Is a tricuspid annuloplasty ring significantly better than a De Vega's annuloplasty stitch when repairing severe tricuspid regurgitation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether tricuspid valve (TV) repair with an annuloplasty ring leads to an improved outcome over a conventional suture annuloplasty for patients with severe tricuspid incompetence. Altogether, 306 papers were found using the reported search, of which 14 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. We found seven studies supporting the use of ring annuloplasty over De Vega's suture annuloplasty. Five studies found no significant difference in outcome between the two techniques. We found only two studies supporting the use of De Vega's suture annuloplasty over ring annuloplasty. Therefore, most of the tabulated studies show good evidence in support of ring annuloplasty compared with De Vega's suture repair for treatment of moderate to severe TV regurgitation. One cohort study identified a 20.4% postoperative failure rate for tricuspid regurgitation (TR) repair and concluded non-application of ring as a predictor for reoperation. One cohort study with a mean follow-up of 17 months reported success rates as high as 97% with ring annuloplasty for TV regurgitation. One large cohort study of 2277 patients with TR who had undergone repair reported a sustained reduction in TR and the rate of recurrence in a 5-year echocardiographic follow-up. One cohort study of 129 patients concluded that ring annuloplasty has the lowest rate of recurrence compared with De Vega's suture repair. An old randomized controlled trial (RCT) on the subject also reported a similar result to the mentioned studies. In contrast, we reviewed one recent study and four older studies and found no significant difference between the two techniques. We reviewed one study that reported De Vega's suture repair as a superior technique to ring annuloplasty. We conclude that there is good evidence supporting ring annuloplasty over conventional De Vega's suture annuloplasty.     

Is cytology required for a hematuria evaluation?

PURPOSE: The value of urine cytology in evaluating patients with hematuria remains controversial. The American Urological Association Best Practice Policy on Asymptomatic Microscopic Hematuria recommends cytology only in patients with risk factors for transitional cell carcinoma (TCC). This study evaluated how often urine cytology yielded supportive or unique information that led to the diagnosis of transitional cell carcinoma, the cost of that information and whether it would have been obtained using the current best practice policy. MATERIALS AND METHODS: Between March 1976 and June 1985, 1,000 sequential patients with 1 episode of gross hematuria or microscopic hematuria, defined as greater than 3 red blood cells per high power field on 2 of 3 properly collected urinalyses, were evaluated according to a standard protocol in a closed panel health care system in the state of Hawaii. These records were reviewed to determine if urine cytology yielded supportive or unique information that led to the diagnosis of TCC. RESULTS: In 4 patients positive urine cytology was the sole finding supporting a TCC diagnosis. Urine cytology had a sensitivity of 55% and a specificity of 99.3%. The cost of a cytology result that yielded unique information was 8,367 US dollars using the 2002 Medicare reimbursement schedule. CONCLUSIONS: Urine cytology can have an important role in the evaluation of hematuria. The current American Urological Society Best Practice Policy using risk factors to select patients for urine cytology would have captured the 4 patients for whom cytology was the key to diagnosis. Urine cytology was comparable to excretory urography, creatinine and cystoscopy in terms of cost analysis.     

Displaced intracapsular hip fractures: hemiarthroplasty or total arthroplasty?

The role of total hip arthroplasty for the treatment of displaced intracapsular fractures of the proximal femur in active patients is controversial. Some authors have shown that such patients, when treated with a bipolar or unipolar hemiarthroplasty, are at increased risk of having acetabular erosion develop that might require later revision to a total hip replacement. In fact, the results of some authors were not substantially different from those reported for elective total hip arthroplasty and were better than results reported for hemiarthroplasty. However, other authors have strongly recommended avoiding total hip replacement in active elderly patients without preexisting acetabular disease (osteoarthritis, rheumatoid arthritis, Paget's disease). Although the current belief is that there is a place for primary total hip arthroplasty after intracapsular hip fracture, and that this procedure should be reserved for patients with preexisting symptomatic acetabular disease, in a preliminary prospective comparative study of 46 active patients without preexisting acetabular disease, the current author found better results with cemented Charnley's total hip arthroplasty than with cemented Thompson's hemiarthroplasty. Long-term outcome and more detailed indications for total hip replacement as the primary treatment for intracapsular displaced fractures of the proximal femur are topics for additional study.     

Is a ureteral stent required before flexible ureteroscopy?

BackgroundTo retrospectively evaluate the therapeutic effectiveness and safety of flexible ureteroscopes without preoperative ureteral stent placement.MethodsA total of 243 patients who had undergone flexible ureteroscopy (fURS) lithotripsy were reviewed. The patients were divided into two groups: 119 patients without preoperative ureteral stent placement were set as group A; and the remaining 124 patients who received preoperative ureteral stent placement were set as group B. The operative time, length of hospital stay, hospital costs, stone-free rates (SFRs), complications, and re-operation rates of the two groups were respectively compared.ResultsPairwise analysis indicated the following: the average operative time of group A was longer than that of group B (66.53±10.19 versus 59.85±9.85 min, P=0.0001), the average length of hospital stay of group A was considerably shorter than that of group B (6.56±0.90 versus 10.67±1.50 d, P=0.0001), the SFRs of group A were significantly lower than those of group B at 3 days postoperatively (36.1%, 43/119 versus 51.6%, 64/124, P=0.0034), and the average hospital costs were substantially lower in group A than those in group B (18,756 versus 23,450 RMB, P=0.0001). However, there were no notable differences observed in the following: SFRs between the groups at 1 month postoperatively (84.0%, 100/119 of group A versus 85.5%, 106/124 of group B, P=0.895), complications rates (20.1%, 26/124 in group A versus 20.1%, 23/114 in group B, P=0.597), and re-operation rates (15.1%, 18/119 in group A versus 16.9%, 21/124 in group B, P=0.558).ConclusionsThese results indicated that fURS without preoperative ureteral stent placement is safe and effective for the treatment of upper urinary calculi.     

Is wound drainage necessary in hip arthroplasty? A meta-analysis of randomized controlled trials

Purpose

The use of closed suction drainage systems for hip arthroplasty (HA) is a common practice. However, the effectiveness and safety are still questionable. Thus, the aim of this meta-analysis was to review the advantages and adverse effects of closed suction drainage systems in hip arthroplasty.

Methods

All randomized or quasi-randomized trials comparing the use of closed suction drainage systems with no drainage systems for hip arthroplasty were searched in PubMed, Medicine, EMBASE and other internet databases. We assessed the methodological quality of the studies and abstracted the relevant data independently.

Results

Sixteen studies involving 1,663 participants with surgical wounds comparing HA with and without the use of drainage were included in our analysis. Our results demonstrated blood transfusion was required more frequently the same as the persistent discharge in those who received drains. No significant differences in the incidence of wound hematoma, dehiscence or deep vein thrombosis were found between those allocated to drains and the non-drained wounds. Wound infection and the range of movement of the joint after surgery were similar between the two groups.

Conclusions

Based on the current evidence, there is insufficient evidence to support the routine use of closed suction drainage in hip arthroplasty. At the same time, our meta-analysis study suggested that using of closed suction drainage in HA increased requirement for postoperative blood transfusion. However, there is a moderate possibility of selection bias and publication bias in this review. Because of the limited number of studies which may weaken the strength of the evidence of our results, more samples, high-quality randomized trials are needed to increase the reliability of evidences.

Level of evidence

II.     

Is there a difference in outcome when treating traumatic intraperitoneal bladder rupture with or without a suprapubic tube?

PURPOSE: Primary bladder repair with a suprapubic tube is considered to be effective for managing intraperitoneal bladder injury. We compared the outcomes of suprapubic tube placement and no suprapubic tube for this injury. MATERIALS AND METHODS: We reviewed the charts of 31 men and 3 women with a mean age of 28.5 years who required emergency operative repair without a cystogram of traumatic bladder injury from 1992 to 1997. Patient characteristics, mechanism of injury, associated injuries, and short and long-term complications were reviewed. RESULTS: Penetrating and blunt trauma occurred in 28 (82%) and 5 (15%) patients, respectively, while 1 had spontaneous bladder rupture. After primary bladder repair the bladder was drained with a suprapubic tube in 18 cases (53%) and a urethral catheter only in 16 (47%). There were no significant differences between the 2 groups with respect to mechanism of injury, patient age, location of injury in the bladder, coexisting medical illnesses, stability in the field or emergency room, or the bladder repair technique. The 18 patients treated with a suprapubic tube had an associated injury that resulted in 2 deaths, while 13 of the 16 treated with urethral catheter drainage only had an associated injury and 1 died. Urological and nonurological complications in the suprapubic tube versus urethral catheter only group developed in 28 and 33 versus 19 and 19% of the cases, respectively (p <0.05). Followup ranged from 1 month to 4 years. No significant long-term morbidity was noted in either group. CONCLUSIONS: These data indicate that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and urethral catheter drainage only versus suprapubic tube drainage.     

Prolonged antibiotic prophylaxis in tissue reconstruction using autologous fat grafting: Is there a benefit for wound healing?

Fat grafting is a well‐established method in plastic surgery. Despite many technical advances, standardised recommendations for the use of prophylactic antibiotics in fat grafting are not available. This retrospective multicentre study aims to analyse the use of prophylactic antibiotics in fat grafting and to compare complication rates for different protocols. A retrospective medical chart review of 340 patients treated with fat grafting of the breast from January 2007 to March 2019 was performed in three plastic surgery centres. Complications, outcomes, and antibiotic regimes were analysed. The Clavien‐Dindo classification was applied. All patients received perioperative antibiotic prophylaxis: 33.8% (n = 115) were treated with a single shot (group 1), 66.2% (n = 225) received a prolonged antibiotic scheme (group 2). There was no significant difference in the number of sessions (P = .475). The overall complication rate was 21.6% (n = 75), including graft resorption, fat necrosis, infection, and wound healing problems. Complication rates were not significantly different between groups. Risk factors for elevated complication rates in this specific patient group are smoking, chemotherapy, and irradiation therapy. The complication rate for lipografting of the breast is low, and it is not correlated to the antibiotic protocol. The use of prolonged prophylactic antibiotics does not lower the complication rate.     

Is a long leg a risk for hip or knee osteoarthritis?

Background and purpose — 7% of the asymptomatic population has leg-length inequality (LLI) greater than 12?mm. It has been proposed that LLI of >5?mm can be associated with an increased risk of osteoarthritis (OA) of the knee and hip. We studied a possible association between LLI and OA of the knee and hip joint.

Patients and methods — We followed 193 individuals (97 women, 96 men) for 29 years. The initial mean age of the participants was 43 (34–54) years, and they had no clinical histories or signs of leg symptoms. The initial standing radiographs of their hips were re-examined and measured for LLI and signs of OA. None had any signs of OA. At the follow-up, data on performed hip or knee arthroplasties were obtained.

Results — 24 (12%) of the subjects had no discernible leg-length difference, 62 (32%), had LLIs of 1–4?mm, 74 (38%) of 5–8?mm, 21 (11%) of 9–12?mm, and 12 (6%) of over 12?mm. 16 (8%) of the subjects had undergone arthroplasty for primary OA during follow-up, and of those, 8 for both hip and knee OA. 10 individuals had undergone an arthroplasty of the longer leg and only 3 of the shorter leg. In the group of equal leg length, 3 had had an arthroplasty of hip or knee.

Interpretation — We noted that hip or knee arthroplasty due to primary OA had been done 3 times more often to the longer leg than to the shorter.     

Does using a modular variable offset hemiarthroplasty reduce length of stay after hip fracture? Early experience with the Exeter Unipolar hemiarthroplasty

Purpose

The Exeter Unipolar hemiarthroplasty is a variable offset modular device. We compared the early results of the Exeter Unipolar (Exeter) with the Cemented Thompson (Thompson) hemiarthroplasty in a retrospective cohort study.

Methods

One hundred and twenty-three patients underwent Thompson (n?=?68) or Exeter (n?=?55) hemiarthroplasty by 24 different primary surgeons.

Results

Median follow-up was 9 months (interquartile range (IQR) 6–11, Range 3–13). Median length of stay was lower in the Exeter group 5.72 days (IQR 4.01–7.95, Range 2.7–33.7) vs 6.99 days (IQR 4.58–9.24, Range 1.2–59), p?=?0.048. Median time to discharge from rehabilitation was also lower in the Exeter group (13.6 days (IQR 11.0–23.8, Range 5.8–59) vs 21.7 days (IQR 16.0–31.2, Range 1.2–86.3), p?=?0.0003). Three Thompson prostheses dislocated, there was one deep infection and one superficial wound infection. One Exeter prosthesis became infected requiring revision; there were no dislocations. There were no statistically significant differences between groups in other factors studied. Power analysis suggested these differences should have been observed if present. Rehabilitation was faster in the Exeter group. This might result from more accurate restoration of femoral neck offset during surgery. The higher cost of the Exeter prosthesis is likely to be offset by the reduction in length of hospital stay.

Conclusions

The Exeter Unipolar hemiarthroplasty reduces length of stay and hastens rehabilitation after hip fracture.     

Is there a role for sustainable medicine in wound care?

Is it ethical to prolong life by providing aggressive palliative care to chronically ill patients with a short life expectancy? Here, Andrea Cavicchioli argues that epidemiology studies can help us to resolve this difficult ethical dilemma.     

No drain, autologous transfusion drain or suction drain? A randomised prospective study in total hip replacement surgery of 168 patients

We performed a prospective, randomised controlled trial to assess the differences in the use of a conventional suction drain, an Autologous Blood Transfusion (ABT) drain and no drain, in 168 patients. There was no significant difference between the drainage from ABT drains ( mean : 345 ml) and the suction drain (314 ml). Forty percent of patients receiving a suction drain had a haemoglobin level less than 10 g/dL at 24 hours, compared to 35% with no drain and 28% with an ABT drain. Patients that had no drains had wounds that were dry significantly sooner, mean 3.0 days compared to a mean of 3.9 days with an ABT drain and a mean of 4 days with a suction drain. Patients that did not have a drain inserted stayed in hospital a significantly shorter period of time, compared with drains. We feel the benefits of quicker drying wounds, shorter hospital stays and the economic savings justify the conclusion that no drain is required after hip replacement.     

Is a drain tube necessary for minimally invasive lumbar spine fusion surgery?

Purpose

This study aimed to evaluate if closed suction wound drainage is necessary in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF).

Methods

This is a prospective randomized clinical study. Fifty-six patients who underwent MIS TLIF were randomly divided into groups A (with a closed suction wound drainage) and B (without tube drainage). Surgical duration, intraoperative blood loss, timing of ambulation, length of hospital stay and complications were recorded. Patients were followed up for an average of 25.3 months. Clinical outcome was assessed using the Oswestry disability index and visual analogue scale (VAS). Fusion rate was classified with the Bridwell grading system, based on plain radiograph.

Results

Both groups had similar patient demographics. The use of drains had no significant influence on perioperative parameters including operative time, estimated blood loss, length of stay and complications. Patients in group B started ambulation 1 day earlier than patients in group A (p < 0.001). Clinical outcomes were comparable between group A and group B.

Conclusion

A drain tube can lead to pain, anxiety and discomfort during the postoperative period. We conclude that drain tubes are not necessary for MIS TLIF. Patients without drains had the benefit of earlier ambulation than those with drains.

     

Incidence of periprosthetic fractures after hip hemiarthroplasty: Are uncemented prostheses unsafe?

Displaced intracapsular fractures of the neck of femur are routinely treated in the elderly with either cemented or uncemented hemiarthroplasty. Recent evidence suggests a superior outcome with the use of cement, but uncemented prostheses are still employed for those with multiple co-morbidities or particular frailty. In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) recommendations are used to identify which patients should receive a cemented prosthesis. These are simply based upon the presence of cardiorespiratory disease, particularly in the frail elderly patient.     

Intraoperative subcutaneous wound closing culture sample: a predicting factor for periprosthetic infection after hip- and knee-replacement?

Introduction  

It is unknown whether intraoperative subcutaneous wound closing culture samples (WCCS) are useful to predict periprosthetic joint infection (PJI).