Should a Patients BMI Status be Used to Restrict Access to Total Hip and Knee Arthroplasty? Functional Outcomes of Arthroplasty Relative to BMI - Single Centre Retrospective Review.

We reviewed the experience of a dedicated orthopaedic elective service to determine whether we could establish a BMI group where arthroplasty was no longer effective as assessed by the patient's functional outcome. This was a prospective observational study with retrospective analysis of data collected on 1439 total hip arthroplasty, 934 total knee arthroplasty and 326 unicompartment knee arthroplasty patients. Functional scores (WOMAC, Oxford hip and knee scores and HAAS) were obtained preoperatively and at 12 months post op. Patients had their BMI recorded at the preoperative assessment and were divided into BMI groups (BMI<25, BMI 25-30, BMI 30-35 and BMI > 35). Patients with a BMI of ≤ 30 had significantly better functional scores at 12 months post op compared to those with a BMI of > 35. The absolute gain in functional scores from pre op to 12 months post op did not differ significantly between BMI groups, the only significant difference we found for absolute gain showed patients with a BMI of > 35 have a greater increase in HAAS scores following total hip arthroplasty compared to patients with a BMI of 30 or less (p = 0.0435). Our patients with higher BMI's had worse preoperative and post operative functional scores but their benefit from surgery measured by the change in functional scores showed no difference compared to patients with lower BMI. We could find no reason on the basis of the 12-month results to limit surgery to obese patients because of an expected poorer functional outcome.

YAG laser resection of complicated hemangiomas of the hand and upper extremity.

Complicated hemangiomas of the hand or upper extremity have been resected in eight patients with use of the YAG laser with sapphire scalpels. This laser allows excellent hemostasis and precise surgery, thus allowing resection of complicated problems. Many of the patients have had preoperative arteriography with selective embolization, which has aided in hemostasis. Almost complete but subtotal resection of hemangioma was possible in four of the eight patients with well localized lesions. Three patients had only partial resections of hemangiomas and one lesion was considered unresectable.

Benefits of contact and noncontact YAG laser for periorbital hemangiomas.

Twenty patients with capillary/cavernous hemangiomas of the periorbital area (eyelid, eyebrow, nose extending to canthus) have been treated with a variety of techniques. Six patients were treated by yttrium-aluminum-garnet (YAG) laser photocoagulation and direct injection of steroids. Rapid shrinkage of the hemangiomas occurred in all patients, and 2 infants whose eye was totally occluded by the hemangioma had their eyes rapidly opened. YAG laser excision with or without previous photocoagulation plus injection and with arteriogram plus superselective embolization was performed in the other 14 patients. Results were satisfactory in all patients.

Combination treatment for massive cavernous hemangioma of the face: YAG laser photocoagulation plus direct steroid injection followed by YAG laser resection with sapphire scalpel tips, aided by superselective embolization.

A massive cavernous hemangioma of the face in an 11 month old child has been successfully resected utilizing a combination of laser and non-laser techniques. The hemangioma was initially treated twice with YAG laser photocoagulation plus direct injection of steroids. This treatment promptly stopped the rapid growth and induced blanching as well as a 25% shrinkage with each treatment. Arteriogram with superselective embolization produced a further shrinkage of the hemangioma. Finally, the contact YAG laser with sapphire scalpel tips was utilized for complete and cosmetically satisfactory hemangioma resection. The treatment of a massive cavernous hemangioma by a combination of modalities is discussed.

High- and low-technology solutions for massive cavernous hemangioma of the face: lasers and leeches to the rescue.

A massive cavernous hemangioma of the face has been resected using a combination of old and new techniques. The ability of the neodymium: YAG laser to cut with excellent hemostasis formed the basis for the resection. Adjuncts to the surgical excision included such high-technology modalities as laser Doppler flowmeters and tissue expanders. Flap viability was salvaged by the lowly but essential common leech. This case is presented to illustrate the fantastic array of modalities available to plastic surgeons for major resections and reconstructions.

Sapphire tip technology for YAG laser excisions in plastic surgery.

Thirty-two patients with a variety of vascular and nonvascular lesions have been resected over a 3-year period with the neodymium:YAG laser utilizing sapphire peripheral scalpel devices. These innovative peripheral devices concentrate the YAG laser energy to a small area at the end of the scalpel, providing precise incisions with excellent hemostasis. In addition, the tactile sensation of the scalpel contacting tissue is more comfortable and familiar than the "no touch" aspect of other lasers that are held away from the surface and depend on laser light transmission to approach the skin. Total excision with excellent hemostasis was achieved in 17 patients, while 15 patients had subtotal resection. The YAG laser with sapphire scalpels has allowed resection of very difficult and massive hemangiomas previously considered unresectable by standard techniques.

Benefits of the CO2 laser for verruca resistant to other modalities of treatment.

The benefits of the carbon dioxide (CO2) laser in the treatment of verruca resistant to other forms of treatment have been studied. Twenty-five patients with warts unsuccessfully treated from one to five times previously were treated with the laser, followed for a minimum of 6 months, and evaluated. Eight of these patients (32%) gained a total permanent cure. An additional five treatments resulted in a subtotal (over 75%) cure but some warts remained. Thus, 13 of 25 patients (52%) experienced complete or partially successful treatment. The CO2 laser is a valuable modality in the treatment of recalcitrant warts but cannot be expected to cure all such warts.

A preliminary study of the combined effect of neodymium: YAG laser photocoagulation and direct steroid instillation in the treatment of capillary/cavernous hemangiomas of infancy.

Thirteen patients with capillary/cavernous hemangiomas of infancy have been treated with a combination of neodymium: YAG laser photocoagulation plus direct local instillation of steroids. In all cases, rapid growth immediately ceased and blanching started. Shrinkage of the lesions then occurred spontaneously over the ensuing months; any plateau in shrinkage was retreated. Five of 13 patients experienced dramatic blanching and shrinkage with one treatment. Six experienced mild to moderate shrinkage. Complications occurred in 2 patients.

Failure of carbon dioxide laser excision of keloids.

Seven patients with nine keloids have been treated by excision with the carbon dioxide laser. Eight of the nine keloids have recurred to their original or close to original size as early as 10 months following treatment and as late as 22 months. Keloids included in this study were located on the trunk, nuchal region, back, and earlobe. Only one patient (who underwent earlobe keloid excision) has greatly improved keloids after only 9 months follow-up, but this patient needs to wear pressure earrings continuously. The long-term benefits of keloid excision with the carbon dioxide laser is not demonstrated in this case study series.

Computerized suction lipectomy aspirator monitor for improved results in suction lipectomy.

A new computerized suction aspirator monitor is described. This device offers the benefits of instantaneous and concurrent scientifically accurate readout of aspirate contents in five separate bodily areas. Thus knowledge of amounts of blood versus fat can be immediately known without resorting to guess, estimate, or cumbersome lipocrit determination by centrifuging. Advantages of such a device include better accuracy in determination of fat removal from each area, with improvement of symmetrical fat removal. More exact determination of blood loss with improved hemodynamic replacement is also more easily and safely accomplished. In an area of mystique, experience, artistry, and aesthetic appreciation which has cloaked the initial enthusiasm for suction lipectomy, a new generation of scientific accuracy is now possible. Thus accurate determination of aspirate content vis-a-vis fat and blood can now transform this procedure into a more sophisticated and scientifically accurate operation which traditionally is desired by most practitioners of suction lipectomy.

532-nanometer green laser beam treatment of superficial varicosities of the lower extremities.

Green laser light at 532 nm was utilized in an attempt to thrombose and blanch superficial varicosities of the lower extremity in 14 patients. Selective vascular damage with sparing of overlying skin was the theoretical rationale for use of green light. Seven of the 14 patients achieved satisfactory results (total or near-total obliteration of vessels without scarring) after a 6-month period of observation.

Treatment of xanthelasma palpebrarum with the carbon dioxide laser.

Six patients with xanthelasma palpebrarum of the eyelids have been treated with the CO2 laser and followed for periods varying up to 4 years. Satisfactory cosmetic results were achieved in all patients without significant scarring, and no recurrence has been discovered thus far.

Preliminary report on use of the neodymium-YAG laser in plastic surgery.

Thirty-four patients with 57 cutaneous lesions have been treated with the Nd:YAG laser under an experimental protocol over a year of study. The majority of treatments were done on an outpatient basis under local anesthesia. Capillary/cavernous hemangiomas of the oral cavity responded well, but hemangiomas of infancy responded poorly. Hypertrophic scars and keloids responded well only in conjunction with steroid treatment. Epistaxis in patients with hereditary hemorrhagic telangiectasia responded well for 4-5 months and then recurred. Areas with thin skin or mucosa have the potential for full-thickness injury with complications of scar, bony exposure, or septal perforation.

Dot or pointillistic method for improvement in results of hypertrophic scarring in the argon laser treatment of portwine hemangiomas.

In an attempt to limit scarring, 51 patients have been treated over a period of 2 years with the argon laser in a dot or pointillistic fashion. One- to 2-mm dots are blanched at intervals of 1-2 mm with minimal power, and the interspaces are filled in at 12 weeks. Scar-prone areas of the face such as the upper lip, nasolabial fold, nose, and lower lip have been successfully treated with minimal scarring and good fading. Lesions of the trunk and extremity have also been successfully treated.

Study of three laser systems for treatment of superficial varicosities of the lower extremity.

Three separate laser modalities were investigated in the treatment of superficial varicosities/telangiectasias of the lower extremities. Sixteen patients were treated and followed for 12 months. The superpulse CO2, the pulsed focally specific CO2, and the Nd:YAG laser transmitted through a diffusing sapphire tip were able to produce cosmetically satisfactory permanent obliteration of vessels after a 12-month follow-up interval. These results were a significant improvement over six-month results indicating a long fading time for laser treatment of leg veins.

Superpulse CO2 laser treatment of facial syringomata.

Eight patients with facial syringomata have been treated with the superpulse CO2 laser and followed for periods up to 3 years. Superpulse capability allows satisfactory photovaporization of overlying skin and exposure and liberation of the underlying cyst. Healing was satisfactory with minimal scarring and no persistence or recurrence of syringomata in five of eight cases.

Carbon dioxide laserbrasion for treatment of adenoma sebaceum in tuberous sclerosis.

Adenoma sebaceum is a disfiguring facial deformity that constitutes part of the multiple system involvement in tuberous sclerosis. Three affected patients have been treated with carbon dioxide "laserbrasion," which has resulted in a long-lasting improvement without scarring or recurrence. Tuberous sclerosis is described, and the CO2 technique is discussed.

Comparison of argon and carbon dioxide laser treatment of decorative tattoos: a preliminary report.

Seven patients with either homemade or professional decorative tattoos have been treated with both the argon and CO2 lasers and studied clinically as well as histologically. The argon laser is absorbed by dermal pigment and vaporizes this pigment out of the skin. The CO2 laser vaporized tissue layer by layer and must be accompanied by mechanical debridement. Results and complications of treatment with the two lasers were markedly similar, as were histological studies.

Benefits of the CO2 laser in oral hemangioma excision.

Twenty-one patients with small localized oral cavity hemangiomas of the lips, tongue, and buccal mucosa are reported in this series. Although the lesions were not massive or high-flow/high-pressure vascular tumors, the simultaneous cutting and coagulation capabilities of the CO2 laser were demonstrated, rendering such excisional surgery more precisely and easily accomplished with a great deal less bleeding and a marked reduction in postoperative pain and edema. Many of the patients in this series were done as outpatients under local anesthesia. Results were acceptable and complications were minimal. Thus this laser is recommended both for the patient care and comfort aspects and the ability to render oral cavity hemangioma excisional surgery much more safely and easily done with a significant decrease in hospital utilization and overall medical expenses.

Angiokeratoma of Fordyce: successful treatment with the argon laser.

Argon laser photocoagulation of angiokeratomas of Fordyce, or scrotal angiomas, has been described. The benefits of the argon laser in treatment of these lesions include permanent eradication of the lesions and alleviation of the symptoms of pruritus and episodic bleeding. This method of treatment is safe, does not produce iatrogenic malignant neoplasms, is noninvasive, and is accomplished as an outpatient procedure under local anesthesia with minimal discomfort or disability.