An early experience of the use of dual mobility cup uncemented total hip arhroplasty in young patients with avascular necrosis of the femoral head

IntroductionTHA (Total hip arthroplasty) in advanced grade (grade 4) avascular necrosis (AVN) is a challenge to the treating surgeon as it affects young patients who have high functional demands and increased dislocation risk. The aim of the study was to evaluate the efficacy, survivorship, and dislocation rate of uncemented dual mobility cups (DMC) in advanced grade IV AVN young patients.MethodsRetrospective cohort study involving 204 DMC THA for advanced grade IV AVN from January 2013 to December 2015. The sample size of the study was estimated to be 188 hips with an α error of 0.05 and β error of 0.2. Inclusion criterion was patients less than 55 years of age with advanced grade IV AVN. Patients >55 years of age, patients diagnosed with primary osteoarthritis of the hip and hip fracture were excluded from the study. 172 patients (32 with bilateral & 140 with unilateral affection) with 204 DMC THA were evaluated clinically by Harris Hip Score (HHS) and radiologically at a follow up of 60 months. P value < 0.05 was considered significant.ResultsMean age of the patients was 42.5 ± 5.3. Preoperative HHS was 50.6 ± 10.5. Postoperative HHS at 5 years follow up was 96.4 ± 2.6. None of the operated patient had any dislocation episode or had undergone hip revision surgery (statistically significant against historical control of 2%, p value = 0.042). The radiological evaluation at 5 years showed no signs of radiolucent lines, periprosthetic osteolysis, polyethylene wear and signs of displacement or migration of the DMC. Cumulative survivorship rate at 5 years follow up was 100% without any revision/dislocation.ConclusionUse of DMC THA in young, advanced grade IV AVN patients was found to be a reliable option showing excellent early functional results with no dislocation. Ongoing follow up of this cohort is required to confirm the maintenance of these excellent functional results at follow up in the long term.     

How is quality of life after total hip replacement related to the reconstructed anatomy? A study with low-dose stereoradiography

PurposeThe purpose of this study was to evaluate the relationships between the three-dimensional anatomy of operated hip in standing position using low-dose stereo-radiography imaging system and postoperative hip disability and osteoarthritis outcome score (HOOS) after total hip arthroplasty (THA).Material and methodsA total of 123 patients who underwent THA during a one-year period were included. There were 50 men and 73 women with a mean age of 67.3 ± 13.6 (SD) years (range: 19–89 years). All patients underwent pre- and postoperative low-dose stereo-radiography examination and completed a HOOS form (score from 0 to 100, 100 for full satisfaction). We recorded 16 anatomical parameters before THA, and 15 after THA. After binary transformation of HOOS score using 70 as threshold value, outcome was assessed using logistic or generalised linear models.ResultsA total of 103 patients (103/123; 83.7%) had a HOOS score ≥ 70 and were considered as the satisfied group. A significant difference in pelvic incidence (the angle between a line perpendicular to the sacral plate at its midpoint and a line connecting the same point to the centre of the bicoxofemoral axis) was found between the satisfied 56.4 ± 10.4 (SD)° (range: 31–85°) and the unsatisfied group 48.7 ± 8.9 (SD)° (range: 40–65) (P = 0.006). The relative variation of offset (distance from the centre of rotation of the femoral head to a line bisecting the long axis of the femur) compared to the contralateral hip was ?7% in the satisfied group and 7.2% in the unsatisfied group (P = 0.01).ConclusionPelvic incidence, a parameter independent of the reconstructed anatomy, probably influences the quality of life of patients with THA, via pelvic compensatory capabilities. A loss of femoral offset negatively influences the satisfaction of patients.     

Surgery versus conservative care for Rathke's cleft cyst

BackgroundRathke's cleft cysts are benign cystic lesions of the sellar region, which may cause headache, pituitary deficiencies and visual disturbances from mass effect. Their management is not standardized yet. This study is about establishing a consensus for medical care of RCC.Material and methodsWe performed a retrospective observational study of all patients that were diagnosed or followed for RCC between 2008 and 2018 (11 years), in the neurosurgical and the adult endocrine departments of our institution. The study's average time length of follow-up is 72.9 months (from 2 to 385 months).ResultsThe 57 included patients were divided into 2 groups: group A, which included 39 patients that were conservatively managed and group B, which included 18 surgically treated patients. Group A showed either an improvement or a spontaneous resolution of headaches in 56.1% of the cases (P < 0.01); a resolution of hyperprolactinemia in 70% of the cases (P = 0.21); and of hypogonadism, ACTH deficiency, growth hormone deficiency in 100% of the cases. There was no spontaneous improvement of visual disturbances (P < 0.01) or diabetes insipidus (P = 0.29) during follow-up. Regarding group B, surgery allowed improvement or complete resolution of headaches in 60% of the cases; visual troubles in 100% of the cases (P < 0.01); and hyperprolactinemia in 100% of the cases. Pituitary deficiencies were not improved by surgery.ConclusionsThis study offers guidance in decision-making regarding the management of RCC patients. Surgery is particularly suitable for treating visual disturbances caused by RCC. Regular follow-up is more appropriate than surgery concerning headaches, hyperprolactinemia, endocrine disruptions and diabetes insipidus.     

Clinical and radiological outcome after minimally invasive surgical approach for type II unstable odontoid fractures

IntroductionAnterior odontoid screw fixation is a valid surgical option for unstable odontoid fractures, as type II Anderson D’Alonzo fractures. Grauer further divided type II fractures in subtypes according to the fracture line, providing recommendations for implementation of screw fixation techniques.ObjectivePrimary endpoint of our study is to evaluate the postoperative results of minimally invasive odontoid screw insertion in terms of outcome, fusion rate and stability of cranio-cervical junction. Secondary endpoint was to investigate the influence of age or fractures’ features on outcome and fusion rate.Materials and methodsWe report the clinical and radiological features of 32 patients harbouring unstable type II fractures operated by a minimally invasive odontoid screw insertion technique. All patients underwent a high resolution multiplanar CT in order to assess fracture features according to Grauer's classification; the integrity of ligaments was investigated by MRI. In addition, a preoperative neurological performance (modified Rankin Scale, mRS) was evaluated for patients either directly or interviewing their families. Follow-up at one, three and six months and 1 year have been performed (averaging 13.5 months) by cervical CT (fusion rate and stability) and mRS update. In order to investigate the influence of age on postoperative neurological performance, two groups (≤ 50 yrs, 9 pts/ > 50 yrs, 23 pts) were separately considered and analysed. Overall, we observed no surgery related complications. We also analysed the fusion rate and its correlation with patient age and Grauer's subtype of fracture.ResultsAt last available clinical follow-up, the preoperative performance was preserved (mRS 0/1: 24, 75%; mRS 2–4: 9, 15%) although with slight reduction of intact patients (mRS 0: 22 vs. 19; 71.8 vs. 59.3%). Younger patients (≤ 50 yrs) fared significantly better than older ones, achieving a good clinical outcome (mRS 0/1) in 100% vs. 69.5% (9/9 vs. 16/23 pts). Statistical analysis showed a fair correlation between age and outcome. Other factors such as sex and Grauer's type did not influence significantly the clinical outcome. Nine patients did not complete a full radiological follow-up and were therefore excluded from analysis of radiological outcome. Among the remaining 23 patients, only 25% of those who were followed three months or less showed fusion; conversely, all patients who have been examined from 6 to 48 months fused. Among the non-union patients, two underwent a second surgery by posterior approach.ConclusionsIn our recent experience, the minimally invasive AOSF proved safe and effective in treating odontoid peg fractures. Selection based on Grauer's type is mandatory to achieve best results. While in the elderly, an anterior approach is well accepted as the first choice treatment, we recommend that this option should be offered as a suitable alternative to Halo or orthosis also in younger patients since it provides prompt, excellent clinical outcome and high fusion rate especially in this age group.     

The incidence of avascular necrosis following a cohort of treated developmental dysplasia of the hip in a single tertiary centre

PurposeAvascular necrosis (AVN) may occur following treatment for developmental dysplasia of the hip (DDH). The primary aim of this study was to identify the incidence of AVN in a cohort of patients treated for DDH. Secondary aims were to classify AVN using available classification systems, analyze the correlation between the systems and investigate their relationship with the age at diagnosis of DDH.MethodsAn 11-year retrospective study was carried out at a single tertiary centre, using data from the clinical portal (patient records database) and IMPAX (system used to store plain radiographic images). Clinical details (patient demographics and outcomes) and plain radiographic images were used to identify cases of DDH and categorize cases of AVN using available classification systems: Tonnis and Kuhlmann, Kalamchi and McEwen, Bucholz and Ogden and Salter. Severin was used to assess final clinical outcome.ResultsIn total, 405 (522 hips) cases of DDH were identified, of which 213 resolved without treatment, 93 were treated conservatively and 99 surgically. Only treated cases were included in the analysis (n = 192). AVN (45/99; 45.5%) was found to occur only postoperatively. A positive correlation was present between age at presentation and severity of AVN as classified according to Salter’s criteria (chi-squared p value < 0.01).ConclusionAVN incidence was 23.4% (45/192) and only occurred in surgically treated patients. Older age at diagnosis was associated with a higher incidence of AVN, as defined according to Salter’s criteria. The classification systems appeared to show no correlation amongst each other (p-value < 0.01).Level of evidence:III - Retrospective cohort study     

Trans-lateral decubitus radiograph of the hip: A new view to measure the anteversion of the femoral stem

BackgroundMalposition of the femoral stem is a risk factor for dislocation after total hip arthroplasty (THA). Currently, two radiological methods are available for the measurement of stem anteversion. However, one method is not applicable in patients with a stiff hip, and the other one cannot differentiate the anteversion and retroversion of the stem. Therefore, we developed a method to measure the stem anteversion and assessed its reliability as well as validity.MethodsTrans-lateral decubitus view of the proximal femur was taken with the patient in lateral decubitus position, the hip in extension and the knee in 90° flexion. Hip anteroposterior (AP) view, trans-lateral decubitus view and CT scan of the hip were taken in 36 patients, who underwent THA. Their mean age was 59.8 (27–84) years and the mean body mass index was 25.2 (18.8–30.9) kg/m². The stem neck-femoral shaft angle was measured on hip AP view and the trans-lateral decubitus view. Then, the stem anteversion was calculated using the Ogata-Goldsand formula. We assessed the intra- and inter-observer reliabilities and evaluated the validity by comparing with the measurements on CT scan.ResultsThe intra- and inter-observer reliabilities were 0.934 and 0.935, respectively. The calculated stem anteversion (23.72°±8.17°) correlated well with the stem anteversion on CT scan (23.91°±10.25°), especially when the radiological anteversion was <30° (correlation coefficient = 0.729, p = 0.001).ConclusionWe developed a reliable and valid method to measure stem anteversion using hip AP view and trans-lateral decubitus view of the femur. This method can replace conventional radiological methods.     

A modified surgical approach of the hip in children: is it safe and reliable in patients with developmental hip dysplasia?

PurposeTreatment is easier and complications are less likely to occur if developmental dysplasia of the hip (DDH) is diagnosed early. In this study, we examined the early results of open reduction using a medial approach which we had modified for DDH and analyzed the success of this technique and the associated complication rates, with a focus on avascular necrosis (AVN).Methods This is an Institutional Review Board-approved retrospective review of all patients diagnosed with DDH and treated with a modified medial approach at a single institution from July 1999 to December 2010. The patients'' charts were analyzed for clinical and radiographic features.Results Fifty-five hips of 41 patients, all of whom were treated by open reduction using a modified medial approach due to DDH, were evaluated retrospectively. The mean age of the patients at surgery was 19 (range 11–28) months, and the average follow-up was 5.5 (range 3–9.5) years. AVN was the most important complication in terms of radiological outcomes as assessed according to the Kalamchi–McEwen classification. Radiologic results were excellent or good in 51 hips (92.7 %) and fair–plus in four (7.3 %). Type 1 temporary AVN was detected in only two hips (3.6 %), and the lesions had disappeared completely in the final control graphs of these two patients. A secondary intervention was needed for two hips (3.6 %) of the same patients who were operated on due to bilateral DDH. No other complications, such as infection, re-dislocation, or subluxation, were seen in the operated patients.Conclusions We believe that treatment for DDH using a modified medial approach during early childhood is an effective and reliable method with low AVN rates. As shown here, this method achieves great success in radiological and clinical outcomes after a minimum 3-year follow-up.     

Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions

BackgroundWarfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear.MethodsThis was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the “wait and watch” method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery.ResultsThere were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.ConclusionsPartial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.     

First ray alignment in Lapidus arthrodesis – Effect on plantar pressure distribution and the occurrence of metatarsalgia

BackgroundLapidus arthrodesis is an established treatment option for severe hallux valgus deformity especially in patients suffering from instability of the first tarsometatarsal joint. Surgery related metatarsalgia is known to be associated with persistent elevation of the first ray after realignment surgery. Nevertheless, detailed information on ideal positioning of the first ray in Lapidus surgery is missing so far. This study was designed to determine any correlations between radiographic and pedobarographic outcome following the Lapidus procedure with regard to clinical outcome and the occurrence of metatarsalgia.MethodsThirty feet (28 patients) after Lapidus surgery were available for follow-up at 42.5 ± 21.0 months. All subjects had radiographic and pedobarographic evaluation of the operated foot and patient satisfaction was recorded using questionnaires.ResultsMetatarsalgia was associated with a poorer outcome in FADI and AOFAS scores (p < 0.005). A lateral shift of plantar pressure distribution to the third metatarsal head in these cases could be observed. Although Lapidus surgery resulted in significant shortening of the first metatarsal, no correlation to the occurrence of metatarsalgia was detectable. Likewise, axial plane malalignment showed no influence, whereas elevation of the first ray was highly correlated to surgery related metatarsalgia (p = 0.007). Subjects suffering from metatarsalgia had a higher BMI (body mass index), but its effect on metatarsalgia turned out not to be significant (p = 0.090).ConclusionIn Lapidus surgery realignment of the first metatarsal in the sagittal plane seems to be decisive for good clinical outcome. Failing to plantarflex the arthrodesis resulted in a lateral shift of plantar loading with overload of the lesser metatarsals and the occurrence of metatarsalgia.     

Closed vs open reduction in developmental dysplasia of the hip: The short-term effect on acetabular remodeling

BackgroundThis study aims to assess acetabular remodeling following closed vs, open hip reduction in children younger than 2 years of age.MethodsRecords of children with DDH, who underwent closed or open reduction, were reviewed. Acetabular index (AI) was measured on radiographs taken prior to reduction and on outcome radiographs taken at age 4 years. Radiographic outcomes were analyzed and residual dysplasia (outcome AI ≥ 30) degrees recorded.Results42 hips had closed reduction; and 26 hips had open reduction. A higher percentage of hips treated with successful closed reduction, had outcome AI ≥ 30° (29% vs. 19% p = 0.387). Residual dysplasia was more common in IHDI-IV hips than IHDI-III hips for both groups. A higher incidence of AVN was seen in the open reduction group (13% vs. 7%; p = 0.43).ConclusionIn children with DDH under the age of two, open reduction with capsulorrhaphy may benefit acetabular remodeling more so than closed reduction despite maintenance of reduction. Although AVN remains a risk, higher remodeling might be expected with open reduction.     

Impact of early Coronavirus Disease 2019 pandemic on pediatric cardiac surgery in China

ObjectiveThis study aimed to provide an insight into the impact of the early outbreak of the novel Coronavirus Disease 2019 on the care management for patients with congenital heart disease.MethodsThis study respectively enrolled a cohort of surgical patients who underwent surgery in 2018 (group I), 2019 (group II), and 2020 (group III) and a cohort of follow-up patients who had follow-up in 2017 (group A), 2018 (group B), and 2019 (group C) in 13 children hospitals.ResultsDuring the Coronavirus Disease 2019 era, there was a significant decrease in total surgical volume and a change in case mix in terms of an increase in the proportion of emergency operations. Decrease in migration scale index was correlated to the decrease in both surgical volume (r = 0.64, P = .02) and outpatient visit volume (r = 0.61, P = .03). There was a significantly higher proportion of patients who had follow-up through the internet or phone in group C (26.4% vs 9.6% in group B and 8.9% in group A; P < .0001). There was no statistical difference in death or rehospitalization among the 3 follow-up groups (P = .49). There was higher parents' anxiety score (P < .0001) and more use of telemedicine (P = .004) in group C compared with groups A and B.ConclusionsThe Coronavirus Disease 2019 pandemic has resulted in a considerable decrease in total surgical volume and a change of case mix, which seems to be related to the strict traffic ban. Follow-up through the online medical service appears to be an effective alternative to the conventional method.     

Hip arthroscopy in the presence of dysplasia

Purpose: Intra-articular pathology of the hip is often associated with dysplasia. The presence of dysplasia is often believed to be a harbinger of poor results for arthroscopy. The purpose of this study was to report the results of operative hip arthroscopy in conjunction with dysplastic disease of the hip. Type of Study: Prospective clinical case series. Methods: All patients undergoing hip arthroscopy are prospectively assessed with a modified Harris hip score performed preoperatively and postoperatively at 3, 12, 24, and 60 months. A minimum of 1-year follow-up has currently accumulated for 184 consecutive cases. The center edge (CE) angle of Wiberg is measured on the anteroposterior pelvis film and categorized as normal (> 25°), dysplastic (< 20°), or borderline dysplasia (20°-25°). Results: In this study, 48 patients were identified with either dysplasia (16) or borderline dysplasia (32). At an average of 27 months, 100% follow-up was noted. For the dysplastic group, the average preoperative score was 57 and postoperative score was 83. For borderline dysplasia, the average preoperative score was 50 and postoperative score was 77. Statistically, no difference was found between the 2 groups. Collectively, the average improvement was 27 points, with 79% (38 patients) of patients showing at least a 10-point improvement. Conclusions: The results of arthroscopy in the presence of dysplasia compare favorably with the general population previously reported. The response to treatment is probably dictated more by the nature of the intra-articular pathology rather than simply the presence or absence of radiographic evidence of dysplasia.     

Minimally invasive surgery for intradural spinal meningioma: A new standard? A comparative study between minimally invasive and open approaches

BackgroundSome authors used minimally invasive surgery (MIS) in the treatment of spinal cord tumor, but these studies had a small sample sizes and mixed extra- and intra-medullary tumors, resulting in confounding biases. The objectives of the present study were to evaluate the effectiveness and safety of MIS for spinal meningioma resection in comparison with open surgery (OS).MethodsConsecutive patients with spinal meningioma who received either MIS or OS were included. Data for extent of resection, functional outcome, postoperative morbidity and recurrence were collected.ResultsA total of 48 patients (with 51 spinal meningiomas) were included. Eighteen underwent MIS and 30 OS. Meningioma volume and location did not differ significantly between groups: tumors were predominantly thoracic (n = 39, 76.5%) and voluminous (occupying more than 50% of the spinal canal: n = 43, 84.3%). In the MIS group, patients were older (mean age: 66.5 vs. 56.4 years, P = 0.02) and more fragile (mean ASA score: 2.0 vs. 1.6, P = 0.06). In the MIS group, the surgical procedure was shorter (mean duration: 2.07 vs. 2.56 h, P = 0.04), blood loss lower (mean: 252 vs. 456 mL, P = 0.02), and hospital stay shorter (mean: 6.6 vs. 8.1 days). Surgery improved the modified McCormick scale (P < 0.0001) irrespective of the surgical technique. MIS led to no significant differences in extent of resection or postoperative morbidity. Mean follow-up was 46.6 months. At last follow-up, 91.7% (n = 44) of patients were free of progression; all cases of tumor progression (n = 4) occurred in the OS group.ConclusionsMIS outperformed OS in the management of intradural spinal meningioma, irrespective of location and volume. MIS appears to be particularly suitable for elderly and fragile patients.     

Open reduction and Salter innominate osteotomy combined with femoral osteotomy in the treatment of developmental dysplasia of the hip: Comparison of results before and after the age of 4 years

ObjectiveThis study aimed to compare the clinical and radiological findings of radical reduction (open reduction and Salter innominate osteotomy combined with femoral osteotomy) for children of walking age, younger and older than 4 years in the treatment of with developmental dysplasia of the hip (DDH).MethodsIn this retrospective study, children of walking age with DDH who underwent radical reduction between 2008 and 2014 were identified. They were then divided into 2 groups according to the age at which the surgery was performed: before and after the age of 4 years. Improvement in the acetabular index was examined on follow-up radiographs. The presence of avascular necrosis (AVN) was determined and classified on the basis of the Kalamchi-MacEwen classification on final follow-up radiographs. Clinical assessment was performed with the modified McKay criteria at the final follow-up appointment.ResultsA total of 19 children (14 girls, 5 boys; mean age=37.5±21 months) (25 hips) were included. Their mean age was 27.9±4.9 and 63.3±19.7 months in children operated before and after the age of 4 years, respectively. The mean follow-up time was 29.9±19 and 19.6±5 months in children operated before and after the age of 4 years, respectively. No significant difference was observed in improvements in the acetabular index between children younger than 4 years (24±6.9°) and those older than 4 years (20.7±6.7°) (p=0.25). According to the modified McKay criteria, all the children younger than 4 years exhibited excellent or good clinical results compared with those operated after the age of 4 years (67%) (p=0.013). At the final follow-up, 64% of all patients demonstrated no radiographical sign of AVN. The rates of AVN were significantly higher in children operated after the age of 4 years (33%) than in those operated before the age of 4 years (19%) (p=0.049).ConclusionBetter clinical and radiographical results can be expected from radical reduction in children undergoing surgery before the age of 4 years.Level of Evidencelevel III, Therapeutic Study     

Diagnostic accuracy of ultrasonography for occult femoral neck fracture

BackgroundA delay in the diagnosis and treatment of an occult femoral neck fracture (OFNF) can negatively affect the subsequent quality of life. We investigated the diagnostic accuracy of ultrasonography for OFNF in patients confirmed with this condition by magnetic resonance imaging (MRI), and compared these results with other clinical findings.MethodsNinety-four outpatients aged above 70 years with acute hip pain but without radiographic abnormal findings who were suspected of having an occult femoral neck fracture (11 men and 83 women with a mean age of 81.8 ± 6.0 years) were enrolled. Both ultrasonography and MRI were performed in all cases within 24 h. The ultrasonographic distance between the anterior aspect of the femoral neck and the anterior joint capsule (ultrasound joint swelling) was measured.ResultsBy MRI findings, 27 patients were assigned to an occult femoral neck fracture (OFNF) group (1 man, 26 women) and 67 patients to a non-OFNF group (10 men, 57 women). The mean ultrasound joint swelling in both groups was 7.53 ± 1.52 mm and 3.45 ± 0.89 mm, respectively (p = 0.006, 95% CI, 3.58–4.59). A cut-off value of 5.3 mm showed a sensitivity of 0.96 (0.89–0.96) and a specificity of 0.98 (0.92–1.00).ConclusionsUltrasonography shows very high diagnostic accuracy for occult femoral neck fracture. This modality can thus contribute to initial bed-side examinations for this condition in patients over 70 years with acute hip pain.     

A Comparative Study of Clinical and Radiological Outcomes of Open Reduction Using the Anterior and Medial Approaches for the Management of Developmental Dysplasia of the Hip

BackgroundThe literature is scanty on reports directly comparing the outcomes of anterior open reduction (AOR) and medial open reduction (MOR) in the management of developmental dysplasia of the hip (DDH).Purpose of the StudyTo compare clinical and radiographic outcomes of surgical treatment using either AOR or MOR in children with DDH aged < 24 months and to evaluate the procedure-inherent risks of avascular necrosis of the femoral head (AVN) and need for further corrective surgery (FCS).Methods61 children who underwent surgical treatment for DDH were categorized into two groups: AOR (31 hips of 28 patients) and MOR (39 hips of 33 patients). The mean age was 17 ± 5.85 (range 7–24) months in group AOR and 13 ± 5.31 (range 6–24) months in group MOR. The mean follow-up was 118 ± 41.2 (range 24–192) months and 132 ± 36.7 (range 24–209) months in group AOR and MOR. At the final follow-up, mid- to long-term clinical and radiographic outcomes were assessed. FCS was recorded.ResultsRegarding McKay’s clinical criteria, both groups exhibited similar results (p = 0.761). No significant differences were observed between the groups in both the center–edge–angle (p = 0.112) and the Severin score (p = 0.275). The AVN rate was 32% in the AOR group and 20% in the MOR group (p = 0.264). The FCS rate was 22% in the AOR group and 12% in the MOR group (p = 0.464).ConclusionsThis study showed similar clinical and radiological outcomes with AOR and MOR with no significant relation to AVN and FCS.Level of EvidenceLevel III.     

Renal perfusion with histidine-tryptophan-ketoglutarate compared with Ringer's solution in patients undergoing thoracoabdominal aortic open repair

ObjectiveThe objective of this study was to compare the efficacy of renal perfusion with Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany) versus enriched Ringer's solution for renal protection in patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair.MethodsNinety consecutive patients scheduled for elective open TAAA repair were enrolled between 2015 and 2017 in a single-center, phase IV, prospective, parallel, randomized, double-blind trial (the CUstodiol versus RInger: whaT Is the Best Agent [CURITIBA] trial), and randomized to renal arteries perfusion with 4°C Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany; n = 45) or 4°C lactated Ringer's solution (n = 45). The incidence of acute kidney injury (AKI) in patients undergoing TAAA open surgery using Custodiol renal perfusion versus an enriched Ringer's solution was the primary end point.ResultsNinety patients completed the study (45 patients in each group). The incidence of postoperative AKI was significantly lower in the Custodiol group (48.9% vs 75.6%; P = .02). In the multivariable model, only the use of Custodiol solution resulted as protective from the occurrence of any AKI (odds ratio, 0.230; 95% confidence interval, 0.086-0.614; P = .003), whereas TAAA type II extent was associated with the development of severe AKI (odds ratio, 4.277; 95% confidence interval, 1.239-14.762; P = .02). At 1-year follow-up, serum creatinine was not significantly different from the preoperative values in both groups.ConclusionsThe use of Custodiol during open TAAA repair was safe and resulted in significantly lower rates of postoperative AKI compared with Ringer's solution. These findings support safety and efficacy of Custodiol in this specific setting, which is currently off-label.     

Impact of Covid-19 pandemic on arthroplasty services and early experience after resuming surgeries at a ‘non Covid’ center

BackgroundThe aim of this study is to assess the impact of Covid-19 crisis on hip and knee joint replacement surgeries at a high volume tertiary care hospital in the Indian National Capital Region and to evaluate the early experience of resumption of arthroplasty services.MethodsInstitutional records of the arthroplasty cases, operated between 1st March to 31 August of 2019 (Group A, pre-Covid) and 2020 (Group B, pandemic year) were compared retrospectively over numerous parameters including the complications within six weeks of surgery.ResultsThere was a significant drop (by 82.53 %) in the total number of arthroplasty surgeries in Group B (62) as compared with Group A (355). Average number of arthroplasties per month were 59.17 ± 12.93 and 10.67 ± 13.29 in Group A and Group B respectively (p < 0.001). There was a significant increase in postoperative complication rate 7/355 (1.97 %) in Group A vs 7/62 (11.29 %) in Group B during pandemic (p < 0.002), along with a higher 30-days mortality rate 2/355 (3.22 %) vs 2/62 (0.56 %). Pandemic year also saw an increased readmission rate (4.83 %) vs (0.56 %) and postoperative ICU transfer rate (1.61 %) vs (0.56 %) in comparison with pre-Covid year.ConclusionIn the pandemic, arthroplasty services got severely affected at our center. With nearly six fold increase in complication rates, higher 30-days mortality and increased readmission rates, caution is advised in resuming arthroplasty surgeries without robust evaluation of cases. Whether undetected Covid-19 infection or poor pre-existing disease control due to lockdown can be linked to these results is a matter of further research with larger multicenter studies.     

Stapled video-assisted thoracoscopic segmentectomy preserves as much lung volume as nonstapled video-assisted thoracoscopic segmentectomy

BackgroundTwo different techniques of performing segmentectomy have been reported in the era of video-assisted thoracosopic surgery (VATS), including stapled segmentectomy (SS) and non-stapled segmentectomy (NSS). Some surgeons favor stapled segmentectomy for better pneumostatic control, while others prefer non-stapled segmentectomy to avoid compromising adjacent pulmonary parenchyma. In this study, we used multidetector computed tomography (MDCT) and spirometry to evaluate lung volume preservation of different segmentectomy techniques.MethodsA total of 269 patients undergoing video-assisted thoracic surgery (VATS) segmentectomy between October 2013 and September 2016 in a single institution were reviewed. Perioperative outcomes, the cost of hospital admission, the change in forced expiratory volume in 1 s (FEV1) (ΔFEV1 and ΔFEV1%), and residual ipsilateral volume ratios (RiVR) were compared.ResultsThe final study population consisted of 107 patients: 30 patients underwent NSS, and 77 patients underwent SS. The NSS group had significantly longer operative time, more blood loss, longer duration of chest tube placement and postoperative hospitalization than the SS group. The follow-up of RiVR (at 6 months, 12 months, 24 months), ΔFEV1(L), and ΔFEV1(%) demonstrated no significant difference between NSS and SS group.ConclusionOur study demonstrated that postoperative residual lung volume was not influenced by different segmentectomy techniques.     

Safety and Cost Savings Using Polymeric Clips in Appendectomies in the Pediatric Population: Single-Center Experience

IntroductionAlthough laparoscopic appendectomy is standard management for appendicitis, management of the appendiceal stump remains debated. Even though most surgeons can agree on the safety and effectiveness of various closure methods for the appendiceal stump, such as the surgical stapler (SS) or the Endoloop, the cost of these methods should also be considered. A relatively new alternative method, the polymeric clips (PC), has been gaining acceptance in the surgical community as it has repeatedly proven to be as safe as other methods, while being significantly cheaper.MethodsFor the period of January 2019 to December 2021, we performed a retrospective chart review of a single surgeon's laparoscopic appendectomies in children 18 years or younger for acute, non-complicated appendicitis and grouped the cases by appendiceal stump management (SS or PC). Demographics collected included gender, age, BMI percentile, race, and ASA score. Surgical variables included length of stay, surgical time, and anesthesia time. Outcomes were number of intra- and post-operative complications, reoperations, ER visits within 30 days, and total implant cost. Mann–Whitney U tests were performed to test for differences between SS and PC groups in surgical variables. Chi-square or Fisher's exact tests were performed to test differences in demographics and outcome variables.ResultsThere were 107 patients identified. The PC group represented 16% (n = 17) of our study population. The PC group was significantly younger than the SS group at 10 years (2.8) vs 12 years (3.5) p = 0.04. No differences were observed in length of stay and anesthesia time between the two groups. However, a significantly longer length of surgery was observed in the PC group at 33.5 min [30.0–43.3] when compared to the SS group at 28.0 min [23.0–36.0] (p = 0.003). No significant differences were seen in post-op complications, post-op ED visits and reoperations within 30 days. The median total implant cost of the PC closure method was significantly lower than the SS method ($35.36 vs. $375.67 p = <0.001).ConclusionThere were no significant differences in clinical outcomes. However, the significant difference in the implant cost between the 2 methods could favor the use of PC for selected cases. The increase in length of surgery can be attributed to the learning curve associated with a new device.Level of Evidence3.