Is surgical treatment of lipoblastoma always necessary?

Lipoblastoma is an uncommon, benign mesenchymal tumor with an excellent prognosis despite its potential to local invasion and rapid growth. However, in the literature, a spontaneous resolution has never been reported, and, consequently, the need for a complete surgical excision has never been questioned. The authors report a case of a 2-day-old boy with congenital diffuse lipoblastoma in the left thigh, which forced us to withhold from surgical treatment to avoid the risk of mutilation in a patient so young. The lesion was followed-up by imaging, and a complete spontaneous resolution of the diffuse lipoblastoma was shown by magnetic resonance imaging (MRI) at 1-year follow-up. In the literature, a complete surgical excision is recommended. The results of this case suggest that a "wait and see" approach is justified at least in infants with huge invasive lesions requiring a mutilating excision.     

Surgical treatment of proximal humeral fractures. Is the T-plate still adequate osteosynthesis procedure?

No general agreement exists on the operative therapy of displaced proximal humeral fractures. The purpose of this study is to evaluate different internal fixation techniques (plate fixation, figure-of-eight tension wiring, lagscrew) and to verify if the plate fixation is still an adequate therapy in the treatment of displaced proximal humeral fractures. A follow-up investigation was conducted in 51 patients after an average of 4.2 years. A T-plate fixation was performed in 62.7%, a minimal invasive technique in 21.6% and a shoulder prosthesis in 15.7% of these patients. At follow-up 60.7% of the patients with a 3- or 4-part fracture had good or excellent results in the Constant score (59% T-plate, 66% minimal invasive). Humeral head necrosis was seen in 15.9% of the patients with a T-plate fixation and in 9.1% of the patients with minimal invasive techniques. Based on our results and the reviewed literature we can confirm advantages of the minimal invasive techniques in the treatment of 4-part fractures. However, good results can be obtained with T-plate fixation in 2- or 3-part fractures especially in younger patients.     

Fibula fixation in the treatment of tibial pilon fractures – Is it really necessary?

BackgroundThere is a lack of consensus about the role of fibula fixation in these complex fractures, with only two clinical studies in the literature. We hypothesize that the fibula fracture need not be fixed in the tibial pilon fractures if primary stability can be achieved with tibial fixation alone.MethodsWe reviewed 79 patients with operatively treated tibial pilon with associated fibula fractures from 2007 to 2017 and divided them into two groups; patients with fibula fracture fixation and those without fixation. The primary outcome measure was any mechanical complications. Secondary outcomes were wound complications and other morbidities.ResultsThere were 54 (68.4%) patients with fibula fixation and 25 (31.6%) patients without fixation. There were no statistically significant differences in mechanical complications between the two groups. However, patients without fibula fixation were noted to have more wound complications (44% vs 25.9%, p = 0.108) although this was not statistically significant. In terms of removal of implant (ROI), there were no differences noted in patients with or without fibula fixation (33.3% vs 28%, p = 0.796). There were also no significant differences in ROI for those fixed with plate and screws when compared to those fixed with Rush rod and K wire within the group with fibula fixation.ConclusionFibula fixation in the treatment of tibial pilon fractures is not routinely necessary and does not result in decreased mechanical complications such as malunion, delayed union, nonunion and implant failure. Fibula fracture fixation should be reserved for cases where it may aid reduction or provide additional stability.     

Strategy of treatment of patients with recurrent spontaneous pneumothorax: is active surgical treatment necessary?

The diagnostic accuracy of computed tomography in treatment of bullous disease as the most frequent cause of recurrent spontaneous pneumothorax was 55.5%, while that of roentgenography was 16%. The recovery of patients with recurrent spontaneous pneumothorax treated by active surgical measures takes place in 85% of cases, while with drainage of the pleural cavity--in 65%.     

Is grip strength useful in screening to predict the severity of locomotive syndrome?

BackgroundThis study was conducted to investigate the relationship between grip strength and the 25-question Geriatric Locomotive Function Scale (GLFS-25) score and the diagnosis of locomotive syndrome (LS), and the usefulness of grip strength in screening for LS.MethodsThis cross-sectional study was conducted on 2251 community-dwelling residents (male, n = 1035; female, n = 1216). Subjects with GLFS-25 scores of 0–6 points, 7–15 points, 16–23 points, and 24–100 points were diagnosed with non-LS, LS-1, LS-2, and LS-3, respectively. Multivariate linear regression and multivariate logistic regression analyses were performed to assess the relationship between grip strength and the GLFS-25 score and LS after adjustment for age, sex, and body mass index. A conventional receiver operating characteristic (ROC) curve analysis was used to calculate the optimal cutoff value of grip strength for predicting the severity of LS. The discriminative ability of the model was assessed using the area under the ROC curve (AUC).ResultsThe multivariate linear regression analysis showed that grip strength was significantly associated with the GLFS-25 score. The multivariate logistic regression analysis revealed that grip strength was significantly associated with the diagnosis of LS. The optimal cutoff values of grip strength for identifying LS-1 or more, LS-2 or more, and LS-3 or more were 36.0 kg (sensitivity 65.7%, specificity 57.1%, AUC 0.66), 35.0 kg (sensitivity 70.0%, specificity 57.5%, AUC 0.70), and 34.0 kg (sensitivity 67.2%, specificity 62.5%, AUC 0.70), respectively, in males, and 24.0 kg (sensitivity 69.1%, specificity 45.4%, AUC 0.61), 23.0 kg (sensitivity 69.5%, specificity 52.3%, AUC 0.67), and 22.0 kg (sensitivity 69.1%, specificity 61.0%, AUC 0.69) in females.ConclusionsThe use of grip strength in screening to predict the severity of LS may not be clinically useful. However, the results will increase our understanding of the relationship between grip strength and the GLFS-25 scores and LS.     

Intramedullary nailing of humeral diaphyseal fractures. Is distal locking really necessary?

Purpose:

Distal interlocking is regarded as an inherent part of the antegrade humeral nailing technique, but it exposes both the patient and surgeon to radiation, is time consuming, and has a potential risk of damaging neurovascular structures. We have presented our technique of diaphyseal humeral nailing without any distal interlocking in this paper.

Materials and Methods:

We have presented a series of 64 consecutive patients (33 male and 31 female, mean age: 41.5 years) with humeral shaft fractures treated with antegrade rigid intramedullary nailing without distal interlocking following a strict intra and postoperative protocol. According to the AO classification, there were 36 type A fractures, 22 type B, and 6 type C. Nails were inserted unreamed or by using limited proximal reaming and they were fitted as snuggly as possible into the medullary canal. After impaction of the nail into the fossa, we carefully tested rotational stability of fixation by checking any potential external rotation when the arm was slightly turned externally and left to the gravity forces. We were ready to add distal screws, but that was not required in these cases. Follow-up assessment included fracture union, complications and failures, and the final clinical outcome at minimum 2-year follow-up using the parameters of the constant score.

Results:

All fractures, except two, united between the 4^th and 5^th postoperative month. In one case, nail was exchanged with plate, and, in another, a larger nail was used at a second surgery. Shoulder function according to constant score, at a minimum of 2-year follow-up, was excellent or very good in 93.7% of the patients.

Conclusions:

Provided that some technical issues are followed, the method reduces intraoperative time and radiation exposure and avoids potential damage to neurovascular structures.     

Proximal humeral fractures in geriatric patients. Is the angle-stable plate osteosynthesis really a breakthrough?

This is a retrospective study of the results of angle-stable plating of displaced 3- or 4- part fractures of the proximal humerus in 92 geriatric patients treated between 2/2000 and 2/2004. At final follow-up patients were clinically evaluated using the Constant-Murley score and were examined radiologically. The mean non-age-related Constant-Murley score was 69.8 points. A clear correlation was found between the final score and the quality of reposition of the tuberosities and/or plate position. Accurate reduction and plate positioning led to a significantly better functional result. For 28 patients (30.4%), sinkage of the humeral head into the shaft occurred despite angle-stable anchoring. The currently celebrated angle-stabilising plates did not lead to a significant improvement in functional outcome, compared with other established osteosynthesis procedures.     

Are proximal screws necessary for osteosynthesis of stable-stem periprosthetic femoral fractures fixed with non-locking plate and cable?

IntroductionThe purpose of this study was to assess the effectiveness of the cable-plate-cable technique which comprises fixation of the proximal fragment using cable loops without additional proximal screws on the plate for the treatment of stable-stem periprosthetic femoral fractures around hip prostheses.MethodsWe retrospectively reviewed Vancouver types B1 and C periprosthetic femoral fractures treated with a dynamic compression plate combined with Dall-Miles cable between 2010 and 2016 at a single institution and followed for at least 12 months. Patients were treated with proximal fragment fixation using cable combined with screws (Group I) or with proximal fragment fixation using cable alone (Group II). Demographic data, fracture types, and clinical and radiological outcomes were analyzed.ResultsA total of 50 patients were included (Group I, n = 23 patients; Group II, n = 27). Fracture union was achieved in 49 patients with one case of non-union in Group I and no cases of non-union in Group II. Mean time to union was 5.4 months in Group I and 5.1 months in Group II (P = 0.624). Mean Harris hip score at latest assessment was 69.5 in Group I and 69.4 in Group II (P = 0.919). Regarding complications, there was one deep wound infection, one stem subsidence, and one loss of reduction in Group I, and one stem subsidence in Group II. No significant difference in clinical and radiological outcomes between groups was observed.ConclusionsThe cable-plate-cable technique sufficiently treats Vancouver types B1 and C periprosthetic femoral fractures without use of additional screws in the proximal fragment.     

Is posterior leaflet preservation in the surgical treatment of rheumatic mitral insufficiency without left ventricular dysfunction necessary?

Preservation of the mitral valve leaflet and tensor apparatus during valve replacement is believed to maintain left ventricular performance. To determine the effect of posterior leaflet preservation in pure severe mitral insufficiency without left ventricular dysfunction 56 patients were operated on between 1993 and 2000. Twenty-three patients underwent mitral valve replacement with posterior chordal preservation and 33 patients underwent mitral valve replacement with chordal transection. Preoperative data in the both groups were similar. After 30days there were no mortalities observed. Dimensions of the left ventricle had significantly decreased within one group, but there was no difference in the other group. The improvement of the functional and cardiac performance in all patients was significant without any difference between the two groups. Actuarial freedom from death was not significantly different at 6yr (P=0.23). To preserve left ventricular function in pure severe mitral regurgitation without left ventricular dysfunction, mitral valve replacement is very effective with or without posterior leaflet preservation. But, it is difficult to suggest that posterior leaflet preservation alone can increase cardiac performance.     

The epidemic of ankle fractures in the elderly – is surgical treatment warranted?

Ankle fractures in the elderly are extremely common (up to 184 fractures per 100,000 persons per year, and of these approximately 20%–30% occur in the elderly). The medical literature contains no research that has investigated ankle fractures in the elderly. A prospective, randomised study was conducted of 84 patients with displaced ankle fractures, who were over the age of 65 years and were assigned to operative or conservative treatment after closed reduction. The results of treatment assessed according to the American Orthopedic Foot and Ankle Society (AOFAS) Score showed a mean of 91.37 ± 8.96 in the non-operated group compared with 75.2 ± 14.38 (P = 0.001) in the operated group. The costs of treatment were accordingly higher. These results call for consideration of a non-operative approach to the treatment of well-reduced ankle fractures in the elderly. Increased efforts should be invested in the prevention of these common fractures.

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Received: 29 November 1999     

Is multichannel urodynamic assessment necessary before considering a surgical treatment of BPH? Pros and cons

Purpose

Lower urinary tract symptoms (LUTS) are common in middle-aged men and could be consequences of multiple etiologies responsible for bladder outlet obstruction (BOO), detrusor underactivity (DUA) and/or overactive bladder. When LUTS are suggestive of BOO secondary to benign prostatic hyperplasia, a surgical treatment can sometimes be consider. Even if multichannel urodynamic study (UDS) is currently the gold standard to properly assess LUTS, its use in non-neurogenic men is still a matter of controversy. Here, we aim to explore the evidence supporting or not the use of systematic multichannel UDS before considering an invasive treatment in men LUTS.

Methods

The debate was presented with a “pro and con” structure. The “pro” side supported the systematic use of a multichannel UDS before considering a surgical treatment in men LUTS. The “con” side successively refuted the “pro” side arguments.

Results

The “pro” side mainly based their argumentation on the poor correlation of LUTS and office-based tests with BOO or DUA. Furthermore, since a multichannel UDS could allow selecting men that will most benefit of a surgical procedure, they hypothesized that such an approach could reduce the overall morbidity rate and cost associated with. The “con” side considered that, in most cases, medical history and symptoms were reliable enough to consider surgery. Finally, they underlined the UDS limitations and the frequent lack of alternative to surgery in this context.

Conclusions

Randomized clinical trials are being conducted to compare these two approaches. Their results would help the urological community to override this debate.

     

Failure after osteosynthesis of trochanteric fractures. Where is the limit of osteoporosis?

Summary

The aim of this study is to identify osteoporosis values, beyond which there is a high risk of osteosynthesis failure. Bone mineral density (BMD) of 30 cadaveric femora with a pertrochanteric fracture osteotomy was correlated to the risk of cut out after osteosynthesis on a biomechanical testing approach. For a BMD less than 250 mg/cm³, there is a high risk of fixation failure after surgical treatment of pertrochanteric fractures. This value can be regarded as a reference value for future experimental and clinical studies.

Introduction

Despite continuous modification of intramedullary load carriers for the surgical stabilization of trochanteric fractures, cut out remains the most frequent complication. The aim of this experimental study was to identify threshold osteoporosis values, beyond which there is a high risk of osteosynthesis failure.

Methods

Bone mineral density (BMD) of 30 cadaveric femora was recorded for the femoral head by QCT measurement. Subsequently, a standardized osteotomy mimicking an unstable trochanteric type fracture was stabilized by intramedullary nailing. The constructs were loaded axially at a force of 2,100 N up to 20,000 cycles. Cut out at the femoral head was documented by radiograph. Statistical evaluation of the cohort group was performed by calculation of relative risk in relation to the BMD values.

Results

In total, there were six cases of cut out after 10,000 cycles. The incidence of cut out for BMD less than 250 mg/cm³ was 0.55 (5 of 9) and for BMD greater than 250 mg/cm³, it was 0.05 (1 of 21). Therefore, the relative risk of cut out for BMD <250 mg/cm³ is 11× greater than for a BMD >250 mg/cm³. After 20,000 cycles, an additional test caused one cut out (relative risk of cut out for a BMD <250 mg/cm³ 5.8).

Conclusions

For a BMD less than 250 mg/cm³, there is a high risk of fixation failure after surgical treatment of pertrochanteric fractures. Although this value is based on an experimental in vitro study design with all its associated limitations, it can be regarded as a reference value for future experimental and clinical studies.     

Long-term results of dorsally displaced distal radius fractures treated with the pi-plate: is hardware removal necessary?

The purpose of this study was to evaluate the outcome of patients treated with open reduction and internal fixation (ORIF) using dorsal plates and screws (AO/ASIF pi-plate) for dorsally displaced fractures of the distal radius. Although extensor tendon rupture is a recognized complication of all distal radial fractures, there appears to be an increased risk of this using dorsal plating. In addition, there is the added complication of extensor tendon irritation and dorsal wrist pain, which may necessitate plate removal. The low-profile pi-plates intended to overcome this problem have not done so, with quoted rates ranged from 19% to 55%.We treated 32 completely evaluated patients (13 men and 19 women) in our department between 2000 and 2004, with an average age of 46 years. They underwent ORIF of dorsally displaced fractures of the distal radius using the specially designed pi-plate. Bone graft was used in 18 patients who had significant metaphyseal defect. Clinical examination, plain radiographs, and functional assessments using the modified Mayo Wrist Score were performed at an average follow-up of 86 months (range, 56-115 months). Satisfactory reduction was achieved in all 32 fractures at the time of operative fixation with no instances of loss of fracture reduction during the study period. According to the Mayo Wrist Score, 23 patients (72%) had excellent or very good results, 7 (22%) had fair results, and 2 (6%) had poor results. Two cases (6.25%) of extensor tendon rupture were noted during the first postoperative month, and 2 other patients showed progressive weakness of index finger extension 6 months postoperatively. The remaining 28 patients had no soft tissue problems.