Femoral neck resorption following hybrid metal-on-metal hip resurfacing arthroplasty: a radiological and biomechanical analysis

Introduction  

With the resurgence of resurfacing hip arthroplasty complications such as femoral neck fracture and thinning have been identified. We therefore conducted a radiological and biomechanical evaluation of factors affecting femoral neck resorption following resurfacing hip arthroplasty (RHA).     

“Extended length” endoscopic harvest of the great saphenous vein for coronary artery bypass grafting

Introduction The endoscopically harvested vein from thigh usually falls short by half to one length in patients requiring multiple conduits. Increased risk of complications precludes routine endoscopic vein harvest from the leg and an extra incision for open technique is often required thereby nullifying the sole purpose of the former. We employed the endoscope to harvest this extra length of vein from the upper half of the leg with little or no extra risk. Methods From January 2006 to September 2006 we endoscopically harvested the vein in thigh as well as the leg using the same entry point incision over the medial epicondyle in 40 cases. The only exclusion criterion for the study was a superficial location and subcutaneous visibility of the vein in the leg. We made 3 incisions in each patient of average size 2.5 cm. Results Five patients required conversion to the open technique. The average harvest time was 59 minutes. Average length of the conduit was 48 cms. Complications included 1 minor wound infection, 1 case of superificial wound dehiscence, 1 haematoma requiring aspiration and minor erythema at the incision site in 2 patients. Most common complication observed was ecchymosis in 6 patients (5 high; 3 leg). None of the patient developed lymphoedema and none required re-hospitalization for vein harvest related wound complications. Conclusion “Extended endoscopic vein harvest” and avoidance of the open incision was possible in most patients with no additional risk and that the procedure could be routinely employed in patients requiring multiple conduits.     

Role of Fibrin Glue as a Sealant to Esophageal Anastomosis in Cases of Congenital Esophageal Atresia with Tracheoesophageal Fistula

Objective The aim of this study was to characterize a successful approach for the management of infants with long-gap esophageal atresia (EA) with tracheoesophageal fistula (TEF). The goal was to preserve the native esophagus and minimize the incidence of esophageal anastomotic leaks using fibrin glue as a sealant over the esophageal anastomosis. Method A total of 52 patients were evaluated in this study. Only patients in whom, gap between the two ends of the esophagus was ≥ 2 cm were selected during January 2005 to January 2007. Patients were divided in two groups on the basis of block randomization. Group A comprised the patients in whom fibrin sealant was used as reinforcement on a primary end-to-end esophageal anastomosis; in group B, fibrin glue was not used. The two groups were compared in terms of esophageal anastomotic leak (EL), postoperative esophageal stricture (ES), and mortality. The statistical analysis was done using Fisher’s exact test and the chi-squared test. Result The number of anastomotic leaks in group A (glue group) was about one-fifth that in group B (no glue group). The incidence of ES was almost twice as high in group B as in group A. The mortality rate was almost threefold higher in group B (no-glue group). The higher incidence of EL and ES in group B compared to group A was statistically significant. Conclusion Thus, fibrin glue when used as an adjunct to esophageal anastomosis for primary repair of long-gap EA with TEF appears safe in the clinical setting and may lower the chances of esophageal leak and anastomosis-site strictures. Hence, it can diminish the mortality and morbidity of these patients.     

Deep vein thrombosis and thromboprophylaxis in arthroscopic anterior cruciate ligament reconstruction

Background:

There is no clear evidence in the literature regarding the incidence of deep vein thrombosis (DVT) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. Literature also lacks on the recommendations on thromboprophylaxis in patients undergoing elective arthroscopic ACL reconstruction. We conducted a prospective analysis to assess incidence of DVT in patients undergoing arthroscopic ACL reconstruction.

Materials and Methods:

120 consecutive patients with MRI proven ACL injury who were operated for arthroscopic ACL reconstruction were enrolled in this prospective study. None of the patients had risk factors (on history) for DVT, and all were below the age of 45 years. All cases were operated upon by a single surgeon and a standard rehabilitation regime was followed. The patients underwent clinical examination and screening (Doppler ultrasonography/venous scan) for any DVT, on the day prior to surgery, day of discharge (Day 3) and at 4 weeks postsurgery. None of the patients received any form of thromboprophylaxis against DVT.

Results:

One hundred and twelve patients (61 males and 51 females) completed the study. The average age was 31.6 years (range 24-42 years). All patients underwent arthroscopic assisted ACL reconstruction surgery within 3 weeks of the injury. Two patients (males) in the series had Doppler venous scan proven DVT. One patient was asymptomatic but the screening Doppler picked up the DVT on the third postoperative day. The other patient was symptomatic at 12 weeks with pain and swelling in the leg and had ultrasound -proven DVT.

Conclusion:

In our study the incidence of deep vein thrombosis in patients undergoing arthroscopic ACL reconstruction is 1.78%. We do not recommend routine thromboprophylaxis in patients, who are not high risk candidates for thrombosis and are of less than 45 years, in patients undergoing arthroscopic ACL reconstruction, with early postoperative rehabilitation.     

Valgus intertrochanteric osteotomy for neglected femoral neck fractures in young adults

Twenty cases of neglected (more than 1 month old) displaced femoral neck fractures in young adults were treated with a valgus intertrochanteric osteotomy. A fracture union rate of 85% (17 cases) was achieved. Two of the healed cases developed avascular necrosis. After 30 months 15 patients (75%) had achieved good to excellent results. We believe that intertrochanteric osteotomy provides good alternative management for neglected femoral neck fractures.     

Anatomy of the pectoralis minor tendon and its use in acromioclavicular joint reconstruction

Many procedures described for operative management of acromioclavicular joint separations entail transfer of the coracoacromial ligament. We sought to describe the anatomy and morphology of the pectoralis minor tendon better, to assess its anatomic potential as a substitute for sacrificing the coracoacromial ligament, and to compare the ultimate tensile strength of the pectoralis minor with that of the coracoacromial ligament and detached coracoclavicular ligament. The morphology of the pectoralis minor tendon was carefully delineated and compared with that of the coracoacromial ligament, and 10 paired fresh-frozen cadaveric shoulders were tested to failure by applying a single uniaxial tensile load. Anatomic study of the pectoralis minor tendon confirmed its adequacy as a source of local autograft tissue in acromioclavicular joint reconstruction. We hypothesize that, in cases of acromioclavicular joint separation necessitating operative intervention, the use of the pectoralis minor tendon as a potential source of autograft tissue is anatomically feasible and it is slightly stronger than the coracoacromial ligament.     

The use of bone morphogenetic protein in thoracolumbar spine procedures: analysis of the MarketScan longitudinal database

Background contextThe use of recombinant human bone morphogenetic protein (BMP) in the thoracolumbar spine remains controversial, with many questioning the risks and benefits of this new biologic.PurposeTo describe national trends, incidence of complications, and revision rates associated with BMP use in thoracolumbar spine procedures.Study design/settingAdministrative database study.Patient sampleA matched cohort of 52,259 patients undergoing thoracolumbar fusion surgery from 2006 to 2010 were identified in the MarketScan database. Patients without BMP treatment were matched 2:1 to patients receiving intraoperative BMP.Outcome measuresRevision rates and postoperative complications.MethodsThe MarketScan database was used to select patients undergoing thoracolumbar fusion procedures, with and without intraoperative BMP. We ascertained outcome measures using either International Classification of Disease, ninth revision, or Current Procedural Terminology coding, and matched groups were evaluated using a bivariate and multivariate analyses. Kaplan-Meier estimates of fusions failure rates were also calculated.ResultsPatients receiving intraoperative BMP underwent fewer refusions, decompressions, posterior and anterior revisions, or any revision procedure (single level 4.53% vs. 5.85%, p<.0001; multilevel 5.02% vs. 6.83%, p<.0001; overall cohort 4.73% vs. 6.09%, p<.0001). After adjusting for comorbidities, demographics, and levels of procedure, BMP was not associated with the postoperative development of cancer (odds ratio 0.92). Bone morphogenetic protein use was associated with an increase in any complication at 30 days (15.8% vs. 14.9%, p=.0065), which is only statistically significant among multilevel procedures (19.74% vs. 18.02%, p=.0013). Thirty-day complications in multilevel procedures associated with BMP use included new dysrhythmia (4.68% vs. 4.01%, p=.0161) and delirium (1.08% vs. 0.69%, p=.0024). A new diagnosis of chronic pain was associated with BMP use in both single-level (2.74% vs. 2.15%, p=.0019) and multilevel (3.7% vs. 2.52%, p<.0001) procedures. Bone morphogenetic protein was negatively associated with infection in single-level procedures (2.12% vs. 2.64%, p=.0067) and wound dehiscence in multilevel procedures (0.84% vs. 1.18%, p=.0167).ConclusionsIn national data analysis of thoracolumbar procedures, we found that BMP was associated with decreased incidence of revision spinal surgery and with a slight increased risk of overall complications at 30 days. Although no BMP-associated increased risk of malignancy was found, lack of long-term follow-up precludes detection of between-group differences in malignancies and other rare events that may not appear until later.