Synchronous polypectomy during endoscopic diagnosis of colorectal cancer - is the risk of tumour implantation at the polypectomy site significant?

BACKGROUND: Synchronous polypectomy in colonic malignancies is contentious due to the perceived risks of tumour implantation at polypectomy sites (PS). We assess the risks of tumour implantation after synchronous polypectomy. METHODS: An analysis of all endoscopies for cancer that were accompanied by synchronous polypectomies from 2005 to 2009 was performed. The incidence of metachronous colorectal cancers located at the same segment of a previous PS was the surrogate for tumour implantation. Data on patient demographics, tumour and polyp location(s) and follow-up outcomes were extracted. The rate of metachronous lesions at the same segment of a previous PS between patients who had all synchronous PS resected (Group A) and patients with PS left in-situ (Group B) were compared. RESULTS: Two hundred and eighty-four patients had synchronous polypectomy performed during their initial endoscopy for cancer. Three patients were lost to follow-up and, in the remaining 281 patients, 87 (31.0%) were in Group A while 194 (69%) were in Group B. Median age, gender, tumour location, tumour stage, and pathological characteristics were similar between both groups. 2 (0.7%) patients developed local recurrences. Six (2.1%) patients developed metachronous lesions, four of which were located at the same segment where synchronous polypectomy was previously performed. The rates of metachronous lesions at the PS in groups A and B were similar at 1.1% (1/87) and 1.5% (3/194), respectively (p = 0.795). CONCLUSION: Malignant implantation after synchronous polypectomy in the setting of a newly diagnosed cancer remains unproven. Even if tumor implantation did occur, the incidence is likely low.

Screw fixation versus arthroplasty versus plate fixation for 3-part radial head fractures.

PURPOSE: To compare the outcome following headless compression screw fixation versus radial head arthroplasty versus plate fixation for 3-part Mason types III or IV radial head fracture. METHODS: Records of 25 men and 16 women aged 21 to 80 (mean, 43.3) years who underwent fixation using 2 to 3 2-mm cannulated headless compression screws (n=16), radial head arthroplasty (n=13), or fixation with a 2-mm Synthes plate (n=12) for 3-part Mason types III or IV radial head and neck fracture were reviewed. Treatment option was decided by the surgeon based on the presence of associated injury, neurovascular deficit, and the Mason classification. Bone union, callus formation, and complications (such as heterotopic ossification, malunion, and nonunion) were assessed by an independent registrar or consultant using radiographs. The Mayo Elbow Performance Score and range of motion were assessed by an independent physiotherapist. RESULTS: The median age of the 3 groups were comparable. Associated injuries were most common in patients with arthroplasty, followed by screw fixation and plate fixation (61.5% vs. 50% vs. 33%, p=0.54). The median time to bone union was shorter after screw fixation than plate fixation (55 vs. 86 days, p=0.05). No patient with screw fixation had nonunion, but 4 patients with plate fixation had nonunion. The 3 groups were comparable in terms of the mean Mayo Elbow Performance Score (p=0.56) and the mean range of motion (p=0.45). The complication rate was highest after plate fixation, followed by screw fixation and arthroplasty (50% vs. 18.8% vs. 15.4%, p=0.048). Excluding 20 patients with associated injuries (8 in screw fixation, 8 in arthroplasty, and 4 in plate fixation), the 3 groups were comparable in terms of the median time to bone union (p=0.109), mean Mayo Elbow Performance Score (p=0.260), mean range of motion (p=0.162), and complication rate (p=0.096). CONCLUSION: Headless compression screw fixation is a viable option for 3-part radial head fracture. It achieves earlier bone union with fewer complications.

Clinically relevant heterotopic ossification after elbow fracture surgery: a risk factors study.

BACKGROUND: Heterotopic ossification (HO) is a common complication of elbow fracture surgery that can significantly impair function and range of motion (ROM). Whereas numerous studies have assessed HO after hip trauma or replacement surgery, few data have been reported on the prevalence and risk factors of HO after elbow fractures. HYPOTHESIS: Our objective was to investigate the prevalence and risk factors of clinically relevant HO after elbow fracture surgery under the hypothesis that the ability to identify high-risk patients would improve treatment tailoring and assist in meeting patient expectations. MATERIALS AND METHODS: We retrospectively included consecutive patients who had surgery for elbow injuries between January 2007 and December 2011. Patient demographics, operative details, and radiographs were reviewed. RESULTS: Of 124 elbows in 122 patients, 38 (30.6%) had HO and 26 (21%) clinically relevant HO. The prevalence of clinically relevant HO was highest in floating elbow injury, followed by combined olecranon and radial head fractures, types A and B distal humerus fractures, and terrible triad injury. By multiple logistic regression, factors that independently predicted clinically relevant HO were fracture-dislocation (OR, 4.87; 95%CI, 1.78-13.29; P=0.002) and longer time to surgery (P<0.05). Of the 26 patients with clinically relevant HO, 6 (23%) eventually required revision elbow surgery to improve ROM. DISCUSSION: HO of the elbow occurred in almost one-third of our patients with surgically treated elbow fractures. Fracture-dislocation of the elbow and longer time to surgery independently predicted HO responsible for ROM loss. Clinically relevant HO was associated with significant morbidity. LEVEL OF EVIDENCE: Level IV, retrospective study.

A Look Back in Time: Sir Robert Jones, 'Father of Modern Orthopaedics'.

This paper describes the life of Sir Robert Jones, from his humble beginnings as an apprentice of Thomas Smith, to his many contributions to the orthopaedic specialty. Robert Jones' passion and interest in the subject led to its advancement from a specialty that dealt mainly with crippling diseases in children, to that of treating and rehabilitating disabled adults. He revolutionized the practice by integrating the use of plain radiography, and by developing many new surgical and procedural techniques. He largely improved the specialty by publishing many textbooks and papers, and trained many orthopaedic surgeons from within England and internationally. The purpose of this paper seeks to provide a platform for readers to learn about the man behind the Jones fracture and bandage. It will help readers understand how one man's passion for orthopaedics helped transform it into a specialty in its own rights.

Frozen shoulder.

Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.

Functional outcomes following ceramic total joint replacement for hallux rigidus.

INTRODUCTION: The aim of this study was to evaluate functional outcomes following ceramic arthroplasty used in the treatment of osteoarthritis of the hallux metatarsophalangeal (MTP) joint. MATERIALS AND METHODS: Thirty-seven consecutive patients who underwent press-fit ceramic joint arthroplasty were identified. Joint movement, gait pressure studies, radiographs, patient's outcome based on the American Orthopaedic Foot and Ankle Society (AOFAS) scale, hallux metatarsal phalangeal-interphalangeal index (HMPI) and visual analogue pain scales were assessed. RESULTS: Mean follow-up was 33 (12-60) months. Ninety-two percent of patients were satisfied with the surgery. AOFAS and HMPI scores were good to excellent in more than 90%. Six implants had lucent lines of greater than 2mm at 18 months. Three of these joints also had subsidence of both components. There was no correlation between implant loosening and patient outcomes. Mean hallux pressure at toe-off decreased from 7.1 to 3.5 N cm⁻² (p<0.01) equalising with normal contralateral toe pressure. Three patients required revision surgery and one patient had a transient wound infection. CONCLUSIONS: Good to excellent results have been achieved following ceramic total MTP joint arthroplasty. The clinical relevance of progressive lucencies around the implant is uncertain and longer follow-up may identify subsidence and ultimate failure.

Total hip replacement in morbidly obese patients with osteoarthritis: results of a prospectively matched study.

We compared 55 consecutive total hip replacements performed on 53 morbidly obese patients with osteoarthritis with a matched group of 55 total hip replacements in 53 non-obese patients. The groups were matched for age, gender, prosthesis type, laterality and preoperative Harris Hip Score. They were followed prospectively for five years and the outcomes were assessed using the Harris Hip Score, the Short-form 36 score and radiological findings. Survival at five years using revision surgery as an endpoint, was 90.9% (95% confidence interval 82.9 to 98.9) for the morbidly obese and 100% for the non-obese patients. The Harris Hip and the Short-form 36 scores were significantly better in the non-obese group (p < 0.001). The morbidly obese patients had a higher rate of complications (22% vs 5%, p = 0.012), which included dislocation and both superficial and deep infection. In light of these inferior results, morbidly obese patients should be advised to lose weight before undergoing a total hip replacement, and counselled regarding the complications. Despite these poorer results, however, the patients have improved function and quality of life.

Antibodies prevalence against HPV-6b and -16 recombinant fusion proteins in Korean patients with cervical neoplasia.

OBJECTIVES: This study was to investigate the adjunctive diagnostic utility of HPV fusion proteins from the sera in the patients with cervical neoplasia. Immunologic researches on host factors in HPV infection could contribute to better understanding of patho-physiologic mechanisms of cervical carcinogenesis, and provide valuable information for HPV vaccine development. METHODS: Prevalence of antibodies against human papillomavirus (HPV) in sera of the patients with carcinoma (n = 81), precancers (n = 25) of uterine cervix and normal controls (n = 40) in Korean women were investigated by Western blot immunoassay using partially purified TrpE fusion recombinant proteins for HPV-6b and HPV-16. RESULTS: In 81 patients with cervical cancer, 15 (19%) and 54 (67%) patients were positive for antibodies to at least one of the tested recombinant proteins related to HPV-6b or HPV-16, respectively. And in 25 patients with HPV-related squamous intraepithelial lesion (SIL) of cervix, 10 were positive for at least one of the tested antibodies for HPV-6b gene products (40%) and 11 were positive for HPV-16 related antibodies (44%). The prevalence rates of antibodies for HPV-6b in the sera of SIL patients were significantly higher than those from the sera of cervical cancer patients (p < 0.05). There was an inverse correlation between increasing the positivity against HPV-16 E6 protein and progression of cervical lesions, but there was no significant correlation between the positivities of the other antibodies to HPV-16 and the severity of disease. CONCLUSION: These results suggest that the recombinant proteins related to HPV-6b and HPV-16 could be useful in evaluation of the patients with HPV-related cervical lesions and these might play an adjunctive role in diagnosis and management of cervical neoplasia.

Immunologic diagnosis and monitoring of cervical cancers using in vitro translated HPV proteins.

E6 and E7 proteins, the transforming proteins of oncogenic HPVs, are known to be associated with the occurrence of cervical cancer. In radioimmunoprecipitation assays in which in vitro-transcripted and translated HPV-16 E6 and E7 proteins were used, patients with HPV-16-associated invasive cervical cancer (group I) had greater seroreactivity than patients in most of the other groups, including patients with invasive cervical cancer who were infected with other types of HPVs (group II), cervical cancer patients with nondetectable HPVs (group III), patients with HPV-16-associated cervical intraepithelial neoplasia (group IV), and unaffected normal controls with noncervical lesions (group V) (P < 0.05). The sera of patients in group I, when compared with the sera of other groups, were significantly reactive with one and/or two proteins (P < 0.05). Antibodies to HPV-16 E6 and E7 proteins were detected in patients with invasive cancer more than in those with CIN. The positive rates for E6 protein were 4.2% (1/24), 43.8% (7/16), 57.1% (8/14), 100% (5/5), and 100% (1/1), and the positive rates of E7 protein were 4.2% (1/24), 12.5% (2/16), 35.7% (5/14), 60% (3/5), and 100% (1/1) from CINs through stages I, IIa, IIb, and III of HPV-16-associated cervical cancers, respectively. The positive rates for E6 and E7 proteins were significantly increased with the advancing of the clinical stages of cervical cancer (P < 0.05 for E6 and E7). To examine the change in antibody titers of HPV-16 E7 protein during diagnosis, treatment, and follow-up, we tested serial serum samples from 14 patients of group I. The antibody titers were correlated to the clinical course of disease in some cases. The positive levels of E7 antibody were decreased when the treatment was effective, but in 1 patient who had shown recurrence or progression, positive seroreactivity was maintained. Antibodies to HPV-16 E6 and E7 proteins might be effective virus-specific and disease state-specific markers of HPV-16-associated cervical cancer.

Human papillomavirus detection in cervical carcinoma tissues and paraaortic lymph nodes by the polymerase chain reaction.

Tissues of 45 cervical cancers and paraaortic lymph nodes from the same patients were evaluated by polymerase chain reaction with L1 consensus primers and hybridization with type-specific oligomer probes of HPV-6, -11, -16, -18, -31, -33, -35, and -45 for the detection and classification of subtypes of human papillomavirus (HPV). The clinicohistologic findings of surgical specimens from radical hysterectomy were compared with the results of HPV detection to use as a possible prognostic marker for the early detection of paraaortic nodes involvement. Metastasis to paraaortic nodes in cervical cancer, suggesting extrapelvic involvement of tumor, is clinically important to predict prognosis. The HPV-16 DNA was most prevalent in cervical cancers (76%; 34/45). Five tumors were positive for HPV-18, two tumors each were positive for HPV-31 or -33, one tumor was hybridized to HPV-45, and one woman had an unidentified type of HPV. No HPV was detected in three cases of cervical cancer. The histologic types of the cervical cancers were correlated with the HPV types. Of the 39 tissue specimens of squamous carcinomas analyzed, only 2 (5%) showed HPV-18, in contrast to 30 (77%) of 39 squamous carcinomas having HPV-16. Of the 5 cases of adenocarcinomas, 3 (50%) showed HPV-18, and 3 (50%) showed HPV-16. HPV DNAs were detected in histologically negative paraaortic lymph nodes (31%; 14/45): the HPV-positive PCR products from paraaortic nodes were only hybridized to HPV-16. The nature of the relationship between the presence of HPV DNA and node tumor involvement is still not known. HPV-16 DNA in paraaortic nodes may suggest subclinical early metastasis or tumor cells destroyed by immune cells and may provide important information in decisions regarding postoperative adjuvant treatment. The prognostic significance of HPV DNA in histologically negative paraaortic lymph nodes remains to be established after several years of follow-up.

Cervical intraepithelial neoplasia 3, coinfected with HPV-16 and -18--case report.

Recently, detection of human papillomavirus (HPV)mRNA expression was made possible by in situ hybridization. We described a patient with cervical intraepithelial neoplasia (CIN) 3, showing a distinctive and rare form of co-infection with HPV type 16 and 18. HPV-16 was detected in high grade squamous intraepithelial neoplastic lesion (CIN 3) and HPV-18 was in low grade lesion just adjacent to the HPV-16 infected area. This case suggests that HPV infection may be one of the most responsible causative agents producing malignant transformation and two distinctive HPV types can also simultaneously infect the squamous epithelium of the uterine cervix.