Minimum Follow-up Duration Research Articles

Association Between Acromial Index and Outcomes Following Arthroscopic Repair of Full-Thickness Rotator Cuff Tears

The purposes of this study were to evaluate the association between the acromial index and full-thickness rotator cuffs and to determine if the size of the acromial index was associated with outcomes in a cohort of patients who had had arthroscopic repair of full-thickness rotator cuff tears. The acromial index was calculated for three groups by individual researchers: 115 patients (120 shoulders) who had arthroscopically repaired full-thickness rotator cuff tears without osteoarthritis (Group I); sixty-four patients (sixty-eight shoulders) who had intact rotator cuffs with osteoarthritis (Group II); and twenty-one patients (twenty-one shoulders) who had intact rotator cuffs, without osteoarthritis, and were managed for other pathology (Group III). The acromial index is the distance between the glenoid plane and the lateral border of the acromion divided by the distance between the glenoid plane and the lateral aspect of the humeral head. Ninety-two patients (ninety-three shoulders) from Group I met inclusion criteria for subjective follow-up. Minimum two-year subjective data were obtained on 86% (seventy-nine patients [eighty shoulders]) of these ninety-two patients to determine the association of the acromial index on surgical outcomes. Surgical factors were also analyzed. Significance was set at p < 0.05. The acromial index demonstrated high intraobserver agreement (kappa, 0.960; 95% confidence interval, 0.940 to 0.984) and high interobserver agreement (kappa, 0.960; 95% confidence interval, 0.922 to 0.979). The mean acromial index (and standard deviation) was 0.687 ± 0.08 for Group I, 0.685 ± 0.11 for Group II, and 0.694 ± 0.07 for Group III. No significant differences were found. At an average duration of follow-up of 3.0 years (range, 2.0 to 5.4 years), the mean American Shoulder and Elbow Surgeons scores improved from 59 to 93 points (p = 0.001) in the seventy-nine patients from Group I who had minimum two-year duration of subjective follow-up. The mean postoperative scores were 10.4 points (range, 0 to 54.5 points) for the Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure and 9.2 points (on a scale of 1 to 10 points) for patient satisfaction. When the patients with a large acromial index (>0.682) were compared with those with a small acromial index (≤ 0.682), the patients in the former group had a greater likelihood of having a tear involving two or more rotator cuff tendons (p = 0.017), required more anchors to achieve repair (p = 0.007), had slightly lower patient satisfaction scores (mean, 8.9 compared with 9.5 points; p = 0.055) and Short Form-12 Physical Component Summary scores (mean, 49.1 compared with 55.2 points; p = 0.04), and had higher Quick Disabilities of the Arm, Shoulder and Hand scores (mean, 12.9 compared with 7.4 points; p = 0.042). An association between the size of the acromial index and that of full-thickness rotator cuff tears was not confirmed; however, a larger acromial index was associated with an increased number of tendons torn and anchors used for repair. In addition, patients with a larger acromial index had more disability as recorded by the Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure and poorer physical health as measured by the Short Form-12 Physical Component Summary score.

Paper 273: Posterior Cruciate Ligament Reconstruction with Stent Operation for Remnant augmentation

Although, recently, it has been reported that posterior cruciate ligaments(PCLs) have spontaneous healing potential and can heal by conservative treatment, despite good early functional results, the posterior laxity of the knee is not completely eliminated after conservative treatment. The PCL can retain the normal tension only when the injured ligament is maintained anatomically. The purpose of this study was to develop and evaluate a technique of PCL reconstruction with stent operation for remnant PCL augmentation. Between September 2003 and March 2006, 23 patients who had a tear of the PCL underwent reconstruction with stent operation using hamstring tendon graft(20cases) or tibialis posterior allograft(4 cases) for remnant PCL augmentation. 20 patients were evaluated after a minimum duration of follow-up 24 months. The remnant PCL and the synovium were preserved, and the augmentation was performed using transtibial technique. Femoral tunnel was created at near the foot-print of anterolateral bundle. Stability was measured on posterior stress radiographs and with a maximal manual displacement test performed with a KT-1000 arthrometer. Clinical evaluation was carried out with use of the scoring systems of the international Knee Documentation Committee(IKDC) and the Orthopadische Arbeitsgruppe Knie Score(OAK). The mean side-to-side differences in displacement was reduced from 9.9 ± 4.0 mm preoperatively to 3.0 ± 2.6 mm at last follow-up on the stress radiographs, and it was reduced from 6.9 ± 2.1 mm preoperatively to 2.7 ± 1.5 mm as measured with the KT-1000. The final IKDC score was A in 7(35%), B in 10(50%), C in 2(10%) and D in 1(5%) patients. The average OAK score improved from 61.6 ± 13.1 to 88.2 ± 9.5. The group in which tibialis posterior allografts were used for augmentation showed worse results than hamstring autograft group in clinical result. In one case, posterior instability was recurred more than 10mm compare to contralateral side, PCL revision was performed as a double bundle reconstruction using achilles allograft. Excellent posterior stability and relatively good clinical results were achieved with the stent operation for remnant PCL augmentation. This technique is technically feasible and the PCL remnants and synovium may be beneficial to ligament healing and proprioception. However, other combined injuries seem to affect clinical results. The short-term results are encouraging, but long –term results are needed to confirm the value of this technique for alternative operative method of acute or subacute PCL injuries.

Proximal Row Carpectomy Combined with Wrist Hemiarthroplasty

Proximal row carpectomy (PRC) combined with distal radius hemiarthroplasty is a relatively novel procedure that rivals total wrist arthrodesis and offers a new surgical treatment option for select patients with painful, end-stage wrist disease. We present our early experience with this procedure. A retrospective chart review was conducted for nonrheumatoid patients diagnosed with wrist arthritis and subsequently treated with wrist hemiarthroplasty combined with PRC. The minimum follow-up duration was 12 months. Preoperative and postoperative flexion, extension, and grip strength were recorded. Postoperative radiographic findings were assessed. The Patient-Rated Wrist Evaluation (PRWE) questionnaire was administered to gauge postoperative pain and function. The records of 10 patients were reviewed. The mean age was 64 years and the mean postoperative follow-up duration was 19 months. Postoperative flexion, extension, and grip strength were all found to be less than the preoperative levels. The mean postoperative PRWE score for pain and function were 26 and 23, respectively. The complications were diverse and occurred at a relatively high rate. PRC combined with distal radius hemiarthroplasty is a novel procedure that offers a potential surgical option for the treatment of wrist arthritis in select patients. Our early experience has lead us to modify our technique with regard to the implant material, and at this stage, the surgical technique and the most appropriate implant may require further optimization. The level of evidence for this study is IV (therapeutic).

High-Flexion Total Knee Arthroplasty: Survivorship and Prevalence of Osteolysis

We are aware of no information about the mid-term performance of the high-flexion total knee arthroplasty, although early results have been reported. The purpose of this study was to evaluate the mid-term results of high-flexion and conventional knee prostheses. We prospectively compared the results of 100 patients with osteoarthritis who had received a NexGen Legacy Posterior Stabilized (NexGen LPS) prosthesis in one knee and a NexGen Legacy Posterior Stabilized-Flex (NexGen LPS-Flex) prosthesis in the other. Seventy-five patients (150 knees) were women and twenty-five (fifty knees) were men. The mean age was sixty-five years (range, forty-eight to eighty-five years) at the time of the index procedure. The mean duration of follow-up was 10.3 years (range, ten to 10.6 years). The patients were assessed with radiographs, with the rating system of the Knee Society, and with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at three months, one year, and annually thereafter. Total knee scores, knee function scores, pain scores, WOMAC scores, knee motion, and activity scores did not differ significantly between the two designs of the implants, on the basis of the numbers studied, either preoperatively or at the time of final follow-up. One knee in the NexGen LPS-Flex group was revised because of recurrent infection. No knee in either group had aseptic loosening of the components. The Kaplan-Meier survivorship at ten years postoperatively, with revision defined as the end point, was 100% (95% confidence interval, 94 to 100) for the NexGen LPS prosthesis and 99% (95% confidence interval, 93 to 100) for the NexGen LPS-Flex prosthesis. After a minimum duration of follow-up of ten years, there were no significant differences between the two groups with regard to implant survivorship, functional outcome, knee motion, or prevalence of osteolysis.

Treatment of Lumbar Curves in Scoliotic Adolescent Females With Progressive Action Short Brace

A prospective interventional study. To determine the outcomes of adolescents affected by idiopathic lumbar scoliosis treated with a progressive action short brace (PASB). The efficacy of conservative treatment of scoliosis is still debated. In a recent study, we showed that the PASB was effective in correcting deformities in adolescents with idiopathic thoracolumbar scoliosis. The purpose of the present study was to extend our preliminary findings by determining the results of PASB treatment in scoliotic adolescents with lumbar curves. Patients were 40 adolescent girls (age [mean ± SD] = 11.6 ± 0.7 yr]) with lumbar curves and a pretreatment Risser score between 0 and 2. All patients were prescribed with a full-time PASB. The minimum duration of follow-up was 24 months (mean ± SD = 41.6 ± 34.5 mo). Anteroposterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), 1 year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), and 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization, and curve progression. RESULTS.: A significant reduction in CM was achieved from t1 (Cobb angle [mean ± SD] = 26.4° ± 2.8) to t5 (Cobb angle [mean ± SD] = 13.8° ± 7.9; P < 0.001). Likewise, the PASB reduced TA from Perdriolle rotation angles of 10.8° (SD = 3.7) at t1 to 7.9° (SD = 4.2) at t5 (P < 0.05). Curve correction was accomplished in 82.5% of patients, whereas curve stabilization was obtained in 17.5% of patients. None of the patients experienced curve progression. The PASB allows a complete curve correction in most cases. No patients exhibited curve progression.

Sarcoidosis of the Spine

Sarcoidosis, also called Morbus Boeck disease , is a potentially systemic disease defined by noncaseating granulomatous inflammation of uncertain etiology1. The natural history of sarcoidosis is unpredictable as it can involve one or multiple organ systems and it can be progressive or resolve spontaneously. While sarcoidosis has been described as affecting most organ systems, the lungs are involved in >90% of cases2. Skeletal involvement is much less frequent; the prevalence has been reported to range from <1% to 13%2,3. The small bones of the hands and feet are most often involved, whereas spinal disease is rare4. Most patients with spinal sarcoidosis present with axial pain that resolves either on its own or after the administration of corticosteroids. However, pathologic fractures have been reported with associated neurologic sequelae5,6. We report the clinicopathologic features of five patients with sarcoidosis involving the spine. The Massachusetts General Hospital Institutional Review Board reviewed and approved this study. We searched our bone sarcoma registry to identify all patients diagnosed with sarcoidosis of the spine from 1980 through 2007. In addition, we utilized our Department of Pathology database to search for pertinent cases. Inclusion criteria were the diagnosis of sarcoidosis, confirmed with a bone biopsy of the spine, and a minimum duration of follow-up of two years. The initial group included thirteen patients. One patient was excluded because there was no histological evidence of bone sarcoidosis. We also excluded five patients who had bone sarcoidosis but not of the spine. Two patients were excluded because of a lack of sufficient follow-up. This left a cohort of five patients with sarcoidosis of the spine who formed the final study group, and we reviewed their medical records, radiographs, and pathology reports. The tissue specimen from each case …

Clinical Trials in Orthopaedics Research. Part III. Overcoming Operational Challenges in the Design and Conduct of Randomized Clinical Trials in Orthopaedic Surgery

As we aspire to implement evidence-based medicine in the daily practice of orthopaedics, it is critical to understand the level of evidence that guides routine clinical decisions. Randomized controlled trials (RCTs) offer methodology for delivering the highest level of evidence1. Whereas the first RCTs were conducted half a century ago to test the efficacy of new pharmacologic agents, such trials are now being used increasingly to evaluate therapies other than medications, including surgery and behavioral interventions. Surgical RCTs involve additional complexity with regard to several key methodological components of the RCT: the willingness of patients to enroll, implementation of blinding (masking), and the impact of crossovers from one trial arm to another. The American Academy of Orthopaedic Surgeons (AAOS) and the Orthopaedic Research Society (ORS) sponsored a symposium on clinical trials in orthopaedic research in May 2009 at which each of these challenges was discussed2,3. Discussions during the symposium focused on offering suggestions regarding how to address these methodological issues during the design and implementation phases of a study. This paper summarizes key discussion points highlighted during the AAOS-ORS Symposium and comments on related issues, including compliance with nonsurgical regimens in studies comparing surgery with nonoperative treatment and the appropriate use of subgroup analysis. The paper concludes with suggestions regarding cost-effectiveness analysis in orthopaedic research. For an RCT to make a difference in the clinical management of musculoskeletal disorders, it must be planned carefully. In addition to detailed specification of the treatment regimen for each arm in the trial, it is critical to perform a careful analysis of the sample size required to conduct a trial that is conclusive (positive or negative). A study with an insufficient sample size may fail to detect a statistically significant difference between the arms of the study even …

Short-Term Complications of the Latarjet Procedure

Although the results of the Latarjet procedure have been reported previously, there is little literature regarding the early complications of this procedure. The purpose of this study was to report our experience with the Latarjet procedure for glenohumeral instability and to highlight the initial complications that may occur following this procedure. Forty-seven patients (forty-eight shoulders) underwent the Latarjet procedure for anterior glenohumeral instability between January 2005 and January 2010. All shoulders had some osseous deficiency of the anterior glenoid rim or had undergone an unsuccessful prior soft-tissue Bankart repair. The minimum duration of patient follow-up was six months. Forty-five shoulders were available for follow-up. The overall complication rate was 25% (twelve of the original forty-eight shoulders). Complications were divided into three groups: infection, recurrent glenohumeral instability, and neurologic injury. A superficial infection developed in three shoulders (6%); in all cases, the infection resolved following irrigation and debridement and administration of antibiotics for up to four weeks. Four shoulders (8%) developed recurrent glenohumeral instability; this occurred within eight months in two shoulders and at nineteen and forty-two months postoperatively in the other two. Five procedures (10%) resulted in a neurologic injury. Two of these involved the musculocutaneous nerve, one involved the radial nerve, and two involved the axillary nerve. The three musculocutaneous and radial nerve injuries involved sensory neurapraxia that resolved fully within two months. Both of the patients with axillary nerve dysfunction continued to have persistent sensory disturbances and one continued to have residual weakness that had not yet resolved fully at the time of the final follow-up. The overall complication rate of 25% is higher than that reported in the literature. Although most of these complications resolved completely, two patients continued to have residual neurologic symptoms. Patients should be informed of the risk of complications associated with the Latarjet procedure, although most of the potential complications will resolve.

The Latarjet Procedure: The Patient Population Makes All the Difference

This retrospective review with Level-IV evidence represents the experience of a highly skilled and experienced physician group with the Latarjet procedure. They report a substantial 25% complication rate for this procedure, including a 6% infection rate, an 8% instability recurrence rate, and a 10% rate of neurologic injury. The recurrence rate is especially worrisome, given the very short minimum follow-up duration of only six months. Two axillary nerve injuries were persistent at the time of the final follow-up. It should be remembered that complications reported for coracoid process transfer in the early 1990s resulted in that operation falling into some disfavor in the United States1. It is difficult to compare this candid study with other reports …

The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials

Advocates of minimally invasive discectomy (MID) have promoted this operation as an alternative to open discectomy (OD), arguing that there may be less injury to the paraspinal muscles, decreased postoperative pain, and a faster recovery time. However, a recently published large randomized controlled trial (RCT) comparing these approaches reported inferior relief of leg pain in patients undergoing MID. The authors conducted a meta-analysis to evaluate complications and improvement in leg pain in patients with radiculopathy enrolled in RCTs comparing OD to MID. The authors performed a literature search using Medline and EMBASE of studies indexed between January 1990 and January 2011. Predetermined RCT eligibility included the usage of tubular retractors during MID, a minimum follow-up duration of 1 year, and quantification of pain with the visual analog scale (VAS). Trials that only evaluated patients with recurrent disc herniation were excluded. Data on operative parameters, complications, and VAS scores of leg pain were extracted by 2 investigators. A meta-analysis was performed assuming random effects to determine the difference in mean change for continuous outcomes and the risk ratio for binary outcomes. Six trials comprising 837 patients (of whom 388 were randomized to MID and 449 were randomized to OD) were included. The mean operative time was 49 minutes during MID and 44 minutes during OD; this difference was not statistically significant. Incidental durotomies occurred significantly more frequently during MID (5.67% compared with 2.90% for OD; RR 2.05, 95% CI 1.05-3.98). Intraoperative complications (incidental durotomies and nerve root injuries) were also significantly more common in patients undergoing MID (RR 2.01, 95% CI 1.07-3.77). The mean preoperative VAS score for leg pain was 6.9 in patients randomized to MID and 7.2 in those randomized to OD. With long-term follow-up (1-2 years postoperatively), the mean VAS score improved to 1.6 in both the MID and OD cohorts. There was no significant difference in relief of leg pain between the 2 approaches with either short-term follow-up (2-3 months postoperatively, 0.81 points on the VAS, 95% CI -4.71 to 6.32) or long-term follow-up (2.64 on the VAS, 95% CI -2.15 to 7.43). Reoperation for recurrent herniation was more common in patients randomized to the MID group (8.50% compared with 5.35% in patients randomized to the OD group), but this difference was not statistically significant (RR 1.56, 95% CI 0.92-2.66). Total complications did not differ significantly between the operations (RR 1.50, 95% CI 0.97-2.33). The current evidence suggests that both OD and MID lead to a substantial and equivalent long-term improvement in leg pain. Adequate decompression, regardless of the operative approach used, may be the primary determinant of pain relief-the major complaint of many patients with radiculopathy. Incidental durotomies occurred significantly more frequently during MID, but total complications did not differ between the techniques.

Postoperative Complications of Posterior Ankle and Hindfoot Arthroscopy

Posterior ankle and hindfoot arthroscopy, performed with use of posteromedial and posterolateral portals with the patient in the prone position, has been utilized for the treatment of various disorders. However, there is limited literature addressing the postoperative complications of this procedure. In this study, the postoperative complications in patients treated with posterior ankle and hindfoot arthroscopy were analyzed to determine the type, rate, and severity of complications. The study included 189 ankles in 186 patients (eighty-two male and 104 female; mean age, 37.1 ± 16.4 years). The minimum duration of follow-up was six months, and the mean was 17 ± 13 months. The most common preoperative intra-articular diagnoses were subtalar osteoarthritis (forty-six ankles), an osteochondral lesion of the talus (forty-two), posterior ankle impingement (thirty-four), ankle osteoarthritis (twenty), and subtalar coalition (five). The most common extra-articular diagnoses were painful os trigonum (forty-six), flexor hallucis longus tendinitis (thirty-two), and insertional Achilles tendinitis (five). The most common intra-articular procedures were osteochondral lesion debridement (forty-four ankles), subtalar debridement (thirty-eight), subtalar fusion (thirty-three), ankle debridement (thirty), and partial talectomy (nine). The most common extra-articular procedures were os trigonum excision (forty-eight), tenolysis of the flexor hallucis longus tendon (thirty-eight), and endoscopic partial calcanectomy (five). Complications were noted following sixteen procedures (8.5%); four patients had plantar numbness, three had sural nerve dysesthesia, four had Achilles tendon tightness, two had complex regional pain syndrome, two had an infection, and one had a cyst at the posteromedial portal. One case of plantar numbness and one case of sural nerve dysesthesia failed to resolve. Our experience demonstrated that posterior ankle and hindfoot arthroscopy can be performed with a low rate of major postoperative complications.

Impact of carbon ion radiotherapy for unresectable osteosarcoma of the trunk

The authors summarized the outcomes of patients with unresectable osteosarcoma of the trunk who received carbon ion radiotherapy (CIRT). The authors performed a retrospective analysis of 78 patients who had medically inoperable osteosarcoma of the trunk and received treatment with CIRT between 1996 and 2009. Tumor sites included the pelvis in 61 patients, the spine and paraspinal region in 15 patients, and other sites in 2 patients. The median applied CIRT dose was 70.4 Gray equivalent (GyE) in a total of 16 fixed fractions over 4 weeks. The minimum duration of follow-up for survivors was 14 months. Forty-eight patients remained alive. The 5-year overall survival rate was 33%, and the local control rate was 62%. Thirty-eight patients who had a clinical target volume <500 cm(3) had a 5-year overall survival rate of 46% and a 5-year local control rate of 88%. Except for 3 patients who experienced severe skin/soft tissue complications requiring skin grafts, no other severe toxicities were observed. Of 9 patients who were continuously disease free for >5 years, 8 were able to walk with or without the help of a cane, and 6 were free from pain killers. CIRT appeared to be a safe and effective modality for the management of unresectable osteosarcoma of the trunk, providing good local control and offering a survival advantage and good long-term functional results without unacceptable morbidity.

Adductor Surgery to Prevent Hip Displacement in Children with Cerebral Palsy: The Predictive Role of the Gross Motor Function Classification System

The purpose of this study was to evaluate the relationship between walking ability, as determined with use of the Gross Motor Function Classification System (GMFCS), and the outcome of hip adductor surgery used to prevent hip displacement in children with cerebral palsy. We performed a retrospective review of the records of all children with cerebral palsy whose index surgery, performed between January 1994 and December 2004 at one tertiary-level pediatric hospital, was bilateral hip adductor releases. All children had a hip migration percentage of >30% in at least one hip prior to the adductor surgery, and the minimum duration of follow-up was twenty-four months. Kaplan-Meier survivorship curves were generated by determining the time from the index surgery to "failure," defined as either the need for subsequent surgical procedures or a migration percentage of ≥50% in either hip. Hazard ratios were calculated for sex, migration percentage at the time of the index surgery, age at the time of the index surgery, and GMFCS level. Three hundred and thirty children were included in the study; 73% (242) were nonambulatory (GMFCS level IV or V). The mean age at the time of the index surgery was 4.2 years, the mean migration percentage was 43%, and the mean duration of postoperative follow-up was 7.1 years. Surgery consisted of open lengthening of the adductor longus and gracilis muscles in all children, with additional procedures as deemed necessary. "Success" was defined as the absence of subsequent surgical procedures during the study period and a migration percentage of <50% in both hips at the time of follow-up. One hundred and six children (32%) met these criteria for success. The success rate was 94% (thirty-one of thirty-three) in children at a GMFCS level of II, 49% (twenty-seven of fifty-five) in children at a level of III, 27% (twenty-eight of 103) in children at a level of IV, and 14% (twenty of 139) in children at a level of V. Walking ability, as defined with use of the GMFCS level, is a strong predictor of success or failure after hip adductor surgery in children with cerebral palsy. The paradox of hip adductor surgery for children with cerebral palsy is that the children who are most severely affected and need the surgery the most have the poorest results.

Cervical ossification of the posterior longitudinal ligament: Anterior versus posterior approach

Background:The optimal approach to provide satisfactory decompression and minimize complications for ossification of the posterior longitudinal ligament (OPLL) involving multiple levels (3 levels or more) remains controversial. The purpose of this study was to compare the results of two surgical approaches for cervical OPLL involving multiple levels; anterior direct decompression and fixation, and posterior indirect decompression and fixation. We present a retrospective review of 56 cases followed at a single Institution.Materials and Methods:We compared patients of multiple levels cervical OPLL that were treated at a single institution either with anterior direct decompression and fixation or with posterior indirect decompression and fixation. The clinical records of the patients with a minimum duration of follow-up of 2 years were reviewed. The associated complications were recorded.Results:Fifty-six patients constitute the clinical material. 26 cases were treated by anterior corpectomy and fixation and 30 cases received posterior laminectomy and fixation. The two populations were similar. It was found that both anterior and posterior decompression and fixation can achieve satisfactory outcomes, and posterior surgery was accomplished in a shorter period of time with lesser blood loss. Although patients had comparable preoperative Japanese Orthopaedics Association (JOA) scores, those with a canal occupancy by OPLL more than 50% and managed anteriorly had better outcomes. However, for those with more severe stenosis, anterior approach was more difficult and associated with higher risks and complications. Despite its limitations in patients with high occupancy OPLLs, through the multiple level laminectomy, posterior fixation can achieve effective decompression, maintaining or restoring stability of the cervical spine, and thereby improving neural outcome and preventing the progression of OPLL.Conclusions:The posterior indirect decompression and fixation has now been adopted as the primary treatment for cervical OPLL involving multiple levels with the canal occupancy by OPLL <50% at our institution because this approach leads to significantly less implant failures. Those patients with the occupancy ≥50% managed with anterior approach surgeries had better outcomes, but approach was more difficult and associated with higher risk and complications.

An Analysis of 1–3-Year Follow-up Results of Laparoscopic Sleeve Gastrectomy: an Indian Perspective

Laparoscopic sleeve gastrectomy (LSG) has become very popular nowadays among bariatric surgeons because of its surgical simplicity and good postoperative results. We present our experience on LSG as a single stage primary bariatric procedure for morbid obesity and its 1-3-year follow-up results. Between March 2008 and March 2011, a total of 110 patients underwent laparoscopic sleeve gastrectomy. Two patients were excluded from the study and thus the prospectively maintained data of 108 patients were retrospectively reviewed and outcomes were recorded. The mean patient age was 39.3 ± 11.1years, mean body mass index was 44.5 ± 6.8, mean excess body weight was 54.1 ± 16.3kg, and the mean American Society of Anesthesiologists score was 3.1 ± 0.57. The mean operative time for the LSG procedure was 64.8 ± 10.6min. The minimum follow-up duration was 6months and maximum of 36months. The mean postoperative percent excess body weight loss achieved was 67.5 ± 13.0 at 1year, 71.1 ± 13.8 at 2years, and 66.09 ± 14.3 at 3years. At the end of 3years, there was 83.3% resolution in diabetes, 85.7% resolution in hypertension, and 85.71% resolution in dyslipidemia. There were no reports of postoperative hemorrhage, gastric leak, deep venous thrombosis, pulmonary embolism, delayed gastric tube stricture, and operative mortality. LSG is a safe and effective bariatric procedure with low perioperative complications. Before it is considered as a single stage primary procedure, a long-term prospective comparative study with other bariatric procedures is required.

Comparison of the Clinical Outcomes after Total Knee Arthroplasty with the LCS Rotating Platform Mobile Bearing Knee System and the PFC Sigma RP-F Mobile Bearing Knee System

BackgroundWe compared clinical outcomes after total knee arthroplasty with the Low Contact Stress (LCS) rotating platform mobile bearing knee system and the Press Fit Condylar Sigma rotating platform high flexion (PFC Sigma RP-F) mobile bearing knee system.MethodsFifty cases of total knee arthroplasty were performed with the PFC Sigma RP-F mobile bearing knee system and sixty-one cases were performed with the LCS mobile bearing total knee arthroplasty. The average duration of follow-up was 2.9 years.ResultsThe mean Hospital for Special Surgery (HSS) knee score was 62.1 (range, 52 to 75) in the LCS group and 61.9 (range, 50 to 74) in the Sigma RP-F group preoperatively, and 90.1 (range, 84 to 100) in the LCS group and 89.8 (range, 83 to 100) in the Sigma RP-F group at the final follow-up. The mean preoperative flexion contracture was 6.7° (range, 0° to 10°) in the LCS group and 9.3° (range, 0° to 15°) in the Sigma RP-F group preoperatively. The mean range of motion was 124.6° (range, 105° to 150°) in the LCS group and 126.1° (range, 104° to 145°) in the Sigma RP-F group at the final follow-up.ConclusionsAfter a minimum duration of follow-up of two years, we found no significant differences between the two groups with regard to the range of knee motion or the clinical or radiographic results.

Long-term Outcomes of Tension-free Vaginal Tape Procedure for Treatment of Female Stress Urinary Incontinence with Intrinsic Sphincter Deficiency

PurposeTo assess the long-term outcomes of tension-free vaginal tape (TVT) for stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD) and to identify influencing factors for failure in these cases.MethodsA total of 136 women who underwent TVT procedures with minimum follow-up duration of 3 years were included in the study. Patients were divided into two groups (non-ISD and ISD groups) based on preoperative urodynamic studies. Patient outcomes were assessed from retrospective chart review and telephone research. Cure was defined as the subjective resolution of SUI in any circumstances. Improvement was defined as the subjective improvement of SUI without complete resolution. Failure was defined as the subjective lack of improvement of SUI. Patients in ISD group were subdivided into two subgroups (cure and non-cure groups) and were compared to identify influencing factors for TVT procedure failure.ResultsEighty-nine patients were in non-ISD group, and 47 in ISD group. The mean follow-up durations were 50.3±9.2 and 49.7±9.7 months, respectively. Subjective cure rate was 75.3% for non-ISD group, and 76.7% for ISD group (P>0.05). Improvement rate was 6.7% for non-ISD group, and 2.1% for ISD group (P>0.05). Satisfaction scores was 3.8±1.2 points in the non-ISD group, and 3.5±1.2 points in ISD group (P>0.05). In ISD subgroups, VLPP was 41.9±12.0 cmH2O for non-cure group, and 50.5±8.6 cmH2O for cure group, and was the only factor that showed significant statistical difference between the two subgroups (P=0.011).ConclusionsWith our long-term results, TVT is an effective treatment even in women with ISD. However, ISD patients with low VLPP should be counseled carefully about TVT outcome.

Long-Term Outcome of Primary Endoscopic Realignment for Bulbous Urethral Injuries: Risk Factors of Urethral Stricture

PurposeAlthough endoscopic realignment has been accepted as a standard treatment for urethral injuries, the long-term follow-up data on this procedure are not sufficient. We report the long-term outcome of primary endoscopic realignment in bulbous urethral injuries.MethodsPatients with bulbous urethral injuries were treated by primary endoscopic realignment between 1991 and 2005. The operative procedure included suprapubic cystostomy and transurethral catheterization using a guide wire, within 72 hours of injury. The study population included 51 patients with a minimum follow-up duration of 5 years.ResultsThe most common causes of the injuries were straddle injury from falling down (74.5%), and pelvic bone fracture (7.8%). Gross hematuria was the most common complaint (92.2%). Twenty-three patients (45.1%) had complete urethral injuries. The mean time to operation after the injury was 38.8±43.2 hours. The mean operation time and mean indwelling time of a urethral Foley catheter were 55.5±37.6 minutes and 22.0±11.9 days, respectively. Twenty out of 51 patients (39.2%) were diagnosed with urethral stricture in 89.1±36.6 months after surgery. A multivariate analysis revealed that young age and operation time were independent risk factors for strictures as a complication of urethral realignment (hazard ratio [HR], 6.554, P=0.032; HR, 6.206, P=0.035).ConclusionsUrethral stricture commonly developed as a postoperative complication of primary endoscopic urethral realignment for bulbous urethral injury, especially in young age and long operation time.

What Is the Benefit of Introducing New Hip and Knee Prostheses?

New joint replacement prostheses are being continually introduced into the market. The underlying purpose of the introduction of new devices is to improve patient outcomes. This study was undertaken to determine how many new prostheses were associated with improved patient outcomes. Data were obtained from a comprehensive national database. Outcome analysis was performed on all new hip and knee prostheses introduced into the market between January 1, 2003, and December 31, 2007, and used on at least 100 occasions. The findings were compared with the combined results of the three best performing established hip and knee prostheses with a minimum duration of follow-up of five years. The principal outcome measures were the rate of revision per observed component years and the time to first revision, with use of Kaplan-Meier estimates of implant survivorship. Most prostheses introduced into the market during the study period were used on fewer than 100 occasions. Analysis of those that had been used in a sufficient number of procedures showed that 27% (nine of thirty-three) of the hip replacements and 29% (eight of twenty-eight) of the knee replacements had a significantly higher rate of revision than the established prostheses. None of the newer prostheses had a lower rate of revision than the established prostheses. This study indicates that there was no benefit to the introduction of new prostheses into this national market during the five-year study period. Importantly, 30% of the new prostheses were associated with a significantly worse outcome compared with the prostheses with a minimal duration of follow-up of five years.

Prevalence of Pseudotumor in Asymptomatic Patients After Metal-on-Metal Hip Arthroplasty

The cause of recently reported pseudotumor formation in patients with metal-on-metal hip replacements is unknown. It has been postulated that there is an association between elevated levels of serum metal ions and pseudotumor formation. The primary purpose of this study was to assess the prevalence of pseudotumor formation in asymptomatic patients with a metal-on-metal total hip replacement after a minimum duration of follow-up of two years. A secondary purpose was to assess whether a correlation exists between elevated serum metal ion levels and pseudotumor formation. In the present study, the prevalence of pseudotumor formation, as detected with ultrasound, was evaluated for thirty-one asymptomatic patients with a metal-on-metal total hip arthroplasty, twenty-four asymptomatic patients with a metal-on-polyethylene total hip arthroplasty, and twenty asymptomatic patients with a metal-on-metal hip resurfacing arthroplasty. Serum levels of cobalt and chromium were measured in the metal-on-metal total hip arthroplasty and hip resurfacing arthroplasty groups. Ten patients (32%) in the metal-on-metal total hip arthroplasty group had a solid or cystic mass, with another three patients (10%) having a substantial fluid collection. Five patients (25%) in the hip resurfacing arthroplasty group had a solid or cystic mass, with another patient (5%) having a fluid collection. Pseudotumor formation was significantly more frequent in the metal-on-metal total hip arthroplasty group compared with the metal-on-polyethylene total hip arthroplasty group (p = 0.015). We did not detect a significant correlation between the serum metal ion levels and the size of pseudotumor abnormality. The median serum metal ion level was greater in patients with pseudotumor formation than it was in those without pseudotumor formation, but the difference was not significant. We recommend high-resolution ultrasound surveillance of all asymptomatic patients with a metal-on-metal implant that is known to result in high serum metal ion levels. Once a metal-on-metal implant is known to be associated with high serum metal ions, the measurement of ion levels does not helpfully contribute to surveillance.