[Anterior shoulder instability with Hill-Sachs on-track. Bankart or Bankart-remplissage?] / Inestabilidad anterior de hombro con lesión de Hill-Sachs on-track. ¿Bankart o Bankart-remplissage?

INTRODUCTION: in patients with anterior glenohumeral (GH) instability together with an off-track or engaging Hill-Sachs (HS) defect, Bankart-remplissage (B-R) surgery reduces the recurrence rate when compared to Bankart (B) surgery alone. There is controversy regarding whether the recurrence rate also decreases in patients with on-track or non-engaging Hill-Sachs defects. OBJECTIVE: to compare the recurrence rate and clinical evolution of patients with anterior glenohumeral instability with 'on-track' Hill-Sachs defect treated with either B or B-R surgery. MATERIAL AND METHODS: non-randomized, retrospective, single-center cohort study of patients with anterior glenohumeral instability and on-track Hill-Sachs defect, operated between January 2010 and December 2018. Patients operated with B versus B-R were compared. Recurrence, complications and re-operation were recorded. In addition, VAS, SSV, WOSI and qDASH scores were obtained and compared in both groups. RESULTS: of the 105 patients who met the inclusion criteria, 78 (74.3%) patients had a complete follow-up (52 B and 26 B-R, 4.3 years median follow-up). There was a higher recurrence rate in group B compared to B-R, with this difference not reaching statistical significance (17.3% vs 7.7%, p = 0.21). There were no significant differences in residual pain, feeling of instability, complications or VAS, qDASH, SSV or WOSI scores between both groups. In the subgroup analysis, patients who practiced contact sports and were operated with B showed higher recurrence rates (24.1% vs 0%, p = 0.08) and complications (41.4% vs 18.2%, p = 0.16) when compared to B + R, although these differences were not significant. CONCLUSION: there were no significant differences in recurrence rates and functional evolution between patients with anterior glenohumeral instability operated with B or B-R surgery. Comparative, prospective studies should be performed to establish definitive recommendations.

INTRODUCCIÓN: en pacientes con inestabilidad glenohumeral (GH) anterior con defecto de Hill-Sachs (HS) off-track o enganchante, Bankart-remplissage (B + R) reduce tasa de recurrencia en comparación a Bankart aislado (B). Hay controversia si tasa de recurrencia también disminuye en pacientes con defecto de HS on-track o no enganchantes. OBJETIVO: comparar la tasa de recurrencia y evolución clínica entre la cirugía de B versus B-R en pacientes operados por inestabilidad glenohumeral anterior con defecto de Hill-Sachs on-track. MATERIAL Y MÉTODOS: estudio de cohorte, no randomizado, retrospectivo y unicéntrico, en pacientes operados por inestabilidad glenohumeral anterior, entre Enero 2010 y Diciembre de 2018. Se incluyen sólo pacientes con defecto de Hill-Sachs on-track. Fueron comparados pacientes operados con cirugía de B versus B + R. Se consigna recurrencia, complicación, reoperación y sensación de inestabilidad. Además, se realizan y comparan puntajes de EVA, SSV, WOSI y qDASH. RESULTADOS: de los 105 pacientes que cumplieron criterios de inclusión, 78 (74.3%) realizaron seguimiento completo (52 B y 26 B + R, 4.3 años mediana de seguimiento). Hubo mayor tasa de recurrencia en grupo B en comparación a B + R, siendo esta diferencia no significativa (17.3% versus 7.7%, p = 0.21). No hubo diferencia significativa en dolor residual, sensación de inestabilidad residual, complicaciones o puntajes de escala EVA, qDASH, SSV ni WOSI. En análisis por subgrupo, pacientes con deportes de contacto, B tienen mayor tasa de recurrencia (24.1% versus 0%, p = 0.08) y complicaciones comparadas con B + R (41.4% versus 18.2%, p = 0.16), siendo estas diferencias no significativas. CONCLUSIÓN: no hubo diferencias significativas en tasa de recurrencia y evolución funcional entre cirugía de Bankart aislado o Bankart-remplissage para inestabilidad glenohumeral anterior asociada a defecto de Hill-Sachs on-track. Estudios comparativos, prospectivos deben realizarse para establecer recomendaciones definitivas.

Can cerebral vasoreactivity predict cerebral tolerance to carotid clamping during carotid endarterectomy?

Cerebral vasoreactivity (CVR) was evaluated as a preoperative test in predicting cerebral tolerance to carotid clamping.A consecutive series of 115 carotid endarterectomy (CEA) cases were studied. Before surgical operation CVR was evaluated, by measuring the mean velocity of the middle cerebral artery (mv-MCA) using transcranial Doppler (TCD) at the basal condition and 20 min after intravenous administration of acetazolamide (1 g). CEA was performed under general anesthesia. TCD was used during surgery to evaluate mv-MCA and to calculate mv-MCA clamping/mv-MCA pre-clamping x100 ratio (mv-MCA%), which was used as the parameter to validate CVR.CVR did not correlate with mv-MCA% (r=0.22). There was no significant difference (P=0.09) between mean values of the non shunted subgroup and the shunted one.CVR does not seem to be suitable for evaluating cerebral tolerance to carotid clamping.

External carotid artery shunting during carotid endarterectomy: an alternative for cerebral protection?

OBJECTIVES: to assess the application of external carotid artery (ECA) shunting in cerebral protection during carotid endarterectomy (CEA). DESIGN: prospective study. MATERIALS AND METHODS: the study comprised 137 consecutive patients who underwent CEA under locoregional anaesthesia. Transcranial Doppler was used to monitor the mean velocity of the middle cerebral artery (mv-MCA): (1) before carotid clamping; (2) after clamping both the common and external carotid arteries; (3) after clamping the internal carotid artery alone ("ECA test"). The decision to shunt was based on the occurrence of neurological deficit during carotid clamping. If the ECA test revealed mv-MCA approaching the pre-clamping values ECA shunting was used, whereas the remaining patients in need of a shunt had a standard internal carotid artery (ICA) shunt. RESULTS: shunting was necessary in 12/137 cases (9%). The ECA test indicated that in four cases - 3% of the whole series or 33% of the shunted cases. In these four patients ECA shunting reversed the neurological deficit, and CEA was successfully performed without any complications. CONCLUSIONS: ECA shunting could be considered as an alternative to standard ICA shunting. Suitable cases can be identified on the basis of the ECA test.

Predictive value of transcutaneous oximetry for selection of the amputation level.

BACKGROUND: Transcutaneous oximetry was studied to select the correct amputation level for limb ischemic necrosis with possible identification of threshold value. METHODS: The method was evaluated in 30 cases (20 patients, 5 males and 15 females, of ages ranging from 61 to 93, average 73.1+/-8.5) where patients underwent amputation because of severe leg ischemia. Surgical operations were: minor amputation (toe or transmetatarsal) in 23 cases, below knee amputation in 7. Oxygen tension was measured at the dorsum foot and at the third superior of the anteromedial calf aspect. RESULTS: Results were classified as success (primary or delayed healing) or failure (necrosis at the surgical wound). Amputation was successful in 17/30 cases with oxygen tension of 0-65 mmHg (mean 32.5+/-16.1) and failed in 13/30 with oxygen tension of 0-57 mmHg (mean 7.8+/-17.3). The difference was statistically significant (p=0.0004). Sensitivity of the method resulted 88.2%, specificity 84.6%, diagnostic accuracy 86.7%, positive predictive value 88.2% and negative predictive value 84.6%. A threshold of 20 mmHg was identified: 15/17 successful cases showed values greater than 20 mmHg, while 11/13 failed cases presented values lower than the threshold. CONCLUSIONS: Following our observations and according to some reported studies, we believe transcutaneous oximetry to be the best method for selection of amputation level This is a simple, noninvasive and accurate method, which has showed itself superior to other techniques (i.e., Doppler and radioisotope).

[Surgical management of asymptomatic carotid artery stenosis. Authors' experience, problems and prospectives]. / La chirurgia della stenosi carotidea asintomatica. Nostra esperienza, problemi e prospettive.

BACKGROUND: Some trials have demonstrated effectiveness of carotid endarterectomy (CEA) for preventing stroke in patients with severe symptomatic carotid stenosis. Although some researches, indication to surgery for asymptomatic carotid stenosis is debated up today. Based on personal experience and literature, the main problems of CEA for asymptomatic stenosis are discussed. DESIGN: Retrospective study. SETTING: Section of Vascular Surgery, University Department. PATIENTS: CEA was performed in a consecutive series of 63 cases with asymptomatic stenosis (59 patients, 40 males and 19 females, ages ranging from 46 to 80 years, mean 67.9). INTERVENTIONS: CEA was performed under general anesthesia, with primary closure of arteriotomy in 37 cases and patch angioplasty using PTFE in 24, using eversion technique in 2 cases. Pruitt-Inahara shunt was used in 10/63 cases (15.9%), according to the mean velocity of the middle cerebral artery at carotid clamping/mean velocity of the middle cerebral artery pre-clamping ratio x 100 equal to or lesser than 15%, evaluated with transcranial Doppler, or stump pressure lesser than 50 mmHg, when transcranial Doppler examination was not possible. MEASURES: Operative mortality and postoperative morbidity. RESULTS: Operative mortality plus postoperative stroke were 1.6% (1/63). Operative mortality was precisely 0.0%. Postoperative complications were two: one was a neurologic deficit (monoparesis of the arm) and the other was myocardial ischemia. CONCLUSIONS: Four main problems have been shown in CEA for asymptomatic stenosis: 1. Identification of asymptomatic stenosis: 2. Assessment of risk for stroke: 3. Role of CEA: 4. Questions about surgical treatment. For the first problem, it is important to consider possible indicators for carotid stenosis (contralateral carotid stenosis, coronary artery disease, aortic aneurysm, peripheral arterial disease, etc.). With regard to the second problem, it is important to know the natural history of the carotid stenosis, which shows a stroke rate of 1-2% per year. Regarding the third problem, the role of CEA is conditioned by: trials, patient conditions, lesion characteristics and ability of the surgeon. Further studies should identify some groups of patients (with severe carotid stenosis, dyshomogeneous plaque, progression of plaque, etc.), who can profit from CEA. Finally (fourth problem), CEA for asymptomatic carotid stenosis carries all common problems of carotid surgery (preoperative assessment, evaluation of cerebral ischemia due to carotid clamping, shunt, closure of arteriotomy, etc.). Some of these problems can receive ultimate solutions from some studies in next years.

[Surgery of recurrent varices of the minor saphenous vein]. / Chirurgia delle varici recidive della vena piccola safena.

BACKGROUND: Investigation of the diagnostic and technical problems of redo surgery of the lesser saphenous vein for primary varicose veins. DESIGN: a retrospective study. SETTING: Section of Vascular Surgery in a University Hospital. PATIENTS: Fifteen lower extremities were operated upon (13 patients, 3 males and 10 females, ages ranging from 43 to 65 years with a mean of 53.2). INTERVENTIONS: Each case was assessed by clinical examination, duplex scanning and venography (ascending venography and/or varicography). Surgical procedure was carried out via a longitudinal approach over the popliteal region or the posterior aspect of the thigh. Each case presented with a stump of the lesser saphenous vein. MEASURES: Hemodynamic (correction of reflux of the lesser saphenous vein) and clinical (improvement of clinical state in the operated lower limb and complications) results were evaluated. RESULTS: Reflux at the ostium of the lesser saphenous vein was corrected in 15/15 (100%) cases. Clinical result was good in 15/15 (100%) cases. Postoperative edema was observed in 7/15 (46.7%) cases. Lesion of the common peroneal nerve with paresis of the foot dorsal flexion was found in 1/15 (6.7%) cases. Hypertrophic scar was observed in 4/15 (26.7%) cases. CONCLUSIONS: Redo surgery of the lesser saphenous vein is requested less frequently than other surgical procedures for superficial venous diseases. This surgery requires two essential features: a) accurate diagnosis of the lesser saphenous vein insufficiency; b) adequate surgical technique. For the former purpose, venography is a fundamental method of assessment. Surgical technique should be cautious and gentle. A longitudinal approach leads to a wide exposure of the structures in the popliteal fossa.

[Iliac vein insufficiency syndrome. Clinical contribution]. / La sindrome da insufficienza della vena iliaca interna. Contributo clinico.

BACKGROUND: Definition of essential findings in chronic venous insufficiency without valvular incompetence of the greater and/or lesser saphenous vein and due to reflux in the system of the internal iliac vein. DESIGN: a retrospective study. SETTING: Section of Vascular Surgery in a University Hospital. PATIENTS: Five patients, all females, ages ranging from 24 to 62 years, (6 lower extremities) with internal iliac venous insufficiency syndrome were identified. INTERVENTIONS: Each case was assessed with clinical examination, Doppler CW and venography. Moreover, all cases were surgically treated using the technique of varicose vein avulsion. MEASURES: Venographic picture and results of surgical treatment were evaluated. RESULTS: Reflux in the system of the internal iliac vein was demonstrated in all cases. Connections between this vein and subcutaneous varicose veins network were identified using venography. Surgical treatment has given good results in 5 lower extremities followed-up from 6 months to 3 years, while recurrent varicose veins were observed in 1 leg after 6 months. CONCLUSIONS: Syndrome of internal iliac vein insufficiency requires more attention than in the past. As to diagnostic evaluation, venography (particularly varicography) plays an essential role. The best treatment is stab avulsion of varicose vein, if pelvic congestion syndrome is excluded.

Treatment of leg ulcers with cryopreserved allogeneic cultured epithelium. A multicenter study.

BACKGROUND: In the past few years, several authors have described the usefulness of cultured allogeneic epidermal sheets in promoting wound healing of burns, leg ulcers, and donor sites. This study reports clinical results obtained by different departments in the treatment of chronic leg ulcers by cryopreserved cultured allogeneic epithelium. The freezing procedure and the assessment of viability of the cryopreserved epithelium are also described. A total of 30 ulcers were treated using 138 cryopreserved allografts. OBSERVATIONS: Twenty ulcers (66.6%) healed completely within 12 weeks. Four ulcers showed a 30% to 84.4% reduction in size by 3 weeks but did not heal completely; the remaining six ulcers did not show any improvement. A strong stimulation of granulation tissue formation and of reepithelialization from the wound edge were observed. RESULTS: The results indicate that frozen cultured epidermis, stored in a skin bank, is a valid and generally applicable alternative therapy for the treatment of chronic ulcers.