Need For Further Surgery Research Articles

Avascular necrosis of the femoral head due to sickle-cell disease in tribal population around Vishakhapatnam district, treated with core de-compression and non - vascularised fibular graft

Sickle-cell disease (SCD) is the most common cause of avascular necrosis (AVN) of the hip in childhood. It results in significant physical impairment and chronic pain, and ohen progresses to require hip replacement. Conservative therapy is ineffective. We evaluated whether core decompression can arrest progression of AVN. We performed 10 core decompression procedures in 6 patients with SCD and AVN. Patients ranged from age 12—18 years at diagnosis (mean, median age, 14 years); Six hips were stage II, Four hips were stage III, and. follow-up on these patients was 1.2 years. Efficacy of the procedure was evaluated by clinical improvement in pain, radiographic progression, and need for further surgery. All 6 stage II patients had substantial improvement in pain, and only one showed X-ray progression. Both stage III patients progressed on X-ray, but one was clinically improved. One patient was operated with Non-Vascularised Fibular Graft. Our results demonstrate that in early AVN, core decompression was beneficial for almost all patients, even with progression on X-ray. Core decompression should be considered in the management of SCD patients with early AVN. But in our study, only one pt was operated with Non-Vascularised Fibular Graft

Fixation of Comminuted Fracture of the Inferior Pole of the Patella Using Suture Anchors with Reinforcement by Ipsilateral Semitendinosus Tendon

BACKGROUND: Many options have been used for treatment of comminuted fractures of the inferior pole of the patella as the ideal treatment has not yet been identified. The hypothesis was that fixation of these fractures using suture anchors with reinforcement by ipsilateral semitendinosus tendon will be rigid enough to allow early rehabilitation with good functional results with no need for further surgery for hardware removal. METHODS: Ten patients (7 males and 3 females) with closed comminuted fractures of the infe-rior pole of patella were included in this study. Of the ten fractures, six resulted from a fall and four resulted from a car accident. The average age of patients was 31.6 years (range, 19 to 42 years). All patients were operated within 24 hours from the trauma. Fixation of fracture was done using suture anchors with reinforcement by ipsilateral semitendinosus tendon. RESULTS: All fractures treated with this technique healed. All patients were followed-up for an average of 21 months (range, 13 to 30 months).Patients were evaluated according to the patellofemoral rating system. All patients were available for follow-up. The average patella femoral score was 94.7 points. The score was excellent for nine patients and good for one patient. CONCLUSION: Fixation of comminuted fractures of the inferior pole of the patella using suture anchors with reinforcement by ipsilateral semitendinosus tendon left attached distally is rigid enough to allow early motion and shows good functional results. The technique is relatively sim-ple and feasible. Harvest of the tendon is easy with low donor site morbidity. No further surgery for hardware removal is necessary.

Recurrent Casting for Recurrent Clubfoot . . . A Triumph of Technique Over Reason or the New Norm?: Commentary on an article by Veroniek M. van Praag, MD, MA, et al.: "Casting Is Effective for Recurrence Following Ponseti Treatment of Clubfoot".

Commentary We have all had recurrences among our patients after the Ponseti method of clubfoot correction. Even Ponseti himself reported a substantial number of recurrences. First, as noted by van Praag et al., recurrence rates of up to 40% have been documented in high-quality studies and reviews. Second, are these really failures of the technique or simply a relapse in a foot that only required a longer period of corrective casting and orthotic management? Van Praag et al. set out to examine this question in a well-documented study at The Hospital for Sick Children in Toronto, where all of the recurrences (19% in this study of 382 children) were routinely treated with recasting rather than with surgical intervention. Why these recurrences occurred appears to be an enigma to both the researchers and their readers. Could it be that these were familial clubfeet, which are noted to be more rigid? Or were they all from a certain ethnic background such as Arabic people from the Middle East, where clubfeet are more severe? In a dedicated clubfoot clinic in an academic center, it is doubtful that improper technique was a cause; hence, the answer is that we do not know why they recurred, providing that the parents were compliant with the bracing protocol. In my experience, parental shortcuts in brace use are a major cause of recurrence. A concern here is that the authors had 71 patients who had a recurrence, but less than half, i.e., 35 patients, returned for recasting. Were these the patients with the worst recurrences and, if so, does this throw some doubt on the results of the subsequent Ponseti castings, which may have been skewed to higher severity? It may throw into question the statement that “. . . the results are not the same as those for patients who do not have recurrent clubfoot.” We do not know, of course, and thus a larger study group with more statistical power is needed. However, the authors have kicked the door a bit ajar for us and have shown that recasting can obviously be successful the second, third, and even more times out. Since our world is now becoming an even greater melting pot of humanity, authors of studies related to clubfeet should be encouraged to record ethnicity and genetic (familial) inheritance, which may turn out to have a bearing on recurrence rates. For several years, I practiced in the Middle East, where clubfeet are very common among Arabic people and the condition is more severe than that seen in North America. It is of interest that a recurrence rate of 17% was uncovered in the authors’ “corrected” control group, which had been followed for as long as 7 years. I personally have made it a practice to follow all my patients with clubfoot until they are 12 years old. An imbalance between the peroneal tendons and invertors may develop well after 5 years of age, requiring a rebalancing of the foot with an anterior tibial tendon transfer. Whether repeat casting will improve the results from that after anterior tibial tendon transfer (i.e., decrease the need for further surgical procedures) is enticing and awaits further study. The authors have convinced me that if our next grandchild is born with a clubfoot that relapses after the first series of Ponseti casts, recurrent casting would be my recommendation. Is it the new norm? The authors provided very good evidence that it is, at least for up to 3 recurrences. Recasting is certainly not a triumph of technique over reason and may well, with larger numbers and longer follow-up, be accepted as the new norm.

Increased time between diagnosis and surgery in slipped capital femoral epiphysis results in increased radiographic deformity.

PurposePrevious work has examined the impact of delay of diagnosis in slipped capital femoral epiphysis (SCFE) but not the impact of delay in treatment after radiographic diagnosis. Due to requirements for long distance transportation from less developed regions for many of our patients, our hospital was able to study variation in time between diagnosis and surgery for SCFE, as related to slip severity.MethodsThis is a retrospective review of patients treated for SCFE between 2005 and 2014 at a tertiary care paediatric hospital. Demographics, time between diagnosis and surgery, radiographic deformity (Southwick angle), postoperative complications and need for further surgery were variables of interest. Statistical analysis included Pearson and Spearman rank correlations and chi-squared tests.ResultsThe study sample included 147 hips (119 patients). Mean time between radiographic diagnosis and surgery was 20.9 days (sd 46, 0 to 321). The mean Southwick angle (SA) at the time of surgery was 31.9˚ (sd 19.6˚, 1° to 83˚). There was a significant relationship between increased delay and increased SA (0.34, p < 0.001). Increased SA was correlated with need for future significant surgery (0.27, p < 0.01).Patients from less-developed regions, with barriers to timely care, had moderate and severe deformity (SA) (p < 0.01), and required significant further surgery more often than SCFE patients from the local population (p < 0.01)ConclusionThe unique referral environment of our hospital provided an opportunity to examine traditional recommendations for treating SCFE promptly after radiographic diagnosis. Delay in treatment is correlated with increased radiographic deformity.Level of EvidenceIII

Risk of further surgery on the same or opposite side and mortality after primary total hip arthroplasty: A multi-state analysis of 133,654 patients from the Swedish Hip Arthroplasty Register

Background and purpose — The hip-related timeline of patients following a total hip arthroplasty (THA) can vary. Ideally patients will live their life without need for further surgery; however, some will undergo replacement on the contralateral hip and/or reoperations. We analyzed the probability of mortality and further hip-related surgery on the same or contralateral hip.Patients and methods — We performed a multi-state survival analysis on a prospectively followed cohort of 133,654 Swedish patients undergoing an elective THA between 1999 and 2012. The study used longitudinally collected information from the Swedish Hip Arthroplasty Register and administrative databases. The analysis considered the patients’ sex, age, prosthesis type, surgical approach, diagnosis, comorbidities, education, and civil status.Results — During the study period patients were twice as likely to have their contralateral hip replaced than to die. However, with passing time, probabilities converged and for a patient who only had 1 non-revised THA at 10 years, there was an equal chance of receiving a second THA and dying (24%). It was 8 times more likely that the second hip would become operated with a primary THA than that the first hip would be revised. Multivariable regression analysis reinforced the influence of age at operation, sex, diagnosis, comorbidity, and socioeconomic status influencing state transition.Interpretation — Multi-state analysis can provide a comprehensive model of further states and transition probabilities after an elective THA. Information regarding the lifetime risk for bilateral surgery, revision, and death can be of value when discussing the future possible outcomes with patients, in healthcare planning, and for the healthcare economy.

Modified Transanosphincteric (York Mason) Repair of Nonradiated Rectourinary Fistulae: Patient-reported Fecal Continence Outcomes

To review our experience with the modified York Mason (MYM) procedure in the treatment of rectourinary fistulas (RUFs) and to assess fecal continence using patient-reported measures. A retrospective review was performed of patients who underwent MYM repair of nonradiated RUF with gluteal free fat graft from 2008 to 2016 at a single institution. Success was defined as resolution of the fistula without need for further surgery. The Cleveland Clinic-Florida Wexner Fecal Incontinence Score (CCFFIS) and the Patient Global Impression of Improvement (PGI-I) surveys were administered by phone. Of 17 patients who underwent MYM repair with a mean age of 61.8 years old, the most common fistula etiologies were prostatectomy in 11 patients (65%), cryoablation in 2 patients (12%), and transanal tumor excision (12%). Three patients (18%) failed prior perineal repairs. The mean fistula size was 10.1 mm (range 2-25), the median operative time was 231 minutes (range 151-365), and the median length of stay was 2.0 days (range 1-13). At the median follow-up of 39.4 months, 16 of the 17 patients (94%) had successful primary closures. The condition of the 10 patients who responded to the phone survey was "much better" (median PGI-I score 2), with 89.5% mean improvement. The mean CCFFIS was 1.4 (range 0-5) on a scale of 0 (total continence) to 20 (complete incontinence). Two patients (20%) reported rare (<1 per month) fecal incontinence, and 2/10 (20%) reported frequent flatal incontinence, but none reported significant lifestyle change or sought further treatment for bowel symptoms. The MYM technique has a high success rate in the treatment of nonradiated RUF with negligible impact on fecal continence.

Transanal endoscopic surgery is effective and safe after endoscopic polypectomy of potentially malignant rectal polyps with questionable margins.

To determine the percentage of residual lesion observed in the pathology study of transanal endoscopic surgery (TEM) specimens after endoscopic polypectomy of malignant rectal polyps with questionable margins, and the need for further surgery. Secondary aims: to determine the morbidity and mortality associated with this procedure and to identify the percentage of recurrence after excision by TEM. Observational study with prospective data collection of all patients undergoing TEM after endoscopic polypectomy for malignant rectal polyps or non-invasive high-grade neoplasia, from January 2004 to December 2016. An en bloc full-thickness wall excision of the scar was performed. Variables recorded: histology of TEM specimen, 30-day morbidity and mortality according to the Clavien-Dindo classification, need for salvage surgery and recurrence. Fifty out of 690 patients undergoing TEM during the study period (36 adenocarcinomas, five non-invasive high-grade neoplasias and 9 neuroendocrine tumors) were included. Post-surgery histology showed residual lesion in 21 (42%) patients: 7 neuroendocrine tumors, 10 adenomas and 4 adenocarcinomas (two pT1, one pT2 and one pT3). The pT2 and pT3 patients (4%) underwent salvage surgery. No recurrence was observed, and mean follow-up was 29.1Â ± 21.6 months. The 30-day morbidity rate was 14%, but 4/7 with Clavien-Dindo grade I. After endoscopic polypectomy of malignant rectal polyps with questionable margins, the presence of residual lesion in the pathology study of transanal resection specimens is high. TEM with full-thickness resection of these lesions is an appropriate treatment, allowing disease control and achieving minimal morbidity.

Use Of Synthetic Skin Substitute (Biobrane) For Plantar Foot Burn

Background : In Singapore, we experience a unique annual surge of burn cases involving sole of foot during the Hindu fire walking festival. Traditionally, superficial partial-thickness burns of the soles were managed expectantly with regular dressings. We conducted a study to evaluate the effectiveness of an alternative approach of using synthetic skin substitute (Biobrane®).&#x0D; Method : A case series of foot burns admitted October 2016 to the Singapore General Hospital Burns Centre. Burn cases with superficial partial-thickness burn of bilateral sole of foot were included in the study. Exclusion criteria included deep dermal burns and burns that required excision and closure with skin grafting. The patient demographics, time to presentation, medical co-morbidities were analyzed. Outcomes such as length of hospital stay, incidence of infection, need for further surgery, return to pre-injury ambulation status and occupation and cost were studied.&#x0D; Result : A total of 6 partial thickness burns of sole of foot in 3 patients with bilateral foot burns which were treated with Biobrane® were included in the study. Patients were able to return pre-injury functional status- return to work and pre-morbid ambulation status. Neither incidence of wound infections nor any needs for repeat surgery were recorded. However, this group required an increased length of stay and incurred high treatment cost.&#x0D; Conclusion: Biobrane® is a viable adjunct in the management of sole of foot burns. The authors believe there is potential for an improved rate of recovery with Biobrane®. However, the higher cost and length of stay are among its drawbacks. In view of the limitations of our study- case series and small sample size, a prospective and double arm assessment will be required to present definite evidence for synthetic skin substitute in these cases

Fragility fractures of the acetabulum

There are limited epidemiological data dedicated to geriatric acetabular fractures. The incidence in individuals older than 60 years of age has more than doubled in the past three decades and expected to double further over the next 20 years. These fractures represent a challenging subset of acetabular trauma patients to treat. Conservative treatment is a valid option in those with minimal displaced fractures and a preserved congruent hip joint. Similarly the frail patient with multiple medical co-morbidities and those unlikely to tolerate surgical intervention should have appropriate analgesia and their fracture managed or ignored by watchful neglect. Surgical treatment options include percutaneous fixation or open reduction and internal fixation techniques. Good outcomes may be expected should a concentric reduction be achieved. Age-related involutional osteoporosis associated with fracture comminution and acetabular dome impaction complicate surgical fixation with higher complication rates and the need for further surgery recognised. Historically described as central fracture dislocations, stoved in hip or burst fracture, acute arthroplasty is advocated in the setting of femoral head damage and in significant acetabular impaction injuries. Controversy remains whether geriatric patients should be treated by open reduction and internal fixation or total hip arthroplasty either acute or delayed and needs to be assessed based on the patient and personality of the fracture.

Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion

ObjectivesTo evaluate the effectiveness of videothoracoscopic surgery in the treatment of complicated parapneumonic pleural effusion and to determine whether there is a difference in the videothoracoscopic surgery outcome before or after the chest tube drainage. MethodsThe medical records of 79 children (mean age 35 months) undergoing videothoracoscopic surgery from January 2000 to December 2011 were retrospectively reviewed. The same treatment algorithm was used in the management of all patients. Patients were divided into two groups: in group 1, videothoracoscopic surgery was performed as the initial procedure; in group 2, videothoracoscopic surgery was performed after previous chest tube drainage. ResultsVideothoracoscopic surgery was effective in 73 children (92.4%); the other six (7.6%) needed another procedure. Sixty patients (75.9%) were submitted directly to videothoracoscopic surgery (group 1) and 19 (24%) primarily underwent chest tube drainage (group 2). Primary videothoracoscopic surgery was associated with a decrease of hospital stay (p = 0.05), time to resolution (p = 0.024), and time with a chest tube (p < 0.001). However, there was no difference between the groups regarding the time until fever resolution, time with a chest tube, and the hospital stay after videothoracoscopic surgery. No differences were observed between groups regarding the need for further surgery and the presence of complications. ConclusionsVideothoracoscopic surgery is a highly effective procedure for treating children with complicated parapneumonic pleural effusion. When videothoracoscopic surgery is indicated in the presence of loculations (stage II or fibrinopurulent), no difference were observed in time of clinical improvement and hospital stay among the patients with or without chest tube drainage before videothoracoscopic surgery.

Role of frozen section in sentinel lymph node biopsy for breast cancer in the era of the ACOSOG Z0011 and IBCSG 23-10 trials

BackgroundIntraoperative frozen sections (FS) of sentinel lymph nodes (SLN) were evaluated to avoid the need for deferred axillary lymph node dissection (ALND) in patients with early breast cancer (EBC). However, FS has low sensitivity for detecting micro-metastases (<2 mm), resulting in patients who later undergo deferred ALND. The aim of the study was to determine the best clinical approach for selecting patients who would derive real benefit from ALND, as well as to minimize the functional and psychological damage caused by delayed surgery, and the risk of undertreating EBC patients. MethodsThis study evaluated 1453 patients with early breast cancer (EBC) who underwent SLN biopsy, FS and definitive evaluation. Causes of discrepancies between SLN biopsy and FS results and the need for further surgery were evaluated. ResultsA total of 1226 (86%) patients underwent FS; of these patients, 146 (11.9%) were false negatives. The global sensitivity of FS in detecting both macro and micrometastases was 53.7%. Although ACOSOG Z0011 criteria found that ALND could be avoided in 236 patients, 40 (17%) of these had >3 positive axillary lymph nodes. In contrast, application of the IBCSG 23-10 trial criteria, found that only three patients (3.1%) had >3 positive axillary lymph nodes. ConclusionsFS has a low sensitivity in detecting micrometastases (19%), but a reasonable sensitivity for macrometastases (75%). Most false negatives were smaller metastases (mean 2.1 mm) and more likely in patients with infiltrating lobular carcinoma. Retrospective modelling of the IBCSG 23-10 criteria reduced the percentage of patients requiring deferred surgery from 12% to 4%. Guidelines recommend irradiation of lymph node drainage stations in patients with ≥4 axillary metastatic lymph nodes. Omission of ALND from 40% of patients who met Z0011 criteria would have resulted in their undertreatment. This risk decreases to 3% by omitting axillary clearing only in patients with micrometastases.

Fixation of Comminuted Fracture of the Inferior Pole of the Patella Using Suture Anchors with Reinforcement by Ipsilateral Semitendinosus Tendon

BACKGROUND: Many options have been used for treatment of comminuted fractures of the inferior pole of the patella as the ideal treatment has not yet been identified. The hypothesis was that fixation of these fractures using suture anchors with reinforcement by ipsilateral semitendinosus tendon will be rigid enough to allow early rehabilitation with good functional results with no need for further surgery for hardware removal. METHODS: Ten patients (7 males and 3 females) with closed comminuted fractures of the infe-rior pole of patella were included in this study. Of the ten fractures, six resulted from a fall and four resulted from a car accident. The average age of patients was 31.6 years (range, 19 to 42 years). All patients were operated within 24 hours from the trauma. Fixation of fracture was done using suture anchors with reinforcement by ipsilateral semitendinosus tendon. RESULTS: All fractures treated with this technique healed. All patients were followed-up for an average of 21 months (range, 13 to 30 months).Patients were evaluated according to the patellofemoral rating system. All patients were available for follow-up. The average patella femoral score was 94.7 points. The score was excellent for nine patients and good for one patient. CONCLUSION: Fixation of comminuted fractures of the inferior pole of the patella using suture anchors with reinforcement by ipsilateral semitendinosus tendon left attached distally is rigid enough to allow early motion and shows good functional results. The technique is relatively sim-ple and feasible. Harvest of the tendon is easy with low donor site morbidity. No further surgery for hardware removal is necessary.

Computed tomography-guided catheter drainage with ozone in management of pyogenic liver abscess.

PurposeTo compare the treatment efficacy of percutaneous catheter drainage alone to catheter drainage combined with ozone in the management of pyogenic liver abscess (PLA).Material and methodsThis prospective study included 85 patients diagnosed with PLA. All patients were randomly divided into two groups: catheter drainage alone (Group I); catheter drainage combined with ozone (Group II). Drainage was considered successful when: 1) the abscess cavities were completely drained, and 2) clinical symptoms were resolved. Kruskall-Wallis nonparametric test was used to compare the success rates, length of stay (LOS), and need of further surgery. A value of p < 0.05 was considered significant for all statistical analyses.ResultsIn all the patients’ percutaneous catheters were placed successfully under the guidance of computed tomography. All of the patients in Group I (43; 50.6%) were treated with percutaneous catheter drainage alone, while the patients in Group II (42; 49.4%) were treated with PCD combined with ozone. The success rates of Group I and II were 81% and 94%, respectively (p < 0.05). The duration of fever as well as LOS was longer for Group I when compared with Group II (p < 0.05).ConclusionsCatheter drainage combined with ozone is an effective and safe treatment in PLA.

The Value of Ozone in CT-Guided Drainage of Multiloculated Pyogenic Liver Abscesses: A Randomized Controlled Study.

Objective This study was designed to compare the effects of catheter drainage alone and combined with ozone in the management of multiloculated pyogenic liver abscess (PLA). Methods The prospective study included 60 patients diagnosed with multiloculated PLA. All patients were randomly divided into two groups: catheter drainage alone (group I) and catheter drainage combined with ozone (group II). Drainage was considered successful when (1) the abscess cavity was drained and (2) clinical symptoms were resolved. Kruskal-Wallis nonparametric test was used to compare the success rates, length of stay (LOS), and need for further surgery of the two groups. P < 0.05 indicates significant difference. ResultsAll patients' catheters were successfully placed under CT guidance. Group I was treated with catheters alone and group II was treated with catheters and ozone. The success rates of groups I and II were 86% and 96%, respectively (P < 0.05). And compared with group II, the duration of fever in group I was longer (P < 0.05), and the LOS was also longer (P < 0.05). Conclusion Catheter drainage combined with ozone is an effective and safe treatment in multiloculated PLA. The Clinical Registration Number is ChiCTR1800014865.

Surgery for Velopharyngeal Dysfunction: A Systematic Review of Interventions and Outcomes.

This systematic review sought to evaluate the consensus in the literature regarding the surgical management of VPD and to determine whether a particular procedure results in superior speech outcome or less morbidity Design: A systematic review was carried out according to PRISMA-P guidelines. Systematic review software was used to facilitate 3-stage screening and data extraction by 2 reviewers. University teaching hospital. Studies that reported perceptual speech assessment or obstructive sleep apnea (OSA) in patients who had undergone surgery for VPD were included in the review. Four categories of surgery for VPD were examined-pharyngeal flap, sphincter pharyngoplasty, palatoplasty, and posterior pharyngeal wall augmentation. Perceptual speech assessment, need for further surgery, and occurrence of OSA were the outcomes of interest. Eighty-three relevant studies were identified, comprising data on 4011 patients. Pharyngeal flap was the most common procedure (64% of patients). Overall, 70.7% of patients attained normal resonance and 65.3% attained normal nasal emission. There was no notable difference in speech outcomes, need for further surgery, or occurrence of OSA across the 4 categories of surgery examined. Heterogeneous groups of patients were reported upon and a variety of perceptual speech assessment scales were used. There is a lack of consensus in the literature to guide procedure selection for patients with VPD. The development of a standardized minimum data set to record postoperative speech, OSA, and patient-reported outcomes is required.

Metachronous colorectal cancer following segmental or extended colectomy in Lynch syndrome: a systematic review and meta-analysis

Around 5% of colorectal cancers are due to mutations within DNA mismatch repair genes, resulting in Lynch syndrome (LS). These mutations have a high penetrance with early onset of colorectal cancer at a mean age of 45 years. The mainstay of surgical management is either a segmental or extensive colectomy. Currently there is no unified agreement as to which management strategy is superior due to limited conclusive empirical evidence available. A systematic review and meta- analysis to evaluate the risk of metachronous colorectal cancer (MCC) and mortality in LS following segmental and extensive colectomy. A systematic review of the PubMed database was conducted. Studies were included/ excluded based on pre-specified criteria. To assess the risk of MCC and mortality attributed to segmental or extensive colectomies, relative risks (RR) were calculated and corresponding 95% confidence intervals (CI). Publication bias was investigated using funnel plots. Data about mortality, as well as patient ascertainment [Amsterdam criteria (AC), germline mutation (GM)] were also extracted. Statistical analysis was conducted using the R program (version 3.2.3). The literature search identified 85 studies. After further analysis ten studies were eligible for inclusion in data synthesis. Pooled data identified 1389 patients followed up for a mean of 100.7 months with a mean age of onset of 45.5 years of age. A total 1119 patients underwent segmental colectomies with an absolute risk of MCC in this group of 22.4% at the end of follow-up. The 270 patients who had extensive colectomies had a MCC absolute risk of 4.7% (0% in those with a panproctocolecomy). Segmental colectomy was significantly associated with an increased relative risk of MCC (RR = 5.12; 95% CI 2.88–9.11; Fig. 1), although no significant association with mortality was identified (RR = 1.65; 95% CI 0.90–3.02). There was no statistically significant difference in the risk of MCC between AC and GM cohorts (p = 0.5, Chi-squared test). In LS, segmental colectomy results in a significant increased risk of developing MCC. Despite the choice of segmental or extensive colectomies having no statistically significant impact on mortality, the choice of initial surgical management can impact a patient’s requirement for further surgery. An extensive colectomy can result in decreased need for further surgery; reduced hospital stays and associated costs. The significant difference in the risk of MCC, following segmental or extensive colectomies should be discussed with patients when deciding appropriate management. An individualised approach should be utilised, taking into account the patient’s age, co-morbidities and genotype. In order to determine likely germline-specific effects, or a difference in survival, larger and more comprehensive studies are required.

Aspirin and the prevention of venous thromboembolism following total joint arthroplasty: commonly asked questions.

The number of arthroplasties being performed increases each year. Patients undergoing an arthroplasty are at risk of venous thromboembolism (VTE) and appropriate prophylaxis has been recommended. However, the optimal protocol and the best agent to minimise VTE under these circumstances are not known. Although many agents may be used, there is a difference in their efficacy and the risk of bleeding. Thus, the selection of a particular agent relies on the balance between the desire to minimise VTE and the attempt to reduce the risk of bleeding, with its undesirable, and occasionally fatal, consequences.Acetylsalicylic acid (aspirin) is an agent for VTE prophylaxis following arthroplasty. Many studies have shown its efficacy in minimising VTE under these circumstances. It is inexpensive and well-tolerated, and its use does not require routine blood tests. It is also a ‘milder’ agent and unlikely to result in haematoma formation, which may increase both the risk of infection and the need for further surgery. Aspirin is also unlikely to result in persistent wound drainage, which has been shown to be associated with the use of agents such as low-molecular-weight heparin (LMWH) and other more aggressive agents.The main objective of this review was to summarise the current evidence relating to the efficacy of aspirin as a VTE prophylaxis following arthroplasty, and to address some of the common questions about its use. There is convincing evidence that, taking all factors into account, aspirin is an effective, inexpensive, and safe form of VTE following arthroplasty in patients without a major risk factor for VTE, such as previous VTE.Cite this article: Bone Joint J 2017;99-B:1420–30.

Outcomes of Esophageal Replacement: Gastric Pull-Up and Colonic Interposition Procedures.

No consensus exists about the optimal surgical technique for esophageal replacement. This study reports the surgical outcomes for the gastric pull-up and the colonic interposition procedures. A retrospective review of children undergoing esophageal replacement surgery between January 2001 and June 2015 across four different pediatric surgery centers was conducted. Data collected included indications, epidemiology, surgical technique, complications, and outcomes. Patients were divided into group A, those that had a gastric pull-up procedure and group B, those that had a colonic interposition procedure. In total, 50 patients were included; 29 in group A and 21 in group B. Indications included esophageal atresia, caustic ingestion, and infective esophageal stricture. The median age at the time of surgery was 13 months. The mean length of follow-up was 5.2 years. Three patients died giving a mortality rate of 6%; 2 in group A and 1 in group B.In both groups, early postoperative complications included infective complications, such as wound infections, sepsis, and pneumonia (11), anastomotic leak (7), and respiratory complications (7). Late complications included adhesive bowel obstruction (2), anastomotic strictures (4), redundancy (1), and jejunostomy problems (1). Septic complications and anastomotic strictures occurred more frequently in group B. Further surgery was needed in eight patients; this was significantly higher in group B. Full oral feeding was achieved within 6 months in 91.5%. The gastric pull-up and colonic interposition have comparable mortality and outcomes. The colonic interposition was associated with a higher rate of early septic complications, anastomotic strictures, and need for further surgery.

Hemiepiphyseodesis for Juvenile and Adolescent Tibia Vara Utilizing Percutaneous Transphyseal Screws.

In juvenile and adolescent tibia vara patients with sufficient growth remaining, implant-controlled hemiepiphyseodesis, or guided growth, can be used to correct deformity. Recent reports have described hardware failure of certain hemiepiphyseodesis implants in overweight patients with tibia vara. We describe our experience using transphyseal screws to correct deformity in this patient population. A retrospective chart and radiograph review was conducted on all juvenile and adolescent tibia vara patients who underwent lateral proximal tibial hemiepiphyseodesis using a single transphyseal screw. Charts were queried for preoperative and postoperative mechanical axis deviation, medial proximal tibial angle, lateral distal femoral angle, and postoperative complications or need for further surgery. In total, 14 affected limbs in 9 patients (6 males) who underwent lateral proximal tibial transphyseal screw hemiepiphyseodesis were considered. Average chronologic age at implantation was 10.4 years and average body mass index was 31.7 kg/m. At average 23-month follow-up, the average mechanical axis deviation improved from 46 to 0 mm (P<0.001), and the average medial proximal tibial angle improved from 81 to 92 degrees (P<0.001). No limbs underwent further surgery to correct residual deformity. There were no complications or instances of implant failure associated with the transphyseal screws. Hemiepiphyseodesis using transphyseal screws is an effective technique to correct deformity in juvenile and adolescent tibia vara patients with sufficient growth remaining. This method can be used safely with few complications and with minimal risk of mechanical failure, even in overweight patients. Level IV-therapeutic.

Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion

ObjectivesTo evaluate the effectiveness of videothoracoscopic surgery in the treatment of complicated parapneumonic pleural effusion and to determine whether there is a difference in the videothoracoscopic surgery outcome before or after the chest tube drainage. MethodsThe medical records of 79 children (mean age 35 months) undergoing videothoracoscopic surgery from January 2000 to December 2011 were retrospectively reviewed. The same treatment algorithm was used in the management of all patients. Patients were divided into two groups: in group 1, videothoracoscopic surgery was performed as the initial procedure; in group 2, videothoracoscopic surgery was performed after previous chest tube drainage. ResultsVideothoracoscopic surgery was effective in 73 children (92.4%); the other six (7.6%) needed another procedure. Sixty patients (75.9%) were submitted directly to videothoracoscopic surgery (group 1) and 19 (24%) primarily underwent chest tube drainage (group 2). Primary videothoracoscopic surgery was associated with a decrease of hospital stay (p=0.05), time to resolution (p=0.024), and time with a chest tube (p<0.001). However, there was no difference between the groups regarding the time until fever resolution, time with a chest tube, and the hospital stay after videothoracoscopic surgery. No differences were observed between groups regarding the need for further surgery and the presence of complications. ConclusionsVideothoracoscopic surgery is a highly effective procedure for treating children with complicated parapneumonic pleural effusion. When videothoracoscopic surgery is indicated in the presence of loculations (stage II or fibrinopurulent), no difference were observed in time of clinical improvement and hospital stay among the patients with or without chest tube drainage before videothoracoscopic surgery.