High Survival Rate and Very Low Wear of Lateral Unicompartmental Arthroplasty at Long Term: A Case Series of 54 Cases at a Mean Follow-Up of 17 Years

BackgroundSurvivorship of lateral unicompartmental knee arthroplasty (UKA) has progressively improved. However, there are few studies describing long-term results, and no study reports on polyethylene (PE) wear in lateral unicompartmental arthroplasty.The aims of this study are to determine the survival rate of lateral UKA with a fixed, all-PE bearing, and the PE wear of the tibial implant at a minimum of 15 years follow-up.MethodsFrom January 1988 to October 2003, we performed 54 lateral UKAs in 52 patients. All patients had isolated lateral osteoarthritis (OA). The mean age at the index procedure was 65.4 ± 11 years. Thirty-nine UKAs were available for follow-up (30 alive and 9 dead after 15 years). Twelve patients had died before 15 years and 3 patients were lost to follow-up. The mean follow-up was 17.9 years (range, 15-23 years).ResultsAt the final follow-up, 8 knees of 39 (20.5%) had a surgical revision. The cumulative survival rate was 82.1% at 15 years and 79.4% at 20 years. The main reason of revision was progression of OA (87.5%), followed by aseptic loosening of the tibial component (12.5%). With a mean follow-up of 17.9 years, the mean PE wear was 0.061 mm/y. There was no radiographic loosening in the surviving implants and no revisions for wear. The mean functional International Knee Society score was 66.5 ± 26.8, with a mean objective score of 84.4 points ± 13.2. In the population without revision, 90.5% were satisfied or very satisfied at the latest follow-up.ConclusionLateral UKA with a fixed, all-PE tibial bearing and a femoral resurfacing implant presents a high survivorship at long term, with very low PE wear.     

Carcinoma of the thoracic esophagus. Results of one-stage surgery (271 cases)

A group of 271 squamous carcinomas of the thoracic esophagus were studied. All of these patients underwent the same operation: one-stage esophagogastrectomy through a combined abdominal and right thoracic approach. Adenocarcinomas, tumors of the cardia and excisions through a left-sided thoracic approach were excluded. The resectability of these tumors has increased progressively and, at present, applies to 74 percent of operative cases. A majority of these excisons (73 percent) were only palliative. Operative mortality was 16.6 percent for the group as a whole. In the last 3 years this rate has fallen to 4.6 percent. Overall survival at 5 years was 9.3 percent (8.7 percent without recurrence). There was a marked difference between the 5 year survival rate after curative excision (28 percent) and after palliative excision (2.3 percent). Despite such poor results, palliative excision remains justified and offers the patient longer and more comfortable survival than any other type of treatment. Two-stage excision represents a longer, more complex and more grave procedure than one-stage esophagogastrectomy. The addition of postoperative radiotherapy with or without chemotherapy in the last 3 years had led to a marked improvement in survival.     

Obliteration of the pelvic space with pedicled omentum after excision of the rectum for cancer

From 1979 through 1982, removal of the rectum for cancer in 67 patients (50 of whom underwent preoperative radiotherapy) was completed by obliteration of the resulting dead space with pedicled omentum. No complication could be related to the method. After abdominoperineal resection (54 patients), primary healing of the perineal wound was achieved in 77 percent of the patients (85 percent during the last 2 years), and the mean postoperative hospital stay was 22 days. Minor perineal suppuration occurred in 10 patients with a 40 day average time of healing, and major suppuration occurred in 1 patient only with a 3 month time of healing. After the extended Hartmann operation (12 patients), no pelvic abscess was observed and the median hospitalization stay was 19 days. Pelvic filling in the management of patients undergoing rectal excision is an adjunctive procedure that is mainly intended to provide a better postoperative course. It might also facilitate postoperative radiotherapy.     

Impact of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) on growth of colorectal liver metastases

Background

Associating liver partition and portal vein ligation for staged hepatectomy induces an unprecedented liver hypertrophy and enables resection of otherwise unresectable liver tumors. The effect of associating liver partition and portal vein ligation for staged hepatectomy on tumor proliferation, however, remains a concern. This study investigated the impact of associating liver partition and portal vein ligation for staged hepatectomy on growth of colorectal metastases in mice and in humans.

Prostate cancer: Diagnosis and staging

The discovery and the use of serum prostate specific antigen (PSA) has considerably improved the diagnosis of prostate cancer during the past 20 years. Before PSA era, early diagnosis was only based on the digital rectal examination (DRE) of which the Limitations have been evidenced; over half of the tumours diagnosed by such means had already spread out of the prostate and were incurable. Assessment of serum PSA has allowed the diagnosis to be made at an earlier stage of the disease, curable by current treatments. Whichever the diagnostic tools, transrectal ultrasound (TRUS) prostatic biopsies remain necessary for diagnosis ascertainment, taking into account the low specificity of PSA assessment. The feasibility of a diagnosis at an early and curable stage of the disease has logically resulted in screening procedures aimed at reducing the high mortality related to prostate cancer. The numerous publications on prostate cancer screening provide precise information on the accuracy of available diagnostic means (PSA, DRE, TRUS, combined PSA and DRE), on the characteristics of screened tumours (stage and differentiation), and also on the population of men likely to benefit from the screening (age at beginning and end of the screening, frequency of PSA testing, identification of the men with ethnic and/or genetic predisposition). In those early diagnosed prostate cancers, the assessment of loco-regional cancer extension (extracapsular and/or, microscopic nodal involvement), remains unsatisfactory because no imaging technique (ultrasonography, CT scan, MRI,...) allows visualising the tumour itself or microscopic metastases. Nevertheless, the combination of multiple parameters such as DRE data, PSA level, biopsy data and tumour differentiation helps approaching with an increasing precision (nomograms) the true pathologic stage of the disease. Such advances allow distinguishing, among the very heterogeneous group of prostate cancers, tumours that differ from one to another in terms of disease stage, progression and prognosis, which is helpful for the determination of an adapted therapeutic strategy.     

Cervical lymph node dissection and thyroid carcinoma

After an anatomic recall of the cervical lymph node compartments we describe the surgical technique of the lymph node dissection in patients with differentiated thyroid carcinoma. These lymphadenectomies should be associated with total thyroidectomy. Cervical lymph node dissection always concerns central compartment and is sometimes extended to the cervico lateral compartments. Lymphadenectomy of a compartment should be complete, reoperations leading to an important morbidity. The two main complications of cervical lymph node dissection are inferior laryngeal nerve palsy and hypoparathyroidism.     

Epidemiologic Study and Genotyping of BK Virus in Renal Transplant Recipients

BK virus (BKV) infection occurs during childhood and remains latent in the urinary tract. The virus is reactivated in immunosuppressed patients, particularly in those with cellular immunity deficiency, allowing its detection in urine and blood. Nephropathy caused by the virus in renal transplantation recipients may lead to graft failure. The purpose of this study is to know the prevalence of BKV variables in renal transplantation recipients and to evaluate their clinical evolution through molecular methods of “in house” development. Urine and peripheral blood samples from 66 renal transplantation recipients from the province of Buenos Aires, Argentina, were systematically analyzed every 3 months as well as when there was graft dysfunction. Renal biopsies, which were included in the BKV detection study, were performed on those patients with graft dysfunction. Genotyping of 24 BKVs was performed, and the following distribution was found: 21 (87.5%) belonged to subtype I, 3 (12.5%) to subtype II. BKV belonging to subtypes III or IV were not found. As regards subtype I subgroups, the following were identified: 1 (4.76%) from Ia, 10 (47.61%) from Ib1 and 10 (47.61%) from Ib2. Presence of subgroup Ic was not shown. Viremia presented in 33.33% of cases, whereas 75% corresponded to subgroup Ib 1. Genotype Ib1 is prevailing in Southeast Asia, while Ib2 is prominent in Europe. Although an important proportion of the inhabitants of the province of Buenos Aires are European descendants, the prevailing genotype is Ib1, the Asian type. Genotyping might be related to the evolution of the disease in the recipient.     

Localized Sudeck's dystrophy and distal interphalangeal osteoarthritis of a finger: anatomicoradiologic study

After an injury to the right ring finger, a 44-year-old woman experienced pain in the distal interphalangeal joint. A subcutaneous mucoid cyst was noted near the joint. The x-ray films revealed no fracture but a narrowing of the joint space and a well-defined radiolucent area in the ulnar condyle of the middle phalanx. The biopsy specimen of this area excluded infection or tumor and revealed active osteogenic remodelling. These elements permitted a diagnosis of distal interphalangeal osteoarthritis that was associated with highly localized Sudeck's dystrophy (also called " parcellar algodystrophy"). This unusual case suggests the possibility that this dystrophy might be favored by an "osteoarthritic terrain" and might also play a role in the evolution of the osteoarthritis.     

The importance of lymph node dissection in medullary thyroid macrocarcinomas

Medullary thyroid carcinoma (MTC) is often regarded as good medium-term forecast. The 5- and 10-years survival rates are, respectively, appraised at 78-85% and 70-78%. These rates take no care, however, of the fact that 50-56% of the patients keep a pathological calcitonine (CT) level giving evidence of an evolutive disease. The treatment is based on the total thyroidectomy and cervical lymphadectomy. This treatment remains often incomplete and the results of reintervention are disappointing. AIM OF THE STUDY: About 48 patients, we wanted to demonstrate the importance of a complete lymph node dissection performed in the neck as soon as possible. PATIENTS AND METHODS: Between 1979 and 2000, 48 patients were treated for macroMTC (size >1 cm). The duration of follow-up was of 1-29 years (mean 9.3 years). The complete (central and lateral) neck dissection was initially made only in 22 cases. The selected criterion to assess the result was the normalization of the basal CT level. RESULTS: The rate of node involvement was 66.6% if the complete lymphadectomies (n = 22), the secondary neck dissections (n = 15), the incomplete (n = 10) and not made lymphadectomies (n = 2) were gathered. In case of primary or secondary complete lymphadectomies, the rate of node involvement was 81%. The 22 primary complete lymphadectomies performed in 13 patients (59%) allowed to normalize the basal CT level and among 17 (77.2%) to decrease this rate over 90%. All the incomplete neck dissection failed in case of positive nodes. CONCLUSION: The frequency of node involvement in macroMTC is about 80%. It does not have a preferential territory and the bilaterality is frequent (28-49%): that justifies a bilateral complete neck dissection. Initial surgical treatment seems essential in regard to the rate of normalization of basal CT level, which is, when a first complete lymphadectomy is done and in case of iterative surgery, respectively 59 and 26.6%. A complete lymphadectomy is still too rarely carried out: 22 times (45.8%) in our own experience and from 14 to 42% in the literature.     

Chronic obstructive pancreatitis after healing of a necrotic pseudocyst

Seven patients presented with chronic pancreatitis localized upstream to a complete stenosis of the main pancreatic duct in its median part. This stenosis seemed to be secondary to the healing of a necrotic pseudocyst after either acute pancreatitis (four patients) or blunt abdominal trauma (three patients). In five patients, after spontaneous regression of the clinical symptoms of the initial pseudocyst, a silent period which ranged from 2 to 5 months was followed by recurrent attacks of pain of lesser intensity and shorter duration (less than 2 days) than observed during the evolution of the initial pseudocyst. These attacks of pain decreased spontaneously with time, probably because of the atrophy of the left part of the pancreas drained by the obstructed duct (in 6 months to 2.5 years). In 2 patients, the initial pseudocyst was revealed at the same time as the obstructive pancreatitis.The histologic features of chronic obstructive pancreatitis have been described. Fibrosis uniformly spread throughout the diseased pancreas with uniform atrophy of the exocrine parenchyma. Dilated ducts showed far less damages than in chronic calcifying pancreatitis. Since spontaneous clinical healing may be observed, surgical treatment is often useless. Only in patients with severe or frequent attacks is a Roux-Y anastomosis with the dilated part of the main pancreatic duct indicated rather than a risky left pancreatectomy.     

Early diagnosis and surgical management of prostate cancer

Prostate cancer is a significant cause of morbidity and mortality in the United States and Europe. The natural ageing of the population as well as the continued and widespread use of diagnostic tests such as prostate specific antigen (PSA), has led to an increase in the numbers of men diagnosed with localised prostate cancer. Screening to identify organ-confined disease has provoked much public and scientific attention, but remains controversial. Radical prostatectomy is one of the most challenging urological procedures performed. Improvements in technique due to better understanding of pelvic anatomy have reduced complications, with acceptable standards and excellent results in high-volume institutions. Continual refinements in technique and the recent introduction of laparoscopic radical prostatectomy are likely to improve functional outcome further. However the effectiveness of surgery in improving survival and quality of life, in men with early prostate cancer remains to be determined. The results from large randomised controlled trials are eagerly awaited.     

Genetic bases of craniosynostoses: An update

Craniosynostosis (CS) is defined as the premature fusion of cranial sutures, leading to an abnormal skull shape. The overall incidence is between 1: 2,000 and 1: 3,000 live births. Genetic causes are found in 20% of cases. CS can be isolated (non-syndromic CS/NSCS) or they can be part of multiple congenital abnormalities syndromes (syndromic CS/SCS). A few SCS, such as Crouzon, Pfeiffer, Apert and Saethre-Chotzen syndromes, are very well known and their molecular bases have been clarified in the 90s and early 2000s, thus showing the major role of the FGF receptors and TWIST signaling pathways in the etiology of these conditions. The recent availability of powerful molecular tools for genetic diagnosis, such as whole exome or whole genome sequencing, has led to the characterization of the molecular bases of an increasing number of CS, thus emphasizing the significant genetic heterogeneity of these conditions, and blurring the limit between SCS and NSCS. The genetic characterization of patients affected by CS leads to appropriate genetic counseling and provides relevant information concerning comorbidity and prognosis. Nevertheless, this can also lead to the detection of susceptibility factors with low penetrance whose interpretation in genetic counseling is difficult and it raises the question of its cost-effectiveness for health systems. These aspects suggest the need of a patient-tailored clear rationale for performing genetic tests. In this study, we reviewed the main molecular etiologies reported in the last 15 years of either SCS or NSCS, and we propose a systematic multidisciplinary approach as well as a diagnostic flowchart for the genetic evaluation of these patients.