Femoral neck non-unions: how do I do it?

Femoral head necrosis and non-union are frequent complications after femoral neck fracture. The main reason for failure leading to non-union is an inadequate osteosynthesis and/or poor mechanical conditions, leading to instability. Criteria for optima reduction and fixation techniques, which can prevent non-union in the majority of cases, are described. This knowledge is mandatory for each surgeon as in the non-expert situation up to 30% inadequacy of the "simple" procedure occurs! Although in the elderly endoprosthetic replacement is the treatment of first choice, in the younger and active patients the treatment should be directed towards salvage of the own hip. In non-complex cases a valgisation osteotomy according to Pauwels will lead to very good results. The technique of this secondary procedure is demonstrated by a case report. In case of combined pathology with (complete) a vascular necrosis of the femoral head, the age threshold for endoprosthetic replacement will be far lower nowadays, but even in those cases, especially below the age of 50, salvage procedures with free fibular grafting lead to a good outcome and form a useful alternative.     

Laparoscopic antireflux surgery: how I do it?

Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the US, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) are effective in the majority of patients. However, some patients will become candidates for surgical intervention, because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI. In these patients, a properly executed laparoscopic antireflux surgery controls esophageal and extra-esophageal symptoms and avoids life-long medical therapy. Important technical elements should be taken into account during the operation to avoid troublesome side effects and obtain optimal postoperative outcomes.     

I think I have a good idea: what do I do with it?

The orthopaedic device industry is an ever changing market, often guided by creative surgeons who have the common goal of creating a solution to a problem. While being a surgeon-inventor can be both a challenging and rewarding process, there are several steps that the individual must follow to create intellectual property. This article serves as a guide to the novice surgeon-inventor; intended to be used as an early stage reference for those interested in taking their "solution to a problem" to the device industry.     

When does obstetric coagulopathy occur and how do I manage it?

Anticipating obstetric coagulopathy is important when obstetric anaesthetists are involved in the clinical management of women with postpartum haemorrhage. Although the incidence of coagulopathy in women with postpartum haemorrhage is low, significant hypofibrinogenaemia is associated with major haemorrhage-related morbidity and thus early identification and treatment is essential to improve outcomes. Point-of-care viscoelastic haemostatic assays, including thromboelastography and rotational thromboelastometry, provide granular information about alterations in clot formation and hypofibrinogenaemia, allow near-patient interpretation of coagulopathy, and can guide goal-directed treatment. If these assays are not available, anaesthetists should closely monitor the maternal coagulation profile with standard laboratory testing during the active phase of postpartum bleeding in order to rule coagulopathy ‘in or out’, decide if pro-haemostatic therapies are indicated, and assess the response to haemostatic support.     

Hallux rigidus: How do I approach it?

Hallux rigidus is a degenerative disease of the first metatarsalphalangeal(MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1~(st) MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intraarticular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing vs joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthroplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient's goal and expectations, and surgeon's experience with the technique.     

Video-assisted thoracic surgery (VATS) for primary spontaneous pneumothorax: how I do it ?

The precise management of primary spontaneous pneumothorax remains controversial due to the lack of large prospective randomized trials. This not only regards the indications for conservative or invasive treatment but also the precise technique for air evacuation and recurrence prevention. The technique of video-assisted thoracic surgery is described as it is performed in our centre for the treatment of primary spontaneous pneumothorax.     

Appendix mass: do we know how to treat it?

INTRODUCTION: The traditional management of appendiceal mass has been an initial conservative approach followed by interval appendicectomy. More recently, the necessity of interval appendicectomy has been questioned by a growing amount of evidence in the surgical literature. The aim of this study was to review the available scientific evidence and to determine how appendiceal masses are currently being managed in the Mid-Trent region by general surgeons. PATIENTS & METHODS: A literature search using Medline, Embase, Cinahl, HMIC and Biosis was carried out. A personal or telephonic survey of all consultants and specialist registrars working in general surgery in the Mid-Trent region (n = 67) was conducted recording their management protocol of 3 different clinical scenarios--a 14-year-old boy, a 29-year-old female and a 68-year-old male. Responses of the questionnaire were entered to a database in Microsoft Access 2000 and analysed. RESULTS: The results showed that there was difference of opinion on the management of appendix mass in either scenario. Appendectomy (interval or emergency) is still practised by 75% of general surgeons in the Mid-Trent region and less that 25% manage asymptomatic appendix mass without interval appendectomy. Additionally, specialist registrars appear more likely not to offer patients interval appendicectomy after successful conservative management (P < 0.05). CONCLUSIONS: At present, there is no agreed consensus on the management of appendiceal mass. There is a need to develop a protocol for the management of this common problem.     

Surgical techniques: how I do it? Mini open reduction and fixation of calcaneal fractures with fine wire circular frames

Patients with calcaneal fractures associated with significant soft tissue swelling or open wounds are not ideal candidates for extensive incisions and open reductions with internal fixation. Fine wire frame external fixateurs are being used for the treatment of displaced intraarticular fractures of the calcaneus with soft tissue compromise or in patients with moderately displaced fractures. In this paper, we present our surgical technique of treating displaced intraarticular calcaneal fractures with circular frame external fixateurs.     

Transfacet screw fixation of the subaxial cervical spine—how I do it?

Background

Transfacet screw fixation is a biomechanically effective way of fusing the subaxial cervical spine. The technique used by this author is described.

Methods

With the patient in prone position, a conventional posterior exposure of the cervical spine is done. The entry point used by this author is 2 mm above the middle of the lateral mass without any lateral angulation. Under fluoroscopic guidance the facet is drilled until all the four cortical surfaces are purchased. Then the depth is measured to assess the length of the screw required. This is followed by tapping and screw insertion both of which are done under fluoroscopic control. All screws are placed prior to laminectomy to decompress the cervical cord.

Conclusions

This is a simple, inexpensive and biomechanically effective way of stabilizing the subaxial cervical spine.     

Young patients with colorectal cancer: how do they fare?

Background: Younger patients with colorectal cancer (CRC) have long been thought to have a poorer prognosis than older patients. Recent overseas reports, however, have disputed this. The aim of the present study was to conduct a review of data on patients with colorectal cancer collected over a 29‐year period at Princess Alexandra Hospital (PAH) to ascertain the outcome of a younger subset of patients at this hospital. Methods: The PAH Colorectal Project records on 2495 patients with malignancies of the colon, rectum and anus who were treated and followed since 1971, were analysed to determine clinical presentation, treatment and outcome. A group of 61 patients with colo­rectal adenocarcinoma was identified who were aged less than 40 years at presentation. Their clinical data were then compared with the larger group of older patients. Results: There were 30 male and 31 female patients in the younger group. A positive family history was the most consistent risk factor, present in 34% of patients. Despite this, only one patient out of 61 had been diagnosed as a result of a screening programme. The Australian Clinico‐Pathological Stage (ACPS), histology and distribution of tumours corresponded to that of the older patients. The overall 5‐year survival among younger patients was 53%. The 5‐year survival rates in younger patients were better than that for older patients for ACPS A and B, reaching statistical significance for both of these stages. Conclusions: Our results indicate that younger patients with colorectal cancer have the potential to do just as well as older ones. With the influence of a family history of colorectal cancer being very apparent in this group, greater emphasis should be placed on an adequate screening programme for them.     

Surgical techniques: how I do it? The Reamer/Irrigator/Aspirator (RIA) System

Although reamed intramedullary nailing has long been considered a safe procedure, pulmonary complications have been reported in some groups of patients. Concerns over fat embolisation, adult respiratory distress syndrome (ARDS), and sudden intraoperative death have prompted some authors to question whether the benefits of reaming are outweighed by its potential adverse effects to the patient.In response to these complications, recent evaluations have focused on alternative systems that reduce intramedullary pressure during reaming. The Reamer/Irrigator/Aspirator (RIA) system (Synthes, Inc., West Chester, PA) was developed as a simultaneous reaming and aspiration system to reduce the intramedullary pressure, heat generation, operating time, and systemic effects of reaming. It was designed with an aggressive one-pass reamer head which is connected to a hand-held reamer via a drive shaft, simultaneously irrigating and aspirating femoral canal contents during reaming, thus preventing thermal necrosis and fat embolisation. After its early use, investigators examined the “aspirate” captured by the RIA which appeared to be loaded with osteogenic substrates. This discovery revealed a second potential use for the RIA-a bone graft harvester.The different design characteristics and technicalities of the RIA system necessitate a deep and clear understanding of its technique, a meticulous preoperative planning and a strict adherence to its principles intraoperatively. We present our current approach to the use of the RIA system, including the preoperative planning, the details of the operative procedure, the pitfalls and the potential complications that could be encountered.     

Prosthetic material in inguinal hernia repair: how do I choose?

With numerous prosthetic options and a changing landscape of prosthetic development, a systematic approach to choosing a prosthetic is more sensible than trying to memorize all the details of each prosthetic. The surgeon should hone a single technique for the vast majority of inguinal hernia repairs to maximize proficiency. This limits the number of prosthetics to those suitable for that technique. Narrowing the choice further should be based on the likelihood that a given prosthetic will achieve the preoperative goals of the hernia repair. For alternative clinical scenarios, the surgeon should know one to two additional techniques, which may require a different prosthetic. The surgeon should use existing experimental and clinical data to estimate long-term benefits of any new prosthetic.     

Prosthetic material in ventral hernia repair: how do I choose?

Several factors must be considered in deciding which mesh to use for a ventral hernia repair. Open hernia repairs with no exposure of mesh to viscera can be performed with unprotected synthetic mesh, preferably a "lightweight" option. For open repair with high risk for fascial dehiscence and visceral exposure to mesh, and for open underlay repair and laparoscopic underlay repair, recommendations call for a tissue-separating mesh that prevents ingrowth of intra-abdominal contents into the mesh. Although no long-term data are available about biologic (acellular collagen scaffold) meshes, these may have good results when used in contaminated or well-drained infected fields, and do best when used according to the principles of a high-quality synthetic mesh repair (wide mesh overlap, frequent fixation points). Evidence is still insufficient to support the use of biologic materials for primary hernia repair.