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Revision Surgery (revision + surgery)
Selected AbstractsIncreased metal allergy in patients with failed metal-on-metal hip arthroplasty and peri-implant T-lymphocytic inflammationALLERGY, Issue 8 2009P. Thomas Background:, In 16 patients with revised metal-on-metal arthroplasty and peri-implant lymphocytic inflammation, we verified the role of metal hypersensitivity by patch testing (PT) and lymphocyte transformation test (LTT). Methods:, In the 16 patients with lymphocyte dominated periprosthetic inflammation, allergy history was obtained by a questionnaire, specific serum IgE to aeroallergens was measured to assess atopy, PT to standard and metal series was performed and metal sensitivity was further assessed by LTT using blood mononuclear cells. Results:, Revision surgery was performed because of pain (8/16), osteolysis (4/16), dislocation (3/16) and loosening of the stem (1/16). Histological examination showed perivascular infiltrates of T lymphocytes, high endothelial venules, fibrin exudation and accumulation of macrophages with drop-like inclusions. Five patients had a history of cutaneous metal allergy and atopy was found in 25% of the patients. In 13/16 patients (81%), systemic metal sensitivity was found based on PT and/or LTT. Patch test reactions were seen in 11/16 patients (69%; partly multiple reactions/patient): 7/16 to Cobalt (Co), 7/16 to Chromium (Cr), 4/16 to Nickel (Ni), and one each to Molybdenum (Mo) and Manganese (Mn). Ten of 16 patients (62%) showed enhanced LTT reactivity to metals: 7/16 to Ni, 7/16 to Co, 5/16 to Cr, 5/16 to Mo and 4/16 to Mn. Conclusions:, The lymphocyte dominated peri-implant inflammation may well reflect an allergic hyper-reactivity in these patients, given the high rate of concomitantly found metal allergy. Despite the overall incidence of metal implant allergy being low, allergic reactions should be included as differential diagnosis in failed metal-on-metal arthroplasty. [source] The Glass Half Empty or Half Full,How Effective Are Long-Term Intrathecal Opioids in Post-herpetic Neuralgia?NEUROMODULATION, Issue 3 2009A Case Series, Review of the Literature ABSTRACT Objectives.,Post-herpetic neuralgia (PHN) is a painful complication of herpes zoster infection and a common cause of chronic severe pain in elderly and/or debilitated patients. Although a wide range of treatments have been tried, a substantial number of patients continue to experience pain which remains refractory to all therapies. Increasingly, studies have demonstrated that oral opioids can have a beneficial effect on neuropathic pain. However, to date, few studies have examined the potential benefit(s) of chronic intrathecal opioids in the treatment of PHN. Methods.,Long-term outcome results of four PHN patients who had a successful intrathecal opioid trial and underwent implantation of an intrathecal opioid pump were examined. Data were analyzed using univariate analysis of variance. Results.,Duration of continuous intrathecal opioid therapy ranged from five to 50 months and mean pain reduction was 41% (range 27,50%) as measured by a verbal pain score (0,100), with the greatest benefit noticed earlier in therapy. Mean 24-hour intrathecal morphine dose was 2.29 mg (range 0.78,3.94 mg). Intrathecal therapy was discontinued in two patients because of opioid side-effects, depression, and loss of efficacy. Revision surgery was required in two cases. Patients most commonly reported improvement in the deep component of their pain, next allodynia, and less so superficial lancinating pain. Conclusions.,In conclusion, while a complex therapy, long-term use of intrathecal opioids is well tolerated, doses are titratable, administration is safe, and may help relieve severe short- and long-term neuropathic pain in selected PHN patients. Whether the addition of newer investigational intrathecal agents could improve these results is yet to be determined. [source] Hybrid Assembly of Metal Head and Femoral Stem From Different Manufacturers During Isolated Acetabular RevisionARTIFICIAL ORGANS, Issue 8 2010Cheng-Fong Chen Abstract During revision of a failed acetabular component with well-fixed antiquated femoral stem, the same variant of metal head is usually not available in the inventory production. We gathered the stems retrieved from revision surgeries and tried to reassemble with the commercially available femoral heads. This study reports the results of suitable hybrid assembly of metal heads with the most common antiquated femoral stems from different manufacturers. Three hybrid combinations were determined and pull-off strengths of these hybrid combinations were performed through in vitro studies to evaluate the quality of the taper locks. [source] Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablationHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 4 2008FRCSC, Tareck Ayad MD Abstract Background. The purpose of this study is to review our experience with the use of the facial artery musculo-mucosal (FAMM) flap for floor of mouth (FOM) reconstruction following cancer ablation to assess its reliability, associated complications, and functional results. Methods. This was a retrospective analysis of 61 FAMM flaps performed for FOM reconstruction from 1997 to 2006. Results. No total flap loss was observed. Fifteen cases of partial flap necrosis occurred, with 2 of them requiring revision surgery. We encountered 8 other complications, with 4 of them requiring revision surgery for an overall rate of revision surgery of 10% (6/61). The majority of patients resumed to a regular diet (85%), and speech was considered as functional and/or understandable by the surgeon in 93% of the patients. Dental restoration was successful for 83% (24/29) of the patients. Conclusion. The FAMM flap is well suited for FOM reconstruction because it is reliable, has few significant complications, and allows preservation of oral function. © 2007 Wiley Periodicals, Inc. Head Neck, 2008 [source] Tunica albuginea urethroplasty for anterior urethral strictures: A urethroscopic analysisINTERNATIONAL JOURNAL OF UROLOGY, Issue 9 2009Raj K Mathur Objective: To assess the efficacy of tunica albuginea urethroplasty (TAU) for anterior urethral strictures. Methods: We assessed 206 patients with anterior urethral strictures who underwent TAU. The procedure involves mobilization of strictured urethra and laying it open with a dorsal slit. Edges of the slit-open urethra are sutured to edges of the urethral groove with a silicon catheter in situ. Thus in neourethra, the roof is formed by tunica albuginea of the urethral groove. Results were assessed at 6, 12, 24 and 36 months by comparative analysis of patient satisfaction along with retrograde urethrogram, urethrosonogram, uroflowmetry, and were categorized as good, fair and poor. Good and fair results were considered as successful. Thirty patients were taken for postoperative urethroscopic analysis to allow better understanding of both successful and failed cases. Results: Postoperative evaluation at 6 months showed a 96.6% success rate, which decreased to 94.7% at 1 year, 93.2% at 2 years and over 90% at the end of 3 years. The overall failure rate was 9.2%, which required revision surgery. Urethroscopic visualization of the reconstruction site showed wide, patent and distensible neourethra uniformly lined by urothelium over roof formed by tunica albuginea of the corpora cavernosa in successful cases. Failure cases showed diffuse fibrotic narrowing or circumferential scarring. Conclusion: Tunica albuginea is a locally available distensible tissue, sufficient to maintain the patency of the neourethra, without any graft or flap. TAU is easier and useful when patients have unhealthy oral mucosa due to tobacco chewing. [source] Standardized analysis of UHMWPE wear particles from failed total joint arthroplastiesJOURNAL OF BIOMEDICAL MATERIALS RESEARCH, Issue 5 2002Jay D. Mabrey Abstract Periprosthetic tissue obtained at revision surgery from eight total hip replacement cases was hydrolyzed, and polyethylene debris particles were isolated from each case. Individual particles were analyzed by scanning electron microscopy (SEM) and computerized image analysis in accordance with ASTM F1877-98, a standard for quantitative description of wear debris. For comparison, periprosthetic tissues from eight total knee revision and four total shoulder revision cases were processed and analyzed with identical methods. A total of 2599 hip, 4345 knee, and 1200 shoulder particles were analyzed. The morphologies of the isolated polyethylene particles from the total hip specimens were distinctly different from the total knee and total shoulder particles. The mean equivalent circle diameter (ECD) for hip particles was 0.694 ,m ± 0.005; knee particles measured 1.190 ,m ±0.009; and shoulder particles 1.183 ,m ± 0.017. The ECD was significantly different between hip particles and those from the shoulder and knee. The mean aspect ratio (AR) for the hip particles was 1.626 ± 0.015, compared to the knee particles at 1.935 ± 0.015 and shoulder particles at 2.082 ± 0.033. The AR was statistically different among all three groups. Other descriptors from the ASTM standard, elongation (E), form factor (FF), and roundness (R) were all significantly different among the three groups of joints. This study demonstrates the utility of ASTM F1877-98 in differentiating wear debris particles from different sources. © 2002 Wiley Periodicals, Inc. J Biomed Mater Res (Appl Biomater) 63: 475,483, 2002 [source] Quantitative evaluation of the prosthetic head damage induced by microscopic third-body particles in total hip replacementJOURNAL OF BIOMEDICAL MATERIALS RESEARCH, Issue 4 2001Manuela Teresa Raimondi Abstract The increase of the femoral head roughness in artificial hip joints is strongly influenced by the presence of abrasive particulate entrapped between the articulating surfaces. The aim of the present study is to evaluate the dependence of such damage on the geometry of the particles entrapped in the joint, with reference to the UHMWPE/chrome-cobalt coupling. Five chrome-cobalt femoral heads and their coupled UHMWPE acetabular cups, retrieved at revision surgery after a short period of in situ functioning, have been investigated for the occurrence of third-body damage. This was found on all the prosthetic heads, where the peak-to-valley height of the scratches, as derived from profilometry evaluations, ranged from 0.3,1.3 ,m. The observed damage has been divided into four classes, related to the particle motion while being embedded into the polymer. Two kinds of particle morphology have been studied, spherical and prismatic, with size ranging from 5,50 ,m. In order to provide an estimation of the damage induced by such particles, a finite element model of the third-body interaction was set up. The peak-to-valley height of the impression due to the particle indentation on the chrome-cobalt surface is assumed as an index of the induced damage. The calculated values range from 0.1,0.5 ,m for spherical particles of size ranging from 10,40 ,m. In the case of prismatic particles, the peak-to-valley height can reach 1.3 ,m and depends both on the size and width of the particle's free corner, indenting the chrome-cobalt. As an example, a sharp-edged particle of size 30 ,m can induce on the chrome-cobalt an impression with peak-to-valley height of 0.75 ,m, when embedded into the polyethylene with a free edge of 5 ,m facing the metallic surface. Negligible damage is induced, if a free edge of 7.5 ,m is indenting the counterface. Our findings offer new support to the hypothesis that microscopic third-body particles are capable of causing increased roughening of the femoral head and provide a quantitative evaluation of the phenomenon. © 2001 John Wiley & Sons, Inc. J Biomed Mater Res (Appl Biomater) 58: 436,448, 2001 [source] High-Turnover Periprosthetic Bone Remodeling and Immature Bone Formation Around Loose Cemented Total Hip JointsJOURNAL OF BONE AND MINERAL RESEARCH, Issue 1 2001Michiaki Takagi Abstract Aseptic loosening and periprosthetic osteolysis are the major problems awaiting solution in total hip surgery. The clinical investigation focused on the analysis of periprosthetic bone remodeling to clarify one important key event in the cascade of periprosthetic connective tissue weakening and osteolysis around loose artificial hip joints. Twelve acetabular bone samples adjacent to granulomatous synovial-like membrane of loose hip prosthesis were retrieved at revision surgery and processed for Villanueva bone staining for morphological observation and bone histomorphometric analysis. Eight well-fixed bony samples were used as control. Although osteoclastic surface and eroded surface by osteoclasts were evident in the periprosthetic bone from loose hip joints (p = 0.003 and p = 0.027), increased osteoid/low-mineralized bone matrix (p < 0.001) and osteoid width (p < 0.001) also were significant findings in structural analysis. In addition, not only elevated mineral apposition rate (MAR; p = 0.044) but also increased mineralizing surface (p = 0.044) and bone formation rate (BFR; p = 0.002) in loose periprosthetic bones were shown in dynamic data analysis. These results were confirmed by precise morphological observation by confocal laser scanning microscopy. Active coupling of bone formation and resorption and increased osteocytes with abundant bone canalicular projections were found in combined with the presence of immature bone matrices (osteoid and low-mineralized bone areas) in periprosthetic bones from loose hip joints. These results indicated that active osteoclastic bone resorption and/or defective bone formation are coupled with monocyte/macrophage-mediated foreign body-type granuloma in the synovial-like interface membrane of loose hip joints. Thus, this unique high-turnover periprosthetic bone remodeling with bad bone quality probably is caused by the result of cellular host response combined with inappropriate cyclic mechanical loading. The fragile periprosthetic bone may contribute to hip prosthesis loosening. [source] Major elective joint replacement surgery: socioeconomic variations in surgical risk, postoperative morbidity and length of stayJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 3 2010Jennifer Hollowell PhD Abstract Background, Patient deprivation is associated with greater need for total hip and knee replacement surgery (THR/TKR) and a higher prevalence of risk factors for surgical complications. Our aim was to examine associations between deprivation and aspects of the inpatient episode for patients undergoing these procedures. Methods, We analysed socioeconomic variations in preoperative surgical risk, postoperative morbidity and length of stay for 655 patients undergoing elective THR/TKR at a large metropolitan hospital. Surgical risk was assessed using the orthopaedic version of the POSSUM scoring system, postoperative morbidity was assessed using the postoperative morbidity survey, and socioeconomic status was measured using the Index of Multiple Deprivation. We adjusted for age, sex, surgical site and primary vs. revision surgery. Results, We found only a modest, clinically insignificant socioeconomic gradient in preoperative surgical risk and no socioeconomic gradient in postoperative morbidity. There was a strong socioeconomic gradient in length of stay, but only for patients undergoing TKR. This was due to deprived patients being more likely to remain in hospital without morbidity following TKR. Conclusions, Our findings suggest differential selection of healthier patients for surgery. Hospitals serving deprived communities may have excess, unfunded costs because of the increased length of stay of socioeconomically disadvantaged patients. [source] Interface membrane fibroblasts around aseptically loosened endoprostheses express MMP-13JOURNAL OF ORTHOPAEDIC RESEARCH, Issue 2 2008Susanne Wagner Abstract The objective of this article was to assess whether matrix metalloproteinase-13 (MMP-13) is produced by cells of the peri-implant interface tissues and to further characterize these cells. Tissue specimens were collected from the bone,prosthesis interface at the time of revision surgery of clinically loosened hip and knee arthroplasties (n,=,27). Synovial tissues from osteoarthritic patients and young patients with mild joint deformity were used as controls (n,=,6). Tissue samples were fixed in 4% PFA, decalcified with EDTA, and embedded in paraffin. Sections (4 µm) were stained with hematoxylin/eosin and for the osteoclastic marker enzyme tartrate resistant acid phosphatase. Monocytes/macrophages were characterized with a monoclonal antibody against CD68 and mRNAs encoding MMP-13 and ,1 collagen I (COL1A1) were detected by in situ hybridization. Cells expressing transcripts encoding MMP-13 were found in 70% of the interface tissues. These cells colocalized with a cell population expressing COL1A1 mRNA, and were fibroblastic in appearance. MMP-13 expressing cells were found in the close vicinity of osteoclasts and multinuclear giant cells. No signals for transcripts encoding MMP-13 were detected in multinuclear giant cells or in osteoclasts. Control tissues were negative for transcripts encoding MMP-13 mRNA. Fibroblasts of the interface from aseptically loosened endoprostheses selectively express MMP-13. By the expression and the release of MMP-13, these fibroblastic cells may contribute to the local degradation of the extracellular matrix and to bone resorption. © 2007 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:143,152, 2008 [source] Use of volumetric computerized tomography as a primary outcome measure to evaluate drug efficacy in the prevention of peri-prosthetic osteolysis: A 1-year clinical pilot of etanercept vs. placeboJOURNAL OF ORTHOPAEDIC RESEARCH, Issue 6 2003Edward M. Schwarz Although total hip replacement (THR) is amongst the most successful and beneficial medical procedures to date, long-term outcomes continue to suffer from aseptic loosening secondary to peri-prosthetic osteolysis. Extensive research over the last two decades has elucidated a central mechanism for osteolysis in which wear debris generated from the implant stimulates inflammatory cells to promote osteoclastogenesis and bone resorption. The cytokine tumor necrosis factor alpha (TNF,) has been demonstrated to be central to this process and is considered to be a leading target for intervention. Unfortunately, even though FDA approved TNF antagonists are available (etanercept), currently there are no reliable outcome measures that can be used to evaluate the efficacy of a drug to prevent peri-prosthetic osteolysis. To the end of developing an effective outcome measure, we evaluated the progression of lesion size in 20 patients with established peri-acetabular osteolysis (mean = 29.99 cm3, range = 2.9,92.7 cm3) of an uncemented primary THR over 1-year, using a novel volumetric computer tomography (3D-CT) technique. We also evaluated polyethylene wear, urine N-telopeptides and functional assessments (WOMAC, SF-36 and Harris Hip Score) for comparison. At the time of entry into the study baseline CT scans were obtained and the patients were randomized to etanercept (25 mg s.q., twice/week) and placebo in a double-blinded fashion. CT scans, urine and functional assessments were also obtained at 6 and 12 months. No serious adverse drug related events were reported, but one patient had to have revision surgery before completion of the study due to aseptic loosening. No remarkable differences between the groups were observed. However, the study was not powered to see significant drug effects. 3D-CT data from the 19 patients was used to determine the mean increase in lesion size over 48 weeks, which was 3.19 cm3 (p < 0.0013). Analysis of the urine N-telopeptides and functional assessment data failed to identify a significant correlation with wear or osteolysis. In conclusion, volumetric CT was able to measure progression of osteolysis over the course of a year, thus providing a technology that could be used in therapeutic trials. Using the data from this pilot we provide a model power calculation for such a trial. © 2003 Orthopaedic Research Society. Published by Elsevier Science Ltd. All rights reserved. [source] The safety and outcome of joint replacement surgery in liver transplant recipientsLIVER TRANSPLANTATION, Issue 4 2003Josh Levitsky A small group of patients may require total hip arthroplasty, total knee arthroplasty, or other joint replacement surgery after OLT for osteoporotic fractures, osteonecrosis, and osteoarthritis. Although arthroplasty is safe in the general population, its safety in liver transplant recipients is unclear. The aim of the study was to determine the safety and outcome of joint replacement surgery in our liver transplant recipients. A retrospective analysis was performed on all liver transplant recipients who had total joint arthroplasty at a single teaching institution between 1986 and 2002. Data regarding major intraoperative and postoperative complications was obtained from the medical charts and a hospital-based computer system. Of over 1,200 liver transplant recipients, we identified 7 patients who underwent 12 total arthroplasties (8 knee, 3 hip, 1 ankle). Joint replacements were performed electively for osteonecrosis (5 of 12) and osteoarthritis (5 of 12), whereas two hip arthroplasties were performed emergently for fractures. All patients with osteonecrosis or hip fracture had been treated with prolonged corticosteroids. There were no deaths or major complications in the intraoperative and postoperative periods. On long-term follow-up, no patients have had pain, dislocation, or infection in the postsurgical joint. No joint revision surgery has been required. In conclusion, a small number of stable liver transplant recipients at our institution underwent joint replacement surgery without major short-term or long-term complications. Our study suggests that joint replacement surgery may be safely and successfully performed in this population, although larger, randomized, prospective trials are needed to confirm our findings. [source] Transoral atlantoaxial reduction plate internal fixation for the treatment of irreducible atlantoaxial dislocation: a 2- to 4-year follow-upORTHOPAEDIC SURGERY, Issue 2 2010Qing-shui Yin MD Objective:, To evaluate the mid-term outcomes of transoral atlantoaxial reduction plate (TARP) internal fixation for the treatment of irreducible atlantoaxial dislocation. Methods:, From April 2003 to April 2005, 31 patients with irreducible atlantoaxial dislocation were treated with TARP internal fixation. The average age was 37.9 years (range, 15,69 years). The subjective symptoms, objective signs, and neurological function of the patients were assessed. Radiography and magnetic resonance imaging (MRI) were performed and the results analyzed according to the Symon and Lavender clinical standard, Japanese Orthopaedic Association (JOA) score for spinal cord function and imaging standard for spinal cord decompression. Results:, Complete or almost complete anatomical reduction was obtained in all 31 patients. No screw-loosening or atlantoaxial redislocation was found in 29 cases. According to the Symon and Lavender clinical standard, 14 cases had recovered completely, 7 to mild, 6 to moderate, and 4 to severe type by final follow-up, compared to the preoperative classifications of 4 as moderate, 15 as severe, and 12 as extra severe type. The outcome for 26 patients was evaluated as excellent and in 5 as adequate. The average postoperative improvement in spinal cord function was 73.3% and of decompression of the cervical cord 92.6%. The only complication was loosening of screws in two cases with senile osteoporosis. One case underwent TARP revision surgery and the other posterior occipitocervical internal fixation. Both of them were eventually cured. Conclusion:, The TARP operation is a good choice for patients with irreducible atlantoaxial dislocation and has valuable clinical application. [source] To POP or Not: Ossiculoplasty in Congenital Aural Atresia Surgery,THE LARYNGOSCOPE, Issue 8 2008Eric J. Dobratz MD Abstract Objectives/Hypothesis: To examine indications for ossiculoplasty (OP) in aural atresia surgery and to compare audiometric results and surgical revision rates between patients undergoing OP and those undergoing intact native chain reconstruction (INCR). Study Design: Retrospective chart review. Methods: Charts of patients undergoing surgery for congenital aural atresia were reviewed for demographic data, preoperative Jahrsdoerfer score, ossicular chain status, and audiometric data. Patients undergoing OP were compared with an equal number of age and Jahrsdoerfer grade-matched patients who had an INCR. The preoperative and postoperative average air-bone gap (ABG), speech reception thresholds (SRT), and rates of revision surgery were compared between the two groups. Results: Nineteen patients (20 ears) underwent OP during aural atresia repair and were compared with 20 matched patients who had INCR. Mean age, Jahrsdoerfer score, preoperative ABG, and SRT were similar for both groups. Mean postoperative audiometric follow-up was 33.1 months for the OP group and 20.4 months for the INC group (P = .24). Mean postoperative ABG was 33.8 dB HL for OP and 23.8 dB HL for INCR (P < .05). Mean improvement in ABG was 16.8 dB HL for OP and 29.9 dB HL for INCR (P < .001). Mean improvement in SRT was 24.6 dB HL for OP and 34.8 dB HL for INCR (P < .05). Nine ears (45%) in the OP group and four ears (20%) in the INCR group underwent revision surgery (P = .09). Conclusions: Patients reconstructed with their own intact native chain during aural atresia surgery have better audiometric outcomes than those undergoing OP and are less likely to undergo revision surgery. [source] Algorithm for Reconstruction After Endoscopic Pituitary and Skull Base Surgery,THE LARYNGOSCOPE, Issue 7 2007Abtin Tabaee MD Abstract Introduction: The expanding role of endoscopic skull base surgery necessitates a thorough understanding of the indications, techniques, and limitations of the various approaches to reconstruction. The technique and outcomes of endoscopic skull base reconstruction remain incompletely described in the literature. Study Design and Methods: Patients undergoing endoscopic skull base surgery underwent an algorithmic approach to reconstruction based on tumor location, defect size, and presence of intraoperative cerebrospinal fluid (CSF) leak. A prospective database was reviewed to determine the overall efficacy of reconstruction and to identify risk factors for postoperative CSF leak. Results: The diagnosis in the 127 patients in this series included pituitary tumor in 70 (55%) patients, encephalocele in 16 (12.6%) patients, meningioma in 11 (8.7%) patients, craniopharyngioma in 9 (7.1%) patients, and chordoma in 6 (4.7%) patients. Successful reconstruction was initially achieved in 91.3% of patients. Eleven (8.7%) patients experienced postoperative CSF leak, 10 of which resolved with lumbar drainage alone. One (0.8%) patient required revision surgery. Correlation between postoperative CSF leak and study variables revealed a statistically significant longer duration of surgery (243 vs. 178 min, P = .008) and hospitalization (12.1 vs. 4.5 days, P < .0001) and a trend toward larger tumors (mean, 3.2 vs. 2.3 cm; P = .058) in patients experiencing postoperative CSF leak. Conclusion: The algorithm for reconstruction after endoscopic surgery presented in this study is associated with excellent overall efficacy. A greater understanding of risk factors for postoperative CSF leak is imperative to achieve optimal results. [source] Surgical Outcomes Following the Endoscopic Modified Lothrop Procedure,THE LARYNGOSCOPE, Issue 5 2007Mobeen A. Shirazi MD Abstract Objective: We performed a systematic review of 97 patients in whom an entirely endoscopic modified Lothrop procedure (EMLP) was performed. We studied the safety, efficacy, need for revision surgery, and rate of complication following an EMLP. Study Design: The study design was a retrospective chart analysis. Methods: We performed a retrospective chart review and patient survey of 97 patients who underwent an EMLP at our institution from January 1999 to March 2006. Main outcomes measured were the need for revision surgery including an osteoplastic flap (OPF), improvement in patients' symptoms, and rate of cerebrospinal fluid (CSF) leak. Results: The most common indication for the procedure was chronic frontal sinusitis and/or formation of mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. CSF leak rate was 1% (1/97) and was managed successfully at the time of surgery without any long-term sequelae. Twenty-two (23%) patients required revision surgery. Three (3%) patients required revision with an OPF. Some degree of symptomatic clinical improvement was reported by 98% (95/97) of patients. Conclusion: EMLP is a safe and effective surgical alternative to OPF for patients with recalcitrant frontal sinus disease. Major complications are rare. A large percentage of patients may require revision surgery. [source] Laryngotracheal Anastomosis: Primary and Revised ProceduresTHE LARYNGOSCOPE, Issue 4 2001Michael Wolf MD Abstract Objectives Acquired upper airway stenosis is usually associated with a complex of pathological conditions at the high tracheal and the subglottic levels. Reported reconstructive techniques include widening by incorporation of grafts, segmental resection, and anastomosis or combined procedures. The management of recurrent stenosis after reconstructive surgery is a major challenge and has rarely been discussed in the literature. The purposes of the present study are to compare the clinical course of primary versus revised reconstructive procedures and to analyze the effect of age, diabetes, chronic lung disease, grading of stenosis, extent of resection, and revised procedures on the operative rate of success. Study Design A cohort study in a tertiary referral medical center. Methods The clinical course of 23 consecutive patients undergoing laryngotracheal anastomosis was studied comparing a group of 13 primary with 10 revision procedures. Seventeen patients underwent cricotracheal and six patients thyrotracheal anastomoses. All patients but one were tracheotomized before the definitive reconstructive procedure. Suprahyoid release was routinely performed except for two cases, and only one patient required sternotomy. The Wilcoxon test was used to examine the relationship between preoperative clinical parameters and the postoperative success (i.e., airway patency). Results Twenty-two of 23 patients (95.6%) had successful decannulation. Four patients required a revision procedure because of repeat stenosis at the site of the anastomosis (2) or distal tracheal malacia (2). Residual airway stenosis of less than 50% was noted in six patients, although only three complained of dyspnea during daily-activity exertion. There was no associated mortality. Complications included subcutaneous emphysema (4), granulation tissue formation (3), pneumonia (2), cardiac arrhythmia (2), and one each of pneumomediastinum, neck hematoma, and urosepsis. Protracted aspirations were noted in one patient who had revision surgery. Age was the only parameter that correlated with postoperative airway patency (P <.07), whereas the presence of chronic obstructive lung disease and diabetes, grade of stenosis, type of surgery, and revision surgery were found to be insignificant. Conclusions The clinical course of laryngotracheal anastomosis in primary and revised procedures was similar in our group of patients. The operation can be performed safely, with an expected high rate of success and acceptable morbidity. [source] The Becker Technique for Otoplasty: Modified and Revisited With Long-Term Outcomes,THE LARYNGOSCOPE, Issue 6 2000Dennis Lee MD Abstract Objectives To demonstrate a modification of the Becker technique for otoplasty and to evaluate the long-term results. Study Design Case series with follow-up survey assessment. Methods A sample of 16 patients treated by a single surgeon at an academic pediatric referral center who met the inclusion criteria was reviewed for surgical results and patient/parental satisfaction. Results A total of 30 ears underwent repair. Patients ranged from 4 to 17 years (mean age, 8.2 y) with an average follow-up of 4.6 years. One patient had an immediate postoperative hematoma from blunt trauma that was treated with good long-term results. No cases required revision surgery. Preservation of the antihelix with good to excellent ear symmetry was obtained in all patients at follow-up. All patients were happy or very happy with the surgical procedure. All patients had at least five of the six criteria for surgical success as defined by the survey. Conclusions This modification of the Becker technique of otoplasty is efficacious for correction of protruding ears with excellent long-term results. [source] MOSHER AWARD HONORABLE MENTION,THE LARYNGOSCOPE, Issue 4 2000Natural History of Acoustic Neuromas Abstract Objectives/Hypothesis 1) Develop a computerized technique to accurately compare acoustic neuroma size on routine computed tomography and magnetic resonance imaging (MRI) scans; 2) use this technique to determine the growth pattern in a large series of patients with acoustic neuroma who were conservatively managed; 3) describe the natural history of patients with acoustic neuromas who did not receive surgical intervention and those who underwent subtotal resection; 4) correlate the size and growth rate of acoustic neuromas to clinical presentation and auditory and vestibular testing; and 5) recommend guidelines for the management of patients with acoustic neuromas. Study Design A retrospective study from 1974 to 1999 of patients with unilateral acoustic neuromas who had conservative treatment by serial imaging studies (80 patients) or subtotal resection (49 patients). Methods All patient charts were evaluated for presenting symptoms, reasons for the type of management given, and clinical outcome. Charts were also reviewed with respect to serial audiological assessment, electronystagmography, and brainstem auditory evoked response. Imaging studies were analyzed using a computer technique so that serial studies could be compared to determine growth rates. Results Rigorous computer analysis of tumor size and growth rate was statistically the same as the radiologist's description of the tumor size and growth rate. Of 70 patients who were older than 65 years of age old at the time their tumor was discovered, 4 (5.7%) required intervention and 18 (26%) were dead of unrelated causes. These patients had a mean follow-up of 4.8 years (range, 0.01,17.2 y). Overall, growth rate for nonsurgical patients was 0.91 mm per year. Nonsurgical tumors did not grow or regressed in 42.3%. Overall postoperative growth rate for surgical subtotal resection patients was 0.35 mm per year. Surgical tumors did not grow or regressed after subtotal resection of acoustic neuroma in 68.5% of patients. Three patients (6.1%) required revision surgery because of tumor growth or the development of symptoms. Neither auditory nor vestibular testing was a reliable measure for determining tumor growth. Conclusion Measurement of the maximal tumor diameter on MRI scans is a reliable method for following acoustic neuroma growth. There is no need to perform a rigorous analysis of tumor size to determine whether the tumor is growing significantly. The vast majority of patients older than 65 years with acoustic neuromas do not require intervention. The indications for intervention should be based on a combination of rapid tumor growth with the development of symptoms. [source] Outcomes of the overlay graft technique in tympanoplastyANZ JOURNAL OF SURGERY, Issue 9 2010Jennifer E. Ryan Abstract Background:, This audit was undertaken to review the outcomes achieved with the overlay graft technique of tympanic membrane repair in tympanoplasty surgery. Methods:, The charts of all patients who underwent tympanoplasty, in whom an overlay graft technique of temporalis fascia tympanic membrane repair was used, between 1994 and 2007 were reviewed. Information with respect to patient demographics, presence of cholesteatoma or active infection and perforation size was documented. Details of the surgical procedure and clinical outcomes and pre- and post-operative hearing thresholds were recorded in a computer database. Results:, A total of 147 overlay graft procedures were performed in 130 patients. Graft failure with reperforation occurred following five procedures, for an overall success rate of 96.6%. Eighty Type 1 tympanoplasty procedures were performed in which one failure occurred for a 98.75% success rate. Overlay grafting was combined with intact canal wall mastoidectomy (ICW) in 38 cases and with modified radical mastoidectomy (MRM) in 17 cases for a success rate of 93.8 and 95%, respectively. Delayed graft healing as a result of infection, problems such as epithelial pearl, blunting and myringitis occurred in 39 cases (26.5%). Thirty-one cases underwent procedures for ossicular chain reconstruction, 21 of which were 2nd stage procedures. Hearing outcomes were significantly better with Type 1 tympanoplasty compared with ICW or MRM procedures. Conclusion:, This review demonstrates the overlay graft technique of tympanoplasty to be highly successful for tympanic membrane repair, particularly for the more difficult cases such as revision surgery, subtotal perforations and mesotympanic cholesteatoma. [source] Clinical and radiological outcomes after revision to the low-contact-stress mobile-bearing total knee arthroplastyANZ JOURNAL OF SURGERY, Issue 5 2009David J. Whitehead Abstract Background:, The aim of the present study was to investigate the short,medium-term clinical and radiological outcomes in revision total knee arthroplasty using a mobile-bearing implant. Methods:, Forty patients (42 knees) who had revisions using the New Jersey low-contact-stress (LCS) mobile-bearing total knee arthroplasty between 1996 and 2000 were reviewed. Results:, The average age at revision was 71 years (range, 38,86 years) and the average follow up was 6 years (range, 5,9 years). Of the 34 patients reviewed clinically, six had excellent results, and 20 had good results, to give a total of 76% excellent or good results. There were five (15%) fair results and three (9%) poor results. Seven patients required revision of the components. There was one case of instability within the first year of revision, which required only exchange of the polyethylene bearing to achieve a satisfactory clinical outcome. Of the 31 knees reviewed radiologically, progressive radiolucent lines were seen at the bone,cement interface in five (16%) of the femoral components and in two (6%) of the tibial components. Conclusion:, Unconstrained LCS mobile-bearing total knee arthroplasty can be used in revision surgery with satisfactory results after medium-term follow up (level of evidence: therapeutic level III). [source] The small ubiquitin-like modifier mediates the resistance of prosthesis-loosening fibroblast-like synoviocytes against fas-induced apoptosisARTHRITIS & RHEUMATISM, Issue 7 2009Ingmar Meinecke Objective To study the expression of small ubiquitin-like modifier 1 (SUMO-1) in aseptic loosening of prosthesis implants and to investigate its role in regulating the susceptibility of prosthesis-loosening fibroblast-like synoviocytes (FLS) to Fas-induced apoptosis. Methods Specimens of aseptically loosened tissue were obtained at revision surgery, and the expression of SUMO-1 was analyzed by in situ hybridization. SUMO-1 levels in FLS were determined by quantitative polymerase chain reaction and Western blot analysis. Immunohistochemistry and confocal microscopy were used to study the subcellular localization of SUMO-1. The functional role of SUMO-1 in Fas-induced apoptosis of prosthesis-loosening FLS was investigated by small interfering RNA,mediated knockdown of SUMO-1 and by gene transfer of the nuclear SUMO-specific protease SENP1. Results SUMO-1 was expressed strongly in aseptically loosened tissue and was found prominently at sites adjacent to bone. Prosthesis-loosening FLS expressed levels of SUMO-1 similar to the levels expressed by rheumatoid arthritis (RA) FLS, with SUMO-1 being found mainly in promyelocytic leukemia protein nuclear bodies. Knockdown of SUMO-1 had no effect on spontaneous apoptosis but significantly increased the susceptibility of prosthesis-loosening FLS to Fas-induced apoptosis. Gene transfer of the nuclear SUMO-specific protease SENP1 reverted the apoptosis-inhibiting effects of SUMO-1. Conclusion These data suggest that SUMO-1 is involved in the activation of both RA FLS and prosthesis-loosening FLS by preventing these cells from undergoing apoptosis. Modification of nuclear proteins by SUMO-1 contributes to the antiapoptotic effects of SUMO-1 in prosthesis-loosening FLS, providing evidence for the specific activation of sumoylation during their differentiation. Therefore, SUMO-1 may be an interesting target for novel strategies to prevent aseptic prosthesis loosening. [source] Assessment of Five Interleukins in Human Synovial Fluid as Possible Markers for Aseptic Loosening of Hip ArthroplastyARTIFICIAL ORGANS, Issue 7 2009Alina Beraudi Abstract One of the most important factors that seems to be involved in total hip replacement is periprosthetic osteolysis. As it is well documented that several interleukins (ILs) are triggered in periprosthetic osteolysis, this article investigates the role of five ILs in primary and replacement total hip arthroplasty, understanding if one of them can also predict hip implant loosening, secondary surgery, and prosthesis breakage. The levels of IL-1,, 1,, 6, 8, and 10 in synovial fluid were examined, using a high sensitivity enzyme-linked immunosorbent assay (ELISA) test kit (Pierce Biotechnology, Inc., Rockford, IL, USA) to determine whether these cytokines could be used as markers of enhanced periprosthetic osteolysis, leading to aseptic loosening of total/partial hip arthroplasty or revision surgery. Synovial fluid was harvested from 23 patients undergoing primary total hip arthroplasty and 35 patients undergoing total/partial hip revision due to aseptic loosening. In the revision group, four cases had suffered a prosthesis fracture and five were second revisions. ILs 6 and 8 were significantly higher in the revisions (305 and 817 pg/mL) compared with the primary arthroplasties (151 and 151 pg/mL), including cases with prosthesis fracture and those requiring a second revision. IL-10 levels were lower (not significantly) in second revision samples compared with those of revision samples. IL-1, levels were significantly higher in prosthesis fracture samples compared with those of all the other revision samples. No statistically significant differences in IL levels were found between osteoarthritis samples and those of other diseases. These results are a step forward to elucidating the complex network of events that are involved in loosening of hip implants. [source] Microendoscopic discectomy for recurrent lumbar disc herniation*ASIAN JOURNAL OF ENDOSCOPIC SURGERY, Issue 2 2010M Matsumoto Abstract Introduction: The purpose of this study is to elucidate the feasibility of microendoscopic discectomy (MED) for the treatment of recurrent lumbar disc herniation. Methods: Thirty-six patients with recurrent lumbar disc herniation were treated using MED (30 men and six women; mean age: 45.7 years, range: 26,80 years; mean follow-up: 24.4 months, range: 12,52 months; mean duration between the primary and revision surgery: 65.9 months, range: 1,320 months) (recurrent group). Sex- and age-matched patients with primary lumbar disc herniation treated by MED served as the control group (primary group). The clinical outcomes were evaluated using the Japanese Orthopaedic Association score for low back pain and questionnaires regarding MED. Results: The average Japanese Orthopaedic Association scores before surgery and at the final follow-up were significantly lower in the recurrent group than in the primary group (10.8 ± 3.4 versus 15.0 ± 4.0 before surgery, P=0.001 and 25.4 ± 2.6 versus 26.8 ± 1.9 at follow-up, P=0.013), while the average recovery rates were not significantly different between the two groups (80.3 ± 14.1% versus 84.5 ± 14.6, P=0.22). The surgical time was significantly longer for the recurrent group than for the primary group (83.0 ± 41.8 min versus 67.1 ± 18.1 min,P=0.042). Of the 18 questionnaire respondents, 17 answered that postoperative pain was milder after MED than after a standard discectomy. Conclusion: MED is a feasible surgical option for recurrent lumbar disc herniation, yielding surgical outcomes comparable to those obtained in primary lumbar disc herniation. [source] Laparoscopic obesity surgery in an Asian Institute: A 10-year prospective study with review of literatureASIAN JOURNAL OF ENDOSCOPIC SURGERY, Issue 2 2009Wei-Jei Lee Abstract Objective: Obesity surgery is the most effective treatment for morbid obesity and leads to dramatic improvement in related co-morbidities. The aim of this study was to present the long-term results of a prospective trial studying the efficacy of laparoscopic obesity surgery in a group of oriental patients. Method: From April 1998 to March 2009, 2385 patients who underwent obesity surgery in a single bariatric center in Asia were recruited. Various procedures have been adopted so far, including laparoscopic vertical banded gastric partition in 652 patients (27.3%), laparoscopic gastric bypass (LGB) in 1228 patients (51.5%), laparoscopic adjustable gastric banding in 226 patients (9.5%), laparoscopic sleeve gastrectomy in 128 patients (5.4%), gastric balloon in 68 patients (2.8%) and laparoscopic revision surgery in 83 patients (3.5%). We evaluated the clinical data and effect of obesity surgery on different procedures. Results: Overall, the major complication rate and mortality were 1.5% and 0.12%. There was an increase of surgical risk in laparoscopic sleeve gastrectomy and laparoscopic revision surgery patients. The mean total weight loss for the population was 28.1%, 33.9%, 21.3% 18.7% and 17.4% at 1, 3, 5, 7 and 9 years after surgery, respectively. LGB had a better weight loss (30.1%) than that of the restrictive-type procedures (20.9%) at 5 years after surgery. After surgery, most of the obesity-associated co-morbidities were resolved or improved in these patients. Conclusion: Laparoscopic obesity surgery resulted in significant and sustained weight loss in morbidly obese Asian patients with resolution of associated co-morbidities. LGB had a better result in weight reduction than other restrictive procedures. [source] The national comparative audit of surgery for nasal polyposis and chronic rhinosinusitisCLINICAL OTOLARYNGOLOGY, Issue 5 2006C. Hopkins Objectives: This study summarises the results of a National Audit of sino-nasal surgery carried out in England and Wales. It describes patient and operative characteristics as well as patient outcomes up to 36 months after surgery. Design: Prospective cohort study. Setting: NHS hospitals in England and Wales. Participants: Consecutive patients undergoing surgery for nasal polyposis and/or chronic rhinosinusitis. Main outcome measure: The total score derived from a 22-item version of the Sino-Nasal Outcome Test (SNOT-22). Lower scores represent better health-related quality of life. Results: A total of 3128 consecutive patients at 87 NHS hospitals were enrolled. There is a large improvement in SNOT-22 scores from the pre-operative period (mean = 42.0) to 3 months after surgery (mean = 25.5). The scores for patients undergoing nasal polypectomy improved from 41.0 before surgery to 23.1 at 3 months after surgery, while the scores for patients undergoing surgery for chronic rhinosinusitis alone improved from 44.2 to 31.2. The SNOT-22 scores reported at 12 and 36 months after surgery were similar to those reported at 3 months. Excessive bleeding occurred in 5% of patients during the operation and in 1% of patients after the operation. Intra-orbital complications were reported in 0.2%. Of those patients undergoing primary surgery for bilateral grade I or II polyposis, 18% had not received a pre-operative course of steroid treatment. At the 36-month follow-up, 11.4% of patients had undergone revision surgery. Conclusions: The audit confirms that sino-nasal surgery is generally safe and effective. There is some evidence that patient selection for surgery could be improved. [source] A retrospective comparison of endonasal KTP laser dacryocystorhinostomy versus external dacryocystorhinostomyCLINICAL OTOLARYNGOLOGY, Issue 5 2002S. Mirza We retrospectively reviewed all primary external dacryocystorhinostomies (DCRs) and endonasal KTP laser DCRs performed for epiphora as a result of nasolacrimal duct obstruction in our unit between 1993 and 2000. Forty-nine patients underwent an external approach and 76 endonasal laser procedures were performed. The success rate of the external group was 94% with a mean follow-up of 9 months. In contrast, the endonasal group's success rate was 64% with a mean follow-up of 12 months. This difference reached statistical significance (P = 0.0002). However, when including revision procedures, the success rate in the endonasal group increased from 64% to 82%. The success rate in the endonasal group improved from 50% in the first 38 cases to 79% in the last 38 cases (P = 0.0084), thereby demonstrating a learning curve. Our study confirms external DCR as the ,gold standard' for a successful outcome. However, the endonasal technique has significant advantages, including being a quicker procedure with less morbidity, no cutaneous scar, and being more amenable to a bilateral procedure, daycase surgery and local anaesthetic. We are persisting with the endonasal technique because of its advantages but have moved towards more ,cold steel' techniques in an effort to improve results and emulate other series. In conclusion, for nasolacrimal duct obstruction, the endonasal technique is our approach of choice, with revision surgery if necessary, and the external technique is held in reserve. [source] | |||||||||||||||||||||||||