Objective To explore the protection of the structure and function around the upper pole of the thyroid gland by endoscopic thyroidectomy combined with nerve detection through the gasless unilateral axillary approach. Methods From January 2019 to June 2020, 48 thyroid patients who underwent the gasless unilateral axillary approach combined with the endoscopy and nerve detection technology in the Department of Head and Neck Surgery of Zhejiang Provincial People’s Hospital were reviewed as the endoscopic group, and 53 thyroid patients underwent open surgery combined with the endoscopy and nerve detection technology as the open group. The protection of the functional structure of the suprathyroid pole were compared. Results In terms of operation time, the endoscopic group was longer than that of the open group (67.5 min vs. 54.1 min, P=0.001). There was no statistical difference between the two groups in terms of postoperative hospital stay and blood loss (P>0.05). Forty-seven patients with the endoscopic thyroid surgery through the gasless unilateral axillary approach effectively detected the superior laryngeal nerve (47/48, 97.9%), which was higher than that of the open group (40/53, 75.5%), P=0.003, and the exposure rate of hypoglossal nerve descending branch in the endoscopic group was also higher [31.3% (15/48) vs. 3.8% (2/53), P=0.001]. In the endoscopic group, the superior parathyroid gland was kept in situ during the operation, and there was no change of voice and cough after the operation. In the open group, there were 2 cases of autologous transplantation of the upper pole parathyroid gland, 2 patients had voice changes, and 1 case had partial upper pole banded muscle incision. There was no significant difference in the incidence of nerve injury complications, the rate of autologous transplantation of the upper pole parathyroid gland and the rate of anterior cervical banded muscle injury between the two groups (P>0.05). In addition, there was no significant difference in the levels of parathyroid hormone, blood calcium, blood magnesium and blood phosphorus between the two groups before/after operation (P>0.05). Conclusion During the endoscopic thyroidectomy through the gasless unilateral axillary approach, the nerve monitoring technology is combined with the exploration and protection of the superior laryngeal nerve on the surface of the medial cricothyroid muscle of the upper pole of the thyroid, and the fine capsule anatomy technology is used to protect the superior parathyroid gland in situ, which can more effectively expose the external branch of the superior laryngeal nerve. It is conducive to the protection of the structures around the upper pole.
ObjectiveTo study the changes of bacterial flora after a series of preoperative oral disinfection and the postoperative recovery of patients with craniovertebral junction disorders who were treated with transoral approach operations. And to provide a theoretical basis for the prevention of postoperative complications such as infection.MethodsThe clinical data of 20 cases with craniovertebral junction disorders and treated with transoral approach operations between October 2009 and May 2010 were analyzed. There were 8 males and 12 females, aged 2-66 years (median, 34.5 years). According to the classification of American Spinal Injury Association (ASIA), there were 4 cases of grade B, 8 of grade C, 6 of grade D, and 2 of grade E. The Japanese Orthopedic Association (JOA) score was 10.3±3.0. The mucosa samples of the posterior pharyngeal wall were sent for bacteria culture. These samples were collected by sterile cotton swabs at four crucial points including 3 days before operation/before gargling (T1), 3 days after continuous gargling by chlorhexidine acetate/after anesthesia intubation on the day of operation (T2), after intraoperative cleaning and washing of the mouth (T3), and after intraoperative iodophor immersion for 5-10 minutes (T4). The microflora was stained by means of smear and further counted after an investigation by microscope. The ASIA classification and the JOA scores were applied to evaluate the postoperative nerve function of the patients. A regular reexamination of cervical vertebra with X-ray film, CT, and MRI was conducted after operation to evaluate the reduction of atlantoaxial dislocation, internal fixation position, bone graft fusion, inflammatory lesion, and tumor resection in the craniovertebral junction.ResultsAfter a series of oral disinfection, the mucosa of the posterior pharyngeal wall of all the patients was in a sterile state, which was considered as type Ⅰ incision. All these 20 patients were treated with successful operations, without any intraoperative injury in vertebral artery and spinal cord, or any postoperative complications such as plate loosening, incision infection, or intracranial infection. All the patients were followed up 3-23 months, with an average of 5.15 months. The symptoms such as neck pain, limb numbness and weakness, neural symptoms, etc. were improved to different degrees after operation. The JOA score was improved to 13.4±1.9 at 3 months after operation, showing significant difference when compared with preoperative score (t=8.677, P=0.000); and the atlantoaxial joints had been fused. At last follow-up, the ASIA grades were improved when compared with those before operation. ConclusionIt is safe and effective to cut the posterior pharyngeal muscle layer and implant internal fixation by means of transoral approach in the treatment of craniovertebral junction disorders.
Transcatheter aortic valve replacement (TAVR) has become an increasingly important therapy option for patients with severe aortic stenosis who are not suitable for traditional aortic valve surgery. Transfemoral access remains the most utilized and preferred route for TAVR. Several alternative routes exist, including transapical, direct aortic, axillary-subclavian, transcarotid, and transcaval accesses. Many factors will be taken into account when operators determine the best vascular access, such as diameters of the access and sheater, valve size, calcification, and tortuosity. Vascular complications are the most common complications of TAVR, which are closely related to the adverse outcome and prognosis, and their occurrences are related to many factors, including the surgeon’s experience, the patient-associated factors, and the device-associated factors. The risk of vascular complications can be reduced through the choice of valve type and vascular approach, detailed preoperative imaging evaluation, and improvement of the patient’s baseline disease. It is suitable to determine whether conservative treatment or reintervention will be chosen according to the severity of the complications.
ObjectiveTo evaluate the feasibility and clinical value of robot-assisted lobectomy through anterior approach.MethodsWe retrospectively analyzed the clinical data of 180 patients who underwent robot-assisted lobectomy through anterior approach in our hospital between April 2017 and February 2018. There were 97 males and 83 females, aged 59.5 (32.0-83.0) years. The clinical effects were analyzed.ResultsOne patient was transferred to thoracotomy due to tumor invasion of adjacent blood vessels and injury to the blood vessels, and there was no perioperative death. There were 8.5 (1.0-35.0) dissected lymph nodes for each patient. The median operation time was 120 (50-360) min, including robot Docking time 5 (1-23) min and robot operation time 65 (7-270) min. The median blood loss was 50 (5-1 500) mL, 132 (73.3%) patients had malignant tumors and median drainage time was 5 (2-30) d. The mean postoperative pain score was 3.4±0.7 points and the postoperative hospital time was 8 (2-32) d. At the median follow-up of 24 months, 11 patients developed recurrence and metastasis, and 3 died.ConclusionRobot-assisted lobectomy through anterior approach is a safe and convenient operation method, which is worthy of clinical application.
ObjectiveTo investigate the effectiveness of modified Stoppa approach with medial wall spring plate (MWSP) for involving quadrilateral of acetabulum fracture. MethodsBetween March 2008 and September 2013, 38 patients with involving quadrilateral of acetabulum fracture were treated, including of 23 males and 15 females with an average age of 36.08 years (range, 19-56 years). The causes included traffic accidents injury (21 cases), crash injury of heavy object (10 cases), and falling injury from height (7 cases). The interval of injury and admission was 3 hours to 2 days (mean, 11 hours). There were 12 cases of anterior column fracture (type D), 5 cases of transverse fractures (type E), 8 cases of T shaped fractures (type H), 6 cases of anterior column fracture with posterior transverse fractures (type I), and 7 cases of double column fractures (type J) according to Letournel-Judet classification. Based on fracture types, MWSP was used to fix fracture by modified Stoppa approach in 19 cases or combined with the ilioinguinal approach in 10 cases or combined with Kocher-Langenbeck approach in 9 cases. The operation time, blood loss, and complications were recorded. The effectiveness of reduction and the hip function were evaluated according to Matta score system and Merled' Aubigne and Postel score system. ResultsThe operation time was 85-210 minutes (mean, 130 minutes).The intra-operative blood loss was 450-900 mL (mean, 650 mL). There were 1 case of vascular avulsion, and 1 case of bladder injury during operation; there were 8 cases of venous thrombosis and 2 cases of fat liquefaction of incision after operation. Screw was implanted into the articular joint in 1 case on CT after operation. Matta X-ray assessment showed anatomical reduction in 9 cases, satisfactory reduction in 24 cases, and unsatisfactory reduction in 5 cases, and the satisfaction rate of reduction was 86.84%. Three patients had limb shorting of 0.8-1.0 cm when compared with normal limb. All patients were followed up for 7 to 18 months with an average of 10 months. Fractures healed well within 13-16 weeks with an average of 14 weeks. At 1 year after operation, the results were excellent in 9 cases, good in 21 cases, general in 5 cases, and poor in 3 cases, and the excellent and good rate was 78.95% according to the Merled'Aubigne and Postel hip score standards. ConclusionInvolving quadrilateral of acetabulum fracture can be fixed with MWSP by modified Stoppa approach or combined with other approaches to obtain good exposure, less invasion, satisfactory reduction, stable fixation, and low complications.
Objective To compare the effectiveness of one-stage bilateral total hip arthroplasty by direct anterior approach (DAA) and by posterolateral approach, and to investigate the application value of DAA in one-stage bilateral total hip arthroplasty. Methods The clinical data of 65 patients who underwent one-stage bilateral total hip arthroplasty by DAA or posterolateral approach between June 2010 and November 2015 were analyzed retrospectively. DAA was used in 34 cases (group A) and posterolateral approach was used in 31 cases (group B). There was no significant difference in the gender, age, body mass index, preoperative hemoglobin level, etiology, disease duration, preoperative Harris score, and preoperative visual analogue scale (VAS) score between 2 groups (P>0.05) with comparability. The incision length, operation time, intraoperative blood loss, total blood transfusion volume, hospitalization time, early postoperative complications, Harris score, and VAS score were recorded and compared between 2 groups. The simple Likert scale method was applied to evaluate the patient satisfaction, and the imaging evaluation was used. Results The incision length, operation time, intraoperative blood loss, total blood transfusion volume, and hospitalization time of group A were significantly less than those of group B (P<0.05). The patients were followed up 15-48 months (mean, 25.3 months) in group A and 12-51 months (mean, 27.6 months) in group B. The overall incidence of complications related to surgery in group A (10.29%) was significantly lower than that of group B (19.35%) (χ2=8.769, P=0.023). The acetabular anteversion and abduction angle were in the normal range of 2 groups except 1 hip (1.47%) of group A had a higher acetabular anteversion than normal value. Unstable fixed prosthesis happened in 1 hip of groups A and B respectively, and the remaining femoral calcar had no obvious bone resorption and fixed stably. The Harris score and VAS score at each time point after operation of 2 groups were significantly improved when compared with preoperative scores (P<0.05), and the differences between the time points after operation were also significant (P<0.05). The Harris score at 1 and 3 months after operation and the VAS score at 3 days after operation of group A were significantly better than those of group B (P<0.05), but no significant difference was found at last follow-up between 2 groups (P>0.05). According to the simple Likert scale method to analyze patient satisfaction, comprehensive satisfaction of group A (97.1%, 33/34) was significantly higher than that of group B (67.7%, 21/31) (χ2=10.343, P=0.001). Conclusion The application of DAA in one-stage bilateral total hip arthroplasty can significantly relieve the pain, accelerate the recovery of hip joint function, and improve the patient satisfaction. But in clinical application, more attentions should be paid to strictly grasp the indications and prevent the early complications. The long-term effectiveness needs to be further observed.
ObjectiveTo investigate the effectiveness of arthroscopic talocalcaneal coalition resection in painful adults via a modified posterior approach.MethodsBetween January 2015 and December 2017, 9 patients with painful talocalcaneal coalition accepted arthroscopic resection via the posterior malleolus high lateral observation approach combined with the lower medial operation approach. Of them, 6 were male and 3 were female, aged from 19 to 30 years (mean, 24 years). Among them, 2 cases had no definite local trauma and 7 cases had a history of sprain of foot and ankle. The disease duration ranged from 6 to 30 months, with a median of 12 months. Rozansky classification of talocalcaneal coalition for the 9 patients: 5 cases (5 feet) were type Ⅰ, 2 cases (2 feet) type Ⅱ, and 2 cases (2 feet) type Ⅲ. The patients had no sequelae of limb dysfunction and no limb joint surgery in the past. All the patients received anteroposterior and lateral X-ray films and CT scans of the ankle joint during follow-up. The visual analogue scale (VAS) score and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot score were used to evaluate the effectiveness.ResultsThe operation time was 60-90 minutes (mean, 76 minutes). All patients were followed up 12-24 months (mean, 18 months). All the incisions healed by first intention, without infection, skin necrosis, lower extremity deep vein thrombosis, vascular nerve and tendon injury, bone bridge recurrence, and other complications. The ankle function recovered well and the pain was relieved obviously after operation, and the patients returned to work at 3-5 months after operation, with an average of 3.9 months. At last follow-up, the VAS score was 0.7±0.5, which was significantly improved (t=20.239, P=0.000) when compared with preoperative score (4.2±0.5); the AOFAS ankle-hind foot score was 94±4, which was significantly improved (t=−27.424, P=0.000) when compared with preoperative score (62±2). According to AOFAS ankle-hindfoot scoring system, the results were excellent in 7 cases and good in 2 cases at last follow-up.ConclusionIt is more intuitive, more space, and more flexibility for operation via the modified posterior malleolus high lateral observation approach combined with the lower medial operation approach in talocalcaneal coalition. It is feasible to remove talocalcaneal coalition programmatically according to the specific anatomic signs during the operation.
ObjectiveTo evaluate the feasibility and effectiveness of proximal femoral nail anti-rotation (PFNA) combined with curettage and bone graft through Watson-Jones approach in the treatment of proximal femur benign tumors and tumor like lesions.MethodsThe clinical data of 38 patients with benign tumors and tumor like lesions in the proximal femur who were treated through the Watson-Jones approach with PFNA combined with curettage and bone graft between January 2008 and January 2015 were retrospective analysed. There were 24 males and 14 females with an average age of 28 years (range, 15-57 years). Pathological types included 20 cases of fibrous dysplasia, 7 cases of bone cyst, 5 cases of aneurysmal bone cyst, 3 cases of giant cell tumor of bone, 2 cases of enchondroma, and 1 case of non-ossifying fibroma. Before operation, hip pain occurred in 19 patients, pathological fracture occurred in 12 patients, limb shortening and coxa varus deformity was found in 4 patients, and 3 patients received surgery for the local recurrence. The operation time, intraoperative blood loss, and full-weight bearing time after operation were recorded. Patients were followed up to observe union of bone graft and the position of internal fixator on X-ray films and CT images. Visual analogue scale (VAS) score was used to evaluate the level of pain. The Musculoskeletal Tumor Society (MSTS93) score was used to evaluate lower limb function. Harris hip score was used to evaluate hip joint function.ResultsThe operation time was 130-280 minutes (mean, 182 minutes) and the intraoperative blood loss was 300-1 500 mL (mean, 764 mL). After operation, 3 cases of fat liquefaction of incision healed successfully by carefully dressing, and the rest incisions healed by first intention. All patients started partially weight-bearing exercise at 2-4 weeks after operation. The total weight-bearing time was 3-6 months (mean, 4.2 months). All the patients were followed up 24-108 months (median, 60 months). Imaging examination showed that the bone graft fused and the fusion time was 8-18 months (mean, 11.4 months). During the follow-up period, there was no complication such as pathological fracture, femoral head ischemic necrosis, hip joint dislocation, internal fixation loosening and fracture, and no tumor recurrence or distant metastasis occurred. At last follow-up, the VAS score, MSTS93 score, and Harris score were significantly improved when compared with preoperative ones (P<0.05).ConclusionThe treatment of proximal femoral benign lesions by PFNA combined with curettage and bone graft through the Watson-Jones approach is safe and effective, with advantages of better mechanical stability, less residual tumor, and less postoperative complications.
Objective To explore the effectiveness of unilateral percutaneous vertebroplasty (PVP) through mild side and severe side approaches in the treatment of elderly osteoporotic vertebral compression fracture (OVCF). Methods The clinical data of 100 patients with OVCF with symptoms on one side who were admitted between June 2020 and June 2021 and met the selection criteria were retrospectively analyzed. The patients were divided into the severe side approach group (group A) and the mild side approach group (group B) according to the cement puncture access during PVP, with 50 cases in each group. There was no significant difference between the two groups in terms of general information such as gender composition, age, body mass index, bone density, damaged segments, disease duration, and chronic comorbidities (P>0.05). The lateral margin height of the vertebral body on the operated side in group B was significantly higher than that of group A (P<0.001). The pain level and spinal motor function were evaluated using the pain visual analogue scale (VAS) score and Oswestry disability index (ODI) before operation, at 1 day, 1 month, 3 months, and 12 months after operation in both groups, respectively. Results No intraoperative or postoperative complications such as bone cement allergy, fever, incision infection, and transient hypotension occurred in both groups. Four cases of bone cement leakage occurred in group A (3 cases of intervertebral leakage and 1 case of paravertebral leakage), and 6 cases of bone cement leakage occurred in group B (4 cases of intervertebral leakage, 1 case of paravertebral leakage, and 1 case of spinal canal leakage), and none of them had neurological symptoms. Patients in both groups were followed up 12-16 months, with a mean of 13.3 months. All fractures healed and the healing time ranged from 2 to 4 months, with a mean of 2.9 months. The patients had no complication related to infection, adjacent vertebral fracture, or vascular embolism during follow-up. At 3 months postoperatively, the lateral margin height of the vertebral body on the operated side in groups A and B were improved when compared with preoperative ones, and the difference between pre- and post-operative lateral margin height of the vertebral body in group A was higher than that in group B, all showing significant differences (P<0.001). The VAS scores and ODI in both groups improved significantly at all postoperative time points when compared with those before operation, and further improved with time after operation (P<0.05). The differences in VAS scores and ODI between the two groups before operation were not significant (P>0.05); VAS scores and ODI in group A were significantly better than those in group B at 1 day, 1 month, and 3 months after operation (P<0.05), but no significant difference was found between the two groups at 12 months after operation (P>0.05). Conclusion Patients with OVCF have more severe compression on the more symptomatic side of the vertebral body, and patients with PVP have better pain relief and better functional recovery when cement is injected through the severe symptomatic side.
【摘要】目的探讨经乳晕入路腔镜甲状腺手术的可行性。方法回顾分析2007年12月2009年4 月采用经乳晕入路行腔镜甲状腺手术15例临床资料。结果术后患者均痊愈出院。手术时间90～200 min,平均135 min;术中出血20～60 mL,平均32 mL；均未出现喉返神经及甲状旁腺损伤等并发症;术后平均住院5 d。随访6 ～ 20个月,均无复发,患者对伤口满意。结论经乳晕入路腔镜甲状腺手术,安全可靠、并发症少、美容效果好、住院时间短,有应用前景。