A retrospective cohort study of intra-corporeal versus extra-corporeal anastomosis for right hemicolectomy with cost-effectiveness analysis.

BACKGROUND: We aimed to compare outcomes and cost effectiveness of extra-corporeal anastomosis (ECA) versus intra-corporeal anastomosis (ICA) for laparoscopic right hemicolectomy using the National Surgical Quality Improvement Programme data. METHODS: Patients who underwent elective laparoscopic right hemicolectomy for colon cancer from January 2018 to December 2022 were identified. Non-cancer diagnoses, emergency procedures or synchronous resection of other organs were excluded. Surgical characteristics, peri-operative outcomes, long-term survival and hospitalisation costs were compared. Incremental cost-effectiveness ratio (ICER) was used to evaluate cost-effectiveness. RESULTS: A total of 223 patients (175 ECA, 48 ICA) were included in the analysis. Both cohorts exhibited comparable baseline patient, comorbidity, and tumour characteristics. Distribution of pathological TMN stage, tumour largest dimension, total lymph node harvest and resection margin lengths were statistically similar. ICA was associated with a longer median operative duration compared with ECA (255 min vs. 220 min, P < 0.001). There was a quicker time to gastrointestinal recovery, with a shorter median hospital stay in the ICA group (4.0 versus 5.0 days, P = 0.001). Overall complication rates were comparable. ICA was associated with a higher surgical procedure cost (£6301.57 versus £4998.52, P < 0.001), but lower costs for ward accommodation (£1679.05 versus £2420.15, P = 0.001) and treatment (£3774.55 versus £4895.14, P = 0.009), with a 4.5% reduced overall cost compared with ECA. The ICER of -£3323.58 showed ICA to be more cost effective than ECA, across a range of willingness-to-pay thresholds. CONCLUSION: ICA in laparoscopic right hemicolectomy is associated with quicker post-operative recovery and may be more cost effective compared with ECA, despite increased operative costs.

Recent Chinese migrants' health, adjustment to life in New Zealand and primary health care utilization.

A community survey of 271 Chinese migrants aged 15 years and older living in Auckland was conducted to assess self-rated adjustment and health. The majority of respondents came from Hong Kong and Taiwan. Despite significant changes in their lives, including the absence of family members, unemployment and underemployment, most did not report major adjustment problems or regret having come to New Zealand. Few considered their health to be poor. Forty-two per cent reported having consulted a doctor within the past 12 weeks. Factors significantly associated with having experienced major problems included being aged 26-35 years, rejection from locals and having low English proficiency. Factors associated with poor adjustment included expectations not having been met, regretting coming, low proficiency in English, recent arrival in New Zealand, unemployment, younger age and lower levels of education. Self-rated fair or poor health was found to be associated with Chinese-only reading knowledge, residency of more than 5 years and regretting having come to New Zealand.

Risk factors for postoperative femoral fracture in cementless hip arthroplasty.

The objective of this study was to evaluate the incidence of and risk factors for femoral fracture in patients who underwent cementless hip arthroplasty during a 3-year period. Several predisposing factors have been reported; we tried to find another predictive indicator that could be recognized preoperatively. The records of all patients who underwent cementless hip arthroplasty from December 1993 to December 1996 were reviewed. The characteristics and clinical features (including age, gender, diagnosis, geometry of the proximal femur, and quality of bone) of the patients who had fractures were compared with those of patients who did not have fractures. During the 3-year study, 425 patients underwent a total of 454 cementless hip arthroplasties. There were 16 postoperative fractures (3.5%, 16 patients). Patients who suffered femoral fracture were significantly older than patients without fracture (65.6 +/- 10.9 yr vs 52.6 +/- 16.2 yr, p < 0.001). The fracture group had poorer preoperative bone quality compared with the nonfracture group (3.3 +/- 0.6 vs 3.8 +/- 0.7, Singh's Index of Osteoporosis, p < 0.01). The canal flare index of the proximal femur was significantly lower in the fracture group than in the nonfracture group (3.3 +/- 0.40 vs 3.8 +/- 0.7, p < 0.01). Our results indicate that old age and osteoporosis affect the likelihood of periprosthetic femoral fractures, and that a low flare index is a predictive indicator of femoral fracture. These factors should be taken into account during preoperative planning, and cemented arthroplasty should be considered for patients with these risk factors.

Osteoid osteoma in the talar neck: a report of two cases.

This article describes two cases of juxta-articular osteoid osteoma of talar neck. Both patients were initially treated as having ankle sprains or arthritis before diagnosis of osteoid osteoma. A high index of suspicion and appropriate imaging studies are important to make an early diagnosis of this disorder. Once diagnosis is confirmed, en bloc resection and autogenous bone graft can cure the disorder.

Treatment of a large segmental bone defect with allograft and autogenous bone marrow graft.

Management of segmental bone defects is a challenge to orthopedic surgeons. We report a 23-year-old man who sustained segmental bone loss of 9 cm in length in his left femur due to an open fracture. Open reduction and internal fixation with a 95 degrees angle blade plate and screws, supplemented with a composite of two femoral head allografts and a graft of 100 mL of autogenous bone marrow, was performed 3 weeks after the injury, when the soft tissues had healed. The postoperative rehabilitation program included delayed weight bearing (crutches for 3 months), a limited early range of motion of the left knee, and quadriceps muscle exercise. Callus bridging was noted on x-ray films 3 months postoperatively. Clinical and radiographic union were noted 6 months after the surgery. We suggest that this new and simple method can be applied to successfully treat segmental bone loss of more than 6 cm in length.

Localized pigmented villonodular synovitis of the knee: a report of two cases.

Two cases of localized pigmented villonodular synovitis (PVNS) are reported, both having received surgery. Localized PVNS and diffuse PVNS have not been clearly separated in the literature. Although the clinicopathologic features of the former lesions are similar to diffuse PVNS involving the synovium of the knee joint, the villous component with brownish red color, brownish-stained bloody fluid, and the hemosiderin in the surface-lining cells were lacking in these two cases. Localized PVNS can be treated with simple excision arthroscopically, but it tends to recur as diffuse PVNS if it is excised inadequately. It is suggested that attention must be paid to a soft tissue mass within the knee joint by doing comprehensive pre-operative evaluations which include history taking, computed tomography, and/or magnetic resonance imaging. Intra-operative findings focused on the morphology including the proliferated synovial membrane, gross appearance of the lesion and the pattern of effusion which are all important for distinguishing between localized PVNS and diffuse PVNS. There was no evidence of recurrence in these two cases during the 18 months' follow-up.

Management of rigid post-traumatic kyphosis.

STUDY DESIGN: Rigid post-traumatic kyphosis after fracture of the thoracolumbar and lumbar spine represents a failure of initial management of the injury. Kyphosis moves the center of gravity anterior. The kyphosis and instability may result in pain, deformity, and increased neurologic deficits. Management for symptomatic post-traumatic kyphosis always has presented a challenge to orthopedic surgeons. OBJECTIVES: To evaluate the surgical results of one stage posterior correction for rigid symptomatic post-traumatic kyphosis of the thoracolumbar and lumbar spine. SUMMARY OF BACKGROUND DATA: The management for post-traumatic kyphosis remains controversial. Anterior, posterior, or combined anterior and posterior procedures have been advocated by different authors and show various degrees of success. METHODS: One vertebra immediately above and below the level of the deformity was instrumented posteriorly by a transpedicular system (internal fixator AO). Posterior decompression was performed by excision of the spinal process and bilateral laminectomy. With the deformed vertebra through the pedicle, the vertebral body carefully is removed around the pedicle level, approximating a wedge shape. The extent to which the deformed vertebral body should be removed is determined by the attempted correction. Correction of the deformity is achieved by manipulation of the operating table and compression of the adjacent Schanz screws above and below the lesion. RESULTS: Thirteen patients with post-traumatic kyphosis with symptoms of fatigue and pain caused by slow progression of kyphotic deformities received posterior decompression, correction, and stabilization as a definitive treatment. The precorrection kyphosis ranged from 30-60 degrees, with a mean of 40 degrees +/- 10.8 degrees. After correction, kyphosis was reduced to an average of 1.5 degrees +/- 3.8 degrees, with a range from -5 degrees to 5 degrees. The average angle of correction was 38.8 degrees +/- 10.4 degrees, with a range from 25 degrees to 60 degrees. Significant difference was found between pre- and post-operative kyphosis measures (P < 0.001). The follow-up period for all patients was 2 years, and the average kyphosis angle measured at the moment was 3.8 degrees +/- 3 degrees with a range from -3 degrees to 8 degrees. Substantial overall improvement was achieved in the 13 patients. CONCLUSION: This method provides single-stage posterior decompression, correction, and stabilization on as definitive management for post traumatic kyphosis of the thoracolumbar and lumbar spine.

Duration of oxygen therapy and exchange transfusion as risk factors associated with retinopathy of prematurity in very low birthweight infants.

One hundred and thirteen consecutive infants with a very low birthweight of less than 1500 g were followed prospectively for 6 months to determine the incidence of retinopathy of prematurity (ROP) and associated risk factors. Of this group, 36 (31.9%) infants developed ROP (13 infants had stage 1 ROP, nine had stage 2, six had stage 3, six had stage 4, and two had cicatricial stage ROP). Stepwise logistic regression analysis of various potential risk factors (birthweight, gestation, duration of oxygen therapy, duration of ventilation, highest documented PaO2 and exchange transfusion) showed that only two risk factors were significantly associated with the development of ROP. These risk factors were: the duration of oxygen therapy (p = 0.0005) and exchange transfusion during the neonatal period (odds ratio 5.754, 95% confidence interval 1.002 to 32.997, p = 0.049). The equation of the regression model is: log (odds of developing ROP) = -0.8395 + 0.1447 (OXY)- 0.8750 (ET), where OXY is the duration of oxygen therapy in days, ET = -1 when there was a history of exchange transfusion, and ET = 1 when there was no history of exchange transfusion.

Isoelastic total hip replacement: clinical evaluation of prosthetic isoelasticity.

By using the lower modulus material, polyacetal, ie, prosthesis made by R. Mathys', isoelastic hip prosthesis is claimed to reduce stress shielding effects and secure long-term, stable fixation of prostheses. In Tri-Service General Hospital from October 1985 to October 1989, 23 patients (25 hips) were treated using this prosthesis. Twenty patients (22 hips) were followed for clinical and radiographic evaluation for an average of 44.8 months (29-58 months). In clinical evaluation, the overall results were comparable to other cemented or cementless hip prostheses. The Merle d'Aubigne and Postel score for pain, motion and walking were improved from 1.6, 3.9, and 2.4 to 4.6, 4.3, and 4.9, respectively. The acetabular cup showed more favorable radiographic evaluation with a total mean score by combined Charnley and Engh's system of 7.9. It was not optimal on the femoral side and it showed that 20 of the femoral stems were stable fibrous fixations with a mean score of 15.8. Early complications included two dislocations, two significant femoral shaft fractures, and five medial neck cracks at surgery. The late complications included one loosening, one screw breakage, and one screw back out. The isoelastic hip always gained an inferior score in clinical evaluation from the "self comparison" in three patients with one side isoelastic hip and the other side different cemented or cementless prosthesis. There is no obvious benefit in radiographic evaluation, both in elimination of stress shielding and enhancement of fixation stability. As a result, the theoretical advantages of the isoelasticity concept are difficult to justify in our clinical practice.

Growth and metabolism of cultured bone cells using microcarrier and monolayer techniques.

The traditional in vitro cell culture methods provide bone cells on matrix-coated Petri dishes to grow the cells in a monolayer. This limits the usefulness in situations where there is a need to suspend anchorage dependent cells. To promote the massive production of the cultured cells and to enable the suspension of the cells in a medium, microcarrier cell culture was developed and evaluated. Isolated bone cells from rat calvaria were incubated in a microcarrier culture flask with Cytodex 1. The microcarrier cell morphology was examined by a phase contrast microscope, a scanning electron microscope, and a transmission electron microscope. Cell growth, enzyme markers, and biosynthetic characteristics were examined and compared for microcarrier and monolayer methods. The results indicate that all the characteristics of the bone cells, whether cultured in the Petri dish or microcarrier, were the same. Therefore, the studies of the function and behavior of bone cells still remain useful using the microcarrier system culture.

Etiology of deep sepsis in total hip arthroplasty. The significance of hematogenous and recurrent infections.

Between January 1970 and August 1986, 3051 total hip arthroplasties (THAs) were performed at the authors' institution. Forty-seven hips in 43 patients developed deep infection. Using clinical and laboratory criteria, patients were classified into four modes of infection: (1) surgical contamination, which included hips (N = 13) with a suspicious clinical course (e.g., persistent elevation of sedimentation rate, early radiographic signs of loosening) without another identifiable source; (2) hematogenous spread, which included septic hips (N = 19) with a temporally related infectious source and an organism consistent with that source; (3) recurrent sepsis, septic failure in a previously infected hip (N = 13); and finally, (4) infection from direct or contiguous spread, which occurred in an additional two patients. Thus the majority of infections were nonsurgical. Patients with surgically acquired infections tended to present earlier, were less likely to require a Girdlestone procedure for salvage, and were more likely to be reimplanted (p = 0.024). The incidence of surgical infections decreased with the use of improved antiseptic techniques. The incidence of hematogenous infection, however, increased during the time that a cohort was followed. Additionally, in a previously septic hip, septic failure may occur as late as seven years after THA.

The effect of piroxicam in preventing surgically induced miosis.

The effect of an antiprostaglandin, piroxicam, in preventing surgically induced miosis is studied. Patients undergoing extracapsular cataract surgery were randomly divided into the piroxicam and placebo groups. Intra-operative measurements of the pupillary diameters were performed. The stages of procedure at which they were measured were at the beginning of operation (Stage 1), after anterior capsulotomy (Stage 2), after lens nucleus delivery (Stage 3) and at the end of irrigation and aspiration (Stage 4). It is noted in this Study that the pupillary diameters were larger at stages 2,3 and 4 in the piroxicam group. The increase in the mean pupillary areas of the piroxicam group were statistically significant for Stages 3 and 4.

Spinal transpedicular drill guide: design and application.

Short-segment stability problems of the spine, such as fracture, pseudoarthrosis, tumor, degenerative disc, and spondylolisthesis should be resolved by short-segment stabilization methods. The "rod long, fuse short" technique using traditional Harrington or Luque rods still have unavoidable problems of facet arthritis at the segments temporarily instrumented but not grafted. Transpedicular fixation of the spine is currently being used in many systems. Biomechanical studies have shown that three-level transpedicular fixation is more rigid than five-level fixation of Harrington or Luque rods. Regardless of the system used, the primary concern is how the transpedicular screw can be inserted safely through the pedicle as deep into the vertebral body as possible. A spinal transpedicular drill guide has been designed for transpedicular screws, and a prototype has been completed. Cadaver studies have been carried out and transpedicular screw position has been confirmed by computed tomography scan. Early clinical experience has demonstrated its efficacy and safety.

Incidence of deep sepsis in total hip arthroplasty. Survivorship analysis over 17 years from one hospital.

Of 3,051 total hip arthroplasties (THA) performed between January 1970 and August 1986, 47 hips in 43 patients developed deep periprosthetic infection. This population was divided temporally into three groups based on changes in our perioperative antiseptic technique. Using survivorship analysis, a significant decrease in the sepsis rate in primary THA was seen in the period since 1974 (P less than .03). Comparing all surgeries in the most recent cohort (1980-1986) to others by a Cox Proportional Hazards model (which accounts for differences in follow-up results), indicates that the relative risk of sepsis has decreased by half in this latest group. Contemporary perioperative antiseptic techniques have lowered the risk of infection in THA. Further significant decreases in sepsis incidence will likely require a reduction in the incidence of infection acquired outside the operating room.

Spinal pedicle finder for transpedicular screw fixation--design and early clinical result.

Spinal transpedicular fixation has gained widespread popularity in the past 5 years. In biomechanical studies, the deeply-inserted transpedicular screws withstood the largest number of cycles in the cephalad-caudad and medial-lateral direction before failure. However, in clinical practice, the risk of screw placement which is too far medially or too far laterally do exist. The optimization of increasing screw depth to avoid complication is of significant clinical importance. A Spinal Pedicle Finder (S.P.F) has been designed for transpedicular screws and a prototype has been completed. It is composed of an I-shaped body with a pair of front rails and a pair of rear rails. The front rail comprises two positioning arms that fit against the laminal bony crest, and the rear rail comprises two guiding bases that provide the transpedicular pin inserted with a specific angle. Both positioning arms and both guiding bases can be adjusted synchronously, and the specific angle over the guiding bases can be pre-set preoperatively according to the angle of pedicle axis. To date, in 7 cases (5 fracture and 2 spondylolisthesis) transpedicular screw fixation has been applied by aid of the S.P.F. Two-level fixation was applied in a fracture group and three-level fixation was applied in a spondylolisthesis group. The position of the transpedicular screw has been checked by CT scan postoperatively. A total of 32 transpedicular screws were inserted and all were in the pedicle and vertebral body except in one instances. One transpedicular screw was malpositioned on one side, partially lateral to the pedicle. However, this malposition did not cause any neurologic problem, such as dural tear, nerve root injury or other. Clinical experience has demonstrated its efficacy and safety.