Prediction of postoperative pancreatic fistula using a nomogram based on the updated definition

PURPOSE: The International Study Group on Pancreatic Fistula's definition of postoperative pancreatic fistula (POPF) has recently been updated. This study aimed to identify risk factors for POPF in patients having pancreaticoduodenectomy (PD) and to generate a nomogram to predict POPF.METHODS: Data on 298 patients who underwent PD from March 2012 to October 2017 was retrospectively reviewed and POPF statuses were redefined. A nomogram was constructed using data from 220 patients and validated using the remaining 78 patients. Independent risk factors for POPF were identified using univariate and multivariate analyses. A predictive nomogram was established based on the independent risk factors and was compared with existing models.RESULTS: Texture of the pancreas, size of the main pancreatic duct, portal vein invasion, and definitive pathology were the identified risk factors. The nomogram had a C-index of 0.793 and was internally validated. The nomogram performed better (C-index of 0.816) than the other most cited models (C-indexes of 0.728 and 0.735) in the validation cohort. In addition, the nomogram can assign patients into low- (less than 10%), intermediate- (10% to 30%), and high-risk (equal or higher than 30%) groups to facilitate personalized management.CONCLUSION: The nomogram accurately predicted POPF in patients having PD.

Modified surgical techniques of free vascularized fibular grafting for treatment of the osteonecrosis of femoral head: results from a series of 407 cases.

The goal for treatment of osteonecrosis of the femoral head (ONFH) is to relieve pain, preserve the contour of the femoral head, and delay the need for total hip arthroplasty. The free vascularized fibular grafting (FVFG) has been shown to support the subchondral architecture as well as restore local circulation for the necrotic femoral head in treatment of ONFH. This report aimed to present the clinical results of the use of a modified surgical technique of FVFG for treatment of ONFH. Four hundred and seven patients with 578 hips of ONFH were included. The patients' average age was 36.7 years old (ranging 19-55 years old). The disease was staged from II to V based on the Steinberg classification system. By the modified procedure, the vascularized fibular graft was harvested via a lateral incision with fibular osteotomy prior to the exposure of the vascular pedicle, and the removal of necrotic tissue and inset of graft were performed through an anterior approach. The operative time averaged 90 min for unilateral ONFH (ranging 75-110 min) and 190 min for simultaneous treatment of bilateral ONFH (ranging 160-230 min). The average length of follow-up was 5.0 years (ranging 3-10 years). The complications included one infection in one case, temporary loss of sensation of the thigh in eleven cases, and restricted motion of the great toe in nine cases. The Harris hip score of patients improved from 65.0 to 86.9 on average. Radiographic evaluation showed no changes in 331 hips (57.3%), improvement in 195 hips (33.7%) and necrosis progression in 52 hips (9.0%). Twenty-three hips (4.0%) in 20 patients had total hip arthroplasty during the period. These results show that the modified technique of the use of FVFG for treatment of ONFH yields similar postoperative results in comparison to the traditional method.

Injury-to-surgery interval does not affect the occurrence of osteonecrosis of the femoral head: a prospective study in a canine model of femoral neck fractures.

BACKGROUND: It is controversial whether an early reduction and internal fixation can reduce the occurrence of femoral neck fracture-induced osteonecrosis of the femoral head (ONFH). This prospective study was designed to reflect the relationship between injury-to-surgery interval (ISI) and traumatic ONFH based on a canine model of femoral neck fractures. MATERIAL/METHODS: Twenty-four dogs were equally divided randomly into 3 groups. A lateral L-shape approach centered left great trochanter was used for exposure of the femoral neck. A low-speed drill was used for making displaced fractures in the narrow femoral neck, with the femoral head kept in situ with ligamentum teres intact. In Group A, the fracture was immediately reduced and fixed with 3 parallel pins; while the operation was done 3 days later in Group B, and 3 weeks later in Group C. Another 2 dogs had their fractures untreated. Postoperatively, all dogs were fed separately and received regular x-ray examination. Left femoral heads were harvested for histological examination with a postoperative follow-up of 3.5 months. RESULTS: The canine model of femoral neck fractures could be achieved successfully. Radiological signs of post-fracture ONFH could not be detected at intervals of 2 weeks, 4 weeks, 1 month and 2 months. Histologically, there were 2 cases with ONFH in Group A, 1 case in Group B, and 2 cases in Group C. The difference had no statistical significance. For untreated fractures, obvious ONFH could be found radiologically. CONCLUSIONS: A shorter ISI may not reduce the incidence of fracture-induced ONFH, which suggests that intrinsic factors play an important role in the occurrence of ONFH.

Free vascularised fibular grafting combined with a locking plate for massive bone defects in the lower limbs: a retrospective analysis of fibular hypertrophy in 18 cases.

OBJECTIVE: Free vascularised fibular grafting (FVFG) could be a good option for the restoration of massive bone defects in lower limbs when combined with use of a locking plate. The progress of fibular hypertrophy is closely related to regain of function, as well as to prevention of stress fractures. Multiple variables affecting fibular hypertrophy were investigated in the current study to elucidate correlative factors. METHODS: Eighteen patients with a massive bone defect in a lower limb reconstructed by FVFG combined with a locking plate were retrospectively enrolled in the current study. The degree of fibular hypertrophy was calculated based on the measurements from anteroposterior imaging at regular intervals of 3 months, 6 months, 1, 2 and 3 years postoperatively. Repeated measures analysis of variance was employed to evaluate and compare correlative factors including gender (male vs. female), age distribution (<30 years vs. >30 years), site (femur vs. tibia) and length of bone defect (6-10 cm vs. >10 cm), previous number of operations (once vs. more than twice) and concomitant infection (detected vs. non-detected). RESULTS: All defects could be successfully repaired by FVFG and bone union was achieved uneventfully. The degree of fibular hypertrophy was 0.14%, 11.27%, 31.53%, 58.14% and 71.81% retrospectively at the five follow-up time points. Statistical analysis revealed that the above-mentioned factors did not affect the progress of fibular hypertrophy. CONCLUSIONS: FVFG could be a good choice for the reconstruction of massive bone defects when combined with a locking plate. Factors including gender, age distribution, site and length of bone defects, number of previous operations and infection do not impact the progress of fibular hypertrophy, which implies that intrinsic factors might play an important role in restoration.

Pain relief following osteonecrosis of the femoral head treated by free vascularized fibular grafting.

BACKGROUND: Pain is the core and basic problem in the treatment of osteonecrosis of the femoral head (ONFH). However, it is unclear about the status of pain relief following ONFH treated by free vascularized fibular grafting (FVFG) and the level of pain relief contributed to clinical results. Therefore, we designed a consecutive and prospective study to investigate post-operative pain relief in the treatment of osteonecrosis of the femoral head by FVFG. METHODS: One hundred and fifty-one patients with unilateral osteonecrosis of the femoral head were enrolled consecutively for current prospective study from January to August of 2006. Patients were managed by modified technique of free vascularized fibular grafting. Pre-operative, post-operative Harris hip score (HHS) and Harris pain score (HPS) were recorded and compared statistically, meanwhile, correlation between disease severity and Harris hip score, Harris pain score were revealed. RESULTS: All patients had an average follow-up of 54.3 months. Post-operative Harris hip score could be improved from 73.7 to 83.5 averagely in stage-II patients, 64.6 to 78.9 in stage-III, and 53.6 to 72.4 in stage-IV. As for Harris pain score, it was elevated from 28.8 to 38.6 in stage-II patients, 25.5 to 36.6 in stage-III, and 21.8 to 34.2 in stage-IV. Taken together, HHS was improved from 67.7 to 80.3 (ΔHHS = 12.6), and HPS was improved from 26.6 to 37.3 (ΔHPS = 10.7) averagely. CONCLUSIONS: Harris pain score could be employed to monitor prognosis of osteonecrosis of the femoral head treated by free vascularized fibular grafting. Improvement of HPS was the heaviest contributor to elevation of HHS, and both of them conceived of a close relationship with disease severity.

Free vascularized fibular grafting in combination with a locking plate for the reconstruction of a large tibial defect secondary to osteomyelitis in a child: a case report and literature review.

Although a large skeletal defect secondary to osteomyelitis in children is not an uncommon problem, there are no descriptions of the management of such a defect with a free vascularized fibular graft in combination with a locking plate. We performed such a technique, after radical debridement and systemic antibiotic treatment, on a 13-year-old boy suffering from a large 10 cm tibial defect secondary to osteomyelitis. Primary union of the graft was achieved at 6 months. No recurrence of osteomyelitis occurred in the 29-month follow-up period, and limb salvage and eradication of the infection were achieved successfully.

Treatment of aseptic nonunion after intramedullary nailing fixation with locking plate.

OBJECTIVE: To evaluate the safety and efficacy of locking plate combined with bone grafting in the treatment of aseptic nonunion following intramedullary nailing fixation of fractures of the long bones. METHODS: Thirty-eight consecutive patients treated in our hospital between January 2004 and December 2006 were included in this retrospective study. The nonunions included 20 femurs, 15 tibias, and 3 humeri. The duration of non-union ranged from 6 to 84 months and 21 (55.3%) of them were located around the metaphysis of the affected long bones. There were 12 women and 26 men with a mean age of 39.2 years (range, 9-70 years). Locking plate combined with bone grafting was the procedure chosen to treat every case of nonunion in this series. The clinical outcomes were evaluated. RESULTS: All patients were followed up for 6-20 months (average 11.6 months). After locking plate fixation combined with bone grafting, union was achieved in all cases, the average healing time being 5.3 months (range, 4-8 months). Infection of the superficial incision occurred in three cases (7.9%) and delayed healing of the incision in one case, all of which healed with no further complications. The function of the adjacent joints was excellent to good in 30 patients (78.9%), fair in 7 (18.4%) and poor in 1 (2.6%) after follow-up. CONCLUSION: Locking plate fixation combined with bone grafting is a highly effective treatment for aseptic nonunions of the long bones after intramedullary nailing fixation, especially in the case of metaphyseal nonunion.

[The surgical technique and follow-up of the treatment with locking internal fixation on long bone nonunion of extremities].

OBJECTIVE: To report the outcome of long bone nonunion of humerus, femur and tibia treated with locking internal fixation and bone graft. METHODS: From February 2003 to October 2006, locking internal fixation and bone grafting were employed to treat 5 cases at humerus, 33 cases at femur, 23 cases at tibia. Forty-four of the patients were men, and 17 were women. The mean age was 38 years (range 7-70 years). The nonunion had resulted from failure of internal fixation in 47 cases, failure of external fixation in 5 cases, infection in 9 cases. The history of nonunion lasted from 10 to 156 months (mean 19 months). There were 42 patients treated with locking compression plate (LCP), and 19 patients with less invasive stabilization system (LISS). For bone grafting, autogenous ilium was used in 55 patients, autogenous ilium and allograft bone was used in 3 patients, allograft bone and Wright DBM artificial bone was used in 3 patients. RESULTS: All the 61 patients were followed up for an average 12 months (range 6-24 months) only to reveal solid bone union in all the fracture, with a mean healing time of 4.8 months (ranged from 4 to 6 months). No loosening or breakage of the implants occurred in this series. The Knee Society Scores (KSS) was used to evaluate knee function in 47 patients with peri-knee joint nonunion, excellent result were seen in 35 patients, good in 7 patients, fare in 1 patients, poor in 4 patients. CONCLUSION: Locking internal fixation can be used to treat effectively bone nonunion at the humerus, femur and tibia.