Higher Rates Of Revision Surgery Research Articles

C2 Versus C3 as the Upper Instrumented Vertebra for Cervicothoracic Posterior Laminectomy and Fusion Demonstrate Equivalent Postoperative Outcomes

Abstract INTRODUCTION For patients undergoing posterior cervical laminectomy and fusion (PCLF) with an upper thoracic lower instrumented vertebra (LIV), the evidence is unclear as to whether C2 vs C3 is the ideal upper instrumented vertebra (UIV). This study analyzes short-term postoperative outcomes for PCLF comparing cervicothoracic constructs with UIV at C2 and C3. METHODS Adult patients with degenerative cervical spine disease undergoing PCLF from 2012 to 2018 at a single center were identified. Patients with UIV at C2 or C3 and a lower instrumented vertebra (LIV) at T1 or T2 were included. Univariate analysis was performed using Student's t-test, Chi-squared test, or Fisher's exact test. Multivariate regression including variables significant at P = .20 determined the effect of UIV on clinical and radiographic outcomes. RESULTS A total of 74 patients were included, of whom 30 (40.5%) and 44 (59.5%) had a UIV at C2 and C3, respectively. Mean follow-up time was 13.8 mo. Baseline characteristics including age (C2 62.4 vs C3 63.0, P = .80) and preoperative Nurick score (C2 2.3 vs C3 2.2, P = .57) were similar across groups, though the C2 UIV group had a higher rate of revision surgery (23.3% vs 2.7%, P = .006) and diabetes (40.0% vs 9.1%, P = .003). Multivariate analysis of clinical outcomes showed no significant differences, including in the rate of postoperative complications (OR: 1.5, P = .62), discharge home (OR: 1.2, P = .35), hospital length of stay (ß = −1.17 d, P = .28) or Nurick score (ß = −0.46, P = .22). Differences in radiographic outcomes including postoperative cervical lordosis (ß = −7.4 degrees, P = .09) and cSVA (ß = −8.9 degrees, P = .08) approached but did not reach significance. CONCLUSION In a study of PCLF with upper thoracic LIV, there were no significant short-term clinical or radiographic differences between a C2 and C3 UIV when adjusting for baseline characteristics. These results may aid surgeons considering PCLF for degenerative cervical spinal disease.

Surgical treatment, complications, and reimbursement among patients with clavicle fracture and acromioclavicular dislocations: a US retrospective claims database analysis

Aims: To assess rates of surgical treatment, post-surgical complications, reoperations, and reimbursement in patients with clavicle fractures and acromioclavicular (AC) dislocations.Materials and methods: This US retrospective study used data from patients with ≥1 diagnosis of clavicle fracture or AC dislocation (index) between 2012–2016. Surgical treatment was defined as a procedure within 4 weeks after clavicle fracture/AC dislocation. Rates of complications (infection, non-union, mal-union), reoperations (device removal or revisions), and all-cause healthcare reimbursement (adjusted to 2016$) were evaluated 2 years post-index among surgical patients.Results: A total of 95,243 patients with clavicle fracture and 52,100 patients with AC dislocation were identified. Mean (SD) age for clavicle fracture and AC dislocation was 23.8 (18.6) and 33.0 (15.6) years, respectively. Most clavicle fracture and AC dislocation patients were male (70.9% and 78.0%, respectively), and had few comorbidities (86.4% and 84.8% had a Charlson Comorbidity Index = 0 and 73.1% and 66.0% had Elixhauser = 0, respectively). Only 15.2% of clavicle fracture and 5.3% of AC dislocation patients received surgical treatment. Among patients undergoing surgical treatment, 2-year rates of infection, non-union, and mal-union were 1.0%, 4.2%, and 0.9%, respectively, for clavicle fracture, and 2.0%, 0.9%, and 0.1%, respectively, for AC dislocation. Reoperations occurred in 83.0% of clavicle fracture and 67.5% of AC dislocation patients. Mean (SD) 2-year reimbursement was $27,635 ($68,173) for clavicle fracture and $23,096 ($28,746) for AC dislocation.Limitations: Administrative claims data lack clinical information, limiting inferences that can be made. This data may not be generalizable to other patients.Conclusions: Rates of surgical treatment for clavicle fractures and AC dislocation and rates of infection, non-union, and mal-union among surgically-treated patients were low. However, surgical patients had high rates of device removal or revision surgery during 2-year follow-up. Improved surgical methods and technologies could reduce non-planned reoperations and device removals, thereby reducing healthcare system costs.

Graft flow predictive equation in distal bypass grafting for critical limb ischemia

ObjectiveGraft flow (GF) seems to be an important prognostic predictor in distal bypass for critical limb ischemia, but previous studies have failed to clarify the association between GF and the graft prognosis. GF differs significantly among grafts, and each graft seems to have an optimal GF depending on various factors. We hypothesized that comparison between the measured GF (mGF) and optimal estimated GF (eGF) would be important in predicting graft prognosis. Herein, we aimed to develop a GF predictive equation by assessing GF determinants and to validate the equation against a clinical dataset. MethodsA total of 198 distal bypasses with vein grafts for critical limb ischemia from 2011 to 2016 were enrolled. Of these grafts, 135 normal grafts without any abnormalities on early postoperative ultrasound examination were used to develop and validate the equation. Various anatomic and patient-related factors were analyzed to detect GF determinants with stepwise selection, and the GF predictive equation was developed with multiple linear regression analysis. After developing the equation, all 198 grafts were categorized into two groups according to the equation developed based on data from the 135 normal grafts as follows: optimal flow grafts (OFGs), in which mGF > eGF – 14.6, and suboptimal flow grafts (SFGs), in which mGF < eGF – 14.6. The cutoff value of 14.6 was determined using receiver operating characteristic curves to detect graft abnormalities. By comparing OFGs and SFGs, the efficacy of the equation in predicting bypass abnormalities and graft prognosis was assessed. ResultsThe GF determinants were runoff, hemodialysis (HD), diabetes mellitus (DM), and graft quality (GQ). The predictive equation was estimated as follows: GF(ml/min)=(32.9×run-off)+(9.9×GQ)−(13.0×DM)−(35.1×HD)+12.1 (R2 = 0.71, coefficient: runoff and GQ, 3 [good], 2 [fair], 1 [poor]; DM and HD, 1 [yes], 0 [no]). In the efficacy assessment of the equation, SFGs showed a significantly higher rate of bypass abnormalities (64.0% vs 12.2%; P < .0001), graft intermediate stenosis (10.7% vs 1.6%; P = .0071), graft critical stenosis (28.0% vs 3.2%; P < .0001), and early graft occlusion (17.3% vs 4.3%; P = .0037) than OFGs and were associated with a higher rate of revision surgery within 2 years after surgery (50.7% vs 34.2%; P = .026). SFGs also showed significantly lower primary patency rates (P < .0001) and secondary patency rates (P = .0005). ConclusionsGF was well-estimated with runoff, GQ, and the presence of DM and HD. A comparison between mGF and eGF, calculated with the equation, will help to detect bypass abnormalities and determine the necessity of additional intraoperative procedures and, thus, achieve optimal outcomes.

Retrospective Long-Term Follow-Up Survival Analysis of the Management of Osteonecrosis of the Femoral Head With Pedicled Vascularized Iliac Bone Graft Transfer

BackgroundOsteonecrosis of the femoral head (ONFH) often affects young, active adults and leads to the destruction of the hip joint and disabling arthritis. Several procedures have been developed to prevent conversion to total hip arthroplasty (THA), especially in young patients who have a high rate of hip revision surgery. The aim of this long-term follow-up is to analyze the results of vascularized iliac bone flap transfer for ONFH treatment. MethodsWe retrospectively reviewed 856 patients (1006 hips) who accepted hip-preserving surgery with vascularized iliac bone grafting due to ONFH (Ficat and Arlet stages II-IV) from January 1985 to December 2012 at our hospital. Radiographic assessment was performed with the Ficat and Arlet system, clinical assessment was performed with the Harris Hip Score system, and quality of life was evaluated with the 36-Item Short Form Survey. The hips included 575 stage II hips, 382 stage III hips, and 49 stage IV hips. We defined clinical failure as conversion to THA or any other hip-preserving surgery because of hip symptoms. ResultsA total of 856 patients (1006 hips) were eventually followed up with an average time of 15 years (range 5-25). In total, 75 patients were lost to follow-up, and 105 hips were converted to THA. The average Harris Hip Score was 87.43 ± 6.42 points at the last follow-up, representing a great improvement compared to the 66.42 ± 6.52 points obtained preoperatively. The Kaplan-Meier survival analysis showed no difference in the 15-year survival rate between patients with stages II and III disease (using THA as an end point). However, the survival rate was lower for patients with stage IV disease than that for patients with stages II and III disease. The survival rate for patients in the glucocorticoid group was lower than that for patients in the idiopathic, alcoholic, and trauma groups. The Physical Component Summary scores ranged from 78 ± 10 to 85 ± 14 postoperatively compared to 30 ± 14 to 55 ± 15 preoperatively, and the postoperative Mental Component Summary scores (range from 34 ± 11 to 59 ± 12) were significantly higher than the preoperative scores (range from 72 ± 11 to 90 ± 10), representing great improvement in patient quality of life. Postoperative complications occurred in 86 patients (4.5%) during the follow-up, including 23 patients with deep venous thrombosis, 16 patients with meralgia paresthetica (which resolved), and 47 patients with secondary wound healing. ConclusionThe vascularized iliac bone flap grafting technique yields significant improvement (particularly in the precollapse disease stages in young patients) for restoration of the biomechanical support of the collapsed femoral head and reconstruction of the blood supply to the osteonecrotic area. This procedure allows these patients to avoid or delay the need for THA surgery.

Comparison of In Situ Versus Subcutaneous Versus Submuscular Transpositions in the Management of McGowan Stage III Cubital Tunnel Syndrome.

Background: The objective of the study was to evaluate and compare the clinical outcomes of in situ decompression with subcutaneous and submuscular transpositions for surgical management of advanced (McGowan stage III) cubital tunnel syndrome (CuTS). Methods: A retrospective review of patients in our institution undergoing primary surgery for CuTS from February 1989 to May 2009 was performed. Patients with advanced CuTS with a minimum of 12 months of follow-up without any previous bony or soft tissue procedures around the elbow were included. Seventy-four patients underwent 80 primary ulnar nerve surgeries. Patients' demographics, presenting symptoms, physical examination, electrodiagnostic findings, and perioperative complications were recorded. Primary surgical techniques were compared and the risk factors for revision surgery were assessed. Results: Of the 80 surgical procedures, there were 17 decompressions (21%), 47 subcutaneous transpositions (59%), and 16 submuscular transpositions (20%). Fifty-two percent of patients had resolution of their symptoms after primary surgery. The overall complication rate after primary surgery was 12.5%. Nineteen patients (24%) had revision surgery at a median of 30 months after their primary procedure. Eight patients (42%) had symptomatic improvement after revision surgery. Patients with their dominant extremity affected, static 2-point discrimination (S2PD) greater than 10 mm, and age less than 50 years at presentation had a higher rate of revision surgery. Three patients had a second revision surgery and neurolysis for persistent symptoms. Conclusions: The overall revision rate in advanced CuTS was 24%. Forty-two percent of patients had reported subjective symptomatic improvement after revision surgery. Younger age at presentation and a greater S2PD were associated with a higher rate of revision surgery.

Arthroscopic Shoulder Stabilization in the High-Risk Young Athlete: Return to Sport and Second Surgery Rates

Objectives:Shoulder instability in the young athlete has become an increasingly significant clinical problem in recent years. This high-risk population of athletes less than 25 years of age is a difficult cohort to manage because they have high failure rates with non-operative treatment and they reportedly have the lowest return to sport (RTS) rates and highest second surgery rates following arthroscopic shoulder stabilization compared to older patients. The purpose of this retrospective study is to evaluate the two-year clinical outcomes of a cohort of high-risk athletes less than or equal to 22 years of age following arthroscopic shoulder stabilization with a focus on RTS and incidence of second surgery.Methods:The primary outcomes evaluated were RTS and revision surgery following arthroscopic shoulder stabilization performed by the senior author at minimum follow-up of 24 months. Athletes were excluded if they had > 5 pre-operative episodes of instability, significant bone loss or had primary posterior instability. Demographic data was recorded including age, sex, BMI, last recorded range of motion, # episodes of recurrent instability, and revision surgery. A brief survey was completed regarding their shoulder instability history, sports prior to surgery, sports returned to following surgery, satisfaction with and level of RTS, time at which return to sports was achieved, recurrent instability, revision operations, and single assessment numeric evaluation (SANE) score.Results:A total of 67 athletes met inclusion criteria, with a mean age of 17.4 years (range, 13-22 years). There were 19 females (28%) and 48 males (72%). The mean number of instability events was 2 (range 0-5), 57% in the dominant arm and 43% in the non-dominant arm. Evaluation of RTS, demonstrated that 59 (88%) were able to RTS with 56 (84%) of those returning to the same level or higher, while 8 (12%) patients did not RTS for reasons other than recurrent instability or apprehension. Among the 59 patients who RTS, the average time to return was 7.3 months (range: 5-12 months) and baseball and football were the most common sports. There was a gender specific difference with respect to RTS and revision surgery. The male RTS rate was 94% compared to the female rate of 74%. Four of 67 (6%) patients underwent revision stabilization 11 to 36 months for recurrent instability, however all were male athletes 4/48 (8%). There were no female athletes who required revision surgery. Patient reported mean SANE score was 88 (SD, ±15).Conclusion:Shoulder instability in the young high-risk athlete is a complex problem with a relatively high rate of recurrence and revision surgery in the literature. In our case series, we found a relatively low reoperation rate (6%) with a high rate of RTS (88%), at an average time of 7.3 months. There was a gender specific difference with respect to RTS and revision surgery. The male RTS rate was 94% and revision surgery rate was 8% (4/48) while the female RTS rate was 74% and revision surgery rate was 0%. The athletes reported a return to near full function with an average SANE score of 88. We believe the improved outcomes in this cohort of high risk young athletes are related to the pre-operative selection criteria excluding those athletes with a greater number of pre-operative episodes of instability and those with significant bone loss and bipolar lesions as open stabilization and bone augmentation (Latarjet) are more predictable operations in athletes with these risk factors.

Factors Associated With Revision Surgery After Internal Fixation of Hip Fractures.

Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (for every 5-point increase) (HR 1.19, 95% CI 1.02-1.39; P = 0.027), displaced fracture (HR 2.16, 95% CI 1.44-3.23; P < 0.001), unacceptable quality of implant placement (HR 2.70, 95% CI 1.59-4.55; P < 0.001), and smokers treated with cancellous screws versus smokers treated with a sliding hip screw (HR 2.94, 95% CI 1.35-6.25; P = 0.006). Additionally, for every 10-year decrease in age, participants experienced an average increased risk of 39% for hardware removal. Results of this study may inform future research by identifying high-risk patients who may be better treated with arthroplasty and may benefit from adjuncts to care (HR 1.39, 95% CI 1.05-1.85; P = 0.020). Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous pinning versus volar locking plate fixation for dorsally displaced distal radius fractures- reoperation rates over an eight year period

PurposeTo compare reoperation rates between closed reduction with percutaneous pinning (CRPP) and internal fixation with a volar locking plate (VLP) for the treatment of distal radius fractures. MethodsA retrospective review of all patients with dorsally displaced distal radius fractures presenting to a hospital over an eight-year period. Results1364 procedures were reviewed after applying the exclusion criteria; 663 underwent CRPP and 701 underwent VLP. The results showed that CRPP had higher rates of revision surgery due to fixation failure than VLP (p = 0.003), however there was no statistical significance in overall reoperation rates when all complications were considered (p = 0.060). This was due to higher rates of tendon related problems (p = 0.003), neurological complications (p = 0.005) and hardware removal (p = 0.01) in the VLP group. ConclusionOverall reoperation rates were similar between both techniques however there were differences in complication profile and nature of revision surgery. This information is useful when discussing treatment options with patients to help guide selection of the best procedure for that individual.

Reducing Surgical Revisions in Intracranial Complications of Pediatric Acute Sinusitis.

Objective (1) To describe the demographics and clinical course of children with intracranial complications of sinusitis. (2) To elucidate factors that predict revision surgery in this population, such as type of initial surgery. Study Design Case series with chart review. Setting Tertiary care academic children's hospital. Subjects and Methods A 15-year retrospective review identified 71 patients with intracranial complications of acute sinusitis. Primary outcome was need for revision surgery. Secondary outcomes were readmission, length of hospitalization, and long-term complications. Results This study is the largest to date examining this disease process. Overall, 69 (97%) patients had surgery; 33 (46%) required revision surgery. Half of the patients with frontal sinus opacification underwent frontal sinus surgery at presentation (endoscopic, trephination, or cranialization). There was no difference in revision surgery between patients who had frontal sinus surgery and those who did not. Patients with frontal sinus surgery did not have a higher rate of complications or chronic sinusitis ( P > .05). Subdural abscess was associated with multiple surgical procedures (odds ratio, 20.0; P < .01). Thirty-four patients (49%) required neurosurgery. These patients had a longer length of stay (odds ratio, 11.0; P < .01) and a higher readmission rate ( P = .02). During the mean 92-month follow-up, 22 patients (33%) had long-term complications, and there was 1 death (1.4%). Conclusion Almost half of this cohort required multiple surgical procedures. In particular, patients with subdural abscess had significantly higher rates of revision surgery. Type of frontal sinus surgery was not correlated with need for revision surgery and was not associated with an increased rate of complications.

Total ankle replacement leads to high revision rates in post-traumatic end-stage arthrosis.

Extremely heterogeneous revision rates in total ankle arthroplasty (TAA) of the upper ankle joint are reported and result to heterogeneous collectives and to short follow-up times. The aim is to investigate revision rates and the underlying reasons, as well as treatment outcome and quality of life after TAA in post-traumatic cases with sufficient follow-up. In 2008-2013, 74 patients with post-traumatic arthrosis were treated using TAA with a Tornier Salto prosthesis, and 60 (35 males and 25 females; mean age 56) were followed-up (mean: 59months; range 24-91months). The revision rate after TAA was 42% (n = 25), and it was 8% after 12months and 18% after 24months. Twenty percent of the patients had significant symptomatic periprosthetic bone cysts, 5% had impingement, 3% had soft tissue infections, and, in 14%, revision was caused by other factors. The most commonly performed procedures were cyst debridement and autologous spongy bone grafting (20%). Fifteen percent (n = 9) of the prosthetics were explanted or switched to a tibiotalar arthrodesis (TTA). The mean AOFAS (American Orthopaedic Foot and Ankle Society) score was 55.15 (range 12-100) and the mean FAO (Foot and Ankle Outcome) score was 49.6 (range 18-100). The revision subgroup had impaired outcomes (AOFAS 38.84; FAO 35.5) while the non-revision subgroup had improved outcomes (AOFAS 66.8; FAO 60.48). TAA patients undergoing conversion to TTA had worse outcomes (AOFAS 39; FAO 35.29). Total ankle replacement in post-traumatic end-stage arthrosis patients is associated with high revision rates. High rates of symptomatic periprosthetic bone cysts caused high rates of revision surgery and worse outcomes, which were not improved by secondary TTA.

Complications, Readmissions, and Revisions for Spine Procedures Performed by Orthopedic Surgeons Versus Neurosurgeons: A Retrospective, Longitudinal Study.

Retrospective database analysis. To examine the impact of training pathway, either neurosurgical or orthopedic, on complications, readmissions, and revisions in spine surgery. Training pathway has been shown to have an impact on outcomes in various surgical subspecialties. Although training pathway has not been shown to have a significant impact on spine surgery outcomes in the perioperative period, long-term results are unknown. A retrospective analysis of 197,682 patients receiving 1 of 3 common spine surgeries [lumbar laminectomy, lumbar fusion, and anterior cervical discectomy and fusion (ACDF)] between 2006 and 2010 was conducted. Patient data were obtained from a large claims database. Postoperative adverse effects, all-cause readmission, revision surgery rates, and intermediary payments in these cohorts of patients were compared between spine surgeons with either neurosurgical or orthopedic backgrounds. Patient demographics, hospital-stay characteristics, and medical comorbidities were similar between neurosurgeons and orthopedic surgeons. The risks of surgical complications, all-cause readmission, and revision surgery were also similar between neurosurgeons and orthopedic surgeons across all procedure types assessed, with several minor exceptions: neurosurgeons had marginally higher odds of any complication for lumbar fusions [odds ratio (OR) 1.14; 95% confidence interval (CI), 1.09-1.20] and ACDFs (OR, 1.09; 95% CI, 1.04-1.15). Neurosurgeons also had slightly higher rates of revision surgery for concurrent lumbar laminectomy with fusion (OR, 1.14; 95% CI, 1.08-1.22), and ACDFs (OR, 1.20; 95% CI, 1.14-1.28). No associations between surgeon type and any particular complication were consistently observed for all procedure groups. There were also no associations between surgeon type and 30-day all-cause readmission. Median total intermediary payments were somewhat higher for neurosurgery patients for all procedure groups assessed. Few significant associations between surgeon type and patient outcomes exist in the context of spine surgery. Those which do are small and unlikely to be clinically meaningful. Level 3.

Treatment of Radial Head Fractures and Need for Revision Procedures at 1and2Years.

Optimal treatment strategies for radial head fractures remain a subject of debate. We examined national practice patterns in the management of radial head fractures to determine rates of surgical treatment, type of surgery employed, and the incidence of reoperation. Between 2007 and 2011, we identified patients with radial head fractures along with their associated injuries by International Classification of Diseases, Ninth Revision codes in a national database of orthopedic insurance records. For those who underwent surgery, the type of intervention was identified and each patient was observed to determine whether a subsequent procedure was needed by 1 and 2 years. Chi-square analysis was performed to make comparisons between groups. A total of 58,404 radial head fractures were identified between 2007 and 2011; of these, 2,981 underwent surgical treatment (5.1%). Rates of surgical intervention were significantly higher in the context of associated injuries. Among the 2,981 radial head fractures treated surgically, 57.1% underwent open reduction internal fixation (ORIF), 37.9% were treated with radial head arthroplasty, and 4.9% underwent radial head excision. When the surgically treated radial head fracture was associated with a coronoid fracture, elbow dislocation, or proximal ulna fracture, 64.2%, 54.3%, and 47.2% were treated with arthroplasty, respectively, compared with 32.6%, 41.9%, and 52.6% treated with ORIF, respectively. After initial surgical treatment, 12.7% and 14.4% of radial head fractures that underwent ORIF required a secondary surgery at 1 and 2 years, respectively, compared with 8.6% and 10.7% of radial head arthroplasties and 8.3% and 8.4% of resections. Rates of arthroplasty were significantly higher in the context of associated injury, particularly in the setting of a coronoid fracture or elbow dislocation. Fractures initially treated with ORIF had a higher rate of revision surgery at both 1 and 2 years after the index procedure compared with arthroplasty. Therapeutic II.

Surgical Outcomes After Segmental Limited Surgery for Adjacent Segment Disease: The Consequences of Makeshift Surgery.

To minimize surgical morbidity, surgeons may opt to perform segmental limited surgery instead of fusion extension for adjacent segment disease (ASD) after lumbar fusion surgery. This study evaluated clinical outcomes from segmental limited surgery without fusion extension for ASD and assessed which clinical factors were associated with reoperation after segmental limited surgery. Medical data of 50 patients who underwent segmental limited surgery for ASD after lumbar fusion surgery between 2005 and 2015 were reviewed. Demographic data, ASD type, preoperative disc and facet degeneration, ASD location, and surgical summary were collected. The primary outcome was reoperation rate at 24 months after surgery. Of patients, 28 (56%) experienced recurrent radiculopathy (visual analog scale score ≥4). Revision surgery was performed in 22 patients (44%). Reoperation was performed more frequently in multilevel fusion first-surgery cases (15/23; 65.2%) than single-level fusion first-surgery cases (7/27; 25.9%; P= 0.005). The lowermost mobile segment group had a lower reoperation-free survival rate than the other group (hazard ratio= 9.85, 95% confidence interval 1.32-73.54, P= 0.01 [log-rank]). The 2-year reoperation-free survival rate for the lowermost mobile segment group was 31.5%, whereas the rate for the other group was 83.3%. Segmental limited surgery as a treatment for ASD after lumbar fusion surgery is likely to fail frequently and result in a high rate of recurrent radiculopathy and revision surgery. Fusion extension surgery is especially recommended for ASD at the lowermost mobile segment owing to the high failure rate.

Diabetes Outcomes More than a Decade Following Sustained Weight Loss After Laparoscopic Adjustable Gastric Band Surgery.

Long-term outcome data are needed to define the role of bariatric surgery in type 2 diabetes (T2D). To address this, we collated diabetes outcomes more than a decade after laparoscopic adjustable gastric band (LAGB) surgery. Clinical and biochemical measures from 113 obese T2D patients who underwent LAGB surgery in 2003 and 2004 were analyzed. Diabetes remission was defined as HbA1c <6.2% (44mmol/mol) and fasting glucose <7.0mmol/L. Seventy-nine patients had weight data at 10years and attained a median [Q1, Q3] weight loss of 16 [10, 21] percent. Sixty patients attended a follow-up assessment. Their baseline HbA1c of 7.8 [7.1, 9.3] percentage units (62 [54, 78] mmol/mol) had decreased to 6.6 [6.1, 8.4] (49 [43, 68] mmol/mol) despite no significant change in glucose-lowering therapy. Eleven patients (18%) were in diabetes remission and another 18 had HbA1c≤6.5%. Significant improvements in physical measures of quality of life, blood pressure, and lipid profile were also observed but there was no change in the proportion of patients with albuminuria and a significant decline in estimated glomerular filtration rate. Twelve patients in the follow-up cohort (20%) required anti-reflux medication after surgery and 26 (43%) underwent gastric band revision surgery. Weight loss for over 10years after LAGB surgery delivers clinically meaningful improvements in HbA1c, blood pressure, lipids, and quality of life at the cost of a high rate of revision surgery and increased use of anti-reflux medication. These findings support the use of bariatric surgery as a long-term treatment for weight loss and wellbeing in patients with T2D. Registered with the Australian Clinical trials registry as ACTRN12615000089538.

Perioperative Serum Lipid Status and Statin Use Affect the Revision Surgery Rate After Arthroscopic Rotator Cuff Repair

Background: Recent animal studies have demonstrated that hyperlipidemia is associated with poor tendon-bone healing after rotator cuff repair; however, these findings have not been substantiated in human studies. Purpose: To examine any association between hyperlipidemia and the failure of arthroscopic rotator cuff repair requiring revision surgery and to investigate whether the use of statin lipid-lowering agents had any influence on observed associations. Study Design: Cohort study; Level of evidence, 3. Methods: From a national insurance database, patients who underwent arthroscopic rotator cuff repair with perioperative lipid levels (total cholesterol, low-density lipoprotein [LDL], and triglycerides) recorded were reviewed. For each lipid test, patients were stratified into normal, moderate, and high groups based on published standards. For the total cholesterol and LDL cohorts, a subgroup analysis of patients stratified by statin use was performed. The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair or debridement. A logistic regression analysis controlling for patient demographics and comorbidities was utilized for comparison. Results: There were 30,638 patients included in the study. The rate of revision rotator cuff surgery was significantly increased in patients with moderate (odds ratio [OR], 1.20; 95% CI, 1.03-1.40; P = .022) and high total cholesterol levels (OR, 1.36; 95% CI, 1.10-1.55; P = .006) compared with patients with normal total cholesterol levels perioperatively. Within each of these groups, patients without statin use had significantly higher rates of revision surgery, while those with statin prescriptions did not. The absolute risk reduction for statin use ranged from 0.24% to 1.87% when stratified by the total cholesterol level, yielding a number needed to treat from 54 to 408 patients. The rate of revision surgery was significantly increased in patients with moderate (OR, 1.24; 95% CI, 1.10-1.41; P = .001) and high LDL levels (OR, 1.46; 95% CI, 1.08-1.99; P = .014) compared with patients with normal LDL levels perioperatively. Again, patients without statin prescriptions had significantly increased rates of revision surgery, whereas patients with statin use did not. The absolute risk reduction for statin use ranged from 0.26% to 1.89% when stratified by the LDL level, yielding a number needed to treat from 53 to 387 patients. There were no significant differences in the rates of revision rotator cuff surgery between patients with moderate and high triglyceride levels compared with patients with normal triglyceride levels. Conclusion: The present study found a significant association between moderate and high perioperative total cholesterol and LDL levels and the rate of revision surgery after primary arthroscopic rotator cuff repair. Furthermore, the use of statin agents appeared to mitigate the need for revision rotator cuff repair. Further prospective studies are necessary to validate these preliminary findings and determine if better perioperative lipid control can improve clinical outcomes after arthroscopic rotator cuff repair.

Isolated Head and Liner Exchange in Revision Hip Arthroplasty.

As the number of primary total hip arthroplasties increases, so does the burden of revision procedures. The decision to revise well-fixed components in the setting of polyethylene wear and osteolysis is controversial. Modular head and liner exchange offers the advantages of reduced invasiveness, faster recovery, and bone preservation. These advantages come at the expense of higher rates of revision surgery for instability. Using the native locking mechanism for securing the new liner is preferred; however, cementing a liner into a well-fixed acetabular component is a practical alternative. The use of bone allograft or bone graft substitute for areas of osteolysis is controversial. In the setting of osteolysis, outcomes associated with the use of highly cross-linked polyethylene liners have been better than those associated with the use of conventional polyethylene; therefore, thinner liners and larger femoral heads can be used and reduce the risk of instability.

Three-year outcomes of intracapsular femoral neck fractures fixed with sliding hip screws in adults aged under sixty-five years

IntroductionIntracapsular femoral neck fractures remain associated with high rates of post-traumatic femoral head necrosis, non-union, and revision surgery. AimOur aim was to identify factors associated with revision surgery in intracapsular femoral neck fractures treated with sliding hip screws (SHS) in adults aged <65 years. Patients and methodsConsecutive admissions were identified retrospectively from the Royal Victoria Hospital, Belfast, which was the largest volume hospital on the National Hip Fracture Database. Of 2201 hip fractures between 1st August 2008 and 31st December 2010, 97 (4%) intracapsular fractures treated with SHS in adults <65 years were followed for a mean of 2.9 years (range 0–6.6). ResultsTwenty-one (22%) hips were revised to arthroplasty. Avascular necrosis developed in 28 (29%) femoral heads. Eight (8%) fractures proceeded to non-union. Displaced fractures (p<0.001, Fisher’s exact [FE]), posterior comminution (p=0.049, FE), chronic respiratory disease (p=0.006, FE) and residual distraction (p=0.011, χ2) were associated with revision to arthroplasty. Multiple regression found displaced fractures (p=0.006) and chronic respiratory disease (p=0.017) significant; in the latter 4 of 6 were revised (67%), including all four patients with chronic obstructive pulmonary disease (COPD). Eleven (11%) individuals required walking aids before injury, which rose to 34 (35%) at one year (p<0.0001, χ2). Eighty-nine (92%) individuals could walk alone outdoors before injury, but only 76 (78%) at one year (p=0.009, χ2). ConclusionsDisplaced fractures in individuals with chronic respiratory disease should be considered high risk for revision to arthroplasty. Posterior cortex deficiency should be evaluated prior to choice of operation. Fracture biology and revascularisation play a greater role than operation timing. A significant proportion of individuals do not recovery pre-morbid mobility by one year.

Predicting revision sinus surgery in allergic fungal and eosinophilic mucin chronic rhinosinusitis.

Chronic rhinosinusitis consists of several disease processes. Eosinophilic mucin is found in the subtypes of allergic fungal sinusitis (AFS) and eosinophilic mucin chronic rhinosinusitis (EMCRS). These entities frequently require surgical intervention and have high recurrence rates. We aimed to determine factors in patients with AFS and EMCRS that may be associated with a higher rate of revision surgeries. Our hypothesis is that patients who have polyps, high Lund-Mackay score (LMS), and fungus may have higher revision rates. Retrospective cohort study. This is a retrospective analysis of 117 patients identified over a 5-year period (2005-2009) with the diagnosis of AFS or EMCRS. Contingency tables were created to obtain the odds ratios estimates, and 95% confidence intervals were used to access the association between the outcome (having revision surgery or not) and other clinical binary predictors. Twenty-six of 117 (22%) of the study patients underwent revision surgery. Within the 2-year follow-up period, an additional five of 26 (19%) required another revision surgery. Average LMS was slightly higher in those who underwent revision surgery (16 vs. 13) on a scale of 0 to 24, with an overall mean score of 18 and standard deviation of 6.82 for the whole sample (117). Other factors evaluated were the presence of fungus, polyps, eosinophilic mucin, and the eosinophilic count and medical therapy received. The presence of eosinophilic mucin was significantly associated a higher rate of revision surgery. 4. Laryngoscope, 127:59-63, 2017.

Indications, technique and results of the STARR procedure

Rectal intussusception and ventral rectocele are frequent morphological findings in patients suffering from obstructed defecation syndrome (ODS). After failed conservative treatment asurgical option can be discussed. Surgical approaches include the stapled transanal rectal resection (STARR) procedure, which is performed as atransanal approach by using two circular (PPH01) staplers for ventral and dorsal full-thickness resection of the distal rectum. Both retrospective and prospective studies as well as data from the German STARR registry demonstrated that the STARR procedure is safe and effective for symptom improvement and resolution in ODS associated with rectal intussusception in the short-term; however, disappointing functional results, particularly related to fecal incontinence and urgency, severe complications and high rates of revision surgery have also been documented. In general, based on the diagnostic and therapeutic challenges in ODS related to rectal intussusception, patient selection for STARR seems to be the key for success; therefore, this review summarizes and evaluates the indications, surgical technique, results, controversies and current trends of the "conventional" STARR procedure using two circular (PPH01) staplers.

The Clinical Correlation of the Hart-ISSG Proximal Junctional Kyphosis Severity Scale With Health-Related Quality-of-life Outcomes and Need for Revision Surgery.

Retrospective analysis of prospective data. Evaluate the utility of the Hart-International Spine Study Group proximal junctional kyphosis severity scale (Hart-ISSG PJKSS). Proximal junctional kyphosis (PJK) and failure (PJF) are well-described complications after long-segment instrumentation. The Hart-ISSG PJKSS was recently developed and incorporates neurological deficit, pain, instrumentation issues, degree of kyphosis, presence of fracture, and level of upper-most instrumented vertebrae. All adult spinal deformity patients with PJK or PJF were identified from two academic centers over a 7-year period. Health-related quality-of-life (HRQOL) outcomes were prospectively collected: Oswestry Disability Index (ODI), visual analogue scale (VAS) pain, SF-36 questionnaire, and SRS-30 questionnaire. Patients were retrospectively assigned Hart-ISSG PJKSS scores. Correlation between the Hart-ISSG PJKSS and outcomes was assessed with linear regression, Pearson correlation coefficients, and χ² analysis. A total of 184 cases were included; 21.2% were men and mean age was 65.0 years. Weakness and/or myelopathy were present in 11.4% of patients and 88.6% had pain. Instrumentation issues occurred in 44.0% and 64.1% had PJK-associated fractures. PJK occurred in the upper thoracic spine in 21.7% of cases. Mean PJKSS score was 5.9. The Hart-ISSG PJKSS was significantly and strongly associated with ODI (P < 0.001, r = 0.611), VAS pain (P < 0.001, r = 0.676), SRS-30 function (P < 0.001, r = -0.401), SRS-30 mental health (P < 0.001, r = -0.592), SRS-30 self-image (P < 0.001, r = -0.511), SRS-30 satisfaction (P < 0.001, r = -0.531), and SRS-30 pain (P < 0.001, r = -0.445). Higher scores were associated with higher proportion of patients undergoing revision surgery (P < 0.001); scores of 9 to 11 and 12 to 15 underwent revision 96.0% and 100.0% of the time, respectively. The Hart-ISSG PJKSS was strongly correlated with validated functional outcomes and higher scores were associated with higher rates of revision surgery. The Hart-ISSG PJKSS may be a useful clinical tool in the treatment of patient with PJK. 3.