Comparison of complications and results of early versus delayed surgery for Gartland type III supracondylar humeral fractures in pediatric patients

Objective: To investigate the effect of timing of surgery on clinical results and perioperative complications in pediatric patients with Gartland III type supracondylar humeral fractures without neurovascular compromise. Methods: Eighty‐six c onsecutive children treated surgically at our hospital from April 2005 to June 2007 for displaced supracondylar humeral fractures were reviewed. All these patients were treated by the same group of doctors. The children were divided into two groups: early if treated within 12 hours after injury and delayed if treated later than that. Perioperative complications and clinical results, especially for open surgery, were compared between the two groups. Results: Forty pediatric patients underwent surgery in the early group and 46 in the delayed group. There were no significant differences between the two groups in perioperative complications such as pin tract infection, iatrogenic nerve injury, compartment syndrome and conversion to open surgery. For open surgery, both the clinical results and perioperative complications were not affected by delaying for more than 12 hours after injury. However, blood loss and operation time were greater in the early than in the delayed group, possibly due to relatively more edema. Conclusion: Delay in surgery, regardless of whether it is closed or open, for more than 12 hours after injury does not influence the perioperative complications and clinical results for displaced supracondylar humeral fractures in children. However early open reduction and pinning may increase intra‐operative blood loss and take longer.     

The role of invasive and non-invasive urodynamics in male voiding lower urinary tract symptoms

Introduction

Troublesome voiding lower urinary tract symptoms (LUTS) are a common problem in men, particularly with ageing. Implicitly, management of voiding LUTS can be guided by accurate determination of underlying mechanisms, distinguishing men with voiding symptoms caused by outlet obstruction from those with reduced bladder contractility.

Methods

A PubMed search of the published literature on invasive and non-invasive methods used to assess lower urinary tract function was carried out.

Results

A multitude of methods have been applied to assess LUTS. Multichannel pressure flow studies (PFS) are the standard for diagnosing bladder outlet obstruction and underlying mechanisms of LUTS, though their invasive nature can be difficult to tolerate, and improved prediction of treatment outcome is disputed. Uroflowmetry and post void residual measurement are insufficient to make a definitive diagnosis. Ultrasound-derived measurements of bladder wall thickness and estimated bladder weight offer a potential non-invasive alternative to PFS, but their diagnostic parameters are still under evaluation. Non-invasive methods that measure isovolumetric bladder pressure by interrupting the urinary stream can reproducibly measure pressure and urinary flow, but are unable to determine the effects of abdominal straining during voiding and give no insight into urine storage symptoms. Doppler ultrasound during urethral flow is informative, but it is an expensive approach whose clinical utility has yet to be established.

Conclusion

A variety of non-invasive urodynamic and non-urodynamic techniques have been used to evaluate LUTS and some show great promise. However, there is as yet, insufficient evidence to justify replacement of invasive voiding cystometry by these investigational approaches.     

Toward Optimization of Imaging System and Lymphatic Tracer for Near-Infrared Fluorescent Sentinel Lymph Node Mapping in Breast Cancer

Background

Near-infrared (NIR) fluorescent sentinel lymph node (SLN) mapping in breast cancer requires optimized imaging systems and lymphatic tracers.

Materials and Methods

A small, portable version of the FLARE imaging system, termed Mini-FLARE, was developed for capturing color video and two semi-independent channels of NIR fluorescence (700 and 800 nm) in real time. Initial optimization of lymphatic tracer dose was performed using 35-kg Yorkshire pigs and a 6-patient pilot clinical trial. More refined optimization was performed in 24 consecutive breast cancer patients. All patients received the standard of care using ^99mTechnetium-nanocolloid and patent blue. In addition, 1.6 ml of indocyanine green adsorbed to human serum albumin (ICG:HSA) was injected directly after patent blue at the same location. Patients were allocated to 1 of 8 escalating ICG:HSA concentration groups from 50 to 1000 μM.

Results

The Mini-FLARE system was positioned easily in the operating room and could be used up to 13 in. from the patient. Mini-FLARE enabled visualization of lymphatic channels and SLNs in all patients. A total of 35 SLNs (mean = 1.45, range 1–3) were detected: 35 radioactive (100%), 30 blue (86%), and 35 NIR fluorescent (100%). Contrast agent quenching at the injection site and dilution within lymphatic channels were major contributors to signal strength of the SLN. Optimal injection dose of ICG:HSA ranged between 400 and 800 μM. No adverse reactions were observed.

Conclusions

We describe the clinical translation of a new NIR fluorescence imaging system and define the optimal ICG:HSA dose range for SLN mapping in breast cancer.     

Radial shortening following a fracture of the proximal radius

Background and purpose

The Essex-Lopresti lesion is thought to be rare, with a varying degree of disruption to forearm stability probable. We describe the range of radial shortening that occurs following a fracture of the proximal radius, as well as the short-term outcome in these patients.

Patients and methods

Over an 18-month period, we prospectively assessed all patients with a radiographically confirmed proximal radial fracture. Patients noted to have ipsilateral wrist pain at initial presentation underwent bilateral radiography to determine whether there was disruption of the distal radio-ulnar joint suggestive of an Essex-Lopresti lesion. Outcome was assessed after a mean of 6 (1.5–12) months using clinical and radiographic results, including the Mayo elbow score (MES) and the short musculoskeletal function assessment (SMFA) questionnaire. One patient with a Mason type-I fracture was lost to follow-up after initial presentation.

Results

60 patients had ipsilateral wrist pain at the initial assessment of 237 proximal radial fractures. Radial shortening of ≥ 2mm (range: 2–4mm) was seen in 22 patients (mean age 48 (19–79) years, 16 females). The most frequent mechanism of injury was a fall from standing height (10/22). 21 fractures were classified as being Mason type-I or type-II, all of which were managed nonoperatively. One Mason type-III fracture underwent acute radial head replacement. Functional outcome was assessed in 21 patients. We found an excellent or good MES in 18 of the 20 patients with a Mason type-I or type-II injury.

Interpretation

The incidence of the Essex-Lopresti lesion type is possibly under-reported as there is a spectrum of injuries, and subtle disruptions often go unidentified. A full assessment of all patients with a proximal radial fracture is required in order to identify these injuries, and the index of suspicion is raised as the complexity of the fracture increases.The Essex-Lopresti lesion is the eponym given to radio-ulnar instability caused by sequential injury to the distal radio-ulnar joint, the interosseous membrane, and fracture of the proximal radius (Essex-Lopresti 1951). The original paper by Essex-Lopresti suggested that this is a rare injury, with subsequent literature indicating that the lesion is present in approximately 1% of all radial head fractures (Essex-Lopresti 1951, Trousdale et al. 1992). A varying degree of force, in order to sustain such an injury, has been reported (Hotchkiss et al. 1989, Wallace et al. 1997).The diagnosis and treatment are challenging, with further imaging used when an unstable lesion is suspected (Starch and Dabezies 2001, Wallace 2002). When there is instability, open reduction and internal fixation or radial head replacement with added longitudinal stabilization of the forearm bones is recommended (Lewin 1973, Edwards and Jupiter 1988, Bruckner et al. 1996).A recent study has shown that the incidence of associated injuries following radial head fractures is high on MRI (Kaas et al. 2010). The purpose of our study was to describe the spectrum of radial shortening suggestive of an Essex-Lopresti lesion that occurs following a radial head or neck fracture, along with determining the short-term outcome in these patients.     

Is reverse hybrid hip replacement the solution?: 3,963 primary hip replacements with cemented cup and uncemented stem,from the Norwegian Arthroplasty Register

Background and purpose

Reverse hybrid hip replacement uses a cemented all-polyethylene cup and an uncemented stem. Despite increasing use of this method in Scandinavia, there has been very little documentation of results. We have therefore analyzed the results from the Norwegian Arthroplasty Register (NAR), with up to 10 years of follow-up.

Patients and methods

The NAR has been collecting data on total hip replacement (THR) since 1987. Reverse hybrid hip replacements were used mainly from 2000. We extracted data on reverse hybrid THR from this year onward until December 31, 2009, and compared the results with those from cemented implants over the same period. Specific cup/stem combinations involving 100 cases or more were selected. In addition, only combinations that were taken into use in 2005 or earlier were included. 3,963 operations in 3,630 patients were included. We used the Kaplan-Meier method and Cox regression analysis for estimation of prosthesis survival and relative risk of revision. The main endpoint was revision for any cause, but we also performed specific analyses on different reasons for revision.

Results

We found equal survival to that from cemented THR at 5 years (cemented: 97.0% (95% CI: 96.8–97.2); reverse hybrid: 96.7% (96.0–97.4)) and at 7 years (cemented: 96.0% (95.7–96.2); reverse hybrid: 95.6% (94.4–96.7)). Adjusted relative risk of revision of the reverse hybrids was 1.1 (0.9–1.4). In patients under 60 years of age, we found similar survival of the 2 groups at 5 and 7 years, with an adjusted relative risk of revision of reverse hybrids of 0.9 (0.6–1.3) compared to cemented implants.

Interpretation

With a follow-up of up to 10 years, reverse hybrid THRs performed well, and similarly to all-cemented THRs from the same time period. The reverse hybrid method might therefore be an alternative to all-cemented THR. Longer follow-up time is needed to evaluate whether reverse hybrid hip replacement has any advantages over all-cemented THR.The reverse hybrid method (also known as “inverse hybrid”) uses a cemented all-polyethylene cup in combination with an uncemented stem. This method is partly based on good clinical results of cemented cups and of some uncemented stems in the Norwegian Arthroplasty Register (NAR) (Havelin et al. 2000a,b, Hallan et al. 2007). The register has also shown that some uncemented femoral stems may have better long–term results (> 10 years) than cemented stems in patients 60 years of age or younger. Based on these findings, the NAR suggested 10 years ago that the use of cemented cups in combination with uncemented stems might be justified in young patients (Havelin et al. 2000a). In the Swedish Hip Arthroplasty Register, the performance of uncemented THR was found to be inferior to that of cemented THR (Hailer et al. 2010). The authors of that study found that cemented cups performed better than uncemented cups and that uncemented femoral stems had better survival than cemented stems, with aseptic loosening as endpoint. In the Finnish Arthroplasty Registry, Mäkelä et al. (2010) found better long-term survival regarding aseptic loosening for the best performing types of cementless stems compared to the cemented reference group, in the age group 55–74 years.McNally et al. (2000) studied survival of the Furlong HA coated femoral stem in combination with a cemented ultra-high-density polyethylene cup at 10–11 years, and found values of 99% for the stem and 95% for the cup. Alho et al. (2000) reported results with cemented Lubinus cups and uncemented Furlong stems, and they also pointed out the possibility of using the principle of reverse hybrid arthroplasty. We are not aware of any other reports on the reverse hybrid method.In a reverse hybrid THR, an uncemented stem and a modular head are most often combined with a cemented cup of another name or from another company. Combining implants that are not designed to fit each other might theoretically lead to unexpected complications such as increased wear, loosening, or dislocation. This concern was raised by the NAR already in their report from 2005 (Norwegian Arthroplasty Register 2005). As the use of reverse hybrids is increasing, we decided to evaluate the short- to medium-term results with this concept and to compare them with those from all-cemented THRs, using data from the NAR.     

Interventions for treating proximal fifth metatarsal fractures in adults: A meta-analysis of the current evidence-base

Background

This study assessed the clinical and radiological outcomes of different non-surgical interventions, surgical versus non-surgical interventions, and different surgical interventions used in the management of proximal fifth metatarsal fractures.

Methods

A systematic review of published and unpublished literature was undertaken.

Results

Six studies, assessing 330 patients and 333 fractures of the proximal fifth metatarsal were reviewed. Four studies assessed outcomes following tuberosity fractures, whilst 2 studies recruited patients following proximal diaphyseal or Jones fractures. The findings suggested that bandage is superior to below knee cast immobilisation for patient-reported functional and pain scores, with no difference in fracture union or re-fracture, and a shorter duration to return to work. There was no significant difference in complication rates or functional outcomes for patients managed in a plaster slipper compared to a bandage post-injury. When comparing surgical and non-surgical management, intramedullary screw fixation results in a shorter time to fracture union, reduced complication rates and earlier return to pre-injury activities compared to non-surgical cast immobilisation. However, the evidence-base is limited in it size and presented with a number of methodological limitations.

Conclusions

Further well-conducted randomised controlled trials are required to determine the optimal management strategy for the different types of proximal fifth metatarsal fractures.     

Defining the Origins of the Iliofemoral, Ischiofemoral, and Pubofemoral Ligaments of the Hip Capsuloligamentous Complex Utilizing Computer Navigation

Purpose  

To use computer navigation software to investigate the specific origins of the hip capsuloligamentous complex.     

Non-Invasive Monitoring Based on Bioreactance Reveals Significant Hemodynamic Instability during Elective Cesarean Delivery under Spinal Anesthesia

Background and objectives

Blood pressure monitoring offers a limited understanding of the hemodynamic consequences of spinal anesthesia for cesarean delivery. The purpose of this study was to assess, with the aid of a non-invasive cardiac output monitor based on bioreactance, the hemodynamic changes during elective cesarean delivery under spinal anesthesia in which intermittent boluses of phenylephrine were used to prevent and treat hypotension.

Methods

This observational study was conducted with the Research Ethics Board approval, and all participants provided written informed consent. Healthy patients undergoing elective cesarean delivery under spinal anesthesia were enrolled. Intermittent boluses of phenylephrine were administered in an attempt to maintain systolic blood pressure at baseline levels, and patients were assessed with a non-invasive cardiac output monitor based on bioreactance. Hemodynamic data was collected continuously at baseline, and during the postspinal and postdelivery periods. Data was analyzed using a mixed model ANOVA, and a p < 0.05 was considered significant.

Results

Systolic blood pressure was maintained within 79.2 ± 14.2 and 105.8 ± 10.0 percent of baseline during the postspinal period, and 78.4 ± 11.3 and 100.9 ± 10.7 percent of baseline in the postdelivery period (mean ± SD) There were significant fluctuations in systolic blood pressure, heart rate, and cardiac output during the postspinal period, and significant fluctuations in systolic blood pressure and cardiac output in the postdelivery period.

Conclusions

A new non-invasive monitor based on bioreactance reveals significant hemodynamic fluctuations during cesarean delivery under spinal anesthesia, despite attempts to maintain blood pressure at baseline levels with intermittent boluses of phenylephrine.     

Average 7-Year Survivorship and Clinical Results of a Newer Primary Posterior Stabilized Total Knee Arthroplasty

We evaluated the average 7-year survivorship and clinical results of a newer primary posterior stabilized total knee arthroplasty (TKA). The modifications in this design included a deeper patellar sulcus aimed at reducing contact stresses, improving patellar tracking, and achieving greater maximum flexion. A consecutive group of 137 patients (171 knees) who underwent TKAs using the Optetrak PS knee prosthesis between October 1997 and March 2004 were followed for an average of 6.8?years (range 4.0-11.5?years). Preoperative range of motion (ROM) and Knee Society scores were obtained and compared to that of the patients' most recent follow-up. Manipulation under anesthesia (MUA) and revision of the implant for any reason were considered endpoints for Kaplan-Meier survival analysis of all knees. Twenty-one knees (12.3%) underwent MUA. Three knees (1.8%) underwent revision, resulting in a 97.2% survival at a mean 10?years follow-up. Pain scores and ROM significantly improved after surgery (from preoperative average of 5.3 and 105° respectively to 44.6 and 120° postoperatively). These findings suggest that this posterior stabilized knee design is both a safe and effective option for patients undergoing primary TKA.