.02) and incomplete emptying (p = 0.004). Patients with colorectal resection had also significative postsurgical urinary dysfunction with hesitancy (p = 0.02), strain to start (p = 0.03), stopping flow (p = 0.007) and incomplete emptying (p = 0.004). In patients with rectal resection, urinary dysfunctions are raised when rectal resection is associated to resection of both utero-sacral ligaments. CONCLUSION: Postoperatively, urinary side effects occurred only in patients with segmental colorectal endometriosis resection associated with bilateral utero-sacral ligament resection. Sparing nerve surgery of the pelvic nerves, can reduce these urinary side effects.

Stress radiography in the assessment of residual deformity in clubfoot following postero-medial soft tissue release.

X-ray is important in the assessment of clubfoot. Stress radiographs give more information than routine radiographs. Because of the inaccuracy of the positioning and the disadvantages of radiation, paediatric orthopaedic surgeons do not like and do not use X-ray examination. In this study we report a technique we use to obtain stress radiographs in paediatric patients with clubfoot using a custom-made radiolucent modular splint. This technique provides better assessment of the initial status and the result of treatment. Although this method has limitations it can help to compare different feet and treatment results with regard to axis and angle. We validated this splint by means of a prospective study in 11 patients with 21 feet having type 2 clubfoot who underwent (PMSTR) in our centre. Two sets of radiographs were taken, one with manual positioning and one with our splint. We found significant differences in the values of midfoot and forefoot radiological parameters between the two sets. We found that the correlation between the clinical and radiological assessment of residual deformity improved significantly for these values when a splint was used to obtain stress views. Hence we recommend routine use of a radiolucent splint for taking stress views to assess residual deformity in clubfoot.

Laparoscopic uterine nerve ablation versus vaginal uterosacral ligament resection in postmenopausal women with intractable midline chronic pelvic pain: a randomized study.

OBJECTIVE: To assess and compare the laparoscopic uterine nerve ablation (LUNA) and the vaginal uterosacral ligament resection (VUSR) in postmenopausal women with chronic pelvic pain (CPP). STUDY DESIGN: Eighty postmenopausal women with intractable and severe midline CPP were randomized to undergo LUNA or VUSR. Costs of two surgical procedures were assesses. Cure rate, severity of CPP, and deep dyspareunia were also evaluated after 6 and 12 months from surgery. RESULTS: The mean cost of LUNA resulted significantly higher in comparison with VURS (2078+/-637 versus 1497+/-297, P<0.001). The cure rate was not significantly different between the two groups at 6 (33/40, 82.5% versus 35/40, 87.5% for groups A and B, respectively; P=0.530; RR 0.94, 95% CI 0.78-1.13), and 12 months (27/36, 75.0% versus 28/38, 73.7%, for groups A and B, respectively; P=0.901; RR 0.90, 95% CI 0.78-1.33) of follow-up. At same times, a significant (P<0.01) decrease in severity of CPP and deep dyspareunia was observed in both groups with no difference between them. CONCLUSIONS: Both LUNA and VUSR are equally effective surgical treatments in postmenopausal women with central CPP but VUNR is significantly cheaper than LUNA.