Intramedullary nailing of humeral diaphyseal fractures. Is distal locking really necessary?

Purpose:

Distal interlocking is regarded as an inherent part of the antegrade humeral nailing technique, but it exposes both the patient and surgeon to radiation, is time consuming, and has a potential risk of damaging neurovascular structures. We have presented our technique of diaphyseal humeral nailing without any distal interlocking in this paper.

Materials and Methods:

We have presented a series of 64 consecutive patients (33 male and 31 female, mean age: 41.5 years) with humeral shaft fractures treated with antegrade rigid intramedullary nailing without distal interlocking following a strict intra and postoperative protocol. According to the AO classification, there were 36 type A fractures, 22 type B, and 6 type C. Nails were inserted unreamed or by using limited proximal reaming and they were fitted as snuggly as possible into the medullary canal. After impaction of the nail into the fossa, we carefully tested rotational stability of fixation by checking any potential external rotation when the arm was slightly turned externally and left to the gravity forces. We were ready to add distal screws, but that was not required in these cases. Follow-up assessment included fracture union, complications and failures, and the final clinical outcome at minimum 2-year follow-up using the parameters of the constant score.

Results:

All fractures, except two, united between the 4^th and 5^th postoperative month. In one case, nail was exchanged with plate, and, in another, a larger nail was used at a second surgery. Shoulder function according to constant score, at a minimum of 2-year follow-up, was excellent or very good in 93.7% of the patients.

Conclusions:

Provided that some technical issues are followed, the method reduces intraoperative time and radiation exposure and avoids potential damage to neurovascular structures.     

Is bilateral duplex scanning necessary in patients with symptoms of deep venous thrombosis?

BACKGROUND: Venous duplex ultrasound scanning (VDUS) has been shown to be an accurate non-invasive means to diagnose symptomatic deep venous thrombosis (DVT). The aim of our study was to determine whether bilateral VDUS is necessary in patients who present with symptoms of DVT. METHODS: We retrospectively reviewed the results of bilateral lower extremity VDUS performed on 1029 inpatients at Royal Prince Alfred Hospital in the 24 months from 1 January 1998 to 31 December 1999. RESULTS: Of the 1029 patients, 705 (69%) presented with unilateral symptoms and 324 (31%) with bilateral symptoms. The overall incidence of DVT was 168 (16% of 1029 patients). In 705 patients with unilateral symptoms the diagnosis of DVT was confirmed in 120 (17.0%), of whom 20 (16.7%) had unsuspected bilateral DVT. There were 12 patients (1.7% of the 705 patients) who had DVT in the asymptomatic limb, without DVT identified in the symptomatic limb. Overall there were 32 (5% of 705) patients with unilateral symptoms who had unsuspected DVT in the asymptomatic limb. Of the 20 patients with bilateral DVT, only one patient had more extensive DVT in the asymptomatic limb than in the symptomatic limb, that was therefore likely to alter treatment. Bilateral symptoms of DVT were present in 324 (31.5%) patients, 48 (14.8%) of whom were found to have DVT. Nineteen (39.6%) of these DVTs were bilateral. CONCLUSION: Overall the diagnostic yield of VDUS was low in this study, with an incidence of 16% of DVT detected in symptomatic patients. Techniques that improve the diagnostic yield of VDUS in symptomatic patients are required. A significant proportion (23%) of the DVT detected in this study were bilateral, and a small but significant proportion (10%) of DVT found in patients presenting with unilateral symptoms were only in the asymptomatic contralateral limb. Our study supports bilateral VDUS in symptomatic inpatients, as the detection of DVT in asymptomatic limbs aids future patient management if symptoms develop in the asymptomatic limb.     

Role of preoperative arthrography in early Perthes disease as a decision-making tool. Is it really necessary?

Arthrograms are commonly done in conjunction with an examination under anaesthesia (EUA), before any surgical intervention in Perthes disease. This usually is done as an independent day case procedure in the radiology department. The aim of this study is to confirm that the affected hip meets the prerequisites of a containment procedure. This study was carried out to investigate whether arthrogram findings ever altered the preoperative clinical decision of proposed osteotomy.One hundred and seven cases were reviewed retrospectively. Forty patients were excluded. Decision was not changed in 62 out of 67 hips, after the procedure. Five patients required different management following arthrogram and this was based mainly on EUA findings. EUA under image intensification helps the surgeon to decide the angle of varus osteotomy, required to contain the femoral head in the acetabulum and confirms an adequate range of abduction to undertake the procedure. This quick assessment can be done at the time of surgery under the same anaesthesia without the need for arthrography.Our findings question the role of arthrography as a routine before surgical intervention in Perthes disease and suggest that it may represent an unnecessary cost. We now reserve arthrography for cases of late Perthes disease where valgus osteotomy may be appropriate or for those unusual or questionable cases where clinical findings are inconclusive and therefore the type or appropriateness of treatment is uncertain.     

Is saphenofemoral junction reconstruction necessary during stripping of the saphenous vein?

BACKGROUND: Patients who had undergone complete ankle-to-groin stripping of the greater saphenous vein were evaluated retrospectively to assess the necessity of saphenofemoral junction reconstruction during the stripping procedure. Since 1996, in addition to the conventional complete stripping operation, we routinely perform a saphenofemoral junction reconstruction in patients presenting with greater saphenous vein reflux associated with low-grade (grades I-II) saphenofemoral junctional reflux. In this method, the size of the common femoral vein was adjusted to the desired diameter by a running linear suture technique after division of the greater saphenous vein. METHODS: Retrospective evaluation revealed that 73 limbs in 56 patients treated with this technique (group I). This group of patients was matched to another group of 65 patients (78 limbs) with similar characteristics and symptoms (group II) in whom the conventional complete ankle-to-groin stripping of greater saphenous vein was the treatment. The 2 groups were compared with respect to the incidence of complications, including recurrence of varicosities, ecchymosis, lymphocele, lymphorrhagia, wound infection, and paresthesia in the operated extremity. All patients also were evaluated by Doppler ultrasonography at 6 months, 12 months, and annually thereafter to determine the saphenofemoral junction reflux time (valve reflux time). The mean duration +/- SD of follow-up was 6.7 +/- 1.6 years (range, 2.1-10.8 years). RESULTS: Recurrence of varicosity was noted in 14 patients, 3 in group I and 11 in group II (P = .02). There were no statistically significant differences between the 2 groups in terms of ecchymosis, hematoma, lymphocele, lymphorrhagia, wound infection, and paresthesia. At 6 months, a rapid decrease in valve reflux time was noted in group I (P = .0001). In addition, there was a significant improvement in valve reflux time at each subsequent Doppler examination in group I. Group II showed a decrease in valve reflux time, compared with the preoperative value (P = .068). During subsequent Doppler examinations, a decrease in valve reflux time also was noted in group II; this difference reached statistical significance only at 24 months (P = .04). CONCLUSIONS: We believe that saphenofemoral junction reconstruction is a simple technique to perform and that addition of this method to the conventional stripping provides more durable results with a lesser incidence of recurrence. This method should be considered as a treatment modality in patients with greater saphenous vein reflux associated with low-grade (grades I-II) saphenofemoral junctional reflux.     

Fibula fixation in the treatment of tibial pilon fractures – Is it really necessary?

BackgroundThere is a lack of consensus about the role of fibula fixation in these complex fractures, with only two clinical studies in the literature. We hypothesize that the fibula fracture need not be fixed in the tibial pilon fractures if primary stability can be achieved with tibial fixation alone.MethodsWe reviewed 79 patients with operatively treated tibial pilon with associated fibula fractures from 2007 to 2017 and divided them into two groups; patients with fibula fracture fixation and those without fixation. The primary outcome measure was any mechanical complications. Secondary outcomes were wound complications and other morbidities.ResultsThere were 54 (68.4%) patients with fibula fixation and 25 (31.6%) patients without fixation. There were no statistically significant differences in mechanical complications between the two groups. However, patients without fibula fixation were noted to have more wound complications (44% vs 25.9%, p = 0.108) although this was not statistically significant. In terms of removal of implant (ROI), there were no differences noted in patients with or without fibula fixation (33.3% vs 28%, p = 0.796). There were also no significant differences in ROI for those fixed with plate and screws when compared to those fixed with Rush rod and K wire within the group with fibula fixation.ConclusionFibula fixation in the treatment of tibial pilon fractures is not routinely necessary and does not result in decreased mechanical complications such as malunion, delayed union, nonunion and implant failure. Fibula fracture fixation should be reserved for cases where it may aid reduction or provide additional stability.     

Pre-operative cardiac workup after anthracycline-based neoadjuvant chemotherapy. Is it really necessary?

INTRODUCTION

In patients receiving pre-operative anthracyclines for locally advanced breast cancer, early cardiotoxicity is a well-recognised complication that may interfere with surgery. The aim of this study was to assess the safety of breast surgery after neoadjuvant treatment with Doxorubicin.

PATIENTS AND METHODS

A retrospective study of breast cancer patients treated with Doxorubicin as part of their neoadjuvant protocol. All patients were subsequently operated in our institution. Intra-operative and postoperative haemodynamic, cardiac or respiratory events were collected.

RESULTS

A total of 83 patients were included. All patients had a normal left ventricular ejection fraction before starting on chemotherapy. Doxorubicin was given in conjunction with Cyclophosphamide and Paclitaxel. The cumulative dose of Doxorubicin was 240 mg/m². All patients completed their chemotherapy less than a year before surgery and were clinically asymptomatic. Of the patients, 2.3% displayed a significant reduction in cardiac function to meet cardiotoxicity criteria, although not clinically apparent. No complications occurred intra-operatively or postoperatively.

CONCLUSIONS

Breast surgery can be safely performed after breast neoadjuvant chemotherapy with Doxorubicin. The risk of early cardiotoxicity does not mandate a cardiac function assessment after completion of treatment. Work-up should be individualised according to the anthracycline regimen, patient''s cardiac risk factors and functional status before surgery.     

Reassessing reconstruction in the management of obstructive azoospermia: reconstruction or sperm acquisition?

Treatments for male factor infertility secondary to reconstructable obstructive azoospermia include either surgical reconstruction or direct sperm retrieval. We examine the risks and benefits of both types of therapies and discuss their respective medical and economic implications. Most male factor infertility studies comparing vasectomy reversal with sperm retrieval favor the former as the more cost-effective therapy for obstructive azoospermia. Analysis should include assessment of direct procedural costs and indirect costs, including the cost of complications, lost productivity, and multiple gestation pregnancies. When considering sperm retrieval, the impact of in vitro fertilization-related indirect costs, specifically that driven by multiple gestation pregnancies, is significant.     

Scoliosis correction maintenance in skeletally immature patients with idiopathic scoliosis. Is anterior fusion really necessary?

STUDY DESIGN: A retrospective evaluation of the occurrence of the crankshaft phenomenon in skeletally immature patients with idiopathic scoliosis. OBJECTIVE: To determine what factors, if any, contribute to a decreased occurrence of crankshaft phenomenon in patients treated with posterior surgery only. SUMMARY OF BACKGROUND DATA: Reports have described the progression of scoliotic deformity, termed the crankshaft phenomenon, in a region of solid posterior arthrodesis in skeletally immature patients. This has led some authors to advocate the use of concomitant anterior discectomy and fusion to prevent crankshaft. METHODS: From 1989 through 1994, 18 Risser 0 patients with thoracic or thoracolumbar idiopathic scoliosis underwent Isola (De Puy-Acromed, Raynham, MA) posterior instrumentation and fusion. They were assessed for evidence of the crankshaft phenomenon, identified by coronal plane deformity progression of 10 degrees or more, or a rib vertebra angle difference of 10 degrees or more. The average age of the patients was 12.5 years (range, 10.5-15.5 years), and the average follow-up period was 39 months (range, 24-68 months). RESULTS: Eleven patients (10 girls and 1 boy) had closed triradiate cartilage at the time of surgery. Their average Cobb angle was 62 degrees before surgery, 21 degrees after surgery, and 22 degrees at follow-up assessment. No patients in this group met the criteria for crankshaft. Seven patients (6 girls and 1 boy) had open triradiate cartilage at the time of surgery. Their average Cobb angle was 62 degrees before surgery, 18 degrees after surgery, and 20 degrees at follow-up evaluation. No patient had a 10 degrees or more increase in rib vertebra angle difference. One patient had more than a 10 degrees increase in her Cobb angle (11 degrees) from postoperative to latest follow-up assessment. Her instrumentation construct, performed in 1989, used sublaminar wires as the caudal anchors. Hooks and pedicle screws are now used. Two of the seven patients with open triradiate cartilage underwent surgery during or before their peak height velocity and displayed no evidence of crankshaft. No deaths, neurologic complications, or infections occurred in either group. CONCLUSIONS: These findings suggest that scoliotic deformity progression can be prevented in skeletally immature patients with idiopathic scoliosis as young as 10 years of age with the use of stiff segmental posterior instrumentation, without the necessity of concomitant anterior arthrodesis.