Restoration of intrinsic hand function by superficial radial nerve: an anatomical study.

BACKGROUND: The contralateral seventh cervical (cC7) nerve root transfer represents a cornerstone technique in treating total brachial plexus avulsion injury. Traditional cC7 procedures employ the entire ulnar nerve as a graft, which inevitably compromises its restorative capacity. OBJECTIVE: Our cadaveric study seeks to assess this innovative approach aimed at preserving the motor branch of the ulnar nerve (MBUN). This new method aims to enable future repair stages, using the superficial radial nerve (SRN) as a bridge connecting cC7 and MBUN. METHODS: We undertook a comprehensive dissection of ten adult cadavers, generously provided by the Department of Anatomy, Histology, and Embryology at Fudan University, China. It allowed us to evaluate the feasibility of our proposed technique. For this study, we harvested only the dorsal and superficial branches of the ulnar nerve, as well as the SRN, to establish connections between the cC7 nerve and recipient nerves (both the median nerve and MBUN). We meticulously dissected the SRN and the motor and sensory branches of the ulnar nerve. Measurements were made from the reverse point of the SRN to the wrist flexion crease and the coaptation point of the SRN and MBUN. Additionally, we traced the MBUN from distal to proximal ends, recording its maximum length. We also measured the diameters of the nerve branches and tallied the number of axons. RESULTS: Our modified approach proved technically viable in all examined limbs. The distances from the reverse point of the SRN to the wrist flexion crease were 8.24 ± 1.80 cm and to the coaptation point were 6.60 ± 1.75 cm. The maximum length of the MBUN was 7.62 ± 1.03 cm. The average axon diameters in the MBUN and the anterior and posterior branches of the SRN were 1.88 ± 0.42 mm、1.56 ± 0.38 mm、2.02 ± 0.41 mm,respectively. The corresponding mean numbers of axons were 1426.60 ± 331.39 and 721.50 ± 138.22, and 741.90 ± 171.34, respectively. CONCLUSION: The SRN demonstrated the potential to be transferred to the MBUN without necessitating a nerve graft. A potential advantage of this modification is preserving the MBUN's recovery potential.

Biomechanical testing of a modified knotless transscleral suture fixation technique: an ex vivo study.

Background: To investigate the safety and effectiveness of a modified transscleral suture through ex vivo tests. Methods: Ex vivo tests were performed in full-thickness porcine scleral pieces using modified knotless transscleral zigzag-shaped suture (Z-suture) fixation technology. The minimum traction force required to loosen or rupture the suture was assessed. The effects of different polypropylene sutures (10-0, 8-0), different suture spans (2.0, 3.0, 4.0 mm), different passes (3, 4, 5 passes), and scleral grooves were investigated. Results: The average minimum traction forces required to loosen 10-0 polypropylene sutured for 3.0 mm with a suture span of 3, 4, and 5 passes, were 0.18 (0.15-0.18), 0.22 (0.21-0.22), and 0.37 (0.37-0.37) N, respectively. The maximum traction force to prevent the suture from rupturing for the 10-0 polypropylene suture was 0.37-0.41 N in the sclera. The average of the minimum traction forces required to loosen the 8-0 polypropylene sutured with 5 passes and spanning 2.0, 3.0, and 4.0 mm were 0.37 (0.3 -0.39), 0.42 (0.42-0.45), and 0.50 (0.50-0.51) N, respectively, which were 14-28% higher than that of the 10-0 polypropylene suture under same conditions (all P values <0.01). In addition, there was no statistical difference (P=0.3258) for the 8-0 polypropylene suture used with a 3.0-mm suture span and 5 passes between conditions with or without scleral grooves. Conclusions: The minimum traction force required to loosen or rupture the suture in the sclera was associated with suture specification, suture span, and the number of passes, but was uncorrelated with double scleral grooves. The 8-0 polypropylene suture with double scleral grooves may be a more favorable choice for knotless transscleral fixation.

Solve the post-operative subdural pneumatosis of chronic subdural hematoma: A novel active bone hole drainage system.

Background: Post-operative subdural pneumatosis (PSP) is commonly encountered after the chronic subdural hematoma (CSDH) surgery which currently lacks effective methods to avoid the condition. This study invented an active bone hole drainage system to change the venting technique with the aim of comparing post-operative efficacy and prognosis to traditional drilling and drainage. Methods: We conducted a randomized controlled trial between January 2020 and January 2021. A total of 86 patients undergoing surgery were assessed for eligibility, with 50 patients randomly assigned to the control group (received drilling and drainage) and 36 patients to the test group (received modified surgery). The 6-month follow-up was done after surgery. CSDH recurrence and post-operative hematoma re-increasement were the primary endpoints. The data from the two groups were compared and analyzed. This study was registered with the Chinese Clinical Trials Register (ChiCTR2200057158), and had ethics committee approval and patient consent. Results: The incidence of PSP in the test group (0%, 0/30)was lower than the control group (93.88%, 46/49) (P < 0.001). The brain non-expansion rates 3 days/weeks/months after surgery of the test group were 59.25 [49.62, 76.97], 52.10 [42.88, 72.45], and 29.45 [23.40, 36.95] respectively, which were lower than the control group which were 78.60 [69.50, 94.70], 73.10 [60.70, 87.40], and 61.70 [51.50, 78.30], respectively (P < 0.001). The ADL scores a week/month/3/6 months after surgery of the test group were 100.00 [60.00, 100.00], 100.00 [85.00, 100.00], 100.00 [100.00, 100.00], 100.00 [100.00, 100.00], which were better than the control group's 60.00 [60.00, 80.00], 75.00 [60.00, 100.00], 100.00 [60.00, 100.00], 100.00 [60.00, 100.00] (P < 0.05). The incidence of primary endpoints in the test group (10%, 3/30) was lower than the control group (34.69%, 17/49) (P < 0.05). Conclusions: Compared to drilling and drainage, the modified surgery with the active bone hole drainage system significantly reduced the incidence of PSP and primary endpoints and improved the post-operative efficacy and prognosis. Clinical trial registration: Identifier: ChiCTR2200057158.

"Fenestration and Tunnel Method" a Modification for the Holmium Laser Transurethral Prostatectomy of Large-Volume Prostates >80 ml: A Retrospective Study Based on 1-Year Follow-Up.

The purpose of this study was to promote the holmium laser enucleation of the prostate (HoLEP) technology for large-volume prostates (>80 ml) and compare it with the traditional method, we modified the technique and applied this technology to clinical practice. A retrospective study comprising 118 patients who underwent HoLEP surgery from February 2018 to December 2019 was conducted in our center. Group A consisted of 57 patients with large-volume prostate (>80 ml) who received modified "fenestration and tunnel method" from February 2019 till December 2019, while group B consisted of 61 patients who received the traditional trivalvular operation method from February 2018 to December 2018 for comparison. Control subjects are selected such that they match the cases concerning certain characteristics, and perioperative data, voiding outcomes, and complications were evaluated at 1- and 12-month follow-up. The international prostatic symptomatic score (IPSS), quality of life (QoL), and maximum flow rate (Qmax) at 1 month and 12 months were both significantly improved compared with the preoperative baseline, and no significant differences were found between Groups A and B. The mean enucleation time, operation time, catheter indwelling duration, and hemoglobin decrease during the operation of Group A showed superiority compared with Group B (p<.05). The modified "fenestration and tunnel method" of HoLEP was statistically superior to the traditional trivalvular method in terms of the operation time, enucleation time, catheter indwelling duration, and hemoglobin decrease. For large-volume prostates (>80 ml), modified HoLEP was suggested to be a better treatment option.

Surgical correction of severe congenital ptosis using a modified frontalis muscle advancement technique: A single-arm trial.

PURPOSE: To describe our experience with a modified frontal muscle advancement flap to treat patients with severe congenital ptosis. METHODS: Analysis of the clinical charts of 154 patients who underwent a modified frontal muscle advancement flap. The FM was exposed by a crease incision. The FM flap was created by deep dissection between the orbicularis muscle and orbital septum from the skin crease incision to the supraorbital margin and subcutaneous dissection from the inferior margin of the eyebrow to 0.5 cm above the eyebrow. No vertical incision was made on the FM flap to ensure an intact flap wide enough to cover the entire upper tarsal plate. Contour, symmetry of height, marginal reflex distance (MRD1), and complications were assessed. Mean follow-up was 10 months. RESULTS: The mean patient age was 7.6 ± 5.6 (range, 2-18) years. The mean MRD1 was 3.2 ± 1.3 mm after the operation. All bilateral cases achieved symmetry and optimal lid contour; 17 unilateral cases were under corrected, with a success rate of 89.0%. Complications such as entropion, exposure keratitis, FM paralysis, frontal hypoesthesia, severe haematoma, and entropion were not observed in our series. CONCLUSION: A modified frontal muscle advancement flap produced a high success rate with a clear field of vision, mild trauma, and few complications. This technique is relatively simple and should be considered for correcting severe congenital ptosis.Date of registration: 29-03-2020Trial registration number: ChiCTR2000031364Registration site: http://www.chictr.org/.

A New Modified Hysteroscopic-Laparoscopic Surgery for Cesarean Scar Pregnancy of Stable Type III.

OBJECTIVE: To introduce a modified hysteroscopic-laparoscopic operation for cesarean scar pregnancy (CSP) of stable type III. PATIENTS AND METHODS: We retrospectively studied the case notes of 31 patients with stable type III cesarean scar pregnancy who underwent hysteroscopic-laparoscopic surgery in our hospital. Thirteen patients received the modified hysteroscopic-laparoscopic surgery (modified surgery group), and eighteen patients received traditional hysteroscopic-laparoscopic surgery (traditional surgery group). RESULTS: There was no significant difference in patients' age, gestational age, number of previous cesarean sections, the serum human chorionic gonadotropin (hCG) level before surgery, gestational sac diameter, myometrium thickness between the two groups. In the modified hysteroscopic-laparoscopic surgery, the mean surgical time was 50.45±24.45 mins, the mean length of stay in hospital was 4.50±0.50 days, which was significantly shorter than the traditional surgery group (84.75±33.28 mins and 5.50±0.75 days, respectively). And the intraoperative hemorrhage in the modified group was also less than that in the traditional group (40.50±12.25 mL vs 75.33±25.45mL). Whereas the time for hCG normalization, postoperative vaginal bleeding and menstrual recovery had no significant difference between the modified surgery group and the traditional surgery group. There was no recurrence of CSP in both groups. CONCLUSION: The modified hysteroscopic-laparoscopic surgery had shorter operation time, less blood loss, and sooner recovery time after surgery compared to traditional hysteroscopic-laparoscopic surgery, which could be more beneficial to our patients and should be applied in clinics generally.

Curative effect and safety of modified dacryocystorhinostomy with simple anterior flap anastomosis in the treatment of chronic dacryocystitis / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To analyze the curative effect and safety of modified dacryocystorhinostomy with simple anterior flap anastomosis in the treatment of chronic dacryocystitis.<p>METHODS: A total of 99 patients(113 affected eyes)with chronic dacryocystitis who underwent dacryocystorhinostomy in the hospital between March 2016 and July 2018 were enrolled in the retrospective study. They were divided into the traditional group(traditional dacryocystorhinostomy, 46 cases, 52 affected eyes)and the modified group(modified surgery with simple anterior flap anastomosis, 53 cases, 61 affected eyes)according to the surgical procedures. The surgical results, rates of granulation tissue formation around the anastomotic stoma at different time after surgery, rates of nasal mucosal epithelialization, size of the anastomotic stoma, the occurrence of surgical complications and the recurrence rate during 1a of follow-up were compared between the two groups.<p>RESULTS: The grade of curative effect in the modified group was better than the traditional group(75.0% <i>vs </i>95.1%)during 6mo of follow-up(<i>P</i><0.05). The total cure rate was higher than that of the traditional group(<i>P</i><0.005). The rates of granulation tissue formation(3.8%, 5.7%, 9.4%)in the modified group at 1mo, 3mo and 6mo after surgery were lower than those in the traditional group(64.2% <i>vs</i> 39.1%, <i>P</i><0.001). The rate of nasal mucosal epithelialization in the modified group was higher than that in the traditional group(25.63±4.76 <i>vs </i>11.34±3.52mm2, <i>P</i><0.01)at 1mo after surgery. The area of anastomotic stoma in the modified group was larger than that in the traditional group(25.63±4.76 <i>vs </i>11.34±3.52mm2,<i>P</i><0.01)at 6mo after surgery. The incidence rates of postoperative hemorrhage and complication in the modified group and the recurrence rate in 1y of follow-up were lower than those in the traditional group(<i>P</i><0.05).<p>CONCLUSION: The cure rate of patients undergoing modified dacryocystorhinostomy with simple anterior flap anastomosis is higher than those undergoing traditional surgery. The former can promote nasal mucosal epithelialization, maintain the size of anastomotic stoma and prevent the formation of surrounding granulation tissue. It is safe and effective, with few complications and low recurrence rate.

Curative effect and safety of modified dacryocystorhinostomy with simple anterior flap anastomosis in the treatment of chronic dacryocystitis / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To analyze the curative effect and safety of modified dacryocystorhinostomy with simple anterior flap anastomosis in the treatment of chronic dacryocystitis.<p>METHODS: A total of 99 patients(113 affected eyes)with chronic dacryocystitis who underwent dacryocystorhinostomy in the hospital between March 2016 and July 2018 were enrolled in the retrospective study. They were divided into the traditional group(traditional dacryocystorhinostomy, 46 cases, 52 affected eyes)and the modified group(modified surgery with simple anterior flap anastomosis, 53 cases, 61 affected eyes)according to the surgical procedures. The surgical results, rates of granulation tissue formation around the anastomotic stoma at different time after surgery, rates of nasal mucosal epithelialization, size of the anastomotic stoma, the occurrence of surgical complications and the recurrence rate during 1a of follow-up were compared between the two groups.<p>RESULTS: The grade of curative effect in the modified group was better than the traditional group(75.0% <i>vs </i>95.1%)during 6mo of follow-up(<i>P</i><0.05). The total cure rate was higher than that of the traditional group(<i>P</i><0.005). The rates of granulation tissue formation(3.8%, 5.7%, 9.4%)in the modified group at 1mo, 3mo and 6mo after surgery were lower than those in the traditional group(64.2% <i>vs</i> 39.1%, <i>P</i><0.001). The rate of nasal mucosal epithelialization in the modified group was higher than that in the traditional group(25.63±4.76 <i>vs </i>11.34±3.52mm2, <i>P</i><0.01)at 1mo after surgery. The area of anastomotic stoma in the modified group was larger than that in the traditional group(25.63±4.76 <i>vs </i>11.34±3.52mm2,<i>P</i><0.01)at 6mo after surgery. The incidence rates of postoperative hemorrhage and complication in the modified group and the recurrence rate in 1y of follow-up were lower than those in the traditional group(<i>P</i><0.05).<p>CONCLUSION: The cure rate of patients undergoing modified dacryocystorhinostomy with simple anterior flap anastomosis is higher than those undergoing traditional surgery. The former can promote nasal mucosal epithelialization, maintain the size of anastomotic stoma and prevent the formation of surrounding granulation tissue. It is safe and effective, with few complications and low recurrence rate.

Modern Surgery-First Approach Concept in Cleft-Orthognathic Surgery: A Comparative Cohort Study with 3D Quantitative Analysis of Surgical-Occlusion Setup.

Despite the evident benefits of the modern surgery-first orthognathic surgery approach (reduced treatment time, efficient tooth decompensation, and early improvement in facial esthetics), the challenge of the surgical-occlusion setup acts as a hindering factor for the widespread and global adoption of this therapeutic modality, especially for the management of cleft-skeletofacial deformity. This is the first study to assess three-dimensional (3D) quantitative data of the surgical-occlusion setup in surgery-first cleft-orthognathic surgery. This comparative retrospective study was performed on 3D image datasets from consecutive patients with skeletal Class III deformity who had a unilateral cleft lip/palate (cleft cohort, n = 44) or a noncleft dentofacial deformity (noncleft cohort, n = 22) and underwent 3D computer-assisted single-splint two-jaw surgery by a single multidisciplinary team between 2014 and 2018. They received conventional orthodontics-first or surgery-first approaches. 3D quantitative characterization (linear, angular, and positional measurements) of the final surgical-occlusion setup was performed and adopted for comparative analyses. In the cleft cohort, the occlusion setup in the surgery-first approach had a significantly (all p < 0.05) smaller number of anterior teeth contacts and larger incisor overjet compared to the conventional approach. Considering the surgery-first approach, the cleft cohort presented significantly (all p < 0.05) larger (canine lateral overjet parameter) and smaller (incisor overjet, maxillary intercanine distance, maxillary intermolar distance, ratio of intercanine distance, and ratio of intermolar distance parameters) values than the noncleft cohort. This study contributes to the literature by providing 3D quantitative data of the surgical-occlusion setup in surgery-first cleft-orthognathic surgery, and delivers information that may assist multidisciplinary teams to adopt the surgery-first concept to optimize cleft care.

Modified contralateral C7 nerve transfer: the possibility of permitting ulnar nerve recovery is confirmed by 10 cases of autopsy.

Contralateral C7 nerve transfer surgery is one of the most important surgical techniques for treating total brachial plexus nerve injury. In the traditional contralateral C7 nerve transfer surgery, the whole ulnar nerve on the paralyzed side is harvested for transfer, which completely sacrifices its potential of recovery. In the present, novel study, we report on the anatomical feasibility of a modified contralateral C7 nerve transfer surgery. Ten fresh cadavers (4 males and 6 females) provided by the Department of Anatomy, Histology, and Embryology at the Medical College of Fudan University, China were used in modified contralateral C7 nerve transfer surgery. In this surgical model, only the dorsal and superficial branches of the ulnar nerve and the medial antebrachial cutaneous nerve on the paralyzed side (left) were harvested for grafting the contralateral (right) C7 nerve and the recipient nerves. Both the median nerve and deep branch of the ulnar nerve on the paralyzed (left) side were recipient nerves. To verify the feasibility of this surgery, the distances between each pair of coaptating nerve ends were measured by a vernier caliper. The results validated that starting point of the deep branch of ulnar nerve and the starting point of the medial antebrachial cutaneous nerve at the elbow were close to each other and could be readily anastomosed. We investigated whether the fiber number of donor and recipient nerves matched one another. The axons were counted in sections of nerve segments distal and proximal to the coaptation sites after silver impregnation. Averaged axon number of the ulnar nerve at the upper arm level was approximately equal to the sum of the median nerve and proximal end of medial antebrachial cutaneous nerve (left: 0.94:1; right: 0.93:1). In conclusion, the contralateral C7 nerve could be transferred to the median nerve but also to the deep branch of the ulnar nerve via grafts of the ulnar nerve without deep branch and the medial antebrachial cutaneous nerve. The advantage over traditional surgery was that the recovery potential of the deep branch of ulnar nerve was preserved. The study was approved by the Ethics Committee of Fudan University (approval number: 2015-064) in July, 2015.

Modified surgery for cerebral palsy of both lower extremities with spastic diplegia / 中国矫形外科杂志

[Objective ] To investigate the improvement of the surgical treatment effect on cerebral palsy with spastic diplegia by performing modified surgeries since 2004. [Method ] Twenty-three cases of severe cerebral palsy with spastic diplegia were operated, 14 male, 9 female; age 3 ～ 12 years; the average age of 5.7 years; their main symptoms were unable to stand and walk independently, with severe hypermyotonia of both lower extremities, and a scissoring type of gait when standing, hip and knee flexing contracture, ankle and foot equinovarus. Physical examination: there was hypermyotonia of the iliopsoas, adductor musculus, hamstrings, triceps surae, anterior and posterior tibial muscle, flexor pollicis longus and flexor digitorum longus. The muscle tone was 3 ～4 grade according to Ashworth criterion. Treatment: The intramuscular tenotomy, fascial division or sliding elongation were performed, to lengthen the tendon of the joint flexion contracture, the lateral half of anterior tibial muscle tendon was transferred laterally to balance the muscle force at the foot. Finally, both lower extremities were fixed by a new designed external frame, to straigthen the articular genu, keep both ankles and feet in neutral position, both lower extremities abducting 30°, and to correct all joint deformities. Family rehabilitation programs started after the external frame was removed 6 weeks later. [Result] All cases were followed up in 1 ～3 years with the average 2. 2 years. The results were evaluated as excellent, good and ineffective, according to correction of the joint deformities, the ability to stand and walk, and parent's satisfaction to the treatment. Of them 21 cases were excellent, 2 cases good, and no ineffective case. [ Conclusion ] For the severe cerebral palsy with spastic diplegia in children, reasonable release of the tight tendons of the multi-joint flexion contracture, balance of muscle force at the foot, correction of all deformities and fixation of the lower extremities with the new external frame, and long term of family rehabilitation after the surgery, are more effective treatment.

Clinical Analysis for Lymph Node Metastasis as a Guide to Modified Surgery for Early Gastric Cancer

The authors have analyzed the clinicopathologic data of 855 patients with early gastric cancer (EGC) who underwent D2 lymph node dissection during the 7-year period between January 1990 and December 1996 in order to evaluate the factors influencing lymph node metastasis and to establish the clinical indications and guidelines for modified surgery in EGC patients. The overall rate of lymph node metastasis was 13.5% (115/855). There was a significant statistical difference for lymph node metastasis between men (67/575, 11.7%) and women (48/280, 17.1%)(p<0.05). In mucosal cancer, the rate of lymph node metastasis was 4.7% (20/427), and in submucosal cancer, it was 22.2% (95/428), which is a significant difference between the two groups. There was also a significant difference for lymph node metastasis between the elevated types (EGC type I and IIa) and the depressed types (type IIb, IIc, and III), 8.4% (13/154) and 14.6% (102/701), respectively (p=0.05). There were only one lymph node positive case (1/82, 1.2%) among the elevated mucosal cancers. Smaller tumors((10 mm) showed a significantly lower incidence of lymph node metastasis than larger tumors (11 mm)(p<0.01); 4 cases invoving tumors of less than 11 mm had lymph node metastasis(2 mucosal and 2 submucosal lesions). Differentiated mucosal carcinomas showed a significantly lower incidence of lymph node metastasis than undifferentiated carcinomas (0.9% vs 8.5%, p<0.001), whereas there was no significant difference between differentiated and undifferentiated submucosal cancers. There were 14 cases of EGC with metastasis in the secondary lymph node group (N2) consisting of 5 men and 9 women, with a mean age of 53 years. Among them, the 7 cases under the age of 50 were all female patients. For thses 14 case, the average tumor size was 34 mm (15~90 mm), and the majority of were depressed types (11 cases) and undifferentiated type (12 cases). These results suggest that modified surgery is indicated as an optimal treatment option for mucosal cancer with elevated and/or differentiated type tumors, on the basis of not only radicality but also postoperative quality of life.