Approach to Early Barrett’s Cancer

Because of effective surveillance programs in patients with known Barretts esophagus, adenocarcinoma of the distal esophagus is increasingly diagnosed at early stages. With the introduction of limited surgical and endoscopic treatment modalities, the need for radical esophagectomy and extensive lymphadenectomy in such patients has been questioned. When selecting the approach to early Barretts cancer, the precancerous nature of the underlying Barretts esophagus, the frequent multicentricity of neoplastic alterations within the Barrett mucosa, the inaccuracy of current staging modalities, and the presence of lymph node metastases should be taken into account. Invasiveness and morbidity of the procedures, as well as quality of life aspects, should also be considered. From an oncologic point of view the minimum extent of a resection for early Barretts cancer should include a full-thickness removal of the entire segment of the distal esophagus covered by intestinal metaplasia together with a regional lymphadenectomy. In appropriately selected patients this can be achieved by a limited surgical procedure involving transhiatal resection of the distal esophagus, but not by endoscopic mucosal ablation or endoscopic mucosa resection. Our experience with 49 limited surgical resections with regional lymphadenectomy indicates that this procedure is oncologically adequate and safe. Reconstruction with an interposed jejunal loop prevents postoperative gastroesophageal reflux and is associated with good quality of life. In contrast, endoscopic interventions are plagued by a high tumor recurrence rate, probably from persistence of Barretts mucosa and gastroesophageal reflux.     

Surgical Treatment of Barrett’s Esophagus: 1980-2003

Barretts esophagus is a complication of long-standing gastroesophageal reflux and can be a premalignant condition. The goals of surgical treatment, which were well summarized by DeMeester, have been increased and more detailed by us. They consist of (1) controlling symptoms of gastroesophageal reflux disease; (2) abolishing acid and duodenal reflux into the esophagus; (3) preventing or eliminating the development of complications; (4) preventing extension of or an increase in the length of intestinal metaplasia; (5) inducing regression of intestinal metaplasia to the cardiac mucosa; and (6) preventing progression to dysplasia, thereby inducing regression of low-grade dysplasia and avoiding the appearance of an adenocarcinoma. We have reviewed 25 articles in the English-language literature published from 1980 to 2003 dealing specifically with the surgical treatment of Barretts esophagus. In most of these papers too few patients were included, the follow-up was less than 60 months, and the clinical success deteriorated with time. Acid reflux persists after surgery in nearly 35% of Barretts esophagus patients; and at 10 years after surgery duodenal reflux is present in 95%. Peptic ulcer, stricture, and erosive esophagitis are present in 15% to 30% late after surgery, and in 16% there is progression of the intestinal metaplasia. There is the appearance of low-grade dysplasia in 6.0% and adenocarcinoma in 3.4%, and there is regression of low-grade dysplasia in 45.0%. These results challenge the arguments supporting antireflux surgery for patients with Barretts esophagus: The clinical results are not optimal, no long-lasting effect has been demonstrated, and it does not prevent the appearance of dysplasia or adenocarcinoma. An excellent alternative is acid suppression and a duodenal diversion procedure, which has had 91% clinical success for more than 5 years. This regimen has almost eliminated acid and duodenal reflux, and there has been no progression to dysplasia or adenocarcinoma. Moreover, in 60% of the patients with low-grade dysplasia, regression to nondysplastic mucosa has occurred.     

Effect of <Emphasis Type="Italic">Helicobacter pylori</Emphasis> Infection in Barrett’s Esophagus and the Genesis of Esophageal Adenocarcinoma

The relation between Helicobacter pylori and gastroesophageal reflux disease is unclear. Recent reports have suggested a possible protective role for H. pylori, particularly in preventing the complications of gastroesophageal reflux disease (GERD). The purpose of this article is to present a brief overview of the recent literature regarding the role of H. pylori in the genesis of the complications of GERD, focusing on Barretts esophagus and esophageal adenocarcinoma. The prevalence of H. pylori infection in the population of the West is around 40% and is not different in cohorts of patients with GERD. When the infection induces pangastritis or corpus-predominant gastritis, there may be concomitant reduced gastric acid secretion. Eradication of the bacteria in this subgroup of patients may enhance gastric acid secretion and provoke reflux symptoms. H. pylori organisms do not colonize the specialized intestinal metaplasia characteristic of Barretts esophagus. H. pylori infection rates in gastric mucosa of patients with Barretts esophagus occur at a similar or slightly lower frequency than is found in controls. Gastric infection with cagA-positive strains of H. pylori appears to be uncommon in patients with Barretts esophagus. Furthermore, epidemiologic studies indicate that cagA-positive strains are protective against esophageal adenocarcinoma. Several investigators have proposed that the decreasing prevalence of H. pylori infection might be an important factor in the rising incidence of this tumor.     

Barrett’s esophagus: Histopathologic definitions and diagnostic criteria

Adenocarcinoma of the distal esophagus is rising more rapidly in incidence than any other visceral malignancy in the Western world. It is well established that most, if not all, of these tumors develop in Barretts esophagus via the metaplasia-dysplasia-carcinoma sequence and could theoretically be detected at an early stage, but despite this, the majority of these tumors are still detected late in their course. This highlights the fact that the goal of effective surveillance for patients at risk for developing an adenocarcinoma of the distal esophagus is still far off. In addition, adenocarcinomas of the esophagogastric junction and gastric cardia are also rising in incidence, but their carcinogenesis and their relation to Barretts esophagus are still being defined, as are the meaning and significance of the relatively new entities short-segment Barretts and ultra-short-segment Barretts. This review attempts to clarify the main histopathologic issues concerned with the definition of Barretts esophagus, its distinction from intestinal metaplasia of the gastric cardia, as well as the criteria for the histologic diagnosis of dysplasia and carcinoma in Barretts esophagus.This article is part of the World Progress in Surgery symposium on Barretts esophagus and esophageal cancer, which was published in Volume 27, Number 9 of World Journal of Surgery.     

Scintigraphic Evaluation of Jejunal Interposition after Distal Esophageal Resection for Early Barrett’s Carcinoma

Subtotal esophagectomy still is the major treatment for early Barretts carcinoma. The inevitable loss of the gastric reservoir leaves an unresolved functional problem. Distal esophageal resection combined with a short jejunal interposition might be a safe alternative with the advantage of better functional results. In this series, 12 or more months after limited surgery for early Barretts carcinoma 8 patients underwent functional investigation by alimentary scintigraphy. The activity of a technetium-labeled bolus passing through the esophagus and the jejunal interposition into the stomach was consecutively measured. Compared to 11 healthy controls the transit through the tubular esophagus showed no significant delay; transit time, however, increased with a bolus-induced dilation of the jejunal interposition. The length of the transit time through the jejunal interposition correlated with the length of the jejunal segment. The delay of bolus passage into the stomach did not result in substantial symptoms in jejunal segments shorter than 12 cm. Propulsive activity within the jejunal interposition resulted in a bolus transport into the stomach without any reflux to the esophagus. These data demonstrate good transport function and reflux prevention of short jejunal segments interposed between the esophagus and the stomach.     

High Grade Dysplasia: Surveillance,Mucosal Ablation,or Resection?

Barretts esophagus is a common premalignant condition that results from chronic gastroesophageal reflux. High grade dysplasia in the metaplastic esophagus is thought to be the last step in the metaplasia-to-carcinoma sequence that characterizes this disease. The management of high grade dysplasia in Barretts esophagus is controversial. Some investigators advocate a rigorous endoscopic surveillance program with biopsies, but this approach has been questioned because of its clinical impracticality, high cost, possibility of sampling errors, and difficulty demonstrating effectiveness on a reproducible basis. Others advocate mucosal ablative therapy to eradicate the dysplastic and metaplastic epithelium. This approach, still in its infancy, cannot be accepted as standard therapy at the present time because of limited follow-up, its questionable ability to completely eradicate the abnormal mucosa, the phenomenon of pseudoregression, and the patients require continued rigorous endoscopic surveillance. Esophagectomy, on the other hand, can be accomplished with a low mortality rate in these patients. We advocate this approach because a large number of them have invasive cancer in the esophagus despite a preoperative diagnosis of only high grade dysplasia. In addition, the 5-year survival is excellent even if invasive cancer is present, and these patients are liberated from rigorous endoscopic surveillance for the rest of their lives. For patients with high grade dysplasia in Barretts esophagus who are poor operative risks, less invasive approaches such as mucosal ablation may play a role, but longer follow-up information is needed before this technique can be accepted even in this setting.     

Comparison of high- vs low-dose 5-aminolevulinic acid for photodynamic therapy of Barrett’s esophagus

Background: Barretts esophagus is the major risk factor for esophageal adenocarcinoma, the incidence of which is increasing rapidly in the Western world. Aminolevulinic acid for photodynamic therapy (ALA-PDT) is effective in the treatment of Barretts esophagus, but controversy exists regarding optimum ALA dosage. The aim of this study was to establish the optimum dosage regime for ALA-PDT for Barretts esophagus. Methods: Twenty-five patients with Barretts esophagus were randomized to receive 30 (low-dose) or 60 (high-dose) mg/kg oral ALA at 4 or 6 h or 30 mg/kg in two fractions 4 and 6 h before PDT. PDT was standardized using red (635 nm) light. Biopsy specimens were taken for protoporphyrin IX (PpIX) quantification. Endoscopy was repeated 4 weeks later. Results: All patients showed a macroscopic response, with squamous re-epithelialization. This response was greatest in the 30 mg/kg and fractionated ALA groups. There was no significant difference in response between dosing 4 or 6 h prior to PDT. Tissue levels of PpIX were similar for all dosage groups and were not predictive of clinical response. Side effects were more common with the higher dose of ALA. Conclusion: Low-dose ALA-PDT appears to be a safe protocol for the ablation of Barretts esophagus.     

Experimental Evidence for Mutagenic Potential of Duodenogastric Juice on Barrett’s Esophagus

The aim of this article is to review the current experimental knowledge of mutagenesis in Barretts esophagus (BE) with special emphasis on the effect of bile salts and acid. Human evidence of direct mutagenicity is rare. Only the correlation of increased quantities and a change in the quality of bile salts with the complications of duodenogastric reflux such as BE and esophageal adenocarcinoma as an indirect marker of mutagenicity has been shown in several studies. Further evidence comes from p53 studies demonstrating an increased number of mutated p53 genes in patients with BE, esophageal adenocarcinoma, or both. Most animal and cellular experiments are carried out in a neutral pH environment, not reflecting the true nature of a reflux episode. The few studies using moderate low acid reflux conditions in combination with bile salts demonstrated a combined effect on mutagenicity. Our current knowledge of bile salt mutagenicity is predominantly based on experiments with hepatocytes and colon cancer cell lines. Future studies must be aimed at esophageal cell lines, cultured Barretts tissue, and esophageal adenocarcinoma cell lines.     

Results of Surgical Therapy in Patients with Barrett’s Adenocarcinoma

The incidence of adenocarcinoma arising from Barretts esophagus is dramatically increasing in Western countries. The purpose of this study was to report our experience in the surgical management of these patients. Between November 1992 and December 2000, 330 consecutive patients with adenocarcinoma of the esophagogastric junction were observed in our institution. Of these, 105 (31.8%) had Barretts carcinoma. In 12 individuals (11.4%) adenocarcinoma was discovered during endoscopic surveillance for Barretts esophagus. Twelve patients with doubtful cleavage planes at preoperative investigation were treated with neoadjuvant chemotherapy. Overall, 80 patients (76.2%) underwent esophagectomy without operative mortality. The Ivor Lewis approach was used in 70 patients; of these, 31 underwent extended mediastinal lymph node dissection. Seventy-four patients (92.5%) had R0 resection. The overall 5-year survival rate was 48%. Survival was significantly associated with stage, lymph node status, and completeness of resection. Early diagnosis remains the prerequisite for curative treatment of esophageal carcinoma. An extended mediastinal lymphadenectomy does not increase morbidity, allows precise tumor staging, and may prove effective in preventing local recurrences. Neoadjuvant therapy requires major improvement before it can be unconditionally recommended outside clinical trials.     

Trends in Incidence and Prevalence of Specialized Intestinal Metaplasia,Barrett’s Esophagus,and Adenocarcinoma of the Gastroesophageal Junction

Most available information on the epidemiology of Barretts esophagus (BE) relates to patients with long segments (> 3 cm) of specialized intestinal metaplasia (SIM). Its prevalence is 3% in patients undergoing endoscopy for reflux symptoms and 1% in those undergoing endoscopy for any clinical indication. The latter prevalence is similar to the 1% found in autopsy series. A silent majority with BE remain unrecognized in the general population. BE is more common in men, and the prevalence rises with age. Recent endoscopic series document a rise in the diagnosis of endoscopically apparent short segments (< 3 cm) of BE (SSBE). The prevalence of SSBE in both unselected and reflux patients is 8% to 12%. Specialized intestinal metaplasia at the cardia, below a normal-appearing squamocolumnar junction, has been reported to vary from 6% to 25% in patients presenting for upper endoscopy. Unlike patients with long segment Barretts esophagus (LSBE), the role of gastroesophageal reflux disease in the pathogenesis of SSBE and SIM of the cardia is controversial. Recent data suggest that the etiology of SIM of the cardia might be secondary to Helicobacter pylori infection, although the role of other environmental factors cannot be ruled out. The incidence of adenocarcinoma of the esophagus and esophagogastric juction (EGJ) has been increasing over the past 15 years in Western countries. Surgical series and population-based studies show that by 1994 adenocarcinomas of the esophagus accounted for half of all esophageal cancer among white men. LSBE and SSBE predispose to the development of adenocarcinoma of the esophagus and EGJ. The role of SIM of the cardia as a precursor lesion for EGJ adenocarcinoma is still unclear. The prevalences of dysplasia in LSBE and SSBE are around 6% and 8%, respectively. The incidence of adenocarcinoma in patients with LSBE is about 1 in 100 patient-years. Cancer risk for SSBE and SIM at the cardia is unknown. Smoking and obesity increase the risk for esophageal and EGJ adenocarcinomas.     

Significance of Fas and Retinoblastoma Protein Expression During the Progression of Barrett’s Metaplasia to Adenocarcinoma

Background: Barretts esophagus (BE) is a premalignant lesion characterized by replacement of normal squamous epithelium with columnar epithelium. This lesion can progress to dysplasia and adenocarcinoma. Recently, the Fas receptor and retinoblastoma (Rb) protein have been described as important mediators of apoptosis and tumor suppression, respectively. This study was undertaken to examine their expression during the progression of metaplasia to adenocarcinoma in BE.Methods: In a review of 56 adenocarcinomas arising in BE, the specimen blocks were examined using the immunohistochemical avidin-biotin-peroxidase complex technique. For each specimen, areas of normal epithelium were compared with areas of metaplasia, dysplasia, or carcinoma (when present). Monoclonal mouse anti-human antibodies were used to identify Rb protein (Rb-Ab5, 1/50 dilution; Oncogene Science) and the 40–50-kDa cell membrane Fas protein (APO-1/Fas, 1/5 dilution; DAKO Corp.).Results: Loss of Rb staining was observed as the metaplasia progressed to dysplasia and carcinoma, indicating accumulation of unstainable aberrant protein. Conversely, Fas protein staining was undetectable or weak in normal or metaplastic epithelium, increasing in the areas of high-grade dysplasia and carcinoma. These differences were statistically significant (P < .001).Conclusions: The accumulation of abnormal Rb protein during the progression of Barretts metaplasia to carcinoma leads to unsuppressed tumor growth. Fas overexpression may represent a cellular attempt to balance the uncontrolled tumor proliferation by promoting apoptosis.     

Vascular Endothelial Growth Factor Expression and Neovascularization in Barrett’s Carcinoma

Angiogenesis is essential for tumor growth and metastasis. An association between microvessel density, a measure of tumor angiogenesis, and conventional prognostic variables has been shown for many tumor entities. For Barretts carcinoma, the results are controversial. Immature vessels formed in tumors are structurally and functionally different from those in mature vessels. The relation between mature and immature vessels as a prognostic factor for Barretts carcinoma has not been assessed. Specimens from 45 R0-resected Barretts carcinomas were immunostained for vascular endothelial growth factor (VEGF), CD 31, and smooth muscle -actin to discriminate between mature and immature vessels. VEGF staining was evaluated quantitatively by measuring optical density with a new computer-based program and expressed as a percentage of the staining (juvenile placental tissue) on control slides. The neovascularization coefficient (i.e., the relation between mature and immature vessels) was estimated with an interactive analytic computer program. The median survival of the study group was 45.7 months. The neovascularization coefficient correlated with the histopathologic classification (p < 0.001). Survival time in patients with a low neovascularization coefficient was significantly better than the survival time in patients with a high neovascularization coefficient (p = 0.021). VEGF expression did not correlate with clinicopathologic data (p > 0.05) or with patient survival (p > 0.05). The tumors with a high neovascularization coefficient did not have significantly elevated VEGF expression. Based on a strong quantitative computer evaluation program, the present study indicates that neovascularization has an important impact on the survival of patients with Barretts carcinoma. However, VEGF does not appear to be the vascular growth factor stimulating neovascularization in Barretts carcinoma patients.     

Role of Surveillance in Intestinal Metaplasia of the Esophagus and Gastroesophageal Junction

This article reviews current concepts of cancer surveillance in esophageal columnar metaplasia (Barretts esophagus) and intestinal metaplasia at the gastroesophageal junction. An overview is given of the available data on the prevalence of intestinal metaplasia in biopsies from the distal esophagus and from the gastroesophageal junction. Furthermore, special attention is given to the endoscopic detection of dysplasia and early malignancy. Finally, the costs of endoscopic surveillance and its effect on mortality rates from esophageal adenocarcinoma are discussed.     

Pattern of lymphatic spread of Barrett's cancer

As in squamous cell esophageal cancer, the presence and number of lymph node metastases constitutes the major prognostic factor in patients with adenocarcinoma of the distal esophagus (the so-called Barretts cancer) who have had complete tumor resection (R0 resection). In contrast to squamous cell esophageal cancer, however, lymphatic spread in patients with Barretts cancer appears to follow certain rules. Lymphatic spread is closely correlated with the pT category of the primary tumor; it starts only after infiltration of the basal membrane, and initially it is limited to the regional lymph nodes. Lymph node metastases at distant locations—i.e., the upper mediastinum and the celiac axis—are found almost exclusively in patients with multiple positive regional nodes. Skipping of regional lymph node stations occurs in less than 5% of the patients. These observations set the stage for individualized and tailored lymphadenectomy strategies. The sentinel lymphadenectomy concept may be applicable to patients with early Barretts cancer.     

Barrett’s Esophagus: Model of Neoplastic Progression

Human cancer progression is characterized by clonal expansion of cells with accumulated genetic errors. Invasive carcinomas contain all the genetic errors that were acquired during neoplastic progression and then continue to accumulate further abnormalities, leading to tumor heterogeneity. Many investigations of human cancer have given valuable insights in genetic abnormalities important for tumor biology. Early events responsible for neoplastic progression, however, are often impossible to investigate in invasive cancers because the premalignant tissue in which the tumors develop are often overgrown and the premalignant conditions cannot be studied in vivo because they are either not detected owing to lack of symptoms or are removed before cancer develops. Unlike many other premalignant conditions Barretts esophagus is often associated with symptoms leading to diagnosis at an early stage before cancer develops, and the premalignant epithelium is seldom removed at an early stage of cancer progression. Furthermore, in patients who present with invasive carcinoma the tumor is often surrounded by premalignant epithelium, which is available for further investigations. Therefore Barretts esophagus is an excellent model in which to study the early events of neoplastic progression. It may not only contribute to a better understanding of the neoplastic process but also provide a base for safer assessment of cancer risk during surveillance for early detection of esophageal adenocarcinoma.     

Surgical Approach to Invasive Adenocarcinoma of the Distal Esophagus (Barrett’s Cancer)

Barretts carcinoma, usually arising in the distal esophagus, must be considered a separate entity from squamous cell esophageal cancer. Epidemiology, etiology, patients risk profiles, biology of metastases, and prognosis differ markedly between these two major esophageal tumor types. The preoperative work-up of patients with Barretts cancer is primarily directed toward assessing the chances for R0 resection and estimating the risk of the patient to survive an esophagectomy. If R0 resection appears likely and the surgical risk is acceptable, the indication for an operative approach is given. From the oncologic point of view there is no difference between a radical transmediastinal approach and a transthoracic approach. A possible advantage of a transthoracic approach is the extension of lymphadenectomy to the upper mediastinum. Lymph node metastases in the upper mediastinum, however, usually indicate advanced lymphatic and subclinical systemic tumor dissemination, i.e., a poor prognosis even with extended surgery. Consequently the controversies about the surgical approach are reduced to technical and functional aspects. A better swallowing function argues for an intrathoracic anastomosis; the lower morbidity, for a cervical approach. We prefer transthoracic en bloc esophagectomy with an intrathoracic anastomosis in patients with moderate risk and early tumor stages. In all other patients radical transmediastinal esophagectomy with a cervical anastomosis is the procedure of choice. The overall 5-year survival rate of more than 40%, which is superior to most published data, supports this therapeutic strategy.     

Periprosthetic fractures around cementless hydroxyapatite-coated femoral stems

We studied 14 periprosthetic femoral fractures out of a series of 619 hydroxyapatite coated hip implants and compared the outcome to published treatment algorithms using the Vancouver classification. There were five type A fractures, six B1, two B2, and one type B3 fracture. All but one type A fractures were treated conservatively. Compared with the Vancouver classification, we observed a different fracture type in the type B fractures. No fractures at the tip of the stem were seen, as in cemented implants. Three B1 fractures were treated operatively due to fracture displacement, and three were treated conservatively. The B2 and B3 fractures were managed with long, uncemented, revision stems because of a disrupted bone–prosthesis interface. All fractures healed well. This study confirms that the modified algorithm of management of periprosthetic fractures, using the Vancouver classification, is a simple, reproducible, classification system for uncemented prostheses. Conservative treatment is a valid option if the implant is stable whilst surgical intervention is mandatory if the implant is loose.

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Résumé Nous avons étudié 14 fractures fémorales péri prothétiques dans une série de 619 implants de la hanche recouverts dhydroxyapatite et nous avons comparé le résultat à lalgorithme de traitement utilisant la classification de Vancouver. Il y avait cinq fractures de type A, six de type B1, deux de type B2 et une de type B3. Toutes les fractures de type A, sauf une, ont été traités dune manière conservatrice. Comparé à la classification de Vancouver nous avons observé un type de fracture différent dans le type B. Aucune fracture à lextrémité de la tige na été vue comme dans les implants cimentés. Trois fractures B1 ont été opérées à cause du déplacement et trois a été traité dune manière conservatrice. Les fractures B2 et B3 ont été traités avec des tiges longues de révision, sans ciment, à cause dune interface os-prothèse interrompu. Toutes les fractures ont consolidé. Cette étude confirme que lalgorithme modifié de gestion des fractures péri prothétiques, en utilisant la classification de Vancouver, est un système de classification simple, reproductible, pour les modalités du traitement avec des implants sans ciment. Le traitement conservateur est une option valable en cas dimplant stable, cependant quen cas dimplant descellé lintervention chirurgicale est obligatoire.

     

Association of Aneurysmal and Occlusive Lesions in Behçet’s Disease

Arterial involvement in Behçets disease is rare, occurring in various locations with multiple clinical expressions. When Behçets disease is associated with large arteries, lesions are usually in the form of aneurysms or occlusions. The simultaneous occurrence of these two lesions is even more unusual. We present a case of Behçets disease in which arterial involvement included an iliac artery thrombosis and an asymptomatic aneurysm of the infrarenal abdominal aorta. Behçets disease must be considered in the diagnosis of any unexplained inflammatory arteriopathy. Surgery is indicated for the majority of aneurysms and severe symptoms. The postoperative follow-up is based on noninvasive radiologic examinations.     

Valgus impacted proximal humeral fractures and their blood supply after transosseous suturing

We treated 16 patients (11 women and five men, average age 45 years), all having four-part valgus impacted fractures of the proximal humerus, with transosseous suturing. All had preoperative angiography performed 6–12 h after admission. The average impaction angle was 43°, and the mean lateral displacement of the humeral head was 1.4 mm. Postoperative angiography was performed 8–10 weeks after the operation followed by digital image processing using the segmentation technique. No statistically important reduction in the length and area of large (>0.5 mm) vessels was seen. Union was confirmed by the reduction in the length and area of small vessels (<0.5 mm). At a mean follow-up of 40 months, avascular necrosis was only found in one patient. The average Constant–Murley score was 87 (67–100) points, whereas the functional score in comparison with the unaffected shoulder was 94% (89–100%). Despite the small number of patients, transosseous fixation seems to preserve the remaining blood supply of the humeral head.

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Résumé Nous avons traité 16 malades (11 femmes et 5 hommes, dâge moyen 45 ans), présentant une fracture de lhumérus proximal à 4 fragments, impactée en valgus, avec suture trans-osseuse. Tous avaient une angiographie préopératoire exécutée 6 à 12 heures après ladmission. Langle moyen de limpaction était 43° et le déplacement latéral moyen de la tête humérale 1.4 mm. Langiographie postopératoire a été exécutée 8–10 semaines après lopération, en utilisant la technique de la segmentation. Aucune réduction statistiquement importante dans la longueur et le territoire des vaisseaux de plus de 0.5 mm na été noté. Lunion a été confirmée par la réduction de la longueur et du territoire des petits vaisseaux (<0.5 mm). À un suivi moyen de 40 mois, une seule nécrose avasculaire a été trouvé. Le score de Murley Constant moyen était 87 (67–100) points alors que le score fonctionnel en comparaison de lépaule non affectée était 94% (89–100%). En dépit du petit nombre de malades étudiés, la fixation trans-osseuse paraît conserver la vascularisation restante de la tête humérale.

     

Patient-perceived outcome measures following unicompartmental knee arthroplasty with mini-incision

We reviewed 150 patients (183 knees) who underwent mini-incision unicompartmental knee arthroplasty (Oxford). Mean age was 71.5 (36–92) years. Review was conducted at least 12 months following surgery. To assess results, we used the Oxford knee questionnaire, modified Grimby score, return to sport and work, knee normality and patient general health. The mean Oxford knee score was 22.17 (range 12–54). Kneeling scored worse than other activities. No significant age or gender difference was found. Mean modified Grimby score was 3.89, equating to moderate exercise less than 2 h a week. Patients with artificial-feeling knees had significantly worse scores than patients with normal/near-normal-feeling knees. Patients who returned to/increased sporting activity had better Oxford scores than those who did not. Ninety-four percent of patients working pre-operatively returned to work. Sixty-seven percent continued at the same level of or increased sporting activity. Oxford knee scores and return to sport compared well to published data. Results regarding modified Grimby score, return to work and pain relief were encouraging. The best results were achieved in active patients who felt their health was good and their knee felt normal or near normal following surgery.

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Résumé Nous avons examiné 150 malades (183 genoux) qui ont subi une arthroplastie unicompartmentale (Oxford) par une mini-incision. Lâge moyen était 71,5 ans (36–92). Lexamen a été conduit au moins 12 mois après la chirurgie. Nous avons utilisé le questionnaire de genou Oxford, le score modifié de Grimby, le retour au sport et au travail, la normalité du genou et la santé générale du malade. Le score moyen dOxford était 22.17 (12–54). Le défaut dagenouilllement était le plus péjoratif. Aucune différence notable de sexe ou dage na été trouvée. Le score moyen modifié de Grimby était 3.89, équivalent à un exercice modéré moins de deux heures par semaine. Les malades avec la sensation de genou artificiel avaient des scores nettement moins bons que les malades ayant la sensation dun genou normal ou proche de la normale. Les malades qui avaient retrouvé ou augmenté lactivité sportive avaient un meilleur score dOxford que les autres. Ninety-fourpercentage des malades travaillant avant lopération ont repris le travail après. 67% des malades ont continué au même niveau de sport ou ont augmenté lactivité sportive. Les scores dOxford et le retour au sport étaient comparables aux données publiées. Les résultats selon le score modifié de Grimby, le retour au travail et la disparition des douleurs étaient encourageant. Les meilleurs résultats ont été obtenus chez des patients actifs, en bonne santé, et qui ont senti leur genou comme normal ou sub-normal après lopération.