Oncologic uses of the retrograde femoral nail.

Destructive lesions about the distal femur represent difficult treatment situations. Patients who present with impending or pathologic fractures require a method of fixation that provides adequate stabilization to allow for early, pain-free ambulation. Other considerations include restoration of functional range of motion, low perioperative morbidity and mortality risk, and minimal soft tissue dissection. Eleven patients with 12 pathologic or impending fractures of the distal femur who were treated with retrograde intramedullary nailing with and without polymethylmethacrylate augmentation were retrospectively reviewed. Followup averaged 17 months. Postoperative range of motion averaged 94 degrees flexion, 90% of patients reported no or modest pain, 81% were functioning with no restrictions or recreational restrictions only, and all patients were enthusiastic or satisfied with their surgical outcome. There were no perioperative mortalities, but one patient had 2 cm shortening secondary to broken distal locking screws and asymptomatic nail protrusion into the knee. Using the system for functional evaluation of reconstructive treatment of tumors of the musculoskeletal system, the average score for each patient was 25 (range, 18-30) or 83% (60%-100%) of the maximum score. The retrograde nail was an easy and successful method of fixation in this clinical setting.     

Preliminary experience with the combined use of recombinant bone morphogenetic protein and bisphosphonates in the treatment of congenital pseudarthrosis of the tibia

Purpose  

Congenital pseudarthrosis of the tibia (CPT) is a rare but serious disorder in children. No single approach has clearly emerged as superior in terms of operative procedure, fixation, optimal time for surgery or adjunctive pharmaceutical intervention. CPT is frequently associated with neurofibromatosis type 1 (NF1), a condition featuring deficient bone anabolism and excessive catabolism. We have therefore combined the use of bone morphogenetic proteins (BMP) with bisphosphonates (BP) as an adjunct to surgical intervention.     

Development and Evaluation of an Observational Tool for Assessing Surgical Flow Disruptions and Their Impact on Surgical Performance

Background  

Many researchers have previously explored the correlation between surgical flow disruptions and adverse events in cardiac surgery; however, there is no reliable tool to prospectively categorize surgical flow disruptions and the conditions that predispose a surgical team to adverse events.     

Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in men

BACKGROUND: We used data from the Patient Safety in Surgery Study to compare patient populations, operative characteristics, and unadjusted and risk-adjusted 30-day postoperative mortality and morbidity between the Veterans Affairs (VA) (n = 94,098) and private (n = 18,399) sectors for general surgery operations in men. STUDY DESIGN: This is a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in male patients undergoing major general surgery operations at 128 VA medical centers and 14 university medical centers from October 1, 2001, to September 30, 2004. Multiple logistic regression analysis was used to identify preoperative predictors of postoperative mortality and morbidity. An indicator variable for VA versus private-sector medical center was added to the model to determine if risk-adjusted outcomes were significantly different in the two systems. RESULTS: The unadjusted 30-day mortality rate was higher in the VA compared with the private sector (2.62% versus 2.03%, p = 0.0002); unadjusted morbidity rate was lower in the VA compared with the private sector (12.24% versus 13.99%, p < 0.0001). After risk adjustment, odds ratio for mortality for the VA versus private sector was 1.23 (95% CI, 1.08-1.41). For morbidity after risk adjustment, the indicator variable for health-care system just missed statistical significance (p = 0.0585). Thirty-day postoperative mortality was comparable in the VA and private sector for very common operations but was higher in the VA for less common, more complex operations. CONCLUSIONS: In general surgery operations in men, the VA appeared to have a higher risk-adjusted mortality rate compared with the private sector, but differences in mortality ascertainment in the two sectors might account for some of this effect. The higher mortality in the VA could be the result of higher mortality in the less common, more complex operations. There is a trend toward lower risk-adjusted morbidity in the VA compared with the private sector.     

Review of total hip resurfacing and total hip arthroplasty in young patients who had Legg-Calvé-Perthes disease

Patients with Legg-Calvé-Perthes disease can often be successfully treated with femoral head-preserving measures, such as bracing, or containment procedures with osteotomies. However, in some cases, after resolution of the disease, the femoral head may proceed to collapse or progress to severe arthritis at a young age. If nonoperative methods have failed, the only treatment options available for these adolescents or young adults may be a total hip resurfacing or a total hip arthroplasty (THA). This article focuses on the results and unique technical considerations of resurfacing and THA for patients who have severe hip osteoarthritis after resolved Legg-Calvé-Perthes disease.     

Total knee arthroplasty in patients over 80 years of age

We conducted this study to review the clinical and radiographic outcomes of patients 80 years of age or older who underwent total knee arthroplasty (TKA). We identified clinical results in 60 patients (66 knees) who had a mean age of 84 years (range, 80 to 95 years) and who underwent TKA. These were compared with a non-age-matched group of 63 patients (66 knees) who had a mean age of 69 years (range, 60 to 79 years). Four patients were lost to follow-up. After a mean 43-month follow-up (range, 24 to 117 months), Knee Society pain and function scores for the study group improved from 53 points (range, 25 to 70 points) and 53 points (range, 40 to 70 points), respectively, to 94 points (range, 75 to 100 points) and 87 points (range, 45 to 100 points). There were no implant failures, 2 surgical complications, and 13 medical complications. In the matching group, there were four surgical complications (two required revision) and two medical complications. There were no radiographic failures or progressive radiolucencies. Although the incidence of medical complications in the perioperative period may be higher, TKA is a safe and effective treatment for refractory joint pain in patients over 80 years of age.     

Postischemic infusion of 17-beta-estradiol protects myocardial function and viability

BACKGROUND: Females demonstrate improved cardiac recovery after ischemia/reperfusion injury compared with males. Attenuation of myocardial dysfunction with preischemic estradiol suggests that estrogen may be an important mediator of this cardioprotection. However, it remains unclear whether post-injury estradiol may have clinical potential in the treatment of acute myocardial infarction. We hypothesize that postischemic administration of 17beta-estradiol will decrease myocardial ischemia/reperfusion injury and improve left ventricular cardiac function. MATERIALS AND METHODS: Adult male Sprague Dawley rat hearts (n = 20) (Harlan, Indianapolis, IN) were isolated, perfused with Krebs-Henseleit solution via Langendorff model, and subjected to 15 min of equilibration, 25 min of warm ischemia, and 40 min reperfusion. Experimental hearts received postischemic 17beta-estradiol infusion, 1 nm (n = 4), 10 nm (n = 4), 25 nm (n = 4), or 50 nm (n = 4), throughout reperfusion. Control hearts (n = 4) were infused with perfusate vehicle. RESULTS: Postischemic recovery of left ventricular developed pressure was significantly greater with 1 nm (51.6% +/- 7.4%) and 10 nm estradiol (47.7% +/- 8.6%) than with vehicle (37.8% +/- 9.7%) at end reperfusion. There was also greater recovery of the end diastolic pressure with 1 nm (47.8 +/- 4.0 mmHg) and 10 nm estradiol (54.0 +/- 4.0) compared with vehicle (75.3 +/- 7.5). Further, 1 nm and 10 nm estrogen preserved coronary flow after ischemia and decreased coronary effluent lactated dehydrogenase compared with controls. Estrogen at 25 nm and 50 nm did not provide additional benefit in terms of functional recovery. Estrogen at all concentrations increased extracellular signal-regulated protein kinase phosphorylation. CONCLUSIONS: Postischemic infusion of 17beta-estradiol protects myocardial function and viability. The attractive potential for the clinical application of postischemic estrogen therapy warrants further study to elucidate the mechanistic pathways and differences between males and females.