Indications For Revision Surgery Research Articles

Risk factors for recurrence after Bankart repair a systematic review

Arthroscopic Bankart repair of anterior shoulder instability is a common practice in orthopedics. The aim of this study was to evaluate pre-operative risks factors associated with recurrent instability and to delineate possible indications for revision surgery. A systematic review was performed including the following keywords: arthroscopy, Bankart repair, anterior shoulder instability, recurrence of instability, suture anchors and treatment outcome. Studies eligible for inclusion in the review were clinical trials published in the last 10years investigating patients with anterior shoulder instability managed by an arthroscopic repair technique with suture anchors. The studies had to report data about recurrence of instability and investigational parameters (risk factors) that influenced the results referred to the rate of recurrence. Twenty-four articles were identified that met the inclusion criteria and underwent further review. Data from these studies were collected, and the risk of treatment failure was statistically recalculated. An estimate of the overall recurrence rate was obtained by pooling data about failure from the trials. The rate of recurrent instability at 10years of follow-up ranged from 3.4 to 35%. Epidemiological parameters significantly associated with the recurrence of instability were age below 22years old, male gender, the number of preoperative dislocations and participation in competitive sports. Surgical parameters significantly associated with recurrence of instability were repair with fewer than three anchors and the use of knotless anchors. The patho-anatomical factors significantly associated with recurrences were substantial associated glenoid or humeral head bone loss and the presence of anterior labroligamentous periosteal sleeve avulsion. Knowledge of risk factors for post-operative outcomes allows surgeons to provide appropriate preoperative counselling to patients and support more realistic expectations. An accurate analysis of causes of failure should enable the correct revision strategy to be adopted. II.

Surgery for Failed Cervical Spine Reconstruction

Review article. To review the indications, operative strategy, and complications of revision cervical spine reconstruction. With many surgeons expanding their indications for cervical spine surgery, the number of patients being treated operatively has increased. Unfortunately, the number of patients requiring revision procedures is also increasing, but very little literature exists reviewing changes in the indications or operative planning for revision reconstruction. Narrative and review of the literature. In addition to the well-accepted indications for primary cervical spine surgery (radiculopathy, myelopathy, instability, and tumor), we have used the following indications for revision surgery: pseudarthrosis, adjacent segment degeneration, inadequate decompression, iatrogenic instability, and deformity. Our surgical goal for pseudarthrosis is obviously to obtain a fusion, which can usually be performed with an approach not done previously. Our surgical goals for instability and deformity are more complex, with a focus on decompression of any neurologic compression, correction of deformity, and stability. Revision cervical spine reconstruction is safe and effective if performed for the appropriate indications and with proper planning.

Clinical outcomes of revision biceps tenodesis

Purpose:Biceps tenotomy and tenodesis are effective treatment options for biceps pathology, but outcomes of revision surgery are not known. This study examines the clinical outcomes of patients who have undergone a revision biceps tenodesis.Materials and Methods:A retrospective review of all patients since 2004 (N = 21) who had undergone a revision biceps tenodesis with greater than 6-month follow-up was completed. A follow-up survey was carried out, and the visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and University of California – Los Angeles (UCLA) scores were obtained, along with SF-12 Mental (MCS-12) and Physical Component Summaries (PCS-12).Results:Indications for revision surgery were continued pain (14) and ruptured biceps (7). Complete follow-up examinations were performed in 15 of 21 patients (71.4%). Average follow-up was 33.4 ± 23.5 months. The mean postoperative scores were 1.9 out of 10, VAS; 79 out of 100, SANE; 10.2 out of 12, SST; 83 out of 100, ASES; 29 out of 35, UCLA; 44, PCS- 12; and 47.1, MCS- 12. Five patients were considered failures with a UCLA score below 27. Seventeen of twenty-one patient underwent concomitant procedures. Complete preoperative and postoperative data were collected for 14 patients. All scores demonstrated highly significant improvement from preoperative levels (P < 0.005), except for the MCS-12. There was no statistically significant difference in the outcomes of revision due to rupture and revision due to persistent pain.Conclusions:The results suggest that revision subpectoral biceps tenodesis provides significant pain relief and improvement in functional outcomes at a mean follow-up of 33.4 months.Level of Evidence:Case Series, Level 4.

Clinical and Economic Burden of Revision Knee Arthroplasty

Surgery is indicated for symptomatic knee osteoarthritis (OA) when conservative measures are unsuccessful. High tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA), and total knee arthroplasty (TKA) are surgical options intended to relieve knee OA pain and dysfunction. The choice of surgical intervention is dependent on several factors such as disease location, patient age, comorbidities, and activity levels. Regardless of surgical treatment, complications such as infection, loosening or lysis, periprosthetic fracture, and postoperative pain are known risks and are indications for revision surgery. The clinical and economic implications for revision surgery are underappreciated. Over 55,000 revision surgeries were performed in 2010 in the US, with 48% of these revisions in patients under 65 years. Total costs associated with each revision TKA surgery have been estimated to be in excess of $49,000. The current annual economic burden of revision knee OA surgery is $2.7 billion for hospital charges alone. By 2030, assuming a 5-fold increase in the number of revision procedures, this economic burden will exceed $13 billion annually. It is appealing to envision a therapy that could delay or obviate the need for arthroplasty. From an actuarial standpoint, this would have the theoretical downstream effect of substantially reducing the number of revision procedures. Although no known therapies currently meet these criteria, such a breakthrough would have a tremendous impact in lessening the clinical and economic burden of knee OA revision surgery.

Forearm pain associated with loose radial head prostheses

After post-traumatic radial head replacement, pain caused by a loose prosthesis might incorrectly be assumed to be post-traumatic. Reliable guidelines for diagnosing a symptomatic loose radial head prosthesis are lacking. We noted that pain from a loose stem within the proximal radius may present as proximal radial forearm pain. The medical records and radiographs of 14 consecutive cases (13 patients) with proximal radial forearm pain associated with a loose radial head prosthesis were reviewed retrospectively. The indication for revision surgery was painful loosening of the prosthesis within the canal of the proximal radius in 7 patients (8 cases) and pain without preoperative confirmation of the loosening in 2 patients (2 cases). Various prosthetic designs had been used in the primary operations. In 12 of 14 cases, the loosening was evident radiographically, but in 2 the only indication of a loose prosthesis (confirmed surgically) was proximal radial forearm pain. One patient was lost to follow-up. Revision or prosthetic removal eliminated the pain in 7 of 9 cases and decreased it in 1. One patient with moderate pain had an arthritic elbow and had no significant lasting relief from surgery. Follow-up averaged 27 months. The presence of proximal radial forearm pain in a patient with a radial head prosthesis is an indicator of symptomatic mechanical loosening. If the prosthesis has a textured surface for bone ingrowth, and was inserted without cement, we now consider this a strong indicator of loosening, even in the absence of radiographic signs.

Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year. In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group. We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.

Revision cochlear implantation in children

The cochlear implant intervention is the standard of care for the rehabilitation of severe to profound hearing loss in children. Growing case numbers are associated with increasing prevalence of conditions that may require surgical revision to maintain electrical hearing and language acquisition. Scalp complications can be avoided by observing core surgical principles, which also reduces the risk of wound infections. Providers of cochlear implant care should also become familiar with the indications for revision surgery, including the work-up and appropriate technique for electrode re-insertion. A summary of the literature reveals varied outcomes depending on indication, ranging from diminished speech performance to significant gains after revision surgery. Patient selection must be carefully considered to minimize additional delays in language development. The decision for revision surgery is straightforward in cases of documented speech perception decline, device failure and infection. In cases of failure to progress, however, the outcome may be reduced or unchanged.

The Modular Universal Tumour And Revision System (MUTARS®) in endoprosthetic revision surgery

The aim of this study was to present the clinical and functional results of revision surgery after failed hip endoprostheses using the Modular Universal Tumour And Revision System (MUTARS®). Functional results of the hip endoprostheses were recorded by applying the Harris hip score. The extent of the presurgical radiological bone defect was measured according to the classification system of the German orthopaedic association (DGOOC). Indications for revision surgery on 45 patients (21 female, 24 male) were aseptic loosening (19 patients), infection (16 patients), or periprosthetic fracture (Vancouver classification B2, B3 and C, in nine patients). Revision surgery was performed after 8.6 years on average (min. 0.6; max. 14.25 years). Large defects of the proximal femur (80% medial or lateral diaphysis; 20% meta-diaphysis according to DGOOC classification) were adequately reconstructed. The average follow-up was 38.6 months. Complications occurred in eight patients: one luxation, two aseptic loosenings, and five reinfections were diagnosed. The Harris hip score (presurgical 30; postsurgical 78) showed significant improvement after revision surgery. Regarding the extent of the patients' bone defects, good functional results were achieved. The comparatively low number of luxations and loosenings is due to the high modularity of the prosthesis with arbitrary antetorsion in the hip joint. However, high reinfection rates in mega-implants still constitute a problem and should be the subject of further studies.

Flexion reminder device to discourage recurrent posterior dislocation of a total hip replacement: a case report

IntroductionRecurrent dislocation of a total hip replacement prosthesis is a frustrating complication for both the surgeon and the patient. For positional dislocations with no indications for revision surgery, the current best treatment is physiotherapy, the use of abduction braces and avoidance of unsafe hip positions. Abduction braces can be cumbersome and have poor compliance. We report the successful use of a new lightweight flexion reminder device that can be used to treat people with this condition.Case presentationA 64-year-old British woman experienced recurrent positional posterior dislocation after primary hip replacement, particularly when involved in activities involving unsafe flexion of the operated hip. She disliked using an abduction brace and hence was given a simple 'flexion reminder device' that could be strapped to the thigh. Beyond the safe flexion limit, the padded top end of the device hitched against the groin crease and reminded her not to flex further, to avoid dislocation. She experienced no discomfort in wearing the device continuously throughout the day and was very satisfied. She has had no further dislocations in the 2 years since she began using it.ConclusionIn cases of arthroplasty dislocation caused mainly by an unsafe hip position, and with no indication for revision surgery, this new lightweight and easily worn flexion reminder device may be a good option for avoiding such positional dislocations, particularly those caused by unsafe flexion.

The survival of support rings in complex acetabular revision surgery

Between 1980 and 2000, 63 support rings were used in the management of acetabular deficiency in a series of 60 patients, with a mean follow-up of 8.75 years (2 months to 23.8 years). There was a minimum five-year follow-up for successful reconstructions. The indication for revision surgery was aseptic loosening in 30 cases and infection in 33. All cases were Paprosky III defects; IIIA in 33 patients (52.4%) and IIIB in 30 (47.6%), including four with pelvic dissociation. A total of 26 patients (43.3%) have died since surgery, and 34 (56.7%) remain under clinical review. With acetabular revision for infection or aseptic loosening as the definition of failure, we report success in 53 (84%) of the reconstructions. A total of 12 failures (19%) required further surgery, four (6.3%) for aseptic loosening of the acetabular construct, six (9.5%) for recurrent infection and two (3.2%) for recurrent dislocation requiring captive components. Complications, seen in 11 patients (18.3%), included six femoral or sciatic neuropraxias which all resolved, one grade III heterotopic ossification, one on-table acetabular revision for instability, and three early post-operative dislocations managed by manipulation under anaesthesia, with no further instability. We recommend support rings and morcellised bone graft for significant acetabular bone deficiency that cannot be reconstructed using mesh.

Revision Cochlear Implant Surgery in Children

To determine the incidence of revision cochlear implant (CI) surgery in children and the indications for revision surgery and to examine the pattern of events that lead to revision CI surgery. Retrospective case review. Two tertiary pediatric CI centers. Pediatric CI patients who underwent revision surgery related to their CI. Reasons for revision, surgical outcomes, complications, performance, and device analyses were sought. Nine hundred fifty-two pediatric CI operations were performed between 1991 and 2005. Ninety-three patients underwent 107 (11.2%) revision operations. Hard device failure occurred in 46% (n = 49); soft failure occurred in 15% (n = 16); medical/surgical causes were responsible for 37% (n = 40); and magnet dislodgement requiring revision surgery occurred in 2% (n = 2). Head trauma was associated with 41% of the hard failure cases (n = 20). Device analyses revealed identifiable abnormalities in most of both hard and soft failure cases. In most patients, auditory performance equaled or surpassed the best preoperative performance by 6 to 12 months after revision. Revision CI surgery is common among pediatric CI recipients. Hard failure is the most common reason for undertaking revision surgery, and this mode of failure is frequently associated with preceding head trauma. Patients and parents should be counseled that performance is expected to equal or surpass the child's best level of performance before revision surgery, although this may take some time, and exceptions do exist.

Spinal Stenosis C1-2 Following Redo Surgery For Failed Odontoid Screw Fixation - Scrutinizing The Odontoid Fracture Classification

There are sparse data concerning redo surgery for failed odontoid screw fixation and posttraumatic spinal stenosis C1-2. Also, a comprehensive classification of odontoid and C2-vertebral body fractures does not exist. We report on a referred patient with spinal stenosis C1-2 following anterior screw fixation for an alleged unstable odontoid type III fracture, secondary cut-out of the odontoid screw, malunion at the fracture site, and uncommon redo anterior fusion C2-3. Utilizing static and dynamic X-rays, MRI, dynamic CT and MRI, and neurophysiological tests, the indications for revision surgery were worked up. Finally, surgical intervention in our patient was not performed. The patient remained free of symptoms in one-year follow-up. Spinal stenosis C1-2 following an odontoid type III fracture is discussed on a selected review of literature. The strictly applied classification in our case, as well as its definition of osseous instability is scrutinized. Full diagnostic work up and a review of literature supports approaching treatment solutions in failed odontoid surgery with spinal stenosis C1-2, but an individual biomechanically based approach to odontoid and vertebral body fractures of C2, and their failed surgery is still demanded.

Success Rate in Revision Stapes Surgery for Otosclerosis

The aim of this study was to evaluate the hearing results of revision stapes surgery performed because of previously failed operations and to determine the causes of failure. Retrospective review of revision stapes operations. Tertiary referral center. Sixty-three consecutive revision stapes operations were performed in 56 patients over a period of 12 years (1992-2004). The indication for revision surgery was recurrent or persistent air-bone gap greater than 20 dB after primary surgical treatment of otosclerosis of the oval window. All patients were operated on to improve hearing. Sixty-three revision stapes operations resulted in closure of the air-bone gap to 10 dB or less in 52.4% of cases. The average postoperative air-bone gap was 13.1 dB, and the mean pure-tone average improvement was 12.9 dB. In six patients (9.5%), revision surgery produced no change in hearing, and in four (6.3%) the hearing decreased by 5 dB or more. In one patient, the operation resulted in a profound hearing loss. Prosthesis malfunction was the most common primary cause of failure (60.3%). The original prosthesis was replaced with a new one in 48 cases. In 30 of these (62.5%), closure of the air-bone gap to within 10 dB was achieved. In 15 cases, the prosthesis was not replaced, and in only four of these (26.7%), closure of the air-bone gap within 10 dB was obtained (p < 0.022). Revision stapes surgery is less likely to be successful than the primary operation. Closure of the air-bone gap to within 10 dB was achieved in 52.4% of patients. The success rate was better in cases where the original prosthesis was replaced with a new one. The risk for decreased bone-conduction threshold does not seem to be higher than in primary surgery.

Acetabular revision for recurrent dislocations: results in 14 cases after 3 years of follow-up.

17 acetabular revisions (16 patients) were performed for recurrent dislocations. 14 patients were examined clinically and radiographically after mean 3 (1-8) years. We found malpositions of components in 12 of 17 cases. 8 of 17 had redislocations and 2 were rerevised. Harris hip scores improved from 57 to 70. 10 of 14 patients were satisfied with the surgical result. Recurrent dislocations have several causes. In our patients, lack of cup anteversion was the commonest indication for revision surgery. We noted a high rate of redislocations and poor clinical results, despite correction of the preoperative component malposition in the 14 cases with follow-up.

Revision Hip Arthroplasty in the Octogenarian is it Worth It?

We retrospectively reviewed the clinical and patient perceived results of 76 revision hip arthroplasties performed in 68 octogenarians since 1990. 60% of patients gained a worthwhile reduction in pain. In contrast to previous studies, however, the functional level of the majority of patients did not improve. 29% of patients felt that they gained no benefit from their operation and, with the benefit of hindsight, 24% of patients would not have consented to surgery, from which they found recovery harder than their first operation. 47% of patients suffered complications which were multiple in over a quarter. There was a 17% dislocation rate which was usually recurrent and rarely salvageable. The indication for revision surgery in the octogenarian must be pain of sufficient severity to justify these risks.

Revision Spine Surgery in Children with Cerebral Palsy

Ten children with neuromuscular scoliosis and pelvic obliquity had revision spinal instrumentations and fusions performed at an average age of 14.7 years. The initial spinal deformity in all children was the result of static encephalopathy with nine children diagnosed as having spastic cerebral palsy without another specific diagnosis and one child diagnosed as also having Noonan syndrome. All 10 children had a revision performed after the first surgery, and two of the 10 children underwent a second revision because of failure of rod cross-links. The indications for revision surgery were symptomatic recurrent deformity, symptomatic pseudoarthrosis, or perforation of one leg of the unit rod through the pelvis. The average time between the first and second surgery was 2.7 years, and from revision to final follow-up was 2.5 years. The goal of providing symptomatic relief and correction of deformity was accomplished in nine of 10 children; however, two of the nine required two revisions. One patient continues to have a residual painful pseudoarthrosis. The two postoperative complications requiring further surgery were related to the failure of rod connectors.