Biology and Biomechanics in Osteosynthesis of Proximal Humerus Fractures

Abstract Surgical treatment of proximal humeral fractures still remains a challenge. This is primarily due to the fact that sufficient implant fixation in humeral head fractures is often not achieved due to substantial bone tissue loss with increasing age. In the last few years the locking plates and locking nails have been introduced into clinical practice with varying results. The biomechanical studies have focused on locking plate osteosynthesis as well. The following paper focuses on bone quality, biomechanical studies and biology of proper osteosynthesis and reviews the most recent literature.     

Intraoperative radiotherapy (IORT) is an option for patients with localized breast recurrences after previous external-beam radiotherapy

Background  

For patients suffering of recurrent breast cancer within the irradiated breast, generally mastectomy is recommended. The normal tissue tolerance does not permit a second full-dose course of radiotherapy to the entire breast after a second breast-conserving surgery (BCS). A novel option is to treat these patients with partial breast irradiation (PBI). This approach is based on the hypothesis that re-irradiation of a limited volume will be effective and result in an acceptable frequency of side effects. The following report presents a single center experience with intraoperative radiotherapy (IORT) during excision of recurrent breast cancer in the previously irradiated breast.     

Effects of hypertension and type 2 diabetes mellitus on the risk of total cardiovascular events in Japanese patients with hypercholesterolemia: implications from the Japan Lipid Intervention Trial (J-LIT).

Hyperlipidemia, hypertension, and diabetes mellitus (DM) are well-established risk factors for cardiovascular disease. We analyzed the cardiovascular events in hyperlipidemic patients with or without DM who were administered open-labeled simvastatin in groups stratified by blood pressure level using data from the Japan Lipid Intervention Trial (J-LIT). Hyperlipidemic patients with DM (n=6,288) had significantly more cardiovascular events than those without DM (n=33,933). The incidence rates of total cardiovascular events in the Non-DM and DM groups were 15.40 and 25.76 per 1,000 patients for the 6-year period, respectively. The relative risk of total cardiovascular events in the DM vs. the Non-DM group was 1.68, and the relative risk was significantly higher in the DM than in the Non-DM group. The relative risks of total cardiovascular events were significantly higher in DM and Non-DM patients whose systolic blood pressure (SBP) was greater than or equal to 130 mmHg compared to that of Non-DM patients whose SBP was less than 130 mmHg, and in DM and Non-DM patients whose diastolic blood pressure (DBP) was greater than or equal to 80 mmHg compared to that of Non-DM patients whose DBP was less than 80 mmHg. In all groups stratified by SBP and DBP, relative risks of total cardiovascular events were higher in DM patients than in Non-DM patients. For patients with hypercholesterolemia and DM, blood pressure should be strictly controlled in order to prevent both coronary events and stroke. These results are in good agreement with the JNC 7 and the ESH/ESC guidelines for DM patients, which recommended that the SBP and DBP be less than 130 and 80 mmHg, respectively.     

Urological emergency in neonates with congenital hydronephrosis

OBJECTIVE: It is well described that unilateral pelviureteric junction obstruction (PUJO) is a benign condition, because the dilatation resolves spontaneously and the function does not decrease in most of the kidneys. However, there is exceptional PUJO that requires emergent treatment in neonatal periods. The aim of this article is to report the urological emergency and management in neonates with PUJO. MATERIALS AND METHODS: Nine children (seven boys and two girls) with PUJO who underwent neonatal emergent treatment during the last 13 years were reviewed. Renal function was evaluated according to decay curve of serum creatinine (SCr) levels corresponding to gestational age (GA) at delivery. Physical examination, ultrasonographic monitoring, and chest and abdominal plain radiographs were repeated in each neonate. RESULTS: Eight patients were detected prenatally. In five patients, multicystic dysplastic kidney (MCDK) was demonstrated on the contralateral side. Three patients underwent percutaneous puncture of fetal hydronephrosis. Decrease of amniotic fluid was evident in three fetuses. Indications for emergent treatment included mass effect from hydronephrosis in three patients, renal dysfunction in five, and severe urinary tract infection in one. During neonatal periods, a percutaneous nephrostomy tube was placed in seven, and open nephrostomy in one with anorectal malformation. Repeated punctures of the dilated renal pelvis were done in one patient. Renal function after pyeloplasty was stable in eight patients, while it was moderately decreased in one who was associated with oligohydramnios in utero. CONCLUSION: Indications for emergent treatment in neonates with PUJO included mass effect from giant hydronephrosis, renal dysfunction and severe urinary tract infection. At birth, respiratory and circulatory conditions must first be stabilized. In neonates with hydronephrosis of the solitary kidney or severe bilateral PUJO, serial SCr should be monitored to evaluate renal function. Decrease of amniotic fluid suggested renal functional compromise that would not recover after urological management.     

Surgical treatment for ureterocele with special reference to lower urinary tract reconstruction

OBJECTIVES: We reviewed the results of surgical treatment for children with ureterocele, especially addressing the importance of the lower urinary tract reconstruction. METHODS: We present medical records of 91 children with ureterocele (31 with the intravesical type, and 60 with the ectopic type) treated during the last 14 years. As the initial treatment, we carried out transurethral incision of the ureterocele (TUI). In patients with persistent reflux, breakthrough urinary tract infection (UTI), or signs of bladder outlet obstruction due to a collapsed cele wall, we recommended that patients undergo lower urinary tract reconstruction irrespective of the renal function involved in ureterocele. The average follow-up period was 5 years (ranging 1 year and 6 months to 14 years). RESULTS: Transurethral incision of the ureterocele was carried out as the initial treatment on 68 patients (75%). A total of 34 patients (21 intravesical [68%] and 13 ectopic [22%]) were followed medically after TUI alone. Reconstruction of the lower urinary tract was carried out in 59 patients (65%). Nephroureterectomy combined with bladder level reconstruction was carried out in four children with single system and non-functioning kidney. Follow-up voiding cystourethrography showed that only one girl had reflux, which disappeared after the first follow-up examination. Postoperative UTI occurred in 12 patients (20%) with ectopic ureterocele. Voiding dysfunction was suspected in eight patients. CONCLUSION: We believe that the primary objective for patients with ureterocele, especially of the ectopic type, is to reconstruct the original pathology of the lower urinary tract that may give rise to reflux, obstruction, or abnormalities of urination. Although surgery at the bladder level can be challenging, the lower urinary tract reconstruction successfully corrects the vesicoureteral reflux and bladder outlet pathology under a cosmetically acceptable incision.     

The laterally extended medial hemisoleus flap for reconstruction of a tibial wound in the distal third of the leg

A soleus flap as a local reconstructive option for soft-tissue coverage of a tibial wound in the distal third of the leg has never been well recognized. In a 2-year period, seven patients underwent reconstruction of a less extensive tibial wound (4 × 3 to 10 × 4 cm) in the distal third of the leg after orthopedic trauma with the laterally extended medial hemisoleus flap. The flap was elevated with emphasis on the preservation of the most distal perforators from the posterior tibial vessels to the flap as possible while allowing adequate rotation of the flap to cover the exposed tibia and/or hardware and on the possible preservation of foot planter flexion by reconstruction of the proximal Achilles’ tendon. In this series, there was no total or partial flap loss. All patients healed their tibial wounds primarily with reliable soft-tissue coverage, evidenced fracture healing, and good cosmetic outcome during follow-up. Thus, the laterally extended medial hemisoleus flap described by the author can be a reliable option for soft-tissue coverage of a less extensive tibial wound in the distal third of the leg. It offers a more cost-effective approach for managing this unique problem and can be performed by most reconstructive surgeons without microsurgical expertise.     

The effect of sucralfate,an agent for gastroprotection on the healing of split thickness skin graft donor sites

Skin is the most commonly used tissue for the transplantation. A meticulous care of the donor site is needed to prevent scarring, delayed healing, and pain. Various agents and dressing materials have been reported to help healing of skin graft donor sites. Sucralfate is an extensively used agent, which provides acute gastroprotection and acceleration of chronic ulcer healing. In this study, we assessed the effects of topical sucralfate on the healing of the split thickness skin graft donor sites in a prospective comparative way. The study was carried out on 32 randomly chosen patients undergoing surgery for various causes and requiring split thickness skin graft resurfacing. The upper halves of the skin graft donor sites on the thighs were simply covered with paraffin gauze and the lower half was covered with sucralfate-soaked paraffin gauzes. The day of full epithelization varied from 6 to 9 days and 8–12 days on the sucralfate-applied areas and on the control sites, respectively. The mean value of the healing was 7.01 days in the studied lower halves and 10.8 days in the upper halves. The healing rate was strikingly faster and less painful on the sucralfate-applied areas. We were able to discharge patients earlier than usual, and patients’ comfort increased. It seems that sucralfate is a promising topical agent to increase the healing rate and decrease the incidence of associated problems such as pain and hypertrophic scar.     

New wound protection for rabbits

Rabbits are the experimental animals of choice in many studies including flaps, wounds, and topical trials for new pharmacological agents. Because the topical drugs and other materials used for dressing are irritating to the animal, they tend to remove dressings, bandages, drapes, insensate flaps, and also topical drugs by scratching, licking, and biting if they are within the reach of the animal. In this study, we report an easy to prepare, user-friendly, comfortable, and cheap dressing protector called a dressing shield to prevent these problems.