Need For Secondary Surgery Research Articles

MP38-16 COMPARISON OF OUTCOMES OF MINIARC AND MONARC SLINGS: UPDATE OF A SINGLE-CENTER SURGICAL SERIES

INTRODUCTION AND OBJECTIVES: Previous studies showed that Single incision MiniArc slings are a safe procedure associated with high success and low complications rates. Furthermore, comparative studies, suggest that MiniArc and Monarc perform equally in the treatment of stress urinary incontinence (SUI). A pilot study conducted by our group confirmed similar results between MiniArc and Monarc. However, a larger population with a longer follow-up is needed to validate such results. In this context we aimed at assessing the rate of favourable outcomes and the rate of complications of MiniArc compared to Monarc slings in a large cohort of patients with a long follow up at a single tertiary referral center METHODS: The study includes 381 patients treated with primary sling for SUI between 2003 and 2012 at our center. Of them 166 (44%) underwent a MiniArc sling procedure, and 215 (56%) a Monarc procedure. All surgeons had adequate experience in sling surgery. The choice of sling was left at the discretion of the surgeon. All patients had complete data including age, history of diabetes mellitus (DM), BMI, presence of Mixed Urinary Incontinence (MUI). Postoperative outcomes were: persistent or recurrent stress incontinence rate (PoRSUI), surgical failure (SF) (i.e. need of second surgery for PoRSUI), subjective cure (SC), subjective improvement (SI), and no pads usage over 24 h (zero pad) rates. SC was defined as a negative response to the question “do you still experience any urinary leakage during activities?” while SI was considered in women who responded yes to the question “are you satisfied with the results?”. Finally we assessed post operative pain and erosion rates in both groups. Chisquare and Wilcoxon rank test were used to compare the outcomes between groups RESULTS: Mean follow up was 66 months (range 12-138). MiniArc and Monarc groups resulted homogeneous in terms of age, DM, BMI and MUI. The rate of PoRSUI in MiniArc and Monarc group was 6% and 13% respectively (p1⁄40.02). SF rate was 9% (n1⁄415) in MiniArc and 13% (n1⁄428) in Monarc patients (p1⁄40.22). SC, SI and no pads usage were 87%, 86%, 90% and 89%, 88%, 91% in MiniArc and Monarc respectively (all p>0.05), while post-operative pain and erosion rate were significantly higher in Monarc patients (14% vs 7% and 6% vs 0.6% respectively, all p<0.01) CONCLUSIONS: This study confirms the similar performance of both slings in terms of post-operative outcomes, with difference in erosion and pain rates, in a large cohort of patients with a longer follow up. Our results highlight, once again, the optimal outcomes of MiniArc not only in the short term but also with a mid-term follow-up

Management of the large upper eyelid defects with cutler-beard flap.

Background. To assess Cutler-Beard procedure results in patients after wide excision of malignant eyelid tumours. Materials and Methods. The records of two women and two men (four patients) referred to our clinic with eyelid mass complaints and malign eyelid tumour diagnosis according to the histopathological examination were examined retrospectively. Results. The patients were 60–73 years old and their average age was 66 ± 11.10. The follow-up period of the cases was 16 (6–25) months. Total excisional biopsy was applied to all patients and then Cutler-Beard full thickness lid reconstruction was done because of the wide localization of the tumour. The patients' diagnoses were consistent with basal cell carcinoma, sebaceous gland carcinoma, eyelid lymphoma, and squamous cell carcinoma. The patients' eyelids were separated from each other 1 month postoperatively with a second operation. Superior eyelid entropium and blepharochalasis were seen in one patient during followup. Conclusions. Cutler-Beard flap is a successful procedure for superior eyelid tumours accompanied by wide tissue loss. The long-time closure of the eyelids and the need for secondary surgery are the major disadvantages of this procedure. Our experience with this procedure will reveal better results with large case series.

An Overview of Various Biomimetic Scaffolds: Challenges and Applications in Tissue Engineering

In current year tissue damage, repair and regeneration has become a very serious clinical problem which accounts for billions of health issues all over the world every year. Many tissue repair substitute and techniques are now available although it is having many drawback; these disadvantages give a good reason for the continued research for more acceptable tissue engineered substitutes. Research that are presently going on to improve the design strategies to overcome the surgical outcomeinvolves the development of biopolymers and synthetic polymers as primary scaffold or luminal fillers as secondary scaffold with the tailored mechanical, physical and chemical properties. Biodegradable scaffolds for regenerated tissue is preferred since no foreign body will be left in the host hence there is no need of second surgery so it involves less complications. The purpose of the review article is to discuss about the various tissue engineering researches taking place around the globe, recent developments, and different biomaterials used for it and applications of tissue engineering. The improvement and validation ofmodalities which are capable of spontaneous regeneration would be valuable to properly grade injuries and rapidly identify cases which require surgical intervention with less ambiguity. This review article focuses on different biomaterials used for tissue regeneration or tissue restoration and their methods of fabricationas well as their application in bone, nerve, cartilage, skin tissue engineering.

Reconstruction of a columellar defect with a nasolabial island flap.

Columellar skin defects may be caused by excision of cutaneous malignancy, trauma, or tissue necrosis associated with surgery. Although columellar skin necrosis rarely occurs following rhinoplasty, this condition might be more common when using an external approach than a closed approach. Columellar skin incision performed with exaggerated tip augmentation may cause columellar necrosis. The nasolabial island flap, used unilaterally to cover columellar skin defects, is used for a single-stage reconstruction procedure and is generally not associated with the need for secondary surgeries. This technique is well suited for repairing columellar skin defects. We experienced a patient with columellar skin necrosis occurring after rhinoplasty which was reconstructed using a unilateral single-stage nasolabial island flap.

Olecranon Osteotomy Fixation Using a Novel Device

A posterior approach to the elbow utilizing an olecranon osteotomy has been shown to provide excellent visualization of the distal humerus articular surface. However, many bony stabilization and fixation methods for the olecranon osteotomy are usually prominent, frequently symptomatic, and often require a second operation for removal. This paper evaluates the use of an innovative device, the olecranon sled, in fixation of olecranon osteotomies for exposure of intra-articular distal humerus fractures and provides follow-up results. A retrospective review of all patients with intra-articular distal humerus fracture treated through an olecranon osteotomy approach and fixed with an olecranon sled, between September 2008 and December 2011 was conducted. Charts and radiographs were reviewed to determine olecranon union or nonunion, presence of symptomatic hardware, and need for secondary surgery to remove symptomatic olecranon fixation. Fourteen patients were included in the study. Average clinical follow-up was 33.5 weeks (range, 6 to 118 wk). There were no olecranon nonunions. One patient underwent additional surgery for symptomatic hardware removal (7.1%). Two additional procedures were performed; 1 for revision open reduction and internal fixation of distal humerus fracture nonunion (7.1%) and 1 for release of elbow contracture (7.1%). Although follow-up is limited, the use of this device has been associated with excellent rates of olecranon union with a low rate of symptomatic hardware requiring removal.

The Children’s Hospital of Philadelphia Modification of the Furlow Double-Opposing Z-Palatoplasty

The purpose of this study was to evaluate the long-term outcomes following modified Furlow palatoplasty over a 30-year experience at a single institution. A retrospective review was performed of all nonsyndromic patients undergoing primary modified Furlow palatoplasty at The Children's Hospital of Philadelphia between 1980 and 2011. Surgical success was evaluated by the rate of postoperative oronasal fistula, speech outcomes assessed at a minimum of age 5 years, and the need for secondary surgery for velopharyngeal dysfunction. Results were analyzed by surgeon, Veau cleft type, age at repair, and over time. Eight hundred sixty-nine patients who underwent modified Furlow repair were included in this study. The mean age at palatoplasty was 1.1 years, and the mean length of follow-up was 6.7 years. Repairs were performed by 11 surgeons, with 44.3 percent performed by a single surgeon. The overall oronasal fistula rate was 5.2 percent, and this improved significantly over the 30-year period (p = 0.003). Speech results at age 5 or older were available for 559 patients. Of these 559 patients, 72.4 percent had a competent velopharyngeal mechanism, and 21.5 percent had a borderline mechanism consistent with socially acceptable speech. Secondary pharyngeal surgery was indicated in 8.1 percent of patients. Speech results were stable (p = 0.10), and rates of secondary surgery for velopharyngeal dysfunction declined significantly over the study period (p = 0.005). The authors' 30-year experience with the modified Furlow palatoplasty shows stable speech results, decreasing rates of secondary surgery, and an acceptable rate of postoperative oronasal fistula.

Does the type of cleft palate contribute to the need for secondary surgery? A national perspective

To determine whether the type of cleft palate is associated with a need for secondary surgery (oronasal fistula repair, speech surgery) after primary cleft palate repair. Retrospective analysis of a national pediatric database (2009 Kids' Inpatient Database). We identified two distinct cohorts of children who underwent primary and secondary (revision) cleft palate repairs, respectively, from a national, pediatric database (2009 Kids' Inpatient Database). Revision ratios for each cleft palate diagnosis were calculated to identify diagnoses with higher rates of revision. Revision ratio was calculated by dividing the relative frequency of each diagnosis in the secondary repair cohort by the corresponding relative frequency in the primary repair cohort. In 2009, there were 1942 cases of primary cleft palate repair in the 44 states participating in the KID's inpatient database. Fifty-two percent (n=1018) were male. The average age at the time of surgery was 13.36 months. In the same year secondary cleft palate procedures were performed on 724 different patients, 54% (n=388) were males. The average age for secondary procedures was 59 months. Cleft lip and palate diagnoses had higher revision rate ratios (1.92) compared to cleft palate only (0.54) P <0.05. Children with an initial diagnosis of cleft lip and palate, which is more severe than cleft palate only, have comparatively higher rates of secondary cleft palate procedures than children with cleft palate only. N/A.

Gluteal Lift with Subfascial Implants

Gluteal enhancement surgery includes buttock implants, gluteal flaps, lipografting, and gluteal lifts. However, no information is available on the outcomes achievable using the gluteal lift combined with subfascial gluteal implants. A retrospective study was performed to analyze the outcomes of gluteal lift combined with subfascial gluteal implants performed during a 7-year period by a single surgeon at a single institution. During the study period, 114 patients (228 implants) ages 27-68 years (mean 47 years) were found. The follow-up period was 1-7 years (mean 4.5 years). The findings showed seroma in 11.4 % of the patients, hematoma in 5.26 %, minor wound dehiscence in 19.29 %, major wound dehiscence in 1.75 %, minor infection in 1.75 %, implant exposure in 0 %, capsular contracture Becker 3 and 4 in 3.5 %, implant rupture in 0 %, implant malposition in 5.25 %, long-term numbness of the buttock in 0 %, palpability of the implant in 0 %, implant rippling in 0 %, implant rupture in 0 %, wide scars in 41.2 %, need for secondary surgery in 26.31 %, and dissatisfaction with the final volume in 10.52 %. A patient satisfaction rate of 9.6 in 10 was found. The study showed that the gluteal lift combined with gluteal implants placed in the subfascial pocket provided good long-lasting results with an acceptable rate of complications, very high patient satisfaction, and easily concealed scars. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients

Background:The treatment options for displaced femoral neck fracture in elderly are screw fixation, hemiarthroplasty and total hip arthroplasty based primarily on age of the patient. The issues in screw fixation are ideal patient selection, optimal number of screws, optimal screw configuration and positioning inside the head and neck of femur. The problems of screw fixation may be loss of fixation, joint penetration, avascular necrosis of femoral head, nonunion, prolonged rehabilitation period and the need for second surgery in failed cases. We hereby present results of a modified screw fixation technique in femoral neck fractures in patients ≥50 years of age.Materials and Methods:Patients ≥50 years of age (range 50-73 years) who sustained displaced femoral neck fracture and fulfilled the inclusion criteria were enrolled in this prospective study. They were treated with closed reduction under image intensifier control and cannulated cancellous screw fixation. Accurate anatomical reduction was not aimed and a cross sectional contact area of >75% without varus was accepted as good reduction. Four screws were positioned in four quadrants of femoral head and neck, as parallel and as peripheral as possible. Radiological and functional results were evaluated periodically. Sixty four patients who could complete a minimum followup of two years were analyzed.Results:Radiologically, all fractures healed after mean duration of 10 weeks (range 8-12 weeks). There was no avascular necrosis. Nonanatomical healing was observed in 45 cases (70%). All patients except one had excellent functional outcome and could do cross-legged sitting and squatting. Chondrolysis with progressive head resorption was seen in one case, which was converted to total hip arthroplasty.Conclusion:Closed reduction and cannulated cancellous screw fixation gives satisfactory functional results in large group of elderly patients. The four quadrant parallel peripheral (FQPP) screw fixation technique gives good stability, allows controlled collapse, avoids fixation failure and achieves predictable bone healing in displaced femoral neck fracture in patients ≥50 years of age.

Single-dose methotrexate injection for treatment of ectopic pregnancy in women with relatively low levels of human chorionic gonadotropin

ObjectiveTo evaluate potential risk factors at admission for failed single-dose methotrexate injection in women with ectopic pregnancy. MethodsFile review of a tertiary medical center in Israel yielded 102 consecutive patients with ectopic pregnancy initially treated with single-dose methotrexate. Overall successful treatment was defined as normalization of human chorionic gonadotropin (hCG) levels after the first or second injection. ResultsThe mean pretreatment hCG level for the whole cohort was 2350±2955mIU/mL (median, 1187mIU/mL; 90th percentile, 5000mIU/mL). Resolution of ectopic pregnancy was achieved after a single injection in 76/102 (74.5%) women and after a second dose in 16/21 (76.2%) women. The remaining 10 (9.8%) patients were treated surgically after the first (5/76) or the second (5/26) dose. The overall success rate for methotrexate treatment was 90.2%. On multivariate stepwise logistic analysis, fetal cardiac activity was an independent predictor of a failed first methotrexate injection, and presence of a yolk sac and mass size were independent predictors of overall methotrexate failure and need for secondary surgery. ConclusionIn patients with ectopic pregnancy and relatively low levels of serum hCG, the most important predictors of overall failure of methotrexate injection were the presence of a yolk sac and mass size.

Evaluation of Biomaterials for Bladder Augmentation using Cystometric Analyses in Various Rodent Models

Renal function and continence of urine are critically dependent on the proper function of the urinary bladder, which stores urine at low pressure and expels it with a precisely orchestrated contraction. A number of congenital and acquired urological anomalies including posterior urethral valves, benign prostatic hyperplasia, and neurogenic bladder secondary to spina bifida/spinal cord injury can result in pathologic tissue remodeling leading to impaired compliance and reduced capacity1. Functional or anatomical obstruction of the urinary tract is frequently associated with these conditions, and can lead to urinary incontinence and kidney damage from increased storage and voiding pressures2. Surgical implantation of gastrointestinal segments to expand organ capacity and reduce intravesical pressures represents the primary surgical treatment option for these disorders when medical management fails3. However, this approach is hampered by the limitation of available donor tissue, and is associated with significant complications including chronic urinary tract infection, metabolic perturbation, urinary stone formation, and secondary malignancy4,5. Current research in bladder tissue engineering is heavily focused on identifying biomaterial configurations which can support regeneration of tissues at defect sites. Conventional 3-D scaffolds derived from natural and synthetic polymers such as small intestinal submucosa and poly-glycolic acid have shown some short-term success in supporting urothelial and smooth muscle regeneration as well as facilitating increased organ storage capacity in both animal models and in the clinic6,7. However, deficiencies in scaffold mechanical integrity and biocompatibility often result in deleterious fibrosis8, graft contracture9, and calcification10, thus increasing the risk of implant failure and need for secondary surgical procedures. In addition, restoration of normal voiding characteristics utilizing standard biomaterial constructs for augmentation cystoplasty has yet to be achieved, and therefore research and development of novel matrices which can fulfill this role is needed. In order to successfully develop and evaluate optimal biomaterials for clinical bladder augmentation, efficacy research must first be performed in standardized animal models using detailed surgical methods and functional outcome assessments. We have previously reported the use of a bladder augmentation model in mice to determine the potential of silk fibroin-based scaffolds to mediate tissue regeneration and functional voiding characteristics.11,12 Cystometric analyses of this model have shown that variations in structural and mechanical implant properties can influence the resulting urodynamic features of the tissue engineered bladders11,12. Positive correlations between the degree of matrix-mediated tissue regeneration determined histologically and functional compliance and capacity evaluated by cystometry were demonstrated in this model11,12. These results therefore suggest that functional evaluations of biomaterial configurations in rodent bladder augmentation systems may be a useful format for assessing scaffold properties and establishing in vivo feasibility prior to large animal studies and clinical deployment. In the current study, we will present various surgical stages of bladder augmentation in both mice and rats using silk scaffolds and demonstrate techniques for awake and anesthetized cystometry.

Evaluation of Biomaterials for Bladder Augmentation using Cystometric Analyses in Various Rodent Models

Renal function and continence of urine are critically dependent on the proper function of the urinary bladder, which stores urine at low pressure and expels it with a precisely orchestrated contraction. A number of congenital and acquired urological anomalies including posterior urethral valves, benign prostatic hyperplasia, and neurogenic bladder secondary to spina bifida/spinal cord injury can result in pathologic tissue remodeling leading to impaired compliance and reduced capacity1. Functional or anatomical obstruction of the urinary tract is frequently associated with these conditions, and can lead to urinary incontinence and kidney damage from increased storage and voiding pressures2. Surgical implantation of gastrointestinal segments to expand organ capacity and reduce intravesical pressures represents the primary surgical treatment option for these disorders when medical management fails3. However, this approach is hampered by the limitation of available donor tissue, and is associated with significant complications including chronic urinary tract infection, metabolic perturbation, urinary stone formation, and secondary malignancy4,5.Current research in bladder tissue engineering is heavily focused on identifying biomaterial configurations which can support regeneration of tissues at defect sites. Conventional 3-D scaffolds derived from natural and synthetic polymers such as small intestinal submucosa and poly-glycolic acid have shown some short-term success in supporting urothelial and smooth muscle regeneration as well as facilitating increased organ storage capacity in both animal models and in the clinic6,7. However, deficiencies in scaffold mechanical integrity and biocompatibility often result in deleterious fibrosis8, graft contracture9, and calcification10, thus increasing the risk of implant failure and need for secondary surgical procedures. In addition, restoration of normal voiding characteristics utilizing standard biomaterial constructs for augmentation cystoplasty has yet to be achieved, and therefore research and development of novel matrices which can fulfill this role is needed.In order to successfully develop and evaluate optimal biomaterials for clinical bladder augmentation, efficacy research must first be performed in standardized animal models using detailed surgical methods and functional outcome assessments. We have previously reported the use of a bladder augmentation model in mice to determine the potential of silk fibroin-based scaffolds to mediate tissue regeneration and functional voiding characteristics.11,12 Cystometric analyses of this model have shown that variations in structural and mechanical implant properties can influence the resulting urodynamic features of the tissue engineered bladders11,12. Positive correlations between the degree of matrix-mediated tissue regeneration determined histologically and functional compliance and capacity evaluated by cystometry were demonstrated in this model11,12. These results therefore suggest that functional evaluations of biomaterial configurations in rodent bladder augmentation systems may be a useful format for assessing scaffold properties and establishing in vivo feasibility prior to large animal studies and clinical deployment. In the current study, we will present various surgical stages of bladder augmentation in both mice and rats using silk scaffolds and demonstrate techniques for awake and anesthetized cystometry.

Duplex system ureterocele in infants: Should we reconsider the indications for secondary surgery after endoscopic puncture or partial nephrectomy?

ObjectiveWe assessed outcomes and need for secondary surgery after primary trans-urethral puncture (TUP) or upper pole partial nephrectomy (UPPN) in duplex system ureterocele (DSU) patients undergoing management that disregards vesicoureteral reflux and upper pole function. Subjects and methodsBetween 2003 and 2010, 41 DSU <1 year underwent TUP (n = 32) or UPPN (n = 9). Postoperatively, additional investigations and surgery were limited to cases showing persistent hydroureteronephrosis or developing recurrent febrile urinary tract infections (UTI). Outcome parameters included upper tract decompression, UTI after decompression, continence status, and secondary surgery rate. Preoperative variables were compared between patients who required secondary surgery and those who did not. ResultsAdditional surgery was required for persistent hydroureteronephrosis in 20% of cases after TUP vs none after UPPN. After decompression, 4 female patients developed recurrent febrile UTI and 2 required additional surgeries. No case suffered from urinary incontinence. After a median (range) follow-up of 46 (17–102) months, TUP or UPPN was the only surgery required in 32 (78%) cases irrespective of preoperative variables. ConclusionUPPN seems more effective than TUP in decompressing severely dilated urinary tracts. After decompression, disregarding VUR status and upper pole function, TUP or UPPN is the only procedure required in 80% of DSU cases, regardless of preoperative variables.

Failure of Percutaneous Remodeling of the Ligamentum Flavum and Lamina for Neurogenic Claudication

Percutaneous remodeling of the ligamentum flavum and lamina (PRLL), commercially known as minimally invasive lumbar decompression (mild technique), relies on fluoroscopy and epidural contrast to direct surgical instruments via a 6-mm cannula. To evaluate the safety and efficacy of PRLL and present, to our knowledge, the first reported imaging findings after PRLL. We performed a prospective study of PRLL for neurogenic claudication. Primary outcomes were Oswestry Disability Index, Short-Form 12 version 2.0 health survey, and visual analog scale for pain at 26 weeks. Analgesic use was also assessed. Postoperative magnetic resonance imaging was performed at 12 weeks. Long-term failure, defined as the poststudy need for secondary surgery, was assessed up to 18 months. Ten subjects with an average age of 64 years (range, 41-81 years) were treated between September 2008 and January 2009. There were no major adverse events. Mean postoperative visual analog scale score remained significantly reduced throughout 26 weeks (P =.015, analysis of variance). Mean postoperative Oswestry Disability Index was also improved by 1 week and remained significant throughout 26 weeks (P = .024; analysis of variance). However, there was a trend toward increased reliance on narcotic type medications postoperatively. Imaging studies did not show significant decompression of the spinal canal in any patient. In the poststudy period, recurrent claudication requiring laminectomy developed in 6 patients (60%). Throughout 26 weeks, pain and disability scores were decreased; however, PRLL did not improve the degree of stenosis on imaging studies. Although PRLL appears to be safe in this small cohort of patients, poststudy outcomes indicate that the failure rate is unacceptably high.

Evaluation of Experienced Surgeons’ Decisions Regarding the Need for Secondary Surgery in Developmental Dysplasia of the Hip

We aimed to evaluate experienced surgeons' decisions regarding the need for secondary surgery in developmental dysplasia of the hip (DDH) at 5 to 7 years of age. We selected 21 hips from 17 patients who had mid-term and skeletally mature radiographs and who had neither had complications nor secondary surgery until skeletal maturity after having an initial soft tissue surgery for DDH before the age of 18 months. Twenty experienced orthopaedic surgeons evaluated the mid-term follow-up radiographs of these hips in terms of their need for secondary surgery. On the basis of management grading of the observers at mid-term follow-up, the risk of unnecessary surgical management was 12% in hips that would eventually be normal at skeletal maturity. The risk of not performing needed surgery was 40% in hips that would eventually become dysplastic at skeletal maturity. Experience of the surgeons in terms of years had no significant effect on the management decisions. The center-edge angle, the acetabular index angle (AIA), percentage of femoral head coverage, Shenton line, and the acetabular angle of Sharp were the 5 most commonly used radiographic parameters at mid-term follow-up to assess whether a secondary surgery would be needed. Center-edge angle, AIA, femoral head coverage, and Shenton line correlated, whereas the acetabular angle did not significantly correlate with surgeons' quantitative management decisions on the basis of mid-term radiographs. Experienced surgeons are more likely to opt for nonoperative management in hips that show no ischemic changes or instability at 5 to 7 years of age even in the presence of slightly abnormal radiographic measurements. AIA is considered the best radiographic parameter for making decisions regarding the need for secondary surgery in DDH at 5 to 7 years of age. Level II prognostic study.

Total Hip Replacement Versus Open Reduction and Internal Fixation of Displaced Femoral Neck Fractures

Clinical trials with short and intermediate-term follow-up have demonstrated superior results for total hip replacement as compared with internal fixation with regard to hip function and the need for secondary surgery in elderly patients with a displaced intracapsular femoral neck fracture. The aim of the present study was to compare the results of total hip replacement with those of internal fixation over a long-term follow-up period of seventeen years. We enrolled 100 patients who had sustained a femoral neck fracture in a single-center, randomized controlled trial;all patients had had a healthy hip before the injury. The study group included seventy-nine women and twenty-one men with a mean age of seventy-eight years (range, sixty-five to ninety years). The subjects were randomly assigned to either total hip replacement (the arthroplasty group) (n = 43) or internal fixation (the control group) (n = 57). The primary end point was hip function, evaluated with use of the Harris hip score. Secondary end points included mortality, reoperations, gait speed, and activities of daily life. Follow-up evaluations were performed at three months and at one, two, four, eleven, and seventeen years. The Harris hip score was higher in the total hip arthroplasty group, with a mean difference of 14.7 points (95%confidence interval, 9.2 to 20.1 points; p < 0.001 [analysis of covariance]) during the study period. We found no difference in mortality between the two groups. Four patients (9%) in the total hip replacement group and twenty-two patients (39%) in the internal fixation group had undergone a major reoperation (relative risk, 0.24; 95% confidence interval, 0.09 to 0.64).The overall reoperation rate was 23% (ten of forty-three) in the total hip replacement group and 53% (thirty of fifty-seven) in the internal fixation group (relative risk, 0.44; 95% confidence interval, 0.24 to 0.80). The results related to gait speed and activities of daily living favored the arthroplasty group during the first year. Over a period of seventeen years in a group of healthy, elderly patients with a displaced femoral neck fracture, total hip replacement provided better hip function and significantly fewer reoperations compared with internal fixation without increasing mortality. Therapeutic Level I.

SECONDARY SURGERIES AFTER DIGITAL REPLANTATIONS: A CASE SERIES

We evaluated the injuries, survival rats, and secondary surgeries of patients who had undergone finger replantation or revascularization between October 2005 and July 2010. The 70 digits came from 43 patients (average age, 46 years; range, 19 to 78 years; 37 men). Overall replantation survival rate was 94%; 93% (27/29) for complete amputations and 95% (39/41) for near-amputations. In all, 39 digits from 21 patients required 48 secondary surgeries; skin grafts, tenolysis, joint fusion, bone graft, osteotomy, and web plasty. The more proximal or more severe the injuries, the higher the need of secondary surgeries. The most common surgery soon after replantation was skin coverage; the most common after two months was tendon surgery. Primary repair must be adequate to restore the function and appearance of amputated digits; however, the possible need for secondary surgeries must be kept in mind to avoid restricting the options for secondary procedures.

Management of slipped capital femoral epiphysis: Results of a survey of the members of the European Paediatric Orthopaedic Society

AimTo determine current practice recommendations for the treatment of slipped capital femoral epiphysis (SCFE) among members of the European Paediatric Orthopaedic Society (EPOS).Materials and methodsA questionnaire with 4 case vignettes of a 12-year-old boy presenting with a stable and unstable SCFE. Each, stable and unstable slips, was of mild (20° epiphyseal-shaft angle) and of severe (60° epiphyseal-shaft angle) degree was sent to all members of EPOS in 2009 in order to ascertain their views on the best management of SCFE. Specifically, respondents were asked about the role of reduction, methods of fixation, prophylactic fixation of the non-affected hip, postoperative management and their view on the anticipated need for secondary surgery.ResultsThe response rate was 25% (72/287). The participating surgeons’ average workload was 76% in paediatric orthopaedics, with mean 16 years of experience. Surgeons were most consistent in their advice for stable slips, where around 90% of the respondents did not recommend a reduction of the slip regardless of severity of slip. Seventy per cent of the respondents recommended the use of only one screw for fixation of a stable slip and for mild unstable slips. For severe unstable slips, 46% of surgeons recommended reduction only by positioning of the hip on the fracture table, 35% by manipulation and 11% advised open reduction. Responders were less consistent in their advice on the anticipated need for secondary osteotomies (in mild slips about 40% and about 60% in severe slips would advise an osteotomy) and on treatment of the contralateral hip (with 32% of surgeons recommending prophylactic fixation of the contralateral hip).ConclusionWithin members of EPOS, there is controversy on several aspects of the management of SCFE particularly on aspects of the treatment of unstable SCFE.SignificanceMembers of EPOS predominantly use traditional means of treatment for patients with SCFE. In contrast, the more modern treatment concepts, such as open reduction via surgical dislocation, are rarely used.

Diagnostic performance of one‐step nucleic acid amplification for intraoperative sentinel node metastasis detection in breast cancer patients

The purpose of this prospective multicenter study was to assess one-step nucleic acid amplification (OSNA) for intraoperative sentinel lymph node (SLN) metastasis detection in breast cancer patients, using final histology as the reference standard. OSNA results were also compared to intraoperative histology SLN evaluation and to standard clinicopathological risk markers. For this study, fresh SLNs were cut in four blocks, and alternate blocks were used for OSNA and histology. CK19 mRNA copy number was categorized as strongly positive, positive or negative. Positive histology was defined as presence of macrometastasis or micrometastasis. When discrepancies occurred, the entire SLNs were subjected to histological studies and the node lysates to additional molecular studies. Five hundred three SLN samples from 233 patients were studied. Mean time to evaluate two SLNs was 40 min. Sensitivity per patient was 91.4% (95% CI, 76.9-98.2%), specificity 93.3% (95% CI, 88.6-96.6%), positive likelihood ratio 13.7 and negative likelihood ratio 0.1. Sensitivity was 63.6% for frozen sections and 47.1% for touch imprint cytology. Both methods were 100% specific. Positive histology and positive OSNA were significantly associated with highest clinical stage, N1 status and vascular invasion; and OSNA results correlated with HER2/neu status and benefited patients with negative histology. These findings show that OSNA assay can allow detection of SLN metastasis in breast cancer patients intraoperatively with a good sensitivity, thus minimizing the need for second surgeries for axillary lymph node detection.

Operative Correction of Arch Collapse with Forefoot Deformity: A Retrospective Analysis of Outcomes

There are many forefoot deformities, including hallux valgus, forefoot overload, and hammertoe that are treated as unrelated problems with multiple different techniques. Currently, there has been renewed interest in the role of a gastrocnemius contracture on foot deformities. Our objective was to review a specific surgical treatment plan for forefoot deformities classified by us as Type 2 arch collapse and evaluate the outcomes. We retrospectively reviewed the charts of 374 patients who underwent foot procedures to treat deformity classified as a Type 2 arch collapse. Data was collected regarding complications and need for secondary surgery. A phone survey was performed to assess patient satisfaction, pain level, and Foot Function Index (FFI) scores. Of the 374 patients (412 feet), there was a 96% (357 of 371 feet) union rate at the first tarsometatarsal joint and 98% (227 of 232 feet) union rate at metatarsal shortening osteotomy sites. Recurrence of hallux valgus was 2.7% (7 of 256 feet), while hallux varus occurred in 1.6% (4 of 256 feet). There were 292 patients (78%) available for phone interview. Of those patients, 88% were satisfied with the results of the procedure. The subset of procedures relating to the highest mean FFI was hammertoe correction (22.2) and the highest mean pain score was related to metatarsal shortening osteotomy (2.6). Utilizing the arch collapse model, operative treatment of forefoot deformities with a combination of procedures including gastrocnemius recession, first TMT fusion, modified McBride, hammertoe correction, and metatarsal shortening osteotomy can produce good satisfaction rates with low complication rates.