1–year follow–up of 920 hip and knee arthroplasty patients after implementing fast–track: Good outcomes in a Norwegian university hospital

BackgroundFast–track has become a well–known concept resulting in improved patient satisfaction and postoperative results. Concerns have been raised about whether increased efficiency could compromise safety, and whether early hospital discharge might result in an increased number of complications. We present 1–year follow–up results after implementing fast–track in a Norwegian university hospital.MethodsThis was a register–based study of 1,069 consecutive fast–track hip and knee arthroplasty patients who were operated on between September 2010 and December 2012. Patients were followed up until 1 year after surgery.Results987 primary and 82 revision hip or knee arthroplasty patients were included. 869 primary and 51 revision hip or knee patients attended 1–year follow–up. Mean patient satisfaction was 9.3 out of a maximum of 10. Mean length of stay was 3.1 days for primary patients. It was 4.2 days in the revision hip patients and 3.9 in the revision knee patients. Revision rates until 1–year follow–up were 2.9% and 3.3% for primary hip and knee patients, and 3.7% and 7.1% for revision hip and knee patients. Function scores and patient–reported outcome scores were improved in all groups.InterpretationWe found reduced length of stay, a high level of patient satisfaction, and low revision rates, together with improved health–related quality of life and functionality, when we introduced fast–track into an orthopedic department in a Norwegian university hospital.The health service in Norway has been reorganized in the last decade. The number of available beds and the length of stay (LOS) in somatic hospitals have been reduced. Patients are increasingly being treated as outpatients rather than being admitted to hospital (SSB 2011). Changes in treatment modalities have contributed to this reorganization. Within elective surgery, the “fast–track” principles are increasingly being adopted, although there is still potential for improvement regarding both treatment and clinical results (Rostlund and Kehlet 2007, Kehlet and Soballe 2010). Fast–track originated in Denmark—in gastrointestinal surgery—and has been further developed and documented in joint replacement surgery in hospitals in Denmark over the last decade (Rasmussen et al. 2001, Husted et al. 2010a,d, 2012, Leonhardt et al. 2010). The fast–track concept is an evidence–based multimodality treatment that reduces convalescence time and improves clinical results, including reduction in morbidity and mortality (Kehlet and Wilmore 2008, Schneider et al. 2009). The particularly important elements are: anesthesia, fluid therapy, pain therapy, and early postoperative mobilization (Husted and Holm 2006, Husted et al. 2010a, 2011a, 2012, Khan et al. 2014) as well as preoperative information and supervision (Kehlet 1997, Andersen et al. 2007, 2009, Holm et al. 2010).It has been said that fast–track may result in increased complication rates and re–admissions (Mauerhan et al. 2003). However, several studies have found that reduced length of stay does not compromise patient safety (Pilot et al. 2006, Mahomed et al. 2008, Schneider et al. 2009) or increase complication rates compared to conventional treatment methods (Husted et al. 2010b). Also, it has been shown that fast–track surgery with early mobilization and short deep–vein thrombosis prophylaxis results in low rates of deep–vein thrombosis and pulmonary embolism (Husted et al. 2010c, Jorgensen et al. 2013).A reorganization in the orthopedic department at Trondheim University Hospital in 2010 led to an increased number of knee and hip arthroplasty patients, from 7 to 17 a week (Egeberg et al. 2010). Based on the successful implementation of fast–track in several hospitals in Denmark (Husted et al. 2008, Kehlet and Wilmore 2008), this model was adopted in our department. To be able to continually monitor treatment quality and process data, we established an internal quality register (Bjorgen et al. 2012). We now present the 1–year follow–up results after implementation of this fast–track procedure.     

Trends in the incidence of acute myocardial infarction and stroke: a 21‐year follow‐up of the Oslo study

Objective --In spite of the advances in technology and surgical techniques, cardiac surgical operations with the use of cardiopulmonary bypass (CPB) are still associated with pulmonary morbidity and mortality. The purpose of this study is to morphologically analyze the structure of air-blood barriers in patients who underwent coronary artery bypass grafting (CABG) with use of CPB. Design --The investigation involved 50 patients aged 48-75 who underwent CABG with the use of extracorporeal circulation (ECC). Lung tissue specimens, which were taken before and after CPB, were observed with light and electron microscopy. Results --Both light and electron microscopic observations of pre-pump specimens did not show any pathological changes within the terminal part of the respiratory system. Morphological observations of tissue samples obtained after CPB revealed features of air-blood barrier injury and presence of surfactant within the alveolar capillaries. Conclusion --Whatever the mechanism of the aforementioned changes one should be aware that the presented results indicate that air-blood barriers become leaky after CABG is performed with the aid of ECC.     

Poor maintenance of sinus rhythm after electrical cardioversion of patients with atrial fibrillation or flutter: a 5‐year follow‐up of 268 consecutive patients

Objective—To report long‐term results of direct current (DC)‐cardioversion in unselected patients with atrial fibrillation (AF) or flutter.

Design—The study was a retrospective 5‐year follow‐up of all patients undergoing DC‐cardioversion for AF or flutter at our institution between 1993 and 1997.

Results—Three hundred and eighty‐five DC‐cardioversions were performed in 268 patients. Two hundred and forty‐nine patients underwent cardioversion for the first time. Of these, 183 (74%) were converted to sinus rhythm. During the first month of follow‐up 105 (57%) relapsed into AF. Only 33 patients (13%) of the 249 patients scheduled for cardioversion remained in sinus rhythm after 1 year. In multivariate analysis arrhythmia duration was the only variable that was associated with successful cardioversion. Periprocedural complications occurred in 9.9% of the cardioversions.

Conclusion—In daily routine only a minority of patients will maintain sinus rhythm after DC‐cardioversion for AF or flutter. Also, DC‐cardioversion is not without risk. These observational data suggest a conservative approach to re‐establishment of sinus rhythm in patients with AF.     

Long-term outcome of shoulder arthrodesis performed with plate fixation: 18 patients examined after 3–15 years

Background and purpose?There have been few reports on the long-term function after shoulder arthrodesis. We report the outcome after shoulder arthrodesis with plate fixation in 18 patients who were followed for 3–15 years.

Methods?25 patients with a median age of 64 (19–75) years were operated with a shoulder arthrodesis between 1982 and 2003. Standard AO surgical technique with plating was used in all patients. 18 of the patients were examined retrospectively after a mean of 8 (3–15) years. 6 of the other patients had died and 1 refused examination.

Results?Radiologically, all but two arthrodeses fused completely. The remaining two were partially fused, within the glenohumeral joint or between humerus and acromion. The mean Oxford shoulder score was 32 and the mean ASES shoulder index was 59. Nine patients had intermittent or continuous pain; their mean pain score on a visual analog scale was 3. One patient had been re-operated after 4 months because of severe pain and 1 was operated due to a humeral shaft fracture after 8 months. 1 patient suffered from a complex regional pain syndrome. No infections occurred.

Interpretation?In this patient series there were few complications after shoulder arthrodesis, and the longterm functional results were acceptable.     

Age does not affect the outcome after digital nerve repair in children – A retrospective long term follow up

Background

Digital nerve injuries in children are not common, but they are considered to have an excellent prognosis, compared to adults, after nerve injury and repair. In studies including both children and adults age have been found to have an effect on outcome after nerve repair.

Intraarticular fractures of the distal end of the radius in young adults: A 16 (2–26) year follow-up of 42 patients

Forty-two patients, aged 29 (17–42) years when they sustained an intraarticular fracture of the distal end of the radius, were reexamined after 16 (2–26) years. More than two thirds of the fractures were caused by high-energy trauma. Subjectively, 34 patients had excellent or good results, while only 8 had fair or poor results; 6 patients had changed their occupation owing to disability from the wrist. Almost half of the patients had residual deformity at the follow-up clinical examination. Slightly more than half of the patients had radiographic arthrosis. Subjective evaluation correlated with residual deformity and arthrosis, but not with radiographic displacement or intraarticular step off. Arthrosis correlated with residual deformity and intraarticular step off, but not with radiographic displacement. Clinical residual deformity included soft-tissue changes in contrast to radio-graphic displacement. More interest should be directed to soft-tissue changes following this type of fracture.     

Long term results of video-assisted anal fistula treatment for complex anal fistula: another shattered dream?

Aim

Complex anal fistula represents a burden for patients, and its management is a challenge for surgeons. Video-assisted anal fistula treatment (VAAFT) is one sphincter-sparing technique. However, data on its long-term effectiveness are scant. We aimed to explore the outcomes of VAAFT in a retrospective cohort of patients referred to a tertiary centre.

Method

Consecutive adult patients with a minimum of 2 years’ follow-up after VAAFT were reviewed. Patients were followed up to 5 years postoperatively. Failure was defined as incomplete healing of the external orifice(s) during the first 6 months. Recurrence was defined as new radiologically and/or clinically confirmed onset of the fistula after primary healing. A generalized linear model was fitted to evaluate the association between failure and sociodemographic characteristics. Predictors of recurrence were determined in a subgroup analysis of patients found to be free from disease at 6 months postoperatively.

Results

Overall, 106 patients (70% male; mean age 41 years) were reviewed. Of these 86% had a previous seton placement. Fistulas were either high trans-sphincteric (74%), suprasphincteric (12%) or extrasphincteric (13%). Eight (7%) patients experienced postoperative complications, none of which required reintervention. Mean follow-up was 53 ± 13.2 months. VAAFT failed in 14 (13%) patients. The overall recurrence rate ranged from 29% at 1 year to 63% at 5 years. Multiple external orifices, suprasphincteric fistula, younger age, previous surgery and higher complexity of the fistulous tract were independent risk factors for recurrence.

Conclusion

VAAFT is a safe sphincter-sparing technique. The initially high success rate decreases over time and relates to a higher degree of complexity.     

Laparoscopic management of severe reflux after sleeve gastrectomy using the LINX® system: Technique and one year follow up case report

IntroductionManagement of severe reflux after sleeve gastrectomy (SG) usually requires converting to Roux-en-y gastric bypass (RYGB). We present a case of managing this problem using the LINX^® system.Presentation of caseIn February 2015, we performed a laparoscopic placement of LINX^® system to treat severe reflux after sleeve gastrectomy on a 25-year-old female. The operative time was 47 min. There were no intra or postoperative complications. The hospital stay was one day. The postoperative UGI showed no reflux. Ten days after surgery her Quality of life score (QOL) changed from 64/75 to 7/75 after the LINX^® placement. One year later the patient continued to enjoy no reflux and stayed off medication.DiscussionReflux after sleeve gastrectomy is usually managed by conversion to RYGB by most surgeons. This case report opens the door for an alternative management of this problem while maintaining the original sleeve gastrectomy. This technique is reasonably easy to perform in comparison to the conversion to RYGB with less potential post-operative complications. A one year follow up showed good control of reflux without medication.ConclusionLaparoscopic placement of the LINX^® system to correct severe reflux after sleeve gastrectomy is a safe alternative procedure to conversion to a RYGB.     

Long-term results of venous valve reconstruction: A four- to twenty-one—year follow-up

Purpose: The purpose of this study is to describe the very long-term clinical, hemodynamic, and imaging results of venous valve reconstruction for reflux disease in patients with chronic venous insufficiency.Methods: There were 51 extremities (48 patients) with follow-up of 4 to 21 years with a mean of 10.6 years. Clinical severity was graded as asymptomatic (class 0), mildly symptomatic (class 1), moderately symptomatic but without ulceration (class 2), or severely symptomatic with or without ulceration (class 3). Preoperative and postoperative evaluation consisted of history and physical examination, ascending venography (preoperative only), ambulatory venous pressures or photoplethysmography, and descending venography or duplex scanning.Results: Before surgery, 49 (96%) of 51 limbs demonstrated severe, class 3 disease, and two limbs were classified as class 2 disease. After venous valve reconstruction by either direct femoral vein valve repair, transposition, or transplantation, long-term clinical success of achieving a class 0 or 1 result (by life-table analysis) was 60% at 10 years. Thirty-three percent demonstrated a class 0 result in which the limbs were free from symptoms and had no need for long-term elastic support. After 6 years clinical results were stable and did not deteriorate. Incompetent perforators were identified in 31 cases and were treated selectively. Three disease patterns of chronic venous insufficiency were identified: primary valve insufficiency 43%, postthrombotic syndrome 31%, and a group consisting of both primary valve insufficiency of the superficial femoral vein and postthrombotic syndrome of the calf veins (primary valve insufficiency-postthrombotic syndrome) 26%. Ten-year cumulative clinical success was clearly superior in limbs with primary valve insufficiency corrected by valve repair (73%) as opposed to those with postthrombotic syndrome treated by either valve transposition or transplantation (43%) (p = 0.029). Clinical outcome correlated strongly with postoperative imaging results, and durability of valve repair was confirmed by demonstrating competence up to 16 years after the operation. Significant improvement in ambulatory venous pressure (mean percentage of pressure fall and refill time) was found in limbs with class 0 or 1 outcome; however, values did not reach "normal" levels in all cases. Recurrent ulcerations after the operation were attributed to failed reconstructions (10), incompetent profunda femoris veins (three), incompetent perforators (three), and concomitant lymphedema (one).Conclusions: This report highlights a difference found in very long-term prognosis of surgical treatment of primary valve insufficiency as opposed to postthrombotic syndrome. Long-term elimination of symptoms of chronic venous insufficiency is achieved by valve repair for primary valve insufficiency beyond 10 years, whereas late results of treatment of postthrombotic syndrome in this study was accompanied by high recurrence rates and warrants further investigation. (J VASC SURG 1994;19:391-403.)     

Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long‐term results

Despite refinements in surgical technique, including bone grafting and sophisticated prosthetic reconstructions, there are limitations to what can be achieved with bone‐anchored fixed prostheses in patients with advanced atrophy of the maxillae. A new approach was suggested by a long‐term study on onlay bone grafting and simultaneous placement of a fixture based on a new design: the zygoma fixture, and the aim of this study was to assess its potential. Twenty‐eight consecutive patients with severely resorbed edentulous maxillae were included, 13 of whom had previously had multiple fixture surgery in the jawbone that had failed. A total of 52 zygoma fixtures and 106 conventional fixtures were installed. Bone grafting was deemed necessary in 17 patients. All patients have been followed for at least five years, and nine for up to 10 years. All patients were followed up with clinical and radiographic examinations, and in some cases rhinoscopy and sinoscopy as well. Three zygoma fixtures failed; two at the time of connection of the abutment and the third after six years. Of the conventional fixtures placed at the time of the zygoma fixture, 29 (27%) were lost. The overall prosthetic rehabilitation rate was 96% after at least five years of function. There were no signs of inflammatory reaction in the surrounding antral mucosa. Four patients with recurrent sinusitis recovered after inferior meatal antrostomy. To conclude, the zygoma fixture seems to be a valuable addition to our repertoire in the management of the compromised maxilla.     

A prospective study on the wound healing and quality of life outcomes of patients with venous leg ulcers in Singapore—Interim analysis at 6 month follow up

Venous leg ulceration results in significant morbidity. However, the majority of studies conducted are on Western populations. This study aims to evaluate the wound healing and quality of life for patients with venous leg ulcers (VLUs) in a Southeast Asian population. This is a multi-centre prospective cohort study from Nov 2019 to Nov 2021. All patients were started on 2- or 4-layer compression bandage and were reviewed weekly or fortnightly. Our outcomes were wound healing, factors predictive of wound healing and the EuroQol 5-dimensional 5-level (EQ-5D-5L) health states. Within our cohort, there were 255 patients with VLU. Mean age was 65.2 ± 11.6 years. Incidence of diabetes mellitus was 42.0%. Median duration of ulcer at baseline was 0.30 years (interquartile range 0.136–0.834). Overall, the median time to wound healing was 4.5 months (95% confidence interval [CI]: 3.77–5.43). The incidence of complete wound healing at 3- and 6-month was 47.0% and 60.9%, respectively. The duration of the wound at baseline was independently associated with worse wound healing (Hazard ratio 0.94, 95% CI: 0.89–0.99, P = .014). Patients with healed VLU had a significantly higher incidence of perfect EQ-5D-5L health states at 6 months (57.8% vs 13.8%, P < .001). We intend to present longer term results in subsequent publications.     

Long term results after double and single bundle ACL reconstruction: Is there any difference? A meta - analysis of randomized controlled trials

ObjectiveThe double-bundle (DB) techniques are considered to yield better stability of the knee compared with single-bundle (SB) for anterior cruciate ligament (ACL) reconstruction. However, most studies followed up patients in short to middle-term within 5 years, and the longer-term efficacy of SB and DB ACL reconstruction is still beyond consensus. The purpose of this meta-analysis is to compare the longer-term efficacy between double-bundle (DB) and single-bundle (SB) techniques.MethodsPubMed, EMBASE, and Cochrane Library databases were searched for relevant articles published up to November, 2017 with an English language restriction. The searches were limited to human subjects and randomized controlled trials (RCTs). In addition, the reference lists of identified articles were checked manually to avoid missing other potentially eligible studies. This process was performed iteratively until no additional articles could be included. The quality of the included studies was assessed using The Cochrane Collaboration's risk of bias tool. All statistical analyses were performed with Review Manager soft-ware.ResultsA total of five RCTs involving 294 patients were included finally. No studies were excluded due to insufficient data or low quality. The pooled results showed no statistically significant difference between SB and double bundle DB reconstructions for Lysholm, IKDC, pivot shift, KT scores, and the development of osteoarthritis at a minimum of 5 years. No significant heterogeneity was found across all outcomes.ConclusionThe best available evidence demonstrated that SB and DB techniques could yield similar efficacy for ACL reconstruction. And no superiority was founded in DB ACL reconstruction with a minimal 5-year follow-up. Given that, the relatively simple and proven techniques of SB ACL reconstruction may be preferable for orthopedic surgeons.Level of evidence: Level I, Therapeutic Study.     

Surgical closure of patent foramen ovale in patients with suspected paradoxical embolism: long‐term results

Objective—It is thought that a patent foramen ovale (PFO) is the crucial mechanism in patients with suspected paradoxical embolism and cryptogenic stroke. It has been hypothesized that closure of the PFO would prevent further cerebrovascular incidents. We describe our early and late experience with surgical closure of PFO in patients with paradoxical embolism.

Patients and methods—Between May 1994 and December 2001, 33 patients (26 men, 7 women; mean age, 55.2?±?8.7 years; range, 37–74 years) underwent surgical closure of a PFO at our institution. All patients had preoperatively suffered from a stroke and/or a transient ischemic attack, after which echocardiography showed a PFO. Mean follow‐up at 99?±?30 months (range, 10–111 months) was 100% complete.

Results—All patients survived the operative procedure. Early complications occurred in four patients (12%). Actuarial survival at 1, 5 and 8 years was 97?±?3%, 97?±?5% and 94?±?8%, respectively. At long‐term follow‐up all but two patients were alive. The deaths of these two patients were related to malignancy and ischemic heart disease, respectively. Two patients (6%) had suffered a residual cerebrovascular event after successful surgery.

Conclusion—Surgical closure of PFO in patients with paradoxical embolism can safely be performed with a low risk of early mortality. Residual thromboembolic events were rare and in those few it occurred it did so with the interatrial septum being closed, indicating that in those patients the PFO was not the mechanism of the thromboembolic event in the first place.