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Selected AbstractsOrthopaedic issues in the musculoskeletal care of adults with cerebral palsyDEVELOPMENTAL MEDICINE & CHILD NEUROLOGY, Issue 2009HELEN M HORSTMANN MD Aims, Orthopaedic care of adults with cerebral palsy (CP) has not been well documented in orthopaedic literature. This paper focuses on some of the common problems which present themselves when adults with CP seek orthopaedic intervention. In particular, we review the most common orthopaedic issues which present to the Penn Neuro-Orthopaedics Program. Method, A formal review of consecutive surgeries performed by the senior author on adults with CP was previously conducted. This paper focuses on the health delivery care for the adult with orthopaedic problems related to cerebral palsy. Ninety-two percent of these patients required lower extremity surgery. Forty percent had procedures performed on the upper extremities. Results, The majority of problems seen in the Penn Neuro-Orthopaedics Program are associated with the residuals of childhood issues, particularly deformities associated with contractures. Patients are also referred for treatment of acquired musculoskeletal problems such as degenerative arthritis of the hip or knee. A combination of problems contribute most frequently to foot deformities and pain with weight-bearing, shoewear or both, most often due to equinovarus. The surgical correction of this is most often facilitated through a split anterior tibial tendon transfer. Posterior tibial transfers are rarely indicated. Residual equinus deformities contribute to a pes planus deformity. The split anterior tibial tendon transfer is usually combined with gastrocnemius-soleus recession and plantar release. Transfer of the flexor digitorum longus to the os calcis is done to augment the plantar flexor power. Rigid pes planus deformity is treated with a triple arthrodesis. Resolution of deformity allows for a good base for standing, improved ability to tolerate shoewear, and/or braces. Other recurrent or unresolved issues involve hip and knee contractures. Issues of lever arm dysfunction create problems with mechanical inefficiency. Upper extremity intervention is principally to correct contractures. Internal rotation and adductor tightness at the shoulder makes for difficult underarm hygiene and predispose a patient to a spiral fracture of the humerus. A tight flexor, pronation pattern is frequently noted through the elbow and forearm with further flexion contractures through the wrist and fingers. Lengthenings are more frequently performed than tendon transfers in the upper extremity. Arthrodesis of the wrist or on rare occasions of the metacarpal-phalangeal joints supplement the lengthenings when needed. Conclusions, The Penn Neuro-Orthopaedics Program has successfully treated adults with both residual and acquired musculoskeletal deformities. These deformities become more critical when combined with degenerative changes, a relative increase in body mass, fatigue, and weakness associated with the aging process. [source] Complete hypopharyngeal obstruction by mucosal adhesions: A complication of intensive chemoradiation for advanced head and neck cancerHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 8 2006Elizabeth J. Franzmann MD Abstract Background. Severe swallowing dysfunction is the dominant long-term complication observed in patients treated for head and neck squamous cell carcinoma (HNSCC) with treatment protocols using intensive concurrent chemotherapy with radiation therapy (chemo/XRT). We identified a subset of these patients, who were seen with complete obstruction of the hypopharynx distal to the site of the primary cancer, and in whom we postulate that the obstruction was caused by separable mucosal adhesions rather than obliteration by a mature fibrous stricture. Methods. Seven patients were referred to the senior author with a diagnosis of complete hypopharyngeal obstruction between 1992 and 2001. The diagnosis was confirmed by barium swallow imaging and/or endoscopy before referral in all patients. Patients underwent recanalization by passing a Jesberg esophagoscope under general anesthesia, followed by serial dilations and intensive swallowing therapy. Patient charts were reviewed retrospectively after institutional review board approval. Results. All seven patients were successfully recanalized. No patient had a perforation or other significant complication related to the recanalization procedure or subsequent dilations. Five of the seven patients showed improvement in swallowing at some point after the initial procedure, but just two patients recovered sufficiently to have their gastrostomy tube removed permanently. Conclusions. We conclude that complete hypopharyngeal obstruction secondary to mucosal adhesions is one cause of gastrostomy tube dependence in patients who have been treated with chemo/XRT for HNSCC. It is a difficult problem to treat, but most patients can recover useful swallowing function without undergoing laryngectomy or major surgical reconstruction. The postulated pathophysiology has implications for prevention as well as treatment. © 2006 Wiley Periodicals, Inc. Head Neck, 2006 [source] Transcervical superior mediastinal lymphadenectomy in the management of papillary thyroid carcinomaHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 1 2003Mark L. C. Khoo FRCS Abstract Aim. Surgery is the treatment of choice for lymph node metastases in papillary thyroid carcinoma. When adequately treated by surgical extirpation, the presence of lymph node involvement does not seem to have a negative impact on cure rates or survival. Surgical lymphadenectomy for metastatic papillary thyroid carcinoma has been well described for both the central and the lateral compartments of the neck. Superior mediastinal lymphadenectomy, however, has only sporadically been mentioned. We describe our experience with transcervical superior mediastinal lymphadenectomy (TSML) that avoids the morbidity of the traditional sternal split. Materials and Methods. This retrospective analysis included 30 patients (24 women and 6 men; age range, 17,72 years) who underwent TSML by the senior author (JLF) for papillary carcinoma metastatic to the superior mediastinum between 1985 and 1999. Histopathologic examination confirmed positive nodes in all the mediastinal dissections. All patients received postoperative I131. Results. All the patients are alive after a median follow-up of 5 years (range, 1,14 years). Twenty-nine of 30 patients remain free of disease, whereas one patient is alive with lung and bone metastases. No patient has had local or regional relapse. The only significant complication was a high incidence of temporary (70%) and later permanent (50%) hypoparathyroidism. Conclusions. TSML is a safe and effective treatment for superior mediastinal metastases in papillary thyroid carcinoma. © 2002 Wiley Periodicals, Inc. Head Neck 24: 000,000, 2002 [source] Catheter Tip Granuloma Associated with Sacral Region Intrathecal Drug AdministrationNEUROMODULATION, Issue 4 2003Fernandez Julius MD Abstract Spinal cord compression from catheter tip granulomatous masses following intrathecal drug administration may produce devastating permanent neurologic deficits. Some authors have advocated intrathecal catheter placement below the conus medullaris to avoid the possibility of spinal cord involvement. Multiple cases of catheter tip granulomas in the thoracolumbar region have been reported. We present a unique case of a sacral region catheter tip inflammatory mass producing permanent neurologic deficits. A 71-year-old white male with a diagnosis of failed back surgery syndrome was referred to the senior author for evaluation. After more extensive conservative therapy, including spinal cord stimulation, failed to yield adequate pain relief, he was offered implantation of an intrathecal pump for opioid administration. Excellent pain relief was achieved in the postoperative period; however, three years after implantation, he presented with progressive saddle anesthesia and bowel/bladder incontinence. Magnetic resonance imaging demonstrated a space occupying lesion associated with the catheter tip. The patient underwent emergent second level complete sacral laminectomy with partial resection of an intradural extra-axial mass and removal of intrathecal catheter. At discharge, the patient had no restoration of neurologic function. Histologic examination of the mass confirmed a sterile inflammatory mass. It has been suggested that intrathecal catheters be placed below the conus medullaris to avoid the possibility of spinal cord involvement. We present an unusual case documenting devastating permanent neurologic deficits from a catheter tip granuloma in the sacral region. [source] The Effects of Smoking on Short-Term Quality of Life Outcomes in Sinus Surgery,THE LARYNGOSCOPE, Issue 12 2007Subinoy Das MD Abstract Objective: The purpose of this study was to prospectively compare the short-term benefit of endoscopic sinus surgery for smokers and nonsmokers using a disease specific, clinically validated, quality of life outcomes measure, the Sinonasal Outcomes Test-20 (SNOT-20). Study Design: Prospective clinical trial. Methods: A total of 235 patients were prospectively enrolled at a single tertiary academic center. Preoperative SNOT-20 scores and comprehensive demographic data were obtained. All patients underwent endoscopic sinus surgery under the supervision of the senior author. Preoperative SNOT-20 scores were compared to short-term postoperative SNOT-20 scores. Results: Short-term postoperative results were available for 221 patients for comparison. Preoperative SNOT-20 scores in 49 smokers (mean: 27.8) and 172 nonsmokers (mean: 26.2) were statistically similar. Both smokers and nonsmokers achieved a highly significant reduction in SNOT-20 scores at short-term follow-up evaluations. (P < .0005) Smokers achieved a greater reduction in SNOT-20 scores (mean difference: 22.1) at short-term follow-up compared to nonsmokers (mean difference: 16.1). This result was statistically significant (P < .044). Conclusions: This study confirms that smokers and nonsmokers achieve a highly significant short-term benefit from endoscopic sinus surgery using a clinically-validated symptom severity scale in a prospective study. Interestingly, smokers achieved a greater short-term benefit than nonsmokers did. This study calls into question the notion that current smokers are poorer candidates for endoscopic sinus surgery. Further prospective studies to confirm these results and provide long-term analysis should be performed. [source] A Safe and Cost-Effective Short Hospital Stay Protocol to Identify Patients at Low Risk for the Development of Significant Hypocalcemia After Total ThyroidectomyTHE LARYNGOSCOPE, Issue 6 2006Zayna S. Nahas BS Abstract Objective: The objective of this retrospective chart review was to determine if serial postoperative serum calcium levels early after total thyroidectomy can be used to develop an algorithm that identifies patients who are unlikely to develop significant hypocalcemia and can be safely discharged within 24 hours after surgery. Methods: Records of 135 consecutive patients who underwent total/completion thyroidectomy and were operated on by the senior author from 2001 to 2005 have been reviewed. For the entire study group, reports of the early postoperative serum calcium levels (6 hours and 12 hours postoperatively), final thyroid pathology, preoperative examination, inpatient course, and postoperative follow up were reviewed. An endocrine medicine consultation was obtained for all patients while in the hospital after surgery. For patients who developed significant hypocalcemia, reports of their management and the need for readmission or permanent medications for hypoparathyroidism were reviewed. According to the change in serum calcium levels between 6 hours and 12 hours postoperatively, patients were divided into two groups: 1) positive slope (increasing) and 2) nonpositive (nonchanging/decreasing). Results: All patients with a positive slope (50/50) did not develop significant hypocalcemia in contrast to only 59 of 85 patients (69.4%) with a nonpositive slope (P < .001, positive predictive value of positive slope in predicting freedom from significant hypocalcemia = 100%, 95% confidence interval = 92.9,100). In the nonpositive slope group, 61 patients had a serum calcium level ,8 mg/dL at 12 hours postoperatively (,0.5 mg/dL below the low end of normal), and 53 (87%) of these patients remained free of significant hypocalcemia in contrast to only 6 (25%) of 24 patients with serum calcium level <8 mg/dL at 12 hours postoperatively (sensitivity = 90%, positive predictive value = 87%). In addition, of the eight patients who developed significant hypocalcemia in the nonpositive slope group with a serum calcium level ,8 mg/dL at 12 hours postoperatively, 7 (88%) patients developed the signs and symptoms during the first 24 hours after total thyroidectomy. Readmission and permanent need for calcium supplementation happened in two patients, respectively, all with serum calcium levels <8 mg/dL at 12 hours after total thyroidectomy. The compressive and/or symptomatic large multinodular goiter as an indication for thyroidectomy was associated with developing significant hypocalcemia (P < .05). There was no statistically significant correlation between the development of significant hypocalcemia and gender, age, thyroid pathology other than goiter, or neck dissection. Conclusion: Patients with a positive serum calcium slope (t = 6 and 12 hours) after total thyroidectomy are safe to discharge within 24 hours after surgery with patient education with or without calcium supplementation. In addition, patients with a nonpositive slope and a serum calcium level ,8 mg/dL at 12 hours postoperatively (,0.5 mg/dL below the low end of normal) are unlikely to develop significant hypocalcemia, especially beyond 24 hours postoperatively, and therefore can be safely discharged within 24 hours after total thyroidectomy with patient education and oral calcium supplementation. Our management algorithm identifies those patients at low risk of developing significant hypocalcemia early in the postoperative course after total thyroidectomy to allow for a short hospital stay and safe discharge. [source] Lipotransfer as an Adjunct in Head and Neck ReconstructionTHE LARYNGOSCOPE, Issue 9 2003FRCS(C), Yadranko Ducic MD Abstract Objectives To present our technique of lipotransfer and to evaluate a single center's experience in the use of lipotransfer as an adjunct to head and neck reconstruction. Study Design A retrospective review of all patients undergoing lipotransfer over a 5-year period by the senior author was undertaken. A total of 23 patients with a minimum follow-up of 1 year were available for analysis. Methods Patient records were retrospectively reviewed to assess functional (in the case of palate augmentation) and esthetic outcomes. Results Twenty-three patients undergoing lipotransfer as part of their reconstructive effort included (1) eight patients undergoing temporal fossa augmentation following temporalis muscle flap reconstruction for extirpative skull base surgery, (2) six patients undergoing facial defect augmentation following traumatic atrophy, (3) three patients undergoing palatal augmentation for correction of velopharyngeal insufficiency, and (4) six patients undergoing soft tissue augmentation following flap reconstruction of the face. Twenty of the 23 patients had excellent maintenance of graft volume. An adequately vascularized recipient bed appears to be an important factor in determining ultimate graft survival using our technique. Conclusions Lipotransfer of the head and neck represents a simple, effective adjunctive technique providing for large amounts of readily available, well-tolerated soft tissue filler material. Patient selection is important, specifically in regard to determining that there is adequate vascularity of the recipient bed. [source] Hereditary Hemorrhagic Telangiectasia: A Review of 76 Cases,THE LARYNGOSCOPE, Issue 5 2002Rahul K. Shah MD Abstract Objectives/Hypothesis Hereditary hemorrhagic telangiectasia has long been viewed as a rare condition. Recent evidence indicates that the disorder is more frequent than previously thought. Recalcitrant epistaxis is a salient feature of this disease, and the otolaryngologist is often called on to make the diagnosis and guide the primary management of patients with hereditary hemorrhagic telangiectasia. Wider recognition of this condition, awareness of the natural history and associated findings, appropriate workup and screening for arteriovenous malformations (lungs, brain, liver), and knowledge of appropriate interventions can help avoid the considerable morbidity associated with hereditary hemorrhagic telangiectasia. Study Design Retrospectivereview. Methods Records of patients treated by the senior author (s.m.s.) for hereditary hemorrhagic teleangiectasia from 1993 to 2000 were reviewed. Results Seventy-six patients were identified, 98% of whom had epistaxis as their presenting complaint, with 75% having a family history of hereditary hemorrhagic telangiectasia. The severity of epistaxis varied in the patients: 66% had mild, 21% moderate, and 13% severe epistaxis. Sixty-four percent of patients had no transfusions, 25% had 1 to 10 transfusions, and 11% of patients had more than 10 transfusions. Complications of hereditary hemorrhagic telangiectasia were documented in 30% of patients. Screening for arteriovenous malformations was performed in only 34% of patients. Eighty-two percent of patients received a variable number of Nd:YAG laser treatments. Conclusions The study presents the largest retrospective review of patients treated for hereditary hemorrhagic telangiectasia by a single otolaryngologist. The importance of a multidisciplinary approach facilitated by the otolaryngologist for evaluation of concomitant complications and morbidity (arteriovenous malformations) from hereditary hemorrhagic telangiectasia is demonstrated. An algorithm for controlling the epistaxis is presented. [source] Nephron-sparing surgery: a call for greater application of established techniquesBJU INTERNATIONAL, Issue 10 2008James G. Young OBJECTIVES To examine the results of open partial nephrectomy (OPN) over a 15-year period in a large UK teaching hospital and to compare results with other series including minimally invasive techniques, as nephron-sparing techniques are still under-utilized in the surgical treatment of renal carcinoma. A standardized technique is described that we think minimizes the risk of postoperative urinoma. PATIENTS AND METHODS We retrospectively reviewed a series of 141 patients who underwent OPN performed over a 15-year period in one centre by the senior author (D.M.A.W.). A notable feature of this series compared with others is the high proportion of patients undergoing other major synchronous surgery. RESULTS In all, 141 patients underwent 147 OPNs, with six undergoing bilateral procedures, of which 82 were for imperative indications (single kidney, bilateral synchronous tumours, or pre-existing renal impairment). There were three perioperative deaths, two in patients undergoing other synchronous major surgery. In all, 38 patients had postoperative complications: 28 patients required blood transfusion (four required intervention for their bleeding), five required acute dialysis and three late dialysis. There was a 90% cancer-specific survival rate at a median follow-up of 2 years. CONCLUSIONS This series confirms the trend towards improved outcomes and decreased complications in OPN at a time when its place is challenged by minimally invasive techniques. [source] Laparoscopic emergency and elective surgery for ulcerative colitisCOLORECTAL DISEASE, Issue 4 2008L. Fowkes Abstract Objective, To analyse surgical outcomes of fulminate and medically resistant ulcerative colitis (UC) carried out laparoscopically. Method, A prospective database identified 69 consecutive patients who underwent surgery for UC under the senior author over a 5-year period to April 2006. Results, Thirty-two patients (18 male patients), median BMI 26, underwent laparoscopic subtotal colectomy (LSTC): 22 acute emergencies, 10 refractory to medical therapy and unfit for restorative proctocolectomy. All were receiving iv steroids; azathioprine (7), cyclosporin (5). The median operation time was 135 min (65,280). There was one conversion. Twenty-nine patients have subsequently undergone completion proctectomy and W-pouch formation [24 patients were performed laparoscopically , laparoscopic completion proctectomy (LCP)]; widespread adhesions precluded in five patients. Twenty-six patients underwent restorative laparoscopic proctocolectomy (LRP) , one conversion. Twenty patients underwent W-pouch reconstruction via a Pfannenstiel incision. Six J-pouches were constructed and returned via the ileostomy site. Three underwent a laparoscopic pan-proctocolectomy (LPPC); one conversion. Eight patients underwent open STC. The median time to normal diet was 48 h (1,7 days) for LSTC/LCP and 36 h (1,5 days) for LRP. There were two major complications following LRP, two following LSTC, one following LCP, one following LPPC and five following open surgery. Median hospital stay was 8 days (6,72) for LSTC, 7 days (6,9) for LCP and 5 days (3,45) for LRP. There were six 30-day readmissions following laparoscopic surgery (DVT, reactive depression, ileostomy hold up (2), abdominal pain and high output ileostomy). Conclusion, Laparoscopic subtotal and restorative proctocolectomies in fulminate and medically resistant UC are feasible, safe and largely predictable operations that allow for early hospital discharge. Laparoscopic colectomy facilitates subsequent proctectomy and pouch construction. [source] | ||||||||||||||||||||||