What is the contribution of imaging?

Thyroid imaging has an essentially diagnostic value, but is also plays a role in definition of indications and operative techniques. Ultrasound is the most useful examination. Scintigraphy has become less useful, but remains indicated in hyperthyroidism and in certain retrosternal goitres inaccessible to ultrasound. The other examinations only have a limited value.     

What is the quality of the orthopaedic literature?

The orthopaedic evidence base is far from ideal. In order to truly ensure the effectiveness of orthopaedic interventions, researchers must design and carry out high-quality randomized controlled trials that strive to minimize bias. Such endeavors will ultimately form a high-quality RCT evidence base, which can subsequently be integrated by systematic reviews and meta-analyses in order to provide clinicians with the best evidence for decision-making.     

What is the Long-term Economic Societal Effect of Periprosthetic Infections After THA? A Markov Analysis

Clinical Orthopaedics and Related Research® - Current estimates for the direct costs of a single episode of care for periprosthetic joint infection (PJI) after THA are approximately USD...     

What is the contribution of aspiration cytology?

Aspiration cytology of thyroid nodules is essentially designed to determine the benign nature of the nodule in order to avoid purely diagnosis surgery. It is reliable in the diagnosis of anaplastic papillary and medullary carcinomas and most lymphomas, but is more problematical for the diagnosis of the benign or malignant nature of Hürthle cell tumours and certain vesicular tumours, in which cytology reveals a suspicious, doubtful or undetermined appearance. However, whether they are unambiguous or doubtful, fine needle aspiration cytology results help the surgeon to define the therapeutic strategy under the best possible conditions. A therapeutic approach is proposed, based on the formulation of aspiration cytology results into benign, malignant, suspicious and inadequate.     

Very Long-term Survival of the Transplanted Kidney—Characteristics of Recipients

Background

After kidney transplantation (KTx), donor- and recipient-dependent factors, as well as the immunosuppression protocol, may have an impact long-term graft function. The aim of this retrospective study was to identify and describe recipients from a single center who had their transplanted kidney survive for more than 20 years.

What is the evidence for the efficacy of cryoplasty?

Cryoplasty is a technique for treating vascular stenosis which combines balloon angioplasty with cold injury. The combination is proposed to reduce the incidence of restenosis by inhibition of neointimal hyperplasia. There have been several clinical studies which purport to show improved patency compared to conventional angioplasty. Unfortunately, these are not comparative or controlled studies and have not been performed, analyzed or reported in accordance with recognized reporting standards for peripheral vascular intervention. The studies on femoropopliteal disease have selected favourable patients. Of greatest concern is the use of surrogate endpoints in lieu of objective demonstration of vessel patency. Critical interpretation of the results fails to demonstrate any convincing superiority of cryoplasty compared to conventional balloon angioplasty. Where little difference in outcome exists between two techniques, a trial comparing them will require hundreds of patients to be sufficiently powered to demonstrate a benefit of one technique over the other. As cryoplasty is significantly more expensive than conventional angioplasty, the cost benefit ratio is unfavourable and such a trial is unlikely to occur.This article is a critical review of the technique of cryoplasty. The reader will be able to: describe expected outcomes from balloon angioplasty; describe the theoretical role for cold injury as a component of angioplasty; recognize the need to adhere to well defined standards when reporting the results of new techniques for treating vascular disease; critically review the results of cryoplasty; understand the limitations and relevance of the published clinical results of cryoplasty.     

What is the Future of Surgery in the UK?

Surgery is an invasive form of treatment and must be a ‘last resort’. Research into conditions that can be treated by surgery aims to make it extinct, by discovering the basis for various disease processes and treating them medically. A prime example of this is peptic ulceration, which was the ‘bread and butter’ of surgical training in the UK in the 1970s and 1980s, but is now a condition that has almost vanished from the surgical lexicon with the discovery of Helicobacter pylori and its treatment by triple therapy and proton pump inhibitors. In the ‘molecular age’, there is a strong possibility that other areas of surgery (which currently keep many surgeons occupied) will also diminish in volume and importance. Further, it would be worth looking briefly at a number of different specialties within surgery and speculating where changes may occur in the future, perhaps making operations less necessary. In those areas where molecular advances have not (or will not) eradicate open surgery, there will be a definite tendency towards minimally invasive procedures, even though the introduction of such procedures is seldom evidence based.     

What Is the Survival of the Telescope Allograft Technique to Augment a Short Proximal Femur Segment in Children After Resection and Distal Femur Endoprosthesis Reconstruction for a Bone Sarcoma?

BackgroundLarge, malignant bone tumors and revision limb salvage procedures often result in the resection of extensive lengths of the involved bone segment, leaving a residual segment of bone that may be too short to support a standard intramedullary stem for endoprosthetic reconstruction. Telescope allografting, in which an allograft is used to augment the remaining bone segment by telescoping it into the residual bone segment, was described for situations in which residual bone stock is insufficient after tumor resection or prosthetic revision. Apart from one study that first described the procedure [15], there are no other studies reporting the outcome of this telescopic concept for restoring bone stock.Questions/purposesFor patients younger than 18 years who underwent the telescopic allograft technique to augment a short segment of the proximal femur after resection of bone sarcomas who also underwent endoprosthesis reconstruction of the distal femur, we asked: (1) What is the survivorship free from removal of the telescopic allograft and the endoprosthetic stem at 7 years after surgery? (2) What proportion of these reconstructions will heal to the host bone without delayed union or nonunion? (3) What is the functional outcome based on the Musculoskeletal Tumor Society (MSTS) score?MethodsWe retrospectively studied our institutional database and identified 127 patients younger than 18 years who underwent surgery for a primary malignant bone tumor of the distal femur between December 2008 and October 2018. After excluding 16 patients undergoing amputation and rotationplasty and 57 patients undergoing recycled autograft/allograft reconstruction, 54 patients who underwent primary or revision distal femur endoprosthesis reconstruction were identified. Among these patients, we considered 15 patients who underwent telescopic allograft augmentation of the femur for analysis. One patient was lost to follow-up before 2 years but was not known to have died, leaving 14 for analysis at a median (range) 49 months (24 to 136 months) of follow-up. The indications for telescopic allograft augmentation of the femur in our institution were a proximal femur length of less than 120 mm after resection or resection of more than two-thirds of the total length of the femur. Ten of 14 patients underwent telescopic allograft augmentation as a revision procedure (distal femur resorption in five patients, endoprosthesis stem loosening in three patients, implant fracture in one patient, and infection in one patient), and the remaining four patients underwent telescopic allograft augmentation as a primary limb salvage procedure for large malignant bone tumors of the distal femur. The histologic diagnosis in all patients was osteosarcoma. At the time of telescopic allograft augmentation and reconstruction, the median age of the patients was 14 years (7 to 18 years). The size and the type of bone allograft to be used (femoral shaft or proximal femur) was planned before surgery, with consideration of the extent of resection, level of osteotomy, diameter of the host bone at the osteotomy site, and approximate diameter of the endoprosthesis stem to be used. The segment of the cylindrical allograft used for telescoping was thoroughly washed, prepared, and impacted onto the native femur to achieve telescoping and overlap. Serial digital radiographs were performed once a month for the first 6 months after the procedure, every 2 months until 1 year, and then every 6 months thereafter. Two surgeons in the department (at least one of which was involved in the surgery) retrieved and reviewed clinical notes and radiographs to determine the status of the telescopic allograft and endoprosthesis stem. We defined delayed union as radiological union at the osteotomy site more than 6 months after the procedure without additional surgery; we defined nonunion as no radiological evidence of callus formation at the osteotomy site 9 months after the procedure, necessitating additional surgery. The reviewers did not disagree about the definition of healing time. None of the patients missed radiographic follow-up. Kaplan-Meier survivorship free from removal of telescopic allograft and the endoprosthesis stem at 7 years after surgery was estimated. Patient function was assessed using the 1993 version of the MSTS [9], as determined by chart review of the institutional database performed by one of the surgeons from the department.ResultsThe survivorship free from removal of the telescopic allograft and endoprosthesis stem at 7 years after surgery was 80% (95% confidence interval 22% to 96%). The allograft united with the host bone in 100% (14 of 14) of the patients. Though 21% (3 of 14) had delayed union, no nonunions were seen. The median (range) MSTS score at the final follow-up interval was 27 (22 to 30).ConclusionAlthough this is a small group of patients, we believe that allograft segments help augment short bone stock of the proximal femur after long-segment resections, and the telescopic technique seems to be associated with a low proportion of nonunion or delayed union, which is one of the most common complications of allografts. Maintaining an adequate length of the proximal femur is important in preserving the hip, and this technique may be especially useful for young individuals who may undergo repeated revision procedures.Level of EvidenceLevel IV, therapeutic study.