Laparoscopic colectomy in the elderly: is there a benefit?

The role of laparoscopic surgery has gained widespread acceptance as a feasible and safe option in the management of many benign colorectal diseases. Short-term benefits such as earlier return of bowel function, less postoperative pain, and shorter length of hospital stay have been demonstrated for laparoscopic-assisted colectomy (LAC). This has been accomplished with no significant difference in morbidity and mortality when compared with open colorectal surgery. The role of laparoscopy for malignant disease remains unclear as we await the results of the COST trial. To date there is little literature regarding the impact of LAC in the elderly population (ie, patients over the age of 70 years) as the vast majority of studies regarding laparoscopic colectomy have evaluated younger patients (less than 65 years). It is unknown if elderly patients garner the same benefits from LAC that younger patients have been shown to receive. As a result, there has been reluctance to offer laparoscopy to elderly patients. This is a review of the literature examining the positives and negatives of LAC in patients >70 years of age.     

Does the joint line matter in revision total knee replacement?

We identified 148 patients who had undergone a revision total knee replacement using a single implant system between 1990 and 2000. Of these 18 patients had died, six had developed a peri-prosthetic fracture and ten had incomplete records or radiographs. This left 114 with prospectively-collected radiographs and Bristol knee scores available for study. The height of the joint line before and after revision total knee replacement was measured and classified as either restored to within 5 mm of the pre-operative height or elevated if it was positioned more than 5 mm above the pre-operative height. The joint line was elevated in 41 knees (36%) and restored in 73 (64%). Revision surgery significantly improved the mean Bristol knee score from 41.1 (SD 15.9) pre-operatively to 80.5 (SD 15) post-operatively (p < 0.001). At one year post-operatively both the total Bristol knee score and its functional component were significantly better in the restored group than in the elevated group (p < 0.01). Overall, revision from a unicondylar knee replacement required less use of bone graft, fewer component augments, restored the joint line more often and gave a significantly better total Bristol knee score (p < 0.02) and functional score (p < 0.01) than revision from total knee replacement. Our findings show that restoration of the joint line at revision total knee replacement gives a significantly better result than leaving it unrestored by more than 5 mm. We recommend the greater use of distal femoral augments to help to achieve this goal.     

“Meniscal” scar as a landmark for the joint line in revision total knee replacement

AIM To determine whether tissue identified at the joint line was actually remnant meniscal scar tissue or not. METHODS Nine patients undergoing revision knee surgery following informed consent had meniscal scar tissue sent to the histology department for analyses. All revisions were performed where joint line had been raised or lowered at earlier surgery. Although preoperative radiographic evaluations suggested that the joint line had been altered, intraoperatively there was scar tissue at the level of the recreated joint line. This scar tissue has traditionally been described as meniscal scar, and to identify the origins of this tissue, samples were sent for histological analyses. The tissue samples were stored in formalin, and embedded and sectioned before undergoing histochemical staining. All samples underwent macroscopic and microscopic examination by a histopathologist who was blind to the study aims. The specific features that were examined included tissue organisation, surface and central composition, cellular distribution including histiocytes, nuclear ratio and vasculature. Atypical and malignant features, inflammation and degeneration were specifically looked for. A statistical review of the study was performed by a biomedical statistician.RESULTS The histological findings for the nine patients showingthe macroscopic and microscopic findings, and the conclusion are outlined in a Table. The histological analyses were reviewed to determine whether the tissue samples were likely to be meniscal scar tissue. The response was yes(2, 22%), no(6, 67%) and maybe(1,11%) based on the conclusions. The results were yeswhen on macroscopy, firm cream tissue was identified.In these two yes samples, microscopic analyses showed organised fibrous tissue with focal degenerative areas with laminated pattern associated with histiocytes peripherally but no inflammation. The no samples were assessed macroscopically and microscopically and were deemed to have appearances representing fibrous synovial tissue and features in keeping with degenerate scar tissue or connective tissue. One sample was indeterminate and microscopically contained fibrocollagenous tissue with synovial hyperplasia. It also contained some degenerate hyalinised tissue that may represent cartilage, but the appearances were not specific. CONCLUSION Based on our pilot study, we recommend reliance on a number of markers to identify the joint line as outlined above, and to exercise caution in using the meniscalscar.     

Trochanteric non-union in revision total hip arthroplasty: does it matter?

The aims of this study were to assess whether trochanteric non-union is an important factor in revision total hip arthroplasty in terms of postoperative morbidity. We studied prospectively 97 consecutive patients undergoing revision total hip arthroplasty in the years 1992-1996. All operations were performed by one surgeon through a Charnley trans-trochanteric approach. The patients were followed-up over a period of 1-4 years and at 12 months postsurgery were assessed using a modified scoring system devised by D'Aubigne. Anatomical union of the greater trochanter was assessed by an anterior-posterior pelvic radiograph at 12 months to decide if the greater trochanter was united in the correct anatomical position. The trochanteric non-union rate was 18.5% (18 out of 97 patients). There was no significant difference between the patients in terms of pain, function and satisfaction scores at one year between those with trochanteric union and those without. This study suggests that trochanteric non-union post revision total hip arthroplasty is not a cause of increased morbidity.     

Mortality following revision joint arthroplasty: is age a factor?

With the demand for total joint arthroplasty and overall life expectancy increasing, there will be an increase in the need for revision arthroplasty surgeries. Given that revision joint surgeries are more demanding for both surgeon and patient with longer operative times, increased blood loss, and multiple patient comorbidities, the current mindset is that older patients who undergo a total hip revision or total knee revision have higher mortality rates than younger patients. We identified 1737 revision total joint patients who were at least 2 years postoperative for inclusion in the study. The overall perioperative mortality rate (defined as deaths occurring between 0 and 3 months following revision joint surgery) was calculated and then stratified by revision knee surgery, revision hip surgery, and age. In addition, mortality rates were compared for patients younger than 70 years, between 70 and 80 years and older than 80 years. The overall perioperative mortality rate after revision total hip or knee surgery was 0.7%. After stratifying by age, the perioperative mortality rate was 0.2% in patients younger than 70 years, 0.8% in patients 70 to 79 years, and 2.63% in patients older than 80 years. Of the 1737 patients, 541 died >1 year following their revision surgery at an average time to death of 6.9 years. The observed perioperative mortality rates following revision total joint surgery at a single center were extremely low among all age groups. Therefore, the age of patients undergoing revision surgery should not be the sole determinant of perioperative survival. Additionally, it appears that the mean postoperative survival noted here seems to justify the additional resources used in revision surgery regardless of age. As limited resources exert pressure on an already overburdened healthcare system, rationing of care for certain procedures may ensue using age as a specific criteria. This study should add clarity to this issue.     

Testosterone replacement: when is there a role?

Hypogonadism is an uncommon cause of erectile dysfunction. Unfortunately, hypogonadal states in adult males are difficult to diagnose on purely clinical grounds and it is necessary to seek biochemical support. The simplest way to establish the diagnosis of hypogonadism is by determination of serum testosterone levels. Several methods exist but total testosterone determination plus assessment of sex hormone-binding globulin or bio-available testosterone appear to be the most reliable and accessible. Once a diagnostic of hypogonadism has been established in a man with erectile difficulties, a trial of androgen supplementation is warranted if no contraindications exist. Knowledgeable monitoring is essential. In the absence of an adequate response, co-morbidities should be diligently sought out. In the absence of reliable guidelines for androgen administration to patients with erectile failure, a set of recommendations are provided. International Journal of Impotence Research (2000) 12, Suppl 4, S112-S118.     

Barbed sutures in total hip and knee arthroplasty: what is the evidence? A meta-analysis

Introduction

Newer methods of wound closure such as bidirectional barbed sutures hold the potential to reduce closure time and thus overall operating room costs during total joint arthroplasty (TJA), including total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, it is unclear whether these sutures have similar clinical outcomes or whether they place the patient at risk of developing wound complications that may outweigh the time-saving benefits of these sutures.

Methods

A systematic review of the literature was performed to identify all level I trials that reported the use of barbed suture during TJA. We analyzed the efficacy, safety, major and minor complications, and overall cost related to barbed sutures.

Results

Four studies met our criteria, and included 588 patients who were randomized either to barbed suture closure (n?=?290 TJAs, 268 TKAs, and 22 THAs) or to a matched conventional suture cohort (n?=?298 TJAs, 279 TKAs, and 19 THA). In terms of time savings with wound closure, the barbed suture was 6.3 minutes faster than the conventional cohort (p?<?0.05). The odds for developing a minor complication were nearly identical (odds ratio [OR] 1.04, p?=?0.95) and for major complication was not significantly different (OR 2.94, p?=?0.27). The overall mean savings including both THA and TKA was USD 298 per case.

Conclusions

In randomized controlled trials, barbed sutures are consistently associated with shorter wound closure time, which also corresponds to cost savings, even when the higher cost of these sutures is taken into account. There was no significant difference in the odds of experiencing either minor or major complications between patients in whom barbed sutures versus standard sutures were used for wound closure. Current evidence supports continued use of these sutures.Level of Evidence: Level I

     

Age-related appearance of muscle trauma in primary total hip arthroplasty and the benefit of a minimally invasive approach for patients older than 70?years

Old age is frequently associated with a poorer functional outcome after THA. This might be based upon muscular damage resulting from surgical trauma. Minimally invasive approaches have been widely promoted on the basis of the muscle sparing effect. The aim of the study was to evaluate of the functional outcome and the grade of fatty muscle atrophy of the gluteus medius muscle by magnetic-resonance-imaging (MRI) in patients undergoing minimally invasive or traditional THA. Forty patients (21 female, 19 male) underwent THA either via a modified direct lateral (mDL) or a minimally invasive anterolateral (ALMI) approach. Patients were evaluated clinically and by MRI in terms of age (< or ≥70 y) preoperatively and at three and 12 months postoperatively. The Harris hip score and Trendelenburg’s sign were recorded and a survey of a pain (using a numeric rating scale of 0–10) and satisfaction score (using a numeric rating scale of 1–6) was performed. Fatty atrophy (FA) of gluteus medius muscle was rated by means of a five-point rating scale (0 indicates no fat and 4 implies more fat than muscle). Younger patients reached a significantly higher Harris hip score, lower pain score and lower rate of positive Trendelenburg’s sign accompanied by a significantly lower rate of postoperative FA (P = 0.03; young: FA (MW) = (preop. / 3 / 12 months), 0.15 / 0.7 / 0.7; old: FA (MW) = 0.18 / 1.3 / 1.36). Older patients with an mDL-approach had the significantly lowest clinical scores, the highest rate of positive Trendelenburg’s sign and also the highest rate of fatty atrophy (P = 0.03; FA (old) mDL: 1.8; ALMI: 0.7). Interestingly, no influence of the approach could be detected within the younger group. Patients older than 70 years had a poorer functional outcome and a higher postoperative extent of FA when compared to younger patients, which must be based upon a higher vulnerability and a reduced regenerative capacity of their skeletal muscle. Through a minimally invasive approach the muscle trauma in older patients can be effectively reduced and thus the functional outcome significantly improved. Incision and detachment of tendons and muscles should be strictly avoided.     

Is there a role for extended antibiotic therapy in a two-stage revision of the infected knee arthroplasty?

All major studies have incorporated the use of prolonged courses of parenteral or oral antibiotic therapy in the management of two-stage revision of an infected total knee arthroplasty. We present a series of 59 consecutive patients, all with microbiologically-proven deep infection of a total knee arthroplasty, in whom a prolonged course of antibiotic therapy was not routinely used. The mean follow-up was 56.4 months (24 to 114). Of the 38 patients who underwent a staged exchange, infection was successfully eradicated in 34 (89%) but recurrent or persistent infection was present in four (11%). Our rate of cure for infection is similar to that reported elsewhere. We conclude that a prolonged course of antibiotic therapy seems not to alter the incidence of recurrent or persistent infection. The costs of the administration of antibiotics are high and such a regime may be unnecessary.     

Cementless modular neck stems: are they a safe option in primary total hip arthroplasty?

Purpose

The objective was to assess aseptic complications and functional outcome using a primary total hip arthroplasty with modular neck.

Methods

Prospective cohort of 317 consecutive patients. The mean age was 61.1 (range, 41–84) years. The H-Max-M model (Lima, Italy) system was used in all patients. The functional assessment was made by the Harris Hip Score, Short Form-36 (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index and visual analogue scale for pain. Radiological outcomes were also assessed, and adverse events and complications were noted.

Results

The mean follow-up was 6.1 (range, 2–8) years. Functional outcome significantly improved in most patients. There were 3 deep infections (0.9%) and 17 aseptic complications (5.3%) including 1 intraoperative acetabular fracture, 3 later periprosthetic femoral fractures, 1 broken ceramic insert, 1 acetabular loosening, 3 femoral loosening and 1 broken titanium modular neck in a obese patient. No pseudotumors or elevated serum levels of metal ions were found among the patients with radiolucent lines or aseptic loosening.

Conclusions

The findings in the present study showed that the H-MAX-M stem provided satisfactory functional outcome in most patients with a low rate of complications attributable to the modular neck design. We consider that using this novel modular neck-stem coupling design can be an alternative to the conventional monoblock stems in patients without overweight.

     

Stemless,short and standard humeral stems in total shoulder arthroplasty: is there a difference in intraoperative measures,pain, and outcomes in the short term?

BackgroundAs anatomic total shoulder arthroplasty (aTSA) has evolved, surgeons are utilizing stemless and short-stem humeral implants with increasing frequency. Bone preservation, decreased blood loss, decreased surgical time, decreased pain, and improved outcomes have been described as theoretical advantages for shorter stem and stemless implants. Comparisons of outcomes between different length humeral stems that control for manufacturer and model of humeral and glenoid implants are currently limited. The purpose of this study is to determine if differences exist in the short-term outcomes between stemless, short-stem (SS), and traditional-length (TL) humeral stems in aTSA.MethodsA multicenter international shoulder arthroplasty database utilizing a single implant system was retrospectively analyzed to compare intraoperative and short-term outcomes between stemless, SS, and TL humeral stem implants. Intraoperative measures including surgical time and estimated blood loss were recorded. Postoperative outcomes including improvements in multiple pain measures, Global Shoulder Function Score, Simple Shoulder Test, University of California at Los Angeles, American Shoulder and Elbow Surgeons, and Shoulder Pain and Disability Index scores were compared between the three cohorts at 0-3 months, 3-6 months, 6-12 months, and 1-2 years postoperatively. Statistical analysis was performed using a Student’s unpaired two-tailed t-test to quantify differences in means between cohorts with a P value < .05.Results203 stemless aTSAs were compared with 354 SS and 1159 TL aTSAs. Surgical time showed no difference between stemless (avg 89 min), SS (avg 94 min), and TL (avg 91 min) humeral component use (P > .05). Estimated blood loss was significantly higher in TL (avg 214 cc) when compared to SS (avg 165 cc, P < .001) and stemless (avg 180 cc, P < .001), with no significant difference between SS and stemless (P > .05). No differences were observed in improvement in postoperative pain between any cohort across all pain metrics recorded during the first 3 months postoperatively. Additionally, the stemless aTSA cohort did not show any significantly greater improvement in pain metrics at any time point postoperatively when compared to SS and TL cohorts. When evaluating improvements in global shoulder function, American Shoulder and Elbow Surgeons, Simple Shoulder Test, Constant, University of California at Los Angeles, and Shoulder Pain and Disability Index scores, the stemless cohort did not provide a significant advantage in outcome when compared to the SS and TL cohorts at 6-12 or 12-24 months.Discussion and ConclusionWhile stemless aTSA design provides distinct advantages in select patient populations, the proposed benefit of decreased pain and accelerated postoperative recovery following stemless aTSA are not substantiated by this study. The authors hope this study will aid surgeons in counseling prospective TSA patients in the risks and benefits of stem length selection in total shoulder replacement.