Reasons for revision hip surgery: a retrospective review

The purpose of this study was to determine the indications for contemporary revision hip surgery in a consecutive series of patients. We retrospectively reviewed the clinical records and radiographs of 439 revision hip surgeries done between 1996 and 2003. Fifty-five percent of the surgeries were for aseptic loosening, 14% were for instability, 13% were for osteolysis around a well-fixed implant, 7% were for infection, 5% were for periprosthetic fracture, 3% were for conversion of a hemiarthroplasty, 1% was for psoas impingement, 1% was for loose recalled implants, and 1% was for implant fracture. As expected, aseptic loosening was the most common reason for revision surgery. Instability was a common reason for early revision whereas revision for osteolysis around a well-fixed implant was a more common reason for late revision.     

Health complaints, remedies and medical assistance in a peri-urban area

A questionnaire was used to assess health complaints, remedies, type of medical assistance sought for health complaints, reasons for attendance and frequency of utilisation in a developing peri-urban black community near Pretoria. The most frequently mentioned health complaints were gastric problems, coughing and dental problems. Remedies included laxatives for gastric problems, cough mixture for fever and coughing, extraction for dental problems, rubbing ointment or spirit for aching joints, and eye drops for ophthalmic problems. For medical assistance, 54% had been to a clinic, 12% to a chemist, 11% to hospital and 9% to a doctor. Major reasons for attendance were for diagnosis and treatment at the clinic, hospital or doctor and for medicine collection from the chemist. Over a 6-month period, the majority had made one visit to a chemist or general practitioner and two visits to a clinic. It was concluded that Western-type medicine was used for a wide variety of common health complaints.     

Two-port robotic hysterectomy: a novel approach

The objective of the study was to demonstrate a novel technique for two-port robotic hysterectomy with a particular focus on the challenging portions of the procedure. The study is designed as a technical video, showing step-by-step a two-port robotic hysterectomy approach (Canadian Task Force classification level III). IRB approval was not required for this study. The benefits of minimally invasive surgery for gynecological pathology have been clearly documented in multiple studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis and quality of life. Most gynecological surgeons require 3–5 ports for the standard gynecological procedure. Even though the minimally invasive multiport system provides an excellent safety profile, multiple incisions are associated with a greater risk for morbidity including infection, pain, and hernia. In the past decade, various new methods have emerged to minimize the number of ports used in gynecological surgery. The interventions employed were a two-port robotic hysterectomy, using a camera port plus one robotic arm, with a focus on salpingectomy and cuff closure. We describe a transvaginal and a transabdominal approach for salpingectomy and a novel method for cuff closure. The transvaginal and transabdominal techniques for salpingectomy for two-port robotic-assisted hysterectomy provide excellent tension and exposure for a safe procedure without the need for an extra port. We also describe a transvaginal technique to place the vaginal cuff on tension during closure. With the necessary set of skills on a carefully chosen patient, two-port robotic-assisted total laparoscopic hysterectomy is a feasible procedure.     

Population screening for low bone mineral density: Do non-attenders have a lower risk of osteoporosis?

Poor compliance may be detrimental to the effectiveness of a screening programme if those at greatest risk of the disease do not attend. Therefore we undertook a study to test whether non-attenders to a screening programme for low bone density, a risk factor for osteoporosis, were at a differential risk of low bone density compared with attenders. Seven hundred and eighty-nine women aged 45–49 years living within 32 km of Aberdeen were selected at random from the Community Health Index and invited to attend for screening for low bone density as a risk of factor for osteoporosis. Attenders and non-attenders were surveyed regarding their risk factors for osteoporosis. Non-attenders were significantly heavier than attenders. In addition, 6 non-attenders who subsequently chose to attend had significantly higher body weight and bone mineral density, at Ward's triangle, than initial attenders. Non-attenders to a screening service for bone density may be at lower risk of developing osteoporosis. Non-attendance, therefore, would not be detrimental to the cost-effectiveness of a screening service for bone density. However, this study indicates there is a potential for response bias in studies of bone density and osteoporosis.     

Can radiotherapy be a viable salvage treatment option for the relapsed seminoma confined to the infra-diaphragm region recurring after primary chemotherapy for bulky stage II seminoma?

There has been a paucity of research describing a potential role of radiotherapy as salvage treatment for recurrent seminoma following primary chemotherapy for bulky stage IIC seminoma. We report a case of a bulky stage IIC seminoma relapsed in the pelvis after primary chemotherapy and surgery for post-chemotherapy residual mass, which was subsequently salvaged with radiotherapy. The patient has remained free of relapse at 3.7 years post-salvage radiotherapy. This case demonstrates that radiotherapy can be a salvage therapeutic option for recurrent seminoma following primary chemotherapy for bulky stage IIC seminoma, provided that the recurrent tumour is confined to a limited area of the infradiaphragmatic region. There is a need for further study to examine the potential role of radiotherapy as a salvage therapeutic tool for post-chemotherapy recurrent seminoma.     

The effect of twisting on microanastomotic patency of arteries and veins in a rat model.

The authors examined the effect of twisting on the patency of microvascular anastomoses 3 days after surgery. A total of 69 male Wistar rats were divided randomly into four groups. The femoral arteries and veins were dissected for a standard distance. A total of 69 microarteriorrhaphies and 68 microvenorrhaphies were performed at 0 deg and with twist of the vessel ends of 90, 180, and 270 deg. Three-day patency rates for arterial microanastomoses were 100% with a 0-deg twist, 80.9% with a 90-deg twist, 68.4% with a 180-deg twist, and 64.2% with a 270-deg twist. Three-day patency rates for venous microanastomoses were 100% with a 0-deg twist, 85% with a 90-deg twist, 28.5% with a 180-deg twist, and 25% with a 270-deg twist (p = 0.047 for arteries, p = 0.001 for veins). These data are statistically significant. Moreover, assuming the risk of thrombosis to be 1 for microanastomosis without twisting, the odds ratio for the risk of vessel thrombosis for 270-deg twisting (the maximal examined degree of arterial and venous twist in the current study) is 10.08 for arterial anastomosis and 226.85 for venous anastomosis.     

The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization

BACKGROUND: Deep infection following total hip arthroplasty is a devastating complication for the patient and a costly one for patients, surgeons, hospitals, and payers. The purpose of this study was to compare revision total hip arthroplasty for infection, revision total hip arthroplasty for aseptic loosening, and primary total hip arthroplasty with respect to their impact on hospital and surgeon resource utilization and referral patterns to a tertiary-care hospital. METHODS: Clinical, demographic, and economic data were obtained for twenty-five consecutive patients with an infection after a total hip replacement who underwent a two-stage revision arthroplasty (Group 1) performed by one of two surgeons, between March 2001 and December 2002, at a single institution. Similar data were collected during the same time-period for a cohort of twenty-five consecutive patients who underwent revision of both components because of aseptic loosening (Group 2) and twenty-five consecutive patients who underwent a primary hip arthroplasty (Group 3). Quantitative and categorical variables were compared among the groups. Referral patterns were examined by reviewing the primary diagnosis for all patients referred to our institution for a revision total hip arthroplasty during a five-year period. RESULTS: Revision procedures for infection were associated with longer operative time, more blood loss, and a higher number of complications compared with revisions for aseptic loosening or primary total hip arthroplasty (p < 0.02 for all). Revisions for infection were also associated with a higher total number of hospitalizations, total number of days in the hospital, total number of operations, total hospital costs, total outpatient visits, and total outpatient charges during the twelve-month period following the index procedure (p < 0.001 for all). The incidence of referrals to our institution for a diagnosis of infection following total hip arthroplasty increased significantly over a five-year period (Spearman rank correlation, 1.0; p = 0.0083), while referral rates for revision for causes other than infection remained relatively constant (Spearman rank correlation, 0.500; p = 0.3910). CONCLUSIONS: The treatment of patients with an infection after a total hip arthroplasty is associated with significantly greater hospital and physician resource utilization compared with the treatment of patients who have a revision because of aseptic loosening or who have a primary total hip arthroplasty. We believe that the lack of incremental reimbursement associated with these procedures results in strong financial disincentives for physicians and hospitals to provide treatment for patients with an infection after a total hip arthroplasty.     

The case for specialist units

There is considerable evidence that management in a specialist unit is beneficial both for the individual patient and for the economy. A specialised unit provides a focus for a campaign for prevention, for the improvement in care in areas such as orthopaedic, bladder, bowel, skin, etc and for the promotion of interdisciplinary work, combining the needs of public health, low-cost technology, and high quality. Strategy and training is dictated by the specific problems that occur in patients with spinal injuries, particularly the multisystem impairment, which is a feature of such injuries and can only be comprehensively dealt with in a specialised unit. For developing countries, training may be either on-site or in centres abroad, or a combination of both, and rather than training on an individual basis, it is preferable for a team to be trained together. The likely cost depends on local circumstances. However, even the cost of a purpose-built centre of 44 beds serving 3000 paralysed people in the UK is only the equivalent of the lifetime costs of about 12 people with SCI.     

A biomechanical analysis of four different methods of harvesting bone-patellar tendon-bone graft in porcine knees

BACKGROUND: Anterior cruciate ligament reconstruction with use of bone-patellar tendon-bone graft is commonly performed to treat functional instability of the knee after injury of the anterior cruciate ligament. Patellar fracture is an underreported complication of this procedure, yet it may be a career-ending injury for a professional athlete. The purpose of this study was to design a new technique to procure the patellar bone plug when reconstructing the cruciate ligament with use of patellar tendon. METHODS: Fifty-eight knees were harvested from eighteen to twenty-four-month-old pigs. Bone plugs of four geometrical shapes were cored out of the patellae from forty knees (four plug shapes for each of ten knees). Ten knees had no graft removed. Fifty knees were tested for the effects of a single impact. Eight knees (two plug shapes for each of four knees) were tested for the effects of repeated impacts. Data were analyzed statistically with use of an ordinal logistic model. The probability of impact failure of the patella at different energy levels was calculated. RESULTS: Impact energy has been shown to have a significant effect on the outcome (p < 0.001). When controlling for energy level, there was a significant difference between the sharp and round corners (p < 0.01). The ordinal logistic model was found to be very good for predicting the outcome of impact testing. The impact energy required to create a 1% probability of complete fracture was 7 J for a patella with a sharp-cornered plug defect, 17 J for a patella with a trapezoidal plug, 22 J for a patella with a sharp-cornered defect with a drill-hole at the corner, 40 J for a patella with a round-cornered defect, and about 49 J for a normal patella. Repeat impact testing substantially damaged the patellae with sharp-cornered defects, as they failed earlier at a lower energy and after a lower number of impacts than did the patellae with round-cornered defects. CONCLUSIONS: We propose the use of the round-cornered patellar bone plug when bone-patellar tendon-bone graft is harvested for anterior cruciate ligament reconstruction, to further reduce the small likelihood of a patellar fracture occurring intraoperatively or in the early postoperative rehabilitation phase.     

Optimum tool handle diameter for a cylinder grip.

The ideal diameter for a tool handle for males and females has been determined using an existing biomechanical model of the hand validated in previous works. The model estimates a 33-mm optimum diameter tool handle for the general population (males and females). When the optimum diameter for a tool handle is selected, the muscles exert the minimum force needed to hold the tool and perform gripping activities. Optimal handle design reduces the force required for gripping a tool, protects the underlying joint structures, and reduces the risk of developing cumulative trauma associated with repetitive task requiring high grip forces and awkward postures. This article provides a design parameter for optimal tool diameter to aid the therapist in the selection of assistive devices, built-up handles, or for the fabrication of a tool handle.     

Creation of continence mechanisms (Mitrofanoff) without appendix: the Monti and spiral Monti procedures

This is a review of the technique to create a continent catheterizable stoma using the Yang-Monti principle of a transversely tubularized segment of bowel. Pediatric urologists have widely used this technique for years, especially when the appendix is either not available or suitable for use. It provides the surgeon with a reliable, predictable, and durable method for creating a continent catheterizable channel. The indications for its use, principles of construction, and outcomes in a large population of children are described.     

Magnetic resonance imaging of the knee in children and adolescents. Its role in clinical decision-making

BACKGROUND: Recent studies have questioned the utility of magnetic resonance imaging in the diagnosis of pediatric knee disorders because of the morphologic changes during growth and the low accuracy of the formal interpretation of the magnetic resonance imaging scan by a radiologist. The purpose of this study was twofold: (1) to report the accuracy of formal interpretations of magnetic resonance imaging scans of the knee in children and adolescent patients by a radiologist, and (2) to determine the benefit, if any, of a personal review of the magnetic resonance imaging scan of the knee by the orthopaedic surgeon, as a routine part of the diagnostic evaluation. METHODS: A three-year prospective study of all patients who underwent knee arthroscopy performed by a single surgeon, at two children's hospitals, was completed. The analysis focused on the six most common diagnoses: anterior cruciate ligament tear, lateral meniscal tear, medial meniscal tear, osteochondritis dissecans, discoid lateral meniscus, and osteochondral fracture. The preoperative diagnosis of the surgeon was determined by integrating the history and the findings on the clinical examination, plain radiographs, and magnetic resonance imaging scans (including the radiologist's interpretation). RESULTS: Ninety-six patients with ninety-six abnormal knees were included. The mean age was 14.6 years at the time of surgery. Relative to operative findings, kappa values for the formal interpretations of the magnetic resonance imaging scans by a radiologist were 0.78 for an anterior cruciate ligament tear, 0.76 for a medial meniscal tear, 0.71 for a lateral meniscal tear, 0.70 for osteochondritis dissecans, 0.46 for discoid lateral meniscus, and 0.65 for osteochondral fracture. Relative to operative findings, kappa values for the preoperative diagnoses by the surgeon were 1.00 for an anterior cruciate ligament tear, 0.90 for a medial meniscal tear, 0.92 for a lateral meniscal tear, 0.93 for osteochondritis dissecans, 1.00 for discoid lateral meniscus, and 0.90 for osteochondral fracture. The preoperative diagnosis by the surgeon was better (p < 0.05) than the formal interpretation of the magnetic resonance imaging scans by the radiologist with respect to an anterior cruciate ligament tear, lateral meniscal tear, osteochondritis dissecans, and discoid lateral meniscus. CONCLUSIONS: Integration of patient information with an orthopaedic surgeon's review of the magnetic resonance imaging scan of the knee in children and adolescent patients improves the identification of pathological disorders in four of the six categories evaluated. This study questions the necessity for and appropriateness of a routine interpretation of a magnetic resonance imaging scan of the knee in children and adolescents by a radiologist.     

Surgical practice under the recent health insurance system of Japan

Candidates for surgeon have been declining in number for a long time because the labor conditions for surgeon are worse than those for other specialists, especially for internists. In this symposium, we will examine how to improve the present status of surgeons under the totally controlled health insurance system by discussing regarding what is a surgeon, what is a surgeon's work, what is a rational surgical fee, the necessity for surgeon's fees, etc. for the sake of the future development of both clinical surgical practice and research.     

Fighting the silent epidemic: the Florida Brain and Spinal Cord Injury Program

This article describes a statewide model program that provides a range of services for individuals with traumatic brain injury in Florida. The article answers questions regarding the organization, delivery, and financing of a system that includes surveillance data, case management, health services, a network of contractors, and a Medicaid waiver. With an annual budget of more than 15 million US dollars, the primary source of financing is a trust fund established through state statute with revenues from fines levied for driving while intoxicated. Lessons from Florida that will be useful to states as they respond to Olmstead and develop Medicaid waivers include (a) how a data registry laid the foundation for a service delivery system, (b) how early and aggressive case management has the potential for Medicaid savings, and (c) how a statewide system, critical mass of patients, and standards for providers can improve the quality of services for persons with traumatic brain injury.     

A retrospective comparison of costs for regional and general anesthesia techniques

In this retrospective study, we compared the costs for three different regional anesthesia techniques with the costs of general anesthesia (GA). A total of 1587 anesthesia cases which were performed for orthopedic and trauma patients over a 1-yr period in a tertiary level, university hospital setting were analyzed. The anesthesia technique-related costs were determined calculating case-specific costs for personnel, supplies, and drugs. The techniques were compared on the basis of anesthesia costs and surgical procedure duration. As a result, we found that the costs per surgical minute largely depend on the surgical procedure duration. Based on the regression function, the cost advantage of spinal anesthesia over GA can be estimated to be 13% for a 50-min case, 9% for a 100-min case, and 5% for a 200-min case. The cost disadvantage of brachial plexus anesthesia over GA can be estimated to be 19% for a 50-min case, 8% in a 100-min case, and 1% for a 200-min case. We found no difference in costs between epidural and GA. We concluded that cost comparisons of anesthesia techniques largely depend on the surgical duration of the cases studied. Even in a teaching hospital setting, spinal anesthesia has economic advantages over GA. Especially for short cases, brachial plexus block is more expensive in this setting.     

Incidence and demographics of hand fractures in British Columbia, Canada: a population-based study

PURPOSE: To identify population-based hand fracture annual incidence rates, demographics, and seasonal and geographic variations from all patients seeking treatment for a hand fracture in British Columbia, Canada from May 1, 1996 to April 20, 2001. METHODS: All Medical Service Plan and Hospital Separation records that included International Classification of Diseases-9 codes for metacarpal (815), phalangeal (816), and multiple (817) fractures were extracted from the British Columbia Linked Health Dataset, along with the individual registry demographic records linked to each hand fracture. RESULTS: A total of 72,481 hand fractures were identified. Fifty percent were phalangeal fractures, 42% were metacarpal fractures, and 8% were multiple fractures. The total population annual incidence rate for a hand fracture was 36 per 10,000. Age-adjusted annual incidence rates ranged from 29 per 10,000 for people older than 20 years to 61 per 10,000 for people age 20 or younger. The most common age for a hand fracture was 14 years for males and 13 years for females. Males had a 2.08 greater relative risk for hand fracture and they maintained most of this increase in risk between the ages of 15 and 40. For females there was an increased relative risk for a hand fracture after the age of 65. Spring had the highest rates for hand fractures. People in the Northern half of the province had a 1.6 greater relative risk for sustaining a hand fracture, compared with people in the more urbanized, less-industrialized, and more-affluent Southwestern region. CONCLUSIONS: Our study provides a robust projection of annual incidence rates for hand fractures because we were able to review all occurrences of a hand fracture within a population base of approximately 4 million people over a 5-year period. Our study also allowed for the examination of how age, gender, season, and geographic location influenced hand fracture incidence rates within a large, diverse population.     

《整形外科原则》精选——原则15同物相济

对面部或身体的部分组织缺失，应以相同组织予以替代，如以骨组织修复骨缺损，以肌肉组织重建肌肉功能，以无毛的皮肤组织修复光滑皮肤缺损，这就是同物相济的原则。     

On False Accuracy Verification of UMUSCL Scheme

In this paper, we reveal a mechanism behind a false accuracy verification encountered with unstructured-grid schemes based on solution reconstruction such as UMUSCL. Third- (or higher-) order of accuracy has been reported for the Euler equations in the literature, but UMUSCL is actually second-order accurate at best for nonlinear equations. False high-order convergence occurs generally for a scheme that is high order for linear equations but second-order for nonlinear equations. It is caused by unexpected linearization of a target nonlinear equation due to too small of a perturbation added to an exact solution used for accuracy verification. To clarify the mechanism, we begin with a proof that the UMUSCL scheme is third-order accurate only for linear equations. Then, we derive a condition under which the third-order truncation error dominates the second-order error and demonstrate it numerically for Burgers’ equation. Similar results are shown for the Euler equations, which disprove some accuracy verification results in the literature. To be genuinely third-order, UMUSCL must be implemented with flux reconstruction.     

Successful upper alveolar reconstruction for gingival cancer using a fibular osteoadipofascial flap without osseointegrated implants

An upper alveolar skeletal reconstruction with closure of the palatal fistula using an osteocutaneous free flap is considered an ideal reconstructive strategy after curative surgery for cancer of the lower maxilla. Although installation of osseointegrated implants into the bone has advantages for utilizing a dental prosthesis, it is often time and cost prohibitive. In the case of 1 patient, we reconstructed and fit the patient with a conventional denture, eliminating the need for installation of osseointegrated implants. The patient underwent upper alveolar reconstruction using a fibular osteoadipofascial flap, followed by a skin graft for creation of an alveololabial sulcus. It was then possible for the patient to wear a conventional denture without implants. One explanation for this success is that the regenerated mucosa on the adipofascial flap and skin graft was immobile, which allowed it to serve as a base for the dental prosthesis. The alveololabial sulcus that had been constructed kept the denture in place. This reconstruction confirmed that a fibular osteoadipofascial flap might be a useful choice in restoring a natural upper alveolar osseous and soft tissue structure.     

Diaphragmatic Hernia Masquerading as a Pulmonary Metastasis

Iatrogenic injury accounts for the second most common cause of acquired diaphragmatic hernias after penetrating trauma. An increased incidence of these hernias has been observed with the widespread use of laparoscopic surgery. We present the case of a 65-year-old woman who initially underwent sigmoid resection for an adenocarcinoma and a subsequent liver resection for metastasis. She was noted to have a left lower lobe pulmonary nodule on surveillance computed tomography, for which she underwent a mini-thoracotomy for a planned resection. At the time of surgery, the pulmonary nodule was discovered to be a diaphragmatic hernia, most probably of iatrogenic origin. We discuss the difficulty in diagnosis given her history and the location of such a lesion.