Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study.

BACKGROUND: Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction. METHODS: This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate. RESULTS: Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork. CONCLUSION: Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane. LEVEL OF EVIDENCE: III.

The lifetime risk of revision following total knee arthroplasty : a New Zealand Joint Registry study.

AIMS: The success of total knee arthroplasty (TKA) is usually measured using functional outcome scores and revision-free survivorship. However, reporting the lifetime risk of revision may be more meaningful to patients when gauging risks, especially in younger patients. We aimed to assess the lifetime risk of revision for patients in different age categories at the time of undergoing primary TKA. METHODS: The New Zealand Joint Registry database was used to obtain revision rates, mortality, and the indications for revision for all primary TKAs performed during an 18-year period between January 1999 and December 2016. Patients were stratified into age groups at the time of the initial TKA, and the lifetime risk of revision was calculated according to age, sex, and the American Society of Anesthesiologists (ASA) grade. The most common indications for revision were also analyzed for each age group. RESULTS: The overall ten-year survival rate was 95.6%. This was lowest in the youngest age group (between 46 and 50 years) and increased sequentially with increasing age. The lifetime risk of requiring revision was 22.4% in those aged between 46 and 50 years at the time of the initial surgery, and decreased linearly with increasing age to 1.15% in those aged between 90 and 95 years at the time of surgery. Higher ASA grades were associated with increased lifetime risk of revision in all age groups. The three commonest indications for revision were aseptic loosening, infection, and unexplained pain. Young males, aged between 46 and 50 years, had the highest lifetime risk of revision (25.2%). CONCLUSION: Lifetime risk of revision may be a more meaningful measure of outcome than implant survival at defined time periods when counselling patients prior to TKA. This study highlights the considerably higher lifetime risk of revision surgery for all indications, including infection, in younger male patients. Cite this article: Bone Joint J 2022;104-B(2):235-241.

Short-Term and Long-Term Renal Outcomes in Patients With Obesity After Minimally Invasive Versus Open Partial Nephrectomy for the Treatment of Renal Cancer: Retrospective Study.

BACKGROUND: Obesity is significantly associated with renal cell carcinoma. Surgery is the preferred treatment for demarcated lesions of renal cell carcinoma; however, obesity increases the complexity of surgical outcomes. Minimally invasive surgical techniques are preferred over open partial nephrectomy (OPN), but controversy remains regarding the most efficacious technique in patients with obesity. OBJECTIVE: This study aims to determine whether minimally invasive partial nephrectomy (MIPN) or OPN better preserves renal function and investigate short- and long-term renal outcomes in patients with obesity undergoing a partial nephrectomy. METHODS: We conducted a retrospective chart review of 242 adult patients aged ≥18 years who underwent MIPN or OPN between January 1, 2005, and December 31, 2016, at the University of Arkansas for Medical Sciences. Using creatinine as a measure of kidney function, patients' preoperative levels were compared with their postoperative levels in 2-time frames: short (3-6 months postsurgery) or long (>6 months). The primary outcome was the change in creatinine values from preoperative to >6 months postoperatively in patients with obesity. Secondary outcomes included the change in creatinine values from preoperative to 3 to 6 months postoperatively in patients with obesity who underwent MIPN versus OPN. We also analyzed the creatinine values of nonobese patients (BMI <30) who underwent partial nephrectomy using the same time frames. Unconditional logistic regression was used to estimate crude and multivariable-adjusted odds ratios (ORs) and 95% CI to observe associations between surgery type and changes in creatinine values from while stratifying for obesity. RESULTS: A total of 140 patients were included in the study, of whom 75 were obese and 65 were nonobese. At >6 months after MIPN (n=20), the odds of patients with obesity having a decrease or no change in creatinine values was 1.24 times higher than those who had OPN (n=13; OR 1.24, 95% CI 0.299-6.729; P=.80). At 3 to 6 months after MIPN (n=27), the odds were 0.62 times lower than those after OPN (n=17; OR 0.62, 95% CI 0.140-2.753; P=.56). In the nonobese group, at 3 to 6 months after undergoing minimally invasive surgery (n=18), the odds of having a decrease or no change in creatinine values was 4.86 times higher than those who had open surgery (n=21; OR 4.86, 95% CI 1.085-21.809; P=.04). At more than 6 months after MIPN (n=14), the odds were 4.13 times higher than those after OPN (n=11; OR 4.13, 95% CI 0.579-29.485; P=.16). CONCLUSIONS: We observed a nonstatistically significant preservation of renal function in patients with obesity who underwent OPN at 3 to 6 months postoperatively. Conversely, after 6 months, the same was true for MIPN, indicating the long-term benefit of MIPN. In the nonobese group, MIPN was favored over OPN.

Mitochondriome and cholangiocellular carcinoma.

Cholangiocellular carcinoma (CCA) of the liver was the target of more interest, recently, due mainly to its increased incidence and possible association to new environmental factors. Somatic mitochondrial DNA (mtDNA) mutations have been found in several cancers. Some of these malignancies contain changes of mtDNA, which are not or, very rarely, found in the mtDNA databases. In terms of evolutionary genetics and oncology, these data are extremely interesting and may be considered a sign of poor fitness, which may conduct in some way to different cellular processes, including carcinogenesis. MitoChip analysis is a strong tool for investigations in experimental oncology and was carried out on three CCA cell lines (HuCCT1, Huh-28 and OZ) with different outcome in human and a Papova-immortalized normal hepatocyte cell line (THLE-3). Real time quantitative PCR, western blot analysis, transmission electron microscopy, confocal laser microscopy, and metabolic assays including L-Lactate and NAD+/NADH assays were meticulously used to identify mtDNA copy number, oxidative phosphorylation (OXPHOS) content, ultrastructural morphology, mitochondrial membrane potential (ΔΨm), and differential composition of metabolites, respectively. Among 102 mtDNA changes observed in the CCA cell lines, 28 were non-synonymous coding region alterations resulting in an amino acid change. Thirty-eight were synonymous and 30 involved ribosomal RNA (rRNA) and transfer RNA (tRNA) regions. We found three new heteroplasmic mutations in two CCA cell lines (HuCCT1 and Huh-28). Interestingly, mtDNA copy number was decreased in all three CCA cell lines, while complexes I and III were decreased with depolarization of mitochondria. L-Lactate and NAD+/NADH assays were increased in all three CCA cell lines. MtDNA alterations seem to be a common event in CCA. This is the first study using MitoChip analysis with comprehensive metabolic studies in CCA cell lines potentially creating a platform for future studies on the interactions between normal and neoplastic cells.

Placebos in 19th century medicine: a quantitative analysis of the BMJ.

OBJECTIVE: To provide the first quantitative data on the use of the term "placebo" in the 19th century. DESIGN: Computer search of BMJ's archival database from January 1840 (the first issue) through December 1899 for uses of the words "placebo(s)." Grounded theory was used to categorise the implications of uses of the term. RESULTS: 71 citations contained the term "placebo(s)." Of these, 22 (31%) used the term to mean "no effect" or as a general pejorative term, 18 (25%) portrayed placebo treatment as permitting the unfolding of the natural history (the normal waxing and waning of illness), 14 (20%) described placebo as important to satisfy patients, 7 (10%) described it as fulfilling a physician's performance role, 3 (4%) described its use to buy time, 3 (4%) described its use for financial gain, 2 (3%) used it in a manner similar to a placebo control, and only one implied that placebo could have a clinical effect. Only one citation mentioned telling the patient about his placebo treatment. CONCLUSION: Nineteenth century physicians had diverse a priori assumptions about placebos. These findings remind us that contemporary medicine needs to use rigorous science to separate fact from its own beliefs concerning the "provision of care." As in previous generations, ethical issues concerning placebos continue to challenge medicine.

Relationships between medical students and drug companies in New Zealand.

The relationships between doctors and drug companies have generated considerable global debate. Medical students are unique stakeholders in this discussion, although they are underrepresented in descriptive data. This article reviews international literature on the effects of drug company promotion, the effect on students, the New Zealand context and explores implications for New Zealand medical students. Creating an influence free environment to inform and involve students in the debate is a strong precursor to delivering gold standard patient care in the future.