Revision hip surgery in the elderly: Is it worthwhile?

We prospectively analyzed the outcome in 103 consecutive patients undergoing revision hip replacement, dividing the patients into 2 groups according to their age at the time of surgery. There were 45 patients aged 75 years or older and 58 patients aged younger than 75 years. The results of revision hip replacement in terms of pain relief, functional improvement, and patient satisfaction did not differ between the 2 groups. There was a significantly higher death rate among the elderly patients (13.3% versus 1.7%; P = .0202) and a significantly higher rate of dislocation (20% versus 1.7%; P = .0019). We conclude that revision hip replacement is an effective operation in the elderly, but that patient and surgeon must be aware of the risks that such surgery entails.     

Allergy in total knee replacement surgery: Is it a real problem?

Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.     

Role of the forearm interosseous ligament: is it more than just longitudinal load transfer?

The objective of our study was to measure 3-dimensional force vectors (magnitude and direction) acting in the forearm when load is applied to the hand and to measure the actual force in the interosseous ligament (IOL). Fourteen cadaveric forearms were loaded to 136 N of compression while special load cells measured force vectors in the forearm. Computer forearm models were used to display the 3-dimensional force vector directions. The study results showed that the radius bears most of the load at the wrist but load on the radius at the elbow is reduced because the IOL transfers load to the ulna between the wrist and the elbow. In addition to this role in longitudinal load transfer, our measurement of 3-dimensional forces allowed identification of transverse vectors which suggest that the IOL also functions to keep the radius and ulna from splaying apart. Our results imply that the IOL participates not only in longitudinal load transfer but also in the maintenance of transverse stability of the forearm during compressive load transfer from the hand to the elbow.     

Recurrent pyloric stenosis: to dilate or operate? A preliminary report

Purpose

Idiopathic hypertrophic pyloric stenosis is a common surgical problem in infants, and pyloromyotomy is almost always successful in alleviating the obstruction. There are few reports in the literature that discuss recurrent pyloric stenosis as opposed to incomplete pyloromyotomy. We report 2 such babies with different cures.

Methods

The health records department files were electronically searched for the number of infants at our children's hospital with hypertrophic pyloric stenosis seen over the past 30 years (1973-2003), and the recurrences were reviewed.

Results

Recurrent pyloric stenosis was encountered in 2 cases (<0.07%). Balloon dilatation was first tried in both cases and was successful in 1 case; redo pyloromyotomy was required for the second case.

Conclusion

Recurrent pyloric stenosis is rare. Fluoroscopic balloon dilatation of the pylorus warrants further study as the first choice for curing this problem, and if unsuccessful, redo pyloromyotomy.     

Is there a role for lengthening flexor hallucis and flexor digitorum longus tendons in surgery for club foot?: a preliminary report

Most cases of club foot (congenital talipes equinovarus) respond to non-operative treatment but resistant cases may need surgery. It is broadly accepted that lengthening of tendo Achillis, the tendon of tibialis posterior and capsulotomy of the ankle and subtalar joints are necessary during surgical release, but there is no consensus as to whether lengthening of the tendons of flexor hallucis longus and flexor digitorum longus is required. We randomised 13 children with severe bilateral club foot deformities to undergo lengthening of the flexor hallucis longus and flexor digitorum longus tendons on one side and simple decompression on the other. We found no difference in the deformities of the toes between the lengthened and non-lengthened sides at a mean follow-up of four years (2 to 6). We conclude that routine lengthening of the tendons of flexor hallucis longus and flexor digitorum longus during soft-tissue surgery for resistant club foot is not necessary.     

Costovertebral rib disarticulation and pleurectomy in Askin's tumor: a mandatory approach to radical surgery in children? Case report and guiedelines to surgical treatment

The case report of Askin's tumor in a 16-year-old girl is focused on the still debatable surgical contg roversy in the treatment of PNET tumor, i.e., whether disarticulation of involved rib at the costovertabral joint should be accepted as the mandatory surgical procedure. It was concluded that the procedure, if feasible, may offer better prognosis of PNET because progression-free survival rate of patients without costovertebral junction involvement reported in multicenter studies was statistically significantly better than in patients in whom PNET has involved the costovertebral junction or bone metastases were present at the diagnosis. The cartilage is a natural barrier for tumor spread and this property should be augmented by radical surgery. Disarticulation of involved rib or ribs and pleurectomy should be routinely performed if the surgery is contemplated with proper timing between the cycles of induction chemotherapy.     

Directed blood donation in pediatric general surgery: Is it worth it?

PURPOSE: To date, there are no data to support the safety, efficacy, and cost-benefit ratio of donor-directed blood donation (DD). The objectives were to determine whether a DD program in pediatric general surgery practice is justified. METHODS: A retrospective analysis was conducted of the transfusion practice and all DD requests received by transfusion services in a full calendar year (1997) at a tertiary care pediatric hospital. The authors examined the donations, utilization, and possible benefits for the recipients. RESULTS: A total of 22,527 units of blood were transfused in 1997. General surgery used 471 (2%) of the total and 471 of 4,825 (10%) of all surgical transfusions. Total DD requests were 219 with only 11 of 219 (5%) originating from the general surgery department. After all the exclusions, 133 of 219 (61%) requests had DD blood available. DD blood had a higher true-positive rate for transmissible disease (1.1% v 0.10%), high-risk activity (2.5% v 1.2%), and malaria risk (3.1% v 0.31%). Total utilization of DD blood was 132 of 236 units (55.9%) and general surgery utilized 4 of 11 (36.4%) of their directed donations. Thirty-seven patients (27.8%) benefited from decreased donor exposure. No general surgery patient received more than 1 blood component to benefit from decreased donor exposure. CONCLUSIONS: DD deferral rates are higher than for volunteer donors for infectious disease markers, malaria, and high-risk activities. There is no evidence that DD is safer than volunteer donation. DD blood wastage of 63.6% is much higher than in volunteer donation (7%). Thirty-seven patients (28%) received multiple units from one donor suggesting a benefit from decreased donor exposure. Given the low frequency of transfusion and the poor utilization of DD in general surgical practice, a DD program is not justified.     

Interscalene block in day case open shoulder surgery—a preliminary report

A prospective study of 43 patients undergoing day case open shoulder surgery under general anaesthesia was performed. All patients received an interscalene block for post-operative analgesia. Pre and post-operative pain scores, time to first dose of analgesia and patient satisfaction were recorded. Interscalene blockade provided good pain relief for up to 12 h in the majority of patients. Two patients were admitted due to inadequate pain relief and one complication of interscalene block was recorded.