top of page
Search

Issue #13: September 7th, 2024

Updated: Feb 28

And while, for rhymes, I search around the poles, Your eyes are fixed, as in poetic sleep, Upon the lore so voluble and deep, That aye at fall of night our care condoles.

 —John Keats. To My Brothers. 1816




When it Comes to Inguinal Hernia Repair in Preterm Infants, How Much Does the Timing Matter?

 

By: Nedeke Ntekim

 

 

There is no denying that congenital hernias in preterm infants warrants repair. The dilemma then lies in determining the timing for surgery as these preterm infants, commonly with co-morbidities, may have complications with surgical intervention. As there are no recommended guidelines to direct clinical practice, this multicenter randomized clinical trial aimed to assess the rate of serious adverse events when comparing early versus delayed inguinal hernia repair in preterm infants (gestational age younger than 37 weeks). It is important to note that late inguinal hernia repair was defined as an operative repair post-discharge from the NICU in an infant older than 55 weeks postmenopausal age. Out of the 1072 eligible infants, 338 (32%) were randomized in a 1:1 ratio. Of the 163 infants randomized to the early inguinal hernia repair group, 147 underwent the procedure. Out of the 157 in the late repair group, 129 had the operation. It is important to note that for both groups, some patients had their surgeries moved up (in the late hernia repair group) or postponed as seen in the early repair group. From the 308 infants with data completed, 44 out of 159 (28%) infants experienced at least one serious adverse event in the early repair group compared with the 27 out of 149 (18%) in the late repair group (a 97% posterior probability of benefit with late repair). Serious adverse events included surgical, pulmonary, cardiac events or death. Secondarily, infants in the early repair group spent an average of 19 days in the hospital compared to 16 days in the late repair group. This showed an 82% posterior probability of benefit with late repair. Per the results, delaying inguinal hernia repair may be preferred when it comes to fewer rates of serious adverse events. 

 

Overall, the paper provides additional useful information that could shed some light on additional factors to consider when deciding timing for surgery. For example, the paper shows that infants less than 28 weeks gestation and infants with bronchopulmonary dysplasia (BPD) fared best in the late inguinal repair group. Such useful data and subgroup analyses can help with these very complex decisions. Future studies can further explore the effect of BPD in surgical outcomes between the two groups as well as taking a closer look at if having  concurrent procedures with the hernia repair may play a role in the rate of adverse events. As mentioned in the limitations section of the paper, one also has to take into account the smaller sample size when interpreting the results and how the COVID-19 pandemic may have affected follow-up thereby further leading to barriers. Future studies can emphasize having larger sample sizes and finding ways to potentially mitigate loss of follow-up.

 


What Is the Best Approach for Treating Obesity in Polycystic Ovarian Syndrome Patients? Is Bariatric Surgery an Option?

 

By: Samantha Redden

 


Polycystic ovary syndrome (PCOS) is a leading cause of anovulatory infertility in women of reproductive age, with obesity representing a key contributing factor. Managing obesity in women with PCOS could significantly improve ovulation rates as well as fertility. However, the best approach for treating obesity remains unclear. This multicenter, randomized controlled trial aims to assess whether bariatric surgery improves ovulation rates in women with PCOS, obesity, oligomenorrhea, or amenorrhea, compared to medical and behavioral treatments. Participants were women with obesity, PCOS, and irregular menstrual cycles. They were randomly assigned to bariatric surgery or standard treatment (medical and behavioral therapy). The primary outcome measured was spontaneous ovulation, monitored through regular blood tests and menstrual tracking over a set period. This study found that the surgical group experienced 2.5 times more ovulatory cycles compared to the standard group. However, they also experienced a higher rate of adverse events, which raises concerns about the risks associated with the procedure. Although this study suggests bariatric surgery offers better results for PCOS, it is not without risk. It also doesn’t shed light on the increase in cost and accessibility for women who need this procedure or the long-term effects on fertility. Increasing ovulatory cycles through bariatric surgery could improve the overall physical, mental, and emotional well-being of women. However, a larger sample study could help determine whether the benefits of bariatric surgery outweigh the risks. 



Treatment of Intracerebral Hemorrhage: Clot Removal With or Without Decompressive Craniectomy

 

By: Riva Kelly

 


An intracerebral hemorrhage (ICH) is a type of stroke that involves bleeding within the brain tissue, often caused by high blood pressure, head trauma, or vascular malformations. An ICH can be life-threatening due to the accumulation of blood in the brain, which increases intracranial pressure, compresses brain tissue, and may lead to death. One treatment option for ICH is clot removal (CR), especially when the hemorrhage is large, accessible, and causing significant pressure or symptoms. Another common procedure to relieve intracranial pressure is decompressive craniectomy (DC), where part of the skull is temporarily removed to help reduce pressure in the brain. This randomized controlled trial aimed to explore whether combining DC with CR provides better outcomes for patients with ICH compared to CR alone. To measure their outcomes, they used the Modified Rankin Scale (mRS), which assesses the impact of stroke on a patient’s life. Scores of 0-2 show favorable outcomes and 3-6 demonstrate unfavorable outcomes. The primary outcome was proportion of unfavorable outcomes (mRS 3-6) at three months. The secondary outcome was the mortality rate in each group at 90 days. At three months, 94 patients (92.2%) in the interventional group (CR with DC) had unfavorable outcomes, compared to 83 patients (81.4%) in the control group (CR alone). Additionally, mortality was higher in the interventional group with 14 patients (13.7%) dying, compared to 5 patients (4.9%) in the control group. Based on these findings, clot removal alone appears to be a safer treatment for managing intracranial pressure in patients with ICH.



AI’s Heartfelt Analysis: Harnessing Mammograms for Heart Disease Detection

 

By: Monique Westley

 


Prior research has shown a connection between breast arterial calcifications (BAC) in mammograms and risk of coronary artery disease (CAD) in women. BACs are calcium deposits in breast arteries that may often be overlooked in routine breast cancer screenings. This study uses artificial intelligence deep learning to transform routine mammography into a tool for cardiovascular risk assessment. The team designed a twelve-layer convolutional neural network (CNN) to distinguish BACs from non-BACs and utilized a pixel-wise, patch-based approach for detection. 


The analysis involved 840 full-field digital mammograms from 210 cases from multiple medical facilities. Ground-truth (control) BAC annotations were obtained through a detailed reader study with three experienced breast imaging experts. Evaluating the CNN’s performance via free-response receiver operating characteristic analysis and calcium mass quantification revealed that the model’s accuracy was on par with expert radiologists. The deep learning model achieved a true positive rate of 60% with a false positive rate of 0.4762 cm². Its calcium mass estimation also showed a strong correlation with expert-labeled ground truth with a coefficient of determination (R²) of 96.24%.


These promising results suggest that deep learning models can effectively detect BACs and estimate calcium mass in mammograms. By integrating this deep learning model into existing mammography workflows, it could revolutionize how cardiovascular risks are identified, leading to earlier intervention and improved patient outcomes. However, further large-scale research is needed to fully validate and refine this approach for standardized clinical implementation.



Does Previous Arthroscopic Surgery for Knee Osteoarthritis Increase the Incidence of Total Knee Arthroplasty?

 

By: Benjamin Crews

 

 

Arthroscopy is a known treatment for knee osteoarthritis (OA) and is performed routinely. Total knee arthroplasty (TKA) is another common treatment for OA, with its utilization steadily increasing. However, the impact of prior arthroscopy on knee OA patients who eventually undergo TKA is unclear. This study used secondary analysis to explore TKA incidence in patients with knee OA who previously underwent either arthroscopic or nonoperative management. Data was derived from a single center, assessor-blinded, randomized clinical trial that followed knee OA patients for up to 20 years (mean ~13.7 years). OA was defined as a radiograph Kellgren and Lawrence (KL) grade of > 2. Of the 92 patients in the arthroscopic group, 31 eventually underwent TKA, compared to 36 of the 86 patients in the control group eventually underwent TKA. The hazard ratio for TKA incidence between these two groups was 0.85 (95% CI,0.52-1.40), indicating arthroscopy neither accelerates or delays the need for TKA. The overall incidence of TKA in both groups was around 10% at 5 years and 20% at 10 years, further underscoring the efficacy of arthroscopy as a treatment for knee OA. Of note, only a higher KL grade was associated with increased TKA incidence with a hazard ratio of 2.06 (95%, 1.21 0 3.53). While the long-term data present in this study are valuable, a larger sample size with data from multiple tertiary centers would enhance its robustness. Additionally, further investigation into patient-reported pain outcomes is warranted. If arthroscopy provides meaningful pain relief without increasing the incidence of TKA, it should remain a viable treatment option for knee OA.



Prophylactic Laparoscopic Surgery Versus Expectant Management for Benign Adnexal Mass in Pregnancy

 

By: Kelsey Lane

 

 

Adnexal masses are very common, and many of them are benign. However, benign masses can still pose an increased risk for torsion. The rate of torsion increases with size and also tends to be higher in pregnant women than nonpregnant women. When it comes to pregnant women with benign adnexal masses, patients are counseled on laparoscopic surgery versus conservative management. This single-center retrospective study conducted two sets of analyses on pregnant women with benign adnexal masses. The primary outcome of the first analysis was evaluating surgical and pregnancy outcomes in 126 pregnant patients who underwent laparoscopic cystectomy for their benign adnexal mass between 2001-2020. This first analysis found laparoscopic surgery to be a safe option as no cases were converted to a laparotomy nor had an oophorectomy. The primary outcome of the second analysis was incidence of adnexal torsion in those with masses >5cm who chose conservative management between 2011-2020. In this subgroup, 5 of 28 cases (17.9%) underwent emergency surgery for adnexal torsion. In conclusion, laparoscopic surgery is a safe treatment approach and should be highly considered in pregnant women with benign adnexal masses in order to avoid future risk of adnexal torsion. 


Spinal Compression Fracture: Restoring the Compressed Spine


By: Ryan Liengswangwong



Spinal compression fractures may affect the patient’s overall well-being, such as the experiencing of mobility loss and/or pain. The above scans illustrate the loss of vertebral height associated with compression fractures imaged with CT, MRI, and X-Ray respectively. Providers can use the Genant classification of vertebral fractures to categorize ompression fractures due to osteoporosis as mild (less than 20-25%), moderate (25-40%), and severe (greater than 40%) depending on the magnitude of height loss of the affected vertebral body. If surgical intervention is indicated over non-surgical management, the patient may undergo a vertebroplasty or kyphoplasty.

 

Sources:

 

Bashir U, Elfeky M, Skidmore A, et al. Spinal compression fracture. Reference article, Radiopaedia.org https://doi.org/10.53347/rID-19197

 

Dixon A, Acute and chronic vertebral compression fractures. Case study, Radiopaedia.org https://doi.org/10.53347/rID-31608

 

Radswiki T, Vertebral body compression fracture. Case study, Radiopaedia.org  https://doi.org/10.53347/rID-12074

 

Ramsey, MD A, Vertebral body compression fracture. Case study, Radiopaedia.org https://doi.org/10.53347/rID-71323



Hip Hip Hooray: How Sir John Charnley Revolutionized Hip Surgery



By: Michael Yacoub


 "There is a tendency to imagine that serious research nowadays can only come out of a laboratory, and the contributions from the pure act of thinking on clinical facts ended with the great clinicians of the past. In the training of young surgeons, the attempt to foster the habit of making clinical observations and questioning accepted beliefs ought to start from the earliest moment."

 

The biomechanics of hip stability, though complex, can be fundamentally understood by envisioning the hip joint as a fulcrum with two lever arms. The femoral head acts as the fulcrum, while the opposing lever arms represent the torque generated by body weight and the tension exerted by the lower limb abductors—namely the gluteus medius and minimus. Given that the lever arm of the abductors is, on average, 2.5 times shorter than that of body weight, these muscles must generate forces 2.5 times greater than body weight to maintain pelvic balance during a one-legged stance. Failure in this mechanism can result in gait abnormalities such as Trendelenburg, Duchenne, or waddling gaits. Recognizing how easily this delicate balance can be disrupted by conditions like osteoarthritis, rheumatoid arthritis, or sub-capital trauma underscores the immense contributions of Dr. John Charnley and his development of total hip arthroplasty (THA).

 

John Charnley was born on August 29, 1911, in Bury, Lancashire. He was educated at Bury Grammar School, where his natural affinity for the sciences was recognized early, prompting encouragement to pursue medicine. Dr. Charnley entered the Victoria University of Manchester's medical school in 1929 and graduated with an MB ChB in 1935. Remarkably, at the young age of 25, he became a Fellow of the Royal College of Surgeons of England. After completing his general surgery residency at Salford Royal Hospital, King's College London, and Manchester Royal Infirmary, Dr. Charnley encountered orthopedics for the first time in 1939 at Manchester Royal Infirmary, where he accepted a position as a resident casualty officer. This experience was abruptly interrupted by the outbreak of World War II, which led him to serve in the Royal Army Medical Corps in various locations outside England. This detour, however, proved advantageous as it positioned Dr. Charnley to become an orthopedic officer in charge of a military orthopedic center in Cairo, Egypt. There, he managed an orthopedic workshop where his creativity and inventiveness flourished, earning him a reputation as a pioneering force in orthopedic surgery.

 

After his service in Cairo, Dr. Charnley returned to Manchester and was appointed a consultant orthopedic surgeon at Manchester Royal Infirmary. His growing interest in hip pathology led him to establish a hip center at Wrightington Hospital in Wigan, which became the cornerstone of his career and the birthplace of modern total hip arthroplasty.

 

Understanding the anatomy of the hip joint is crucial to appreciating Dr. Charnley's contribution to orthopedic surgery. The hip is a ball-and-socket joint that masterfully balances stability and mobility, allowing a wide range of movements, including flexion, extension, abduction, adduction, medial and lateral rotation, and circumduction. The joint's articular surfaces consist of the hemispherical head of the femur and the lunate surface of the acetabulum, with the acetabulum nearly encompassing the entire femoral head. The acetabular labrum, a fibrocartilaginous structure, enhances the joint's stability by embracing the femoral head. The joint is further stabilized by three major ligaments: iliofemoral, pubofemoral, and ischiofemoral, which tighten when the hip joint is extended, slightly abducted, and medially rotated to enhance hip stability.

 

Before Dr. Charnley's innovations, common hip replacement methods, such as the Smith-Peterson and Judet operations, failed to achieve a balance between mobility and stability. The Smith-Peterson technique involved placing a loose-fitting metal cup between the femoral head and acetabulum, hoping the interaction would induce the formation of new cartilage-like tissue. Unfortunately, excessive fibrocartilage formation led to loss of joint mobility. The Judet operation replaced the femoral head with a plastic prosthesis, but the high friction between the prosthesis and the damaged acetabulum caused the prosthesis to loosen, leading to instability and further complications.

 

Dr. Charnley's groundbreaking achievement was rooted in his innovative approach to reducing friction within the joint and securing the prosthesis to bone. He overcame frictional challenges primarily by using ultra-high molecular-weight polyethylene (UHMWPE) to line the acetabulum. UHMWPE's exceptional wear resistance, low friction, and high impact strength made it ideal for synthetic cartilage. To address prosthesis loosening, Dr. Charnley used acrylic cement to tightly secure the metal prosthesis to the cancellous bone, creating a stable and durable bond.

 

In 1962, Dr. Charnley performed the first successful total hip arthroplasty at Wrightington Hospital. Today, approximately 500,000 modern hip replacements are performed annually in the United States, with a low revision rate of 0.5 percent per year for the first 20 years.

 

Dr. Charnley received numerous accolades for his contributions, including the Lasker Foundation Clinical Medical Research Award in 1974 and a knighthood in 1977. His work revolutionized orthopedic surgery, impacting millions of lives worldwide. Sir John Charnley passed away on August 5, 1982, in Manchester, England, leaving behind a legacy of innovation and compassion in medicine.

 

Sources:

 

Charnley J. ANCHORAGE OF THE FEMORAL HEAD PROSTHESIS TO THE SHAFT OF THE FEMUR. The Journal of Bone and Joint Surgery British volume. 1960 Feb;42-B(1):28–30.


CHARNLEY J. ARTHROPLASTY OF THE HIP A New Operation. The Lancet [Internet]. 1961 May; 277(7187):1129–32.


Erens G, Crowley M. Total Hip Arthroplasty. 2024 Sep 5;UpToDate.


Gomez PF, Morcuende JA. A historical and economic perspective on Sir John Charnley, Chas F. Thackray Limited, and the early arthoplasty industry. PubMed. 2005 Jan 1;25:30–7.


Gray's Anatomy. Chapter 77. 41st ed. Philadelphia: Elsevier; p. 1352-1394.e2.


Gray's Surgical Anatomy. Chapter 80. 1st ed. Philadelphia: Elsevier; p. 594-598.e2.


Jackson J. Father of the modern hip replacement: Professor Sir John Charnley (1911–82). Journal of Medical Biography. 2011 Nov;19(4):151–6.


Sophia Fox AJ, Bedi A, Rodeo SA. The Basic Science of Articular Cartilage: Structure, Composition, and Function. Sports Health: A Multidisciplinary Approach. 2009 Nov;1(6):461–8.


Wroblewski BM. Professor Sir John Charnley (1911-1982). Rheumatology. 2002 Jul 1;41(7):824–5.



FUTURE OPPORTUNITIES & REMINDERS



 
 
 

Comments

bottom of page