Patient's satisfaction after outpatient forefoot surgery: Study of 619 cases.

INTRODUCTION: The number of outpatient surgical procedures performed in France on the forefoot has grown rapidly in recent years. OBJECTIVES: The goal of this study was to evaluate experience and satisfaction of patients undergoing outpatient foot surgery using a telephone questionnaire developed for this purpose. MATERIAL AND METHODS: In 2012 and 2013, every patient who was admitted to the day surgery unit at our hospital for an open procedure on their forefoot was called the morning after the procedure. A nurse went through the 14-item questionnaire with the patient. The same perioperative protocol, written instructions and treatment were used for all patients. RESULTS: Six hundred nineteen patients were included. The questionnaire response rate was 89% (n=540). Isolated hallux valgus surgery was performed on 319 patients (61%); 107 patients (20%) underwent hallux valgus surgery with lateral metatarsal osteotomy; 57 patients (10.5%) underwent first metatarsophalangeal fusion and 47 patients (8.5%) underwent a procedure on the lateral rays only. In the postoperative phase, 65% reported having satisfactory sleep quality, 32% had experienced nausea, 16% had experienced vomiting and 17% had experienced bleeding. Eighty percent of patients experienced pain (VAS ≥ 1); 80% of these patients had their pain relieved by the prescribed treatment and 4% had not taken it. Nearly all the patients (99%) were satisfied with the outpatient care; the overall satisfaction score was 9.4 out of 10. There was a significant relationship between the type of procedure and vomiting, pain, bleeding and fever. DISCUSSION: Outpatient care is becoming more common in response to economic challenges. The development of outpatient foot surgery appears to have satisfied the vast majority of operated patients. However, adjustments should be made to improve their tolerance to the pain management protocol. Although the logistics of performing follow-up call can be complicated, the patients appreciate receiving this call the next day. The call also seems to reassure both the patients and care providers.

Flexor digitorum brevis tendon transfer to the flexor digitorum longus tendon according to Valtin in posttraumatic flexible claw toe deformity due to extrinsic toe flexor shortening.

Claw toe deformity after posterior leg compartment syndrome is rare but incapacitating. When the mechanism is flexor digitorum longus (FDL) shortening due to ischemic contracture of the muscle after posterior leg syndrome, a good treatment option is the Valtin procedure in which the flexor digitorum brevis (FDB) is transferred to the FDL after FDL tenotomy. The Valtin procedure reduces the deformity by lengthening and reactivating the FDL. Here, we report the outcomes of FDB to FDL transfer according to Valtin in 10 patients with posttraumatic claw toe deformity treated a mean of 34 months after the injury. Toe flexion was restored in all 10 patients, with no claw toe deformity even during dorsiflexion of the ankle.

Influence of socioprofessional category on the duration of sick leave after hallux surgery: a prospective study of 102 cases.

INTRODUCTION: Surgery of the forefoot including the hallux involves procedures on one bone or more. Usually bone union occurs within 45 days after surgery. During convalescence, the patient can gradually return to his/her activities. The duration of sick leave (SL) can be used to evaluate the influence of convalescence on professional life. The goal of this study was to evaluate the influence of the socioprofessional category (SPC) on the duration of SL after surgery of the forefoot including the hallux. PATIENTS AND METHODS: This was a single center, single surgeon prospective cohort study performed between January 2012 and March 2013. It included working patients over 18 who underwent hallux surgery associated or not with surgery of the lateral rays. A standardized questionnaire was filled out during the postoperative day 45 consultation to determine factors that could influence the duration of sick leave. Regression models (Cox model) were used to indentify variables associated with the duration of sick leave. RESULTS: Among the operated patients, 102 were included and divided into 5 SPC. SL lasted a mean 45 days (from 8 to 90 days). The only predictive factors for the duration of SL on multivariate analysis using SPC 2 as a reference were SPC and the VAS (Visual Analogue Scale). The mean duration of SL was 15 days for SPC 2, 35 days for SPC 3, 47 days for SPC 4, 50 days for SPC 5 and 67 days for SPC 6. DISCUSSION-CONCLUSION: The distribution of SPC was comparable to that of the working population in the Île de France. The SPC appears to be a predictive factor for the duration of SL after hallux surgery. Severe pain seems to increase the duration of SL. Surgeons and patients should be informed accordingly. LEVEL OF EVIDENCE: Level IV.

Infected total hip arthroplasty revision: one- or two-stage procedure?

INTRODUCTION: Better outcomes have been reported for two-stage total hip arthroplasty (THA) revision for infection. However, one-stage revision arthroplasty remains an attractive alternative option since it requires only one operation. A decision tree has been developed by the authors in order to determine which type of surgical procedure can be performed safely. The goal of this study was to assess this decision tree for THA replacement in the case of a peri-prosthetic infection. HYPOTHESIS: A one-stage procedure may be as successful as a two-stage procedure provided some criteria are fulfilled. METHODS: A prospective study included 84 patients, all diagnosed with infected THA who had prosthesis replacement. A one-stage exchange was performed in 38 cases and a two-stage procedure in 46 cases. A two-stage procedure was decided in the case of important bone loss or unidentified germ. Postoperatively, patients received intravenous antibiotics (six weeks), then oral antibiotics (six weeks). The main evaluation criterion was the rate of infection eradication at 2 years minimal follow-up since surgery. If new infection was suspected, a hip aspiration was performed to determine whether it was non-eradication (same germ) or a new re-infection (other germ), which was not considered as a failure. RESULTS: The initial infection was cured in 83 out of 84 patients (98.8%), 38 (100%) for the one-stage group and 45 (97.8%) for the two-stage group. Three patients were re-infected with different germs in the two-stage group. Eighty out of 84 (95.2%) patients were infection free, all patients (100%) of the one-stage group and 42 patients (91.3%) of two-stage group. DISCUSSION: If some selection criteria were respected, a high success rate in THA replacement for infection may be achieved with a one-stage procedure. It permits to reduce the costs with no loss of chance for the patients. The decision tree was validated. LEVEL OF EVIDENCE: Level III; prospective case control study.

Prevention of radiolysis of monoclonal antibody during labeling.

UNLABELLED: Monoclonal antibody may undergo loss of immunoreactivity due to radiation damage when labeled with large amounts of 131I or 90Y for therapy. Our aim was to develop a method to protect an antibody during the labeling procedure. METHODS: As a model we used T101, a murine monoclonal antibody directed against CD5 antigen. Iodine-125-T101 (100 micrograms, 1 ml) was mixed with 90Y-DTPA (0.64 MBq to 165.9 MBq) for 24 hr in order to deliver doses of 5 Gy to 1280 Gy to the solution. In separate experiments, 125I-T101 solutions were irradiated with 60Co external beam delivering radiation doses of 40 Gy to 1280 Gy. The effect of radiation on T101 immunoreactivity was tested by using the CCRF-CEM cell line, and the bound T101 radioactivity was determined. In a final experiment, we directly labeled a DTPA conjugated T101 using 561 MBq of 90Y under conditions delivering approximately 640 Gy to the solution. Previously used radioprotectants including human serum albumin, cysteamine and glycerol were evaluated. We focused on ascorbic acid because it is an FDA approved drug that does not interfere with the radiolabeling process. RESULTS: The immunoreactivity of 125I-T101 was approximately 83%, but at 640 Gy the immunoreactivity decrease to 7%. In contrast, in the presence of radioprotectants this decrease could be abrogated. External irradiation also showed a dose dependent decrease in immunoreactivity to as low as 0.3% at 1280 Gy. Adding ascorbic acid (5.5 mg/ml) to the solutions prior to the irradiation largely abrogated this decrease. The immunoreactivity of T101 labeled with 90Y without protectant showed 46% immunoreactivity whereas, in presence of ascorbic acid (11 mg/ml) full retention of immunoreactivity was observed. CONCLUSION: Various radioprotectants can successfully prevent the loss of immunoreactivity or breakdown as a result of radiolysis. Ascorbic acid is an effective radioprotectant that can be used to prevent loss of antibody immunoreactivity during the labeling process.

Population management in an HMO: new roles for nursing.

A project to define and test population-management roles in nursing was implemented in a large HMO. Three patient populations were selected: diabetics, patients with multiple sclerosis, and pregnant adolescents. Expert nurse clinicians in each of the three areas piloted the role for six months, including establishing a system of care coordination for th populations. In all three pilots, patient care outcomes were improved. Keys to success included aligning the work with the critical clinical work of the organization, practicing in multidisciplinary settings, and reporting objective outcome data to constituents.

Variation in sensitizing efficiency for SR 2508 in human cells dependent on glutathione content.

The observation by several authors and ourselves that manipulation of glutathione (GSH) levels in cultured cells would change the relative sensitization of hypoxic cells by nitroimidazole sensitizers led to the hypothesis that natural variation in GSH level could influence the sensitizer enhancement ratio (SER). Since many human tumor cell lines have shown high GSH levels, the A549 lung line, the HeLa line and a skin fibroblast line, the AG1522, were studied in monolayer culture in glass flasks. The GSH levels (nmol/mg protein) measured were 324 for A549, 103 for HeLa, and 32 for 1522 cells. For V-79 cells the level was 25 nmol/mg. In control experiments there was no effect of up to 10 mM SR 2508 in air but BSO (D,L-buthionine-S-R-sulfoximine) treatment modestly sensitized the A549 in air and nitrogen. Calculation of SER values at 1% survival revealed very little sensitization at 0.1, 0.5, and 1.0 mM SR 2508 for A549 cells (SER not significantly different than 1). At 5 mM the SER was 1.5 and at 10 mM 1.65. In contrast, the SER for fibroblasts was 1.65 at 0.5 mM and 2.2 at 1.0 mM SR 2508. The results for HeLa were intermediate, 1.25 and 1.45 at the same concentrations. Thus, the SER relates to the GSH levels in the cells. Treatment with BSO increased the sensitization of A549 to a level similar to that seen for AG1522 at 0.5 and 1.0 mM. These findings could explain the negative results of some sensitizer clinical trials.

Double outlet right ventricle associated with common atrioventricular canal: report of nine anatomic specimens.

Double outlet right ventricle associated with complete atrioventricular (AV) canal is a rare malformation. Nine cases are reported. In this abnormality the anterior AV leaflet is undivided and free floating and the aortic and pulmonary orifices are in the same frontal plane. In four of the nine cases, the conus was bilateral, but it was slightly hypoplastic in two. In five cases there was no subaortic conus and there was mitral-aortic continuity through the ventricular septal defect. Pulmonary stenosis was present in eight cases. Radiograms may best demonstrate the anatomy of the ventricular septal defect; it extends far anteriorly below the aortic valve, and its inferior rim is deviated by the trabecula septomarginalis.