Prevention of knee stiffness following ligament reconstruction: Understanding the role of Arthrogenic Muscle Inhibition (AMI).

The knee is a joint that is often injured in sport, with a large and increasing number of ligament tears and repairs; postoperative complications can lead to poor outcome, such as stiffness. Beyond the well-known and well-described intra- and extra-articular causes of postoperative stiffness, the present study introduces the concept of a central reflex motor inhibition mechanism called arthrogenic muscle inhibition (AMI). AMI occurs after trauma and can be defined as active knee extension deficit due to central impairment of Vastus Medialis Obliquus (VMO) contraction, often associated with spinal reflex hamstring contracture. This explains the post-traumatic flexion contracture that is so common after knee sprain. The clinical presentation of AMI is easy to detect in consultation, in 4 grades from simple VMO inhibition to fixed flexion contracture by posterior capsule retraction in chronic cases. After recent anterior cruciate ligament (ACL) tear, more than 55% of patients show AMI, reducible in 80% of cases by simple targeted exercises initiated in consultation. Practically, in patients who have sustained knee sprain, it is essential to screen for this reflex mechanism and assess reducibility, as AMI greatly aggravates the risk of postoperative stiffness. In case of hemarthrosis, we recommend joint aspiration, which provides immediate benefit in terms of pain and motor inhibition. In case of persistent AMI, classical electrostimulation and "cushion crush", as used by all physiotherapists, are ineffective. To reduce the risk of postoperative stiffness, no surgery should be considered until AMI has resolved. LEVEL OF EVIDENCE: expert opinion.

Postoperative pain and the need for intervention after sacrospinous ligament hysteropexy compared to colpopexy: a retrospective cohort study.

OBJECTIVES: To compare postoperative pain between patients undergoing sacrospinous ligament colpopexy (SSLF) and hysteropexy (SSLH). METHODS: This was a retrospective cohort study of all patients undergoing native tissue SSLF and SSLH between January 2013 and March 2020. The electronic medical record was queried for demographic and perioperative data until the postoperative visit. The primary outcome was a composite incidence of any of the following: telephone calls, urgent office visits, additional analgesic prescriptions and need for intervention for pain in the buttocks, posterior thigh or perirectal area. Secondary outcomes were the incidence of persistent pain at the postoperative visit and perioperative risk factors associated with reported pain. RESULTS: A total of 406 patients met inclusion criteria (308 SSLF, 98 SSLH). The composite pain outcome was seen in 99 patients (24.4%; 95% CI 20.5%-28.8%), and there was no statistical difference between cohorts. Persistent pain was seen in 15.6% and 13.3% of SSLF and SSLH patients at 6 weeks (p = 0.58). Twelve patients (3.0%) underwent interventions for pain, including physical therapy (2), trigger point injections (5) and suture release (5). Compared to SSLF patients, SSLH patients were more likely to need interventions (7 [7.1%] vs. 5 [1.6%], p = 0.005) and office visits (14 [14.3%] vs. 13 [4.2%], p = 0.0005) for pain. CONCLUSIONS: There was no difference in the overall incidence of postoperative pain between patients who underwent SSLF or SSLH. However, patients who underwent hysteropexy were more likely to need intervention and office evaluation for postoperative pain.

Traditional McCall culdoplasty compared to a modified McCall technique with double ligament suspension: anatomical and clinical outcomes.

INTRODUCTION AND HYPOTHESIS: This study compared anatomical and clinical outcomes of traditional McCall culdoplasty versus a modified McCall technique with double ligament suspension (DLS). METHODS: This retrospective study presents outcomes of 68 patients who underwent vaginal hysterectomy and vaginal suspension for apical prolapse ≥ stage II according to the POP-Q score system, at, between January 2016 and February 2018. In 34 women vaginal cuff suspension was obtained with traditional McCall culdoplasty (McCall group), while in 34 women we performed a modified McCall, which consists of a double ligament suspension (DLS group), suspending the vaginal cuff to uterosacral ligaments and also to adnexal peduncles. Primary outcome was prolapse recurrence ≥ stage II according to the POP-Q system. Fisher's, Mann-Whitney U and Student's t tests were used for statistical analysis. RESULTS: There were no statistical differences among patients' preoperative characteristics, operative time, blood loss or postoperative complications. Follow-up mean duration was 23.2 ± 6.7 and 22.4 ± 8.7 months in the McCall and DLS group, respectively. Prolapse recurrence occurred in 11 (32.3%) women in the McCall group versus 2 (5.9%) women in the DLS group (p < 0.05): among them, 2 patients (5.9%) in the McCall group and 1 (2.9%) in the DLS group required further treatment. Total vaginal length was 6.1 ± 0.9 cm in the McCall group versus 6.9 ± 0.7 cm in the DLS group (p < 0.001). No statistical difference in quality of life assessment was observed. CONCLUSIONS: DLS group patients had better anatomical outcomes and lower recurrence rates than McCall group patients, without increasing operative time or complications. A prospective study with more cases is needed to confirm our data.

Slit-lamp Pars Plana Needle Hyaloidotomy-Zonulotomy-Iridotomy for the Treatment of Spontaneous Malignant Glaucoma.

An 88-year-old woman with a history of recent complicated pacemaker insertion presented with acute-onset malignant glaucoma recalcitrant to conservative medical therapy. Surgical intervention was discussed; however, given her complex cardiac history and recent postoperative state, the risk of anesthesia-related systemic adverse events was deemed unacceptably high. As such, a slit-lamp procedure was recommended to break the attack of malignant glaucoma. Here within, we report a novel technique of breaking an attack of malignant glaucoma by needling the anterior hyaloid face at the slit lamp. With this technique, a 25-G needle was entered through the pars plana and was advanced through the anterior hyaloid face, zonules, and peripheral iridotomy to create a unicameral eye and successfully break the malignant closure attack.

Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial.

OBJECTIVE: To evaluate the effectiveness and success of uterus preserving sacrospinous hysteropexy as an alternative to vaginal hysterectomy with uterosacral ligament suspension in the surgical treatment of uterine prolapse five years after surgery. DESIGN: Observational follow-up of SAVE U (sacrospinous fixation versus vaginal hysterectomy in treatment of uterine prolapse ≥2) randomised controlled trial. SETTING: Four non-university teaching hospitals, the Netherlands. PARTICIPANTS: 204 of 208 healthy women in the initial trial (2009-12) with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery who had been randomised to sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. The women were followed annually for five years after surgery. This extended trial reports the results at five years. MAIN OUTCOME MEASURES: Prespecified primary outcome evaluated at five year follow-up was recurrent prolapse of the uterus or vaginal vault (apical compartment) stage 2 or higher evaluated by pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse. Secondary outcomes were overall anatomical failure (recurrent prolapse stage 2 or higher in apical, anterior, or posterior compartment), composite outcome of success (defined as no prolapse beyond the hymen, no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse), functional outcome, quality of life, repeat surgery, and sexual functioning. RESULTS: At five years, surgical failure of the apical compartment with bothersome bulge symptoms or repeat surgery occurred in one woman (1%) after sacrospinous hysteropexy compared with eight women (7.8%) after vaginal hysterectomy with uterosacral ligament suspension (difference-6.7%, 95% confidence interval -12.8% to-0.7%). A statistically significant difference was found in composite outcome of success between sacrospinous hysteropexy and vaginal hysterectomy (89/102 (87%) v 77/102 (76%). The other secondary outcomes did not differ. Time-to-event analysis at five years showed no differences between the interventions. CONCLUSIONS: At five year follow-up significantly less anatomical recurrences of the apical compartment with bothersome bulge symptoms or repeat surgery were found after sacrospinous hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension. After hysteropexy a higher proportion of women had a composite outcome of success. Time-to-event analysis showed no differences in outcomes between the procedures. TRIAL REGISTRATION: trialregister.nl NTR1866.

Transvaginal high uterosacral ligament suspension: An alternative to McCall culdoplasty in the treatment of pelvic organ prolapse.

OBJECTIVES: Defects in female pelvic organ support are highly prevalent. Uterosacral ligament suspension at the time of primary prolapse repair (McCall culdoplasty) is a well-established surgical option to prevent prolapse recurrences. Recently Shull's high uterosacral ligament suspension technique has gained increasing popularity among Uro-Gynaecologists. A study carried out in 2017 by Spelzini et al. compared these two techniques, showing proper safety and efficacy in the treatment of prolapse, with no statistically significant differences as to operative time, complication rate, anatomical, functional and subjective outcomes [1]. Our study aims at comparing the effectiveness, complication rate, recurrence rate, quality of life and functional result of the two techniques. STUDY DESIGN: This is a retrospective study carried out on 224 patients who underwent vaginal cuff suspension for pelvic organ prolapse. Cases were extracted from hospital medical records of all women managed with surgical prolapse repair at our Gynaecology and Obstetrics department between January 2013 and February 2017. Shull suspension (group A) or McCall culdoplasty (group B) were performed according to surgeon's familiarity with the two suspension techniques. RESULTS: A total of 224 patients (69 in group A and 155 in group B) underwent surgical cuff suspension. Median operating time was 88 min for both techniques and ureteral injuries were very rare in both group A and B (1 and 0 respectively). In the evaluation of postoperative questionnaires, no statistically significant differences were found, except for "Urinary Impact Questionnaire" (UIQ), which showed significantly less urinary subjective symptoms in group A. Median follow up was 13 months in group A and 15 months in group B. Post-operative Pop-Q items analysis revealed only a higher Aa point in group A at 12 months follow up visit. Objective vaginal cuff recurrence was observed in 1 patient (1,4%) in group A and 4 patients in group B (2,6%) with no statistically significant difference between the two groups. CONCLUSIONS: Both uterosacral ligament suspension procedures are safe and highly effective. There were no statistically significant differences concerning surgical data, complication rates, and the majority of anatomical, functional and subjective outcomes between Shull suspension and McCall culdoplasty.

A randomized double-blind placebo-controlled trial on the effect of local analgesia on postoperative gluteal pain in patients undergoing sacrospinous ligament colpopexy.

BACKGROUND: The incidence of temporary gluteal pain after sacrospinous ligament colpopexy ranges from 6.1% to 15.3%. Gluteal pain may occur as a result of injury to S3 to S5 nerve roots that course over the mid-portion of the coccygeus-sacrospinous ligament complex at the time of suspension suture placement. There are no data on the use of injections to prevent postoperative pain from nerve entrapment at the time of suture placement. OBJECTIVE: The purpose of this study was to determine whether intraoperative local analgesia that is administered at the level of the sacrospinous ligament can lessen the gluteal pain felt by patients postoperatively after sacrospinous ligament colpopexy. STUDY DESIGN: In a randomized double-blind placebo-controlled trial, women with vaginal apex prolapse who were undergoing surgical treatment with sacrospinous ligament colpopexy underwent intraoperative injection with either 0.25% bupivacaine or normal saline solution. Subjects completed visual analog pain scales (0-10) and the Activities Assessment Scale and recorded the use of pain medications over a 6-week period. The primary outcome was postoperative gluteal pain. A sample size of 50 subjects (25 in each arm) was planned to test the hypothesis that local analgesia administration will lessen postoperative pain compared with placebo. RESULTS: Between April 2014 and March 2016, 51 women were enrolled in the study, and 46 women underwent sacrospinous ligament colpopexy. On postoperative day 1, 90.2% of all subjects (n=41) reported gluteal pain. At weeks 1 and 2, 63.8% (n=29) and 44.1% (n=20) women reported pain; at weeks 4 and 6, 33.3% (n=15) and 26.9% (n=12) women continued to have some pain. On day 1, the mean score for gluteal pain was 3.7±2.9. By week 1, the score was 1.8±2.6; by week 6, the mean score was 0.1±0.3. There were no differences in pain scores for patients who had undergone injection with 0.25% bupivacaine and those who were injected with normal saline solution. Patients in the placebo group used significantly more nonsteroidal antiinflammatory drugs than the treatment group: adjusted odds ratio, 1.25; 95% confidence interval, 1.04-1.35; P=.01). By 6 weeks, 87.5% of patients had returned to their baseline "light" activity level. There was no difference in time to return to baseline between the groups. CONCLUSION: Intraoperative administration of local analgesia does not reduce patients' perceptions of postoperative gluteal pain after sacrospinous ligament colpopexy; however, it may reduce the need for pain medication after surgery.

Laparoscopic inguinal ligament suspension with uterine preservation for pelvic organ prolapse: A retrospective cohort study.

OBJECTIVE: To introduce an alternative surgical technique of laparoscopic inguinal ligament suspension (LILS) with uterine preservation and evaluate its efficacy and safety for patients with severe pelvic organ prolapse (POP). METHODS: Between June 2014 and December 2015, 35 patients with symptomatic stage III or IV were treated by LILS with uterine preservation. The perioperative parameters including surgical time, blood loss, hospital stay and complications were recorded. The anatomical cure rate was evaluated according to the Pelvic Organ Prolapse Questionnaire (POP-Q) assessment. The anatomical points were analyzed by dynamic Magnetic Resonance Imaging (MRI). Validated questionnaire of the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7) and the Pelvic organ prolapse urinary Incontinence Sexual Questionnaire (PISQ-12) were recorded to evaluate the symptom severity, quality of life and sexual activity. RESULTS: The mean surgical time was 163.8 ±â€¯42.3 min (range: 120-280 min), the mean estimated blood loss was 48.6 ±â€¯60.5 ml (range: 10-200 ml), and the mean hospital stay was 5 days (range: 3-7 days). No intra-operative complications were encountered. The anatomical success rate at postoperative 6-month and 12-month was 97.1% and 94.3%, respectively. The postoperative anatomical points on straining showed a significant improvement on dynamic MRI as compared to baselines. The symptom severity, quality of life and sexual activity also presented significant improvement both 6-month and 12-month after surgery. After a minimal 12 months follow-up, no postoperative complications occurred and the recurrence prolapse were low. CONCLUSION: LILS with uterine preservation is a feasible, effective and safe surgical alternative in the treatment of POP for patients who desire to reserve uterus. Longer follow-up data from larger studies are required to confirm the benefits of LILS with uterine preservation as a minimally invasive surgical approach.

Spectrum of atrial arrhythmias using the ligament of Marshall in patients with atrial fibrillation.

BACKGROUND: The role of the ligament of Marshall (LOM) in patients with atrial fibrillation (AF) has not been well defined. OBJECTIVE: The purpose of this study was to describe the role of the LOM in patients with AF and related arrhythmias. METHODS: Fifty-six patients (mean age 63 ± 11 years; persistent AF in 48 [86%]; ejection fraction 0.49 ± 0.13; left atrial diameter 4.7 ± 0.6 cm) with LOM-mediated arrhythmias were included. RESULTS: A LOM-pulmonary vein (PV) connection was present in 18 patients (32%) and was eliminated with radiofrequency (RF) ablation at the left lateral ridge or crux (n = 12), at the mitral annulus (n = 3), or with alcohol/ethanol (EtOH) ablation of the vein of Marshall (VOM; n = 3). A LOM-mediated atrial tachycardia (AT) was present in 13 patients (23%). Thirty-one patients with refractory mitral isthmus conduction were referred for potential EtOH ablation. In the 6 patients in whom VOM was injected during perimitral reentry, EtOH resulted in slowing in 3 patients and termination in 1 patient. In others, EtOH infusion resulted in complete isolation of the left-sided PVs and left atrial appendage. Repeat RF and adjunctive EtOH ablation of the VOM tended to be more effective in creating conduction block across the mitral isthmus than RF ablation alone (P = .057). CONCLUSION: The LOM is responsible for a variety of arrhythmia mechanisms in patients with AF and atrial tachycardia. It may be ablated at any point along its course, at the mitral annulus, at the lateral ridge/PV antrum, and epicardially in the coronary sinus and the VOM itself. EtOH ablation of the VOM may be an adjunctive strategy in patients with refractory perimitral reentry.

Colpopexia al ligamento sacroespinoso con CapioTM; cirugía, resultados y evolución de pacientes / Sacroespinous ligament colpopexy with CapioTM; surgery patient outcomes and evolution

Introducción: El prolapso genital femenino altera significativamente la calidad de vida de la mujer. El prolapso apical es el segundo más frecuente después del defecto de pared anterior y la colposuspensión al ligamento sacroespinoso es una de las técnicas quirúrgicas descritas para su tratamiento. Objetivos: Determinar la factibilidad de la corrección del prolapso apical en pacientes sometidas a la colposuspensión al ligamento sacroespinoso, utilizando el dispositivo de captura de sutura CapioTM. Materiales y métodos: Análisis retrospectivo de pacientes intervenidas desde junio de 2015 a junio de 2016, en la unidad de piso pélvico del Hospital Luis Tisné Brousse, basándose principalmente en la evaluación del punto C del Prolpase Organ Pelvic Quatinfication (POP-Q). Resultados: Se intervinieron 15 pacientes, con edad promedio de 60,7 ± 6,8 años. Todas presentaron prolapso genital estadio III o IV. El seguimiento se realizó entre 3 y 13 meses después de la cirugía. Ninguna presentó complicaciones graves durante ni después de la cirugía y sólo una paciente recidivó. Conclusiones: La colposuspensión al ligamento sacroespinoso con CapioTM, es una técnica factible, segura y eficaz para el tratamiento del prolapso apical, sin embargo, es necesario mayor tiempo de seguimiento y estudios comparativos con otras técnicas de colposuspensión.

Introduction: Female genital prolapse significantly alter the quality of life of women. The apical prolapse is the second common defect after anterior wall and the colposuspension to sacrospinous ligament is one of the described surgical techniques for its treatment. Objective: To determine the feasibility of apical prolapse correction in patients undergoing sacrospinous colposuspension using the suture capture device CapioTM. Methods: Retrospective analysis of patients undergoing this surgery from June 2015 to June 2016, including an objective assessment focused mainly in the C point of Prolapse Organ Pelvic Quatinfication (POP-Q) and a subjective evaluation of the patient. Results: 15 patients, of which only 11 were able to complete follow-up, were included. The mean age of the patients at the time of surgery was 60.7 ± 6.8 years, and all were classified as prolapse stages III or IV. The evaluation was performed in average 6.75 ± 3.39 months after surgery, with a minimum of 3 and a maximum of 13 months. No patient had several complications during or after surgery and only one recurred. Conclusions: The colposuspension to sacrospinous ligament with CapioTM is a safe and effective alternative for the treatment of apical genital prolapse. However, a longer follow-up study is needed, in addition to comparative studies with other colposuspension techniques.

Hysteropexy in the treatment of uterine prolapse stage 2 or higher: a multicenter randomized controlled non-inferiority trial comparing laparoscopic sacrohysteropexy with vaginal sacrospinous hysteropexy (LAVA-trial, study protocol).

BACKGROUND: Pelvic organ prolapse is a common health problem: the lifetime risk of undergoing surgery for pelvic organ prolapse by the age of 85 years is 19%. Pelvic organ prolapse has significant negative effects on a woman's quality of life. Worldwide, vaginal hysterectomy is the leading treatment method for patients with symptomatic uterovaginal prolapse. Several studies have shown that vaginal sacrospinous hysteropexy and laparoscopic sacrohysteropexy are safe and effective alternatives in treating uterine descent. To date, it is unclear which of these techniques leads to the best operative result and the highest patient satisfaction. Therefore, we conducted the LAVA trial. METHODS: The LAVA trial is a randomized controlled multicenter non-inferiority trial. The study compares laparoscopic sacrohysteropexy with vaginal sacrospinous hysteropexy in women with uterine prolapse stage 2 or higher. The primary outcome of this study is surgical success of the apical compartment at 1 and 5 years follow-up. Secondary outcomes are subjective improvement on urogenital symptoms and quality of life (assessed by disease-specific and general quality of life questionnaires), complications following surgery, hospital stay, post-operative recovery, sexual functioning and costs-effectiveness. Evaluation will take place pre-operatively, and 6 weeks, 6 months, 12 months and annually till 60 months after surgery. Validated questionnaires will be used.Analysis will be performed according to the intention to treat principle. Based on comparable recurrence rates of 3% and a non-inferiority margin of 10%, 62 patients are needed in each arm to prove the hypothesis with a 95% confidence interval. DISCUSSION: The LAVA trial is a randomized controlled multicenter non-inferiority trial that will provide evidence whether the efficacy of laparoscopic sacrohysteropexy is non-inferior to vaginal sacrospinous hysteropexy in women with symptomatic uterine prolapse stage 2 or higher. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR4029.

Atrial tachycardias utilizing the Ligament of Marshall region following single ring pulmonary vein isolation for atrial fibrillation.

BACKGROUND: Organized atrial tachycardias (OATs) after pulmonary vein isolation (PVI) procedure are common. Arrhythmia mechanisms include mitral annular, ring gap, or roof-dependent gap-related flutters. In this series, we describe a mechanism of arrhythmia utilizing the ridge between left pulmonary vein (PV) and left atrial appendage (LAA) in the Ligament of Marshall (LOM) region. METHODS AND RESULTS: Five tachycardias involving the LOM region were identified from a group of 240 patients who underwent a single ring PVI procedure for symptomatic atrial fibrillation. The common characteristics of these tachycardias were the endocardial breakout over a broad area adjacent to the LOM region, presence of presystolic or mid-diastolic potentials, and abolition by ablation of the presystolic or mid-diastolic potentials remote from the endocardial breakout site. In all five cases, tachycardias were present after isolation of the veins and posterior left atria. All demonstrated characteristic areas of very slow conduction in the LOM region highlighted by presence of either low voltage, long duration fractionated potentials, or mid-diastolic potentials with a fixed temporal relationship to the subsequent endocardial activation. The pattern of activation and termination of tachycardia during ablation was consistent with an arrhythmia utilizing an electrically insulated tract within LOM and the PV-LAA ridge region. CONCLUSIONS: We identified a pattern of arrhythmias involving a concealed presystolic component and a broad endocardial breakout site related to the LOM region. Successful ablation site involved careful identification of small diastolic potentials in the LAA/ridge region or adjacent to the coronary sinus.

Reinforcement of suspensory ligaments under local anesthesia cures pelvic organ prolapse: 12-month results.

INTRODUCTION AND HYPOTHESIS: In 2005, a new minimally invasive procedure, the tissue fixation system (TFS) was reported. Like TVT (tension-free vaginal tape), the TFS works by creating a foreign body collagenous tissue reaction that reinforces a weakened pelvic ligament. The objective was to assess the effectiveness and perioperative safety of TFS in a day surgery clinic for the treatment of pelvic organ prolapse (POP). METHODS: The TFS tape was applied in a tunnel adjacent to natural ligaments to repair the anterior cervical ring and cardinal ligament, paravaginal tissues and uterosacral ligaments under local anesthesia/sedation. We prospectively studied 60 patients, mean age 67, between October 2008 and February 2010 at Women's Clinic LUNA. Levels of POP were grade 2 (n = 20; 7 %), grade 3 (n = 30; 55 %), and grade 4 (n = 4; 7 %) according to the ICS POPQ classification. Fifty-four patients (90 %) who underwent a total of 162 POP operations presented for review. Follow-up was performed at 12 months. We defined surgical failure according to the ICS POPQ classification. We used prolapse quality of life (P-QOL) questions for QOL measurement. RESULTS: Ninety-eight percent of patients were discharged on the day of surgery. Of the 162 TFS operations reviewed, 157 were successful and 5 failed. The 5 failed operations comprised 4 cystoceles and 1 rectocele. Two patients developed cervical protrusions at the introitus at 6 months with no prolapse of the uterine body. We found 5 cases of erosion in 162 tape insertions. The total number of patients who had no complications, no surgical failures, no erosions, no sensation of bulging, and no cervical protrusions was 47 (87 %). CONCLUSIONS: The TFS uses the same surgical principle for repair as the TVT; this principle vastly minimizes the volume of mesh used, erosions, and other complications.

Septic flexor tendonitis and suspensory desmitis in an alpaca.

CASE DESCRIPTION: A 2-year-old male Suri alpaca was referred for evaluation of severe right forelimb lameness of 2 weeks' duration following a traumatic episode. CLINICAL FINDINGS: Examination of the distal aspect of the metacarpus revealed 4 wounds exuding purulent material. On weight bearing, the metacarpophalangeal joint was severely hyperextended with the palmar surface touching the ground. Ultrasonography of the palmar surface of the metacarpus revealed desmitis of the proximal suspensory ligament, a large core lesion of the deep digital flexor tendon at mid-metacarpus, and complete loss of fiber pattern within the deep digital flexor tendon and lateral aspect of the superficial digital flexor tendon distally. TREATMENT AND OUTCOME: The alpaca was treated systemically with antimicrobials and anti-inflammatory drugs and underwent repeated antimicrobial intraosseous regional limb perfusion. A bandage and splint were applied to stabilize the affected forelimb in an anatomically correct position, and the alpaca underwent prolonged stall confinement. At the time of hospital discharge 5 days after initial evaluation, clinical evidence of infection at the wound sites was absent. Three months following treatment, the alpaca was moving freely in a small paddock and had moderate hyperextension of the metacarpophalangeal joint. CLINICAL RELEVANCE: Treatment of septic flexor tendonitis and suspensory desmitis with antimicrobial intraosseous regional limb perfusion in combination with systemic treatment with antimicrobials and orthopedic support resulted in an excellent outcome in this alpaca. Antimicrobial intraosseous regional limb perfusion is simple to perform and has the potential to be beneficial in the treatment of infections in the distal portion of a limb in camelids.

Treatment of uterine prolapse stage 2 or higher: a randomized multicenter trial comparing sacrospinous fixation with vaginal hysterectomy (SAVE U trial).

BACKGROUND: Pelvic organ prolapse is a common health problem, affecting up to 40% of parous women over 50 years old, with significant negative influence on quality of life. Vaginal hysterectomy is currently the leading treatment method for patients with symptomatic uterine prolapse. Several studies have shown that sacrospinous fixation in case of uterine prolapse is a safe and effective alternative to vaginal hysterectomy. However, no large randomized trials with long-term follow-up have been performed to compare efficacy and quality of life between both techniques.The SAVE U trial is designed to compare sacrospinous fixation with vaginal hysterectomy in the treatment of uterine prolapse stage 2 or higher in terms of prolapse recurrence, quality of life, complications, hospital stay, post-operative recovery and sexual functioning. METHODS/DESIGN: The SAVE U trial is a randomized controlled multi-center non-inferiority trial. The study compares sacrospinous fixation with vaginal hysterectomy in women with uterine prolapse stage 2 or higher. The primary outcome measure is recurrence of uterine prolapse defined as: uterine descent stage 2 or more assessed by pelvic organ prolapse quantification examination and prolapse complaints and/or redo surgery at 12 months follow-up. Secondary outcomes are subjective improvement in quality of life measured by generic (Short Form 36 and Euroqol 5D) and disease-specific (Urogenital Distress Inventory, Defecatory Distress Inventory and Incontinence Impact Questionnaire) quality of life instruments, complications following surgery, hospital stay, post-operative recovery and sexual functioning (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire). Analysis will be performed according to the intention to treat principle. Based on comparable recurrence rates of 3% and considering an upper-limit of 7% to be non-inferior (beta 0.2 and one sided alpha 0.025), 104 patients are needed per group. DISCUSSION: The SAVE U trial is a randomized multicenter trial that will provide evidence whether the efficacy of sacrospinous fixation is similar to vaginal hysterectomy in women with uterine prolapse stage 2 or higher. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR1866.

Ablation of ligament of Marshall attenuates atrial vulnerability to fibrillation induced by inferior left atrial fat pad stimulation in dogs.

BACKGROUND: The role of ligament of Marshall (LOM) in the mechanism of "vagal" atrial fibrillation (AF) is still unknown. OBJECTIVE: To investigate the impact of LOM ablation on atrial vulnerability to AF induced by inferior left atrial fat pad (ILAFP) stimulation in dogs. METHODS: AF inducibility and atrial effective refractory period (ERP) were elevated before and after LOM ablation in 8 of 14 dogs (the ablation group). Same protocol but without LOM ablation was conducted in the remaining 6 dogs (the control group). The activation patterns of LOM and left pulmonary veins (LPVs) during sustained AF were analyzed. The distribution of epicardial cholinergic nerve fibers between LOM and ILAFP was investigated in the control group. RESULTS: Ablation of LOM significantly attenuated AF inducibility (87.5% vs 33.3%, P < 0.001) and prolonged ERPs of the structures in contiguity with LOM (P < 0.05) in the ablation group. In contrast, there was no significant change in ERPs and AF inducibility in the control group. During sustained AF, fractionated atrial electrograms were more common in the LOM area than the LPVs (84% vs 18% of the analyzed episodes, P < 0.001). In 46.7% of the episodes with identifiable LOM spikes, atrial potentials, and LOM spikes were related in 2:1 or 3:2 pattern during the intermittent organized activity. Acetylcholinesterase staining revealed a close cholinergic nerved relationship between LOM and ILAFP. CONCLUSIONS: LOM plays a critical role in maintaining AF induced by stimulation of ILAFP. Ablation of LOM can markedly attenuate AF inducibility in this model.

The efficacy of two electrodes radiofrequency technique: comparison study using a cadaveric interspinous ligament and temperature measurement using egg white.

BACKGROUND: One technique in radiofrequency neurotomies uses 2 electrodes that are simultaneously placed to lie parallel to one another. Comparing lesions on cadaveric interspinous ligament tissue and measuring the temperature change in egg white allows us to accurately measure quantitatively the area of the lesion. METHODS: Fresh cadaver spinal tissue and egg white tissue were used. A series of samples were prepared with the electrodes placed 1 to 7 mm apart. Using radiofrequency, the needle electrodes were heated in sequential or simultaneous order and the distance of the escaped lesion area and temperature were measured. RESULTS: Samples of cadaver interspinous ligament showed sequential heating of the needles limits the placement of the needle electrodes up to 2 mm apart from each other and up to 4 mm apart when heated simultaneously. The temperature at the escaped lesion area decreased according to the distance for egg white. There was a significant difference in temperature at the escaped lesion area up to 6 mm apart and the temperature was above 50 degrees celsius up to 5 mm in simultaneous lesion and 3 mm in the sequential lesion. LIMITATIONS: The limitations of this study include cadaveric experimentation and use of intraspinous ligament rather than medial branch of the dorsal ramus which is difficult to identify. CONCLUSION: Heating the 2 electrodes simultaneously appears to coagulate a wider area and potentially produce better results in less time.

Integrative biomechanics: a paradigm for clinical applications of fundamental mechanics.

Integrative biomechanics uses biomechanics knowledge and methods at multiple scales and among biological entities to address fundamental and clinical problems at the tissue and organ level. Owing to the large ranges of scale involved, integrative biomechanics is intrinsically multidisciplinary, extending from molecular biophysics to contemporary engineering descriptions of kinematics and bulk constitutive properties. Much of this integration is accomplished through multiscale models of the interactions of interest. Applications can range from the development of new biological knowledge to the creation of new technologies for clinical application. In this white paper, the historical background of, and the rationale behind, integrative biomechanics are reviewed, followed by a sampling of clinical advances that were developed using the integrative approach. Refinements of many of these advances are still needed, and unsolved problems remain, in genomic applications, developing improved interventional procedures and protocols, and personalized medicine. Challenges to achieve these goals include the need for better models and the acquisition and organization of the data needed to parameterize, validate and apply them. These challenges will be overcome, because the advances in characterizing disease risk, personalization of care, and therapeutics that will follow, demand that we continue to move forward in this exciting field.

[The value of spleen sub-pedicle two steps severance with LigaSure in laparoscopic splenectomy].

OBJECTIVE: To evaluate the safety and utility of the methods of spleen sub-pedicle two steps severance with LigaSure Vessel Sealing System combined with ultrasound scalpel to resect peri-splenic ligaments during laparoscopic splenectomy. METHODS: The methods and the curative effect of 32 patients with laparoscopic splenectomy performed by the way as mentioned above were summarized and analyzed. 4 males, 28 females, median 36 years (range 16 - 64 years). Mean dimensions of spleens were 17 cm (range 11 - 23 cm). Nineteen patients had idiopathic thrombocytopenia purpura (ITP), 6 hereditary spherocytosis (HS) (5 of them were the same family constellation), 3 hemolytic anemia (HA), 2 spleen injury with haematoma infection, 1 Evan syndrome, 1 leukemia. Peri-splenic ligaments were resected by LigaSure combined with ultrasound scalpel, splenic pedicle was resected by spleen sub-pedicle two steps severance with LigaSure when splenic pedicle were sufficiently free. Splenic pedicle was non-excisional occluded by LigaSure at pancreatic cauda, in the first step and was occluded and resected alongside of the spleen in the second step. RESULTS: All of the 32 cases were completely succeed, the average operating time was 70 min (55 - 130 min), the estimated intraoperative blood loss was 200 ml (50 - 600 ml), no complications such as abdominal haemorrhage, visceral injury, pancreatic leakage and infection were observed. All the patients were healed well, the average hospital stay after an operation was 6 days. The average expense of each patients could save 8050 yuan because Endo-GIA was not used. CONCLUSIONS: Spleen sub-pedicle two steps severance with LigaSure Vessel Sealing System combined with ultrasound scalpel to resect peri-splenic ligaments during laparoscopic splenectomy, which shorten the operating persistence time with less hemorrhage is a safe, effective and low-cost minimally invasive surgery in selective cases.