Faced with unacceptable disability, many patients with osteoarthritis of the hip or knee pursue total joint replacement to improve their quality of life and ability to function. Often, their main goal is to continue to work and earn an income.

After identifying a research gap in work status before and after joint replacement, researchers from the Netherlands looked for 

 and time to return to work among patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). In addition, the authors attempted to identify factors associated with work status.

The investigators searched databases through April 2013 and gathered clinical studies concerning patients undergoing THA or TKA that provided quantitative information on work status before and after surgery. They considered study characteristics, data on work status, and determinants of return to work.

Selecting 19 studies published between 1986 and 2013 — 4 on THA, 14 on TKA and 1 on both THA and TKA &mdash; the authors identified data on 3,872 patients with THA and 649 patients with TKA. After THA, 25-95% of patients returned to work within 12 months, with an average time to return to work of 1.1 to 13.9 weeks. In comparison, 71- 83% returned to work within 6 months after TKA; the average time to return to work after THA was 8 to 12 weeks.

Most patients who wished to return to work were able to do so after THA and TKA. Women, self-employed workers, and those with higher mental and physical health scores seemed more likely to return to work. However, patients were slower to return to work if they had more physically demanding jobs or Worker’s Compensation, which aligned with findings from a similar 

 that found patients receiving Worker’s Compensation were slower to return to work.

The authors noted that the studies’ methodological quality was moderate to low overall, which hampered their ability to provide the best estimates and impressions. They indicated that standardization of data reporting could help resolve those concerns in the future.

Articles

How Fast Do Patients Return to Work After Hip, Knee Replacement?

Human communication relies on more than just words. By observing facial changes, parties engaged in face-to-face communication learn much about the speaker’s emotional state and comfort with the topic being discussed.

Developmental abnormalities, early childhood infection, vascular compression of the facial nerve, inflammatory processes, neoplasms, or iatrogenic or trauma facial nerve injury can paralyze faces partially or completely. Patients who lose facial flexibility often develop depression, social isolation, and poor quality of life.

Surgeons have looked for ways to restore movement through a process called facial reanimation for decades. Ideal facial reanimation corrects impaired eyelid closure, nasal breathing, lip competence, or speech. It also improves tone and restores facial symmetry at rest and in expression. Reanimation is primarily accomplished by using nerve repair for reversible damage or muscle substitution for irreversible damage.

Kofi Boahene, a board-certified facial plastic surgeon with the Department of Otolaryngology Head and Neck Surgery at Johns Hopkins Institute of Medicine, has published a 

 of facial reanimation. He began by explaining the assessment procedure, which determines if reanimation is even possible. Some paralyses — especially those in which facial muscles have atrophied or become fibrous &mdash; require the transfer of functional muscle units. Many reanimations require several steps, and good assessment ensures the steps are completed in the best possible manner. As with most procedures, interventions performed soon after injury are more likely to succeed than those performed long afterwards.

In his review, Boahene covered each part of the face in great detail. He indicated which interventions are most likely to help with common paralyses, and he stressed adherence to biomechanical principles relating to muscle tension when functional muscle transfer is needed. Additionally, he addressed physical therapy and selective chemodenervation when necessary.

In addition to its clear narrative, Boahene’s review included pictures of specific paralyses, surgical techniques, and the ever-encouraging “after” photos that demonstrate possibilities.

Featured Articles

A comprehensive review of reanimation surgery describes interventions to restore facial movement in each part of the face.

Restoring Non-Verbal Clues Through Facial Reanimation Surgery

Initially introduced as a less-invasive approach to cholecystectomy in 1989, laparoscopic surgery has become the mainstay of minimally invasive surgery (MIS) in the United States. Its use has become so widespread that some surgeons are concerned those in training have insufficient exposure to the open procedures MIS has replaced.

Researchers at the University of North Dakota School of Medicine and Health Sciences examined this issue by studying intra-abdominal procedures performed by residents graduating from US general surgery residency programs between 2000 and 2011.

 employed data from the Accreditation Council for Graduate Medical Education (ACGME) national resident case log reports, specifically examining the average number of cases per graduating chief resident in the categories of appendectomy, inguinal/femoral hernia repair, gastrostomy, colectomy, anti-reflux procedures, and cholecystectomy.

The researchers found that graduating residents performed that same total number of major cases in 2000 and 2011, which came as a shock. Restricting residents to an 80-hour workweek — a change that took effect in 2003 &mdash; was expected to reduce residents’ exposure, but it appears that this did not happen.

Nevertheless, the number of MIS procedures increased significantly in all procedure types, except anti-reflux surgery. The increases ranged from 26% for cholecystectomy to 1,011% for colectomy.

The researchers noted a concurrent decrease in the number of open procedures. The rates of open appendectomy, open colectomy, and open anti-reflux procedures continue to decrease; however, the decline in the rates of open hernia repairs and open gastrostomies seems to have plateaued. The researchers said the effect of those declines in “open cases in surgical training and practice remains to be determined.”

Though newer, less-invasive technologies in endoscopic surgery, natural orifice surgery, and robotics will obviate the need for older techniques, there will always be a role for open surgeries.

The use of minimally invasive laparoscopic surgery has become so widespread that some surgeons are concerned those in training have insufficient exposure to the open procedures it has replaced.

Residents Still Gain Exposure to Open Surgeries Replaced by Minimally Invasive Procedures

Damage control surgery is often used after patients experience traumatic injury. In the operative suite, well-defined damage control principles can reduce mortality in non-trauma abdominal emergencies, as well.

As damage control surgery is widely accepted by emergency surgeons as a life-saving strategy for critically ill patients who have abdominal complications, researchers from the Department of Traumatology at John Hunter Hospital and the University of Newcastle in Australia presented a 

 of data from the 10 years leading up to August 2013 in order to describe current knowledge about damage control surgery for abdominal emergencies.

Damage control starts with abbreviated laparotomy, which controls blood loss and contamination in the abdomen. Eventually, surgeons can perform subsequent reoperation for delayed definitive repair after physiological resuscitation.  

Even though minimal evidence validates the benefit of damage control surgery in general surgical abdominal emergencies, the authors proposed that roughly 3% of patients who have shock from uncontrolled hemorrhage or sepsis could benefit, and they described a 6-phase strategy that can be used in severely injured patients.

Analyzing the results of 16 studies — the majority of which were retrospective case series &mdash; the researchers found patients who have experienced hemorrhage and sepsis seem to gain the most benefit if the surgeon uses careful patient selection.

Though damage control procedures can save lives, they expose patients to the risks of multiple surgeries, open abdomen management, and prolonged intensive care stay if they are inadequately performed. Trigger points to consider in damage control surgery for non-traumatic abdominal emergencies might include hypothermia, metabolic acidosis, or coagulopathy; however, they are not supported by controlled clinical trials.

Damage control surgery is employed in a wide range of abdominal emergencies. It appears to be a life-saving tool when patients are physiologically disturbed. Further research on the topic should help surgeons identify patients at greatest need for damage control.

Patients who have experienced hemorrhage and sepsis seem to gain the most benefit from damage control procedures if the surgeon uses careful patient selection. 

Damage Control Procedures Provide Life-Saving Benefit in Abdominal Emergencies

Though women comprise as much as 80% of patients who undergo bariatric surgery, more information on the effects of the procedure in men is needed.

A particular concern is the tendency for obese men to have markedly reduced serum testosterone (T) levels and obesity-related hypogonadotropic hypogonadism (OrHH). This disorder is characterized by reduced serum T with relatively high estradiol (E

), as well as inappropriately low luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels. As OrHH seems to reverse after substantial weight lost, more studies of bariatric surgery in men are needed.

Researchers from Radboud University’s Nijmegen Medical Centre in the Netherlands enrolled 13 men diagnosed with OrHH (free T< 225 pmol/L) and 11 age-matched eugonadal morbidly obese men (free T> 225 pmol/L) in an 

. The goal of the study was to evaluate bariatric surgery’s effects in obese men on free T levels. To do so, the researchers measured serum gonadal hormones, body composition, glucose, lipid, and bone metabolism during the first year after bariatric surgery.

The authors determined that serum-free T was inversely related to body weight and rose gradually after bariatric surgery in both eugonadal and OrHH men. The magnitude of the changes was 30 pmol/L for every 10 kg of weight loss. Three OrHH patients who experienced serum-free T remained within the hypogonadal range despite substantial weight loss.

At one year, patients in both arms of the study had similar outcomes. Thus, a diagnosis of OrHH did not reduce the efficacy of bariatric surgery.

Testosterone/estradiol balance disturbances vary significantly among obese men, which probably reflect differences in the degree of patients’ aromatase activity. Weight loss reduces excess aromatase activity and can normalize estradiol/testosterone balance in most obese men. A subset of obese men may have an additional condition that contributes to low T levels.

A diagnosis of obesity-related hypogonadotropic hypogonadism (OrHH) does not reduce the efficacy of bariatric surgery in men.

Low T Doesn't Reduce Effectiveness of Bariatric Surgery in Men

Patients have been known to refuse blood transfusions due to religious convictions, medical concerns, or personal preferences. To deny those blood conservation (BC) patients the option of non-blood medical care is to deny them access to treatments that the rest of the population takes for granted.

Though surgical centers across the country are observing BC programs using bloodless medical procedures, knowing more about the outcomes in those who refuse transfusions would aid in the decision process for physicians, patients, and their families.

Since little research on BC patient outcomes after non-cardiac surgery is available, Bala Ramanan, MBBS, and colleagues at Creighton University conducted 

 that compared the surgical outcomes of 120 patients enrolled in a BC program to the outcomes of 238 conventional care (CC) patients. Both groups had similar operating times, length of hospital stays, surgical readmission rates, and preoperative conditions with the exception of smoking, which was lower in the BC group.

The bloodless surgery program examined in the study had a high level of success, which enabled the researchers to enroll an adequate number of BC patients. The authors claimed that discussing advance directives and obtaining informed consent are unique features of the BC program at their institution, as most hospitals do not have a dedicated program or protocol for BC patients. Once patients are identified as belonging to the BC program, their data and preferences are available for future hospitalizations. Blood loss in both the preoperative and postoperative periods is minimized by restricting laboratory draws to the minimum required and by using pediatric blood collection tubes. Postoperatively, surgeons monitor BC patients carefully and treat them promptly if hemorrhaging occurs.

After multivariable analysis, the researchers determined that outcomes in BC patients were similar to those in the CC group. Thus, the authors said that patients refusing blood products should not be denied surgical treatment.

While other benefits of BC programs have 

, BC patients’ long-term surgical outcomes need to be evaluated by future studies. Nevertheless, recent literature has demonstrated higher mortality and morbidity in general surgery patients with even limited intraoperative transfusion, which supports the authors’ conservative approach to blood transfusion.

Study concludes that patients refusing blood products should not be denied non-cardiac surgical treatment.

Blood Conservation Doesn't Impact Non-Cardiac Surgical Outcomes

Between 10% and 36% of liver transplant recipients develop new-onset diabetes mellitus after transplantation (NODAT). Most literature describes NODAT’s prevalence and risk factors in patients who received organs from deceased donors. However, transplants involving livers from living donors are more common, due to the ongoing shortage of cadaveric livers for patients awaiting transplant.

Though the incidence and predictors of NODAT in patients who receive organs from living donors is unclear, limited data suggests a lower risk of NODAT among living donor liver transplant (LDLT) recipients, possibly due to favorable recipient and donor characteristics such as younger donor age and lower recipient body mass index (BMI).

 conducted by researchers at the Mayo Clinic Hospital in Phoenix compared the incidence and risk factors for NODAT in 902 LDLT recipients to 19,582 deceased donor liver transplant (DDLT) recipients. The authors drew data from a large national database to assess NODAT incidence over a period of 5 years after liver transplantation.

Like the few studies that previously examined the issue, this study demonstrated that the risk of NODAT was lower in LDLT recipients than in DDLT recipients. One year after liver transplantation, NODAT incidence was 7.4% in LDLT recipients, but 12.5% among DDLT recipients.

Over time, NODAT incidence decreased in LDLT recipients, falling from approximately 5% in the first year to less than 2% within 5 years. The researchers suggested that the decline was related to decreased use of maintenance immunosuppression.

In both patient groups, the incidence of NODAT was high in the first 6 months following liver transplantation, which indicated that early intervention might prevent its development. The researchers also discovered that hepatitis C virus (HCV) liver disease and treated acute cellular rejection events were significant risk factors in LDLT recipients.

Although the study had some limitations — including potential reporting error in the database, lack of diagnostic criteria, and heterogeneous treatment protocols &mdash; its large patient pool gave credence to the findings.

New-onset diabetes mellitus incidence is lower in living donor liver transplant (LDLT) recipients than in deceased donor liver transplant (DDLT) recipients. 

Living Donor Liver Transplant Recipients Have Decreased Diabetes Risk

While self-reported weights are easy to obtain, many researchers believe they are less accurate than those measured by a calibrated scale under medical supervision.

Previous studies have asserted that women tend to underreport their weight more than men. Those studies also indicated the degree of misreporting is related to body mass index (BMI), whereby overweight individuals tend to underreport and underweight individuals are inclined to overreport. However, 

 found that among female gastric bypass candidates, self-reported pre-surgical weights averaged 0.3 kg more than measured weights, and misreporting was not significantly related to BMI.

In that study, Nicholas J. Christian, PhD, and colleagues at the University of Pittsburgh Graduate School of Public Health in Pittsburgh used data collected between April 2010 and November 2012 at annual assessments conducted 1 to 5 years after Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric band (LAGB). The researchers mailed questionnaires to participants annually and asked them to disclose their weight from their last medical office or weight loss program visit, as well as their last self-reported weight taken at home. Of the 992 participants with weights meeting the inclusion criteria, only 4 were excluded due to suspected recording error. The remaining 988 participants included 164 patients with a self-reported medical weight, 580 with a self-reported personal weight, and 244 with both self-reported weights.

Across both types of self-reported weight, the researchers found that women and men underreported their weight by an average of 1 kg or less, and the degree of underreporting was not significantly different between women and men. Self-reported medical weights were significantly closer to measured weights than to self-reported personal weights for both sexes. In a general population survey, obese men and women underreported their weight on average by 1.32 kg and 2.99 kg, respectively.

As self-reported weights following bariatric surgery were close to measured weights, these findings suggest researchers could reasonably use self-reported weights when gathering data about surgically-induced weight change, and can be used when measured weights are not available.

Researchers from the University of Pittsburgh found that women and men who underwent gastric bypass surgery underreported their post-operative weight by an average of 1 kg or less.

Gastric Bypass Patients Don't Lie About Their Post-Op Weight

The amount of cosmetic operations has dramatically increased in the 21st century, with a 162% rise in the US since 1997. In 2009 alone, more than 1.3 million cosmetic procedures were performed — an increase driven by the awareness of various methods to “improve” appearance. Chief among these procedures is rhinoplasty.

Since it is primarily aesthetic rather than functional, rhinoplasty is unique among surgical operations. As such, it raises moral, philosophical, and social questions. Before rhinoplasty, the surgeon must examine patient’s motivation for undergoing the surgery, as well as their psychological condition.

Body dysmorphic disorder (BDD) is a relatively common obsessive-compulsive disorder defined by a patient’s constant and impairing preoccupation with imagined or slight defects in his or her physical appearance. It is associated with poor quality of life, extremely high rates of suicide, and high rates of dissatisfaction after cosmetic surgery that may present as aggressiveness.

While 80% of plastic surgeons in the United States report that they would not operate on a patient with BDD, 84% report that they had unwillingly operated on one, and just as many have operated on patients whom they later realized had BDD and believed that the patient had a poor operative outcome as a result of their condition. This is particularly true for rhinoplasty patients, as they have 

 to have a high rate of BBD, according to 

During the limited period in which the cosmetic surgeon consults with a patient before rhinoplasty, several factors must be assessed and discussed. These include real or perceived nasal defects, the patient’s view of what is “abnormal” and how it can be improved, a realistic explanation of what rhinoplasty can accomplish, and  the patient’s motivations, inner stability, and overall psychological profile. Though not all cosmetic surgery patients have psychological issues, a disproportionately large number of patients who do have those problems tend to undergo cosmetic surgery.

A number of methods have been proposed to better assess patients requesting rhinoplasty for body dysmorphia, including surveys that have proven effective in categorizing patients and their mental state. For example, a 

 published in the November 2013 issue of the 

European Archives of Oto-Rhino-Laryngology

 recommends the use of psychological treatment and antidepressants over surgical options and referrals to doctors who are more willing to fulfill surgical requests.

During the limited period in which the cosmetic surgeon consults with a body dysmorphic disorder (BDD) patient before rhinoplasty, several factors must be assessed and discussed. 

December 2013