Practice in rehabilitation after cartilage therapy: an expert survey

Background

Current cartilage therapy modalities like microfracture, ACT/MACT, AMIC or osteochondral transplantation are important tools to treat symptomatic (osteo)chondral lesions of the knee joint. However, until now there exists no high-level evidence based accepted rehabilitation plan for the postoperative treatment.

Hypothesis/purpose

This survey describes the predominantly used rehabilitation plan as implemented by expert musculoskeletal surgeons for operatively treated (osteo)chondral lesions.

Study design

Survey and systematic review.

Methods

An electronic questionnaire covering general and specific items concerning aftercare following cartilage therapy in the knee joint was designed and disposed to analyze rehabilitation programs among a population of expert musculoskeletal surgeons of the AGA (Society of arthroscopy and joint surgery). All instructors (304 in 01/2011) were included into the survey. A total of 246 (80.9 %) instructors answered the questionnaire.

Results

The predominant used therapy to treat cartilage lesions is microfracture and for osteochondral lesions the osteochondral transplantation. Physiotherapy starts directly after surgery and takes more than 6 weeks. Most surgeons do not immobilize patients after surgery and use partial weight-bearing for up to 5 weeks. The change from partial to full weight-bearing is done step-wise with a 20-kg/week increase. Free ROM is allowed by the majority of instructors (55 %) directly after surgery. A CPM-device is also used directly and up to 5 weeks. Swimming and biking are allowed after 6 weeks, running is allowed after 12 weeks and contact sports after 24 weeks. Most instructors do not use braces in the aftercare procedure, but nearly all (93 %) prescribe crutches. Typical drugs used during the aftercare are NSAID, Heparin and antibiotics. For most instructors (79 % respectively 75 %) knee stability and a straight leg axis are necessary for a successful cartilage therapy. If a concomitant therapy like ACL reconstruction or an osteotomy is performed, aftercare is mainly dependent on cartilage therapy (62 % respectively 59 % of instructors).

Conclusions

Today there exists no detailed rehabilitation program for treatment after a cartilage-related operation on the basis of an evidence-based level I study. The reason might be that many variables contribute to a specific aftercare procedure. Therefore, the survey of experienced surgeons may help to identify the most promising rehabilitation regime for today, at least until evidence-based level I studies are accomplished.     

Welchen Erfolg bringt die Sigmaresektion bei der akuten Sigmadivertikulitis tatsächlich?

Introduction

The correct therapeutic management of acute sigmoid diverticulitis (SD) is still controversially discussed. Essential to the success of therapy is primarily the long-term resolution of Patient symptoms after surgical or conservative therapy. The aim of this study was to compare the long-term outcome after conservative and surgical treatment of Patients with acute SD.

Patients and methods

Consecutive admissions of all Patients with acute SD were prospectively recruited from January 2005 to June 2008 with the exception of a free perforation. The following data were recorded: age, sex, first or recurrent episode of SD, computed tomography (CT) stage, white blood cell count, C-reactive protein, persistent symptoms and recurrence after conservative and surgical therapy. Furthermore, information on the rates of postoperative sexual and bladder dysfunction was collected. The long-term outcome was evaluated by a standardized questionnaire. In June 2008 all Patients were contacted using a standardized questionnaire.

Results

A total of 153 Patients were included in the study of whom 70 (45.8 ?%) presented with the first episode, 83 (54.2 ?%) had a prior history of SD and 40 Patients were treated conservatively whereas 113 Patients were surgically treated by sigmoid resection. Uncomplicated SD was seen in 16 Patients (conservative 4, surgical 12, p?=?0.961), phlegmonous SD was seen in 88 cases (conservative 29, surgical 59, p?=?0.026) and covered perforated SD in 49 cases (conservative 7, surgical 42, p?=?0.022). The median follow-up was 32 months (range 12–52 months). At follow-up 25? % of conservative and 8.8 ?% of Patients treated surgically complained about persistent symptoms (p?=?0.009). The following symptoms occurred (conservative vs. surgery): painful defecation (22.5? % versus 8.8 ?%, p?=?0.024.), constipation (25 ?% versus 8.8 ?%, p?=?0.009), abdominal cramp (22.5 % versus 4.4 ?%, p?=?0.001) and painful flatulence (25 ?% versus 8.8 ?%, p?=?0.009). Sexual or bladder dysfunction occurred postoperatively in 7 ?% and 9 ?%, respectively. Of the conservatively treated Patients 32.5? % had a recurrence of SD during follow-up compared to 3.5?% of surgically treated Patients (p?<?0.001).

Conclusions

Surgical treatment of acute SD is more effective than conservative therapy for the prophylaxis of recurrent SD and avoidance of persistent symptoms.     

Anaplastic astrocytomas: survival and prognostic factors in a surgical series

Background

To study patient characteristics, prognostic factors and overall survival (OS) in a consecutive, surgical series of WHO grade III anaplastic astrocytomas (AA).

Methods

Patients were identified from a prospective tumor database at Oslo University Hospital, Norway, and patients undergoing surgery for an AA from 2005–2012 were included. Patients’ medical charts were retrospectively reviewed for data collection.

Results

A total of 99 adult patients with histologically verified AA were included. Median age was 52 years (20–81). Biopsy was conducted in 33 % and resection in 67 %. Adjuvant treatment with radiation therapy + temozolomide or radiation therapy only was given in 63 % and 26 %, respectively. The thirty-day mortality rate was 3 %. Median OS was 19 months (95 % CI 11–27 months). Age?≥?65 years, KPS?<?70, biopsy as opposed to resection, and no adjuvant treatment were confirmed negative prognostic factors in multivariate analysis. For patients undergoing resection, presence of postoperative contrast-enhanced tumor, not volume of residual tumor, had significant impact on OS in adjusted analysis.

Conclusions

Median OS following surgery was 19 months, though much variable outcome was observed among subgroups of AA (95 % CI 11–27 months). Age ≥65 years, KPS?<?70, biopsy as opposed to resection, and no adjuvant treatment were confirmed negative prognostic factors for OS.     

Complete Cytoreduction and HIPEC Improves Survival in Desmoplastic Small Round Cell Tumor

Background

Desmoplastic small round cell tumor (DSRCT) is a rare tumor of adolescents and young adults. Less than 100 cases per year are reported in North America. Extensive peritoneal metastases are characteristic of this disease. We performed cytoreductive surgery and hyperthermic peritoneal perfusion with chemotherapy (HIPEC) using cisplatin (CDDP) for DSRCT.

Methods

A retrospective cohort study was performed on 26 pediatric and adult patients who underwent cytoreduction/HIPEC using CDDP for DSRCT at a single cancer center. Neoadjuvant chemotherapy, adjuvant chemotherapy, and postoperative enteral nutrition were given to all patients. Postoperative radiation therapy was given to most patients. Follow-up was from 6 months to 6 years. Outcome variables were evaluated for disease-free and overall survival (OS).

Results

Five patients (19 %) were less than 12 years of age at surgery. Patients who had disease outside the abdomen at surgery had a larger risk of recurrence or death than those who did not (p = 0.0158, p = 0.0393 time from surgery to death respectively). Age, liver metastasis, and peritoneal cancer index level did not significantly predict disease-free or OS. Patients who had CR0 or CR1 and HIPEC had significantly longer median survival compared with patients who had HIPEC and CR2 cytoreduction (63.4 vs. 26.7 months).

Conclusions

HIPEC may be an effective therapy for children and young adults with DSRCT. Patients with DSRCT require complete cytoreduction before HIPEC to optimize outcome. Patients with DSRCT and disease outside the abdomen at the time of surgery do not benefit from HIPEC.     

Usefulness of multi-channels in intraoperative spinal cord monitoring: multi-center study by the monitoring committee of the Japanese Society for Spine Surgery and related research

Object

The purpose of this study is to analyze the data in terms of the number of channels employed to examine the usefulness of multi-channels in intraoperative spinal cord monitoring.

Methods

The prerequisites for inclusion in the baseline data were as follows: (1) cases in which only CMAP monitoring was conducted; (2) cases in which monitoring was conducted under the same stimulation condition and the recording condition. Cases where inhalation anesthesia was used or muscle relaxants were used as maintenance anesthesia was excluded from the baseline data. Of the 6,887 cases, 884 cases met the criteria. The items examined for each of the different numbers of channels were the sensitivity and specificity, the false positive rate, the false negative rate, and the coverage rate of postoperative motor deficit muscles.

Result

To examine these two items in terms of the number of channels, the 4-channel group had lower sensitivity and specificity scores compared with the 8- and 16-channel groups (4 channels 73/93 %, 8 channels 100/97 %, 16 channels 100/95 %). Only four channels were derived for these cases and the coverage of postoperative motor deficit muscles was 38 % with only 30 out of the 80 postoperative motor deficit muscles in total being monitored. In the 8-channel group, it was 60 % with 12 of the 20 postoperative motor deficit muscles being monitored. The 16-channel group had 100 % coverage rate of postoperative motor deficit muscles.

Conclusion

We suggest that multi-channel monitoring of at least eight channels is desirable for intraoperative spinal cord monitoring.     

Reverse total shoulder arthroplasty after failed deltoid flap reconstruction

Hypothesis

Reverse shoulder arthroplasty (RSA) yields unsatisfactory results after deltoid flap reconstruction due to defect of the deltoid muscle.

Methods

We retrospectively reviewed the outcome of 19 patients after failed deltoid flap reconstruction treated with RSA. Follow-up was after a mean of 4.5 years.

Results

Seven patients (37 %) had nine postoperative complications requiring totally 16 revision surgeries. Nonetheless, at latest follow-up, 17 patients had no or mild, two had moderate, and none had severe pain. Before RSA; 13 patients had a pseudoparesis. At latest follow-up, none of the patients had a pseudoparesis. Mean flexion was 121° (90°–160°). Abduction strength averaged 2.3 kg (range 0–5.4 kg). The mean constant score was 70 % (range 28–98 %). Of the 19 patients, 15 were very satisfied with the outcome, four were satisfied, and none was dissatisfied. The mean overall subjective shoulder value was 73 % (30–95 %) of the value of a normal shoulder.

Conclusions

Despite of a localized defect of the deltoid muscle after deltoid flap repair, RSA can reliably be associated with a satisfactory outcome.     

Reduction of Postoperative Complication Rate with the Use of Early Oral Feeding in Gynecologic Oncologic Patients Undergoing a Major Surgery: A Randomized Controlled Trial

Background

A randomized controlled trial was performed to assess the outcome of early oral postoperative feeding (EOF) compared with traditional oral feeding (TOF) in gynecologic oncology patients undergoing a complex laparotomy, including upper abdominal surgery.

Methods

Patients aged 18–75 years, undergoing an elective laparotomy and with a preoperative suspicion of gynecologic malignancy, were eligible. Exclusion criteria included infectious conditions, intestinal obstruction, severe malnutrition, American Society of Anesthesiologists score ≥4, intestinal resection, and postoperative stay in the intensive care unit lasting >24 h. Patients allocated to EOF received liquid diet in the first postoperative day and then regular diet. Patients received traditional feeding scheme until resolution of postoperative ileus to start liquid diet. The primary end-point of the trial was length of hospital stay.

Results

Between January 1, 2007, and November 17, 2007, a total of 143 patients were randomized to receive either EOF or TOF. Hospital stay for patients who received EOF (n = 71) was 4.7 vs. 5.8 days for the TOF group (n = 72) (P = 0.006). The mean level of postoperative satisfaction was significantly higher in the EOF group (82.8 vs. 71.7 mm, P ≤ 0.001). Patients who received the TOF scheme had significantly higher overall postoperative complications (39 vs. 17% in EOF group, P = 0.003) and infective complications (14% in TOF group vs. 3% in EOF group, P = 0.017). Variables such as nausea and vomiting, analgesic and antiemetic requirement as well as level of pain and quality of life were not different between groups.

Conclusions

On the basis of these findings, the policy of EOF should be used after a complex gynecologic oncologic laparotomy.     

Course of Ionized Calcium After Thyroidectomy

Background

The goal of the present study was to investigate the course of ionized calcium after thyroidectomy and to define a cut-off value that indicates symptoms of hypocalcemia.

Methods

The sample included 333 patients undergoing thyroidectomy at the University Hospital of UFMG between September 2000 and December 2005. Ionized calcium was determined before and after surgery (days 1, 2, and 30) in all patients and on postoperative days 90 and 180 in those with hypocalcemia. Asymptomatic patients received no calcium replacement therapy, irrespective of calcium concentration. Patients with clinical manifestation of hypocalcemia were treated after laboratory confirmation. The presence or absence of postoperative hypocalcemia was associated with ionized calcium concentration measured on the reported days.

Results

Ionized calcium declined on the first two days after surgery in all patients when compared to preoperative levels (P = 0.000). Forty-seven (34.6%) of the 136 (40.8%) patients with postoperative hypocalcemia had symptoms. Patients with symptomatic hypocalcemia had significantly lower ionized calcium levels than those with asymptomatic hypocalcemia (P = 0.001). Fourteen (4.2%) patients progressed to definitive hypoparathyroidism by the end of 6 months.

Conclusions

Measurement of ionized calcium on postoperative days 1 and 2 is sufficient for the evaluation of post-thyroidectomy hypocalcemia. Ionized calcium concentrations <1.03 mmol/l on postoperative day 1 are indicative of the presence of symptoms and the need for treatment.     

Prognosis in Women with Breast Cancer and Private Extra Insurance Coverage

Background

Many women covered by the Spanish public health system also have an extra private insurance policy for gynecological examinations and routine annual mammography. We retrospectively analyzed the long-term survival rates in these patients when diagnosed with breast cancer.

Methods

We analyzed the survival and prognostic factors in patients diagnosed with breast cancer who were referred to a medical oncology unit for multidisciplinary treatment covered by private health insurance.

Results

Between 1994 and 2009, a total of 434 patients with breast tumor were analyzed: 33 in situ and 401 infiltrating. Among the infiltrating carcinomas, 38 were stage IV and 363 were stage I, II, or III. With a median follow-up of 62 months, the 5-year global survival rate was 91 %: 97 % for stage I, 94 % for stage II, and 77 % for stage III tumors. In the patients diagnosed by routine mammography, the 5-year survival rate was 96 %, compared with 86 % in those consulting their gynecologist after breast self-examination or for other symptoms (p = 0.0159). Seventy-four percent were treated conservatively and experienced better survival than the 26 % who underwent mastectomy (p = 0.0024). Patients with disease with positive hormone receptors had a better survival rate (p = 0.0264); hormone receptor status was the only independent prognostic factor in the Cox multivariate analysis. Postmenopausal patients who received adjuvant tamoxifen plus exemestane had a better prognosis than those who received tamoxifen alone (p = 0.0203).

Conclusions

Long-term survival rate was high in breast cancer patients with extra private insurance coverage. This is probably because disease was diagnosed at an early stage.     

Characteristics of emergency department transfers for hand surgery consultation

Background

The purpose of this study was to establish the characteristics of patients who are transferred from referring emergency departments (EDs) to two receiving institutions for hand-related emergencies. Our primary hypothesis was that many transferred patients would not require emergent specialty intervention. Our secondary hypotheses were that treatment would differ by day of presentation and type of insurance coverage.

Methods

We searched ED records for all hand-related cases over 1 year. We reviewed charts for demographics and treatment details. The main outcome measures were whether patients were seen by a hand surgeon or underwent surgery within 24 h of transfer.

Results

The study group comprised 296 patients. Ninety-two percent saw a specialty resident, and 48 % saw a hand surgeon. Thirty-nine percent of patients were taken to the operating room within 24 h of presentation. Of patients transferred on the weekends, 48 % saw a hand surgeon versus 61 % of those transferred on weekdays. Similarly, 51 % of patients transferred on a weekday were taken to the OR within 24 h, while 38 % of patients transferred on a weekend were taken to the OR in the same time frame.

Conclusions

More than half of transfers for hand emergencies did not result in examination by a hand surgeon, and nearly two thirds did not require a visit to the OR within 24 h. Patients transferred on the weekend were less likely to see a hand surgeon than those transferred on weekdays. Alternative methods of consultation might allow avoidance of transfer.     

Functional outcome and mortality in nonagenarians following hip fracture surgery

Introduction

The world’s population is ageing and the elderly population itself is growing older. This population shows a high incidence of hip fractures. We performed a retrospective study, reviewing the functional status, postoperative complications and mortality rate of nonagenarians who underwent surgery for hip fracture.

Methods and subjects

56 nonagenarian patients underwent hip fracture surgery in our institution between January 2000 and December 2010. Two of these patients had presented with hip fracture on separate occasions, giving a total of 58 hips for analysis. Patients with open fracture, subtrochanteric fracture, polytrauma and pathological fracture were excluded. The case notes, electronic records and X-rays for all those included in the study were reviewed. The main outcome measures were functional status, postoperative complications and mortality rate at 1 year.

Results

Patients with extracapsular hip fractures were associated with higher risks of postoperative complications (60.7 %; p = 0.037), mortality (25 %; p = 0.003) and more likely to be non-ambulant at 1 year (53.6 vs 16.7 %; p = 0.003). Females were more likely to suffer postoperative complications than males (p = 0.016). 46.6 % of the patients had immediate postoperative complications and most commonly due to urological complications (29.3 %). The 1-year mortality rate was 12.1 %. A notable proportion of patients (65.5 %) remained ambulant 1 year postoperatively, although almost half of the patients (48.3 %) who could ambulate independently pre-injury required a walking aid after hip fracture surgery.

Conclusion

Nonagenarians have good surgical outcomes after hip fracture surgery with low mortality rate. They should be treated similarly as their younger counterparts in terms of decision for surgery. Potential decline in functional status and rehabilitation options should be shared with the patient and family at an early stage.     

Comparison between patient and surgeon perception of degenerative spine disease outcomes—a prospective blinded database study

Background

Few have studied the correlation between patients’ and spine surgeons’ perception on outcomes, or compared these with patient-reported outcome scores. Outcomes studies are increasingly important in evaluating costs and benefits to patients and surgeons, and in developing metrics for payer evaluation and health care policy-making.

Objective

To compare patients’ and surgeons’ assessment of spine treatment outcome in a prospective blinded patient-driven spine surgery outcomes registry, and to correlate perceived outcomes ratings to validated outcomes scores.

Methods

Patients filled out surveys at baseline, 3 months and 6 months postoperatively, including Visual Analog Scale (VAS), and Neck Disability Index (NDI) or Oswestry Disability Index (ODI). Outcome was rated independently by patients and surgeons on a 7-point Likert-type scale.

Results

Two-hundred and sixty-five consecutive adult patients were surgical candidates. Of these, 154 (58.1 %) opted for surgery, with 69 (44.8 %) cervical and 85 (55.2 %) lumbar patients. One hundred and thirty-five (87.7 %) had both patient and surgeon postoperative ratings. Surgeons’ and patients’ ratings correlated strongly (Spearman rho?=?0.53, p?<?0.0001, 45.9 % identical, 88.2 % +/? 1 grade). The surgeon rated outcomes were better than patients in 29.8 % and worse in 21.15 %. Patient rating correlated better with the most recent NDI/ODI and pain scores than with incremental change from baseline. In multivariate analysis, age, location (cervical vs lumbar), pain ratings, and functional scores (NDI, ODI) did not have significant impact on the discrepancy between patient and surgeon ratings.

Conclusions

Patients’ and surgeons’ global outcome ratings for spinal disease correlate highly. Patients’ ratings correlate better with most recent functional scores, rather than incremental change from baseline.     

Regenerative Nodular Hyperplasia of the Liver Related to Chemotherapy: Impact on Outcome of Liver Surgery for Colorectal Metastases

Background

Regenerative nodular hyperplasia (RNH) represents the end-stage of vascular lesions of the liver induced by chemotherapy. The goal was to evaluate its incidence and impact on the outcome of patients resected for colorectal liver metastases (CLM).

Methods

Patients who underwent hepatectomy for CLM after six cycles or more of first-line chemotherapy, between January 1990 and November 2006, were included. Detailed histopathologic analysis of the nontumoral liver was performed according to a standard format.

Results

From a cohort of 856 resected patients at our institution, 771 (90%) received preoperative chemotherapy. Of these, 146 fulfilled the selection criteria and were included: 24 (16%) received 5-fluorouracil (5-FU) and leucovorin (LV) alone, 92 (63%) had 5-FU/LV and oxaliplatin, 18 (12%) had 5-FU/LV and irinotecan, and 12 (8%) were treated by 5-FU/LV, oxaliplatin, and irinotecan. RNH occurred in 22 of 146 patients (15%). Twenty of these patients (91%) received oxaliplatin, of whom six (30%) had chronomodulated therapy. Patients treated by oxaliplatin more often had RNH compared with oxaliplatin-naïve patients (22 vs. 4%). Although operative mortality was nil, the presence of RNH was associated with increased postoperative hepatic morbidity (50 vs. 29%). Elevated preoperative gamma-glutamyltransferase (GGT) (>80 U/L; >1N) and total bilirubin levels (>15 μmol/L; >1N) were independent predictors of RNH.

Conclusions

Patients with CLM who receive preoperative oxaliplatin have an increased risk of RNH and associated postoperative morbidity. Increased serum GGT and bilirubin are useful markers to predict the presence of RNH.     

Cinacalcet effects on the perioperative course of patients with secondary hyperparathyroidism

Purpose

Since its registration in 2004, the calcimimetic agent cinacalcet has been established as an alternative treatment for secondary hyperparathyroidism (SHPT). Working by allosteric activation of the calcium-sensing receptor, cinacalcet can lower parathyroid hormone (PTH) and calcium (Ca) in patients with SHPT. The influence of calcimimetics on the perioperative course has been unclear so far.

Methods

We retrospectively analyzed the data of patients with primary operation for SHPT between 2004 and 2011, comparing the perioperative course of patients with and without preoperative cinacalcet treatment.

Results

Fifty-six patients had cinacalcet therapy, and 54 patients had no calcimimetic medication prior to surgery. Gender, age, hemodialysis, and medical treatment were similar in both groups. Also, PTH levels were similar preoperatively and postoperatively (preoperative, 1,249?±?676 vs. 1,196?±?601 pg/ml; postoperative, 86?±?220 vs. 62?±?91 pg/ml). Patients with cinacalcet preoperatively had significant lower Ca levels preoperatively (2.49?±?0.25 vs. 2.61?±?0.24 mmol/l) and postoperatively (1.75?±?0.37 vs. 1.86?±?0.35 mmol/l) and had a higher rate of oral Ca substitution postoperatively (93 vs. 74 %). The risk for postoperative persistent disease was slightly higher in these patients compared to those without preoperative cinacalcet therapy (5 vs. 0 %, not significant).

Conclusions

In our experience, cinacalcet did not alter the perioperative course in SHPT patients.     

Pneumonectomy for node-positive non-small cell lung cancer: can it be a treatment option for N2 disease?

Objective

The feasibility of multimodality therapy in patients with node-positive non-small cell lung cancer (NSCLC) requiring pneumonectomy and the role of pneumonectomy in N2 disease remain controversial. This study evaluated outcomes in patients with node-positive NSCLC undergoing pneumonectomy in a community hospital.

Methods

Perioperative and long-term outcomes of 37 patients with node-positive (pN1–2) NSCLC undergoing pneumonectomy from September 1994 to April 2010 as a clinical practice were retrospectively analyzed.

Results

Twenty patients received induction therapy, and 17 received preoperative chemoradiation (30–40 Gy). Fifteen patients and 22 patients underwent right and left pneumonectomy, respectively. A postoperative complication occurred in 8 patients. In-hospital mortality occurred in 1 patient. Induction therapy did not increase the operative risk including operative time, blood loss and postoperative complications. Nineteen patients were given a diagnosis of pN2. Although 7 bulky N2 patients and 10 multi-station N2 patients were included, 5-year overall survival was 34.3 % in pN1 and 28.0 % in pN2 (p = 0.998), respectively. Twenty-three patients received additional postoperative therapy. Five patients died within 3 months postoperatively due to distant metastases. Induction therapy and laterality did not influence survival. Extended resection, such as vagus nerve or chest wall resection, predicted an unfavorable outcome in multivariate analysis (Hazard ratio 2.81, p = 0.032).

Conclusions

The safety and acceptable long-term outcome of pneumonectomy as a general clinical practice were shown for both pN1 and pN2 patients with various preoperative or postoperative therapies. Extended resection due to the extrapleural or extranodal involvement of tumor was an unfavorable prognostic factor.     

Nephrostomy in percutaneous nephrolithotomy (PCNL): does nephrostomy tube size matter? Results from The Global PCNL Study from The Clinical Research Office Endourology Society

Purpose

To explore the relationships between nephrostomy tube (NT) size and outcome of percutaneous nephrolithotomy (PCNL).

Methods

The Clinical Research Office of the Endourological Society (CROES) prospectively collected data from consecutive patients treated with PCNL over a 1-year period at 96 participating centers worldwide. This report focuses on the 3,968 patients who received a NT of known size. Preoperative, surgical procedure and outcome data were analyzed according to NT size, dividing patients into two groups, namely small-bore (SB; nephrostomy size ≤ 18 Fr) and large-bore (LB; nephrostomy size > 18 Fr) NT.

Results

Patients who received a LB NT had a significantly lower rate of hemoglobin reduction (3.0 vs. 4.3 g/dL; P < 0.001), overall complications (15.8 vs. 21.4 %; P < 0.001) and a trend toward a lower rate of fever (9.1 vs. 10.7 %). Patients receiving a LB NT conversely had a statistically, though not clinically significant, longer postoperative hospital stay (4.4 vs. 4.2 days; P = 0.027). There were no differences in urinary leakage (0.9 vs. 1.3 %, P = 0.215) or stone-free rates (79.5 vs. 78.1 %, P = 0.281) between the two groups.

Conclusions

LB NTs seem to reduce bleeding and overall complication rate. These findings would suggest that if a NT has to be placed, it should better be a LB one.     

Laparoscopic Nissen fundoplication is a good option in patients with abnormal esophageal motility

Background

Patients with gastroesophageal reflux disease (GERD) and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. Our study aim was to determine if Nissen fundoplication is associated with increased postoperative dysphagia in patients with ineffective esophageal motility.

Methods

Medical records of all adult (>18 years old) patients who underwent laparoscopic Nissen fundoplication for GERD over 8 years were reviewed retrospectively. Of the 151 patients, 28 (group A) met manometric criteria for abnormal esophageal motility (<30 mmHg mean contractile pressure or <80% peristalsis), whereas 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. Follow-up time ranged from 1 month to 5 years. Outcomes (postoperative dysphagia, recurrence of GERD symptoms, free of medications) were compared between groups.

Results

Group A had higher age and American Society of Anesthesiologists (ASA) score (p = 0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up time, there was no significant difference between the groups (p = 0.94). Group B had more cases of recurrent heartburn (10.7% versus 3.6%, p = 0.039), and more patients in this group were back on medications (21.4% versus 7.1%, p < 0.05)

Conclusions

This retrospective study found equally low rates of dysphagia following Nissen fundoplication regardless of baseline esophageal motility. Preoperative esophageal dysmotility therefore does not seem to be a contraindication for laparoscopic Nissen fundoplication.     

Impaction bone grafting and a cemented cup after acetabular fracture

Purpose

Patients suffering from post traumatic osteoarthritis of the acetabulum often require a total hip arthroplasty at a relatively young age. Long-term data outcome studies for this population are lacking. We report on the long-term outcome of 20 acetabular fractures in 20 patients treated with impaction bone grafting and a cemented cup after a mean follow-up of 18 years (range, 12–26 years).

Methods

The group consisted of 14 males (70 %) and six females (30 %) with an average age of 53.3 years (range, 35–75 years) at time of surgery. No patients were lost to follow-up. Four patients died and three patients underwent a revision; at review 13 patients were still living with their implant in situ. Survivorship analysis was performed at 20 years follow-up for three endpoints.

Results

Survival rate with endpoint revision for any reason at 20 years postoperative was 74.7 % (95 % confidence interval (CI), 40–91 %), 80.0 % (95 % CI, 41–95 %) for endpoint aseptic loosening, and 63.9 % (95 % CI 32–84 %) for endpoint radiographic failure. Three acetabular components were revised at 14.5, 15.3, and 16.7 years postoperative. Two cups failed for aseptic loosening and one cup failed due to septic loosening. The average postoperative Harris hip score was 82 (range, 56–100).

Conclusion

Acetabular reconstruction with impaction bone grafting and the use of a cemented cup after acetabular fracture is an attractive technique with acceptable long-term results and a low complication and re-operation rate.