Resurfacing hemiarthroplasty of the shoulder for patients with juvenile idiopathic arthritis.

BACKGROUND: This study reports the outcome of resurfacing hemiarthroplasty (RHA) in a cohort of patients with juvenile idiopathic arthritis (JIA) affecting the shoulder joint METHODS: Fourteen uncemented RHA procedures were performed for 11 consecutive patients who required surgery because of JIA. Mean age at surgery was 36.4 years. Mean clinical follow-up was 10.4 years (range, 5.8-13.9 years). A significant humeral head defect (up to 40% surface area) was found in 5 shoulders and filled with autograft from the distal clavicle or femoral head allograft. RESULTS: At latest follow-up, no patient required revision. There was excellent relief from pain. The mean Oxford Shoulder Score and Constant-Murley Score improved significantly. No shoulder had a poor outcome, and 6 had a very good or excellent outcome. Worse outcome was associated with an intraoperative finding of significant humeral head erosion. Two shoulders required early arthroscopic subacromial decompression, but there were no other reoperations. There were no instances of radiographic implant loosening or proximal migration. Painless glenoid erosion was seen in 5 shoulders but was not associated with worse outcome. CONCLUSIONS: The midterm results of RHA for JIA are at least comparable to those for stemmed hemiarthroplasty, with the added benefit of bone conservation.

Arthroscopic Sternoclavicular Joint Diskectomy for Acute and Chronic Tears.

PURPOSE: To describe the results and functional scores in a group of patients who underwent arthroscopic excision of a symptomatic sternoclavicular joint (SCJ) disk tear with a minimum follow-up period of 2 years. METHODS: Between April 2010 and December 2014, 14 patients underwent arthroscopic excision of a torn SCJ disk. Patients whose intended surgery was an isolated diskectomy and underwent that surgery only, with no additional procedure, were included. The minimum follow-up period was 24 months. All patients underwent an arthroscopic SCJ diskectomy. Postoperatively, no immobilization was required, and the patients were encouraged to mobilize as pain permitted. The patients were assessed preoperatively and at final follow-up with the visual analog scale score for pain, Rockwood score, and QuickDASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score. RESULTS: The average age at surgery was 29.4 years (range, 19-39 years). Ten of the patients had been symptom free before a specific incident, after which SCJ symptoms developed. The other 4 patients reported a gradual onset of symptoms and were considered to have chronic tears. The average duration of symptoms was 22.8 months (range, 6-48 months). At a mean follow-up of 33.4 months (range, 24-59 months), a significant improvement in the Rockwood score was noted, from 7 (range, 5-9; standard deviation [SD], 1.4) to 13.6 (range, 9-15; SD, 1.9) (P = .001) (minimal clinically important difference not described). The mean QuickDASH score improved from 23.7 points (range, 6.8-40.9 points; SD, 11.8 points) to 8 points (range, 0-29.5 points; SD, 9 points) (P = .0024) (minimal clinically important difference, 13.4 points). There were no reported complications and specifically no instability. CONCLUSIONS: The results of this series suggest that arthroscopic SCJ diskectomy is a safe and reproducible procedure for the treatment of patients with symptomatic SCJ disk tears. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Management of Atraumatic Posterior Interosseous Nerve Palsy.

The posterior interosseous nerve (PIN) is susceptible to a number of traumatic and atraumatic pathologies. In this article, we aim to review our current understanding of the etiology, pathology, diagnosis, treatment options, and published outcomes of atraumatic PIN palsy. In general, the etiology of atraumatic PIN palsy can be divided into mechanical, which is caused by an extrinsic compressive force on the nerve, and nonmechanical, which is caused by an intrinsic inflammatory reaction within the nerve. As per this discussion, there are 3 causes for atraumatic PIN palsy. These are entrapment neuropathy, Parsonage-Turner syndrome, and spontaneous "hourglass" constriction. The typical presentation of atraumatic PIN palsy is a patient with spontaneous onset of weakness of fingers/thumb metacarpophalangeal joints extension. However, the wrist extension is preserved with radial deviation due to preservation of extensor carpi radialis longus/brevis function. Magnetic resonance imaging is the imaging of choice and neurophysiology is indicated in all patients. If there is an obvious structural cause of the nerve palsy, prompt decompression and removal of the causative lesion are recommended to avoid irreversible damage to the nerve/muscles. Otherwise, in general, we would recommend consideration for exploration should there be no sign of recovery after 6 weeks of observation.

Linked semiconstrained and unlinked total elbow replacement in juvenile idiopathic arthritis: a case comparison series with mean 11.7-year follow-up.

BACKGROUND: Few series report the results of total elbow replacement (TER) in patients with juvenile idiopathic arthritis (JIA). Most report the use of a linked implant. There are theoretical benefits to using an unlinked prosthesis, and thus we report our experience of the clinical benefit and survivorship of both this implant and a linked semiconstrained prosthesis. METHODS: There were 21 elbows replaced in 14 JIA patients (12 women and 2 men; 14 unlinked, 7 linked). Mean age at surgery was 39.5 years (range, 26-52 years). Mean clinical follow-up was 11.7 years (range, 5.4-17.6 years). RESULTS: Reoperation, including implant revision, was required in 9 elbows (42.9%). Using revision as an end point, survivorship was 95% (95% confidence interval [CI], 74%-99%) at 5 years and 68% (95% CI, 45%-86%) at 10 years. The 10-year survival was 70% (95% CI, 40%-89%) for the unlinked group and 69% (95% CI, 28%-94%) for the linked group. The need for bilateral TER was found to be a risk factor for revision within 10 years of primary surgery (6/11 vs. 0/7 elbows; P = .037). The rate of aseptic loosening seen on radiographs was high in the unlinked group (12/14, 85.7%), but many of these patients continue to function well without need for revision. CONCLUSION: Both the unlinked Kudo 5 and linked Coonrad-Morrey prostheses for TER can provide benefits in the long-term for most patients with JIA. The need for bilateral TER in this group is associated with higher rate of revision at 10 years.

The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography.

BACKGROUND: Symptomatic disorders around the sternoclavicular joint (SCJ) are relatively uncommon. Previous cadaveric and radiographic studies have suggested that asymptomatic osteoarthritic changes are relatively common, progressively increasing with age. The purpose of this study was to determine the prevalence of SCJ osteoarthritis in the general population using computed tomography (CT) scans. METHODS: We assessed 464 SCJs in 232 patients undergoing a standardized axial CT scan of the thorax including both SCJs, across a range of ages from the second to tenth decade. The scans were undertaken for multiple clinical indications; however, none were obtained to investigate SCJ pathology. The predominant changes investigated were for the features associated with osteoarthritis including the presence of osteophytes, subchondral cysts, and subcortical sclerosis. RESULTS: The CT scans of 244 SCJs (53%) in 137 patients (59%) showed at least 1 sign of osteoarthritis. No patients younger than 35 years had any features of osteoarthritis. Osteoarthritic changes were present in 89.6% of patients older than 50 years compared with 9.1% younger than this age. All patients above the age of 61 had at least 1 feature of osteoarthritic changes on at least 1 side of the SCJ. Increasing prevalence was noted with increasing age both in the percentage of SCJs showing any positive signs of osteoarthritis and in the severity of osteoarthritis. CONCLUSION: SCJ osteoarthritis is a very common incidental finding on CT scans, particularly with increasing age. This should be taken into consideration when using a CT scan to assess a patient with symptomatic SCJ pathology.

Pre-operative arthritic glenoid assessment: 3D automated planning software versus manual multiplanar measurements of version and inclination.

Background: Preoperative CT-based planning is established in shoulder arthroplasty surgery. Automated planning software has become available to assist the surgeon and may increase reliability and efficiency. This study aims to evaluate the reliability of an automated 3-dimensional (3D) planning software package (Blueprint™ v2.1.5, Wright Medical Ltd) in the assessment of the arthritic shoulder against manual multiplanar measurement (MM). Methods: 74 CT studies acquired for preoperative shoulder arthroplasty planning were reviewed on two occasions by four different evaluators, taking manual measurement (MM) of glenoid version and inclination adjusted with multiplanar reformation and adhering to modified Freidman and Maurier methods. 15 scans were not processed by Blueprint due to incompatible scanning protocols or severe scapular dysmorphia. 59 Blueprint measures were compared with the manual data. Results: Version: Intra-observer reliability of glenoid version MM was excellent (mean ICC 0.92). Inter-observer reliability between all four readers was good (ICC 0.89). A Bland-Altman analysis of Blueprint versus MM for version measurements demonstrated a mean pair difference of -5.77 (95% CI -7.25 to 4.29). Inclination: Intra-rater and inter-rater reliabilities were good (ICC 0.85 and 0.80 respectively). Blueprint and MM values for inclination followed a more convergent pattern than for version. Bland-Altman analysis for inclination did not show substantial bias, with a mean pair difference of 1.4 (95% CI -0.1 to 2.9). Conclusion: Manual preoperative planning for shoulder arthroplasty is time consuming and requires experience. Automated 3D planning offers a consistent tool to assist the surgeon, notwithstanding intra-operative anatomical and technical variation, and margin of error. Surgeons should as ever be mindful of the specifics of a given automated program and our data quantified a bias for retroversion which may be important for measures close to the thresholds for augmentation or customised implants.

The use of platelet-rich plasma therapy in treating tennis elbow: A critical review of randomised control trials.

Tennis elbow (TE) is a painful and debilitating condition of the elbow. Recently, the use of orthobiologics, such as platelet-rich-plasma (PRP), has been proposed to promote tendon regeneration. Despite their popularity, there is a paucity of updated reviews on the use of PRP compared with other treatment modalities for treating TE. The aim of this review is to summarise high quality studies that compare the use of PRP therapy with other therapies for TE and to identify areas where further research is warranted. This systematic review was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive literature search of PubMed, Scopus and Cochrane Library databases was undertaken in May 2021. Articles were screened for the following criteria: randomised control trials (RCTs) involving PRP in at least one of the treatment arms for tennis elbow. The quality of the RCTs included were analysed for their risk of bias using the modified Cochrane Collaboration Risk of Bias Assessment Tool for randomised trials. A total of 20 RCTs of which 1520 TE patients were analysed. The RCTs included in this review compared PRP with various treatment modalities routinely used in clinical practice such as physiotherapy, steroid injections, Autologous Whole Blood (AWB) and surgical interventions. With regards to the quality of RCTs, collectively, selection bias was found to be low risk however, performance bias in terms of blinding of participants and personnel performed poorly. Of the 20 RCTs, only 5 studies were classified as low risk of bias. In these 5 studies, 2 RCTs compared PRP with steroids and reported contrasting results, 1 RCT compared PRP with AWB injections which reported both to be similarly efficacious, 3 RCTs included a placebo group and only 1 reported superior effects with PRP. There are 2 main types of PRP classified according to the number of pro-inflammatory leukocyte i.e. leukocyte-rich and leukocyte-poor PRP. However, only 8 studies documented the formulation of PRP used. While the heterogeneity of PRP formulations could in-part explain the reported differences in outcomes, overall there is limited robust evidence to recommend PRP therapy for TE. Further research is required to establish the optimal formulation and administration of PRP injections. Proper documentation of TE patients need to be standardised before concrete recommendations on the use of PRP therapy may be offered.

Concomitant coracoid base fracture and acromioclavicular joint disruption: A series of patients treated with a clavicle hook plate and review of the literature.

INTRODUCTION: Concomitant acromioclavicular joint (ACJ) disruptions with coracoid base fractures are rare high energy injuries. The management of these injuries can be challenging. The aim of this study is to assess the functional and radiographic outcomes of a retrospective case series of patients presenting with concomitant ACJ and coracoid base injuries managed with a clavicle hook plate with subsequent hardware removal at a later stage. METHODS: Six patients were identified for inclusion in the study. Radiographic and clinical data were available which allowed for collection of demographic information as well as classification of the fractures. Telephone consultation with patients allowed for collection of functional scores which included the Oxford shoulder score (OSS), QuickDASH (Q-DASH), Euroqol-5 Dimension (EQ-5D) and the SF-12 score. RESULTS: All patients were male with a mean age of 39.8 years and a median follow-up period of 34 months. All patients underwent a successful operative procedure with a median time to union of 3.75 months. Good functional outcomes were reported by all patients: mean OSS 45.0, mean Q-DASH 4.8, mean EQ-VAS 82.8 and encouraging SF-12 scores (mean PCS 56.0, mean MCS 56.4). CONCLUSION: The use of a lateral clavicle hook plate can achieve good healing and functional outcomes when managing patients with acromioclavicular joint disruptions associated with a coracoid base fracture.

Phytochemical and pharmacological uses of medicinal plants to treat cancer: A case study from Khyber Pakhtunkhwa, North Pakistan.

ETHNOPHARMACOLOGICAL RELEVANCE: Cancer is the top death causing disease in the world, due to its occurrence through various mechanism and form. Medicinal plants have been extensively used for the purifications and isolations of phytochemicals for the treatment and prevention of cancer. OBJECTIVES: Consequently, this research was designed to document the traditional practices of anti-cancer plants and its phytochemical essay across the districts of KP, Pakistan. MATERIALS AND METHODS: Semi-structured interviews were conducted in 24 districts from the informants mostly the traditional herbalists (key informants). The information were compared with the publish data using various authentic search engines including, google, researchgate, google scholar and NCBI. RESULTS: One hundred and fifty-four (154) anti-cancer plants were recognized belonging to 69 families among all, Lamiaceae (13 sp.), Asteraceae (12 sp.) and Solanaceae (9 sp.) were the preferred families. The local inhabitants in the area typically prepare ethnomedicinal recipes from leaves (33.70%) and whole plants (23.37%) in the form of decoction and powder (24.67%), respectively. Herbs stayed the most preferred life form (61.68%) followed by shrub (21.4%). Similarly, breast (29.22%) and lung cancer (14.83%) was the common disease type. Literature study also authorize that, the medicinal plants of the research area were rich in phytochemical like quercetin, coumarine, kaempferol, apigenin, colchicine, alliin, rutin, lupeol, allicin, berbarine, lutolin, vanilic acid, urocilic acid and solamargine have revealed significant activates concerning the cancer diseases, that replicating the efficacy of these plants as medicines. CONCLUSION: The Khyber Pakhtunkhwa is rural area and the local inhabitants have very strong traditional knowledge about the medicinal plants for different diseases like cancer. The medicinal plants for significant ranked disorder might be pharmacologically and phtyochemicaly explored to demonstrate their efficacy. Moreover, the local flora especially medicinal plants facing overgrazing, overexploitation and inappropriate way of collection, however, proper management strategies like reforestation, controlled grazing, proper permission from concerned department and rangeland strategies among others may be assumed to enhance the proper usage of medicinal plants.

Shoulder arthroplasty for juvenile idiopathic arthritis.

There is limited literature to guide shoulder surgeons in the management of juvenile idiopathic arthritis (JIA). We aim to help clinicians to formulate an approach to the surgical management of the condition through a review of the available literature on arthroplasty in JIA, general considerations when operating on patients with inflammatory arthropathy and recommendations based on the authors' experience. Four articles report formal data on arthroplasty in JIA with favourable improvements in post-operative pain and function scores after the long-term follow-up. Significant heterogeneity in treatment and a lack of standardisation in quantitative outcomes highlights the need for further larger scale and higher quality research. The aim of this study is to review the evidence and provide information on preoperative evaluation of surgical candidates, operative techniques, choice of implant design and to evaluate functional outcomes in patients who undergo shoulder arthroplasty.

Arthroscopically-assisted fixation of anteromedial coronoid facet fracture and lateral ulnar collateral ligament repair for acute posteromedial rotatory fracture dislocation of the elbow.

If left untreated, varus posteromedial rotatory injuries of the elbow result in poor functional outcomes. Surgical treatment allows restoration of elbow kinematics, minimizing the chances of chronic varus instability and early onset osteoarthritis. However, large exposures are associated with extensive soft tissue stripping, a high risk of infection, nerve injury, poor visualization of the articular surface and longer recovery. Consequently, there has been renewed interest in the use of elbow arthroscopy to circumvent these problems. Arthroscopic treatment offers the potential advantage of a swift recovery, with instant rehabilitation, less stiffness and swelling than might be expected after open repair. We present the first combined arthroscopic-assisted anteromedial facet coronoid fracture fixation and lateral ulna collateral ligament repair in a varus posteromedial rotatory injury of the elbow.

Eight-year follow-up of resurfacing hemiarthroplasty for advanced glenohumeral osteoarthritis following total acromionectomy.

Total acromionectomy is now a largely historical procedure due to a number of biomechanical sequelae caused by defunctioning of the deltoid, although its overall effect on joint kinematics is uncertain. This presents a challenge when considering arthroplasty for subsequent glenohumeral arthritis. We report on successful management of such a case, treated with resurfacing hemiarthroplasty 57 years following acromionectomy. The patient continues to enjoy excellent functional outcome of the shoulder at 8 years after arthroplasty.

Arthroscopic Intra-articular Disk Excision of the Sternoclavicular Joint.

The sternoclavicular joint (SCJ) has a complete intra-articular disk that can be damaged either as a result of trauma or as part of ongoing degenerative joint disease. Although often asymptomatic, SCJ disk tears may lead to mechanical symptoms and pain. Previously, isolated symptomatic SCJ disk tears have only occasionally been mentioned in the literature with a few associated case reports of diskectomy by open arthrotomy. With improved imaging and availability of magnetic resonance imaging scans and the advent of SCJ arthroscopy it is now possible to treat symptomatic SCJ disk tears by arthroscopic excision. In this Technical Note, we describe the diagnosis of a torn SCJ disk and the technique of arthroscopic excision of a torn SCJ disk.

Surgical treatment of a concurrent type 5 acromioclavicular joint dislocation and a failed anterior glenohumeral joint stabilization.

Traumatic glenohumeral joint dislocation and acromioclavicular joint subluxations tend to occur in young active males. Use of the coracoid process either as a transfer in recurrent instability or in suspensory reconstructions of the coracoclavicular ligaments have gained popularity. However this requires careful consideration in the event of concomitant injuries if they both require surgery.

Failure of distal biceps repair by gapping.

BACKGROUND: We describe the clinical, radiological and surgical findings of failed distal biceps repair by gapping and report the functional outcomes following revision repair. METHODS: A retrospective review of five consecutive patients was conducted. Patients presented with radial-sided forearm pain after their distal biceps fixation. All patients had less than 5 cm of retraction of the biceps muscle belly, a palpable tendon although the manoeuvre was painful with weakness on resisted supination. Flexed abducted supinated magnetic resonance imaging (FABS MRI) showed a gap between the distal end of the tendon and the footprint on the radial tuberosity. RESULTS: Mean FEA score at presentation was 44/100 (35 to 49). Mean time to re-operation was 18 months (range 4 months to 36 months). At revision, the distal end of the tendon was retracted and not making contact with the bone. All cases were revised to an in-bone endobutton repair. Mean postoperative Functional Elbow Assessment (FEA) scores undertaken at a mean of 14 months (range 5 months to 22 months) after revision improved to 95/100 (90 to 100). CONCLUSIONS: Patients presenting with persistent radial sided forearm pain and weakness on provocative testing after distal biceps repair with a seemingly intact repair should be investigated with FABS MRI to look for evidence of failure of repair by gapping. Revision repair with an anatomic in-bone technique can lead to good results.

Glenoid bone loss in primary and revision shoulder arthroplasty.

The management of glenoid bone loss is a major challenge in both complex primary and revision arthroplasty surgery. To deal with this problem, a number of techniques have been advocated, although there has been no previous systematic review of the literature. In the present review, we have attempted to identify a coherent strategy for addressing this problem, taking into account the degree of bone loss, the advantages and limits of standard implants, bone reconstruction techniques and the use of customized prostheses.

Effect of peri-operative red blood cell transfusion on 30-day and 1-year mortality following coronary artery bypass surgery.

OBJECTIVE: The purpose of this study was to examine the effect of peri-operative red blood cell (RBC) transfusion on 30-day and 1-year mortality following coronary artery bypass grafting (CABG). METHODS: We retrospectively analysed 3024 consecutive patients who underwent isolated CABG between January 1999 and December 2001. Patient records were linked to the National Strategic Tracing Service, which records all mortality in the UK. Thirty-day and 1-year mortality were derived from Kaplan-Meier curves. Confounding variables were controlled for by constructing a propensity score for the probability of receiving a transfusion from core patient characteristics including the lowest recorded laboratory haemoglobin (LL Hb) from a clinical chemistry database (C statistic 0.81). The propensity score and the comparison variable (transfusion versus no transfusion) were included in a Cox proportional hazards analysis, allowing calculation of adjusted hazard ratios (HR) and Kaplan-Meier survival curves. RESULTS: Nine hundred and forty (31.1%) patients received RBC transfusion during or within 72h of surgery. Predictors of the need for transfusion were LL Hb and lower body mass index, use of cardiopulmonary bypass, female sex, number of grafts, renal dysfunction, increased age, extent of disease, and prior CABG; these factors were all included in the propensity score. After 1-year of follow-up, 122 (4.03%) deaths occurred. The crude HR for 1-year mortality in patients transfused was 3.0 (P<0.001). After adjusting for the propensity score, re-operation for bleeding, peri-operative blood loss and post-operative complications, the adjusted 30-day mortality was 1.9% in transfused patients compared to 1.1% in patients not transfused (P<0.05). The adjusted HR for 1-year mortality in patients transfused was 1.88 (P<0.01). CONCLUSIONS: Peri-operative RBC transfusion after CABG is associated with an increased risk of mortality during a 1-year follow-up period, with a large proportion of deaths occurring within 30-days.

The effects of pre-operative intra-articular glenohumeral corticosteroid injection on infective complications after shoulder arthroplasty.

BACKGROUND: Many shoulder surgeons use intra-articular corticosteroid injections (IACI) in shoulder osteoarthritis, with the caveat that it precludes arthroplasty for at least 6 months to 12 months because of the theoretical risk of infection. To our knowledge, there is nothing available in the literature to support this notion. METHODS: We undertook a retrospective, matched cohort study of all patients who underwent shoulder arthroplasty in our unit between December 2010 and December 2013 aiming to assess whether pre-operative IACI had an impact on infective complications. Group I had received an IACI prior to their arthroplasty and Group II had not. A chi-squared analysis was performed (p < 0.05). RESULTS: Group I comprised 23 patients with a mean age of 73 years (range 54 years to 90 years) had 23 shoulder arthroplasties and had mean follow-up of 16.6 months. Patients received an IACI approximately 11.4 months (range 2.5 months to 172.5 months) before their surgery. One patient developed a deep joint infection that warranted revision arthroplasty. Group II comprised 60 patients with a mean age of 75 years (range 34 years to 90 years) had 64 shoulder arthoplasties and a mean follow-up of 20.1 months. No patients developed infective complications (p > 0.05), implying there was no statistically significant relationship between pre-operative IACI and infective complications. CONCLUSIONS: We could not establish a causal link between IACI and infective complications after arthoplasty.

Effect of training on outcomes following coronary artery bypass graft surgery.

OBJECTIVE: We examined our coronary artery bypass surgery (CABG) experience to assess the effect of training on mortality and morbidity outcomes. METHODS: Between April 1997 and September 2002, 5678 consecutive patients underwent isolated CABG. Five hundred and fifty-five (9.9%) were performed by trainee surgeons. Multivariate logistic regression was used to assess the effect of training on adverse outcomes, while adjusting for patient and disease characteristics (treatment selection bias). Cox proportional hazards analysis was used to adjust Kaplan-Meier survival curves. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics including the additive EuroSCORE. The propensity score was the probability of CABG performed by trainee, with a C-statistic of 0.79, and was included along with the comparison variable (trainee vs Consultant) in a multivariable analysis of outcome. The propensity score is used as the sole variable for adjustment due to the low number of events, providing a more complete risk adjustment. RESULTS: CABG procedures performed by trainee surgeons were less likely to be female, hypertensive, obese, triple-vessel disease, redo and emergency cases. Also, trainee surgeons were less likely to operate on patients with cerebrovascular disease, renal dysfunction, and previous myocardial infarctions, prior gastrointestinal surgery, and poor left ventricular ejection fraction. The additive EuroSCORE was 2.9 in trainee cases compared to 3.5 in Consultant led cases (P<0.001) Crude outcomes were significantly better in trainee CABGs due to selection bias. In-hospital results were no longer significantly different between both groups after adjusting for the propensity score. The adjusted freedom from death in the trainee cases at 30 days, 1, 2, 3, and 4 years was 98.1, 96.2, 94.7, 93.2 and 91.8%, respectively, compared to 97.9, 95.7, 94.1, 92.3 and 90.8% for the Consultant led cases (P=0.53). CONCLUSIONS: After adjusting for case-mix, with careful case selection, training does not adversely affect the early and mid-term outcomes of CABG.

The effect of obesity on mid-term survival following coronary artery bypass surgery.

OBJECTIVE: Several studies have shown no significantly increased risk of in-hospital mortality for obese patients after coronary artery bypass grafting (CABG). However, the effect of obesity on mid-term survival has not been adequately studied. We set out to examine whether mid-term survival following CABG is affected by obesity. METHODS: We performed a retrospective study of 4713 consecutive patients undergoing isolated CABG between April 1997 and September 2001. Body mass index (BMI) was used as the measure of obesity, with 3429 patients categorised as non-obese (BMI<30 kg/m(2)), and 1284 patients as obese (BMI> or = 30 kg/m(2)). Patient records were linked to the National Strategic Tracing Service, which records all deaths in the community, to establish current vital status. Deaths occurring over time were described using Kaplan-Meier techniques. To control for differences in patient characteristics, we used Cox proportional hazards analysis to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: Three hundred and thirty (7.0%) deaths occurred during the study period, with a mean follow-up of 2.4+/-1.4 years. The crude HR of mid-term mortality for obese patients was 1.09 (95% CI 0.86-1.39; P=0.457). After adjustment for core pre-operative factors, the adjusted HR of mid-term mortality for obese patients was 1.28 (95% CI 1.01-1.64; P=0.048). The adjusted freedom from death in the obese patients at 30 days, 1, 2, 3, and 4 years was 97.9, 95.9, 94.2, 92.4 and 90.5%, respectively, compared with 98.4, 96.8, 95.5, 94.0 and 92.5% for the non-obese patients. CONCLUSIONS: Although in-hospital mortality after CABG does not seem to be adversely affected by obesity there appears to be a significant increase in mortality in obese patients during a 4-year follow-up period.