Quality of assessment of randomized controlled trials in blood conservation after joint arthroplasty

Blood transfusion after joint arthroplasty occurs in up to two thirds of patients. We conducted a systematic review of the literature to determine the methodological quality of published randomized controlled trials (RCTs). We searched MEDLINE, EMBASE, and Cochrane to identify RCTs in arthroplasty with blood conservation as the primary outcome from 2001 to 2007. Methodological quality was evaluated using the Detsky index. We identified 62 RCTs. The mean Detsky score was 73% ± 14%. Epidemiology affiliation (P = .003), funding support (<.001), and year of publication (<.001) were the predictors of reporting quality, predicting 46% of the variability (R² = 0.46). This suggests poor reporting quality of trials in blood conservation. The inclusion of an epidemiologist or a biostatistician for the design of a trial is strongly recommended.     

Health-related quality of life after short segment instrumentation of lumbar burst fractures

Management of lumbar burst fractures remains controversial. Surgical reduction/stabilization is becoming more popular; however, the functional impact of operative intervention is not clear. The purpose of this study was to assess health-related quality of life and functional outcome after posterior fixation of lumbar burst fractures with either posterolateral or intrabody bone grafting. Twenty-four subjects were included. Radiographs and computed tomography scans were evaluated for deformity (kyphosis, vertebral compression, lateral angulation, lateral body height, and canal compromise) postoperatively, at 1 year, and at final follow-up (mean 3.2 years). Patients completed the SF 36 Health Survey and the Oswestry Low Back Pain Disability Questionnaire at final follow-up. Significant improvement was noted in midsagittal diameter compromise, vertebral compression, and kyphosis. The difference observed between the respondents mean scores on the SF 36 was not significantly different from those presented as the U.S. national average (p = 0.053). Data from the Oswestry questionnaire indicated a similarly high level of function. Overall, we found posterior spinal instrumentation to correlate with positive functional outcome based on both general health (SF 36) and joint-specific outcome scales (Oswestry). Posterior instrumentation provides sound canal decompression, kyphotic reduction, and maintains vertebral height with minimal transgression and long-term sequelae. In cases of severe initial deformity and neurologic compromise, intrabody bone grafting is most certainly indicated; the additional support provided by a posterolateral graft may also prove beneficial as an adjunct.     

Overlapping systematic reviews of anterior cruciate ligament reconstruction comparing hamstring autograft with bone-patellar tendon-bone autograft: why are they different?

BACKGROUND: Systematic reviews published on the same topic during a similar period of time (i.e., overlapping reviews) on anterior cruciate ligament reconstruction complicate the choice between bone-patellar tendon-bone or hamstring tendon autograft. We aimed to evaluate reasons for differences among the overlapping systematic reviews and to assess the quality of reporting and internal validity. METHODS: We performed a search of MEDLINE, the Cochrane Database of Systematic Reviews, and EMBASE to identify systematic reviews in which bone-patellar tendon-bone graft was compared with hamstring tendon autograft for reconstruction of the anterior cruciate ligament. We evaluated cross-citations among the overlapping reviews and the authors' rationale for repeating the review. The quality of reporting was assessed with the Quality of Reporting of Meta-analyses (QUOROM) statement, and the internal validity was assessed with the Oxman and Guyatt index for methodological quality by at least two assessors. Assessor agreement was evaluated with intraclass correlation coefficients. We evaluated the sensitivity analysis that had been performed in the reviews. RESULTS: We identified eleven overlapping systematic reviews. Three reviews favored the patellar tendon graft for stability, and one favored the hamstring graft. Six reviews favored the hamstring graft to prevent anterior knee pain, and the rest were inconclusive. Only six reviews cited previously published systematic reviews on the same topic, and only two of these reviews cited all available systematic reviews that were available at that time. The quality of reporting ranged from 5 to 18 (median, 12; maximum score, 18). The internal validity ranged from 1 to 7 (median, 2; maximum score, 7). Reviewers reached almost perfect agreement (intraclass correlation coefficients, 0.83 and 0.94). Formal sensitivity analysis was utilized infrequently. The highest-quality review favored hamstring grafts to prevent anterior knee pain and showed weak evidence that bone-patellar tendon-bone grafts yielded better stability. CONCLUSIONS: When overlapping or discordant systematic reviews are encountered, each review must be appraised on the basis of its methodological quality before it can be used to guide clinical decision-making or policy making. The currently available best evidence, derived from a methodologically sound meta-analysis, suggests that hamstring tendon autografts are superior for preventing anterior knee pain, and there is limited evidence that bone-patellar tendon-bone autografts provide better stability.     

Evidence-based orthopaedics: is it possible?

EBM is referred to as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. This article describes the history and practice of evidence-based medicine.     

Expression of galectin-3 and its regulation in the testes

Although spermatogenesis is a complex process under hormonal control, which includes mainly follicle stimulating hormone (FSH) and androgens, little is known about the intra-testicular mediators of these hormones. In the present study, galectin-3 (Gal-3) expression has been identified in human, rat and porcine testes where it is under hormonal control. Gal-3 is present in Sertoli cells and appears to be absent in human and (probably) in rat germ cells. Gal-3 expression was evidenced in the testes, in terms of both mRNA and protein (31 kDa). Gal-3 expression in cultured porcine Sertoli cells was shown to be under the positive control of FSH as well as of two cytokines epidermal growth factor (EGF) and tumour necrosis factor-alpha (TNF-alpha). Gal-3 expression in Sertoli cells is also potentially under the control of mature germ cells as an increased expression was observed in adult rat testes depleted in spermatocytes or spermatids. Although the function of testicular Gal-3 remains to be investigated, a potential role of Gal-3 in germ cell survival/regeneration is suggested based on its increased expression 1 month after a transient germ cell death process triggered by 10 days of treatment with the antiandrogen flutamide. Finally, although in the normal human testes, Gal-3 is exclusively located in the Sertoli cell cytoplasm, a nuclear localization is observed in the infertile testes. Together, the present findings have shown that (i) Gal-3 is expressed in the porcine, rat and human Sertoli cells; (ii) Gal-3 is under the positive control of FSH as well as of EGF and TNF-alpha and possibly of adult germ cells. These observations are compatible with a potential pro-survival role of Gal-3 in the testes.     

Protein-tyrosine phosphatase 1B-deficient myocytes show increased insulin sensitivity and protection against tumor necrosis factor-alpha-induced insulin resistance

Protein-tyrosine phosphatase (PTP)1B is a negative regulator of insulin signaling and a therapeutic target for type 2 diabetes. In this study, we have assessed the role of PTP1B in the insulin sensitivity of skeletal muscle under physiological and insulin-resistant conditions. Immortalized myocytes have been generated from PTP1B-deficient and wild-type neonatal mice. PTP1B(-/-) myocytes showed enhanced insulin-dependent activation of insulin receptor autophosphorylation and downstream signaling (tyrosine phosphorylation of insulin receptor substrate [IRS]-1 and IRS-2, activation of phosphatidylinositol 3-kinase, and serine phosphorylation of AKT), compared with wild-type cells. Accordingly, PTP1B(-/-) myocytes displayed higher insulin-dependent stimulation of glucose uptake and GLUT4 translocation to the plasma membrane than wild-type cells. Treatment with tumor necrosis factor-alpha (TNF-alpha) induced insulin resistance on glucose uptake, impaired insulin signaling, and increased PTP1B activity in wild-type cells. Conversely, the lack of PTP1B confers protection against insulin resistance by TNF-alpha in myocyte cell lines and in adult male mice. Wild-type mice treated with TNF-alpha developed a pronounced hyperglycemia along the glucose tolerance test, accompanied by an impaired insulin signaling and increased PTP1B activity in muscle. However, mice lacking PTP1B maintained a rapid clearance of glucose and insulin sensitivity and displayed normal muscle insulin signaling regardless the presence of TNF-alpha.     

Impact of childhood abuse and neglect on substance abuse and psychological distress in adulthood

Structural equation modeling was used to examine the relationship of childhood trauma, educational level, and the use of avoidant coping on substance abuse and psychological distress in a community sample of 285 women. Results indicated that self-reported childhood trauma was significantly related to greater substance abuse and psychological distress, through educational attainment and avoidant coping strategies. Lower level of education affected substance abuse through greater use of avoidant coping, but had no significant relationship with psychological distress. Greater use of avoidant coping was related to increased substance abuse and greater psychological distress. Findings indicate the need for supportive educational strategies and interventions to teach coping skills in preventing substance abuse and longer-term psychological distress in children exposed to trauma.     

An open and shut case for early VATS treatment of primary spontaneous pneumothorax in children

BACKGROUND: Treatment of primary spontaneous pneumothorax (SP) involves thoracostomy tube (TT) drainage, with surgery reserved for persistent or recurrent air leaks. We hypothesized that the advent of video-assisted thoracic surgery (VATS) would change indications and outcomes for surgical treatment of SP in our centre. METHODS: We performed a retrospective (1993-2003) review of children treated for SP. Patients with persistent or recurrent air leaks underwent either limited axillary thoracotomy (LAT), 1993-2001, or VATS, 2001-2003. We included the following outcomes: preoperative SP episodes, TT days (that is, patient days with TT in situ, before surgery), length of hospital stay (LOS), narcotic use and freedom from recurrence. We evaluated the predictive value of preoperative CT scans in guiding treatment of the contralateral side. RESULTS: Among 31 patients with 19 ipsilateral or contralateral recurrences (61%), 11 were managed nonoperatively. Twenty-six surgeries (13 LAT, 13 VATS) were performed in 20 patients, with 9 undergoing bilateral procedures (3 LAT, 6 VATS). VATS patients were treated earlier, had a diminished narcotic requirement postoperatively and had a shorter LOS with an equivalent recurrence rate, compared with LAT patients. The absence of contralateral blebs did not predict freedom from SP on the contralateral side in patients undergoing surgery for ipsilateral SP. CONCLUSIONS: Compared with LAT, VATS causes less pain, has a shorter LOS and encourages earlier surgical treatment (including prophylactic, contralateral treatment) of SP in children.     

Horizontal right axillary minithoracotomy: aesthetic and effective option for atrial and ventricular septal defect repair in infants and toddlers

Introduction

Congenital heart defects treatment shows progressive reduction in morbidity and mortality, however, the scar, resulting from ventricular (VSD) and atrial septal defect (ASD) repair, may cause discomfort. Right axillary minithoracotomy approach, by avoiding the breast growth region, is an option for correction of these defects that may provide better aesthetic results at low cost. Since October 2011, we have been using this technique for repairing VSD and ASD defects as well as associated defects.

Objectives

To evaluate the efficacy of this method in children undergoing correction of VSD and ASD, to compare perioperative clinical outcomes with those repaired by median sternotomy, and to evaluate the aesthetic result.

Methods

Perioperative clinical data of 25 patients submitted to axillary thoracotomy were compared with data from a paired group of 25 patients with similar heart defects repaired by median sternotomy, from October 2011 to August 2012.

Results

Axillary approach was possible even in infants. There was no mortality and the main perioperative variables were similar in both groups, except for lower use of blood products in the axillary group (6/25) vs. control (13/25), with statistical difference (P =0.04). The VSD size varied from 7 to 15 mm in axillary group. Cannulation of the aorta and vena cavae was performed through the main incision, whose size ranged from 3 to 5 cm in the axillary group, with excellent aesthetic results.

Conclusion

The axillary thoracotomy was effective, allowing for a heart defect repair similar to the median sternotomy, with more satisfactory aesthetic results and reduced blood transfusion, and it can be safely used in infants.     

Complications following hip arthroscopy: a retrospective review of the McMaster experience (2009–2012)

Background

The use of hip arthroscopy has been steadily rising as technology, experience and surgical education continue to advance. Previous reports of the complication rate associated with hip arthroscopy have varied. The purpose of this study was to report our experience with hip arthroscopy complications at a single Canadian institution (McMaster University).

Methods

We performed a retrospective chart review of 2 hip arthroscopists at the same institution to identify patients who had undergone the index surgery and had been followed for a minimum of 6 months postoperatively. We used a standard data entry form to collect information on patient demographic and clinical characteristics, including age, sex, surgical indication and type of complication if any.

Results

A total of 211 patients underwent 236 hip arthroscopies. The mean age at time of surgery was 37 ± 13 years and mean follow-up was 394 ± 216.5 days. The overall complication rate associated with hip arthroscopy was 4.2% (95% confidence interval 2.3%–7.6%). We identified 4 major and 6 minor complications.

Conclusion

Overall, hip arthroscopy appears to be safe, with minor complications occurring more frequently than major ones. However, surgeons should recognize the possibility of serious complications associated with this procedure. Future research should focus on prospective designs looking for potential prognostic factors associated with hip arthroscopy complications.