Citations

The coexistence of urologic malignancy (UM) and abdominal aortic aneurysm (AAA) is rare. Simultaneous treatment may increase morbidity, whereas staged operations delay necessary treatment. We reviewed our experience to develop guidelines for evaluation and management. Clinical data of all patients diagnosed between 1980 and 1998 with both AAA and UM, who also had staged or simultaneous surgical treatment were reviewed. Four thousand forty-seven patients underwent AAA repair during the study period at our institution. Of these, 18 (0.44%) patients, 16 men and two women (mean age: 74 years, range: 61 to 92) had UM. UM was discovered incidentally in nine patients with AAA with computed tomography (CT) scan (7) and ultrasonography (2). In one patient with AAA, hematuria raised the suspicion of UM. Eight patients were diagnosed with AAA during evaluation of UM by CT scan or ultrasound (7) or during laparotomy (1). Initial signs and symptoms included abdominal pain (33%), gross hematuria (33%), and urinary tract infections (17%), although 33% were asymptomatic. The AAA was symptomatic at first examination in three (17%) patients, 14 (78%) patients had hypertension, and two (11%) had renal insufficiency (overall mean serum creatinine: 1.6, range: 0.8 to 3.7). Mean AAA diameter was 5.8 cm (range: 3.8 to 8 cm). Aortography documented significant contralateral renal artery disease in two patients. Twelve patients underwent simultaneous AAA repair and resection of UM; the operations were staged in six (AAA repair first in 2, nephrectomy first in 4). One patient required emergent repair of a ruptured AAA three days after nephrectomy. UM was treated with nephrectomy in 17 patients, and with bilateral ureterectomy and cystectomy in one. A straight aortic graft was implanted in seven patients, a bifurcated graft in ten, and one had extra-anatomic reconstruction. Two patients required reconstruction of the contralateral renal artery. The 30-day mortality rate was 0% after staged and 6% after simultaneous repair (p= >0.1). Major perioperative complications occurred more frequently after simultaneous (42%) than after staged repair (33%), although the difference was not significant (p= >0.1). Two patients developed postoperative renal failure. Seventeen patients were followed for an average of 3.9 years (14 days to 10.8 years). Three (17%) patients died of recurrent cancer at 1, 10.7, and 10.8 years after surgery. Patients with resectable UM have satisfactory long-term survival, which justifies aggressive treatment of concomitant AAA. Aortography in these patients is suggested to exclude contralateral renal artery disease. Complications were frequent, but simultaneous repair did not increase morbidity or mortality significantly. The risk of AAA rupture after nephrectomy, need to correct contralateral renal artery disease at the time of nephrectomy, and disadvantage of delaying treatment of UM are compelling reasons to favor simultaneous treatment of AAA and UM.

As endografting technology advances, anatomical constraints limiting access and deployment have become less of a burden. While unsuitable candidates for endografting exist, these patients are becoming less frequent. To broaden the applicability of endovascular abdominal aortic aneurysm repair (EVAR), we have modified the bifurcated AneuRx™ device into a unilimb modular prosthesis, by placing an aortic extender cuff across the flow divider, thus excluding its contralateral limb. This technique was used with success in 3 groups of patients: with occlusion of 1 iliac artery, with a nontraversable iliac stenosis, or with a small calcific aortic bifurcation. In these patients, anatomy can make it difficult, if not impossible, to place a bifurcated stent graft. Whether as a planned preoperative procedure or as a ‘bail-out’ maneuver, this procedure has been successful in avoiding open surgical conversion.

Eighty-six male high school ice hockey players partic ipated in this prospective study to determine both the incidence of injury in high school ice hockey and the influence of physical, situational, and psychosocial fac tors. Physical factors included height, weight, vision, previous injuries, musculoskeletal abnormalities, and injuries present at the time of screening evaluations. Situational factors examined were level of participa tion, playing time, player position, and games versus practices. Psychosocial factors such as confidence, stress, social support, positive states of mind, and mood states were also examined to determine their influences on injury. Twenty-seven injuries occurred during the 1994 to 1995 season. As hypothesized, the overall incidence of injury in high school hockey games (34.4 per 1000 player-game hours) was less than the incidence of injury in Junior A hockey (96.1 per 1000 player-game hours) and was more than previously re ported for Bantam youth hockey (10.9 per 1000 player- game hours). Injuries occurred more often in games than in practices, usually as a result of collisions. Phys ical factors such as player position and previous inju ries did not significantly predict injuries, but players in the high playing time group were more likely to be injured. Psychosocial factors of low vigor and high fatigue as measured by the Incredibly Short Profile of Mood States (ISPOMS) significantly predicted high school ice hockey injuries.

The purpose of this study was to analyze intersegmen tal forces at the tibiofemoral joint and muscle activity during three commonly prescribed closed kinetic chain exercises: the power squat, the front squat, and the lunge. Subjects with anterior cruciate ligament-intact knees performed repetitions of each of the three exer cises using a 223-N (50-pound) barbell. The results showed that the mean tibiofemoral shear force was posterior (tibial force on femur) throughout the cycle of all three exercises. The magnitude of the posterior shear forces increased with knee flexion during the descent phase of each exercise. Joint compression forces remained constant throughout the descent and ascent phases of the power squat and the front squat. A net offset in extension for the moment about the knee was present for all three exercises. Increased quadri ceps muscle activity and decreased hamstring muscle activity are required to perform the lunge as compared with the power squat and the front squat. A posterior tibiofemoral shear force throughout the entire cycle of all three exercises in these subjects with anterior cru ciate ligament-intact knees indicates that the potential loading on the injured or reconstructed anterior cruci ate ligament is not significant. The magnitude of the posterior tibiofemoral shear force is not likely to be detrimental to the injured or reconstructed posterior cruciate ligament. These conclusions assume that the resultant anteroposterior shear force corresponds to the anterior and posterior cruciate ligament forces.

This 3-year prospective cohort observational analysis of elite amateur hockey players ranging in age from 17 to 20 years on a United States Hockey League team de scribes ice hockey injuries using a strict definition of injury, standardized reporting strategies, and diagnosis by a team physician. One hundred forty-two injuries were recorded for an on-ice injury rate of 9.4 per 1000 player hours. A player was 25 times more likely to be injured in a game (96.1 per 1000 player-game hours) than in practice (3.9 per 1000 player-practice hours). Game-related injuries were more frequent in the third period, and practice-related injuries occurred more of ten in the first third of the season. Collisions represented 51% of the total injuries. The most common types of injuries were strains, lacerations, contusions, and sprains. The face and the shoulder were most fre quently injured. A facial laceration was the most com mon injury; acromioclavicular joint sprain was the sec ond most common injury. Facial lacerations typically occurred in games and were stick related. Further re search is necessary to determine if injuries in Junior A amateur ice hockey can be reduced by mandatory full facial protection, enforcement of existing rules, im provement in shoulder pad design, and by focusing more attention on stretching programs.

The purpose of this study was to review patellar tendon ruptures in athletes treated with surgical repair. Six pa tellar tendon ruptures in five athletic patients were iden tified at our institution between 1980 and 1990. All pa tients had operative debridement and primary repair of the ruptured patellar tendon using nonabsorbable su tures passed through patellar drill holes at an average of 2.5 days after injury. Personal interview, physical ex amination, roentgenographic evaluation, and isokinetic strength testing were performed at an average of 6 years after surgery. At final followup, no patient had complaints referable to the patellar tendon repair; all were able to achieve their premorbid levels of sports at an average of 18 months after injury. No patient thought that the surgically repaired knee was unstable or activity-limiting. All patients demonstrated full range of motion and strength equal to or greater than that of the noninjured side. One patient required an arthroscopic lateral release for lateral patellar facet pressure syn drome with an excellent result. No complications oc curred ; no other reoperations were required. Complete disruption of the patellar tendon is an uncommon injury in athletic individuals without predisposing medical con ditions. After acute operative repair and aggressive re habilitation, an excellent and enduring functional outcome can be expected.

The methods and materials for ACL reconstruction are important issues for the practicing orthopaedic sur geon. In this study a model was developed to study the biological and biomechanical characteristics of a patel lar tendon autograft used for ACL reconstruction. Spe cifically it was hypothesized that since vascularity of these grafts reflects their "healthiness," strength and vascularity should be inversely related in the early pe riod after implantation. Using an over the top technique, a patellar tendon graft was placed in three groups of dogs and studied at 37, 57, and 120 days. Vascularity of the grafts was measured using technetium-tagged red blood cells, and percent water by weight was determined by dessication. Tensile testing to failure was performed using an MTS machine. The grafts became more vascular, more hydrated, less stiff, and less strong (by 4 weeks) than controls. By 16 weeks the vascular response was subsiding but the grafts remained only 40% as strong as controls. Percent water increased significantly over controls for all time periods. Decrease in strength correlated poorly with vascularity but correlated well with increase in percent water. These findings suggest that the change in strength of an intraarticular ACL replacement relates more to a basic rearrangement of its collagen-ground substance relationships, and that vascularity may re flect the inflammatory response bringing about these changes. The model developed in this study serves as a basis for further studies, and the findings reveal important information about the behavior of ACL graft ing materials.

Objectives The study goal was to report the oncologic outcomes of transoral laser microsurgery (TLM) in the treatment of squamous cell carcinoma of the supraglottic larynx. Study Design and Setting A two‐center prospective case series analysis. Results Thirty‐eight patients underwent TLM for previously untreated carcinoma of the supraglottic larynx between 1997 and 2005. Pathological T stages were T1 in 8 (21%), T2 in 14 (37%), T3 in 8 (21%), and T4 in 8 (21%). Twenty‐six patients (68%) had neck dissections. Thirteen patients (34%) received adjuvant radiotherapy. The mean follow‐up for all patients was 31 months. The 2‐year Kaplan‐Meier estimates for local control were 97%; locore‐gional control, 94%; disease‐specific survival, 80%; and overall survival, 85%. The overall functional laryngeal preservation rate was 79% (19 of 24). Conclusions TLM is a safe and effective treatment for cancer of the supraglottic larynx Significance TLM is an emerging strategy in the management of laryngeal cancer. © 2007 American Academy of Otolaryngology‐Head and Neck Surgery Foundation. All rights reserved.

Purpose A phase II study was conducted to determine the efficacy and toxicity of radiotherapy with concomitant gemcitabine and cisplatin for patients with locally advanced pancreatic adenocarcinoma. Patients and Methods Forty-eight patients with locally advanced pancreatic adenocarcinoma received gemcitabine (30 mg/m2) and cisplatin (10 mg/m2) twice weekly during the first 3 weeks of radiotherapy. The radiation dose to the primary tumor and regional nodes was 45 Gy in 25 fractions, and the gross tumor volume received an additional 5.4 Gy in three fractions. Four weeks after radiotherapy, patients received gemcitabine (1,000 mg/m2) once weekly every 3 of 4 weeks for a 12-week period. The primary end point was survival at 12 months. Secondary end points were time to progression, toxicity, and quality of life. Results Survival at 1 year was 40% for 47 eligible patients. The median survival was 10.2 months. Confirmed responses were observed for 8.5% (two partial, two complete), and median time to progression was 7.3 months. Grade 4 or higher toxicity was observed for 31% and consisted primarily of hematologic and GI toxicity. There was a trend toward improved overall quality of life, measured by the Symptom Distress Scale (P = .06), with significant improvements in domains of insomnia, pain, and outlook. Conclusion The combination of radiotherapy, gemcitabine, and cisplatin was well tolerated. Survival results were similar to those achieved with other treatment regimens for patients with locally advanced pancreatic cancer but did not meet our predefined criteria for additional evaluation of this regimen.