Sir,

Re: Asymptomatic gallstones in the laparoscopic era. J R Coll Surg Edin 2002; 14: 742-748

Thank you for publishing your recent article on management of asymptomatic gallstones¹ which we read with great interest. It adds greatly to the specific debate that is current in our unit i.e. what to do about gallstones found at routine investigations for other symptoms. However, in reference to work done in our unit and waiting publication, we had reviewed 9332 post mortem reports over a period of 10 years and noted that despite a parity in gallstone prevalence among both sexes in their latter years (28% males and 31% females greater than 60 years of age) women still tended to undergo cholecystectomy at twice the rate compared with men of the same age group (18% vs 10%, respectively). We believe that this difference was determined as much by surgical practice as by surgical need. Furthermore, only 13.5% of those with gallstones actually underwent cholecystectomy (open or laparoscopic). This implied that the majority (86.5%) were asymptomatic requiring no intervention. Unfortunately, our study also highlighted that gallstones were the direct cause of 34 deaths (Mean age 76; 10 males and 24 females) with a further seven deaths recorded post cholecystectomy (Mean age 73; 1 male and 6 females). 

Six of the seven latter deaths were secondary to open rather than laparoscopic cholecystectomy. Six were emergency procedures whilst one was elective. This would suggest that although less than 0.5% of deaths (34/9332) were due to gallstones, a more aggressive policy for asymptomatic gallstones may reduce mortality. Clearly, emergency cholecystectomy has a higher mortality compared with elective procedures and could, therefore, be avoided by early elective procedures. These findings on gallstones and mortality² confirm earlier reports. We would also like to comment on the much-debated proposed link between colonic carcinoma and cholecystectomy. A metaanalysis on this topic from our unit has shown that the association between the two is weak and may be due to publication bias for positive results and should not be a factor in the decision to proceed with elective laparoscopic cholecystectomy.³

Yours sincerely,

H.N. Khan
William Harvey Hospital
Kent, UK

REFERENCES
1. Meshikhes AW. Asymptomatic gallstones in the laparoscopic era. J R Coll Surg Edin. 2002; 14: 742-748.
2. Godfrey PJ, Bates T, Harrison M, King MB, Padley NR. Gallstones and mortality: a study of all gallstone related deaths in a single health district. Gut 1984; 25: 1029-1033.
3. Reid FDA, Mercer PM, Harrison M, Bates T. Cholecystectomy as a risk factor for colorectal cancer: A meta-analysis. Scand J Gastroenterol 1996; 31: 160-169.

Sir,

I thank Mr Khan for his great interest in the article.¹ In reference to Mr Khan’s post-mortem study which showed that only 13.5% of patients with gallstones actually underwent cholecystectomy, it is interesting to note that gallstones were the direct cause of death in 34 patients and that a further seven deaths were post-cholecystectomy (six out of seven were open rather than laparoscopic cholecystectomies) and six were emergency procedures.

I agree that this supports the case against expectant management of asymptomatic gallstones which should be treated more aggressively if the patient is young and fit to avoid future gallstone-related complications. Furthermore, elective cholecystectomy (open or laparoscopic) is much safer than emergency procedures.

Regarding cholecystectomy and colonic cancer, the issue as it has been mentioned in the article is still controversial. I agree that till now there is no conclusive evidence to link cholecystectomy to colonic cancer. This indeed warrants further investigation to settle the issue once and for all. However, this association should not deter surgeons from offering laparoscopic cholecystectomy to their asymptomatic patients based on the guidelines that were highlighted in the article.¹

Yours sincerely,

A.W.N. Meshikhes
Dammam Central Hospital
Dammam
Eastern Province
Saudi Arabia

REFERENCES
1. Meshikhes AW. Asymptomatic gallstones in the laparoscopic era. J R Coll

Sir,

Re: The early management of severe tibial pilon fractures using a temporary ring fixator by Mockford et al. J R Coll Surg Edinb Irel. Apr 2003; 1(2): 104-7.

I read with interest the case report entitled ‘The early management of severe tibial pilon fractures using a temporary ring fixator’ by Mockford et al (2003). I would like to seek clarification on two points.

Firstly, why was an olive wire used instead of a simple wire? The latter should have served the purpose when a single wire was used.

Secondly and more importantly, how does this frame achieve adequate fracture and ankle stability, the authors’ second goal in treatment, with a single wire in the calcaneum distal to the fracture? In this frame any foot movement should inevitably be transmitted to the fracture site making it unstable and causing severe pain. The fact that this frame seemed to work well in three patients may not be a proof of its effectiveness. The authors might consider revising the technique by adding more distal wires or by immobilising the foot.

Yours sincerely,

B. Sankar
Royal Bolton Hospital, Bolton, UK

REFERENCES
1. Mockford BJ, Ogonda L, Warnock D, Barr RJ, Andrews CThe early management of severe tibial pilon fractures using a temporary ring fixator. J R Coll Surg Edinb Irel Apr 2003; 1(2): 104-7.

Sir,

Thank you for sending us the letters by B. Sanka regarding our article in the Surgeon. When supine, the lower limb lies in external rotation. If smooth wires are used there is a tendency for the limb to slip along the frame to rest against the half rings. Using olive wires inserted laterally buttresses the frame and this problem is avoided.

Secondly, the bridging frame across the ankle as described distracts the limb and fracture reduction is maintained by ligamentotaxis. The frame is used primarily to allow soft tissues to settle and, with distraction, a certain amount of fracture stability is produced. Theoretically, by placing a single wire in the calcaneum only ankle movements are not entirely eliminated but the degree of motion imparted to the tibiotalar joint (dorsiflexion and plantar flexion) is minimal with most movement occurring at the talonavicular and subtalar joints. Ankle swelling developing from this injury also inhibits movements. The patient is rested in bed until their definitive procedure is carried out and mobilization is not permitted. We appreciate the concerns regarding movement causing pain but patient comfort is achieved and none in this series complained of severe pain at any point in their temporary frame.

Yours sincerely,

B. Mockford
Co. Armagh

Sir,

Re: Biocompatibility: A biomechanical and biological concept in total hip replacement. Surg. J R Coll Surg Edinb Irel. 2003; 1:1-8.

We commend the excellent and readable review by ID Learmonth.¹ We would raise the enclosed relevant points that have arisen from recent experimental simulator results,² conducted using commercial stainless steel femoral heads and ultra high molecular weight polyethylene (UHMWPE) cups.²

• Stainless steel heads can show significant wear if externally generated debris particles are present, e.g. arising from the operation.

• Under dust/debris free conditions, the stainless steel surface showed little or no wear, being protected by a layer of UHMWPE smeared over its surface.

• Aged irradiated UHMWPE exhibited a high wear rate due to the effect of long lasting free radicals within its bulk. (i.e. processes used to produce sterile cups for operations).

• UHMWPE possesses a granular submicron structure which inevitably results in wear generating submicron debris that cause osteolysis.³

• The submicron debris produced, can be minimised by either the use of a different polymer, e.g. polyetherether ketone (PEEK) or by a protective surface layer over the polymer/stainless steel counter faces.

• Hyaluronic acid and cholesterol lubricants had little practical effect on reducing the wear rate of UHMWPE.

• Liquid crystal lubricant, on the other hand, greatly reduced the wear rate due to the formation of a wavy protective film on both counter face. This kept the surfaces apart even when there was intermittent action of the joint.

Yours sincerely,

R.L. Spedding* and P.L. Spedding
* Accident and Emergency
Warrington Hospital, UK

School of Aeronautical Engineering
Queens University
Belfast

Sir,

I would like to thank Mr Spedding for his relevant comments. ‘Three body wear’ encountered in vivo contributes significantly to accelerated wear processes. The results obtained from a simulator where the conditions are carefully controlled can seldom be extrapolated to in vivo performance.

The deleterious effects of subsurface oxidation associated with aged UHMWPE that was sterilised by gamma irradiation in air is well documented. The newer highly cross-linked polyethylenes together with the modern sterilisation methods perhaps offer a more durable UHMWPE with lower wear (in vitro at least!). The lubrication mechanism (i.e. boundary, fluid film etc) will be determined by the clearance and tolerance. However, lubricants (and specific coatings) can also make a significant contribution to the reduction of wear.

Wear often predicates failure in total hip arthroplasty. This is an exciting and ongoing area of development.

Yours sincerely,

I.D. Learmonth
Bristol Royal Infirmary, UK

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