Long-term risk of ectopic pregnancy varies by method of tubal sterilization: a whole-population study

OBJECTIVE

To evaluate the risk of ectopic pregnancy (EP) associated with different methods of tubal sterilization.

DESIGN

Population-based retrospective cohort study.

SETTING

Hospitals in Western Australia.

PATIENT(S)

All women aged 18-44 years undergoing tubal sterilization between 1990 and 2010 at Western Australian hospitals (n = 44,829).

INTERVENTION(S)

Data on tubal sterilization were extracted from hospital records.

MAIN OUTCOME MEASURE(S)

Long-term risk of EP.

RESULT(S)

There were 89 EPs recorded during the observation period in women previously sterilized. The 10-year and 15-year cumulative probability of EP for all methods of tubal sterilization were 2.4/1,000 and 2.9/1,000 procedures, respectively. The 10-year cumulative probability of EP was 3.5 times higher in women sterilized before the age of 28 years than in those sterilized after the age of 33 years. An increased risk of EP existed in women who received laparoscopic partial salpingectomy (adjusted hazard ratio = 14.57, 95% confidence interval 3.50-60.60) and electrodestruction (adjusted hazard ratio = 5.65, 95% confidence interval 2.38-13.40), compared with those who had laparoscopic unspecified destruction of fallopian tubes.

CONCLUSION(S)

Women undergoing tubal sterilization at a young age are at particular risk for subsequent EP. The risk among younger women doubled between 5 and 15 years after sterilization. Laparoscopic electrodestruction and partial salpingectomy carried the highest risk of EP.

The influence of antenatal exposure to phthalates on subsequent female reproductive development in adolescence: a pilot study

We hypothesised that antenatal exposure to ubiquitous phthalates may lead to an earlier menarche and a lower prevalence of polycystic ovarian syndrome (PCOS) and polycystic ovarian morphology (PCO) in adolescence. The Western Australian Pregnancy Cohort (Raine) Study recruited 3000 women at 18 weeks of gestation in 1989-1991, 1377 had antenatal serum stored without thawing at -80 °C. An unselected subset was evaluated in the early follicular phase for PCO and PCOS by ultrasound and serum evaluation in adolescence. Serum was analysed for anti-Müllerian hormone (AMH), inhibin B, sex hormone binding globulin (SHBG), testosterone, androstenedione and DHEAS. Four hundred microlitres of the frozen maternal serum underwent isotope-diluted liquid chromatography-tandem mass spectrometry, with preceding enzymatic deconjugation followed by solid-phase extraction to determine phthalate exposure. Two hundred and forty four girls attended assessment and most common phthalate metabolites were detectable in the majority of the 123 samples available. Several phthalates were negatively associated with maternal SHBG, and associations with maternal androgens were less consistent. The sum of the metabolites of di-(2-ethylhexyl) phthalate was associated with a non-significant tendency towards an earlier age at menarche (P=0.069). Uterine volume was positively associated with mono-(carboxy-iso-octyl) phthalate (P=0.018). Exposure to monoethyl phthalate (MEP) and the sum of all phthalate metabolites (Σall phth.m) were protective against PCOS in adolescence (P=0.001 and P=0.005 respectively). There were negative associations of MEP with PCO (P=0.022) and of MEP with serum AMH (P=0.031). Consequently, our data suggest that antenatal exposure to environmental phthalates may be associated with oestrogenic and/or anti-androgenic reproductive effects in adolescent girls.

[The effect of central anatomical single-bundle versus anatomical double-bundle reconstruction of the anterior cruciate ligament on knee stability. a clinical study]

PURPOSE OF THE STUDY A comparison of the efficacy of central anatomical single-bundle (CASB) reconstruction with that of double-bundle (DB) repair of the anterior cruciate ligament (ACL) in relation to knee stability in anteroposterior translation (APT), internal rotation (IR) and external rotation (ER) of the joint. MATERIAL AND METHODS A total of 40 patients were evaluated; 20 had ACL reconstruction by the CASB technique using hamstrings and 20 underwent DB repair surgery. The average age was 31.3 years, and the group included 22 men and 18 women with 19 right and 21 left knees. The KT-1000 test was used to assess the amount of APT in the knee and rotational deviations were measured by the Rolimeter. In the DB patients, measurements were performed before surgery (on joints with ACL injury), then after reconstruction of the anteromedial (AM) or the posterolateral (PL) bundle and subsequently after repair of both ACL bundles. The CASB patients were assessed before and after graft insertion. RESULTS The average APT value was 18.5 mm for the pre-operative knees and it fell to 8.9 mm after AM bundle reconstruction. However, when the PL bundle was inserted in the first place, the average APT value was 13.1 mm only. The average values recorded after the DB and CASB reconstructions were 6.1 mm and 9.1 mm, respectively. The average IR range of motion in the pre-operative joints was 18.6 degrees. After AM bundle reconstruction it was 13.9 degrees and after PL bundle repair it was 15.3 degrees. In DB reconstruction the average IR value achieved 10.4 degrees, and in CASB repair surgery it was 13.7 degrees. The average ER range of motion in the pre-operative joints was 17.8 degrees. After AM bundle reconstruction it was 14.5 degrees and after PL bundle repair it was 14.9 degrees. In DB reconstruction the average ER value achieved 11.4 degrees, and in CASB repair surgery it was 14.5 degrees. DISCUSSION Rotational stability of the knee after ACL reconstruction is one of the most important factors in restoring physiological kinematics of the joint after ACL injury. Since there are not many studies comparing knee rotational stability after CASB with that after DB reconstructions, the results presented here may contribute to selecting the optimal method of ACL reconstruction. CONCLUSIONS The results show that, in ACL reconstruction, the DB technique provides better stability to the knee, in both APT and rotation, than the CASB method. The latter has the same effect on knee stability as the presence of the AM bundle alone. When the PL bundle is added, knee stability, in both APT and internal/external rotation, is increased in comparison with central single-bundle ACL repair. Key words:anterior cruciate ligament, navigation, central anatomical single-bundle reconstruction, double-bundle reconstruction.

[Tangent sign - a reliable predictor of risk for tendon re-rupture in rotator cuff repair]

PURPOSE OF THE STUDY

Repair techniques for rotator cuff injury are currently well advanced. However, the risk of re-rupture, particularly when severe damage to the tendons has been repaired, is still high. The causes of failure can be due to the extent of injury, a repair done on a highly degenerated tendon with diminished viability or ischaemic damage to the tendon tissue resulting from suture material. The aim of the study was to ascertain the reliability of the tangent sign, a commonly used indicator of the degree of suprasupinatus muscle atrophy, in the prediction of risk for tendon re-rupture in the post-operative period.

MATERIAL AND METHODS

In 2011 the rotator cuff torn tendons were repaired by the method of double-row suture in 37 patients. The surgery was done by an open technique using the deltoid-splitting approach. A pre-operative magnetic resonance image (MRI) of the shoulder was obtained in all patients and each was assessed by a competent independent radiology specialist with a focus on the extent of a tendon lesion and the tangent sign. At 2-year follow-up, the results of repeated MRI were evaluated in view of the state of repaired tendons and, if a re-tear was found, its relation to the original suture and its extent in the sagittal plane were determined. The pre- and post-operative MRI findings were compared to find out how the presence or absence of a tangent sign before surgery relates to the incidence of supraspinatus tendon re-rupture at 2 years after surgery. The results were statistically analysed using Student's t-test and the Chi-square test.

RESULTS

Of the 37 shoulders, in the pre-operative period, a tangent sign was identified in 21 (56.8%). The average size of a rotator cuff tear was 29.3 mm for the whole group. For the shoulders with no tangent sign, the average value was 21.8 mm, for those with a tangent sign present, it was 39.6 mm. At 2-year follow-up, no tear was found in the patients in whom preoperative MRI showed no tangent sign while re-tears were recorded in 18 of 21 shoulders (85.7%) with a tangent sign present before surgery. On the average, the re-rupture had 40.8 mm in size and, in all cases, it occurred at the site of tendon re-insertion into the greater tubercle. These results were statistically significant (p < 0.01).

DISCUSSION

In repair of injury to the tendons of the rotator cuff muscles, emphasis is currently placed on a thorough pre-operative examination. MRI is an important part of the diagnostic procedure because it provides a detailed image of the muscle as a whole. Although great advances have recently been made in both the diagnostic and surgical techniques, the incidence of tendon re-rupture within a few years of the procedure is still high.

CONCLUSION

Our results show that the presence of a tangent sign detected by pre-operative MRI examination of the shoulder can be an important predictor of failure in rotator cuff repair and can also turn attention to the selection of an alternative technique to be used.

Association between in-vitro fertilization, birth and melanoma

A link between reproductive hormones and melanoma has long been suspected, and has been examined for numerous hormonal exposures, but the association between in-vitro fertilization (IVF) and melanoma has not been studied in depth. We used whole-population linked hospital and registry data to carry out a cohort study of women aged 20-44 years seeking hospital investigation and treatment for infertility in Western Australia from 1982 to 2002 with follow-up to 2010. The cohort comprised a total of 21 604 women followed for an average of 17.2 years. Of these, 7524 had IVF treatment, 14 870 gave birth and 149 women were diagnosed with an incident invasive melanoma. Using Cox regression analysis, we estimated hazard ratios (HRs) for melanoma associated with IVF and parity. Women who had IVF and gave birth had an increased rate of invasive melanoma compared with women who had IVF and remained nulliparous (HR 3.61; 95% confidence interval 1.79-7.26). There was little or no increase in the rate of invasive melanoma associated with giving birth in women who had non-IVF infertility treatment (HR 1.39; 95% confidence interval 0.88-2.20). These results suggest an association between reproductive factors and melanoma in the subgroup of women undergoing IVF treatment.

Treatment of extra-articular and simple articular distal radial fractures with intramedullary nail versus volar locking plate

The purpose of this prospective, randomized and blinded study was to compare the clinical outcomes of distal radial fractures treated with either an intramedullary nail or a volar locking plate. Sixty two patients were enrolled in the study and randomized to treatment with a MICRONAILTM (Group 1, 31 patients) or an adaptive plate (Group 2, 31 patients). Fracture types included were unstable extra-articular metaphyseal distal radial fractures and simple or multifragmentary sagittal articular distal radial fractures (AO classification types A2, A3, B1.1 and B1.2). All patients were evaluated at 6 weeks, 3 months and 12 months after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, the disabilities of the arm, shoulder and hand (DASH) and Mayo wrist scores. We concluded that treatment of this subset of distal radius fractures with minimally invasive intramedullary nailing gives better clinical outcomes at 6 weeks after surgery than treatment with a volar locking plate. By 3 and 12 months following surgery, there are no significant differences in outcome between the two treatment methods. Disadvantages of the MICRONAIL™ fixation system include risk of injury to the superficial branch of the radial nerve and a narrower spectrum of indications than volar locking plates.

The longer-term health outcomes for children born as a result of IVF treatment. Part II--Mental health and development outcomes

BACKGROUND Limited data exist with regard to longer-term mental health and psychological functioning of children born from IVF treatment. With the known adverse perinatal outcome for children born from IVF treatment, it would be expected that there is a negative impact upon their mental development. METHODS A search strategy restricted to studies relating to the medical condition of children of at least 1 year of age, born from IVF treatment was performed to include case series, data linkage and prospective studies published from 1 January 2000 to 1 April 2012. RESULTS Limited long-term follow-up data suggest that there is an increase in the incidence of cerebral palsy and neurodevelopmental delay related to the confounders of prematurity and low birthweight. Previous reports of associations with autism and attention-deficit disorder are believed to be related to maternal and obstetric factors. There exists a potential increase in the prevalence of early adulthood clinical depression and binge drinking in the offspring of IVF, with the reassuring data of no changes with respect to cognitive development, school performance, social functioning and behaviour. Whether these potential associations are related to the IVF treatment, the adverse obstetric outcomes associated with IVF treatment, the genetic or subsequent environmental influences on the children is yet to be determined. CONCLUSIONS In general, the longer-term mental and emotional health outcome for children born from IVF treatment is reassuring, and is very similar to that of naturally conceived children; however, further studies are required to explore any association with depression, and its causality in more detail.

The longer-term health outcomes for children born as a result of IVF treatment: Part I--General health outcomes

BACKGROUND Several million children have been born from in vitro fertilization (IVF) treatment, but limited data exist regarding their health and development beyond the first year of life. It has been alleged that IVF may lead to long-term adverse consequences, in addition to the documented worse perinatal outcome and increased risk of congenital abnormalities in children born resulting from IVF treatment. METHODS A search strategy restricted to studies relating to the medical condition of children of at least 1 year of age born as a result of IVF treatment was performed to include case series, data linkage and prospective studies published 1 January 2000-1 April 2012. RESULTS Limited long-term follow-up data suggest that there is potentially an increase in the incidence of raised blood pressure, elevated fasting glucose, increase in total body fat composition, advancement of bone age and potentially subclinical thyroid disorder in the IVF offspring. Whether these potential associations are related to the IVF treatment per se, the adverse obstetric outcomes associated with IVF treatment or are related to the genetic origin of the children is yet to be determined. CONCLUSIONS This review provides evidence to suggest that the short-term health outcome for children born from IVF treatment is positive. However, it is expected that the cardiovascular and metabolic risk factors found in childhood and tracking into adulthood could be worse in later life, and may be responsible for chronic cardiometabolic disease. These observations need to be addressed by further studies.

[Hinged external fixation in orthopaedic and trauma surgery of the elbow]

PURPOSE OF THE STUDY

A hinged external fixator of the elbow provides stable fixation of the joint while maintaining the range of its motion. The aim of the study was to evaluate a group of patients in whom an external fixator was used to manage severe injuries to the elbow, namely, traumatic unstable dislocation, unstable fracture-dislocation, and elbow fractures not permitting management by primary osteosynthesis. This also involved assessment of early elbow mobilisation and a comparison of this group with a group of patients treated conservatively for less severe elbow injuries.

MATERIAL AND METHODS

A group of 25 patients were evaluated at a follow-up of 18 months. There were 10 women and 15 men; the average age was 48 years (range, 20 to 76). The external fixator was applied in 13 patients, of whom eight had unstable elbow dislocation, three had unstable fracture-dislocation and two suffered a comminuted supracondylar fracture of the distal humerus. The hinged fixator was removed at an average of 7.6 weeks (range, 3 to 9 weeks). In the group of 12 patients treated conservatively by plaster cast application and subsequent rehabilitation, five had elbow dislocation without ligament injury and seven had elbow dislocation with ulnar collateral ligament injury. None of them showed any instability. The patients were evaluated on the basis of clinical and radiological findings, with the Mayo elbow performance (MEP) score being used for clinical assessment.

RESULTS

At a follow-up of 18 months, the patients with the external fixator showed the average range of motion at the elbow joint of 127° (105° to 140°), the MEP score of 92 points (75 to 100) and restriction of elbow extension by 8° (0° to 40°). In the conservatively treated patients, the range of motion was 133° (112° to 145°), the MEP score was 95 points (85 to 100) and extension restriction by 8° (0° to 22°). X-ray examination showed a congruent joint in both groups. The use of external fixator was associated with minor complications: transient radial nerve irritation in one case, and pin-tract infection in two cases (23%) which healed spontaneously after screw removal.

DISCUSSION

The optimal management of a complex elbow injury should results in restoring joint stability and its full range of motion. However, this is often difficult to achieve by surgical means and a marked restriction of movement remains a frequent consequence of severe elbow injury.

CONCLUSIONS

Elbow injuries differ from patient to patient and therefore the approach to their treatment has to be individual in every patient. A hinged external fixator provides stable fixation and allows for early movement of the elbow. Maintenance of the range of motion facilitated by the hinged fixator is not at the expense of joint stability or fracture non-union. Based on the results presented here, we recommend the use of external fixation in severe unstable elbow fractures and in fractures in which primary osteosynthesis cannot be used because of soft tissue injury.

[Computer-assisted kinematic 2D and 3D navigation in medial opening-wedge high-tibial valgus osteotomy]

PURPOSE OF THE STUDY

The aim of the study was to assess the accuracy of axis deformity correction achieved by high-tibial valgus osteotomy either without or with a computer-assisted kinematic navigation system, on the basis of comparing the planned and the achieved frontal axis of the leg. Comparisons of mechanical axis deviation were made using both pre- and post-operative measurements with the planning software and intra-operative measurements with the navigation system before and after osteotomy. In addition, the aim was to test the hypothesis that the use of 3D navigation, as compared with 2D navigation, would help reduce changes in the tibial plateau slope

MATERIAL AND METHODS

In the period 2008-2011, high-tibial osteotomy was performed in 68 patients. Twenty-one patients (group 1) underwent osteotomy without the use of navigation and 47 patients (group 2) had osteotomy with a computer-assisted navigation system (32 with 2D navigation and 15 with 3D navigation). Using the planning software, the mechanical leg axis before and after surgery and the anatomical dorsal proximal tibial angle in the sagittal plane were assessed. Medial openingwedge high-tibial valgus osteotomy was carried out in all patients. When using 2D navigation, the mechanical leg axis was measured intra-operatively before osteotomy and then after osteosynthesis which included a simulated axial load of the heel. When using 3D navigation, the procedure was identical and furthermore involved a measurement of the tibial plateau slope obtained with an additional probe in the proximal fragment. The results were characterised using descriptive statistics and their significance was evaluated using the Mann-Whitney U test and Wilcoxon's test, with the level of significance set at p < 0.05.

RESULTS

In group 1, osteotomy resulted in good correction of the mechanical axis in nine patients (43%), inadequate correction in nine (43%) and overcorrection and three (14%) patients. In group 2 with the use of navigation, accurate correction of the mechanical leg axis was achieved in 24 patients (51%), undercorrection was recorded in 21 (45%) and overcorrection in two (4%) patients. The difference in outcomes between the two groups was not statistically significant (p = 0.73). The average correction of the mechanical axis based on comparing measurements on pre- and post-operative radiographs was 9.1 degrees (range, 5-27 degrees); the average correction of the axis visualised intra-operatively was 8.7 degrees (range, 4-27 degrees). The difference was not significant (p = 0.1615) and confirmed our hypothesis that the accuracy of measuring the mechanical axis was not influenced by the method used. The average change in the dorsal slope of the tibial plateau following osteotomy without navigation was 0.9 degrees (range, -8.9 to 9.0 degrees) and that after osteotomy with intra-operative visualisation of the proximal tibial slope was 0.3 degrees (range, -4 to 4 degrees). This difference was not statistically significant (p = 0.813).

DISCUSSION

A good clinical outcome of high-tibial valgus osteotomy depends on achieving accurate correction of the mechanical leg axis with partial load transfer to the lateral compartment of the knee.

CONCLUSIONS

Although the number of cases with good correction was slightly higher in the patients undergoing osteotomy with navigation, the difference was not significant. Intra-operative visualisation of the mechanical axis proved sufficiently accurate on comparison with the pre-operative planning based on weight-bearing radiography of the leg. A simulated axial load of the heel included in the kinematic navigation system does not sufficiently correspond to normal weight-bearing and therefore an undercorrection of the deformity might occur. Using 3D navigation had no marked effect on a change in the slope of the tibial plateau.

Does the posterolateral bundle influence rotational movement more than the anteromedial bundle in anterior cruciate ligament reconstruction?

The biomechanical function of the anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL) remains controversial. Some studies report that the AM bundle stabilises the knee joint in anteroposterior (AP) translation and rotational movement (both internal and external) to the same extent as the PL bundle. Others conclude that the PL bundle is more important than the AM in controlling rotational movement.

The objective of this randomised cohort study involving 60 patients (39 men and 21 women) with a mean age of 32.9 years (18 to 53) was to evaluate the function of the AM and the PL bundles of the ACL in both AP and rotational movements of the knee joint after single-bundle and double-bundle ACL reconstruction using a computer navigation system. In the double-bundle group the patients were also randomised to have the AM or the PL bundle tensioned first, with knee laxity measured after each stage of reconstruction. All patients had isolated complete ACL tears, and the presence of a meniscal injury was the only supplementary pathology permitted for inclusion in the trial. The KT-1000 arthrometer was used to apply a constant load to evaluate the AP translation and the rolimeter was used to apply a constant rotational force. For the single-bundle group deviation was measured before and after ACL reconstruction. In the double-bundle group deviation was measured for the ACL-deficient, AM- or PL-reconstructed first conditions and for the total reconstruction.

We found that the AM bundle in the double-bundle group controlled rotation as much as the single-bundle technique, and to a greater extent than the PL bundle in the double-bundle technique. The double-bundle technique increases AP translation and rotational stability in internal rotation more than the single-bundle technique.

Status of clomiphene citrate and metformin for infertility in PCOS

Though widely used, there is uncertainty about the effectiveness and adverse effects of metformin and clomiphene citrate (CC) for infertility in polycystic ovary syndrome (PCOS). A systematic review (SR) of the best available evidence suggests that both CC and metformin are better than placebo for increasing ovulation and pregnancy rates, but CC is more effective than metformin for ovulation, pregnancy and live-birth rates, in PCOS patients with body mass index (BMI) >30. A combination of CC and metformin is superior to either metformin alone or CC alone, depending on the BMI and CC sensitivity of the patient. This SR provides key messages to guide clinicians and consumers on the use of these interventions in different subgroups of women with PCOS.

Metformin versus clomiphene citrate for infertility in non-obese women with polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND Recent studies suggest that metformin may be more effective in women with polycystic ovary syndrome (PCOS) who are non-obese. The objective here is to determine and compare the effectiveness of metformin and clomiphene citrate for improving fertility outcomes in women with PCOS and a BMI < 32 kg/m(2) (BMI 32 kg/m(2) was used to allow for international differences in BMI values which determine access to infertility therapy through the public health system). METHODS Databases were searched for English language articles until July 2011.

INCLUSION CRITERIA

women of any age, ethnicity and weight with PCOS diagnosed by all current criteria, who are infertile; at least 1000 mg of any type of metformin at any frequency, including slow release and standard release, compared with any type, dose and frequency of clomiphene citrate.

OUTCOMES

rates of ovulation, live birth, pregnancy, multiple pregnancies, miscarriage, adverse events, quality of life and cost effectiveness. Data were extracted and risk of bias assessed. A random effects model was used for meta-analyses of data, using risk ratios (relative risk). RESULTS The search returned 4981 articles, 580 articles addressed metformin or clomiphene citrate and four randomized controlled trials (RCTs) comparing metformin with clomiphene citrate were included. Upon meta-analysis of the four RCTs, we were unable to detect a statistically significant difference between the two interventions for any outcome in women with PCOS and a BMI < 32 kg/m(2), owing to significant heterogeneity across the RCTs. CONCLUSIONS Owing to conflicting findings and heterogeneity across the included RCTs, there is insufficient evidence to establish a difference between metformin and clomiphene citrate in terms of ovulation, pregnancy, live birth, miscarriage and multiple pregnancy rates in women with PCOS and a BMI < 32 kg/m(2). However, a lack of superiority of one treatment is not evidence for equivalence, and further methodologically rigorous trials are required to determine whether there is a difference in effectiveness between metformin and placebo (or no treatment) or between metformin and clomiphene citrate for ovulation induction in women with PCOS who are non-obese. Until then, caution should be exercised when prescribing metformin as first line pharmacological therapy in this group of women.

The treatment of infertility in polycystic ovary syndrome: a brief update

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. Lifestyle change alone is considered the first-line treatment for the management of infertile anovulatory PCOS women who are overweight or obese. First-line medical ovulation induction therapy to improve fertility outcomes is clomiphene citrate, whilst gonadotrophins, laparoscopic ovarian surgery or possibly metformin are second line in clomiphene citrate-resistant PCOS women. There is currently insufficient evidence to recommend aromatase inhibitors over that of clomiphene citrate in infertile anovulatory PCOS women in general or specifically in therapy naive or clomiphene citrate-resistant PCOS women. IVF/ICSI treatment is recommended either as a third-line treatment or in the presence of other infertility factors.

Aromatase inhibitors for PCOS: a systematic review and meta-analysis

BACKGROUND

The effectiveness of aromatase inhibitors (AIs) in the treatment of anovulatory polycystic ovary syndrome (PCOS) remains unclear. The objective was to determine whether AIs are effective in improving fertility outcomes in women with PCOS.

METHODS

Databases were searched until July 2011. Inclusion criteria were women with PCOS, who are infertile, receiving any type, dose and frequency of AI compared with placebo, no other treatment or other infertility treatment. Outcomes were rates of: ovulation, pregnancy, live birth, multiple pregnancies, miscarriage and adverse events, as well as quality of life and cost effectiveness. Data were extracted and risk of bias was assessed. A random-effects model was used for the meta-analyses, using odds ratios (ORs) and rate ratios (RRs).

RESULTS

The search returned 4981 articles, 78 articles addressed AIs and 13 randomized controlled trials (RCTs) met the inclusion criteria. No RCTs compared AIs versus placebo or no treatment, in therapy naïve women with PCOS. Meta-analyses of six RCTs comparing letrozole with clompihene citrate (CC) demonstrated that letrozole improved the ovulation rate per patient [OR 2.90 (95% confidence interval (CI) 1.72, 4.88), I(2) = 0%, P < 0.0001]; however, there was no statistical difference for the ovulation rate per cycle or the pregnancy, live birth, multiple pregnancy or miscarriage rates. Letrozole also did not improve pregnancy or live birth rates compared with placebo or with CC plus metoformin in women with CC-resistant PCOS. Results of comparisons of letrozole and anastrozole in women with CC-resistant PCOS were conflicting in terms of ovulation and pregnancy rates.

CONCLUSIONS

In the absence of supportive high-quality evidence, AIs should not be recommended as the first-line pharmacological therapy for infertility in women with PCOS, and further research is needed.

Making hard choices easier: a prospective, multicentre study to assess the efficacy of a fertility-related decision aid in young women with early-stage breast cancer

BACKGROUND

Fertility is a priority for many young women with breast cancer. Women need to be informed about interventions to retain fertility before chemotherapy so as to make good quality decisions. This study aimed to prospectively evaluate the efficacy of a fertility-related decision aid (DA).

METHODS

A total of 120 newly diagnosed early-stage breast cancer patients from 19 Australian oncology clinics, aged 18-40 years and desired future fertility, were assessed on decisional conflict, knowledge, decision regret, and satisfaction about fertility-related treatment decisions. These were measured at baseline, 1 and 12 months, and were examined using linear mixed effects models.

RESULTS

Compared with usual care, women who received the DA had reduced decisional conflict (β=-1.51; 95%CI: -2.54 to 0.48; P=0.004) and improved knowledge (β=0.09; 95%CI: 0.01-0.16; P=0.02), after adjusting for education, desire for children and baseline uncertainty. The DA was associated with reduced decisional regret at 1 year (β=-3.73; 95%CI: -7.12 to -0.35; P=0.031), after adjusting for education. Women who received the DA were more satisfied with the information received on the impact of cancer treatment on fertility (P<0.001), fertility options (P=0.005), and rated it more helpful (P=0.002), than those who received standard care.

CONCLUSION

These findings support widespread use of this DA shortly after diagnosis (before chemotherapy) among younger breast cancer patients who have not completed their families.

[Post-operative retransfusion and intra-operative autotransfusion systems in total knee arthroplasty. A comparison of their efficacy]

PURPOSE OF THE STUDY

The aim of the study was to compare the effect of post-operative retransfusion with that of intra-operative autotransfusion in non-anaemic patients undergoing total knee arthroplasty (TKA).

MATERIAL AND METHODS

Between February 2004 and June 2006, a total of 129 patients free of anaemia who underwent elective primary unilateral cemented TKA for primary arthritis received blood retransfusion by means of the post-operative retransfusion system. Intra-operative transfusion was not administered. Patients with coagulation disorders, thrombocytopaenia or other haematological diseases were not included. The results were compared with those of the group of 142 patients undergoing the same surgery, but with use of the intra-operative autotransfusion system, in the period from February 2009 to December 2010. The following patient data were reviewed: patient's age at the time of surgery; value of haemoglobin before and two days after surgery; allergic and febrile reactions associated with retransfusion, renal failure after retransfusion, number of postoperative allogeneic transfusions, early TKA infection and thrombo-embolic complications.

RESULTS

Of the 129 patients with post-operative retransfusion, 25 received one or more allogeneic blood transfusions due to the haemoglobin level below 90g/l and symptoms of anaemia. The average haemoglobin level was 136 g/l (range, 111 to 159 g/l) one day before surgery and 107 g/l (range, 81 to 143 g/l) on the 2nd post-operative day. A single allogeneic blood transfusion was administered to 12 patients and two were necessary in 13 patients. The average blood volume returned to the patient through the post-operative retransfusion system was 725.3 ml (range, 250 to 1 300 ml). Of the 142 patients with intra-operative autotransfusion, 11 patients required blood transfusion in the post-operative period, with seven receiving one and four receiving two transfusions. The average haemoglobin level was 135 g/l (range, 110 to 161 g/l ) one day before surgery and 107 g/l (range, 85 to 130 g/l ) two days after it. The average volume of erythrocyte mass returned to the patient through the intra-operative autotransfusion system was 330.7 ml (range, 0 to 850 ml). No allergic, pyretic or other reaction or complication was recorded in either group. No early TKA infection occurred.

DISCUSSION

No reports comparing the efficacies of post-operative retransfusion and intra-operative auto-transfusion systems in patients undergoing total knee replacement have been found in the literature. Therefore, the only possible comparison can be made with the studies that involve patients receiving blood recuperation and control groups with no blood recuperation. In our study, 19.3% of the patients with post-operative retransfusion required allogeneic blood transfusion while this was necessary in only 7.7% of the patients with intra-operative autotransfusion. This difference was caused by a better efficiency of the intra-operative autotransfusion system which can treat up to 2 litres of harvested blood per hour and return it to the patient in the form of erythrocyte mass, while the post-operative retransfusion system can salvage only 1500 ml of blood.

CONCLUSIONS

The use of either of these systems has proved to be a simple and safe method of reducing the need of allogeneic blood transfusion in the TKA procedure. While the post-operative retransfusion system facilitates the return of drained blood only, the more efficient "cell-saver" technology collects blood shed during both intra- and post-operative periods and allows for erythrocyte mass retransfusion during and after surgery. Since the administration of allogeneic blood was required in less than 10% of the patients receiving intra-operative autotransfusion, this system was adopted as a more efficient method in routine TKA procedures.

[The effect of releasing the medial stabilisers of the knee on the magnitude of correction in opening-wedge high-tibial valgus osteotomy. Anatomy study on cadavers]

PURPOSE OF THE STUDY

When a larger opening of high-tibial osteotomy is necessary to achieve good correction of the lower extremity axis, partial release of the attachments of the medial stabilisers of the knee may be required. The aim of the study was to ascertain, in cadaver specimens, the effect of loosening the medial knee stabilisers on the magnitude of correction in medial opening-wedge high-tibial valgus osteotomy.

MATERIAL AND METHODS

Thirty-eight knees obtained from cadavers of Caucasian race were dissected. Medial opening-wedge high-tibial valgus osteotomy was performed using a dynamic distractor, constructed by us, with a dynamometer to ensure constant force action. Using a kinematic navigation system, the lower leg axis was studied at opening-wedge osteotomy under constant forces of 100 N and 150 N. The change in its angulation was recorded after each step in releasing the medial stabilisers whose structures were gradually made loose, under constant action of the given force, in the following order: superficial portion of the medial collateral ligament, tendons of the gracilis, semitendinosus and sartorius muscles.

RESULTS

The results were statistically analysed using descriptive statistical methods and the two-sample paired t-test with the level of statistical significance set at p < 0.05. Loosening of the medial stabilisers one by one under a constant load led to a statistically significant change in alignment. The most significant change in angulation, both in clinical and statistical terms, was that of 3.4° occurring after the superficial portion of the medial collateral ligament was made loose under a constant force of 100 N applied to osteotomy. Thus, this loosening contributed by 62% to an overall change of 5.5° in the lower extremity mechanical axis, as compared with the condition not allowing for loosening of the stabilisers. Under a load of 150 N applied to osteotomy, loosening of the medial collateral ligament resulted in a change by 4.1°, which accounted for 56% of an overall change of 7.3° that occurred after all stabilisers were released. On distraction of the osteotomy using a higher force, an increase in a stabilising effect of the pes anserinus was apparent.

DISCUSSION

The evolution of angle-stable implants has advanced options for reliable fixation of high-tibial corrective osteotomy which involves cutting out a wedge and forcing it open on the medial side. These implants provide stable fixation even when a large correction of the limb mechanical axis is required, and allow for rehabilitation with early weight-bearing. As with a large correction the force needed to make the wedge open is increasing, it is necessary to consider loosening of the medial stabilisers of the knee. According to our knowledge, no study on the effect of individual medial stabilising structures of the knee on the force required to open high-tibial osteotomy with the wedge opened medially has been published.

CONCLUSIONS

The process of correcting lower extremity alignment by high-tibial opening-wedge valgus osteotomy brings about an increase in tension of the stabilisers on the concave side of the deformity. Our results show an important role of releasing the superficial portion of the medial collateral ligament in the reduction of forces necessary to correct a deformity.