Bikini anterior hip replacements in obese patients are not associated with an increased risk of complication.

PURPOSE: Direct anterior approach (DAA) arthroplasty has generated great interest because of its minimally invasive and muscle sparing nature. Obese patients are reported to be associated with greater incidence of complications in primary joint replacement. The purpose of this study was to compare patient outcomes and complication rates between obese and non-obese patients undergoing primary total hip arthroplasty (THA) through a Bikini direct anterior incision. METHODS: This retrospective, single surgeon study compared the outcome of 258 obese patients and 200 non-obese patients undergoing DAA THA using a Bikini incision, over a 5-year period. The average follow-up was 3.2 years (range 1.1-5.6 years). RESULTS: There was no statistically significant differences in the complication rate between the two groups. The obese group recorded 2 major (venous thromboembolism and peri-prosthetic fracture) and 2 minor complications (superficial wound infection), compared with the non-obese group, which recorded 2 major (deep-wound infection and peri-prosthetic fracture) and 1 minor complication (superficial wound infection). Patient-reported outcomes (WOMAC and Harris Hip Scores) showed significant post-operative improvements (p < 0.001) and did not differ between the two groups. CONCLUSIONS: Bikini DDA THA does not increase the complication rate in obese patients and offers similar clinical improvements compared to non-obese patients.

Enhanced recovery in total hip replacement: a clinical review.

The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions. In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.

An evidence-based review of enhanced recovery interventions in knee replacement surgery.

INTRODUCTION: Total knee replacement (TKR) is a very common surgical procedure. Improved pain management techniques, surgical practices and the introduction of novel interventions have enhanced the patient's postoperative experience after TKR. Safe, efficient pathways are needed to address the increasing need for knee arthroplasty in the UK. Enhanced recovery programmes can help to reduce hospital stays following knee replacements while maintaining patient safety and satisfaction. This review outlines common evidence-based pre, intra and postoperative interventions in use in enhanced recovery protocols following TKR. METHODS: A thorough literature search of the electronic healthcare databases (MEDLINE(®), Embase™ and the Cochrane Library) was conducted to identify articles and studies concerned with enhanced recovery and fast track pathways for TKR. RESULTS: A literature review revealed several non-operative and operative interventions that are effective in enhanced recovery following TKR including preoperative patient education, pre-emptive and local infiltration analgesia, preoperative nutrition, neuromuscular electrical stimulation, pulsed electromagnetic fields, perioperative rehabilitation, modern wound dressings, different standard surgical techniques, minimally invasive surgery and computer assisted surgery. CONCLUSIONS: Enhanced recovery programmes require a multidisciplinary team of dedicated professionals, principally involving preoperative education, multimodal pain control and accelerated rehabilitation; this will be boosted if combined with minimally invasive surgery. The current economic climate and restricted healthcare budget further necessitate brief hospitalisation while minimising costs. These non-operative interventions are the way forward to achieve such requirements.

Nocardia nova septic arthritis following total knee replacement: a case report.

We describe a case of Nocardia nova septic arthritis following a total knee replacement. A 55-year-old obese woman was admitted to hospital 5 months after knee surgery with a 3-week history of pain, swelling, and restricted mobility in her left knee but no preceding trauma/injury. 30 ml of cloudy joint fluid was aspirated and an arthroscopic examination showed extensive fibrin formation and synovitis. An arthroscopic washout was carried out using 16 litres of saline, followed by total synovectomy and intensive antibiotic therapy (clarithromycin 500 mg twice daily and co-trimoxazole [sulphamethoxazole 400 mg and trimethoprim 80 mg] once daily and augmentin duo forte 875 mg twice daily). At 2.5 years, the patient had recovered completely with no prosthetic loosening.

Presence of telomerase activity with undetectable p16 gene mutation in Malaysian patients with brain tumor.

Recent study has shown that activation of the telomerase and p16 gene mutation are both necessary for tumorigenesis. Our objectives were to detect telomerase activity and investigate the possibility of p16 gene mutations in various types of brain tumor. We analyzed 23 tumor tissues collected in 2000 to 2002. Telomerase activity was detected by a TRAP assay using a TRAPEZE Telomerase Detection Kit (Intergen, Co). PCR-SSCP (Single Strand Conformation Polymorphism) analysis was performed to screen for p16 gene mutation at exon 1 and 2. The activity was detected in 26.1% of the brain tumor samples and mostly present in high-grade tumors. There was a significant association between telomerase activity status and tumor grade but not with patient criteria. Telomerase activity was detected in the analyzed tumors, supporting the fact that activation of telomerase is an important feature for tumorigenesis. There was no mobility shift of p16 gene using SSCP and suggested no mutation at exon 1 and 2 occurred in all samples. These results suggest that another mechanism of p16 gene alterations could be involved and associated with detectable telomerase activity in the progression of tumors.

Thallium-201 scintigraphy--a predictor of tumour necrosis in soft tissue sarcoma following preoperative radiotherapy?

AIM: Thallium-201 (Tl-201) scintigraphy in patients with malignant soft tissue tumours was evaluated to determine whether the images correlated with histological response to preoperative radiotherapy. METHODS: We studied 54 patients, median age 32 (range 17-84) years, with non-metastatic, malignant soft tissue tumours diagnosed between 1996 and 2001. Thirty-eight patients had unoperated tumours and 16 patients had previous incomplete excisions. All patients received preoperative radiotherapy followed by surgery. No patient received chemotherapy as part of their initial management. Qualitative analyses of early phase (30 min) and late phase (4 h) Tl-201 scintigraphic images before and after preoperative radiotherapy were compared with the degree of tumour necrosis determined histologically. RESULTS: In the previously unoperated group, all 38 patients had increased TL-201 uptake in the late phase of scanning prior to radiotherapy suggesting metabolically active tissue. In the previously excised group 11 patients had increased Tl-201 uptake in the late phase of scanning prior to radiotherapy. Following radiotherapy, patients with Tl-201 retention on late phase scans had a lower rate of necrosis than patients with minimal retention, p<0.0001. Following radiotherapy, 28 of 29 patients with minimal uptake on the late phase had 80% or more necrosis, while 24 of 25 patients with increased uptake on the late phase had less than 80% necrosis (p<0.0001). Patients with previously excised tumours who had thallium retention following radiotherapy demonstrated evidence of residual disease at surgery. All patients with incompletely excised tumours who had no thallium retention on late phase scanning after radiotherapy demonstrated no evidence of residual disease at surgery. CONCLUSION: Thallium scintigraphy is a readily available investigative tool, which when used in conjunction with other imaging modalities in the assessment of primary and incompletely excised malignant soft tissue tumours, may predict histological tumour response to preoperative radiotherapy.

Mutations of the p53 gene in gliomas from Malay patients.

This is the first investigation performed to detect the presence of the p53 mutation in Malay patients with gliomas. The p53 gene was amplified using polymerase chain reaction (PCR) from 33 fresh-frozen tumour tissues from patients histologically confirmed as glioma. Four hot spot areas that lie between exon 5 to 8 were screened for mutation by mean of non-isotopic "cold" single strand conformation polymorphism (SSCP) analysis and direct sequencing. The frequency of p53 gene mutation in gliomas examined was 33% (11 of 33). Five (45.5%) cases had mutation in exon 7, four (36.4%) had mutation in exon 8 and two (18.1%) had mutation in exon 6. Seven (63.6%) of 11 mutations were single nucleotide point mutations of which 5 were missense mutations, 1 was nonsense mutation and 1 was, silent mutation. Three (27.3%) showed insertion mutation and 1 (9.1%) showed deletion mutation. Of the point mutations, 57.1% were transitions and 42.9% were transversions. These results suggested that p53 mutations frequently occur in gliomas and this gene does play an important role in the tumourigenesis process of Malay patients with brain tumours.