Valgus alignment of the femoral component is associated with higher revision rates 10 years after TKA.

PURPOSE: Appropriate positioning and alignment of tibial and femoral component in primary total knee arthroplasty (TKA) are factors of major importance directly related to patient satisfaction and implant survival. Most literature works elaborate on overall post-operative alignment and its correlation to implant survival. However, less is known about the impact of individual component alignment. The purpose of this study was to investigate the effect of undercorrection of overall alignment as well as the effect of individual tibial and femoral component alignment on the post-operative failure rate after total knee arthroplasty. METHODS: Clinical and radiographic data of primary TKA cases from 2002 to 2004, with a minimum of 10-year follow-up, were retrospectively reviewed. The pre- and post-operative hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA) and mechanical medial proximal tibial angle (mMPTA) were measured on weight-bearing, full-length antero-posterior lower limb radiographs. Statistical analysis was performed to establish the correlation between both overall and implant alignment and revision rate. RESULTS: In total, 379 primary TKA cases were evaluated. The mean time of follow-up was 12.9 years (range 10.3-15.9 years, SD = 1.8). Nine out of 379 cases were revised due to aseptic loosening; the mean time to revision was 5.5 years (range 1.0-15.5 years, SD = 4.6). Varus undercorrection of overall alignment was not associated with a higher rate of revision (p = 0.316). Post-operative valgus femoral alignment (mLDFA < 87°) contributed to a significant decreased prosthesis survival in contrast to neutral femoral alignment (revision rate valgus group: 10.7% and neutral group: 1.7%; p = 0.003). Post-operative tibial mechanical alignment was not identified as a significant predictor for implant survival (revision rate varus group: 2.9% and neutral group: 2.4%; p = 0.855). CONCLUSIONS: Primary TKA showed significantly higher revision rates when the femoral component was placed in > 3° of valgus (mLDFA < 87°). In contrast, postoperative overall residual varus alignment (HKA) and varus alignment of the tibial component were not related to higher revision rates at a minimum 10-year follow-up after TKA. These findings should be considered when choosing component position in individualised TKA. LEVEL OF EVIDENCE: III.

Teaching humanitarian surgery: Filling the gap between NGO needs and subspecialized surgery through a novel inter-university certificate.

Background: Access to surgical care is a global health burden. A broad spectrum of surgical competences is required in the humanitarian context whereas current occidental surgical training is oriented towards subspecialties. We proposed to design a course addressing the specificities of surgery in the humanitarian setting and austere environment.Method: The novelty of the course lies in the implication of academic medical doctors alongside with surgeons working for humanitarian non-governmental organizations (NGO). The medical component of the National Defense participated regarding particular topics of war surgery. The course is aimed at trained surgeons and senior residents interested in participating to humanitarian missions.Results: The program includes theoretical teaching on surgical knowledge and skills applied to the austere context. The course also covers non-medical aspects of humanitarian action such as international humanitarian law, logistics, disaster management and psychological support. It comprises a large-scale mass casualty exercise and a practical skills lab on surgical techniques, ultrasonography and resuscitation. Attendance to the four teaching modules, ATLS certification and succeeding final examinations provide an interuniversity certificate.30 participants originating from 11 different countries joined the course. Various surgical backgrounds, training levels as well as humanitarian experience were represented.Feedback from the participants was solicited after each teaching module and remarks were applied to the following session. Overall participant evaluations of the first course session are presented.Conclusion: Teaching humanitarian surgery joining academic and field actors seems to allow filling the gap between high-income country surgical practice and the needs of the humanitarian context.

Wartime colon injuries: primary repair or colostomy?

A retrospective non-randomized study, comparing primary repair with colostomy, was made on a series of 102 patients with penetrating intraperitoneal colon injuries, in a war surgery programme in Cambodia. The overall case fatality rate (CFR) was 25.5%, whereas in the primary repair group CFR was 20%, compared to 30.8% in the colostomy group. The difference was not statistically significant (P = 0.30). Adjustment for possible confounding factors in the two groups did not alter the results. Considering the numerous advantages to the patient of a primary closure in the precarious situations where war surgery is often performed, this technique merits consideration.

Gardner syndrome and desmoid tumors.

Desmoid tumours present difficult management problems in patients with Gardner's syndrome. We recently studied two patients with Gardner's syndrome, who developed a desmoid tumour arising of the abdominal wall and mesenteric root. One patient had a total resection of the mesenteric desmoid tumour followed by postoperative radiotherapy. No recurrence occurred in the last three years. The other patient had an incomplete resection and refused postoperative radiotherapy. Abdominal CT scan revealed tumour expansion 6 months postoperatively. From our experience and with respect to current literature, we suggest that complete surgical excision combined with radiotherapy (4.000-6.000 rads) could diminish the recurrence rate of desmoid tumours. When resection is incomplete or technically impossible, radiotherapy remains the second choice of treatment.

Noninvasive measurement of nutrient portal blood shunting: an experimental study with [14C]ursodeoxycholic acid.

All of the methods proposed for measuring portal blood flow are either invasive, estimate total rather than nutrient flow, and none has proved reliable in cirrhotic patients. A method has been derived from pharmacokinetic principles used for the calculation of bioavailability of drugs according to the route of administration (i.v. or p.o.) and tested experimentally in 20 pigs. A tracer dose of [14C]ursodeoxycholic acid, a biliary acid with a high-liver first-pass effect, is administered in the duodenum, and serial peripheral blood samples are taken. Later, the same dose of the same drug is administered i.v. The shunt fraction of portal blood F is obtained by the ratio of the areas under the plasma level vs. time curves ("AUC") after p.o. and i.v. administrations: (see formula in text). The pigs were divided into three experimental groups. (i) Group I: undisturbed portal flow; (ii) Group II: total diversion of portal blood with an end-to-side portacaval shunt, and (iii) Group III: partial diversion of portal blood through a side-to-side portacaval shunt. Portal flow was measured during surgery with an electromagnetic flowmeter above and below the shunt and the degree of shunting calculated. Results show that the shunt fraction measured with ursodeoxycholic acid is well-correlated with hemodynamic data. No overlap between Groups I and III is observed. It is concluded that the shunt fraction of nutrient portal blood can be measured with this noninvasive method. Minute amounts of ursodeoxycholic acid were used in order to be completely metabolized by the liver, even in spite of hepatocellular dysfunction. Therefore, this method should be valid in cirrhotic patients and be useful to decide the type of portasystemic shunt to propose for the decompression of gastroesophageal varices.

The management of abdominal wall stomata: skin protection, peristomal wound healing and support for the collecting bag. A multi-center study.

The specific properties of Stomahesive tested in 116 stomal and 20 fistulous patients render it really useful in stomatherapy where it increases the comfort of the patients: 1. it offers an excellent peristomal skin protection whatever the nature of the stoma or origin of the fistula; 2. it promotes rapid healing of skin lesions, even in ileostomy, transverse colostomy, ureterostomy and fistula patients; 3. it ensures an effective degree of impermeability; 4. it provides a large base for adhesion of the collecting bag; 5. it can be kept on for about 6 days in most cases; 6. The local tolerance is excellent (Acta chir. belg., 1977, 76, 533-537).