Constrained condylar knee without stem extensions for difficult primary total knee arthroplasty

Two hundred forty-eight constrained condylar total knee arthroplasties consecutively implanted without the use of diaphyseal stem extensions were studied in 180 patients. Preoperative deformity was severe (82% Ahlb?ck grade 4-5). One hundred ninety-two knees (148 patients) were reviewed at mean 47-month follow-up (range: 24-72 months). Knee Society score improved from 36 to 89 points, and function score improved from 42 to 76 points. Failure rate was 2.5% (2 infections, 1 aseptic loosening, 1 supracondylar femoral fracture, and 1 tibial post fracture). Five (2.5%) knees had patellofemoral complications. Nonprogressive radiolucent lines were present in 16% of cases. Use of a nonmodular constrained condylar knee for primary severely damaged knees demonstrated reliable short- to mid-term results with a low complication rate and questioned the routine use of intramedullary stem extensions in all such cases.     

Citrulline levels following proximal versus distal small bowel resection

Purpose

Citrulline, a nonprotein amino acid synthesized by enterocytes, is a biomarker of bowel length and the capacity to wean from parenteral nutrition. However, the potentially variant effect of jejunal versus ileal excision on plasma citrulline concentration [CIT] has not been studied. This investigation compared serial serum [CIT] and mucosal adaptive potential after proximal versus distal small bowel resection.

Methods

Enterally fed Sprague-Dawley rats underwent sham operation or 50% small bowel resection, either proximal (PR) or distal (DR). [CIT] was measured at operation and weekly for 8 weeks. At necropsy, histologic features reflecting bowel adaptation were evaluated.

Results

By weeks 6–7, [CIT] in both resection groups significantly decreased from baseline (P < 0.05) and was significantly lower than the concentration in sham animals (P < 0.05). There was no difference in [CIT] between PR and DR at any point. Villus height and crypt density were higher in the PR than in the DR group (P ≤ 0.02).

Conclusion

[CIT] effectively differentiates animals undergoing major bowel resection from those with preserved intestinal length. The region of intestinal resection was not a determinant of [CIT]. The remaining bowel in the PR group demonstrated greater adaptive potential histologically. [CIT] is a robust biomarker for intestinal length, irrespective of location of small intestine lost.     

Current concept in dysplastic hip arthroplasty: Techniques for acetabular and femoral reconstruction

Adult patients with developmental dysplasia of the hip develop secondary osteoarthritis and eventually end up with total hip arthroplasty (THA) at younger age. Because of altered anatomy of dysplastic hips, THA in these patients represents technically demanding procedure. Distorted anatomy of the acetabulum and proximal femur together with conjoined leg length discrepancy present major challenges during performing THA in patients with developmental dysplasia of the hip. In addition, most patients are at younger age, therefore, soft tissue balance is of great importance (especially the need to preserve the continuity of abductors) to maximise postoperative functional result. In this paper we present a variety of surgical techniques available for THA in dysplastic hips, their advantages and disadvantages. For acetabular reconstruction following techniques are described: Standard metal augments (prefabricated), Custom made acetabular augments (3D printing), Roof reconstruction with vascularized fibula, Roof reconstruction with pedicled iliac graft, Roof reconstruction with autologous bone graft, Roof reconstruction with homologous bone graft, Roof reconstruction with auto/homologous spongious bone, Reinforcement ring with the hook in combination with autologous graft augmentation, Cranial positioning of the acetabulum, Medial protrusion technique (cotyloplasty) with chisel, Medial protrusion technique (cotyloplasty) with reaming, Cotyloplasty without spongioplasty. For femoral reconstruction following techniques were described: Distraction with external fixator, Femoral shortening through a modified lateral approach, Transtrochanteric osteotomies, Paavilainen osteotomy, Lesser trochanter osteotomy, Double-chevron osteotomy, Subtrochanteric osteotomies, Diaphyseal osteotomies, Distal femoral osteotomies. At the end we present author’s treatment method of choice: for acetabulum we perform cotyloplasty leaving only paper-thin medial wall, which we break during acetabular cup impacting. For femoral side first we peel of all rotators and posterior part of gluteus medius and vastus lateralis from greater trochanter on the very thin flake of bone. This method allows us to adequately shorten proximal femoral stump, with possibility of additional resection of proximal femur. Furthermore, several advantages and disadvantages of this procedure are also discussed.     

A safety,length of stay,and cost analysis of minimally invasive microsurgery for anterior circulation aneurysms

Objectives

The aim of our study was to evaluate minimally invasive techniques for the treatment of anterior circulation aneurysms versus standard surgery, and to calculate the impact of these techniques on health resources, length of stay, and treatment costs.

Methods

A consecutive series of 24 patients with ruptured and 30 with unruptured anterior circulation aneurysms treated with minimally invasive microsurgery (MIM) by the same surgeon was compared with a matched series of standard microsurgeries (SM) conducted for 23 ruptured and 22 unruptured aneurysms. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes, length of stay, and treatment costs were assessed.

Results

Surgical complications, aneurysm obliteration rates and mRS outcomes were comparable between MIM and SM groups in ruptured and unruptured aneurysm cohorts. MIM resulted in shorter operative times both in unruptured (102.7?±?4.35 vs 194.7?±?10.26 min, p?<?0.0001) and ruptured aneurysms (124.3?±?827 vs 209?±?13.84 min, p?<?0.0001). Length of stay was reduced in patients with MIM for unruptured aneurysms (1.55?±?24 vs 4.28?±?0.71 days, p?<?0.000,1) but not in those with ruptured aneurysms. MIM reduced treatment costs of unruptured aneurysm patients, mainly through reduced utilization of inpatient resources (non-acute bed costs in CAD: 371.2?±?80.99 vs 1440?±?224.1, p?<?0.0001), whereas costs were comparable in patients with ruptured aneurysms.

Conclusion

Minimally invasive surgery is a safe and effective approach for the treatment of ruptured and unruptured aneurysms of the anterior circulation. In patients with unruptured aneurysms, reduced invasiveness and shorter operative times decreased length of stay, which reflects improved patient postoperative recovery. Overall, this translated into bed resource economy and cost reduction.     

Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial

Background

Several studies have demonstrated skills transfer after virtual reality (VR) simulation training in laparoscopic surgery. However, the impact of VR simulation training on transfer of skills related to laparoscopic colectomy remains not investigated. The present study aimed at determining the impact of VR simulation warm-up on performance during laparoscopic colectomy in the porcine model.

Methods

Fourteen residents naive to laparoscopic colectomy as surgeons were randomly assigned in block to two groups. Seven trainees completed a 2-h VR simulator training in the laparoscopic sigmoid colectomy module (study group). The remaining seven surgeons (control group) underwent no intervention. On the same day, all participants performed a sigmoid colectomy with anastomosis on a pig. All operations were video recorded. Two board-certified expert colorectal surgeons independently assessed performance during the colectomy on the swine. Examiners were blinded to group assignment. The two examiners used a previously validated clinical instrument specific to laparoscopic colectomy. The primary outcome was the generic and specific skills score values.

Results

Surgeons undergoing short-duration training on the VR simulator performed significantly better during laparoscopic colectomy on the pig regarding general and specific technical skills evaluation. The average score of generic skills was 17.2 (16.5–18) for the control group and 20.1 (16.5–22) for the study group (p = 0.002). The specific skills average score for the control group was 20.2 (19–21.5) and 24.2 (21–27.5) for the study group (p = 0.001). There was acceptable concordance (Kendall’s W) regarding the video assessment of generic (W = 0.78) and specific skills (W = 0.84) between the two examiners.

Conclusions

A single short-duration VR simulator practice positively impacted surgeons’ generic and specific skills performance required to accomplish laparoscopic colectomy in the swine model.     

Outcomes of bariatric surgery in patients with body mass index <35 kg/m2

BackgroundPatients who are categorized with class I obesity have a body mass index (BMI) of 30–34.99 kg/m². This population of patients has a predisposition to diabetes, hypertension, and dyslipidemia. The aim of the present study was to investigate the improvements of these co-morbidities in a class I obese population that had undergone a bariatric procedure.MethodsAfter internal review board approval and with adherence to the Health Insurance Portability and Accountability Act guidelines, a retrospective review was performed of a prospectively maintained database of 42 class I obese patients who underwent a bariatric procedure at our institution during a 10-year period, from February 2000 to May 2010. The fasting glucose level, glycosylated hemoglobin level, lipid profile, initial weight, and BMI were measured in the preoperative and postoperative periods.ResultsOur patient population consisted of 30 women and 12 men, with a preoperative mean BMI of 33.9 kg/m². Laparoscopic sleeve gastrectomy was performed in 24 patients (57%), laparoscopic Roux-en-Y gastric bypass in 8 (19%), and laparoscopic adjustable gastric banding in 10 (24%). Of these 42 patients, 25 (60%) had type 2 diabetes, 1 patient was glucose intolerant, 27 (64%) had arterial hypertension, 25 (60%) had dyslipidemia, 17 (40%) had sleep apnea, and 8 (19%) had osteoarthritis. The postoperative findings included a mean BMI of 26.5 kg/m² and a mean weight loss of 41.4 lb. Of the 25 diabetic patients, 5 (20%) gained remission and 12 (48%) improvement of their diabetic status. The single patient with glucose intolerance showed improvement. Of the 27 patients with arterial hypertension, 9 (33%) showed remission and 13 (52%) improvement. Dyslipidemia resolved in 5 patients (20%) and improved in 13 (52%). Obstructive sleep apnea resolved in 10 (59%) and improvement was seen in 1 patient (6%). Finally, osteoarthritis resolved in 1 patient (12%) and improved in 5 (63%).ConclusionBariatric surgery can significantly improve or resolve co-morbid metabolic conditions in patients with class I obesity.     

Postoperative spinal deformity after treatment of intracanal spine lesions

Background context

Surgical treatment of intracanal (both intramedullary and extramedullary) spine lesions requires posterior decompressive techniques in nearly all instances. Postoperative spinal deformities, most notably sagittal and coronal decompensation, are of significant concern for both the patient and the spinal surgeon.

Purpose

To review and define principles and features of spinal deformities after posterior spinal decompression for intracanal spinal lesions, and to define patients who may benefit from the concomitant spinal fusion.

Methods

A systematic review of MEDLINE was conducted, including articles published between 1980 and 2011. Articles related to spinal deformities after posterior decompression for the treatment of intracanal spine lesions were identified.

Results

Ten articles met all inclusion and exclusion criteria. All were case series with limited evidence (Level IV). Many risk factors to deformity were implied but with limited evidence. Young age was the most commonly identified risk in these articles.

Conclusions

Spinal deformity after posterior decompression is a common complication, most notably in children and young adults, after the removal of intramedullary tumors. Many risk factors have been implied to increase the postoperative development of spinal deformity, including young age, laminectomy extension, preoperative deformity, and extensive facet resection, among others. However, there is a lack of high-quality evidence to propose an algorithm for treatment or preventive measures. New studies with larger series of patients and standardized clinical outcomes are necessary to establish optimal treatment protocols.     

Negative pressure wound therapy for children with an open abdomen

Purpose

The utility of negative pressure wound therapy (NPWT) in the management of adults with an open abdomen has been well documented. We reviewed our experience with NPWT in the management of infants and children with this condition.

Methods

The records of all children who were treated with NPWT for an open abdomen between March 2005 and September 2009 at a single children’s hospital were reviewed.

Results

Twenty-five subjects were identified. They included children who developed abdominal compartment syndrome after a laparotomy (n?=?12) or in whom the abdomen could not be safely closed at the time of laparotomy (n?=?13). NWPT was accomplished with the vacuum-assisted closure (VAC®) system in all patients. The median duration for NPWT was 4.5 days. In 16 subjects, the abdomen was closed successfully after NPWT. In 14 children, the abdominal wall fascia was successfully approximated, and two children underwent a patch abdominal closure. But nine subjects died before an abdominal closure could be attempted. Only two (12.5%) children developed enterocutaneous fistulae.

Conclusions

NPWT is a reliable tool for infants and children with an open abdomen. Wound management was facilitated and abdominal wall closure was ultimately achieved in all survivors. Enterocutaneous fistulae developed in two children, however, these were likely due to underlying bowel injury and would have occurred despite variations in management of the open abdomen.