Radiological findings and outcomes of anterior wall fractures in pertrochanteric fractures

BackgroundAnterior wall fractures with comminution at the anterior cortex in pertrochanteric fractures are relatively rare. We aimed to investigate the prevalence and clinical findings of anterior wall fractures in this comparative cohort study.MethodsWe reviewed 516 consecutive patients who underwent internal fixation. Anterior wall fractures were classified into three types: proximal, distal, and proximal/distal. Outcome measures included demographic data, residual anterior cortex length, fracture reduction, tip-apex distance (TAD), sliding distance, bone union, and revision surgery. We compared radiological outcomes between patients with anterior wall fractures and posterior comminuted fractures without an anterior wall fracture. The groups were matched for age and sex.ResultsAnterior wall fractures were noted in 44 patients (8.5%). Residual anterior cortex length was shorter for the proximal/distal type. The distal type was the most common, was the most difficult to achieve an acceptable reduction status for, and was associated with the longest sliding distance. The proportion of unacceptable reduction status was higher for anterior wall fractures. However, there were no statistically significant differences between anterior wall fractures and posterior comminuted fractures without an anterior wall fracture in terms of TAD, sliding distance, bone union, and revision rate.ConclusionsThis study suggests that anterior wall fracture is not a significant predictor of over-sliding distance.     

Attitudes of pain and opioids prescription practices in U.S. cystic fibrosis centers

BackgroundThe high incidence and prevalence of chronic pain in patients with cystic fibrosis (CF) is well documented. However, there is limited data on chronic pain management in this population.MethodsWe designed a questionnaire examining care team members’ views on the prevalence and characteristics of pain, pain management, and opioid use. The questionnaire was distributed to accredited programs throughout the US via a CF Foundation (CFF) email list-serve.ResultsResponses came from 52 adult core or affiliated centers (Adult Responders – AR), 36 pediatric core or affiliated centers (Pediatric Responders – PR), and 9 were from combined programs. AR perceive more patients having chronic pain compared to PR. Furthermore, 40% of the AR said that > 50% of those with chronic pain also have comorbid depression or anxiety. 61% of PR ranked sinus/headache symptoms as the most common while AR ranked chest wall as the most frequent site (58%). While most centers (83%) report that pain management in patients with CF is a very important or important issue, 50% of AR feel uncomfortable or only slightly comfortable in prescribing opioids. 44% report that CF providers are currently responsible for this task.ConclusionsChronic pain is common in adult patients with CF and management presents a formidable challenge to providers. The development of guidelines and/or collaboration with pain specialists will likely benefit both patients and providers.     

Axial flap for giant basal cell carcinoma of the anterior chest wall: Case report

Introduction and importanceAnterior chest wall Giant Basal Cell Carcinoma (GBCC) is rare amongst GBCC cases and results in a large defect that is challenging to resect and reconstruct. It requires multidisciplinary approach to prevent recurrence.Case presentationA 72-year-old man with giant basal cell carcinoma at the anterior chest wall measuring 10 × 6 cm. Wide resection of 1 cm margin with axial flap was performed to close the defect. The follow-up report stated that the patient was satisfied with the result and there was no recurrence observed.Clinical discussionReview of literatures concludes that GBCC is excised with a minimum of 4-6 mm margin outside the tumor area. The axial IMAP flap is ideal to close the upper chest wall defect because of the better aesthetic outcome compared to other conventional flaps, especially in stable elderly male, patients with noninfected wound. Increased skin laxity and more relaxed skin tension associated with aging allows easier tissue mobilization and transfer to close the defect.ConclusionAxial flap for GBCC in anterior chest wall is ideal, safe, and has the advantage of aesthetic reasons of suitable skin tone, particularly for stable elderly male patients.     

Anterior knee pain in runners after a half-marathon race

BackgroundAnterior knee pain has been associated with sports activity, especially long-distance running and endurance sports. It is important to determine the incidence of anterior knee pain (AKP) in runners after a half-marathon race and identify possible risk factors associated.MethodsCross-sectional study where runners from a half marathon race were randomly invited to participate. Participants were recruited at the race kit pickup site the day before the race. Eligible participants completed a survey regarding demographic information, running experience and training details. An orthopedic surgeon performed a physical examination and recorded the medical history. At the finish line, the participants were evaluated again for possible new injuries.ResultsA total of 205 runners were included in the study, with a 98.5% follow-up rate (n = 203). 24% of runners had an injury at the end of the race (n = 49). Anterior knee pain was the most frequent injury (n = 12), followed by iliotibial band syndrome (n = 10), muscle cramps (n = 7) and hamstring tears (n = 4). Anterior knee pain had a statistically significant association with insufficient stretching of the hamstrings (p = 0.048) and finishing the race in more than 2 h (p = 0.014).ConclusionsAnterior knee pain was the most frequent new injury in the half-marathon runners after the competition. Spending more than 2 h to finish the race and stretching the hamstrings by less than 70° in the supine position were risk factors for anterior knee pain.     

Anterior Knee Pain Following Primary Unilateral Total Knee Arthroplasty With Posterior-Stabilized Prosthesis and Patellar Resurfacing: Prevalence and Clinical Implications

BackgroundAnterior knee pain following total knee arthroplasty (TKA) is associated with patient dissatisfaction. Factors related to postoperative anterior knee pain and its impact on patient outcomes are poorly understood. The following are the aims of this study: (1) to report the prevalence of anterior knee pain before and after TKA using a posterior-stabilized prosthesis with routine patellar resurfacing; (2) to investigate the association of preoperative clinical factors with the presence of anterior knee pain after TKA; and (3) to explore the association of postoperative anterior knee pain with postoperative self-reported function and quality of life.MethodsThis retrospective study included 506 patients who had undergone elective primary unilateral TKA with a posterior-stabilized prosthesis and patellar resurfacing. Outcome measures prior to and 12 months after TKA included self-reported anterior knee pain, knee function, and quality of life.ResultsPrevalence of anterior knee pain was 72% prior to and 15% following TKA. Patients who had preoperative anterior knee pain had twice the risk of experiencing anterior knee pain after TKA than patients who did not have preoperative anterior knee pain (risk ratio: 2.37, 95% CI 1.73-2.96). Greater severity of preoperative anterior knee pain and worse self-reported function were associated with the presence of postoperative anterior knee pain (rho = 0.15, P < .01; rho = 0.13, P < .01, respectively). Preoperative age, gender, and quality of life were not associated with postoperative anterior knee pain. Greater severity of postoperative anterior knee pain was associated with worse knee function at 12 months postoperative (rho = 0.49, P < .01).ConclusionOne in 7 patients reported anterior knee pain 12 months following posterior-stabilized and patella-resurfaced TKA. The presence of preoperative anterior knee pain and worse self-reported function are associated with postoperative anterior knee pain.     

Correlation between spinal and pelvic movements during gait and aggravation of low back pain by gait loading in lumbar spinal stenosis patients

BackgroundLumbar alignment of posterior or anterior tilts affects the exacerbation and remission of symptoms of lumbar spinal stenosis patients. This study aimed to clarify the correlation between spinal and pelvic movements during gait and the aggravation of low back pain after gait loading in lumbar spinal stenosis patients.MethodsA total of 29 patients with lumbar spinal stenosis completed leg and low back pain assessments and gait analysis before and after gait loading tests. Patients were divided into leg and low back pain change (n = 8), leg pain only change (n = 12), and non-change (n = 9) groups based on the differences of leg and low back pain between before and after the tests. Peak kinematic values of the anterior tilts of the trunk, thoracic spine, lumbar spine, and pelvis during the stance phase were obtained via three-dimensional gait analysis.ResultsIn the leg and low back pain change group, the anterior lumbar and pelvic tilts were larger after than before the tests; however, in the leg pain only change and non-change groups, only the anterior lumbar tilt was larger after than before the tests. Anterior lumbar tilt before and after the tests negatively correlated with the aggravation of low back pain, and an increase in the anterior pelvic tilt positively correlated with the aggravation of low back pain.ConclusionsIn lumbar spinal stenosis patients, smaller anterior lumbar tilt and larger anterior pelvic tilt during gait loading may affect the aggravation of low back pain by gait loading. Increasing in lumbar lordosis during gait might be one of the factors leading to low back pain in lumbar spinal stenosis patients.     

Artrite enteropática no Brasil: dados do registro brasileiro de espondiloartrites

Inflammatory bowel diseases (Crohn's disease and ulcerative rectocolitis) have extraint- estinal manifestations 25% of the patients, with the most common one being the entero- pathic arthritis.MethodsProspective, observational, multicenter study with patients from 29 reference cen- ters participating in the Brazilian Registry of Spondyloarthritis (RBE), which incorporates the RESPONDIA (Ibero-American Registry of Spondyloarthritis) group. Demographic and clinical data were collected from 1472 patients and standardized questionnaires for the as- sessment of axial mobility, quality of life, enthesitic involvement, disease activity and func- tional capacity were applied. Laboratory and radiographic examinations were performed. The aim of this study is to compare the clinical, epidemiological, genetic, imaging, treat- ment and prognosis characteristics of patients with enteropathic arthritis with other types of spondyloarthritis in a large Brazilian cohort.ResultsA total of 3.2% of patients were classified as having enteroarthritis, 2.5% had spon- dylitis and 0.7%, arthritis (peripheral predominance). The subgroup of individuals with en- teroarthritis had a higher prevalence in women (P < 0.001), lower incidence of inflammatory axial pain (P < 0.001) and enthesitis (P = 0.004). HLA-B27 was less frequent in the group with enteroarthritis (P = 0.001), even when considering only those with the pure axial form. There was a lower prevalence of radiographic sacroiliitis (P = 0.009) and lower radiographic score (BASRI) (P = 0.006) when compared to patients with other types of spondyloarthritis. They also used more corticosteroids (P < 0.001) and sulfasalazine (P < 0.001) and less non-steroidal anti-inflammatory drugs (P < 0.001) and methotrexate (P = 0.001).ConclusionThere were differences between patients with enteroarthritis and other types of spondyloarthritis, especially higher prevalence of females, lower frequency of HLA-B27, associated with less severe axial involvement.     

Management of a ruptured hydatid cyst involving the ribs: Dealing with a challenging case and review of the literature

IntroductionHydatid liver cysts can rupture into neighboring structures in 15–60% of patients, and most often involves the bile duct, the bronchi, and the peritoneal/pleural cavities. Rarely, chest or abdominal wall involvement occurs that are challenging to manage. This case report and literature review describes the management of patients with chest wall and rib invasion.Presentation of caseA 74-year-old woman, of Spanish origin, presented with right upper quadrant abdominal pain and tender localized swelling. On computer tomography (CT) assessment, the rupture of a hydatid cyst into the right anterior chest wall was identified. Partial involvement of the 10th and 11th rib were noted. The diagnosis was confirmed by a serological test. Surgical treatment involved a radical en bloc right hepatic resection together with resection of the involved ribs, diaphragm and subcutaneous tissue. Primary diaphragm and wall closures were performed. The postoperative course was uneventful with three weeks of albendazole treatment. CT follow-up at six months demonstrated the absence of recurrence.DiscussionComplete resection is the gold standard treatment of patients with hydatid cysts with the aim to remove all parasitic and pericystic tissues.ConclusionThe present report illustrates that an aggressive surgical en bloc resection is feasible and should be preferred for the treatment of hydatid cysts with rupture into the chest wall, even when the ribs are involved.     

Chest pain in patients recovering from noncardiac surgery: A retrospective analysis

Study objectiveChest pain is relatively common postoperatively. Myocardial infarction (MI) is one cause of chest pain after surgery, but chest pain also results from less severe conditions. Because of its potential severity, chest pain usually prompts the activation of Rapid Response Systems (RRS). While chest pain is a cardinal symptom of myocardial ischemia in the non-surgical setting, the significance and relevance of chest pain after noncardiac surgery remains unclear.DesignWe conducted a retrospective analysis of noncardiac surgical inpatients for whom postoperative chest pain triggered our multidisciplinary RRS.SettingSurgical wards at Cleveland Clinic, Cleveland, OH.PatientsPostsurgical patients after noncardiac surgery in whom the RSS system was activated for chest pain.InterventionsRRS specified interventions like ECG readings, troponin measurements, transfer to ICU.MeasurementsOur primary outcome was MI. Secondary outcomes included the proportion of patients who had an ECG performed, troponin measurements, echocardiography, cardiac catheterization, and were admitted to the Intensive Care Unit (ICU).Main results5850 surgical patients experienced postoperative chest pain and triggered an RRS activation between 2009 and 2019. A total of 3110 patients had troponin T measured within 6 h after RRS activation, and 538 of them (17%) had elevated troponin, meeting the Fourth Universal Definition criteria for MI. Additionally, 2 patients had ST-segment elevation infarction (STEMI) without troponin measurement. Among the 540 patients with MI, only 19 (3.5%) were diagnosed with a STEMI by ECG, 388 (72%) had echocardiography, 43 patients (8%) had cardiac catheterization, 8 patients (1.5%) required emergent cardiac surgery, and 424 (79%) were admitted to an ICU.ConclusionChest pain is a serious clinical sign, often indicating a postoperative myocardial infarction, and therefore should be taken seriously. Troponin screening should be routinely considered in postsurgical patients who report chest pain.     

Evidence in orthopaedics: patellar resurfacing in total knee arthroplasty

Abstract Four good quality randomized clinical trials comparing patellar resurfacing versus noresurfacing in knee arthroplasty are analyzed. The outcomes evaluated were anterior knee pain, scores on the Knee Societys rating system and reoperation.No relevant differences were found in knee scores, but anterior knee pain was less frequent in patients with patellar resurfacing. Few patients had severe anterior knee pain. Still, patients with anterior knee pain were less satisfied with the clinical result. Studies with longer follow-up showed that anterior knee pain increased with time in both groups. A clinically relevant increase in reoperation rate in the nonresurfaced group could not be excluded with the numbers available.Anterior knee pain seems to be influenced by the decision of resurfacing the patella during knee arthoplasty. Although it is not associated with important changes in knee scores, patients perceive it as a cause of insatisfaction. Influence of patellar resurfacing on implant supervivence is not clear.     

Ultrasonographic Involvement of the anterior chest wall in Spondyloarthritis: Factors associated with 5-years structural progression. A prospective study in 58 patients

IntroductionTo evaluate, factors associated with new ultrasonographic lesions of the anterior chest wall in spondyloarthritis (SpA) after a follow up of 5 years.MethodsSpA Patients included in 2013 in a first study were evaluated five years later. Ultrasound B mode and power Doppler examination of the two sternoclavicular joints and the manubrio-sternal joint were performed by the same two examinators at baseline and five years later. The presence of erosion, synovitis, ankylosis, power Doppler signal, joint effusion and joint space narrowing were assessed blind of the first evaluation.ResultsAmong the 131 patients at baseline, 58 patients were evaluated 5 years later. The mean age was 48.2 ± 11.9 years old, with 86% of male and mainly an axial disease (78%). Patient characteristics are comparable to the original cohort. The most frequent lesions were ankylosis of the manubriosternal joint (38%) and erosions of the sternoclavicular joint (29%). 31 patients (53%) developed a new lesion of the ACW. There is a statistically significant association between new lesions of the ACW and higher ASDAS CRP (1,86 ± 1,07 VS 3,0 ± 2,17 P < 0,01) and with CRP (5,34 ± 7,85 VS 16,2 ± 35, P = 0,035) in the moment of the examination. There was no baseline factor associated with the structural progression.ConclusionThe occurrence of new lesions of the anterior chest wall is associated with a higher disease activity and a higher CRP at 5 years.     

Efficacy of anti-TNF in patients with spondyloarthritis in absence of any imaging sign

ObjectiveSome clinical pictures satisfy spondyloarthritis criteria without any detected imaging signs and the question sometimes arises in clinical daily practice if biologics should be started. Our aim was to evaluate anti-TNF efficacy in patients with clinical but not imaging (radiographic, CT-scan, MRI) signs of spondyloarthritis.MethodsThis retrospective study concerned patients with axial spondyloarthritis fulfilling European Spondyloarthritis Study Group (ESSG) criteria, treated with anti-TNF after failure of conventional therapies. Therapeutic responses, rated according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)-50% or 20 mm and ASAS-20 or -40 definitions, were evaluated after 12 months. Factors associated with those responses were also sought. Propensity score was used to check thereafter whether there were interactions with some baseline variables.ResultsAmong 385 patients included, 257 with imaging signs had significantly more frequent therapeutic responses (P = 0.0005). About 40% of the spondyloarthritis patients without imaging signs responded to anti-TNF. The response rate was significantly higher in HLA-B27 carriers with initial imaging signs (P = 0.028). Furthermore, responders were younger at biotherapy onset, with lower Bath Ankylosing Spondylitis Functional Index (BASFI) and pain visual analog scale score, and higher C-reactive protein (CRP), compared to non-responders. After weighted calculation, the prediction of response to TNF-blockers was quite similar in both groups.ConclusionThe percentage of patients with exclusively clinical signs who responded to anti-TNF was far from negligible. Regardless the HLA-B27 status, having imaging signs of spondyloarthritis does not provide a superiority of response to anti-TNF compared to the absence of imaging sign. The absence of any imaging sign in patients with spondyloarthritis should therefore not lead to the exclusion of anti-TNF therapy.     

Anterior decompression for far-out syndrome below a transitional vertebra: a report of two cases

Background contextImpingement of the L5 nerve between the transverse process of L5 and the ala of sacrum has been described as the far-out syndrome. Posterior decompression is often performed for this pathology.PurposeTo describe rare cases of far-out syndrome below a transitional vertebra who underwent anterior decompression.Study design/settingA case report and a review of the literature.MethodsReview of the hospital medical record, history, physical examination, and imaging studies.ResultsA 70-year-old woman and a 53-year-old man presented with prolonged and progressive leg pain and/or low back pain. Both of the patients showed muscle weakness and sensory disturbance at L5 level and lumbosacral transitional vertebra on the plain radiography. Magnetic resonance imaging showed huge osteophytes, and there was severe impingement of the L5 nerve at the anterior exit zone of the foramen. Anterior decompression was performed for both cases using a Fraser incision and resulted in successful resolution of the symptom and neurological status.ConclusionIn the extraforaminal stenosis of the L5 nerve with far-out syndrome below the transitional vertebra, entrapment occurs more anterior of exit zone of the L5 nerve foramen than in the other pathologies; anterior decompression brings in more complete decompression.     

Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior laminoplasty

Background contextMultilevel cervical myelopathy can be treated with anterior cervical discectomy and fusion (ACDF) or corpectomy via the anterior approach and laminoplasty via the posterior approach. Till date, there is no proven superior approach.PurposeTo elucidate any potential advantage of one approach over the other with regard to clinical midterm outcomes in this study.Study designA prospective, 2-year follow-up of patients with cervical myelopathy treated with multilevel anterior cervical decompression fusion and plating and posterior laminoplasty.Patient sampleIn total, 116 patients were studied. Sixty-four patients underwent ACDF two levels and above or anterior cervical corpectomy and fusion one level and above. Fifty-two patients underwent posterior cervical surgery (laminoplasty C3–C6 and C3–C7).Outcome measuresSelf-report measures: Japan Orthopedic Association (JOA) score, JOA recovery rate, visual analog scale for neck pain (VASNP), neck disability index (NDI), and American Academy of Orthopaedic Surgeons (AAOS) neurogenic symptom score (AAOS-NSS). Physiologic measures: range of motion (ROM) flexion and extension of neck. Functional measures: short-form 36 (SF-36) score comprising physical functioning, physical role function, bodily pain, general health, vitality, social role function, emotional role function, and mental health scales.MethodsComparison of the JOA scores, JOA recovery rates, NDI scores, SF-36 scores, VASNP, and ROM preoperatively to 2 years. Chi-square and two-sided Student t tests were used to analyze the variables.ResultsPosterior surgery took an hour shorter (p<.05) and had better improvement in JOA scores at early follow-up of 6 months (p=.025). Anterior surgery group had better improvement of NDI scores at early follow-up of 6 months (p=.024) and was associated with less blood loss intraoperatively compared with posterior surgery. There was no statistical difference between the two groups for JOA scores, JOA recovery rates, SF-36 quality-of-life scores, NDI, AAOS-NSS, VAS neck pain, and ROM at 2 years. Complications were higher for anterior surgery group: two hematoma postoperation, one vocal cord paresis, and one new onset C6/C7 dermatome numbness versus one dura leak in posterior surgery group.ConclusionsOur study showed that patients with multilevel disease treated with laminoplasty do well and compare favorably with patients treated with an anterior approach. Notably, posterior surgery was associated with shorter operating time, better improvement in JOA scores at 6 months, and a tendency toward lesser complications. Posterior surgery was not associated with increased neck disability and neck pain at 2 years. Anterior surgery had better NDI improvement at early follow-up. There is a need for a larger study that is prospectively randomized with long-term follow-up before we can confidently advocate one approach over the other in the management of cervical myelopathy.     

A prospective longitudinal study of chronic abdominal pain and symptoms after sleeve gastrectomy

BackgroundSleeve gastrectomy (SG) is widely applied. Few studies have evaluated patient-reported abdominal symptoms after SG.ObjectiveTo evaluate the prevalence of chronic abdominal pain (CAP) and symptom characteristics after SG.SettingOslo University Hospital and Voss Hospital.MethodsWe performed a longitudinal prospective cohort study of patients operated on with SG at two tertiary referral centers. For broad assessments of abdominal pain and symptoms, consultations were performed and questionnaires retrieved before and 2 years after SG. The definition of CAP or recurrent abdominal pain lasting for more than 3 months was sustained. Preoperative predictors of CAP were explored.ResultsOf 249 patients at baseline, 207 (83.1%) had follow-up consultations. Mean preoperative body mass index was 43.9 (6.0) kg/m², and 181 patients (72.7%) were female. Total weight loss was 31.9% (10.4%). CAP was reported in 32 of 223 patients (14.3%) before and in 50 of 186 patients (26.9%) after SG (P =.002). All mean gastrointestinal symptoms rating scale questionnaire scores increased after SG, and they were higher in patients with CAP. Symptoms of depression decreased but were more prevalent in patients with CAP at follow-up. Most quality-of-life scores increased after SG. However, patients with CAP had lower scores (except for physical functioning). Preoperative bothersome Gastrointestinal Symptom Rating Scale reflux symptoms, study center, and younger age seemed to predict CAP after SG.ConclusionThe prevalence of patient-reported CAP increased after SG. Patients reporting CAP had reduced quality-of-life scores.     

The effect of serratus plane block performed under direct vision on postoperative pain in breast surgery

Study ObjectivesTo determine the effectiveness of serratus plane block performed under direct vision on postoperative pain after mastectomy.DesignWe performed a retrospective study of elective breast surgery patients undergoing mastectomy over 6 months. We collected data on the outcomes for the pain score and use of analgesia in recovery, the use of analgesia and antiemetics overnight, and the pain score and mobilization status of the patient 1 day after the operation.SettingBreast cancer is the most common cancer in women, and mastectomy is commonly performed as part of the management. A mastectomy can cause significant acute pain which progresses to chronic pain in 25% to 60% of women. Recent studies have suggested that a serratus plane block is a viable alternative to regional anesthetic techniques without the side effect profile and that injection of local anesthetic into serratus anterior provided predictable and effective anesthesia to the chest wall. Serratus blocks target the thoracic nerves more selectively than pectoral blocks, and local blocks can reduce the use of opiates postoperatively thereby lessening opiate-related side effects.PatientsOur sample included 16 patients who had received a serratus block and 11 patients who only had wound infiltration with levobupivacaine with adrenaline and clonidine.InterventionSerratus plane block was conducted by injecting 50% of the totally available levobupivacaine 0.375% with adrenaline and clonidine deep to serratus anterior under direct observation.Main ResultsNo patients receiving a serratus block suffered severe pain in recovery or day 1 postoperatively. Patients receiving wound infiltration alone had 2 patients suffering severe pain in recovery and 3 patients suffering severe pain day 1 postoperatively.ConclusionSerratus block provides effective regional anesthesia, suitable for mastectomies, and currently appears to be superior to wound infiltration alone. However, further data will need to be collected to support this finding.     

Impact of burn contractures of chest wall and their surgical release on pulmonary function

BackgroundExtensive burn scars and contractures are likely to restrict the movements of the chest wall which may affect the pulmonary ventilation by restricting its expansion during inspiration. We designed this study to evaluate the effect of burn contractures of chest wall on pulmonary function and to estimate the effect of contracture release on pulmonary functions in patients with compromised PFT.MethodsPulmonary function tests (PFT) of 20 patients having chest wall contractures involving more than 50% of the chest circumference were studied. Restrictive lung disease was defined as forced vital capacity (FVC) value less than 80% of predicted normal for the age, weight, and height of that patient. Patients with a restrictive pattern on PFT were subjected to the surgical release of the contracture. PFT was repeated one month after the surgery which was compared with the initial report.ResultsOf the 20 patients included in the study, 5 (25%) patients had a restriction pattern on PFT. 1 patient had a mild restriction, 2 patients had moderate restriction and 2 patients had a severe restriction of pulmonary function. The mean duration of contracture was 58.2 ± 15.75 months in patients with a pulmonary restriction as compared to 29.87 ± 6.21 months in patients with a normal PFT (p = 0.001). All patients having a restrictive pattern on PFT had contracture involvement of >75% of the chest wall circumference (p = 0.0036). The mean forced vital capacity (FVC) increased from 1.94 L preoperatively to 2.11 L after surgical release of the contracture (p = 0.047). However, the restriction pattern in PFT did remain.ConclusionLong standing chest wall contractures and contractures involving >75% of the chest circumference are likely to cause a restrictive pattern on PFT. Any significant improvement of pulmonary function after surgical release of the contracture is unlikely.     

Chest wall resection and reconstruction for recurrent breast cancer – A multidisciplinary approach

BackgroundDespite therapeutic advances in the management of breast cancer, a significant number of patients present with locoregional recurrence. Treatment with hormonal, chemo or radiotherapy remains standard in such cases. However, in selected patients of recurrent breast cancer involving chest wall, multidisciplinary surgical approach could be considered.MethodsBetween 2010 and 2018, 21 patients with recurrent breast cancer, involving chest wall, were treated at a tertiary care center with resection and reconstruction. The mean age of the patients was 55 years (22–77 years).ResultsThe median interval from first breast resection to chest wall resection (CWR) for recurrent disease was 6 years (1–24 years). Eighteen patients underwent bony resection and 3 patients required extensive soft tissue resection. Complete resection was achieved in 90% of patients. All patients had chest wall reconstruction. There was no in-hospital mortality. During follow-up, 8 patients died, of which 7 were due to distant metastases. The 1 year and 3-year overall survival were 90% (95% CI 66–97) and 61% (95% CI 31–81) respectively. The disease-free survival at 1 and 3 years was the same at 70% (95% CI 45–86). At a mean follow up of 23 months, the average survival in patients operated for local recurrence is 51.7 months (95% CI 37.7–65.7) and 24.5 months (95% CI 7.3–41.7) for patients with distant metastatic recurrence.ConclusionA multidisciplinary oncoplastic approach for recurrent breast cancer, which includes chest wall resection and reconstruction is a useful adjunct in selected group of patients. This improves local disease control, symptoms and possibly disease-free survival.     

Advantage of Minimal Anterior Knee Pain and Long-term Survivorship of Cemented Single Radius Posterior-Stabilized Total Knee Arthroplasty without Patella Resurfacing

BackgroundThe single radius total knee prosthesis was introduced with the advantage of reduced patellar symptoms; however, there is no long-term follow-up study of the same. The purpose of this study was to determine the survival rate of single radius posterior-stabilized total knee arthroplasty and patellofemoral complication rates in a consecutive series.MethodsSeventy-one patients (103 knees) who underwent arthroplasty without patellar resurfacing using a single radius posterior-stabilized total knee prosthesis were followed up for a minimum 10 years. Clinical evaluation using Knee Society knee and function scores and radiologic evaluation were performed at regular intervals. Anterior knee pain as well as patellofemoral complications were evaluated with a simple questionnaire. The Kaplan-Meier product-limit method was used to estimate survival.ResultsSeventeen patients (23 knees) were excluded due to death (12 knees) or lost to follow-up (11 knees). Of the 80 knees enrolled, all femoral components and 78 tibial components were well fixed without loosening at final follow-up. Two revisions were performed because of tibial component loosening and periprosthetic joint infection. One patient with tibial component loosening refused to have revision surgery. No obvious tibial insert polyethylene wear was observed. The survivorships at 132 months were 96.7% using revision or pending revision as end points. Anterior knee pain was present in 6 patients (6 knees, 7.5%) at the latest follow-up. No patellofemoral complication requiring revision was encountered.ConclusionsThe single radius posterior-stabilized total knee prosthesis demonstrated an excellent minimum 10-year survivorship. The low rates of implant loosening and 7.5% of anterior knee pain as a patellofemoral complication are comparable with those reported for other modern total knee prosthesis.