An 81 year old man presented with an asymptomatic swelling of his left upper limb. The patient's past medical history included angina, hypertension, and a stroke (five years previously) which left him with mild dysphasia, but no other deficit. There was no past medical or family history of thrombosis. There was a two day history of swelling. The arm was not painful, hot or red, and there was no history of trauma. Apart from pain in the left side of his neck, which had been present for three weeks, the patient was well. System King's Mill Centre,
Purpose: To establish a safety profile for an arthroscopic anatomic glenoid reconstruction using autologous iliac crest bone graft to treat shoulder instability with significant bone loss and to evaluate short-term clinical and radiological outcomes. Methods: A retrospective analysis of prospectively collected data was conducted for the patients who were treated for shoulder instability with bone loss using arthroscopic autologous iliac crest bone graft between November 2014 and June 2018. The safety profile was established by detective intraoperative or postoperative complications such as neurovascular injuries, infections, major bleeding, and subluxations. Short-term clinical and radiologic outcomes also were evaluated. Results: Thirteen patients were included in the study. A safety profile was observed, with no occurrence of intraoperative complications, neurovascular injuries, infection, or major bleeding. There were no dislocations or positive apprehension tests on clinical examination postoperatively. Postoperative Western Ontario Shoulder Instability (WOSI) scores were significantly greater than preoperative WOSI scores, with a mean improvement of 35.0 AE 20.2 (P < .001). Twelve patients (92.3%) received postoperative computed tomography scans, with 11 of 12 patients (91.7%) displaying complete graft union. Conclusions: Arthroscopic treatment of shoulder instability with bone loss via autologous iliac crest bone graft is shown to be a safe operative procedure that results in favourable short-term clinical and radiologic outcomes, with a significant improvement in WOSI scores and high rates of graft union. Although graft resorption was seen in most patients who had postoperative computed tomography imaging, there were no instances of clinical graft failure. Level of Evidence: Level IV, therapeutic case series.
Minimally Invasive Surgery (MIS) needs continuous tool design innovation to support and facilitate the complex task executions of surgeons. In this article, an easily deployable magnetic structure design is presented, which is developed to retract the liver during MIS procedures. During the concept designing phase, a most critical research question, the stability of magnetic anchoring was investigated and analyzed through various experiments. The clinically relevant pulling forces have been applied to N52 neodymium magnets in different size, shape and arrangement to derive the maximum force certain retractor designs could withheld. The numeric results confirmed that the distributed load arrangement would be able to perform a stable human liver retraction. Magnetic encoring technology could have a significant future, encouraging other researchers to investigate the potential of magnetic tissue retraction in MIS procedures that could lead to the development of specialized tools for human clinical deployment.
The rise and advancement of minimally invasive surgery (MIS) has significantly improved patient outcomes, yet its technical challenges—such as tissue manipulation and tissue retraction—are not yet overcome. Robotic surgery offers some compensation for the ergonomic challenges, as retraction typically requires an extra robotic arm, which makes the complete system more costly. Our research aimed to explore the potential of rapidly deployable structures for soft tissue actuation and retraction, developing clinical and technical requirements and putting forward a critically evaluated concept design. With systematic measurements, we aimed to assess the load capacities and force tolerance of different magnetic constructions. Experimental and simulation work was conducted on the magnetic coupling technology to investigate the conditions where the clinically required lifting force of 11.25 N could be achieved for liver retraction. Various structure designs were investigated and tested with N52 neodymium magnets to create stable mechanisms for tissue retraction. The simplified design of a new MIS laparoscopic instrument was developed, including a deployable structure connecting the three internal rod magnets with joints and linkages that could act as an actuator for liver retraction. The deployable structure was designed to anchor strings or bands that could facilitate the lifting or sideways folding of the liver creating sufficient workspace for the target upper abdominal procedures. The critical analysis of the project concluded a notable potential of the developed solution for achieving improved liver retraction with minimal tissue damage and minimal distraction of the surgeon from the main focus of the operation, which could be beneficial, in principle, even at robot-assisted procedures.
A 54-year-old Afro-Caribbean woman presented to the emergency department with a 1-day history of severe headache and general malaise. The pain started suddenly after blowing her nose, was frontal in location and became rapidly severe and throbbing in nature. There were no symptoms that would suggest orthostatic headache, no dizziness or vertigo, no visual or auditory disturbance and no neurological weakness. The pain was worse on movement, coughing and bending and was associated with photophobia, nausea and the development of a clear nasal discharge. Previous medical history was unremarkable; there was no history of sinus or nasal problems, no recent headaches or migraines, no visual abnormalities and no life history of head injury or nasal trauma. Examination was largely unremarkable; on arrival her Glasgow Coma Scale was 15 and she was apyrexial with no meningism or photophobia. No evidence of intracranial hypertension was found. There was slight skull tenderness on palpation over the frontal sinus, but the remainder of her neurological (including cranial nerve) examination and general examination was unremarkable. Biochemical (electrolytes, liver function, glucose, calcium) and haematological tests revealed a mild neutrophilia (12.5×109cells/litre) but were otherwise normal. Over the course of the admission, she became increasingly unwell with increasing nausea, further vomiting and fluctuant levels of consciousness. A computed tomography scan of the head showed an extensive pneumocephalus extending to the foramen magnum with marked sulcal and basal cistern effacement (Figure 1 and 2). Bone windows revealed a hole in the roof of the right sphenoid sinus. The clear discharge was found to be CSF and sent for microbiology analysis. Prophylactic cefotaxime and metronidazole antibiotics were commenced and she underwent endoscopic endonasal exploration. The bony defect in the roof of the right sphenoid and the CSF leak were identified. The dural defect was closed with a fascia lata graft and fat harvested from the thigh. Four days after the operation, she became increasingly confused and a repeat computed tomography scan showed new hydrocephalus. A lumbar puncture was performed and showed an opening pressure of 43 cm (5–20 cm). Two days later she underwent ventricular-peritoneal shunting. She eventually made a full recovery. It is still uncertain whether the hydrocephalus was secondary to a disruption of the sinus by the air pressure in the skull or whether there was hydrocephalus before the events leaking through the ethmoidal bone, suggesting the possibility of spontaneous CSF leak syndrome complicated with pneumocephalus (Schievink, 2000).
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