Laparoscopic versus open appendectomy: a prospective randomized trial of 81 patients

Objective

To compare the efficacy of laparoscopic appendectomy (LA) and open appendectomy (OA) in the treatment of acute appendicitis.

Design

A prospective randomized trial.

Setting

A university teaching hospital.

Patients

Eighty-one patients with a diagnosis of acute appendicitis were prospectively randomized to undergo either LA or OA. The two groups were matched for age and sex.

Interventions

LA or OA.

Main Outcome Measures

Number of days in hospital and time to full recovery.

Results

The mean hospital stay for LA was 3.23 days compared with 3.03 days for OA (p < 0.001). The mean number of narcotic injections required for patients in the LA group was 4.05 compared with 5.58 for patients in the OA group (p < 0.001). The mean time to complete recovery for patients in the LA group was 9.0 days compared with 16.2 days for patients in the OA group (p < 0.001). The mean operative time for LA was 73.8 minutes compared with 45.0 minutes for OA (p < 0.001). Three patients in the LA group had intra-abdominal abscesses (p > 0.25). No significant difference in wound infection rates was demonstrated (p > 0.05). Similarly, pain scores at 7 and 28 days showed no significant difference (p > 0.05).

Conclusions

With LA significantly fewer narcotic injections are required and there is a more rapid return to normal activities. LA takes longer to perform and was associated with three intra-abdominal abscesses. In cases of simple acute appendicitis the hospital stay for LA is significantly shorter.     

Functional outcome of supracondylar elbow fractures in children: a 3- to 5-year follow-up

Background

Long-term functional outcomes of supracondylar elbow fractures (SCEF) have not been well documented in the literature. We retrospectively evaluated functional outcomes of pediatric SCEF using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Methods

We retrospectively reviewed the outcomes of patients who presented to our tertiary care pediatric emergency department with SCEF between January 2005 and December 2009. We reviewed their charts to assess several clinical parameters, including age, sex, Gartland classification of SCEF, weight, comorbidities, treatment intervention, physiotherapy and the extremity involved. The DASH questionnaire was administered in 2012. We performed a multiple linear regression analysis to determine the significance of these clinical parameters as they related to the DASH score for functional outcome.

Results

We included 94 patients with SCEF in our review. Pediatric SCEF had good functional outcomes based on the DASH questionnaire (mean score 0.77 ± 2.10). We obtained the following DASH scores: 0.45 ± 2.20 for type I, 1.09 ± 1.70 for type II and 1.43 ± 2.40 for type III fractures. There was no statistical difference in functional outcome, regardless of sex (p = 0.07), age at injury (p = 0.96), fracture type (p = 0.14), weight (p = 0.59), right/left extremity (p = 0.26) or surgery (p = 0.52).

Conclusion

Our results demonstrate that good functional outcomes can be expected with pediatric SCEF based on the DASH questionnaire, regardless of age at injury, sex, weight, right/left extremity or surgical/nonsurgical intervention, provided satisfactory reduction is achieved and maintained.     

Results of Revision Surgery and Causes of Unstable Total Knee Arthroplasty

Background

The aim of this study was to evaluate causes of unstable total knee arthroplasty and results of revision surgery.

Methods

We retrospectively reviewed 24 knees that underwent a revision arthroplasty for unstable total knee arthroplasty. The average follow-up period was 33.8 months. We classified the instability and analyzed the treatment results according to its cause. Stress radiographs, postoperative component position, and joint level were measured. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) score and range of motion.

Results

Causes of instability included coronal instability with posteromedial polyethylene wear and lateral laxity in 13 knees, coronal instability with posteromedial polyethylene wear in 6 knees and coronal and sagittal instability in 3 knees including post breakage in 1 knee, global instability in 1 knee and flexion instability in 1 knee. Mean preoperative/postoperative varus and valgus angles were 5.8°/3.2° (p = 0.713) and 22.5°/5.6° (p = 0.032). Mean postoperative α, β, γ, δ angle were 5.34°, 89.65°, 2.74°, 6.77°. Mean changes of joint levels were from 14.1 mm to 13.6 mm from fibular head (p = 0.82). The mean HSS score improved from 53.4 to 89.2 (p = 0.04). The average range of motion was changed from 123° to 122° (p = 0.82).

Conclusions

Revision total knee arthroplasty with or without a more constrained prosthesis will be a definite solution for an unstable total knee arthroplasty. The solution according to cause is very important and seems to be helpful to avoid unnecessary over-constrained implant selection in revision surgery for total knee instability.     

The lifetime risk of pneumonia in patients with neuromuscular scoliosis at a mean age of 21?years: the role of spinal deformity surgery

Background

Patients with neuromuscular disorders often have an increased risk of pneumonia and decreased lung function, which may further be compromised by scoliosis. Scoliosis surgery may improve pulmonary function in otherwise healthy patients, but no study has evaluated its effect on the risk of pneumonia in patients with neuromuscular scoliosis (NMS).

Methods

The patient charts of 42 patients (mean age 14.6 years) who had undergone surgery for severe NMS (mean scoliosis 86°) were retrospectively reviewed from birth to a mean of 6.1 years (range 2.8–9.5) after scoliosis surgery. The main outcome was radiographically confirmed pneumonia as a primary cause for hospitalization. We excluded postoperative (3 months) pneumonia from the analyses.

Results

The lifetime annual incidence of pneumonia was 8.0/100 before and 13.4/100 after scoliosis surgery (p > 0.10). The mean number of hospital days per year due to pneumonia were 0.59 (SD 2.3) before scoliosis surgery and 2.24 (SD 6.9) after surgery (p > 0.10). Multivariate analysis demonstrated that lifetime risk factors for pneumonia were epilepsy (RR 15.2, 95 % CI 1.3–176.8, p = 0.027), non-cerebral palsy (CP) etiology (RR = 10.2, 95 % CI 3.2–32.7, p < 0.001) and major scoliosis (main curve >70°; RR = 11.3, 95 % CI 1.8–70.7, p = 0.01).

Conclusions

Epilepsy, non-CP etiology and major scoliosis are significant risk factors for pneumonia in patients with NMS. Scoliosis surgery does not decrease the incidence of pneumonia in patients with severe NMS.

Level of Evidence

Retrospective comparative study, Level III.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-015-0682-8) contains supplementary material, which is available to authorized users.     

Comparison of laparoscopic and open cystectomy for bladder cancer: a single center of 110 cases report

Purpose

We compared the operative time, complications, blood loss, total cost, and hospital days of laparoscopic cystectomy vs. open cystectomy for bladder cancer.

Materials and methods

This retrospective, nonrandomized study was conducted between January 2004 and March 2011 on 110 patients (17 women and 93 men) who underwent radical cystectomy for bladder cancer. A total of 45 cystectomies were performed laparoscopically and 65 by open surgery. Mean patient age was 62.9±10.4 years. The age, gender, American Society of Anesthesiologists score, histopathological results etc. were reviewed in this article.

Results

Intraoperative blood loss was significantly lower in the laparoscopic surgery group (821±776 vs. 1112±706 mL, P=0.044) while operative time was significantly lower in the open surgery group (376±90 vs. 445±119 min, P=0.001). The total costs were also significantly lower in the open surgery group 51,726±13,589 yuan (about $8000) vs. 63,053±19,378 yuan (about $10,000), P<0.001). There was no statistically significant difference in complication rates, postoperative days in hospital between the two groups.

Conclusions

Laparoscopic cystectomy can reduce intraoperative blood loss significantly. Open cystectomy requires less operative time and has a lower cost than laparoscopic cystectomy for bladder cancer. There was no statistically significant difference in postoperative complication rates in the hospital between the two groups.KEY WORDS : Bladder cancer, cystectomy, laparoscopy surgery, open surgery     

Underestimation of Bone Loss of the Spine With Posterior-Anterior Dual-Energy X-Ray Absorptiometry in Patients With Spinal Cord Injury

Background:

Bone mineral density (BMD) of the lumbar spine (L-spine) has been reported to be normal by routine posterior-anterior (PA) bone density imaging in patients with chronic spinal cord injury (SCI).

Objective:

To determine BMD of the L-spine by PA and lateral (LAT) dual-energy radiographic absorptiometry (DXA) in patients with chronic SCI.

Design:

Prospective study.

Setting:

Veterans Affairs Medical Center and a private rehabilitation facility.

Methods:

Measurements of the PA and LAT L-spine and hip were performed in 15 patients with SCI: 9 with tetraplegia and 6 with paraplegia. The DXA (GE Lunar Advance DXA) images were obtained using standard software. Results are reported as mean ± SD.

Results:

The mean age was 35 ± 15 years (range  =  20–62 years), and the duration of injury was 57 ± 74 months (range  =  3–240 months). T- and Z-scores were lower for the LAT L-spine than those for PA L-spine (T-scores L2: −0.7 ± 1.2 vs 0.0 ± 1.4, P < 0.01; L3: −0.9 ± 1.6 vs 0.3 ± 1.3, P < 0.002; L2-L3: −0.8 ± 1.3 vs 0.2 ± 1.3, P < 0.001; Z-scores L2: −0.3 ± 1.1 vs 0.2 ± 1.2, P < 0.05; L3: −0.6 ± 1.3 vs 0.5 ± 1.3, P < 0.01; L2-L3: −0.4 ± 1.1 vs 0.4 ± 1.2, P < 0.005). The T- and Z-scores for the total hip (−1.1 ± 1.0 and −1.0 ± 1.0, respectively) and L2-L3 LAT L-spine demonstrated remarkable similarity, whereas the L2-L3 PA L-spine scores were not reduced. Bone mineral density of the LAT L-spine, but not the PA L-spine, was significantly reduced with increasing duration of injury.

Conclusions:

Individuals with SCI may have bone loss of the L-spine that is evident on LAT DXA that may be misdiagnosed by PA DXA, underestimating the potential risk of fracture.     

Experiences with pins and rubber band traction in the treatment of proximal interphalangeal joint contracture

BACKGROUND:

Proximal interphalangeal joint (PIPJ) contracture is a difficult problem to treat regardless of etiology. Although numerous interventions have been recommended, published results are mediocre at best.

OBJECTIVE:

The authors describe their experience and results of using a modification of pins and rubber band traction (PRBT) – applying a dynamic extension apparatus to a contracted PIPJ using the constant traction force in a stretched rubber (elastic) band.

METHOD:

A retrospective review of patients treated with this method was performed, and the results are presented. The technique itself is described, and clinical photographs illustrate the method.

RESULTS:

Mean PIPJ flexion contracture before PRBT was 82° (range 60° to 110°). The full correction of eight contracted PIPJs in seven patients was achieved, in a mean of 17.8 days (range 14 to 31 days). At one month postremoval of PRBT, the mean PIPJ flexion contracture was 22.8° (range 0° to 46°).

DISCUSSION:

The method is compared with previously described methods of PIPJ contracture correction, whether surgical or splinting; the latter may be static, dynamic or a combination of the two. The results of previously published studies are discussed and compared with the method described.

CONCLUSION:

The present method is a powerful and effective simplification of a previously described method of correcting PIPJ contractures. This technique is simple, ‘low-tech’ and can be applied under local anesthetic; the authors believe it offers a useful adjunct to surgical release.     

Usefulness of Prone Cross-Table Lateral Radiographs in Vertebral Compression Fractures

Background

Dynamic radiographs are recommended to investigate non-healing evidence such as the dynamic mobility or intravertebral clefts in osteoporotic vertebral compression fractures (VCFs). However, it is difficult to examine standing flexion and extension lateral radiographs due to severe pain. The use of prone cross-table lateral radiographs (PrLRs) as a diagnostic tool has never been proposed to our knowledge. The purpose of this study is to clarify the usefulness of PrLRs in diagnosis and treatment of VCFs.

Methods

We reviewed 62 VCF patients examined with PrLRs between January 1, 2008 and June 30, 2011. To compare the degree of pain provoked between standing extension lateral radiographs (StLRs) and PrLRs, numeric rating scale (NRS) scores were assessed and compared by a paired t-test. Vertebroplasty was done for 40 patients and kyphoplasty was done for 9 patients with routine manners. To assess the degree of postural reduction, vertebral wedge angles (VWA) and vertebral height ratios (VHR) were calculated by using preoperative StLRs, PrLRs, and postoperative lateral radiographs. Two variables derived from changes in VWA and VHR between preoperative and postoperative radiographs were compared by a paired t-test.

Results

The average NRS scores were 6.23 ± 1.67 in StLRs and 5.18 ± 1.47 in PrLRs. The degree of pain provocation was lower in using PrLRs than StLRs (p < 0.001). The average changes of VWA between preoperative and postoperative status were 5.24° ± 6.16° with PrLRs and 3.46° ± 3.47° with StLRs. The average changes of VHR were 0.248 ± 0.178 with PrLRs and 0.148 ± 0.161 with StLRs. The comparisons by two variables showed significant differences for both parameters (p = 0.021 and p < 0.001, respectively). The postoperative radiological status was reflected more precisely when using PrLRs than StLRs.

Conclusions

In comparison with StLR, the PrLR was more accurate in predicting the degree of restoration of postoperative vertebral heights and wedge angles, and provoked less pain during examination. The PrLR could be a useful diagnostic tool to detect intravertebral cleft or intravertebral dynamic instability.     

Dedicated operating room for emergency surgery improves access and efficiency

Background

Scheduling emergency cases among elective surgeries often results in prolonged waits for emergency surgery and delays or cancellation of elective cases. We evaluated the benefits of a dedicated operating room (OR) for emergency procedures available to all surgical services at a large children’s hospital.

Methods

We compared a 6-month period (January 2009 to June 2009) preimplementation with a 6-month period (January 2010 to June 2010) postimplementation of a dedicated OR. We evaluated OR use, wait times, percentage of cases done within and outside of access targets, off-hours surgery, cancellations, overruns and length of stay.

Results

Preimplementation, 1069 of the 5500 surgeries performed were emergency cases. Postimplementation, 1084 of the 5358 surgeries performed were emergency cases. Overall use of the dedicated OR was 53% (standard deviation 25%) postimplementation. Excluding outliers, the average wait time for priority 3 emergency patients decreased from 11 hours 8 minutes to 10 hours 5 minutes (p = 0.004). An increased proportion of priority 3 patients, from 52% to 58%, received surgery within 12 hours (p = 0.020). There was a 9% decrease in the proportion of priority 3 cases completed during the evening and night (p < 0.001). The elective surgical schedule benefited from the dedicated OR, with a significant decrease in cancellations (1.5% v. 0.7%, p < 0.001) and an accumulated decrease of 5211 minutes in overrun minutes in elective rooms. The average hospital stay after emergency surgery decreased from 16.0 days to 14.7 days (p = 0.12) following implementation of the dedicated OR.

Conclusion

A dedicated OR for emergency cases improved quality of care by decreasing cancellations and overruns in elective rooms and increasing the proportion of priority 3 patients who accessed care within the targeted time.     

Remnant Preservation is Helpful to Obtain Good Clinical Results in Posterior Cruciate Ligament Reconstruction: Comparison of Clinical Results of Three Techniques

Background

The purpose of the present study was to compare the clinical results of 3 posterior cruciate ligament reconstruction techniques according to the time from injury to surgery and remnant PCL status and to evaluate the efficiency of each technique.

Methods

The records of 89 patients who underwent primary PCL reconstructions with a posterolateral corner sling were analyzed retrospectively. Thirty-four patients were treated by anterolateral bundle (ALB) reconstruction with preservation of the remnant PCL using a transtibial tunnel technique in the acute and subacute stages of injury (group 1). Forty patients were treated with remnant PCL tensioning and an ALB reconstruction using the modified inlay technique in the chronic stage (group 2), and fifteen patients were treated with double-bundle reconstruction using the modified inlay technique (group 3). The double-bundle reconstruction was performed if there was a very weak or no PCL remnant.

Results

The mean side-to-side differences in posterior tibial translation on the stress radiographs were reduced from 10.1 ± 2.5 mm in group 1, 10.6 ± 2.4 mm in group 2, and 12.8 ± 3.2 mm in group 3 preoperatively to 2.3 ± 1.4 mm in group 1, 2.3 ± 1.5 mm in group 2, and 4.0 ± 2.5 mm in group 3 at the last follow-up (p < 0.001, p < 0.001, and p < 0.001, respectively). Statistical analyses revealed that group 1 and group 2 were similar in terms of side-to-side difference changes in posterior tibial translation on the stress radiographs; however, group 3 was inferior to group 1 and group 2 at the last follow-up (p = 0.022). The clinical results were not significantly different among the three groups.

Conclusions

Excellent posterior stability and good clinical results were achieved with ALB reconstruction preserving the injured remnant PCL in the acute and subacute stages and remnant PCL tensioning with ALB reconstruction in the chronic stage. The PCL injuries could be surgically corrected with different techniques depending on both the remnant PCL status and the interval between the knee trauma and operation.     

Pressure support-ventilation versus spontaneous breathing with "T-Tube" for interrupting the ventilation after cardiac operations

Objective

To compare pressure-support ventilation with spontaneous breathing through a T-tube for interrupting invasive mechanical ventilation in patients undergoing cardiac surgery with cardiopulmonary bypass.

Methods

Adults of both genders were randomly allocated to 30 minutes of either pressure-support ventilation or spontaneous ventilation with "T-tube" before extubation. Manovacuometry, ventilometry and clinical evaluation were performed before the operation, immediately before and after extubation, 1h and 12h after extubation.

Results

Twenty-eight patients were studied. There were no deaths or pulmonary complications. The mean aortic clamping time in the pressure support ventilation group was 62 ± 35 minutes and 68 ± 36 minutes in the T-tube group (P=0.651). The mean cardiopulmonary bypass duration in the pressure-support ventilation group was 89 ± 44 minutes and 82 ± 42 minutes in the T-tube group (P=0.75). The mean Tobin index in the pressure support ventilation group was 51 ± 25 and 64.5 ± 23 in the T-tube group (P=0.153). The duration of intensive care unit stay for the pressure support ventilation group was 2.1 ± 0.36 days and 2.3 ± 0.61 days in the T-tube group (P=0.581). The atelectasis score in the T-tube group was 0.6 ± 0.8 and 0.5 ± 0.6 (P=0.979) in the pressure support ventilation group. The study groups did not differ significantly in manovacuometric and ventilometric parameters and hospital evolution.

Conclusion

The two trial methods evaluated for interruption of mechanical ventilation did not affect the postoperative course of patients who underwent cardiac operations with cardiopulmonary bypass.     

Airway complications in traumatic lower cervical spinal cord injury: A retrospective study

Objective

To investigate risk factors for pneumonia in patients with traumatic lower cervical spinal cord injury.

Design

Observational study, retrospective study.

Setting

Spinal cord unit in a maximum care hospital.

Methods

Thirty-seven patients with acute isolated traumatic spinal cord injury at levels C4–C8 and complete motor function injury (AIS A, B) treated from 2004 to 2010 met the criteria for inclusion in our retrospective analysis. The following parameters were considered: ventilation-specific parameters, re-intubation, creation of a tracheostomy, pneumonia, antibiotic treatment, and length of intensive care unit (ICU) stay and total hospitalization.

Results

Among the patients, 81% had primary invasive ventilation. In 78% of cases a tracheostomy was created; 3% of these cases were discharged with invasive ventilation and 28% with a tracheostomy without ventilation. Pneumonia according to Centers for Disease Control criteria occurred in 51% of cases within 21 ± 32 days of injury, and in 3% at a later date. The number of pre-existing conditions was significantly associated with pneumonia. Length of ICU stay was 25 ± 34 days, and average total hospital duration was 230 ± 144 days. Significant factors affecting the duration of ventilation were the number of pre-existing conditions and tetraplegia-specific complications.

Conclusions

Our results confirm that patients with traumatic lower cervical spinal cord injuries defined by lesion level and AIS constitute a homogeneous group. This group is characterized by a high rate of pneumonia during the first 4 weeks after injury. The number of pre-existing general conditions and spinal injury-specific comorbidities are the only risk factors identified for the development of pneumonia and/or duration of ventilation.     

Dyslipidemia in HIV-positive patients: a randomized,controlled, prospective study on ezetimibe+fenofibrate versus pravastatin monotherapy

Introduction

We designed a randomized, controlled prospective study aimed at comparing efficacy and tolerability of ezetimibe+fenofibrate treatment versus pravastatin monotherapy in dyslipidemic HIV-positive (HIV+) patients treated with protease inhibitors (PIs).

Methods

We consecutively enrolled 42 HIV+ dyslipidemic patients on stable PIs therapy (LDL cholesterol >130 mg/dl or triglycerides 200–500 mg/dl with non-HDL cholesterol >160 mg/dl). After basal evaluation, patients were randomized to a six-month treatment with ezetimibe 10 mg/day+fenofibrate 200 mg/day or with pravastatin 40 mg/day. Both at the basal evaluation and after the six-month treatment, the patients underwent blood tests for lipid parameters, and muscle and liver enzymes.

Results

At baseline, the two groups (21 patients each) were similar with regards to gender, age, BMI, blood pressure and virologic and metabolic parameters. After the six-month therapy, total cholesterol, LDL cholesterol and non-HDL cholesterol decreased significantly (p<0.01) in both groups. high-density lipoprotein (HDL) cholesterol increased (44±10 to 53±12 mg/dl, p<0.005) and triglycerides decreased (from 265±118 mg/dl to 149±37 mg/dl, p<0.001) in the ezetimibe+fenofibrate group, whereas both parameters remained unchanged in the pravastatin group. Mean values of creatine kinase (CK), alanine aminotransferase and aspartate aminotransferase were unchanged in both groups; only one patient in the pravastatin group stopped the treatment after two months, due to increased CK.

Conclusions

In dyslipidemic HIV+ patients on PI therapy, the association of ezetimibe+fenofibrate is more effective than pravastatin monotherapy in improving lipid profile and is also well tolerated.     

Functional outcomes and cost estimation for extra-articular and simple intra-articular distal radius fractures treated with open reduction and internal fixation versus closed reduction and percutaneous Kirschner wire fixation

Background

We sought to compare direct costs and clinical and radiographic outcomes for distal radius fractures (DRF) treated with open reduction internal fixation with volar locking plates (VLP) versus closed reduction and percutaneous pinning (CRPP).

Methods

We identified patients with AO-type A and C1 DRFs from a prospective database. Outcomes were assessed at 6 weeks and at 3, 6 and 12 months, and surgical care costs were estimated.

Results

Twenty patients were treated with CRPP and 24 with VLP. There were no significant differences in patient-rated wrist evaluation (PRWE) scores between the 2 groups at any time point (mean 16.2 ± 23.1 in the CRPP group v. 21.5 ± 23.6 in the VLP group, p = 0.91). Overall alignment was maintained in both groups; however, there was a greater loss of radial height over time with CRPP than VLP (0.97 mm v. 0.25 mm, p = 0.018). The mean duration of surgery was longer for VLP than CRPP (113.9 ± 39.5 min v. 86.5 ± 7.8 min, p = 0.029), but there were fewer clinic visits (5.2 ± 1.4 v. 7.8 ± 1.3, p < 0.001) and fewer radiographs (7.4 ± 2.7 v. 9 ± 2.4, p = 0.031). The total cost per case was greater for VLP than CRPP ($1637.27 v. $733.91).

Conclusion

Based on PRWE scores, VLPs did not offer any significant advantage over CRPP in patients with simple fracture types between 3 and 12 months, but they were much more costly. Whether VLP offers any functional advantage earlier in recovery, thereby justifying their expense, requires further investigation in the form of a prospective randomized trial with a detailed cost analysis.     

Repair of aortic root in patients with aneurysm or dissection: comparing the outcomes of valve-sparing root replacement with those from the Bentall procedure

Introduction

Management of aortic root aneurysm or dissection has been the subject of much discussion that has led to some modifications. The current trend is a valve-sparing root replacement. We compared the outcome following valve sparing root repair with Bentall procedure.

Methods

We retrospectively evaluated 70 patients who underwent root replacement for aneurysm or dissection and compared the outcomes of valve-sparing root replacement with those of the Bentall procedure from January 2007 to December 2011 at our institution.

Results

Twenty-five patients had valve-sparing aortic root replacement (VSR, including reimplantation or remodeling) (23 males and 2 females), and 45 patients had the Bentall procedure (34 males and 11 females). Patients who underwent a VSR were younger with a mean age of 55.4 ± 14.8 years compared to those who underwent the Bentall procedure with a mean age of 60.6 ± 12.7 (P=ns). The preoperative aortic insufficiency (AI) in the VSR group was moderate in 8 (32%) patients, and severe in 6 (24%). Preoperative creatinine was 1 ± 0.35 mg/dl in the VSR group and 1.1 ± 0.87 mg/dl in the Bentall group. In the VSR group, 3 (12%) patients had emergency surgery; by contrast, in the Bentall group, 8 (17%) patients had emergent surgery. Concomitant coronary artery bypass grafting (excluding coronary reimplantation) was performed in 8 (32%) patients in the VSR group and in 12 (26.6%) patients in the Bentall group (P=0.78); additional valve procedures were performed in 2 (8%) patients in the VSR group and in 11 (24.4%) patients in the Bentall group. The perioperative mortality was 8% (n=2) and 13.3% (n=6), for the VSR and Bentall procedures, respectively (P=0.7, ns). The total duration of intensive care unit stay was 116.6 ± 106 hours for VSR patients and 152.5 ± 218.2 hours for Bentall patients (P=0.5). The overall length of stay in the hospital was 10 ± 8.1 days for VSR and 11 ± 9.52 days for Bentall (P=0.89). The one-year survival was 92% for the VSR group and 79.0% for the Bentall group. The seven-year survival for the VSR group was 92% and 79% for the Bentall group (95% CI [1.215 to 0.1275], P=0.1).

Conclusion

Aortic valve-sparing root replacement can be performed with acceptable morbidity and mortality with a comparable long-term survival to the Bentall procedure.     

Revision knee arthroplasty with a rotating-hinge design in elderly patients with instability following total knee arthroplasty

Background

Revision knee arthroplasty with a rotating-hinge design could be an option for the treatment of instability following total knee arthroplasty (TKA) in elderly patients.

Purpose

To evaluate the clinical and radiographic results of revision arthroplasties in TKAs with instability using a rotating-hinge design in elderly patients.

Methods

We retrospectively reviewed 96 rotating-hinge arthroplasties. The average age of the patients was 79 years (range, 75–86 years); the minimum follow-up was 5 years (mean, 7.3 years; range, 5–10 years). Patients were evaluated clinically (Knee Society score) and radiographically (position of prosthetic components, signs of loosening, bone loss).

Results

At a minimum followup of 5 years (mean, 7.3 years; range, 5–10 years), Knee Society pain scores improved from 37 preoperatively to 79 postoperatively, and function scores improved from 34 to 53. ROM improved on average from −15° of extension and 80° of flexion before surgery to −5° of extension and 120° of flexion at the last followup (p = 0.03). No loosening of implants was observed. Nonprogressive radiolucent lines were identified around the femoral and tibial components in 2 knees. One patient required reoperation because of a periprosthetic infection.

Conclusions

Revision arthroplasty with a rotating-hinge design provided substantial improvement in function and a reduction in pain in elderly patients with instability following TKA.

Level of evidence

Level IV, therapeutic study.     

Integrated care pathways in lower-limb arthroplasty: are they effective in reducing length of hospital stay?

Purpose

The aim of this study was to examine the effect of an integrated care pathway (ICP) for total hip and knee arthroplasty (THA/TKA) on length of stay (LOS), day of surgery admission rate (DOSA) and postoperative length of stay (POLOS).

Methods

Three hundred and eight THAs and 299 TKAs were assessed in a retrospective before–after trial design. LOS, POLOS and DOSA were recorded for patients before and after introduction of the ICP. The ICP encompassed a patient education programme, specific daily management goals, variance mapping, daily facilitated meetings and a DOSA policy. Subgroup analysis according to age and gender was also performed.

Results

Mean LOS was significantly reduced by 1.4 (from 6.9 to 5.5) days for THA and 0.8 (from 6.4 to 5.6) days for TKA. Elderly patients and men achieved greater LOS reductions than their counterparts for both operations. Younger patients undergoing THA achieved a significantly higher DOSA rate than older patients (89 % vs 71 %, p = 0.010); however, this difference was not observed in the TKA population. Mean POLOS for THA was reduced by 0.6 (from 5.9 to 5.3) days, again with the greatest benefit seen in elderly and male patients. POLOS for TKA patients was not significantly affected by the ICP.

Conclusions

The introduction of an ICP reduced LOS by 1.4 days for THA and 0.8 days for TKA. Elderly and male patients benefitted most.