Calcaneal skeletal traction versus elastic intramedullary nailing of displaced tibial shaft fractures in children

BackgroundThe objective of this study was to compare the outcomes and complications of patients who underwent either the calcaneal skeletal traction (CST) or the elastic intramedullary nails (EIN) procedure.MethodsWe retrospectively reviewed data of patients who underwent EIN or CST surgery for tibia shaft fracture at our center from 2013 to 2018. The patient demographics, fracture characteristics, radiographic information, length of hospital stay, and medical expenses were recorded. All patients were clinically followed-up until they started to walk or for at least 6 months. The treatment outcomes and postoperative complications of the two procedures were compared.ResultsOverall, 186 patients who underwent EIN and CST were included in the study. The EIN patients had more low-energy mechanism of injury. In radiographic evaluation, significant differences were observed in distributions of fracture classification and location. Moreover, associated fibula fractures were higher in the EIN group than in the CST group. The CST procedure had faster surgical time, cast duration and lower expenses, and longer hospitalization time. Although they required more clinical visits, patients in the EIN group began exercising and endured weight-bearing earlier than those in the CST group. The average time for bone healing was 68.5 days in the EIN group, and 69.6 days in the CST group. However, the CST provided slight better results of coronal correction than EIN. Moreover, CST patients had less malalignment (> 5°) in complications. None had delay union, nonunion, and shortening over 10 mm at final assessment.ConclusionsBoth EIN and CST patients showed similar treatment outcomes. Hence, not only the characteristics of the patient and fracture, but also the individual's situation and expectation should be considered when choosing the best approach.     

Comparison of affected lumbar proprioception due to different injuries with healthy controls: An observational study

BackgroundThere is limited evidence about spinal proprioception deficiency due to different injuries.ObjectiveTo compare spinal proprioception in patients with Lumbal Spinal Stenosis (LSS) and healthy controls. Secondary objective is to investigate the effect of pain intensity and Thoracolumbar fascia (TLF) flexibility on spinal proprioception deficiency.DesignCross-sectional and healthy controlled study.SettingThis study was conducted in a state hospital.MethodsNinety participants (mean age: 46.98 ± 12.94 years) were grouped as: Healthy control (n = 30) (Group I), chronic low back pain due to LSS (n = 30) (Group II) and undergoing surgery due to LSS (n = 30) (Group III). Lumbar repositioning error (RE) was defined as reproducing a target position (neutral lumbo-pelvic posture) after tasks. Tasks were: 30° forward bending and 15° backward bending in sitting and standing.Primary outcome measuresRE, pain intensity and TLF flexibility were assesed with iphone tilt-meter app, VAS and goniometric platform, respectively.ParticipantsSixty patients with LSS and 30 healthy controls.ResultsRE scores of Group II and Group III were significantly higher than Group I (p < 0.001). Group III had lower VAS scores (p < 0.001) than Group II, except during standing with backward bending task. TLF flexibility was not differed between Group II and Group III (p˃0.05). There was no significant association between VAS and RE scores in Group II and Group III (p˃0.05).ConclussionIndividuals with LSS and healthy controls have different lumbar proprioception sense. TLF flexibility did not differ, due to different injury, in patients with LSS compared to healthy controls.     

Should the management approach to the anterior abdominal stab wound be different in patients with self-inflicted abdominal injury?

BackgroundSelf-inflicted injury is a leading cause of death worldwide. It is hypothesized that due to instincts for self-preservation, the severity of abdominal injury would be decreased following suicidal self-stabbing in comparison to stab wounds from assault, and therefore a more conservative management might be considered.MethodsAll patients with isolated abdominal stab wound (SW) admitted to 19 Trauma Centers in Israel between the years 1997 and 2018 were included in the study. Patients with self-inflicted abdominal SW (Group I) were compared to victims with abdominal SW following assault (Group II).ResultsGroup I included 9.4% (314/3324) of patients eligible for this study. Compared to Group II, Group I patients were older (median: 39 years, IQR 28,52 vs. 24 years, IQR 19,33; p<0.001), had more females (28.7% vs 4.9%, p <0.001), had longer length of hospitalization (median: 3 days vs. 2 days; p<0.001), underwent surgery more frequently (55.4% vs. 37.4%; p<0.001), and had higher mortality (2.9% vs. 0.7%; p=0.003). Possible covariates for mortality were examined and following logistic regression, self-inflicted injury remained associated with higher death rates compared to assault (OR 4.027, CI95% 1.380, 11.749; p=0.011).ConclusionIn this study, patients with isolated self-inflicted abdominal injuries had higher mortality and more frequently underwent abdominal surgery.     

Case selection and implementation of tubeless percutaneous nephrolithotomy

BackgroundThe tubeless percutaneous nephrolithotomy (PCNL) was proposed to eliminate the side effects of the nephrostomy tube in recent years, such as pain, channel infection, postoperative bleeding, and longer hospital stay. But there is neither clinical guidelines nor consensus about tubeless PCNL in clinical practice. The study is aimed to how to implement the tubeless PCNL step by step, including case selection preoperatively, improving the technique of the surgeon, making the correct decisions at the end of the procedure, which had not been previously examined.MethodsFrom January 2017 to March 2018, 364 consecutive patients requiring PCNL were comprehensively analyzed preoperatively and patients were selected for scheduled tubeless PCNL based on four aspects. The selected patients were divided into two groups according to whether the nephrostomy tube was finally placed. The mean operative time, intraoperative blood loss, stone clearance rate, visual pain score, postoperative hospitalization days and perioperative complications were all evaluated.ResultsBased on the preoperative evaluation, 42 patients were selected for tubeless PCNL, among which there were finally 37 cases of completed tubeless PCNL. Compared with patients undergoing conventional PCNL, there were not statistical differences in the mean operative time (P=0.207) or intraoperative blood loss (P=0.450) in the tubeless group. Stone clearance rate was 100% in both groups. The visual pain scores in the tubeless PCNL group were lower on operation day (P=0.029), first postoperative day (P<0.001) and the day of discharge (P=0.025). The postoperative hospitalization for the tubeless PCNL group was shorter than that of the control group (P<0.001). No significant difference in grade 1 complications was seen (P=0.424), and no grade 2 or higher complications were observed in either group.ConclusionsPostoperative pain was significantly relieved and postoperative hospitalization was significantly shortened in the tubeless PCNL group. Tubeless PCNL is safe if patients are carefully selected using four criteria before operation, attention is paid to four key points and five confirmations are made during operation.     

The association between fibular status and frontal plane tibial alignment post-union in congenital pseudarthrosis of the tibia

PurposeControversy exists regarding fibular status related to tibial alignment after congenital pseudarthrosis of the tibia (CPT) achieves union. We aimed to determine whether fibular status affected frontal plane tibial alignment post-CPT union.MethodsBetween January 2010 and December 2013, we followed 36 patients treated using a combined surgical technique (mean 6.6 years (2.2 to 9.4)). Outcome measures comprised medial proximal tibial angle, tibial diaphyseal angulation, lateral distal tibial angle (LDTA), relative intramedullary rod length and relative fibula length discrepancy.ResultsThe frequency of proximal tibial valgus deformity and ankle valgus deformity were significantly lower in the fibular integrity group than in the fibular un-integrity group (proximal tibial valgus deformity: 2/17 versus 11/19; p = 0.006; ankle valgus deformity: 10/17 versus 18/19; p = 0.016). The mean LDTA was notably higher in the fibular integrity group than in the fibular un-integrity group (81.2° (sd 6.7°) versus 71.3° (sd 6.6°); p < 0.001). A statistically significant difference was observed in relative fibula length discrepancy between patients with fibular integrity (0.06 (0 to 0.11); Malhotra grade 0, n = 6; Malhotra grade I, n = 11) and those without (0.24 (0.01 to 0.36); Malhotra grade 2, n = 2; Malhotra grade 3, n = 17; p < 0.001). Ankle valgus deformity had a significant positive correlation with proximal tibial valgus deformity (r = 0.402; p = 0.015). Patients with an intact and normal length fibula had a lower frequency of ankle valgus deformity than those with an intact but shortening fibula (1/6 versus 9/11; p = 0.035).ConclusionShortening or pseudarthrosis of the fibula was associated with ankle valgus and proximal tibial valgus deformities post-CPT union.Level of evidenceIII     

Medullary Thyroid Carcinoma: Relationship of Method of Diagnosis to Pathologic Staging

Medullary thyroid carcinoma (MTC) develops in virtually all patients affected with multiple endocrine neoplasia type II (MEN II), a disease inherited as an autosomal dominant trait. The thyroid tumor cells secrete calcitonin (CT) and the detection of elevated plasma levels (>300 pg/ml) of this hormone in MEN II kindred members strongly suggests the presence of MTC even though it may not be evident clinically. Intravenously administered calcium ion (Ca⁺⁺) and pentagastrin (Pg) are potent CT secretagogues which are of particular value in establishing the early diagnosis of MTC. In evaluating seven kindreds with MEN II, we detected 90 patients with MTC. Depending on the method of diagnosis, they could be divided into three categories: Group 1; patients with no clinical evidence of MTC whose undetectable basal plasma calcitonin levels became elevated following intravenous Ca⁺⁺ or Pg, Group II; patients with no clinical evidence of MTC who had elevated basal plasma CT levels, and Group III; patients with clinically evident MTC. At the time of diagnosis of MTC, the patients in Group I were younger (20.5 ± 1.9 years) than the patients in Group II (32.5 ± 4.7 years, p < 0.005) and Group III (34.3 ± 2.0, p < 0.00005). The incidence of residual MTC, as indicated by an elevated plasma CT level following provocative testing postoperatively, was less frequent in patients diagnosed biochemically ([6/34]; Group I, 4/26 and Group II, 2/8) than in those diagnosed clinically (Group III, 15/26, p < 0.002). Furthermore, regional nodes were involved less often in patients diagnosed biochemically ([5/28]; Group I, 2/22 and Group II, 3/6) than in those diagnosed clinically (Group III, 15/24, p < 0.02). Distant metastases were only evident in Group III patients. Patients with MEN II who had the diagnosis of MTC established biochemically rather than clinically, had a more favorable pathological stage of disease at the time of thyroidectomy. This was especially true if the biochemical diagnosis had been by provocative testing.     

Developing a Robotic Prostatectomy Service and a Robotic Fellowship Programme – Defining the Learning Curve

Introduction

Robotic radical prostatectomy (RRP) is an established treatment for prostate cancer in selected centres with appropriate expertise. We studied our single-centre experience of developing a RRP service and subsequent training of 2 additional surgeons by the initial surgeon and the introduction of United Kingdom''s first nationally accredited robotic fellowship training programme. We assessed the learning curve of the 3 surgeons with regard to peri-operative outcomes and oncological results.

Patients and Methods

Three hundred consecutive patients underwent RRP between November 2008 and August 2012. Patients were divided into 3 equal groups (Group 1, case 1-100; Group 2, case 101-200; and Group 3, case 201-300). Age, ASA score, preoperative co-morbidities and indications for laparoscopic radical prostatectomy were comparable for all 3 patient groups. Peri-operative and oncological outcomes were compared across all 3 groups to assess the impact of the learning curve for laparoscopic radical prostatectomy. All surgical complications were classified using the Clavien-Dindo system.

Results

The mean age was 60.7 years (range 41-74). There was a significant reduction in the mean console time (p < 0.001), operating time (p < 0.001), mean length of hospital stay (p < 0.001) and duration of catheter (p < 0.001) between the 3 groups as the series progressed. The two most important factors predictive of positive surgical margins (PSM) at RRP were the initial prostate specific antigen (PSA) and tumor stage at diagnosis. The overall PSM rate was 26.7%. For T2/T3 tumors the incidence of PSM reduced as the series progressed (Group 1-22%, Group 2-32% and Group 3-26%). The incidence of major complications i.e. grade Clavien-Dindo system score ≤ III was 2% (6/300).

Conclusion

RRP is a safe procedure with low morbidity. As surgeons progress through the learning curve peri-operative parameters and oncological outcomes improve. This learning curve is not affected by the introduction of a fellowship-training programme. Using a carefully structured mentored approach, RRP can be safely introduced as a new procedure without compromising patient outcomes.Key Words: Robotic radical prostatectomy, Prostate cancer, Learning curve, Fellowship training     

The impact of asymmetry on the radiographical outcomes following hip reconstruction in patients with cerebral palsy

Purpose:The purpose of this study was to evaluate the impact of asymmetric hip dysplasia on the outcome of hip reconstruction in patients with cerebral palsy according to preoperative migration percentage (MP).Methods:This study was institutional review board-approved for retrospective cohort review. From 2008 to 2018, 65 patients met inclusion criteria: Gross Motor Function Scale Classification (GMFSC) III to V with spastic hips (MP > 30%) who underwent bilateral hip reconstruction, with a follow-up > 24 months. Main exclusion criteria: children with associated syndromes or chromosomal disorders. The cohort was subdivided into three groups according to preoperative MP difference between hips: Group A > 50%, group B 20% to 50% and Group C < 20%. Subsequently, the groups were analyzed individually and then compared. The asymmetry of extended abduction of the hip was also evaluated and separated into three groups: no asymmetry (< 20° difference), mild asymmetry (20° to 50° difference) and severe (> 50° difference).Results:In total, 65 patients underwent bilateral bony reconstructive surgery (130 hips). Mean age at surgery was 10.1 years (sd 3.6; 3.6 to 18.4). Mean age at follow-up was 14.7 years (sd 3.8; 8 to 21). Preoperative GMFSC distribution was grade III (four, 6%), IV (15, 23%) and V (46, 71%). In all, 21 symmetric hips (< 20% MP difference) had a preoperative MP difference of 9% and a follow-up MP difference of 18% (p > 0.05); 32 had a preoperative MP difference of 34% and a follow-up MP difference of 16% (p < 0.0001); 12 had a preoperative MP difference of 80% and a follow-up difference of 6% (p < 0.0001). According to pre- and postoperative abduction values, the mean high hip abduction preoperatively was 34° (sd 17°), whereas low hip abduction was 23° (sd 17°).Conclusion:Hips with asymmetrical dysplasia and/or abduction undergoing bilateral reconstructive surgery focused on symmetric abduction, and corrected dysplasia in patients with cerebral palsy has improved symmetry in hip abduction and MP. Obtaining this goal immediately postoperatively is maintained to medium-term follow-up.Level of Evidence:IV     

Impact of an opioid stewardship program on opioid exposure for pediatric appendectomy postsurgical pain

Background/purposeThis study aimed to evaluate the impact of a Pediatric Acute Pain Guideline on postsurgical pain scores, opioid exposure, and discharge opioid prescribing habits in postappendectomy patients.MethodsThis was a retrospective single-center quality improvement project, including patients admitted for an appendectomy at a pediatric medical center between April 1 and December 31, 2018. Patients 0–17 years of age, who underwent a laparoscopic appendectomy without complications, were inpatient for at least 1 calendar day, and designated as presurgical American Society of Anesthesiologists (ASA) category 1 or 2 were included.ResultsTwo hundred fifty-eight patients met inclusion criteria (n = 92 pre-, n = 166 post-guideline implementation). There was a decrease in the number of as needed opioid doses used (p = 0.014) and length of hospitalization (p = 0.003) post-guideline implementation compared to pre-guideline implementation. A decrease in the number of as needed doses of opioids used (p < 0.001) and in opioid exposure (p = 0.038) during hospitalization was also seen when the nonopioid pain agent was scheduled.ConclusionsThe implementation of the Pediatric Acute Pain Guideline was associated with a decrease in the number of as needed opioid doses used during hospitalization, which may have contributed to a decreased length of hospitalization. Scheduling nonopioid pain medications decreased opioid exposure.Level of evidenceTreatment study level III.     

Short-term morbidity and mortality of Indiana pouch,ileal conduit,and neobladder urinary diversion following radical cystectomy

PurposeLiterature surrounding Indiana pouch (IP) urinary diversion suggests a higher incidence of complications and longer operative time compared with ileal conduit (IC) and neobladder (NB). We sought to assess short-term complications of IP diversions compared with other diversions at our institution.Materials and methodsUsing institutional National Surgical Quality Improvement Program data, we identified radical cystectomy cases performed for bladder cancer at Indiana University from January 2011 until June 2013. During this time period, the National Surgical Quality Improvement Program randomly evaluated approximately 70% of radical cystectomies performed for urothelial carcinoma at our institution. Multivariable logistic regression was performed to identify factors associated with Clavien grade III–V complications.ResultsA total of 233 cases were identified, 139 IC, 39 IP, and 55 NB. Mean (standard deviation) operative times for IC, IP, and NB were 257 (84), 383 (78), and 327 (88) minutes, respectively (P<0.001). Half of the patients required blood transfusion during the hospitalization. The overall rate of complications was significantly lower among NB (P = 0.009). Overall, 12% of patients developed a Clavien grade III–V complication, with no difference observed between groups (P = 0.884). After controlling for preoperative confounders, IP patients were not at increased odds of developing a Clavien III–V complication compared with IC (odds ratio = 1.38, P = 0.599).ConclusionsAt a high-volume center, the incidence of serious complications was similar between diversion types. IP patients were more likely to experience minor complications. Patients should be counseled regarding rates of short-term complications and blood transfusion.     

Modified method for reconstruction of thumb abduction function in children undergoing surgical treatment of thumb duplication

PurposeThis study was performed to evaluate a modified method of reconstructing the thumb abduction function in children undergoing surgical treatment of thumb duplication.MethodsThis retrospective study included 33 children (38 thumbs) with Wassel type III to VII thumb duplication who underwent excision of the polydactylism and osteotomy of the preserved thumb. Among them, 16 children (19 thumbs) underwent reconstruction of the attachment of the articular capsule and collateral ligament of the metacarpophalangeal joint, abductor pollicis brevis and flexor pollicis brevis by the anchor technique (Group A), while 17 children (19 thumbs) underwent suturing the attachment of the above-mentioned soft tissues to the periosteum (Group B). All children were followed up for six years after surgery. The appearance, function and joint stability of the preserved thumb were compared between the two groups; the bone alignment and development were observed.ResultsThe deformity rate of preserved thumbs and the positive rate of lateral stress test were significantly lower in Group A than B (p < 0.05). The modified Tada score and the distance of first web were significantly higher in Group A than B (p < 0.05). Flexion, extension, adduction, abduction and palmar movement of the thumbs were good; bone alignment and development were good and no osteophyte or anchor shadow was left in the preserved thumbs in Group A.ConclusionReconstruction of the abduction function using the anchor technique is effective in children undergoing surgical treatment for Wassel type III to VII thumb duplication and it may be superior to the conventional technique.Level of evidenceIII     

A single-center,multidisciplinary experience with radium-223 dichloride in men with metastatic castrate-resistant prostate cancer

IntroductionWe aimed to investigate several clinical and biochemical parameters, including palliative external beam radiation therapy (EBRT) to predict survival in patients with metastatic castrate-resistant prostate cancer (mCRPC) treated with radium-223 (²²³Ra).MethodsWe tested known and possible prognostic parameters, including palliative EBRT, both prior and concurrent to ²²³Ra. Logrank test (Kaplan-Meier method) and Cox regression analysis were used to predict overall survival (OS).ResultsA total of 133 patients were treated with ²²³Ra; median age was 72 years. Median OS was 9.0 (95% confidence interval [CI] 7.4–10.6) months. By univariate analysis (log-rank test), baseline Eastern Cooperative Oncology Group performance status (ECOG PS) 0–1 (p=0.001), ≥5 cycles of ²²³Ra (p<0.001), baseline hemoglobin (Hb) ≥120 g/L (p <0.001), baseline total alkaline phosphatase (tALP) <110 U/L (p=0.001), and any prostate-specific antigen (PSA) decline at week 12 (p=0.013) were associated with increased OS. EBRT prior and/or concurrent to ²²³Ra showed a trend (p=0.051) towards inferior OS by univariate analysis only. By multivariate analysis, significant factors were PS 0–1 (hazard ratio [HR] 1.94, 95% CI 1.3–2.9, p=0.001), Hb ≥120 g/L (HR 0.5, 95% CI 0.3–0.9, p=0.011), and absence of docetaxel use prior to ²²³Ra (HR 1.86, 95% CI 1.08–3.22, p=0.026). With baseline Hb, tALP, and ECOG PS, we were able to divide patients into three groups with different median OS (months): 23.0 (95% CI 12.8–33.2), 8.0 (95% CI 6.7–9.3), and 5.0 (95% CI 3.1–6.9) for low-, intermediate-, and high-risk, respectively (p<0.001).ConclusionsWe found that ²²³Ra therapy can result in an OS of close to two years in carefully selected patients. Earlier administration of ²²³Ra therapy to fitter patients with mCRPC should be tested.     

Prognostic significance of preoperative Naples prognostic score on short- and long-term outcomes after pancreatoduodenectomy for ampullary carcinoma

BackgroundThe Naples prognostic score (NPS) is an effective and objective tool to assess the immune–nutritional status of patients with malignant tumors. The aim of this study was to investigate the clinical significance of preoperative NPS on short- and long-term outcomes after pancreatoduodenectomy (PD) for ampullary carcinoma.MethodsWe retrospectively analyzed 404 consecutive patients with ampullary carcinoma who underwent PD between January 2012 and June 2018. Preoperative NPS was calculated from serum albumin and total cholesterol concentrations, and the neutrophil–lymphocyte ratio and lymphocyte-monocyte ratio (LMR). Patients were then divided into three groups according to their NPS. Clinicopathological variables, postoperative outcomes, and survival data were compared between the three groups. Univariate and multivariate Cox analysis of overall survival (OS) and recurrence-free survival (RFS) were also conducted, and time-dependent receiver operating characteristic (ROC) curves were created to evaluate the discriminatory ability of the prognostic scoring systems.ResultsPatients with higher NPS had worse prognosis, and significant OS difference (group 0 vs. 1, P=0.02; group 1 vs. 2, P<0.001; group 0 vs. 2, P<0.001) and RFS difference (group 0 vs. 1, P=0.088; group 1 vs. 2, P<0.001; group 0 vs. 2, P<0.001). Multivariate analysis revealed that NPS was an independent significant predictor of OS (grade 2 vs. grade 1 or 0, hazard ratio: 3.067; P<0.001) and RFS (grade 2 vs. grade 1 or 0, hazard ratio: 2.732; P<0.001). The time-dependent receiver operating curve analysis showed that NPS had better prognostic performance for OS and RFS than other prognostic models. Additionally, significant differences in the incidence of postoperative morbidity were observed between the three groups, and the NPS was an independent risk factor of overall postoperative complications (grade 2 vs. grade 1 or 0, odds ratio: 1.692; P=0.02).ConclusionsThe NPS was an independent predictor of overall- and RFS in patients undergoing PD for ampullary carcinoma, and was independently associated with the incidence of postoperative complications.     

Hydroxyapatite-coated Collars Reduce Radiolucent Line Progression in Cemented Distal Femoral Bone Tumor Implants

BackgroundAseptic loosening of massive bone tumor implants is a major cause of prosthesis failure. Evidence suggests that an osteointegrated hydroxyapatite (HA)-coated collar would reduce the incidence of aseptic loosening around the cemented intramedullary stem in distal femoral bone tumor prostheses. Because these implants often are used in young patients with a tumor, such treatment might extend the longevity of tumor implants. Questions/purposes We asked whether (1) HA-coated collars were more likely to osteointegrate; (2) HA collars were associated with fewer progressive radiolucent lines around the stem-cement interface; and (3) HA-coated collars were associated with less bone loss at the bone-shoulder implant junction?MethodsTwenty-two patients were pair-matched to one of two groups—either (1) implants with a HA-coated ingrowth collar (HA Collar Group); or (2) implants without an ingrowth collar (Noncollar Group). Age, sex, and length of followup were similar in both groups. HA-coated collars were developed and used at our institution from 1992 to address the high failure rate attributable to aseptic loosening in patients with massive bone tumor implants. Before this, smooth titanium shafts were used routinely adjacent to bone at the transection site. The minimum followup was 2 years (mean, 7 years; range, 2–12 years). Radiographs obtained throughout the followup period were analyzed and osteointegration at the shaft of the implant quantified. Radiolucent line progression around the cemented stem was semi-quantitatively assessed and cortical bone loss at the bone-shoulder implant junction was measured during the followup period.ResultsComparison of the most recent radiographs showed nine of 11 patients had osteointegrated HA collars, whereas only one patient in the Noncollar Group had osteointegration (p > 0.001). The radiolucent line score quantified around the cemented stem was lower in the HA Collar Group when compared with the Noncollar Group (p = 0.001). Results showed an increase in cortical bone loss at the bone-shoulder implant junction in the Noncollar Group when compared with the HA Collar Group (p < 0.001).ConclusionsOsteointegration at the implant collar resulted in fewer radiolucent lines adjacent to the intramedullary cemented stem and decreased cortical bone loss immediately adjacent to the transection site. These results suggest that the HA collar may help reduce the risk of aseptic loosening in patients with this type of implant, but longer followup and a larger prospective comparison series are necessary to prove this more definitively.     

Effective dose of radiation per screw in surgery of adolescent idiopathic scoliosis: matched pair analysis of 293 pedicle screws inserted using three different techniques

PurposeReports on heterogenous groups of patients have indicated that pedicle screw insertion guided by navigation (PIN) leads to, for the patient, higher doses of radiation compared with pedicle screw insertion guided by fluoroscopy (PIF). This would be a major concern, especially in paediatric deformity correction.MethodsAfter a power analysis (aiming at > 0.8) 293 pedicle screws which were inserted in patients with adolescent idiopathic scoliosis were analyzed by comparing effective dose and fluoroscopy time per screw for three different techniques. Groups 2 and 3 were matched to Group 1 by Lenke type of scoliosis. Group 1 were prospectively enrolled consecutive patients that have been operated on by PIN with image acquisition by preoperative CT scan (CTS). Group 2 were consecutive retrospectively matched patients who have been operated on by PIN with image acquisition by an intraoperative 3D scan (3DS). Group 3 were consecutive retrospectively matched patients who have been operated on by PIF.ResultsMean dose of radiation per screw was 1.0 mSv (sd 0.8) per screw in CTS patients, 0.025 mSv (sd 0.001) per screw in 3DS patients and 0.781 mSv (sd 0.12) per screw in PIF patients. The difference was significant (p < 0.0001).ConclusionWhen we compared different techniques of navigation, navigation by image acquisition with CTS showed a significantly higher (by 97.5%) dose of radiation per screw for the patient than navigation by image acquisition by a 3DS. Navigation by 3DS showed significantly lower effective dose per screw for the adolescent patients than the fluoroscopic technique.Level of Evidence:II     

Anterior versus posterior fusion surgery in idiopathic scoliosis: a comparison of health-related quality of life and radiographic outcomes in Lenke 5C curves - results from the Swedish spine registry

PurposeTo compare health-related quality of life and radiographic outcomes in patients treated with either anterior or posterior fusion surgery for Lenke 5C type idiopathic scoliosis.MethodsWe used data from the Swedish spine registry and identified 59 patients with idiopathic scoliosis treated with fusion for Lenke 5C type curves; 27 patients underwent anterior surgery and 32 underwent posterior surgery. All patients had pre- and postoperative radiographic data and postoperative clinical data at a minimum of two years after surgery. Patient-reported outcomes measures included the Scoliosis Research Society (SRS)-22r, EuroQoL 5 dimensions 3 levels (EQ-5D-3L), EQ-visual analogue scale (VAS) and VAS for back pain. Radiographic assessment included measurement of the angle of the major curve, disc angulation below the lowest instrumented vertebra, curve flexibility, rate of curve correction, differences in sagittal parameters, number of fused vertebrae and length of fusion.ResultsThe mean age at surgery was 16 years in both groups. The mean follow-up time was 3.8 years. There were no significant differences in the SRS-22r score and EQ-5D-3L index at follow-up (all p ≥ 0.2). Postoperatively, both the anterior and posterior fusion group demonstrated a significant correction of the major curve (p ≤ 0.001) with no significant difference of the correction rate between the groups (p = 0.4). The posterior fusion group had shorter operative time (p < 0.001) and higher perioperative blood loss (p = 0.004) while the anterior group had lower number of fused vertebrae ( p< 0.001).ConclusionThe type of surgical approach for Lenke 5C curves is not associated with differences in health-related quality of life, despite the lower number of fused vertebrae after anterior surgery.Level of EvidenceIII     

Leg-length discrepancy and associated risk factors after paediatric femur shaft fracture: a multicentre study

PurposeThis study was performed to investigate leg-length discrepancy (LLD) and associated risk factors after paediatric femur shaft fractures.MethodsA total of 72 consecutive patients under 13 years old (mean age 6.7 years; 48 boys, 24 girls) with unilateral femur shaft fracture, and a minimum follow-up of 18 months, were included. The amount of LLD was calculated by subtracting the length of the uninjured from that of the injured limb. Risk factors for an LLD ≥ 1 cm and ≥ 2 cm were analyzed using multivariable logistic regression analysis.ResultsHip spica casting, titanium elastic nailing and plating were performed on 22, 40 and ten patients, respectively. The mean LLD was 7.8 mm (sd 8.8) and 29 (40.3%) had a LLD of ≥ 1 cm, while nine (12.5%) had a LLD of ≥ 2 cm. There were significant differences in fracture stability (p = 0.005) and treatment methods (p = 0.011) between patients with LLD < 1 cm and ≥ 1 cm. There were significant differences in fracture site shortening (p < 0.001) and LLD (p < 0.001) between patients with length-stable and length-unstable fractures. Fracture stability was the only factor associated with LLD ≥ 1 cm (odds ratio of 4.0; p = 0.020) in the multivariable analysis.ConclusionThis study demonstrated that fracture stability was significantly associated with LLD after paediatric femur shaft fractures. Therefore, the surgeon should consider the possibility of LLD after length-stable femur shaft fracture in children.Level of EvidencePrognostic level III     

Trough Level of Mycophenolic Acid Did Not Affect De Novo DSA Development in Kidney Transplantation

IntroductionMycophenolate mofetil has improved long-term outcomes of kidney transplantation. However, the impact of mycophenolic acid (MPA) trough level on the development of de novo donor-specific anti-HLA antibody (DSA) is unclear. We examined the relation between MPA trough level and de novo DSA development.MethodWe retrospectively studied 617 kidney recipients whose MPA trough level and de novo DSA data were available. All patients underwent primary kidney transplant from living donors from 2008 to 2014, and were chronically treated with a calcineurin inhibitor, mycophenolate mofetil, and +/- steroids. They were equally divided into 4 groups according to the mean trough level of MPA (mMPA) at 1 year post-transplantation: Group 1, mMPA < 2.14 ng/mL (n = 152); Group 2, mMPA 2.14-2.83 ng/mL (n = 157); Group 3, mMPA 2.83-3.57 ng/mL (n = 153); and Group 4, mMPA ≥ 3.57 ng/mL (n = 155). The groups were compared by incidence rate of de novo DSA, graft survival rate, and renal function.ResultsThe incidence rates of de novo DSA were 33.3% in Group 1, 23.7% in Group 2, 22.9% in Group 3, and 30.3% in Group 4 (P = .158). Although there was no significant difference in graft survival rates, a significant difference of renal functions was noted: the higher the renal function, the lower the MPA trough level.ConclusionThe mMPA trough level at 1 year post-transplantation was not statistically associated with the incidence rate of de novo DSA after kidney transplantation.     

Retrospective analysis of anesthetic interventions for obese patients undergoing elective cesarean delivery

Study ObjectiveTo examine the relationship between body mass index (BMI), perioperative times, and anesthetic interventions in patients undergoing elective cesarean delivery.DesignRetrospective chart review.SettingUniversity-affiliated hospital.MeasurementsAll patients were ranked according to BMI (kg/m²) at the time of delivery. The BMI groups were designated a priori: ≤ 29.9 kg/m² (Group C); 30-34.9 kg/m² (Group I); 35-39.9 kg/m² (Group II), and ≥ 40 kg/m² (Group III). One hundred patients (25 pts per group) underwent elective cesarean delivery. Data collected included anesthetic technique, perioperative times, anesthesia-related costs, and neonatal outcomes.Main ResultsA higher percentage of Group III patients (60%) received combined spinal-epidural (CSE) anesthesia than did Group C or Group I (18% and 16%, respectively; P < 0.05). The total intraoperative period was significantly longer in Group III (101 min) compared with Groups C, I, and II (81 min, 90 min, and 92 min, respectively; P < 0.05). Total intraoperative time increased significantly with BMI (R = 0.394 kg/m²; P < 0.001). The highest anesthesia-related costs during the study were generated by patients with BMI ≥ 40 kg/m².ConclusionOur single-center experience showed that choice of anesthetic technique (CSE vs. spinal anesthesia) varies according to obesity class. Longer intraoperative periods must be considered in deciding upon the mode of anesthesia for patients with BMI ≥ 40 kg/m² who undergo elective cesarean delivery.     

Assessment of Patellar Morphology in Trochlear Dysplasia on Computed Tomography Scans

ObjectiveTo evaluate the patellar morphology of trochlear dysplasia and normal knees in different genders and in different severities of trochlear dysplasia on CT scans.MethodsA total of 75 patients with trochlear dysplasia (110 knees) treated at the Third Hospital of Hebei Medical University from December 2013 to December 2018 were included in an experimental group, and an age‐matched and sex‐matched cohort of 46 patients with normal trochlear shape (61 knees) were randomly selected into a control group. The experimental group was divided into a female experimental group (Group FE, 47 patients, 72 knees) and a male experimental group (Group ME, 28 patients, 38 knees); the control group was divided into a female control group (Group FC, 31 knees, 24 female patients) and a male control group (Group MC, 30 knees, 22 male patients). Furthermore, according to the severity of trochlear dysplasia, Group FE was divided into a female low‐grade dysplasia group (Group FL, 20 knees) and a female high‐grade dysplasia group (Group FH, 52 knees); Group ME was divided into a male low‐grade dysplasia group (Group ML, 16 knees) and a male high‐grade dysplasia group (Group MH, 22 knees). All participants had undergone CT scans in the supine position; the patellar width and thickness, the lateral patellar facet angle, the Wiberg angle, and the Wiberg index were measured and compared.ResultsIn trochlear dysplasia knees, the mean patellar width and thickness and the lateral patellar facet angle were significantly smaller; the mean Wiberg index was significantly larger than in normal knees, regardless of gender (P < 0.05); and there was no statistically significant difference in the mean Wiberg angle (P > 0.05). In the female groups, the mean patellar width and thickness and the Wiberg angle were significantly smaller; the mean lateral patellar facet angle was significantly larger than those in the male groups (P < 0.05); and there was no significant difference in the mean Wiberg index (P > 0.05). In the low‐grade dysplasia group, the mean Wiberg index was smaller than that in the high‐grade dysplasia group (P < 0.05), regardless of gender; however, there was no significant difference in the mean patellar width and thickness, the lateral patellar facet angle, and the Wiberg angle in low‐grade and high‐grade dysplasia (P > 0.05).ConclusionOn CT scans, the patella in trochlear dysplasia had a smaller width, a thinner thickness, a lengthened lateral facet, and a more flattened articular facet. In addition, the patellar articular facet was more prominent in female patients. With the severity of trochlear dysplasia increased, the lateral patellar facet became longer. In addition, the abnormal stress distribution on the patella influenced the patellar morphology in trochlear dysaplasia.