[Transcranial microsurgical decompression of the optic canal in surgical treatment of meningiomas of the sellar region]. / Transkranial'naya mikrokhirurgicheskaya dekompressiya kanala zritel'nogo nerva v khirurgii meningiom khiazmal'no-sellyarnoi oblasti.

RATIONALE: When removing the meningiomas of the sellar region, there is always a risk of visual impairment for various reasons, in particular, as a result of traction damage to the optic nerve. Decompression of the optic canal increases nerve mobility during tumor manipulation. In cases of meningioma growing into the canal, its decompression often seems necessary. AIM: Evaluation of the effectiveness and risks of performing decompression of the optic canal. MATERIALS AND METHODS: The study included patients with meningiomas of the parasellar location, who underwent surgical treatment at the Burdenko Neurosurgical Center for the period from 2001 to 2017. They were divided into two groups - main and control. The main group consisted of 129 patients who underwent decompression of the optic nerve canals when the tumor was removed. The tumor matrix in this group was most often located in the region of the tuberum sellae, supradiaphragmally, in the region of the anterior clinoid process and the optic canal. In 31 cases, decompression was bilateral - during one operation and using one access in 27 patients; in 4 cases, the decompression of the second canal was delayed for 1.5-3 months after the first operation. 160 decompressions were performed by the intradural and 7 - by extradural methods. During intradural decompression, the roof of the optic canal was resected, and during extradural decompression, the lateral wall of the canal was trephined. The control group consisted of 308 patients who did not undergo canal decompression when the tumor was removed. It included meningiomas with a predominant location of the matrix in the area of the tuberclum and diaphragm of the sella. Tumors in both groups were removed according to the same principles (matrix coagulation, mainly the gradual removal of the tumor, the use of ultrasonic aspirator, a situational decision on the radicality of the operation, etc.). The main difference between operations in these two groups was only canal related algorithms (with or without its trepanation), as well as the probable prevalence of significant lateral tumor growth in cases with canal trepanation. Visual functions in the «primary¼ group were evaluated before and after operations with trepanation of the canal depending on various factors - the initial state of vision and the radicality of the tumor excision, including removal from the canal. The differences in the postoperative dynamics of vision in the main and control groups were studied. The primary data processing was carried out using the program MSExcel. Secondary statistical processing was carried out using the program Statistica. To assess the statistical significance of differences in the results obtained in the compared patient groups, the Chi-square test was used, and in the case of small groups - the exact Fisher test was applied. RESULTS: In the main group postoperative vision improvement of varying degrees on the side of trepanation was registered in 36.9% (59 out of 160) cases, no vision changes were found in 36.9% (59 out of 160), and in 26,2% (42 out of 160) the eyesight deteriorated. If preserving vision is attributed to a satisfactory result, then in general the results of these operations should be considered good. A comparative study of the results of removal of meningiomas with trepanation of the canals (main group) or without it (control group) was carried out among patients with the most critical vision situation (visual acuity 0.1 and below, up to only light perception). These groups are comparable in the number of observations - 62 and 73 respectively. The predominance of cases with improved vision in the main group compared with the control group (50.0% versus 38.36%) and a lower incidence of vision impairment (22.58% versus 34.25%) were found. However, the revealed differences are statistically unreliable and make it possible for us to talk only about the trend. The complications associated with trepanation of the canal include mechanical damage to the nerve by the drill. In our series of observations, there was only 1 case of abrasion of the nerve surface with the burr, which did not lead to a significant visual impairment. With the intradural method of trepanation in the area of the medial wall of the canal, the sphenoid sinus may open (in our series, in 34 cases out of 160 trepanations). Immediately closure of these defects was performed by various auto- and allomaterials in various combinations (pericranium, fascia, muscle fragment, hemostatic materials, and fibrin-thrombin glue). A true complication - CSF rhinorrhea liquorrhea developed in only one case, which required transnasal plastic surgery of the CSF fistula using a mucoperiostal flap. CONCLUSIONS: 1. Trepanation of the optic canal in cases of meningiomas of parasellar localization is a relatively safe procedure in the hands of a trained neurosurgeon and does not worsen the results of operations compared with the excision of the same tumors without trepanation of the canal. 2. The literature data and the results of our study make it possible to consider the decompression of the optic canal as an optional, but in many cases, useful option that facilitates the transcranial removal of some meningiomas of the sellar region.

[Extended endoscopic endonasal posterior (transclival) approach to tumors of the clival region and ventral posterior cranial fossa. Part 3. Analysis of surgical treatment outcomes in 127 patients]. / Éndoskopicheskii éndonazal'nyi zadnii rasshirennyi (transklival'nyi) dostup k opukholiam oblasti skata cherepa i ventral'nykh otdelov zadnei cherepnoi iamki. Chast' 3. Analiz rezul'tatov khirurgicheskogo lecheniia 127 patsientov.

Until recently, tumors of the clival region and ventral posterior cranial fossa were considered hard-to-reach and often inoperable via standard transcranial approaches. The introduction of minimally invasive methods combined with the endoscopic technique into neurosurgical practice has enabled removal of hard-to-reach tumors, including midline tumors of the ventral posterior cranial fossa. OBJECTIVE: To improve and introduce the extended endoscopic endonasal posterior (transclival) approach into clinical practice and to analyze the results of its application in surgical treatment of midline skull base tumors extending into the ventral posterior cranial fossa. MATERIAL AND METHODS: During the period from 2008 to the present, we have operated 127 patients with various skull base tumors located in the clival region and ventral posterior cranial fossa (60 males and 67 females); the patients' age was 3 to 74 years. The distribution of tumors by histology was as follows: 96 (75.6%) chordomas, 9 (7.1%) pituitary adenomas, 8 (6.3%) meningiomas, 3 (2.33%) cholesteatomas, 2 (1.6%) craniopharyngiomas, 3 (2.33%) fibrotic dysplasia, and 6 (4.7%) other tumors (giant cell tumor, glioma of the neurohypophysis, osteoma, plasmacytoma, carcinoid tumors, chondroma). The tumor size was as follows: 36 (28.35%) giant (more than 60 mm) tumors, 71 (55.9%) large (35-59 mm) tumors, 19 (14.96%) medium (21-35 mm) tumors, and 1 (0.79%) small (less than 20 mm) tumor. Intraoperative monitoring of the cranial nerves was performed (20 cranial nerves were identified) in 10 cases. RESULTS: The extent of chordoma resection was as follows: total removal - 63 (65.62%) cases, subtotal removal - 23 (23.96%) cases, and partial removal - 10 (10.42%) cases. Pituitary adenomas were resected totally in 6 cases, subtotally in 1 case, and partially in 2 cases. Meningioma was removed subtotally in 4 cases, partially in 3 cases, and less than 50% in 1 case. Other tumors (cholesteatoma, craniopharyngioma, fibrous dysplasia, giant cell tumor, glioma of the neurohypophysis, osteoma, plasmacytoma, carcinoid tumors, chondroma) were removed totally in 7 cases and subtotally in 7 cases. Postoperative cerebrospinal fluid leakage occurred in 9 (7.2%) cases, and meningitis developed in 12 (9.4%) cases. Oculomotor disorders occurred in 17 (13.4%) patients; in 10 of these patients, the disorders regressed within 4 to 38 days after surgery; in 7 patients the oculomotor disorders did not regress. A lethal outcome occurred in 2 (1.57%) cases. CONCLUSION: The extended endoscopic endonasal posterior (transclival) approach, being minimally invasive, enables removal of various midline skull base tumors with/without involvement of the clivus with high radicalness, low risk of postoperative complications, and low lethality. Until recently, these tumors were considered almost inoperable.

Cranial nerve monitoring in endoscopic endonasal surgery of skull base tumors (observing of 23 cases).

BACKGROUND: Preservation of anatomic integrity and function of the cranial nerves during the removal of skull base tumors is one of the most challenging procedures in endoscopic endonasal surgery. It is possible to use intraoperative mapping and identification of the cranial nerves in order to facilitate their preservation.The purpose of this study was to evaluate the effectiveness of intraoperative trigger electromyography in prevention of iatrogenic damage to the cranial nerves. METHODS: Twenty three patients with various skull base tumors (chordomas, neuromas, pituitary adenomas, meningiomas, cholesteatomas) underwent mapping and identification of cranial nerves during tumor removal using the endoscopic endonasal approach in Department of Neurooncology of Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation from 2013 to 2018. During the surgical interventions, mapping and identification of the cranial nerves were carried out using electromyography in triggered mode. The effectiveness of the method was evaluated based on a comparison with a control group (41 patients). RESULTS: In the main group of patients, 44 nerves were examined during surgery using triggered electromyography. During the study, the III, V, VI, VII, and XII cranial nerves were identified intraoperatively. Postoperative cranial nerve deficiency was observed in 5 patients in the study group and in 13 patients in the control group. The average length of hospitalization was 9 days. CONCLUSION: We did not receive statistically significant data supporting the fact that intraoperative identification of cranial nerves using trigger electromyography reduces the incidence of postoperative complications in the form of cranial nerve deficits (p = 0.56), but the odds ratio (0.6) suggests a less frequent occurrence of complications in the study group.Based on our experience, the trigger electromyography methodology appears quite promising and requires further research.

[Extended endoscopic endonasal posterior (transclival) approach to tumors of the clival region and ventral posterior cranial fossa. Part 2. Topographic and anatomical aspects and surgical technique]. / Éndoskopicheskii éndonazal'nyi zadnii rasshirennyi (transklival'nyi) dostup k opukholiam oblasti skata cherepa i ventral'nykh otdelov zadnei cherepnoi iamki. Chast' 2. Topografo-anatomicheskie aspekty i operativnaia tekhnika.

PURPOSE: to present the main topographic and anatomical features of the clivus and adjacent structures for improving and optimizing the extended endoscopic transnasal posterior (transclival) approach in removal of clival and ventral posterior cranial fossa lesions. MATERIAL AND METHODS: We performed a topographic and anatomical study of 25 cadaver heads, the vascular bed of which was filled with colored silicone using the original technique for visualizing the bed features and individual variability. RESULTS: We present the main anatomical landmarks necessary for performing the extended endoscopic endonasal posterior approach. Superior, medial, and inferior transclival approaches provide access to the anterior surface of the upper, middle, and lower neurovascular complexes of the posterior cranial fossa. CONCLUSION: The endoscopic transclival approach can be used to reach ventral posterior cranial fossa lesions. The endoscopic transnasal transclival approach is an alternative to transcranial approaches to clival lesions.

[Extended endoscopic endonasal posterior (transclival) approach to tumors of the clival region and ventral posterior cranial fossa. Part 1. Topographic and anatomical features of the clivus and adjacent structures]. / Éndoskopicheskii éndonazal'nyi zadnii rasshirennyi (transklival'nyi) dostup k opukholiam oblasti skata i ventral'nykh otdelov zadnei cherepnoi iamki. Chast' 1. Topografo-anatomicheskie osobennosti skata i pogranichnykh s nim obrazovanii.

OBJECTIVE: to describe the main topographic and anatomical features of the clival region and its adjacent structures for improvement and optimization of the extended endoscopic endonasal posterior (transclival) approach for resection of tumors of the clival region and ventral posterior cranial fossa. MATERIAL AND METHODS: We performed a craniometric study of 125 human skulls and a topographic anatomical study of heads of 25 cadavers, the arterial and venous bed of which was stained with colored silicone (the staining technique was developed by the authors) to visualize bed features and individual variability. Currently, we have clinical material from more than 120 surgical patients with various skull base tumors of the clival region and ventral posterior cranial fossa (chordomas, pituitary adenomas, meningiomas, cholesteatomas, etc.) who were operated on using the endoscopic transclival approach. RESULTS: We present the main anatomical landmarks and parameters of some anatomical structures that are required for performing the endoscopic endonasal posterior approach. The anatomical landmarks, such as the intradural openings of the abducens and glossopharyngeal nerves, may be used to arbitrarily divide the clival region into the superior, middle, and inferior thirds. The anatomical landmarks important for the surgeon, which are detected during a topographic anatomical study of the skull base, facilitate identification of the boundaries between the different clival portions and the C1 segments of the internal carotid arteries. The superior, middle, and inferior transclival approaches provide an access to the ventral surface of the upper, middle, and lower neurovascular complexes in the posterior cranial fossa. CONCLUSION: The endoscopic transclival approach may be used to access midline tumors of the posterior cranial fossa. The approach is an alternative to transcranial approaches in surgical treatment of clival region lesions. This approach provides results comparable (and sometimes better) to those of the transcranial and transfacial approaches.

[Endoscopic transnasal surgery for giant fibrous dysplasia of the skull base, spreading to the right orbital cavity and nasopharynx (a case report and literature review)]. / Endoskopicheskaya transnazal'naya khirurgiya gigantskoi fibroznoi displazii osnovaniya cherepa, rasprostranyayushcheisya v polost' pravoi orbity i nosoglotku (opisanie nablyudeniya i obzor literatury).

BACKGROUND: An extended endoscopic endonasal approach is increasingly used in surgical treatment of space-occupying skull base lesions. The international literature reports only 20 cases of surgical treatment for fibrous dysplasia (PD) of the skull base using the endoscopic endonasal approach. We present our experience with the endoscopic endonasal approach in surgical treatment for giant fibrous dysplasia of the skull base, spreading to the right orbital cavity and nasopharynx. CLINICAL CASE: A 26-year-old male patient presented with cranial pain, Vth nerve dysfunction on the right, right keratopathy. OD=0.2 (near acuity - 0.3), OS=1.0, OD - incomplete eyelid closure of 2 mm, conjunctival injection, mucous discharge, corneal opacity in the lower pole and paracentrally, OS - normal appearance. Severe right-sided exophthalmos (more than 15 mm), impaired nasal breathing on the right, nasal (hemorrhagic) discharge. Magnetic resonance imaging and spiral computed tomography scans revealed a bone density lesion located in the area of the orbit, nasal cavity, maxillary sinus on the right, and labyrinth of the ethmoid bone. The patient underwent endonasal endoscopic resection of the lesion. RESULTS: The lesion was resected totally, which was confirmed by control SCT. Right-sided exophthalmos partially regressed (on the right: exophthalmos of 8 mm; protrusion: OD=23 mm, OS=15 mm; the eyeball was displaced downward and outward). The visual and oculomotor functions did not change. The neurological status remained at the preoperative level. CONCLUSION: Fibrous dysplasia of the skull base is an extremely rare disease. Modern techniques expand the indications for surgery of giant tumors of the skull base using minimally invasive approaches, in particular the endoscopic endonasal approach.

Improving community ambulation after hip fracture: protocol for a randomised, controlled trial.

INTRODUCTION: After a hip fracture in older persons, significant disability often remains; dependency in functional activities commonly persists beyond 3 months after surgery. Endurance, dynamic balance, quadriceps strength, and function are compromised, and contribute to an inability to walk independently in the community. In the United States, people aged 65 years and older are eligible to receive Medicare funding for physiotherapy for a limited time after a hip fracture. A goal of outpatient physiotherapy is independent and safe household ambulation 2 to 3 months after surgery. Current Medicare-reimbursed post-hip-fracture rehabilitation fails to return many patients to pre-fracture levels of function. Interventions delivered in the home after usual hip fracture physiotherapy has ended could promote higher levels of functional independence in these frail and older adult patients. PRIMARY OBJECTIVE: To evaluate the effect of a specific multi-component physiotherapy intervention (PUSH), compared with a non-specific multi-component control physiotherapy intervention (PULSE), on the ability to ambulate independently in the community 16 weeks after randomisation. DESIGN: Parallel, two-group randomised multicentre trial of 210 older adults with a hip fracture assessed at baseline and 16 weeks after randomisation, and at 40 weeks after randomisation for a subset of approximately 150 participants. PARTICIPANTS AND SETTING: A total of 210 hip fracture patients are being enrolled at three clinical sites and randomised up to 26 weeks after admission. Study inclusion criteria are: closed, non-pathologic, minimal trauma hip fracture with surgical fixation; aged ≥ 60 years at the time of randomisation; community residing at the time of fracture and randomisation; ambulating without human assistance 2 months prior to fracture; and being unable to walk at least 300 m in 6minutes at baseline. Participants are ineligible if the interventions are deemed to be unsafe or unfeasible, or if the participant has low potential to benefit from the interventions. INTERVENTIONS: Participants are randomly assigned to one of two multi-component treatment groups: PUSH or PULSE. PUSH is based on aerobic conditioning, specificity of training, and muscle overload, while PULSE includes transcutaneous electrical nerve stimulation, flexibility activities, and active range of motion exercises. Participants in both groups receive 32 visits in their place of residence from a study physiotherapist (two visits per week on non-consecutive days for 16 weeks). The physiotherapists' adherence to the treatment protocol, and the participants' receipt of the prescribed activities are assessed. Participants also receive counselling from a registered dietician and vitamin D, calcium and multivitamin supplements during the 16-week intervention period. MEASUREMENTS: The primary outcome (community ambulation) is the ability to walk 300 m or more in 6minutes, as assessed by the 6-minute walk test, at 16 weeks after randomisation. Other measures at 16 and 40 weeks include cost-effectiveness, endurance, dynamic balance, walking speed, quadriceps strength, lower extremity function, activities of daily living, balance confidence, quality of life, physical activity, depressive symptoms, increase of ≥ 50 m in distance walked in 6minutes, cognitive status, and nutritional status. ANALYSIS: Analyses for all aims will be performed according to the intention-to-treat paradigm. Except for testing of the primary hypothesis, all statistical tests will be two-sided and not adjusted for multiple comparisons. The test of the primary hypothesis (comparing groups on the proportion who are community ambulators at 16 weeks after randomisation) will be based on a one-sided 0.025-level hypothesis test using a procedure consisting of four interim analyses and one final analysis with critical values chosen by a Hwang-Shih-Decani alpha-spending function. Analyses will be performed to test group differences on other outcome measures and to examine the differential impact of PUSH relative to PULSE in subgroups defined by pre-selected participant characteristics. Generalised estimating equations will be used to explore possible delayed or sustained effects in a subset of participants by comparing the difference between PUSH and PULSE in the proportion of community ambulators at 16 weeks with the difference at 40 weeks. DISCUSSION: This multicentre randomised study will be the first to test whether a home-based multi-component physiotherapy intervention targeting specific precursors of community ambulation (PUSH) is more likely to lead to community ambulation than a home-based non-specific multi-component physiotherapy intervention (PULSE) in older adults after hip fracture. The study will also estimate the potential economic value of the interventions.

[Neurophysiological identification of the cranial nerves in endoscopic endonasal surgery of skull base tumors]. / Neirofiziologicheskaya identifikatsiya cherepnykh nervov v endoskopicheskoi endonazal'noi khirurgii opukholei osnovaniya cherepa.

INTRODUCTION: Intraoperative identification of the cranial nerves is a useful technique in removal of skull base tumors through the endoscopic endonasal approach. Searching through the scientific literature found one pilot study on the use of triggered electromyography (t-EMG) for identification of the VIth nerve in endonasal endoscopic surgery of skull base tumors (D. San-Juan, et al, 2014). AIM: The study objective was to prevent iatrogenic injuries to the cranial nerves without reducing the completeness of tumor tissue resection. MATERIAL AND METHODS: In 2014, 5 patients were operated on using the endoscopic endonasal approach. Surgeries were performed for large skull base chordomas (2 cases) and trigeminal nerve neurinomas located in the cavernous sinus (3). Intraoperatively, identification of the cranial nerves was performed by triggered electromyography using a bipolar electrode (except 1 case of chordoma where a monopolar electrode was used). Evaluation of the functional activity of the cranial nerves was carried out both preoperatively and postoperatively. RESULTS: Tumor resection was total in 4 out of 5 cases and subtotal (chordoma) in 1 case. Intraoperatively, the IIIrd (2 patients), Vth (2), and VIth (4) cranial nerves were identified. No deterioration in the function of the intraoperatively identified nerves was observed in the postoperative period. In one case, no responses from the VIth nerve on the right (in the cavernous sinus region) were intraoperatively obtained, and deep paresis (up to plegia) of the nerve-innervated muscles developed in the postoperative period. The nerve function was not impaired before surgery. CONCLUSION: The t-EMG technique is promising and requires further research.

[The algorithm for surgical treatment of skull base tumors invading the craniovertebral junction].

UNLABELLED: Surgical treatment of skull base tumors invading the craniovertebral junction is a complex medical problem due to a high rate of adverse postoperative outcomes in these patients. AIM: The study aim was to optimize surgical treatment in patients with skull base tumors invading the craniovertebral junction. MATERIAL AND METHODS: A comparative analysis of 2 groups of patients was performed. The study group included 28 patients with skull base and craniovertebral junction chordomas who underwent single-stage surgery, including posterior occipitospondylodesis and tumour resection using the transoral and combined transoral and transnasal approaches, in the period between 2000 and 2015. The control group included 21 patients with the same pathology who underwent microsurgery using the transoral approach without occipitospondylodesis in the period between 1990 and 2009. RESULTS: Most of the patients in both groups were operated on at late disease stages when they presented with gross clinical signs. The use of single-stage occipitospondylodesis and transoral skull base tumor removal significantly (compared to the control group) extends indications for surgical treatment of skull base tumors, which were previously considered unresectable, and provides better results. CONCLUSION: New surgical techniques significantly increase the completeness of tumor resection, decrease the rate of postoperative complications, accelerate the rehabilitation process, and improve the patient's quality of life.

[Experience in the use of high-frequency selective percutaneous rhizotomy in trigeminal neuralgia associated with multiple sclerosis].

OBJECTIVE: the study was aimed at assessment of the efficacy of percutaneous high frequency selective rhizotomy (PHFSR) after failure of conservative treatment of trigeminal neuralgia (TN) in multiple sclerosis (MS). MATERIAL AND METHODS: A retrospective analysis of 28 patients with TN associated with MS who underwent percutaneous rhizotomy in the period from 2000 to 2014 was performed. All patients were definitely diagnosed with MS according to the McDonald criteria (version of 2001, 2005, and 2010). The patients were divided by age, gender, and the trigeminal nerve branches involved in the process. The patients' condition was evaluated at different times after surgery. RESULTS: Good outcomes in the form of pain syndrome regression were achieved in 100% of the patients. A disease recurrence was observed in 6 (21%) patients during a follow-up period of 3 months to 14 years. Dysesthesia complications occurred in 4 (14%) patients. There were no deaths and severe complications. The percentage of minor complications was low. CONCLUSION: These data confirm that PHFSR is a safe, repeatable, and effective method of symptomatic neurosurgical treatment of TN associated with MS and may be recommended in the case of failure/intolerance of medication.

[Endoscopic endonasal surgical treatment of large pituitary adenoma, spreading into the posterior fossa].

AIM: The objective of the study was to develop the tactics of surgical treatment of large and giant pituitary adenomas, spreading into the posterior cranial fossa. MATERIAL AND METHODS: Patients with large hormonally inactive pituitary adenoma, extending to the right cavernous sinus and posterior cranial fossa. RESULTS: The endoscopic endonasal removal a large endo-supra-latero(D)-retrosellar pituitary tumor was conducted. Control MRI shows that the tumor was removed radically. Oculomotor disturbances were observed in the early postoperative period, which significantly regressed within 6 months. The article provides detailed analysis of the world literature on the issue under discussion. Illustrative pre-, intra-, and post-operative photographs, as well as histological preparations are shown. CONCLUSION: Modern minimally invasive techniques make it possible to remove large pituitary adenomas (and other tumors) of the posterior cranial fossa using endoscopic endonasal approach. Such operations must be carried out at highly specialized institutions by the surgeons who have extensive experience in endoscopic transnasal surgery of skull base tumors.

Possible suppression of fetal erythropoiesis by the Kell blood group antibody anti-Kp(a).

Antibodies to antigens in the Kell blood group system are usually immunoglobulin G, and, notoriously, anti-K, anti-k, and anti-Kp(a) can cause severe hemolytic transfusion reactions, as well as severe hemolytic disease of the fetus and newborn (HDFN). It has been shown that the titer of anti-K does not correlate with the severity of HDFN because, in addition to immune destruction of red blood cells (RBCs), anti-K causes suppression of erythropoiesis in the fetus, which can result in severe anemia. We report a case involving anti-Kp(a) in which one twin was anemic and the other was not. Standard hemagglutination and polymerase chain reaction (PCR)-based tests were used. At delivery, anti-Kp(a) was identified in serum from the mother and twin A, and in the eluate prepared from the baby's RBCs. PCR-based assays showed twin A (boy) was KEL*841T/C (KEL*03/KEL*04), which is predicted to encode Kp(a+b+). Twin B (girl) was KEL*841C/C (KEL*04/KEL*04), which is predicted to encode Kp(a­b+). We describe the first reported case of probable suppression of erythropoiesis attributable to anti-Kp(a). One twin born to a woman whose serum contained anti-Kp(a) experienced HDFN while the other did not. Based on DNA analysis, the predicted blood type of the affected twin was Kp(a+b+) and that of the unaffected twin was Kp(a­b+). The laboratory findings and clinical course of the affected twin were consistent with suppression of erythropoiesis in addition to immune RBC destruction.

Does obesity influence the outcome after the operative treatment of ankle fractures?

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion. This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures. We retrospectively reviewed 279 patients (99 obese (BMI > or = 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function. These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.

Effect of articular step-off and meniscectomy on joint alignment and contact pressures for fractures of the lateral tibial plateau.

OBJECTIVES: To determine the effects of intraarticular step-off and lateral meniscectomy on the alignment of the articular axis, contact area, and pressures for lateral tibial plateau fractures. DESIGN: Biomechanical cadaver study. INTERVENTION: Six fresh cadaveric knees were used. A simulated split fracture of the lateral tibial plateau was reproducibly created by osteotomies, and articular step-offs of zero, one, two, four, and six millimeters were achieved by using support shims. The knee was loaded with 500 newtons in 0 degrees and 350 newtons in 30 degrees of flexion. A digital camera determined changes in the alignment of the articular axis, and F-Scan sensors were inserted into the medial and lateral joint compartments to determine the pressures and pressure distributions. MAIN OUTCOME MEASUREMENT: Each specimen was tested at step-offs of zero, one, two, four, and six millimeters, with the presence or absence of the lateral meniscus. The changes in alignment of the articular axis, the contact area, and the average and maximum contact pressures for each condyle were obtained. RESULTS: Increased articular step-off heights progressively increased valgus angulation and average and maximum contact pressures and progressively decreased contact areas in lateral compartment. At a six-millimeter step-off with 0 degrees of flexion, the valgus angle increased an average of 7.6 degrees, and average contact pressures and maximum contact pressures increased an average of 208 percent and 97 percent, respectively, and contact area decreased an average of 33 percent (p < 0.05). Meniscectomy increased valgus angles by an average of 38 percent and contact pressures by an average of 45 percent and decreased contact areas by 26 percent in the lateral compartment at the same articular step-off heights (p < 0.05). CONCLUSION: The results of this study show the importance of decreasing articular step-off heights in treating lateral tibial plateau split fractures, particularly if a meniscectomy is performed.

Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study.

OBJECTIVE: To compare the analgesic benefit of preoperative skin traction with the placement of a pillow under the injured extremity in patients with hip fractures. DESIGN: Prospective, randomized clinical study. SETTING: University-affiliated teaching institution. PATIENTS AND PARTICIPANTS: One hundred consecutive patients with hip fractures admitted to the authors' institution who met inclusion criteria were enrolled. Fifty-five patients had femoral neck fractures, and forty-five patients had intertrochanteric fractures. The average patient age was seventy-eight years. INTERVENTION: All patients were preoperatively randomized into two intervention groups. One group underwent placement of five pounds of skin traction on the injured extremity, whereas the second underwent placement of a pillow under the injured extremity. Fifty patients were enrolled in each intervention group. RESULTS: With respect to immediate postintervention pain levels, patients treated with a pillow showed a trend toward better pain relief, as compared with patients treated with skin traction; however, this was not statistically significant. On the morning after admission, patients treated with a pillow had a statistically significant greater reduction in pain (p = 0.04). These patients also requested a statistically significant lower amount of pain medication (p < 0.01). CONCLUSIONS: The authors think that preoperative skin traction in patients with hip fractures does not provide significant pain relief, as compared with pillow placement under the injured extremity, and thus should not be routinely performed in this patient population for analgesia.

Fixation of periprosthetic femoral shaft fractures: a biomechanical comparison of two techniques.

OBJECTIVE: To determine which of two currently used techniques for the treatment of periprosthetic femoral shaft fractures provides the greater fixation rigidity and strength. DESIGN: A laboratory study using six matched pairs of femurs. METHODS: Embalmed femur prosthesis constructs had a simulated periprosthetic fracture created and were fixed with a plate with proximal cables and distal bicortical screws (Ogden concept) or two allograft struts and cables. Fixation stability was compared in various loading modalities before and after cycling. They were then tested to failure. OUTCOME MEASUREMENTS: Fixation rigidity was defined as the ratio of applied load to the amount of displacement at the fracture. RESULTS: In all loading modalities, the Ogden construct was more rigid than the allograft strut fixation. The Ogden construct required 1,295 newtons for failure and the allograft strut fixation required 950 newtons (p < 0.05). CONCLUSION: The Ogden construct provided a more rigid and stronger initial fixation of a periprosthetic fracture than did the allograft construct.

Outcome after hip fracture in individuals ninety years of age and older.

OBJECTIVE: To assess outcome after hip fracture in patients ninety years of age and older, as compared with a population of the same age and sex in the United States and younger patients with hip fractures. DESIGN: Prospective, consecutive. SETTING: University teaching hospital. METHODS: Eight hundred fifty community-dwelling elderly people who sustained an operatively treated hip fracture were prospectively followed up. MAIN OUTCOME MEASUREMENTS: The outcomes examined in this study were the patients' in-hospital mortality and postoperative complication rates, hospital length of stay, discharge status, mortality rate, place of residence, ambulatory ability, and independence in basic and instrumental activities of daily living twelve months after surgery. RESULTS AND CONCLUSIONS: The mean patient age was 79.7 years (range 65 to 105 years). Seventy-six (8.9 percent) patients were ninety years of age and older. Patients who were ninety years of age and older had significantly longer mean hospital lengths of stay than younger individuals (p = 0.01). People ninety years of age and older were more likely to die during the hospital stay (p = 0.001) and within one year of surgery (p = 0.001). Patients who were ninety years of age and older were more likely to have a decrease in their basic activities of daily living status (p = 0.03) and ambulation level (p = 0.01). Younger individuals had a higher standard mortality ratio (1.48) than did patients who were ninety years of age and older (1.24). Being ninety years of age and older was not predictive of having a postoperative complication, of being placed in a skilled nursing facility at discharge or at one-year follow-up, or recovering of prefracture independence in instrumental activities of daily living.

Soft-tissue principles for orthopaedic surgeons.

Meticulous handling of the tissues, reversal of known patient risk factors, and attention to detail can avoid many soft-tissue complications. Prompt management or consultation of a soft-tissue expert may reduce the morbidity and need for extensive reconstructive procedures.