Double crisscross sternal wiring and chest wound infections: a prospective randomized study

OBJECTIVE: We sought to assess the efficiency of 2 different sternal wiring techniques in preventing deep sternal wound infection or sternal instability. METHODS: Seven hundred patients were randomized to 2 different groups according to chest-closure techniques. Three hundred fifty patients who underwent a peristernal double crisscross wire closure were included in group X, whereas 350 patients who underwent a standard transsternal closure were included in group T. After sternal closure, the technique for wound suturing was the same for both groups, namely triple-layer sutures up to the intracutaneous skin. All data were prospectively collected and entered in our institute database. RESULTS: The 2 groups of patients were comparable for sex, age, preoperative risk factors, and operative procedures. The overall mortality rate was 4.3% in group X and 4.6% in group T. Postoperative morbidity and mortality were comparable between the 2 groups, unlike for sternal wound complications. None of the patients included in group X had superficial or deep wound complications, whereas in group T 7 (2%) patients presented with a superficial sternal wound infection, 6 (1.7%) presented with a deep chest wound infection with sternal instability requiring re-exploration (P <.05), and 3 presented with a sternal instability caused by sternum disruption without infection. Among patients with deep wound infection and sternal instability, 1 patient died, resulting in a mortality rate of 16.7%. CONCLUSIONS: The peristernal double crisscross wiring technique achieved a greater sternal stability, resulting in a lower incidence of wound infection in association with triple-layer closure of suprasternal tissues.     

Hydro-Jet-assisted laparoscopic cholecystectomy: a prospective randomized clinical study

BACKGROUND: A new dissection technique with high-pressure water stream (Hydro-Jet) has recently been applied for selective dissection during various surgical procedures. The aim of this study was to compare Hydro-Jet with the conventional technique for laparoscopic cholecystectomy. METHODS: Eighty patients were randomized to undergo laparoscopic cholecystectomy with standard (n = 40) or Hydro-Jet-assisted (n = 40) dissection techniques. The rates of intraoperative complications, including blood loss and injury to the adjacent organs, were compared between the groups. The versatility of this technique and the features of surgical dissection were also evaluated and compared. RESULTS: Laparoscopic cholecystectomy was successfully completed in all subjects. The mean operative times were 78 minutes (range, 52-120 minutes) and 81 minutes (range, 45-135 minutes) for Hydro-Jet versus conventional dissection, respectively (P = not significant). Complications included gallbladder perforation in 15% and 30% (P <.1) and liver laceration in 0% and 10% (P <.04) with Hydro-Jet and conventional techniques, respectively. Increased hemorrhage from the gallbladder bed that necessitated fulguration occurred in 12 patients with the conventional technique as compared with none in the Hydro-Jet group (P <.001). Hydro-Jet resulted in a selective dissection of connective tissue preserving blood vessels and the cystic duct. The continuous water flow allowed a clear view for the operator, and the dissection was performed in a relatively bloodless field. The ease of blunt dissection with the bent-tip dissector represents another advantage. CONCLUSION: This study shows that Hydro-Jet dissection represents an excellent alternative to the conventional technique for laparoscopic cholecystectomy. The improved anatomic dissection combined with an almost bloodless operating field as the result of continuous water flow decreased the rate of dissection-related complications.     

Comparison between lengthening over nail and conventional Ilizarov lengthening: a prospective randomized clinical study

The aim of this study is to compare lengthening over an intramedullary nail to the conventional Ilizarov method with regard to percentage length increase, external fixation index, consolidation index and incidence of complications. This is a prospective randomized controlled study. Thirty-one limbs in 28 patients were included in the study; 15 were lengthened over an intramedullary nail, and 16 limbs were lengthened conventionally. The mean duration of external fixation in the lengthening over nail group was 52.2 days compared to 180.4 days in the conventional group. There was higher incidence of complications in the conventional method group. In comparison with conventional Ilizarov lengthening, lengthening over an intramedullary nail offers a shorter period of external fixation and fewer complications overall, but there is a high incidence of deep intramedullary infection which is serious.     

Roentgen stereophotogrammetric analysis and clinical assessment of unipolar versus bipolar hemiarthroplasty for subcapital femur fracture: a randomized prospective study

Background: Hemiarthroplasty is a well‐established treatment for displaced subcapital fracture, but controversy exists about the optimal implant type. Bipolar hemiarthroplasty has proposed advantages over unipolar hemiarthroplasty in terms of better clinical results and decreased wear of acetabular cartilage. Methods: This study is a randomized prospective study of 51 patients (52 hips) receiving either bipolar or unipolar hemiarthroplasty for displaced subcapital fractures. The outcome measurements were clinical scores and Roentgen stereophotogrammetric analysis (RSA) analysis to determine the rate of acetabular wear. Results: Twenty‐three patients completed 2‐year follow‐up. The RSA data demonstrated that there was slightly less acetabular wear by bipolar prostheses than by unipolar. The combined mean three‐dimensional wear of the bipolar prostheses was 0.6 mm compared with 1.5 mm for the unipolar prostheses (P= 0.04). The bipolar group generally achieved higher scores in terms of the Harris Hip Score, Western Ontario and McMaster University Index of Osteoarthritis (WOMAC) questionnaire and 6‐min walk test. These results were statistically significant at 3 months but not at 12 and 24 months. Conclusion: This study suggests that while the bipolar prosthesis performs slightly better than the unipolar in terms of acetabular cartilage wear and clinical outcomes, it remains debatable whether the benefits are worth the increased cost of the prosthesis.     

钢丝环扎与张力带钢丝内固定治疗髌骨骨折的比较

髌骨骨折手术方式以前以钢丝环扎内固定或部分切除为主,目前以张力带钢丝内固定为主。我院1987～1998年行髌骨骨折手术638例,其中钢丝环扎内固定382例,张力带钢丝内固定217例,其他方式39例,报道如下。1　材料与方法11　病例资料　本组皆为新鲜闭合骨折。钢丝环扎内固定382例,男267例,女115例,年龄19～73岁;其中粉碎性骨折216例,占565%。张力带钢丝内固定217例,男136例,女81例,年龄20～68岁,其中粉碎性骨折119例,占548%。12　手术方式121　钢丝环扎组　非粉碎性骨折在髌骨上下骨片横形钻孔后环扎。粉碎性骨折用巾钳将骨折块复位后,用1ｍｍ钢…     

Trauma assessment training with a patient simulator: a prospective, randomized study

BACKGROUND: Patient simulators are computer-controlled mannequins that may increase realism during trauma training by providing real-time changes in vital signs and physical findings during trauma scenarios. We hypothesized that trauma assessment training on a patient simulator would be as effective as training with a more traditional moulage patient/actor. METHODS: This study was conducted during a surgery intern orientation at two academic trauma centers. Interns (n = 60) attended a basic trauma course, and were then randomized to trauma assessment practice sessions with either the patient simulator (n = 30) or a moulage patient (n = 30). After practice sessions, interns were randomized a second time to an individual trauma assessment test on either the simulator or the moulage patient. Two surgeon-judges rated each intern live and on video for completion of 50 predetermined assessment objectives (total score) divided into sections (primary and secondary survey, general performance, diagnostic studies/procedures, and plan) and the identification and management of an acute neurologic deterioration in the test patient (event score). Multiple linear regression with random student effects was used to estimate the independent effects of all study variables. RESULTS: Within randomized groups, mean trauma assessment test scores for all simulator-trained interns were higher when compared with all moulage-trained interns (71 +/- 8 vs. 66 +/- 8, respectively; p = 0.02). Simulator training independently showed a small but statistically significant improvement in both the total score and the event score (+4.6 and +8.6, respectively; p < 0.05). CONCLUSION: Use of a patient simulator to introduce trauma assessment training is feasible and compares favorably to training in a moulage setting. Continued research in this area of physician education is warranted.     

Simple and comminuted displaced olecranon fractures: a clinical comparison between tension band wiring and plate fixation techniques

Introduction

The purpose of this retrospective study is to compare the clinical, functional outcome and complications occurrence between tension band wiring (TBW) and plate fixation both for simple and comminuted displaced olecranon factures.

Materials and methods

Between January 2005 and June 2012 (minimum 1-year follow-up), 78 consecutive patients with Mayo type IIA and IIB fractures were treated with the following methods: tension band wire or plate and screws fixation. The primary outcome of this study was the functional outcome, assessed by the following self-administered evaluation scales: the disabilities of the arm, shoulder and hand, and the Mayo Elbow Performance Score. Secondary outcome measures included the assessment of pain level, analysis of passive range of motion, and the occurrence of any early or late complications.

Results

Comparing the clinical results between the two groups, at mean 33 months follow-up, no significant differences in the functional and clinical outcome were observed. Complications were reported in 48 and 17 % of cases, following TBW and plate fixation in patients treated for type IIA fractures, and similarly in 40 and 23 % of cases in type IIB fractures, respectively. Hardware removal was more frequently performed in TBW group: 38 versus 17 % for type IIA fractures and 20 versus 6 % for type IIB fractures.

Conclusions

The findings of this study indicate that both with the use of TBW and plate fixation excellent/good clinical outcomes with minimal loss of physical capacity, little pain and disability can be obtained in the majority of patients with simple and comminuted displaced olecranon fractures. Hardware removal was most frequently observed after TBW.

Level of evidence

Therapeutic IV.     

Internal fixation versus primary prosthetic replacement in acute femoral neck fractures: a prospective, randomized clinical study.

A prospective, randomized clinical study has been performed on 104 patients with an acute femoral neck fracture, comparing internal fixation (von Bahr screws) with primary prosthetic replacement (Christiansen endoprosthesis). Immediate weight bearing was allowed in both groups. The postoperative mortality rate was similar in the two groups. Internal fixation proved to be a less time-consuming operation, gave a shorter hospitalization time and was associated with a significantly reduced morbidity rate compared with prosthetic replacement. No blood transfusion was needed in the internal fixation group. Primary prosthetic replacement was associated with earlier postoperative mobilization, probably gave a more definitive treatment with fewer reoperations, and showed better results at 1-year follow-up.     

High levator myorraphy versus uterosacral ligament suspension for vaginal vault fixation: a prospective, randomized study

Introduction and hypothesis  

Our study compared high levator myorrhaphy (HLM) and uterosacral ligament suspension (USLS) for vaginal apex fixation from both an anatomical and functional point of view, and assessed the impact of surgery on quality of life (QoL) and sexuality.     

Heterotopic ossification following internal fixation or arthroplasty for displaced femoral neck fractures: a prospective randomized study

One hundred hips in 99 patients of 75 years or older, with a displaced femoral neck fracture, were studied for heterotopic ossification (HO). The patients were randomized to either internal fixation or total hip arthroplasty (THA). In the THA group HO was found in 32 of 45 hips compared with 1 of 39 in the internal fixation group (P < 0.0012). The frequency of HO after THA corresponds well with findings in other studies on patients receiving THA for osteoarthrosis. In cervical fractures the surgical procedure of total hip replacement seems to be a prerequisite for HO, indicating that the procedure itself is more important than the patient's age and the diagnosis. Severe symptoms due to HO were found in only one patient. HO following THA for a femoral neck fracture is of little clinical importance and prophylaxis is unnecessary.     

Liver function and encephalopathy after partial vs direct side-to-side portacaval shunt: a prospective randomized clinical trial

BACKGROUND: The aim of this study was to determine, in a prospective randomized clinical trial, whether the partial portacaval shunt offers any advantage in terms of liver function and encephalopathy rate when compared with direct side-to-side direct portacaval shunt. METHODS: Forty-six "good risk" patients with cirrhosis and with documented variceal hemorrhage were randomly assigned to either a partial shunt procedure (achieved by 10-mm diameter interposition portacaval H-graft) or direct small-diameter side-to-side portacaval anastomosis. RESULTS: Operative mortality was zero in both groups. During the follow-up period, encephalopathy developed in 3 patients in the partial shunt group and 9 in the direct shunt group (P =.04). Kaplan-Meier analysis demonstrated that encephalopathy-free survival was significantly longer in the partial shunt group (P =.025). Direct shunt patients had significant hepatic functional deterioration postoperatively compared with the partial shunt group. CONCLUSIONS: The partial portacaval shunt effectively controls variceal hemorrhage. Compared with direct side-to-side portacaval shunt, partial shunt preserves long-term hepatic function and minimizes postoperative encephalopathy. We conclude that the partial portacaval shunt is the preferred approach over direct shunts for patients with cirrhosis and with variceal bleeding.     

Accelerated rehabilitation after arthroscopic bankart repair for selected cases: a prospective randomized clinical study

Purpose: Increased stress within a certain limit enhances ligament healing and improves joint function. In this prospective randomized clinical trial, we compared the clinical results of early motion versus conventional immobilization after arthroscopic Bankart repair in a selected patient population. Type of Study: Prospective randomized clinical trial. Methods: We performed an arthroscopic Bankart repair using suture anchors in 62 patients with traumatic recurrent anterior instability of the shoulder. Patients were randomized into 2 groups; group 1 (28 patients; mean age, 28 years) was managed with 3 weeks of immobilization using an abduction sling and conventional rehabilitation program, and group 2 (34 patients; mean age, 29 years) was managed with an accelerated rehabilitation program that consisted of staged range of motion and strengthening exercises from the immediate postoperative day. Selection criteria were nonathletes with recurrent anterior shoulder dislocation and a classic Bankart lesion with a robust labrum limited to 1 cm from the midglenoid notch. The patients were followed up for a mean of 31 months (range, 27 to 45 months; standard deviation, 9 months). Analysis of outcome included pain scores at 6 weeks and at final follow-up evaluation, range of motion, return to activity, recurrence rate, patient satisfaction with each rehabilitation program, and shoulder scores assessed by the American Shoulder and Elbow Surgeons Shoulder Index, the rating system of the University of California at Los Angeles, and another scoring system. Results: The recurrence rate was not different between the 2 groups (P = .842). None of the groups developed recurrent dislocation. Two patients from each group were positive for anterior apprehension signs. Patients who underwent accelerated rehabilitation resumed functional range of motion faster (P < .001) and returned earlier to the functional level of activity (P < .001). Accelerated rehabilitation decreased postoperative pain (P = .013), and more patients were satisfied with this program (P <.001). Shoulder scores, return to activity, pain score, and range of motion were not different between the 2 groups at the final follow-up evaluation (P > .05). Conclusions: Early mobilization of the operated shoulder after arthroscopic Bankart repair does not increase the recurrence rate in a selected group of patients. Although the final outcomes are approximately the same for both groups, the accelerated rehabilitation program promotes functional recovery and reduces postoperative pain, which allows patients an early return to desired activities.     

A prospective randomized controlled study of fixation of long oblique and spiral shaft fractures of the proximal phalanx: closed reduction and percutaneous Kirschner wiring versus open reduction and lag screw fixation

Patients with an isolated spiral or long oblique fracture of the proximal phalanx were randomized into two groups. One was treated by closed reduction and Kirschner wire fixation and the second treated by open reduction and lag screw fixation. An independent observer assessed function, pain, movement, grip strength and intrinsic muscle function. X-rays were assessed for malunion. Thirty-two patients were entered the study and 15 in the Kirschner wire and 13 in the lag screw group were reviewed at a mean follow-up of 40 months. There was no significant difference in the functional recovery rates or in the pain scores for the two groups. X-rays showed similar rates of malunion and there were no statistically significant differences in range of movement or grip strength.     

Comparative study between Lichtenstein procedure and modified darn repair in treating primary inguinal hernia: a prospective randomized controlled trial

Purpose

The aim of this study was to evaluate whether modified darn repair (MDR) is comparable to Lichtenstein procedure (LP) in the treatment of primary inguinal hernia, regarding chronic postoperative pain and recurrence.

Methods

Two hundred and twenty-seven male patients with primary inguinal hernia were randomly allocated into two groups: group I included 108 patients [mean age 37.47 ± 11.97 years] who were subjected to MDR and group II that included 119 patients [mean age 37.44 ± 11.93 years] who were subjected to LP.

Results

Recurrence was encountered in only one case after LP. Visual Analog Scale showed significant more early and late postoperative pain after LP compared to MDR. The operative time for LP [72.99 ± 19.90 min] was significantly shorter compared to MDR [78.53 ± 12.76 min]. Both MDR and LP showed no significant differences as regards hospital stay [1.04 ± 0.19 days vs. 1.09 ± 0.28 days], time to return to domestic activity [1.18 ± 0.43 days vs. 1.15 ± 0.36 days], time to return to work activity [6.84 ± 1.09 vs. 6.67 ± 0.94 days], early and late postoperative complications.

Conclusions

After 1-year follow-up, MDR as a tension-free repair seems comparable to LP with less postoperative pain.     

External fixation of distal radial fractures: four compared with five pins: a randomized prospective study

BACKGROUND: The purpose of this study of distal radial fractures was to compare the radiographic and clinical results after use of a standard four-pin external fixator with those after use of a five-pin fixator with the fifth pin stabilizing the distal radial articular fragment. METHODS: In an open prospective trial, fifty patients with an unstable distal radial fracture were randomized for treatment with closed reduction and either a standard small Association for the Study of Internal Fixation (ASIF) four-pin fixator (twenty-five patients) or a five-pin external fixator (twenty-five patients). The fixators were removed at nine weeks, and all patients were assessed radiographically and clinically at six months. RESULTS: Follow-up radiographs demonstrated significantly less loss of alignment and length with the five-pin external fixator. Pin site infections were more prevalent with the four-pin fixator. The range of motion of the wrist and forearm, the grip strength, and the Lidstrom functional ratings at six months were all significantly better after use of the five-pin fixator. CONCLUSIONS: The use of a five-pin external fixator, with the fifth pin stabilizing the distal radial articular fragment, yields better radiographic and functional results than does a four-pin fixator.     

Posterior repositioning of the entire maxilla without postoperative intermaxillary fixation. A clinical and cephalometric study

In 30 patients posterior repositioning of the entire maxilla has been performed. No postoperative intermaxillary fixation (IMF) has been applied. The surgical procedure is described and data given on the distance of repositioning. Results of cephalometric analysis indicate good long-term stability after surgery. We concluded that omitting IMF not only enhances patient comfort, but has no deleterious effect on postoperative stability of the maxilla.