后外侧结构重建对后外侧入路全髋关节置换术后早期脱位的影响

目的 探讨后外侧结构重建对后外侧入路全髋关节置换术（total hip arthroplasty, THA）后早期脱位的影响。方法 回顾性分析2015年1月至2018年1月于我院行后外侧入路初次THA的病人120例,根据术中是否修补关节囊及外旋肌群将病人分为两组：观察组60例,舌形切开关节囊,术中将关节囊及外旋肌群原位缝合在大转子后方及臀中肌肌腱附着处;对照组60例,切除后关节囊,术中未进行外旋肌群修补重建。术后3个月内发生的脱位定义为早期脱位,比较两种方法对术后早期脱位率的影响。记录并比较两组病人的手术时间、术腔引流量、髋关节Harris评分。结果 观察组手术时间为（51.6±9.5） min,对照组为（45.1±7.5） min,对照组手术时间短于观察组,差异有统计学意义（t=2.008,P=0.036）。观察组术腔引流量为（129.6±11.9） ml,对照组为（136.8±12.4） ml,差异无统计学意义（t=1.187,P=0.269）。观察组未发现早期脱位,对照组早期脱位4例（4/60,脱位率为6.667%）,观察组术后Harris评分为（86.1±5.0）分,对照组为（85.9±5.5）分,差异无统计学意义（t=1.416,P=0.092）。结论 在后外侧入路THA过程中行后外侧结构重建的手术方式早期脱位率低,修补关节囊及外旋肌群对维持髋关节软组织平衡有一定意义。     

Mini-incision anterior approach does not increase dislocation rate: a study of 1037 total hip replacements

Correct positioning of the prosthetic components in total hip replacements is important to prevent dislocations. Correct positioning is made easier by extensive approaches, but it also is possible using the mini-incision approach. The mini-incision used to facilitate early rehabilitation should not produce a higher dislocation rate than that of the more conventional approaches. The anterior surgical approach we describe allows for good exposure, despite the reduced size of the skin incision. Its length is 5-10 cm and usually 6-8 cm for patients with normal corpulence. Our mini-incision anterior approach using intermuscular planes allows a surgical approach to the hip and implantation of a total prosthesis with no muscle, tendon, or trochanteric section, even partially. This is not possible with any other surgical approach. A series of 1037 primary total hip replacements done between June 1993 and June 2000 was studied retrospectively. The dislocation rate was 0.96% (10 of 1037 hips). The mini-incision approach allows for adequate positioning of the two prosthetic components. Preserving the muscular potential also may contribute to dynamic stabilization of the hip.     

Pheochromocytoma does not increase risk in laparoscopic adrenalectomy

Background  

Laparoscopic adrenalectomy (LA) has become the standard approach to an adrenal mass. This technique provides for decreased convalescence, less postoperative pain, and improved cosmesis. The use of LA for pheochromocytoma (PHE) has been questioned due to concerns of increased morbidity and negative hemodynamic sequelae. This study aimed to compare the outcomes of LA for PHE with the results of LA for other adrenal pathologies.     

The early dislocation rate in primary total hip arthroplasty following the posterior approach with posterior soft-tissue repair

Although a posterior approach is frequently used for total hip arthroplasties (THAs), some reports have associated this approach with higher dislocation rates than anterior or lateral approaches. To deter dislocations following primary THAs using the posterior approach, the senior author repairs the posterior capsule and the short external rotators to the greater trochanter with nonabsorbable suture. We retrospectively reviewed the occurrence of dislocations among 945 primary THAs performed with this technique at a mean 6.4-year follow-up (range, 2.0-9.3 years). The average patient age was 62.3 years (range, 36-86 years). Eight patients (0.85%) dislocated. Of these, 3 dislocated within the first postoperative year and were treated without surgery; 3 required revision surgery and placement of a constrained liner; and 2 dislocated after trauma and were treated without surgery. With the correct orientation of components and an enhanced soft-tissue repair, the posterior surgical approach can result in an extremely low dislocation rate.     

Induction chemotherapy does not increase the operative risk of pneumonectomy!

BACKGROUND: There is an ongoing debate whether induction therapy increases post-operative mortality and morbidity, especially when performing pneumonectomy. We therefore reviewed a consecutive series of patients having undergone pneumonectomy in a single center. METHODS: The charts of 298 patients operated on between January 1999 and July 2005 were reviewed. Patients were divided into two groups: group 1 included those who received induction chemotherapy (60 patients, 20.1%), and group 2 included those who underwent surgery alone (238 patients, 79.9%). Endpoints were operative mortality at 30 and at 90 days, and major complications such as empyema, bronchial fistula and acute respiratory distress syndrome. Statistical analyses were performed using SPSS 11.0 software. RESULTS: Demographic data were similar for both groups when considering side of operation, comorbidity and weaning from tobacco; patients were older in group 2 (61.83+/-9.58 years vs 57.75+/-8.94 years; p=0.003) and there were more female patients in group 2 (17.2% vs 5.0%; p=0.010). Post-operative mortality at 30 days was 6.7% in group 1 and 5.5% in group 2 (p=0.458), and 11.7% for group 1 and 10.9% in group 2 at 90 days (p=0.512). Incidence of empyema was 1.7% in group 1 and 2.1% in group 2 (p=0.652); incidence of bronchopleural fistulas was 1.7% in group 1 and 5.5% in group 2 (p=0.188); incidence of acute respiratory distress syndrome was 3.3% in group 1 and 3.4% in group 2 (p=0.675). CONCLUSION: In opposition to previous reports, induction chemotherapy did not significantly jeopardize post-operative outcome following pneumonectomy in our experience.     

Apolipoprotein E e4 allele does not increase the risk of early postoperative delirium after major surgery

Background

A relationship between patients with a genetic predisposition to and those who develop postoperative delirium has not been yet determined. The aim of this study was to determine whether there is an association between apolipoprotein E epsilon 4 allele (APOE4) and delirium after major surgery.

Methods

Of 230 intensive care patients admitted to the post anesthesia care unit (PACU) over a period of 3?months, 173 were enrolled in the study. Patients?? demographics and intra- and postoperative data were collected. Patients were followed for the development of delirium using the Intensive Care Delirium Screening Checklist, and DNA was obtained at PACU admission to determine apolipoprotein E genotype.

Results

Fifteen percent of patients developed delirium after surgery. Twenty-four patients had one copy of APOE4. The presence of APOE4 was not associated with an increased risk of early postoperative delirium (4% vs. 17%; P?=?0.088). The presence of APOE4 was not associated with differences in any studied variables. Multivariate analysis identified age [odds ratio (OR) 9.3, 95% confidence interval (CI) 2.0?C43.0, P?=?0.004 for age ??65?years), congestive heart disease (OR 6.2, 95% CI 2.0?C19.3, P?=?0.002), and emergency surgery (OR 59.7, 95% CI 6.7?C530.5, P?<?0.001) as independent predictors for development of delirium. The Simplified Acute Physiology Score II (SAPS II) and The Acute Physiology and Chronic Health Evaluation II (APACHE II) were significantly higher in patients with delirium (P?<?0.001 and 0.008, respectively). Hospital mortality rates of these patients was higher and they had a longer median PACU stay.

Conclusions

Apolipoprotein e4 carrier status was not associated with an increased risk for early postoperative delirium. Age, congestive heart failure, and emergency surgery were independent risk factors for the development of delirium after major surgery.     

Operative treatment of primary patellar dislocation does not improve medium-term outcome

Background?The best treatment for primary patellar dislocation has been the subject of debate. Surgery has been recommended for all patients or for special subgroups to improve outcome. We have previously reported similar 2-year results after closed or open treatment. This report concerns 127 patients who were re-evaluated by questionnaire at least 5 years after the primary onset.

Patients and methods?At baseline, the patients were randomized regarding closed treatment (57) or individually adjusted proximal realignment operation (70). All patients were re-evaluated after a mean follow-up of 7 (6-9) years.

Results?The outcomes were similar: the patient's own overall opinion was excellent or good after closed treatment in 81% of cases and after operative treatment in 67%. Mean Kujala and Hughston VAS knee scores were 90 and 94, respectively, after closed treatment and 88 and 89 after operative treatment. The proportions of stable patellae were 30% and 36% for closed treatment and operative treatment, respectively. In a multivariate risk analysis, there was a correlation between a Kujala score of less than 90 and female sex (OR: 3.5; 95% CI: 1.4-9.0), loose bodies on radiographs (4.1; 1.2-15), and also an initial history of contralateral patellar instability (3.6; 0.9-15). There were 2 risk factors for recurrent instability: initial contralateral instability (4.9; 0.9-28) and young age (0.9; 0.8-1.0/year). Girls with open tibial apophysis had the worst prognosis for instability (88%; 95% CI: 77-98).

Interpretation?We do not recommend proximal realignment surgery for treatment of primary dislocation of the patella.     

Intravenous iron following cardiac surgery does not increase the infection rate

BACKGROUND: Intravenous iron (FeIV) has been used increasingly, alone or in combination with recombinant erythropoietin, to promote red cell production as part of a blood conservation program. Given the important role that iron plays in the growth of bacteria, it has been hypothesized that this use of FeIV may promote surgical site infection. However, this hypothesis has not yet been tested appropriately. To assess this hypothesis, postoperative infection rates in patients undergoing cardiothoracic surgery were analyzed. METHODS: Data were collected on 863 patients undergoing cardiopulmonary bypass surgery in 2001. Patients were either enrolled voluntarily in a blood conservation program in which they received either postoperative FeIV and erythropoietin (n=302), as indicated, or blood transfusions and no FeIV (n=561), as indicated, to correct postoperative anemia. Infections were defined according to the U.S. Centers for Disease Control and Prevention guidelines. RESULTS: Thirty-nine infections developed. The overall infection rate was 4.52%, with an infection rate of 3.97% in the iron-treated group (n=12) and a rate of 4.81% in the untreated group (n=27). When the impact of gender, age, diabetes mellitus, operating time, type of surgery, and blood transfusions were controlled for, FeIV did not increase the risk of infection (odds ratio of 1.031 for each increment of 125 mg of FeIV; 95% confidence interval 0.908, 1.170; p=0.64). CONCLUSIONS: There was no impact of FeIV on the subsequent infection rate in a cardiac surgery patient cohort, indicating its safety for use in the postoperative setting.     

Nitrous oxide does not increase nausea and vomiting following gynaecological laparoscopy

The effect of three different anaesthetic techniques on the incidence and severity of postoperative emesis (nausea, retching and vomiting) was studied in 150 patients undergoing gynaecological laparoscopy. Patients were anaesthetized with isoflurane in nitrous oxide and oxygen (Group A), enflurane in nitrous oxide and oxygen (Group B) or with isoflurane in air and oxygen (Group C). Groups had been predetermined by date of birth. During the first 24 hours after the operation no difference was found at any time in the incidence or severity of emesis among the groups. The overall incidence of emesis during the first 24 hours postoperatively was 54, 48 and 52 per cent, in groups A, B and C, respectively. It is concluded that nitrous oxide does not increase the incidence of emesis after isoflurane anaesthesia and that isoflurane and enflurane anaesthesia are associated with similar incidences of nausea and vomiting after gynaecological laparoscopy.     

Removal of the superficial zone of bovine articular cartilage does not increase its frictional coefficient

OBJECTIVE: To investigate the role of the superficial zone in regulating the frictional response of articular cartilage. This zone contains the superficial protein (SZP), a proteoglycan synthesized exclusively by superficial zone chondrocytes and implicated in reducing the friction coefficient of cartilage. DESIGN: Unconfined compression creep tests with sliding of cartilage against glass in saline were carried out on fresh bovine cylindrical plugs (slashed circle ?6 mm, n=35) obtained from 16 bovine shoulder joints (ages 1-3 months). In the first two experiments, friction tests were carried out before and after removal of the superficial zone ( approximately 100 microm), in a control and treatment group, using two different applied load magnitudes (4.4 N and 22.2 N). In the third experiment, friction tests were conducted on intact surfaces and the corresponding microtomed deep zone of the same specimen. RESULTS: In all tests the friction coefficient exhibited a transient response, increasing from a minimum value (mu(min)) to a near-equilibrium final value (micro(eq)). No statistical change (P>0.5) was found in micro(min) before and after removal of the superficial zone in both experiments 1 and 2. However, micro(eq) was observed to decrease significantly (P<0.001) after removal of the surface zone. Results from the third experiment confirm that micro(eq) is even lower at the deep zone. Surface roughness measurements with atomic force microscopy (AFM) revealed an increase in surface roughness after microtoming. Immunohistochemical staining confirmed the presence of SZP in intact specimens and its removal in microtomed specimens. CONCLUSIONS: The topmost ( approximately 100 microm) superficial zone of articular cartilage does not have special properties which enhances its frictional response.     

Secondary polycythemia does not increase the risk of perioperative hemorrhagic or thrombotic complications

STUDY OBJECTIVE: To determine the effects of secondary polycythemia on perioperative hemorrhagic and thrombotic complications. DESIGN: Retrospective chart review. SETTING: Surgical patients at a university-affiliated Veterans Administration Hospital. PATIENTS: One hundred patients with a diagnosis of chronic obstructive pulmonary disease and a preoperative hemoglobin concentration (Hb) greater than 16 g/dl and 100 age-, sex-, operation-, and ASA physical status-matched control patients without secondary polycythemia having operations during January to June 1988. MEASUREMENTS AND MAIN RESULTS: Anesthetic and perioperative records were retrospectively analyzed for excessive bleeding and transfusion requirements. Charts also were retrospectively analyzed for the presence of hemorrhagic and thrombotic complications for 30 days following surgery. The secondary polycythemic patients were compared with the matched control group and did not have a higher frequency of these complications. Red blood cell transfusion requirements for patients with secondary polycythemia were less than that for the matched controls (p less than 0.005). There was no statistical difference for transfusions of other types of blood products such as platelets and fresh frozen plasma (FFP). CONCLUSION: Secondary polycythemia does not impart any added perioperative risk.     

Tricuspid insufficiency does not increase early after permanent implantation of pacemaker leads

BACKGROUND: Interference between pacemaker (PM) lead and tricuspid apparatus may cause tricuspid regurgitation (TR). However, data regarding TR in patients with implanted PM are controversial. Our aim is to find out the degree of TR in a group of patients before and following PM implantation in a prospective manner. METHODS: The study group consisted of the patients referred for implantation of permanent PM or implantable cardioverter defibrillator (ICD). All patients underwent two-dimensional and Doppler echocardiographic evaluation before and after device implantation. The severity of TR was qualitatively classified into four groups as normal or trivial, mild, moderate, or severe. All studies were reviewed for accuracy by a second independent interpreter. RESULTS: Sixty-one patients (mean age 53 +/- 8 years, 44 male) referred for PM (n = 55) or ICD (n = 6) implantation consisted of the study population. Echocardiographic degree of TR was mild in 21 (70%), moderate in 7 (23%) and severe in 2 (7%) patients before PM implantation. Following device implantation, mild TR was noted in 23 (76%), moderate in 10 (33%), and severe in 2 (6%) cases. After the procedure, the TR severity was increased from normal/trivial to mild in 5 (16%) cases and from mild to moderate in 3 (10%). There was no worsening of the severity of TR in patients with moderate regurgitation following device implantation. The severity of TR did not change at a mean follow-up of 6 +/- 3 months. CONCLUSIONS: New or worsening TR is relatively rare after PM implantation. It is not associated with an acute worsening or clinical deterioration. But echocardiographic follow-up is recommended to monitor other complications in chronic phase.