Partial or non-union after triple arthrodesis in children: does it really matter?

Purpose

Triple arthrodesis is a commonly performed salvage procedure to correct hindfoot deformity. Non-union is considered an undesirable radiographic outcome; however, the clinical ramifications of this are not as well defined. The purpose of this study was to determine the incidence of partial or complete radiographic non-union after triple arthrodesis in children and characterize the clinical consequences.

Methods

An IRB-approved retrospective review of triple arthrodesis surgeries in patients less than 16 years of age performed by a single surgeon (DSW) identified 159 cases meeting the inclusion criteria. Plain radiographs were reviewed for bony fusion (defined as over 80 % radiographic bony union of the subtalar, calcaneocuboid, and talonavicular bones) and charts for clinical outcomes (pain, return to activity, and subsequent hindfoot surgeries). Statistics were used to compare the fused and unfused cases, with p < 0.05 considered to be significant.

Results

Of the 159 cases included in the study, 9 % did not achieve at least 80 % plain film radiographic union. The fused and unfused groups had similar clinical outcomes. Only one patient required surgery for sequelae of symptoms arising from a pseudoarthrosis related to the triple arthrodesis. The fused and unfused groups were similar in terms of gender and pin removal time, but differed significantly in surgical age and underlying diagnosis.

Conclusions

This is one of the largest case series of pediatric triple arthrodesis surgery presented in the literature. This study demonstrated that good clinical outcomes can be achieved despite the lack of radiographic union after triple arthrodesis surgery in children.

Level of evidence

IV.

     

Percutaneous nephrolithotomy in children: does age matter?

Purpose  

To compare the outcomes of percutaneous nephrolithotomy (PCNL) in 2 age groups.     

Patient-centred outcomes in clinical research: does it really matter?

‘It does not matter whether the degree of patients’satisfaction reflects the competence of the physician or thequality of care. The important thing is that if patients aredissatisfied, health care has not achieved its goal’.¹ This statement, which was published 16 yr ago, reflects the(growing) importance of the technical and non-technical dimensionof outcome.² The technical aspect attempts to assess the skilland competence of professionals, and the ability of diagnosticor therapeutic procedures to accomplish what they are meantto, or, from the patients’ perspective: do they reallyget what they need? Patients quite rightly expect that the carethey receive is methodologically     

Blood product storage: does age really matter?

Red blood cell transfusion therapy has been used with the ultimate goal of enhancing oxygen delivery to vital organs and tissue beds, thus enhancing cellular function. Red blood cell transfusion therapy is also a long-standing practice, and since the 1950s it has only grown in utilization, especially within the United States. Recently, transfusion therapy has come under increased scrutiny with a desire to develop evidence-based therapeutic guidelines that not only decrease undue risk to the patient but also decrease the overutilization of this high-cost, low-availability product. Despite the development and implementation of these guidelines, significant complications associated with red cell therapy persist and may be related to storage of blood products. Recently, within the transfusion literature, there has been a renewed focus on red cell storage lesions and their contributions to perioperative outcomes. Several meta-analyses, and now a recently launched, multinational randomized controlled trial, have been initiated to help bring clarity to whether or not the length of product storage has any effect on patient outcomes. This review will focus on the nature of storage lesions, complications associated with storage, as well as a brief review of some of the more provocative literature surrounding this controversial topic.     

Fall from heights: does height really matter?

Introduction

Fall from heights is high energy injuries and constitutes a fraction of all fall-related trauma evaluations while bearing an increase in morbidity and mortality. We hypothesize that despite advancements in trauma care, the overall survivability has not improved in this subset of trauma patients.

Methods

All adult trauma patients treated after sustaining a fall from heights during a 40-month period were retrospectively reviewed. Admission demographics, clinical data, fall height (ft), injury patterns, ISS, GCS, length of stay, and mortality were reviewed.

Results

116 patients sustained a fall from heights, 90.4% accidental. A mean age of 37± 14.7 years, 86% male, and a fall height of 19 ± 10 ft were encountered. Admission GCS was 13 ± 2 with ISS 10 ± 11. Overall LOS was 6.6 ± 14.9 days and an ICU LOS of 2.8 ± 8.9 days. Falls ≥ 25 ft.(16%) had lower GCS 10.4 ± 5.8, increased ISS 22.6 ± 13.8, a fall height 37.9 ± 13.1 ft and associated increased mortality (p < 0.001). Mortality was 5.2%, a mean distance fallen of 39 ± 22 ft. and an ISS of 31.5 ±16.5. Brain injury was the leading cause of death, 50% with open skull fractures.

Conclusion

Level of height fallen is a good predictor of overall outcome and survival. Despite advances in trauma care, death rates remain unchanged. Safety awareness and injury prevention programs are needed to reduce the risk of high-level falls.

     

Presence of pneumomediastinum after blunt trauma in children: what does it really mean?

Background

Pneumomediastinum after blunt thoracic trauma is often considered a marker of serious aerodigestive injury that leads to invasive testing. However, the efficacy of such testing in otherwise stable children remains unknown. We hypothesize that pneumomediastinum after blunt trauma in clinically stable children is rarely associated with significant underlying injury.

Methods

We reviewed all patients in our pediatric trauma database (1997-2007) for pneumomediastinum after blunt injury. Patients were then subdivided into 2 groups: group I, isolated thoracic and group II, thoracic and additional injuries. Procedures and imaging were recorded, and outcomes were assessed.

Results

Thirty-two children with blunt thoracic trauma were included as follows: group I (n = 14) and group II (n = 18). In all patients, there were 28 diagnostic procedures performed resulting in only 1 positive test—a bronchial tear found on bronchoscopy in association with obvious respiratory distress. Group I was more than twice as likely to undergo invasive procedures as group II (P < .0001), resulting in significantly greater costs (?$13683 ± 2520 vs $5378 ± 1000; P < .002). Patients in group I also received more diagnostic imaging to assess pneumomediastinum (1.89 vs 1.08 studies/patient per day; P < .05). More than 28% of all patients were completely asymptomatic and had pneumomediastinum as their only marker of injury. Strikingly, these patients received more than 46% of the procedures.

Conclusions

Children with pneumomediastinum from blunt trauma often receive invasive and expensive testing with low yield, especially those with isolated thoracic trauma.     

Outcomes of peritoneal dialysis catheter reinsertion: does the cause of initial removal matter?

Purpose

In this study, we aimed to compare patient and technique survival between the patients, in whom peritoneal dialysis (PD) catheter was removed due to severe peritonitis and then it was reinserted, and those, in whom PD catheter was removed due to non-peritonitis causes and then it was reinserted.

Method

Sixty-two patients, in whom PD catheter was reinserted surgically, were retrospectively analyzed in this cohort study. Group 1 consisted of 27 patients in whom PD catheter was removed due to severe peritonitis, whereas Group 2 consisted of 35 patients in whom PD catheter was removed due to non-peritonitis causes.

Results

There was no significant difference between Group 1 and Group 2 in terms of the estimation of overall patient survival [43 months (95 % CI 43.6–83.7) versus 80 months (95 % CI 52.8–107.3, p 0.362]. Similarly, there was no significant difference between Group 1 and Group 2 in terms of the estimation of overall technique survival [82 months (95 % CI 0–166.0) versus 31 months (95 % CI 9.7–52.3), p 0.346].

Conclusion

Our results suggest that there was no significant effect of causes of PD catheter removal (peritonitis vs. non-peritonitis) on the outcomes of PD treatment.     

Outcomes after breast reduction: does size really matter?

There is no doubt that reduction mammoplasty (RM) results in significant improvement in a myriad of patient macromastia-related symptoms and other macromastia-related quality of life factors. Whether this improvement is correlated with the amount of tissue resected remains unknown because no previous study of RM has stratified patients by the amount of breast tissue resected. In this study, all patients were given a custom-designed questionnaire designed to evaluate their macromastia-related symptoms and other macromastia-related quality of life issues. Patients were then provided the same questionnaire at their final postoperative visit between 3 and 12 months after surgery. A total of 188 patients completed pre- and postoperative surveys. Before the initiation of this study, patients were stratified by the total weight of breast tissue resected into the following cohorts: 1000 g or less (66 patients), 1001 to 1500 g (55 patients), 1501 to 2000 g (30 patients), and greater than 2000 g (37 patients). RM resulted in significant improvement in all macromastia-related symptoms and quality of life factors analyzed (P < 0.000001). There were no significant differences (P > 0.05) in pre- and postoperative macromastia-related symptoms across our 4 groups with the exception of lower back pain (preoperative P = 0.026), shoulder pain (preoperative P = 0.014), and painful bra strap grooves (preoperative P = 0.0059). Analysis of the symptomatic burden of macromastia on several quality of life factors showed no significant differences (P > 0.05) in either the pre- or postoperative symptom scores across all groups in any of the categories assessed. This study demonstrates that women seeking breast reduction have a similar preoperative symptom burden across a wide range of breast sizes. Furthermore, the symptomatic improvement derived from RM is not significantly different between women of different breast sizes.     

Obesity in total hip arthroplasty—does it really matter?: A meta-analysis

Background and purpose

Discussion persists as to whether obesity negatively influences the outcome of hip arthroplasty. We performed a meta-analysis with the primary research question of whether obesity has a negative effect on short- and long-term outcome of total hip arthroplasty.

Methods

We searched the literature and included studies comparing the outcome of hip arthroplasty in different weight groups. The methodology of the studies included was scored according to the Cochrane guidelines. We extracted and pooled the data. For continuous data, we calculated a weighted mean difference and for dichotomous variables we calculated a weighted odds ratio (OR). Heterogeneity was calculated using I₂ statistics.

Results

15 studies were eligible for data extraction. In obese patients, dislocation of the hip (OR = 0.54, 95% CI: 0.38–0.75) (10 studies, n = 8,634), aseptic loosening (OR = 0.64, CI: 0.43–0.96) (6 studies, n = 5,137), infection (OR = 0.3, CI: 0.19–0.49) (10 studies, n = 7,500), and venous thromboembolism (OR = 0.56, CI: 0.32–0.98) (7 studies, n = 3,716) occurred more often. Concerning septic loosening and intraoperative fractures, no statistically significant differences were found, possibly due to low power. Subjective outcome measurements did not allow pooling because of high heterogeneity (I₂ = 68%).

Interpretation

Obesity appears to have a negative influence on the outcome of total hip replacement.Obesity has reached epidemic proportions in the USA, and the rest of the well-developed world is expected to follow. Since obesity is a well-documented risk factor for the development of osteoarthritis (Sturmer et al. 2000, Flugsrud et al. 2006), an increased need for joint arthroplasty in obese people can be expected. Surgery on obese patients can lead to longer duration of the operative procedures themselves, with higher complication rates and longer hospital stays, and some authors have even suggested refusal of elective surgery in obese patients (Fehring et al. 2007).A controversy that has flared up during the last decennium is whether obesity might also influence the functional results and survival of total hip arthroplasty (THA), with studies showing either different or similar outcome compared to normal-weight patients. For both outcomes, different explanations have been postulated. McClung et al. (2000), for example, found that a higher BMI was associated with lower activity, resulting in less polyethylene wear in these patients, since wear is a function of use and not time. On the other hand, higher forces acting on the prosthesis in obese patients may lead to early loosening.Generally, a person with a BMI between 25 and 30 is categorized as overweight, and someone with a BMI of greater than 30 is obese. In this meta-analysis, we evaluated the results of all published trials comparing outcome and survival of primary THA between different BMI groups (BMI of < 30 and of > 30). Our main research question was whether obesity has a negative effect on the short- and long-term outcome of total hip arthroplasty.     

Impact of a learning curve model in kidney transplantation on functional outcome and surgical complications in a small volume centre: does size really matter?

Purpose

To evaluate surgical complications and functional results of deceased-donor renal transplantations (DDRT) in a small centre dependent on the surgeons level of experience and to derive a leaning-curve model for DDRT.

Methods

Three hundred and ninety-two recipients underwent DDRT at the Department of Urology, Bonn University. Operative procedures were performed by 18 various urological surgeons grouped in 5 levels of experience (LOE). Perioperative data, complications and graft survival after 12?months were recorded depending on LOEs.

Results

Operative time and warm ischaemia time significantly decreased after an experience of 40 DDRT. Complication rates and graft function after 12?months did not differ between all LOEs.

Conclusions

Kidney transplantation in a small centre is a safe and effective procedure even if performed by surgeons under education. As a crucial finding, a surgeon climbing his learning curve becomes faster but not necessarily better.     

Size really does matter—role of gastrojejunostomy in postoperative weight loss

BackgroundAlthough the published data have clearly related the size of the gastrojejunostomy anastomosis to the subsequent likelihood of a stricture, a correlation between the anastomosis size and postoperative weight loss has not previously been described.MethodsA retrospective comparison was made of 124 anastomoses accomplished with the 21-mm circular stapler followed by 100 anastomoses created with the 45-mm linear stapler technique at 6 community hospitals in Southern California. Age, gender, and preoperative weights were not significantly different between the 2 groups. The precise size of the anastomosis created using the linear stapler technique could not be determined, but it was calculated to be slightly larger than a 25-mm circular stapled anastomosis. Both weight loss trends were fit with a 1-phase exponential nonlinear regression analysis. The resulting curves were compared using an F test. A 1-tailed t test was also used to compare the weight loss at 12 months.ResultsAn F test comparison of the exponential weight loss curves generated by the 2 anastomosis groups showed a significantly different trend in weight loss (P <.001). A 1-tailed t test comparison of the 2 groups at 12 months revealed significantly different results (p <.0025).ConclusionThe results of this study show that the size of the anastomosis has a clear correlation with postoperative weight loss. A smaller opening results in significantly more weight loss.