Comparison of posterolateral approach and combined approach in treatment of Mason type 2B posterior malleolar fracture / 中国修复重建外科杂志

OBJECTIVE@#To compare the effectiveness between the posterolateral approach and the posterolateral combined posteromedial approaches in the treatment of Mason type 2B posterior malleolar fracture.@*METHODS@#A retrospective analysis was performed on the clinical data of 79 patients with posterior ankle fracture who met the selection criteria between January 2015 and January 2022. There were 62 cases of Mason 2B Pilon subtype and 17 cases of avulsion subtype. Among Mason 2B Pilon subtype patients, 35 were treated with posterolateral approach (group A), 27 patients were treated with combined approach (group B). There was no significant difference in gender, age, injured side, cause of injury, time from injury to operation, preoperative hospital stay, preoperative visualanalogue scale (VAS) score, and intraoperative internal fixation between the two groups ( P>0.05). All patients with Mason 2B avulsion subtype were treated by posterolateral approach, including 7 males and 10 females, aged from 25 to 68 years, with an average of 46.1 years. The operation time, intraoperative blood loss, postoperative hospital stay, and complications were recorded. The reduction quality was evaluated by Ovadia deals radiographic score, and the ankle function and pain were evaluated by VAS score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and ankle range of motion.@*RESULTS@#Mason 2B Pilon subtype: There was no significant difference in operation time, intraoperative blood loss, postoperative hospital stay, and follow-up time between the two groups ( P>0.05). The radiological evaluation of Ovadia deals in group A was significantly worse than that in group B ( P<0.05). The VAS score in the two groups significantly improved at each time point after operation, and the VAS score and AOFAS score further improved with the extension of time after operation, and the differences were significant ( P<0.05). Except that the AOFAS score of group A was significantly lower than that of group B at last follow-up ( P<0.05), there was no significant difference in VAS score and AOFAS score between the two groups at other time points ( P>0.05). At last follow-up, the ankle range of motion in group A was significantly less than that in group B ( P<0.05). There was no significant difference in the incidence of sural nerve injury, deep tissue infection, limitation of toe movement, and traumatic ankle arthritis between the two groups ( P>0.05). Mason 2B avulsion subtype: The operation time was (119.47±20.61) minutes and the intraoperative blood loss was 50 (35, 55) mL. Seventeen patients were followed up 13-25 months, with an average of 18 months. The Ovadia deals score was excellent in 10 cases, good in 6 cases, and poor in 1 case at 1 week after operation, and the excellent and good rate was 94.1%. All fractures healed in 8-18 weeks with an average of 12.35 weeks. There were 1 case of sural nerve injury and 3 cases of traumatic ankle arthritis after operation. No deep tissue infection or limitation of toe movement occurred. The VAS score decreased significantly and AOFAS score increased significantly with time, and the differences were significant between different time points before and after operation ( P<0.05). The ankle range of motion at last follow-up was (56.71±2.47)°.@*CONCLUSION@#Compared with the posterolateral approach, the combined approach is a better choice for the treatment of Mason 2B Pilon subtype. If the posteromedial bone block does not affect the reduction of the medial malleolus, the posterolateral approach can achieve good effectiveness for Mason 2B avulsion subtype.

An alternative surgical approach to cemento-ossifying fibroma of the maxilla

Objective@#To report an alternative combined gingivobuccal and endoscopic endonasal approach to treating ossifying fibroma of the left maxilla.@*Methods@#Design: Case Report. Setting: Tertiary Private University Hospital. Patient: A 19-year-old girl with a progressively enlarging left cheek mass for 3 years.@*Results@#Our patient underwent left medial maxillectomy via a combined gingivobuccal and endoscopic endonasal approach with complete resection and significant improvement of symptoms, with good functional outcome.@*Conclusion@#Large ossifying fibromas of the maxilla can be completely and successfully excised via a combined gingivobuccal and endoscopic endonasal approach.

Abordaje combinado Kocher-Langenbeck y Stoppa en el tratamiento de fracturas complejas de acetábulo / Combined Kocher-Langenbeck and Stoppa approach in the treatment of complex acetabulum fractures

Resumen: Introducción: Las fracturas de acetábulo complejas son un desafío para los cirujanos ortopedistas. Se realizó una evaluación de la reducción radiográfica y resultado funcional de los pacientes con fractura compleja de acetábulo sometidos a abordaje combinado Kocher-Langenbeck y Stoppa. Material y métodos: Diseño transversal, descriptivo, ambispectivo. Se incluyeron pacientes con fractura compleja de acetábulo que se sometieron a abordaje combinado Kocher-Langenbeck y Stoppa entre 2016 y 2020. Se revisaron los expedientes clínicos y se evaluó la calidad de la reducción radiográfica según criterios de Matta. Además, se realizó evaluación funcional con la escala de Merle d'Aubigné y Postel pasados por lo menos 12 meses de la lesión. Resultados: De los 31 pacientes, el tiempo promedio entre la fecha de fractura y la intervención quirúrgica fue de 13.7 días (de tres a 38 días). En la evaluación radiográfica según criterios de Matta, 21 pacientes tuvieron resultados radiográficos anatómicos (67.7%), siete casi anatómicos (22.5%) y tres imperfectos (9.6%). Los resultados funcionales según la escala Merle d'Aubigné y Postel dieron como resultado ocho pacientes (25.8%) con resultados excelentes, 16 (51.6%) con resultado bueno, con resultado moderado cinco (22.5%) y con resultado malo dos (16.1%). Hubo correlación estadística entre la edad del paciente con el resultado funcional (p = 0.029), también entre el índice de masa corporal y pérdida sanguínea (p = 0.027). Conclusión: Los abordajes combinados Kocher-Langenbeck y Stoppa son una alternativa en estas lesiones, en su mayoría con resultados radiográficos anatómicos y casi anatómicos, según la escala radiográfica de Matta, y con excelentes y buenos resultados funcionales, según la escala de Merle d'Aubigné y Postel.

Abstract: Introduction: Complex acetabulum fractures are a challenge for orthopedic surgeons. An evaluation of the radiographic reduction and functional result of the patients with complex fracture of the acetabulum who underwent the combined Kocher-Langenbeck and Stoppa approach was carried out. Material and methods: Cross-sectional, descriptive, ambispective design. Patients with complex acetabulum fracture who underwent the combined Kocher-Langenbeck approach plus Stoppa between 2016 and 2020 were included. The clinical records were reviewed, and the quality of the radiographic reduction was evaluated according to Matta criteria. In addition, a functional evaluation was performed with the Merle d'Aubigne and Postel scale at least 12 months after the injury. Results: Of the 31 patients, the average time between the date of fractures and the surgical intervention was 13.7 days (3-38 days). In the radiographic evaluation according to Matta criteria, 21 anatomical patients (67.7%), 7 almost anatomical (22.5%), 3 imperfect (9.6%). Functional results according to the Merle d'Aubigne and Postel scale resulted in 8 (25.8%) with excellent results, 16 (51.6%) with good results, 5 (22.5%) moderate and 2 (16.1%) poor patients. There was a statistical correlation between the age of the patient and the functional result (p = 0.029), also between the body mass index and blood loss (p = 0.027). Conclusion: The combined Kocher-Langenbeck plus Stoppa approaches are a valid alternative in these lesions, mostly with anatomical and almost anatomical radiographic results according to the Matta radiographic scale, and with excellent and good functional results according to the Merle d'Aubigne and Postel scale.

​Analysis of Functional Outcome of Column-specific Fixation of Complex Tibial Plateau Fractures: A Prospective Study

Introduction: Most complex tibial plateau fractures are a result of the high-energy injury. Resulting comminution makesinterpreting of fracture patterns difficult. Fully understanding these fractures is the basis for successful treatment.Aim: The aim of this study was to analyze the functional and radiological outcome of column-specific fixation of tibial plateaufracture.Materials and Methods: This was a prospective cohort study; 10 patients with tibial plateau fractures with displaced complextibial plateau fractures operated at Government Rajaji Hospital, Madurai, were included in this study. The follow-up period was36 months. The fractures were evaluated by computed tomography using Lu three-column concepts and managed with lowprofile locking plate system as per column-specific fixation. Follow-up analysis was made using Modified Rasmussen’s Clinicaland Radiological Criteria.Results: In our study, 70% of the patients were in active productive age group (30–50 years). 90% of the patients were male.30% of single-column fractures (LUO) (Schatzker type IV 10% and Hohl and Moore Type I coronal split fracture 20%), 30% oftwo-column fracture (LUO) (Schatzker Type IV 20% and Type V 10%), and 40% of three-column fractures (LUO) (SchatzkerType V 40%) were included. In this study, 40% of patients had an excellent outcome, 50% of patients had a good outcome,10% of patients had poor clinical, and 10% had fair radiological outcome. One patient developed wound necrosis, for whichflap cover is done and eventually patient developed deep infection for whom implant removal was done after 6 months.Conclusion: Three-column fixation is a new fixation concept in treating complex tibial plateau fractures, especially useful formultiplanar fractures involving posterior column with excellent functional outcome.

The clinical outcomes comparison of combined versus staged approach on concomitant carotid and coronary severe stenosis patients / 中华胸心血管外科杂志

Objective To compare the outcome of combined and staged approach on concomitant carotid and coronary severe stenosis.Methods From March 2013 to May 2015,27 patients with concomitant carotid and coronary severe stenosis were treated by carotid endarterectomy and coronary artery bypass grafting,15 cases received one-stage operation and 12 staged.The basic characteristics,details during surgery,complications,quality of life score,hospital stay and cost were compared.Results 27 patients received carotid endarterectomy and off-pump coronary artery bypass grafting under general anesthesia.Revascularization were performed on 27 carotid and 82 coronary artery.The characteristics of patients were similar between two groups,reflected with WIC,combined approach subgroup was (5.27 ± 0.88) and staged subgroup was (4.92 ± 1.24).The operation time was significantly decreased in the synchronous group [(295.33 ± 49.73)min vs (390.83 ± 73.45) min,P ＜ 0.001].Hospital stay days was also reduced [(30.20 ± 12.91) days vs(44.67 ± 6.34) days,P =0.002],the medical cost was lower in combined approach group,but no significant statistical difference.The complications including 1 case TIA,1 recurrent nerve injury in one-stage group and 1 case myocardial infarction,1 mediastinal bleeding post-operation and 1 pulmonary infection in stage group.No cerebral infarction and death.Quality of life scores(SF-36) of the two groups was 5.53 ± 1.30 and 5.75 ± 1.36 respectively,no significant difference.Conclusion The efficacy and safety of treatment for concomitant carotid and coronary severe stenosis patients with combined or staged approach was similar.But the combined approach program can reduce the hospital stay time and cost in some degree.

Lateral elbow approach combined with anterior median approach in treatment of terrible triad of elbow / 局解手术学杂志

Objective To analyze the clinical efficacy of lateral elbow approach combined with anterior median approach in the treatment of terrible triad of elbow.Methods Retrospectively analyzed 20 patients of terrible triad elbow who were admitted into our hospital from April 2012 to January 2015 and treated with lateral elbow approach combined with anterior median approach.The postoperative recovery of arthrosis,forearm rotation range,and range of motion were evaluated by Mayo score system.Results All patients wounds were with primary healing.There were 11 cases of excellent and 4 cases of good through Mayo score system,with the good rate of 75％.At the final follow-up,the range of motion was (122.06 ± 24.17) ° and the forearm rotation was (136.28 ± 8.9) °.Conclusion Lateral elbow approach combined with anterior median approach for the treatment of terrible triad of elbow has clear visual field,excellent surgical rate,without complications such as elbow instability and nerve damage.

The Versatile Approach: A Novel Single Incision Combined with Anterior and Posterior Approaches for Decompression and Instrumented Fusion to Treat Tuberculosis of the Thoracic Spine

STUDY DESIGN: Retrospective case series. PURPOSE: To describe a novel single incision that combines anterior and posterior approaches for decompression and instrumented fusion to treat tuberculosis of the thoracic spine and study the neurological and radiological outcomes. OVERVIEW OF LITERATURE: Tuberculosis of the spine remains a major health issue in many developing countries. The options for treating tuberculosis of the thoracic spine include the anterior, posterior, and combined approaches, each with its advantages and disadvantages. METHODS: Totally, 143 patients with tuberculosis of the thoracic spine were surgically treated using the “Versatile approach”. Posterior fixation was performed using sublaminar wires and a Hartshill rectangle in all patients. Anterior reconstruction was accomplished using bone graft harvested from autologous rib, iliac crest, or fibula. RESULTS: The study included 45 males and 98 females, with a mean age of 33.18±18.65 years (range, 3–82 years) and a mean follow-up of 60.23±24.56 months (range, 18–156 months). Kyphosis improved from a mean value of 24.02 preoperatively to 10.25 postoperatively. A preoperative neurological deficit was observed in 131 patients, with 130 patients regaining ambulatory power. No patient had deterioration of neurological status following surgery. Fusion was achieved in all cases. The visual analogscale score improved from an average score of 7.02 preoperatively to 1.51 at final follow-up. Eight patients had superficial macerations, which healed spontaneously. One patient had buckling of the anterior graft, and one patient had implant breakage following road traffic accident. CONCLUSIONS: The “Versatile approach” is an effective, single-stage, single-incision method that combines anterior and posterior approaches for the surgically treating tuberculosis of the thoracic spine. It offers the advantage of direct visualization for decompression and reconstruction of the anterior and posterior vertebral columns, thus providing an excellent, long-lasting clinical outcome.

Abordaje combinado en columna toracolumbar para los tumores / Approach combined in thoracolumbar spine for tumors

Introducción: el progreso de la imaginología, la supervivencia del paciente oncológico y el desarrollo de instrumentaciones cortas, aumentó el interés por el uso de abordajes combinados. Objetivo: exponer la experiencia del servicio de ortopedia del Hospital Clínico Quirúrgico Hermanos Ameijeiras en abordaje combinado de columna toracolumbar. Descripción: se presentaron 5 casos con procesos tumorales del segmento toracolumbar en los que se empleó abordaje combinado, operados en el servicio de ortopedia desde febrero de 2007 hasta mayo de 2011; se reflejó edad, sexo, tipo de tumor. Se evaluó el dolor (por la escala Denis) y el estado neurológico (por la escala Frankel) preoperatorio y posoperatorio, así como las complicaciones. Resultados: en los pacientes menores de 50 años predominó el sexo femenino y los tumores primarios; 4 pacientes tenían en el preoperatorio un estado Frankel C y en todos se logró pasar a E. En cuanto al dolor por la escala Denis que era entre 3 y 4, pasaron a 0 y 1. Como complicaciones se presentó una luxación del injerto con sepsis profunda, así como 2 desgarros del saco dural. Conclusiones: el abordaje combinado se presenta como opción ventajosa y recomendable de tratamiento quirúrgico en los tumores espinales

Introduction: the progress of imaging, the survival of oncology patient and the development of short instrumentations increased the interest by the use of combined approaches. Objective: to expose the experience of the Orthopedics service of Hermanos Ameijeiras Clinical Surgical Hospital in the combined approach of thoracolumbar spine. Description: authors present 5 cases presenting with tumoral processes of thoracolumbar segment using a combined approach, operated on above mentioned service from February, 2007 to May, 2011. Following variables were included: age, sex, and type of tumor. Pain was assessed (Denis) and the preoperative and postoperative neurologic status (Frankel), as well as the complications. Results: in patients aged under 50 there was predominance of female sex and of primary tumors: in preoperative period 4 patients had a C Frankel and in all of them it was possible to move to E. As regards the Denis pain between 3 and 4 moving to 0 and 1. Complications included graft luxation with a deep sepsis, as well as two dural sac tears. Conclusions: the combined approach is an advantageous and recommendable option for surgical treatment in spinal tumors

The Comparative Study between Combined and Posterior Surgical Treatments for Post-traumatic Kyphosis / 대한정형외과학회잡지

PURPOSE: We wanted to analyse the differences of the radiological and clinical results between the combined approach and the posterior approach for treating posttraumatic kyphosis in elderly patients and to determine the risk factors for the loss of correction after the operation. MATERIALS AND METHODS: Between September 2004 and August 2009, 19 patients who underwent an operation for posttraumatic kyphosis and were follow-up for at least one year were included in this study. The combined approach (A group) was done for 10 patients, while the posterior approach (B group) was done for 9 patients. Radiological study and clinical evaluation, including the Korean version of the Oswestry disability index and the visual analog scale (VAS), were performed before surgery, after surgery and at the final follow-up. The risk factors related to the loss of correction of kyphosis at the fracture site were analyzed. RESULTS: In group A, the mean kyphotic angles were 35.2 before surgery, 11.1 degrees after surgery and 15.7 degrees at the final follow-up. There was 24.1 degrees (correction; 68.5%) of correction of the kyphotic angle with 4.6 degrees (19%) loss of correction. In group B, the mean kyphotic angles were 34.2 before surgery, 9.3 degrees after surgery and 13.8 degrees at the final follow-up. There was 24.9 degrees (72.8%) correction of the kyphotic angle with 4.5 degrees (18.3%) loss of correction. The clinical data was improved to the same degrees. The loss of correction was statistically correlated with osteoporosis. CONCLUSION: In conclusion, the posterior approach can correct the posttraumatic kyphosis in a fashion similar to that of the combined approach. The patient's osteoporosis should be thoroughly treated for preventing correction loss.

Clinicopathological features of retrorectal tumors in adults: 9 years of experience in a single institution / 대한외과학회지

PURPOSE: Primary tumors of the retrorectal space in adults are very rare. Most of them are benign masses, but malignant masses are reported on occasion. This study aimed to investigate the clinicopathological features of retrorectal tumors. METHODS: The medical records of fifteen patients who underwent surgical resection of a retrorectal tumor from March 2002 to April 2010 in our hospital were reviewed retrospectively. RESULTS: Out of 15 patients, thirteen were females and two males. About 1.7 patients were diagnosed with retrorectal tumor annually in our hospital. The incidence is one per 1,500 surgeries performed under general anesthesia. An anterior approach was performed in eight patients and a posterior approach with excision of the coccyx in five patients. Combined approach was performed in two patients. Four patients (three in abdominal approach and one in combined approach) underwent laparoscopic resection. The mean size of tumors was 6.2 +/- 2.9 cm. Mature teratoma (four) and neurilemmoma (four) were the most common tumors. Except for one case of chondrosarcoma, fourteen tumors were confirmed to be of benign nature in histologic examination. Patients who underwent a transabdominal approach with laparoscopic surgery had no postoperative complication and had a tendency to experience earlier recovery than those with open surgery. CONCLUSION: Surgical resection of a retrorectal tumor is recommended to relieve pressure symptoms and to confirm the diagnosis. A laparoscopic approach may offer excellent visualization of the deep structures in the retrorectal space, reduce surgical trauma, and be helpful for early postoperative recovery.

Combination 20 and 23-gauge transconjunctival vitrectomy: A new approach.

The advent of smaller gauge instrumentation allows for minimally invasive vitreoretinal surgery (MIVS) as compared to conventional pars plana vitrectomy. Sutureless posterior segment surgery has the advantages of faster wound healing, minimal surgical trauma, decreased convalescence period besides reduced postoperative astigmatism; however, slower gel removal and limited peripheral vitreous dissection are disadvantages with smaller gauge systems. We herein describe a new technique combining 23-gauge and 20-gauge vitrectomy to improve the effectiveness and outcomes of vitreoretinal surgery.

Setting research priorities by applying the combined approach matrix.

Background & objectives: Priority setting in health research is a dynamic process. Different organizations and institutes have been working in the field of research priority setting for many years. In 1999 the Global Forum for Health Research presented a research priority setting tool called the Combined Approach Matrix or CAM. Since its development, the CAM has been successfully applied to set research priorities for diseases, conditions and programmes at global, regional and national levels. This paper briefly explains the CAM methodology and how it could be applied in different settings, giving examples and describing challenges encountered in the process of setting research priorities and providing recommendations for further work in this field. Methods: The construct and design of the CAM is explained along with different steps needed, including planning and organization of a priority-setting exercise and how it could be applied in different settings. Results: The application of the CAM are described by using three examples. The first concerns setting research priorities for a global programme, the second describes application at the country level and the third setting research priorities for diseases. Interpretation & conclusions: Effective application of the CAM in different and diverse environments proves its utility as a tool for setting research priorities. Potential challenges encountered in the process of research priority setting are discussed and some recommendations for further work in this field are provided.

Clinical Presentation and Management of Jugular Foramen Paraganglioma

OBJECTIVES: Jugular foramen paraganglioma is a locally invasive, benign tumor, which grow slowly and causes various symptoms such as pulsatile tinnitus and low cranial nerve palsy. Complete surgical resection is regarded as the ideal management of these tumors. The goal of this study is to identify the clinical characteristics and most effective surgical approach for jugular foramen paraganglioma. METHODS: Retrospective analysis of 9 jugular foramen paraganglioma patients who underwent surgical resection between 1986 and 2005 was performed. Clinical records were reviewed for analysis of initial clinical symptoms and signs, audiological examinations, neurological deficits, radiological features, surgical approaches, extent of resection, treatment outcomes and complications. RESULTS: Most common initial symptom was hoarseness, followed by pulsatile tinnitus. Seven out of 9 patients had at least one low cranial nerve palsy. Seven patients were classified as Fisch Type C tumor and remaining 2 as Fisch Type D tumor on radiologic examination. Total of 11 operations took place in 9 patients. Total resection was achieved in 6 cases, when partial resection was done in 3 cases. Two patients with partial resection received gamma knife radiosurgery (GKS), when remaining 1 case received both GKS and two times of revision operation. No mortality was encountered and there were few postoperative complications. CONCLUSION: Neurologic examination of low cranial nerve palsy is crucial since most patients had at least one low cranial nerve palsy. All tumors were detected in advanced stage due to slow growing nature and lack of symptom. Angiography with embolization is crucial for successful tumor removal without massive bleeding. Infratemporal fossa approach can be considered as a safe, satisfactory approach for removal of jugular foramen paragangliomas. In tumors with intracranial extension, combined approach is recommended in that it provides better surgical view and can maintain the compliance of the patients.

Mesenchymal Chondrosarcoma of the Cervical Spine

Mesenchymal chondrosarcoma is a rare tumor occurring in both bone and soft tissues and exhibits characteristic of a malignant nature. The authors experienced a case of mesenchymal chondrosarcoma occurring in a 23-year-old woman which had invaded the cervical spine. The patient presented with severe both shoulder pain, left upper extremity weakness(Grade IV) and paresthesia at admission. Radiologic studies of the cervial spine showed an aggressive osteolysis of C4 vertebral body, pedicle and lamina with compression of the spinal cord posteriorly on C3, C4, C5 levels. The tumor was totally removed by a combined anterior and posterior approach. The removed vertebral body was replaced with autogenous bone and stabilized by Codman locking plate symtem. The pathological examination showed characteristic of mesenchymal chondrosarcoma.previous symptoms well improved postoperatively. The authors present a case of mesenchymal chondrosarcoma with review of literature.

Combined Approach Operation for the Lumbar Spine Fractures according to 'The Load-sharing Classification'

BACKGROUND:Lumbar spine fractures treated conservatively or operatively may result in severe kyphotic deformity. Reliable operation plan should be made to prevent the development of delayed kyphosis in unstable lumbar spine fracture. STUDY DESIGN: Between September 1995 and March 1997, twelve cases with highly unstable lumbar spine fractures (7 according to'Load-sharing classification score') or fracture-dislocations were operated with combined retroperitoneal and posterior approach. The patients underwent anterior corpectomy, interbody fusion and short segment fixation with posterior transpedicular screws(1 level above and 1 level below). All patients were operated on the same day except one case. The patients were followed-up at least 12 months and mean follow-up period was 17.2 months after operation. The kyphotic angle was measured by Salter's method preoperative, immediate postoperative and at 12 months. RESULTS: There were 9 cases of burst fractures and 3 cases of fracture-dislocations. The mean kyphotic angle was 24degrees preoperatively, -5degrees postoperatively and -2degrees at 12 months follow-up. This means the patients regained normal lumbar lordosis after the operation and maintained on long term follow-up. There was no case of pseudoarthrosis or delayed kyphosis development during follow-up period. CONCLUSIONS: Highly unstable lumbar spine fracture with high load-sharing classification score could be treated to achieve normal lumbar lordosis immediate postoperatively and prevent kyphotic deformity on long-term follow-up evaluation with combined approach.

Long-term Curative Effective analyse of Open Mastoidectomy With Tympanoplasty(OMT)and Combined Approach Tympanoplasty(CAT) / 听力学及言语疾病杂志

Objective To discuss the surgical interference of chronic suppurative otitis media and it's long-term results.Methods In 113 cases of mastoidectomy with tympanoplasty followed up for 3 years,We discuss the results of recurrence and hearing levle of the open-mastoidectomy with tympanoplasty(OMT)and combined approach tympanoplasty(CAT).Results There is no significant difference between OMT(improved 12 dB HL)and CAT(improved 9.5 dB HL)in the improved hearing threshold leve.The recurrence rate of OMT was 5.8%,but the CAT was 24.4%,the difference is significant.Conclusion The effect of OMT is better than that of CAT for the long-term resulls in these cases.

Surgical Removal of Large Petroclival Meningiomas: the Transpetrosal Approach

For surgery involving complex lesions of the petroclival region, the transpetrosal approach-which may be anterior or posterioris known to have distinct advantages over traditional approaches. Six patients with large petroclival meningiomas(over 4.5cm), underwent surgery. In three cases, where the lesion extended only into the posterior fossa, the posterior transpetrosal approach was used, and in the other three, where it extended into the Meckels cave or cavernous sinus, surgery involved a combined anterior-posterior transpetrosal approach. In three cases with serviceable hearing, the retrolabyrinthine technique was employed, the remaining three, without serviceable hearing, were subjected to the translabyrinthine technique. Total removal was achieved in three cases(50%), and no patient died. Immediate postoperative neurological dysfunction appeared in all cases; almost all involved new cranial nerve deficit. As time passed, this dysfunction became less serious, though in four cases, it was permanent; there was mild to moderate hemiparesis in two cases and facial nerve paralysis in two. The surgical outcome was good in four cases, fair in one and poor in one. The authors suggest that the selection of surgical approach to petroclival meningiomas should be based upon the size and location of the tumor, the extent of dural attachment and the status of the patient's hearing. For a high-risk group, with brain stem invasion, arterial and cranial nerve encasement and cavernous sinus invasion, subtotal resection of the tumor is recommended.

Surgical Experiences of Transpetrosal Approach in Petroclival Lesions

This is a report of 15 consecutive cases of petroclival lesions performed by transpetrosal approach over five years. Pathologies from these cases include 13 cases of tumors and two cases of aneurysms. All cases of tumors were over 4.5cm in size. Two cases of very low-lying basilar bifurcation aneurysms and one case of facial schwanoma extended to the petrosal tip and temporal fossa were operated with anrerior transpetrosal approach, where as nine cases of petroclival tumor which was localized in the posterior fossa were operated via posterior transpetrosal approach. Of these nine cases, one case with lower clival extension was removed totally by adding a retrosigmoid dural opening. Remaining three cases extended to the Meckel's cave or cavernous sinus were operated by combined anterior-posterior transpetrosal approach. Of the 12 cases done with posterior transpetrosal or combined approach, nine cases with preserved serviceable hearing were approached by retrolabylinthine technique and remaining three cases without preservation of serviceable hearing were operated via retrolabylinthine technique. Total removal was achieved in 9 of 13 tumor cases. Of two cases, aneurysmal neck of the first case was clipped completely but was clipped together with right posterior cerebral artery in second case. There was no operative mortality. Immediate postoperative neurological dysfunction were appered in 12 cases. These were significantly improved by the time of follow up examination. Permanent postoperative dysfunction was present in 6 cases, hemiparesis in 2, facial paralysis in 2 and hearing impairment in 2 cases. These results suggest that when selecting the surgical approach to the petroclival lesions, the size, location, extent of the lesion and preoperative status of the hearing were important factors to be considered. We recommend combined anterior-posterior transpetrosal approach for the complex lesions in the petroclival area which extends into the middle fossa(Meckel's cavum or cavernous sinus). Also, we recommend combining with retrosigmoid dural opening or a far lateral type of suboccipital exposure in cases of complex petroclival lesions involving the entire clivus or foramen magnum. In cases with brain stem invasion by tumor, vascular encasement or cavernous sinus invasion without cranial nerve involvement, we recommend subtotal resection of the tumor and radiosurgery to prevent permanent postoperative sequele.

Mesenchymal Chondrosarcoma of the Thoracic Spine: Case Report

Mesenchymal chondrosarcoma is a rare tumor occurring in both bone and soft tissues and exhibits characteristics of a highly malignant tumor. The authors experienced a case of mesenchymal chondrosarcoma ocurring in a 33-year-old man, which had invaded the soft tissues of the chest wall and had been incompletely removed, and recurred in the adjacent T10 vertebra 4 years later. The patient presented with severe back pain and paraparesis at admission. Radiographic studies of the vertebra showed an aggressive osteolysis of the vertebral body, pedicle, lamina, compression of the spinal cord, and soft tissue invasion. The tumor was totally removed by an anterior and posterior combined approach. The removed vertebral body was replaced with a titanium mesh cage, and the thoracic spine was stabilized by both anterior and posterior fixations with instruments. The pathological and the clinical characteristics of mesenchymal chondrosarcoma are discussed.

Clinical Experiences in the Treatment of Far Lateral Lumbar Disc Herni

The authors present 12 cases of far lateral disc herniation(FLDH) diagnosed and treated in our institution from march, 1992 to February, 1994. In the author's series the incidence of far lateral disc herniation was 5% of all lumbar disc herniations. The average age of the patients was 4 years and there were 7 men and 5 women. The L4-5 intervertebral disc level was the most commonly involved level. All patients initially presented with symptoms of radiculopathy. Cases with double herniations at the same level and on the same side seemed to have the most potential source of misdiagnosis and mismanagement, and a careful surgical consideration was needed for such cases. In 4 cases, a combined intraspinal and extraforaminal approach was performed with preservation of facet joints and in 2 cases, paramedian muscle splitting approach was performed. Chemonucleolysis and the usual partial hemilaminectomy were undertaken in 5 cases and in 1 case, respectively. The combined approaches proved to be an effective means of treatment for cases with double herniations, but misdiagnosis of such lesion can lead to an inappropriate and an ineffective treatment and poor surgical results. Furthermore, in the diagnosis of far lateral disc herniation, differentiation must be made from symptoms of conjoined nerve root and congested epidural vein.