Mean Surgical Blood Loss Research Articles

Integrated Acetabular Prosthesis Versus Bone Grafting in Total Hip Arthroplasty for Crowe Type II and III Hip Dysplasia: A Retrospective Case-Control Study.

Many methods of acetabular reconstruction with total hip arthroplasty (THA) for Crowe type II and III adult developmental dysplasia of the hip (DDH) acetabular bone defect have been implemented clinically. However, there was no study comparing the results of integrated acetabular prosthesis (IAP) with bone grafting (BG). This study aims to investigate the efficacy of IAP and BG for acetabular reconstruction in Crowe type II and III DDH. The clinical data of 45 patients with unilateral Crowe type II and III DDH who underwent THA from January 2020 to January 2023 were retrospectively analyzed. The patients were divided into two groups: 25 patients using 3D-printed IAP (IAP group) and 20 patients using BG (BG group). The operation time and intraoperative blood loss were recorded. The clinical outcomes were assessed by Harris Hip Score (HHS) and full weight-bearing time. The radiological outcomes were evaluated by the radiological examination. Accordingly, intraoperative and postoperative complications were observed as well. The data between the two groups were compared by independent sample t-tests and the Mann-Whitney U rank sum test. There were no significant differences between the two groups in Harris Hip Score (HHS) (preoperative, 6 months postoperative, and the last follow-up), leg length discrepancy (LLD), cup inclination, cup anteversion, vertical center of rotation (V-COR), horizontal center of rotation (H-COR) (p > 0.05). The mean HHS in the IAP group was higher than in the BG group at 1 and 3 months postoperative (p < 0.001). The mean surgical time and blood loss in the IAP group were less than in the BG group (p < 0.001). The mean full weight-bearing time in the IAP group was shorter than in the BG group (p < 0.01). No complications were observed in either group during the follow-up period. IAP and BG have similar radiographic outcomes and long-term clinical efficacy in THA for Crowe type II and III DDH, but the IAP technique has higher surgical safety and facilitates the recovery of hip joint function, which is worthy of clinical promotion.

Robot-assisted radical cystectomy for bladder cancer: single-center experience

Abstract Objective Radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. Recently some surgeons have begun to describe outcomes associated with less invasive surgical approaches to this disease, such as laparoscopic or robotic assisted techniques. We report our maturing experience with 100 consecutive cases of robotic assisted laparoscopic radical cystectomy regarding perioperative results, pathological outcomes, and surgical complications. Methods A total of 100 consecutive patients (73 male and 27 female) underwent robotic radical cystectomy with intracorporeal urinary diversion at our institution from February 2018 to February 2021 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes, and complication rate. Results The mean age of this cohort was 60.4 years (range 38 to 82). Ninety-five patients underwent ileal conduit diversion, 5 received a neobladder). The mean operating room time for all patients was 184 min (min time was 160 min) and mean surgical blood loss was 286 ml. On surgical pathology, 2% of the cases were pT1, 35% were pT2, 51+12% were pT3/T4 disease and 17% were node positive. The mean number of lymph nodes removed was 16 (range 10 to 40). In no case was there a positive surgical margin. The mean days to flatus were 2.6, bowel movement 2.8 and discharge home 8.2. There were 21 postoperative complications in 20 patients with 4% having a major complication (Clavien grade 3 or higher) and 15% being readmitted within 30 days after surgery. At a mean follow-up of 12 months 3 patients had disease recurrence and died 4 of disease. Conclusions We report a relatively large cohort and maturing experience with robotic radical cystectomy for the treatment of bladder cancer, providing acceptable surgical and pathological outcomes. These results support continued efforts to refine the surgical management of muscle-invasive bladder cancer.

Simultaneous Anterior and Posterior Release in Lateral Decubitus Position for Rigid Adult Spinal Deformity: A Technical Note and 2 Case Reports

Correction surgery for rigid adult spinal deformity usually involves a complex 360° osteotomy, multiple intraoperative position changes, and staged surgery. Moreover, there is a lack of consensus regarding the surgical strategy for this pathology. We report the technical advantages of a simultaneous anterior and posterior release only in the lateral decubitus position to reduce surgical invasiveness in two case reports. A 76-year-old woman and an 80-year-old woman presented with significant spinal imbalance and segmental fusion in the anterior and posterior columns around the apex of the lumbar spinal curvature. We conducted this procedure for these patients at the first stage of spinal corrective surgery to achieve 360° osteotomy. A long posterior fusion surgery was performed after 1 week. The mean values of the central sacral vertical line, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt improved substantially postoperatively: central sacral vertical line, from 51.0 to 7.5 mm; pelvic incidence minus lumbar lordosis, from 27.5° to 0.5°, sagittal vertical axis, from 107.6 to 14 mm; pelvic tilt, from 34.0° to 13.0°. The mean surgical time and blood loss in the first- and second-stage operations were 242.1 minutes and 702 mL and 315.5 minutes and 549 mL, respectively, and no perioperative complications occurred. Simultaneous 360° segmental release in the lateral decubitus position without repositioning can make it possible to acquire satisfactory correction and reduce surgical invasiveness compared with the conventional procedure for adult spinal deformity.

Early experience with the use of trochanteric reattachment plate for the treatment of Vancouver type B 1 periprosthetic hip fractures

ObjectiveThe purpose of our study is to study the usefulness of trochanteric reattachment plate in the management Vancouver type B 1 periprosthetic femur fractures. MethodsWe describe a case series of 15 (12 F: 3 M) Vancouver type B 1 fracture fixed with trochanteric reattachment plate with 3 years follow up. Patients with Vancouver A, B2, B3 and C fractures were excluded in the study. Clinical and radiological assessment of patients was done at 1, 3, 6, 9, 12, 24 and 36 months. The parameters evaluated were fracture union, Harris hip score and post-operative complications if any. ResultsPatients mean age was 74 years (range 58–84). Eleven patients were operated with cemented hemiarthroplasty while 4 patients had total hip arthroplasty done before. Operation time mean was 137.2 min and mean surgical blood loss was 522.66 ml. All the patients achieved radiological union of the fracture at mean of 14.13 weeks. Mean Harris hip Score was 82 at 36 months follow up. 13 out of 15 hips (86.67%) showed good clinical results and 2 patients (13.33%) showed fair result. All the patients returned to their pre injury activities of daily living. ConclusionOperative fixation of Vancouver type B 1 periprosthetic fractures is a challenge for an orthopedic surgeon. Open reduction and internal fixation of these fractures using of trochanteric reattachment plate incorporating screws and cerclage wires through the plate provides good outcome in these patients. Use of this plate offers the surgeon stability against shearing as well as rotational forces.

New Technique of Laparoscopic Paraaortic Lymph Node Dissection for Colorectal Cancer Using Fluorescence Navigation.

According to limited current reports, therapeutic paraaortic lymph node (PALN) dissection with intensive combined therapy for colorectal cancer improves prognosis in select patients. Laparoscopic PALN dissection is a difficult technique that has not yet been established. We applied this procedure using an intraoperative fluorescence navigation technique with a near-infrared ray catheter (NIRC™) fluorescent ureteral catheter (NIRFUC). We evaluated the utility of laparoscopic fluorescence navigation and the short-term outcomes of 6 patients undergoing laparoscopic PALN dissection. There were 3 surgeries for synchronous metastasis and 3 surgeries for recurrent metastasis. The mean surgical duration, blood loss, and postoperative hospital stay were 677 (range=518-1,090) min, 7.5 (range=3-1,600) ml, and 14 (range=9-33) days, respectively. Postoperative complications (Clavien-Dindo grade >III) occurred in 1 case. Dissection around the ureter was navigated with a NIRFUC. Fluorescence ureteral navigation facilitated completion of the complex laparoscopic PALN dissection procedure.

Intraoperative O-arm navigation guided anterior cervical surgery; A technical note and case series

BackgroundNavigation surgery is becoming very popular for anterior cervical surgery. However, one difficult problem for anterior cervical surgery is setting the reference frame (RF), due to the lack of reliable structures. If the RF is attached to the head holder or operation table instead of the patient, the accuracy of navigation is not good. Materials and methodsThis retrospective study included six patients who underwent anterior cervical surgeries with O-arm navigation. The RF was attached to the Caspar retractor using a special adaptor. Patients comprised three men and three women with a mean age of 62.8 years. Anterior cervical discectomy and fusion was performed in three cases, and anterior cervical corpectomy and fusion in three cases. We evaluated the accuracy of navigation, surgical time, intraoperative blood loss, complications, bony fusion, and clinical results. ResultsMean accuracy of anterior navigation was 1.1 ± 0.7 mm (range, 0–2 mm). Mean surgical time and blood loss were 166 ± 39 min (range, 121–359 min) and 280 ± 189 ml (range, 50–600 ml), respectively. Complications comprised one case of postoperative C5 palsy that recovered within 6 months. Mean Japanese Orthopedic Association (JOA) recovery rate was 52.4% (range, 20–100%). Adequate decompression and solid fusion were obtained in all cases. ConclusionsIntraoperative O-arm navigation-guided anterior cervical decompression and fusion is an effective technique for achieving precise decompression. This new navigation technique provides excellent results for severe cervical ossification of the posterior longitudinal ligament (OPLL) with minimum risk of adverse events from intraoperative radiation. We advocate the use of this novel technique in cases of cervical canal stenosis due to large disc osteophyte complex and OPLL, and also in cases of distorted cervical anatomy due to deformity, tumor, or revision surgery.

Dural Leak: Is It Deterrent to Outcomes in Spine Surgery?: 10 Years Retrospective Analysis of Incidence, Management Protocol, and Surgical Outcomes.

Retrospective case-control study. To review the incidence of dural leaks, evaluate the efficacy of primary closure of durotomy and to study its effect on clinical outcome. The secondary aim is to classify the dural leaks and proposing a treatment algorithm for dural leaks. Dural leaks are described as one of the fearful complications in spine surgery. Literature evaluating the actual incidence, ideal treatment protocol, efficacy of primary repair techniques and its effects on long-term surgical outcomes are scanty. It was a retrospective analysis of 5390 consecutively operated spine cases over a period of 10 years. All cases were divided into two groups-study group (with dural leak-255) and control group (without dural leak-5135). Dural leaks were managed with the proposed treatment algorithm. Blood loss, surgical time, hospital stay, time for return to mobilization, pain free status, and clinical outcome score (ODI, VAS, NDI, and Wang criteria) were assessed in both groups at regular intervals. The statistical comparison between two groups was established with chi-square and t-tests. The overall incidence of dural leaks was 4.73% with highest incidence in revision cases (27.61%). There was significant difference noted in mean surgical blood loss (P 0.001), mean hospital stay (P 0.001), time to achieve pain-free status after surgery, and return to mobilization between two groups. However, no significant difference was noted in operative time (P 0.372) and clinical outcome scores at final follow-up between the two groups. Primary closure should be undertaken in all amenable major dural leak cases. Dural leaks managed as proposed by the author's treatment algorithm have shown a comparable clinical outcome as in patients without dural leaks. Dural leak is a friendly adverse event that does not prove a deterrent to long-term clinical outcome in spine surgeries. 4.

Planned conservative management of placenta increta and percreta with prophylactic transcatheter arterial embolization and leaving placenta in situ for women who desire fertility preservation

IntroductionThe objective of our study was to demonstrate planned conservative management of placenta increta and percreta in a single tertiary center. MethodsFrom April 2005 to July 2019, patients with placenta increta and percreta were managed conservatively at the Kaohsiung Chang Gung Memorial Hospital in Taiwan. The severity of placenta invasion was diagnosed by magnetic resonance imaging (MRI). After delivery of the neonate, prophylactic transcatheter arterial embolization (TAE) was performed immediately. The placenta was left in situ and prophylactic antibiotics were administered during hospitalization. The patient profiles, outcomes, and complications were retrospectively reviewed. ResultsBased on the MRI findings, twenty-one patients with placenta increta or percreta were included. With prophylactic TAE, the mean surgical blood loss was 854.7 ± 478.2 mL. The mean natural resorption time of residual placenta was 4.69 ± 1.65 months. Regarding maternal complications, 4 patients (19%) had delayed postpartum hemorrhage (PPH), 12 patients (57.1%) developed postpartum infections, 3 patients (14.3%) progressed to sepsis, 4 patients (19%) underwent surgical evacuation, and 4 patients (19%) underwent hysterectomy. No maternal mortality was reported. Main neonatal complications were prematurity and respiratory distress. Regarding fertility, 16 (76.1%) patients had return of menstruation, and one (4.7%) had a subsequent pregnancy resulting in a live birth. DiscussionPlanned conservative management with prophylactic TAE and leaving placenta in situ is feasible and safe for women with placenta increta or percreta who desire fertility preservation. Delayed PPH and postpartum infection are common complications after conservative treatment.

Proximal femoral nailing is superior to hemiarthroplasty in AO/OTA A2 and A3 intertrochanteric femur fractures in the elderly: a systematic literature review and meta-analysis.

Unstable intertrochanteric femoral fractures in the elderly require either fixation or joint sacrificing surgery; proximal femoral nail (PFN) and bipolar hemiarthroplasties (BPH) are the most common interventions. PFN is considered to be the ideal construct for these fractures; however, the usage of hemiarthroplasties to facilitate earlier mobilization has been on a rise. Currently there is no consensus on thesuperiority of one of these two techniques over the other and the present review was done to determine this. Is PFN a better alternative to BPH for unstable intertrochanteric femur fractures in the elderly? The present systematic review and meta-analysis was conducted to determine the superiority of PFN over BPH by comparing the primary outcomes like mortality, Harris Hip scores (HHS), complications, and re-operations. Additionally, secondary outcomes like blood loss, duration of surgery, andperiod of hospital stays were also compared. Three databases of PubMed, EMBASE, and SCOPUS were searched for relevant articles that directly compared PFN and BPH in unstable intertrochanteric femur fractures in the elderly. We analyzed a total of seven studies published between the years 2005 to 2017. There were four retrospective and three prospective randomized controlled studies. The number of patients in these studies ranged from 53 to 303. There was a significant difference in HHS between two groups with standard mean difference of - 0.51 (range - 0.67 to -0.36), favouring the PFN group. The rate of mortality was higher in the BPHgroup with odds ratio of 2.07 (range 1.40-3.08). Implant-related complications like fractures and subsidence were more in BPH groupbut this was not significant. Mean surgical time (standard mean difference 2.19) and blood loss (3.75) were significantly less inthe PFN group. The duration of hospital stay was also found to be significantly less in the PFN group (2.66). Proximal femoral nails are superior to bipolar hemiarthroplasties for unstable intertrochanteric femoral fractures in the elderly. PFN imparts better functional outcomes and has lower rates of overall mortality. Additionally it is faster surgery, with lesser blood loss contributing to better results.

Clinical Effectiveness of the Posterior Affected-Vertebrae Fixation Method in Posterior-Anterior Surgery to Treat Thoracic Spinal Tuberculosis

The present retrospective comparative analysis was conducted to assess the effectiveness of affected-vertebrae fixation versus short-segment fixation to treat thoracic spinal tuberculosis. The present study included 110 patients receiving treatment for thoracic spinal tuberculosis at our hospital from January 2006 to June 2013. All cases involved the use of posterior spinal correction, posterior lateral fusion, internal fixation, anterior decompression, radical debridement, and intervertebral supporting bone grafts. The cases were divided by the scope of posterior internal fixation into the affected-vertebrae fixation group (n= 62) and the short-segment fixation group (n= 48). Statistical analysis was used to compare the clinical effectiveness, laboratory test results, and imaging findings. The mean surgical blood loss, mean operating time, and mean inpatient expenditures were all significantly less in the affected-vertebrae fixation group than in the short-segment fixation group (P < 0.05). The affected-vertebrae fixation group had a lower mean graft fusion time (5.21 vs. 5.06 months), mean healing time (5.73 vs. 5.91 months), mean degree of correction of thoracic vertebrae kyphosis Cobb angle (16.9° vs. 18.4°), and mean loss of angle (2.6° vs. 2.1°) compared with the short-segment fixation group. However, these differences all lacked statistical significance. Postoperatively, neurological deficits and pain were effectively relieved in all patients, and the lesion had healed at the final follow-up evaluation (≥5 years postoperatively). As long as the surgical indications are strictly observed, posterior affected-vertebrae fixation in posterior-anterior surgery for thoracic spinal tuberculosis is safe, effective, and feasible; entails minimal surgical trauma; and has a lower inpatient cost.

Combined glue embolization and excision for the treatment of venous malformations

BackgroundThe purpose of this study was to evaluate safety, technical success, and clinical outcomes of treatment for venous malformations using n-BCA glue embolization immediately prior to excision. Sixty three patients (22 male, 41 female; mean age 12 years (range 1–25)) who underwent 70 procedures for extremity and trunk venous malformations were reviewed. Indications for treatment included pain (100%), swelling (22%), and diminished range of motion (16%). Thirty seven patients (59%) had undergone prior stand-alone interventional or surgical treatment but were persistently symptomatic. Safety, technical and clinical success were retrospectively assessed.ResultsEmbolization was technically successful in 100% of patients. Mean lesion size was 3.0 × 2.9 × 5.7 cm. Three patients (5%) underwent planned, second stage procedures for lesions intentionally not treated at the first procedure. Four patients (6%) underwent an unplanned, second stage procedure for residual disease after the primary operation. Mean and median follow-up duration were 18 and 17 months, respectively (range 3 to 35 months). Symptomatic improvement was achieved in 58 patients (92%), of whom 41 (65%) reported complete elimination of pain. There were no recognized instances of nontarget embolization or other complications of the interventional procedure. One patient required additional surgery for wound dehiscence and one patient developed an abscess requiring incision and drainage. Minor surgical complications included surgical site skin infections (n = 5) and numbness (n = 1). Mean and median surgical blood loss volumes were 131 mL and 10 mL, respectively. One patient required perioperative blood transfusion.ConclusionsExtremity and truncal venous malformations can be safely and effectively treated in a single-stage fashion using glue embolization immediately preceding excision.

Comparison of surgical techniques for benign parotid tumours: a multicentre retrospective study

This study aimed to compare the outcomes of three surgical techniques for the treatment of patients with benign parotid tumours: superficial parotidectomy (SP; group 1), partial superficial parotidectomy (PSP; group 2), and ultrasonic scalpel-assisted minimal extracapsular dissection (US-MECD; group 3). Groups 1 and 2 received the conventional surgical technique, while group 3 underwent surgery with an ultrasonic scalpel. A total of 281 patients treated during 2012–2016 were included: 98 in group 1, 91 in group 2, and 92 in group 3. The mean surgical time and blood loss during surgery, as well as drainage time and amount, were significantly lower for US-MECD (P<0.01). The great auricular nerve and parotid fascia were both preserved with US-MECD (P<0.01), while the rate of capsule rupture with US-MECD was slightly higher than in the other groups (P>0.05). There was less transient facial nerve paralysis and Frey syndrome with US-MECD (P<0.01). No significant difference in wound infection, sialocele, or permanent facial nerve paralysis was observed among the three groups. Patients enrolled during 2012–2013 were selected to evaluate the recurrence rates, and no statistically significant differences were found among the groups. In conclusion, US-MECD showed similar effectiveness and fewer side effects than SP and PSP. The long-term effects of the new technique require further study.

Percutaneous Interspinous Spacer vs Decompression in Patients with Neurogenic Claudication: An Alternative in Selected Patients?

BACKGROUNDStandalone interspinous process devices (IPDs) to treat degenerative lumbar spinal stenosis with neurogenic intermittent claudication (NIC) have shown ambiguous results in the literature.OBJECTIVETo show that a minimally invasive percutaneous IPD is safe and noninferior to standalone decompressive surgery (SDS) for patients with degenerative lumbar spinal stenosis with NIC.METHODSA multicenter, international, randomized, controlled trial (RCT) was con- ducted. One hundred sixty-three patients, enrolled at 19 sites, were randomized 1:1 to treatment with IPD or SDS and were followed for 24 mo.RESULTSThere was significant improvement in Zurich Claudication Questionnaire physical function, as mean percentage change from baseline, for both the IPD and the SDS groups at 12 mo (primary endpoint) and 24 mo (−32.3 ± 32.1, −37.5 ± 22.8; and −37.9 ± 21.7%, −35.2 ± 22.8, both P < .001). IPD treatment was not significantly noninferior (margin: 10%) to SDS treatment at 12 mo (P = .172) but was significantly noninferior at 24 mo (P = .005). Symptom severity, patient satisfaction, visual analog scale leg pain, and SF-36 improved in both groups over time. IPD showed lower mean surgical time and mean blood loss (24 ± 11 min and 6 ± 11 mL) compared to SDS (70 ± 39 min and 189 ± 148 mL, both P < .001). Reoperations at index level occurred in 18.2% of the patients in the IPD group and in 9.3% in the SDS group.CONCLUSIONConfirming 3 recent RCTs, we could show that IPD as well as open decompression achieve similar results in relieving symptoms of NIC in highly selected patients. However, despite some advantages in secondary outcomes, a higher reoperation rate for IPD is confirmed.

Minimally Invasive Separation Surgery with Intraoperative Stereotactic Guidance: AFeasibility Study.

The treatment of spinal metastasis consists of algorithms combining surgical and radiation modalities. Recently the concept of separation surgery followed by stereotactic radiosurgery was shown to be a safe and effective treatment to achieve local tumor control. We examined a minimally invasive approach to separation surgery in a cadaveric study followed by a patient cohort with spinal metastasis using navigation to discuss our results and provide a technical note. A cadaveric study using minimally invasive access systems examined the feasibility of spinal cord decompression. Subsequently, 17 patients with spinal metastasis underwent minimally invasive separation surgery and instrumentation using navigation. All patients were at least 3/5 and pre- and post-operative CT scans were used to evaluate the decompression. Endpoints included neurologic function, operative time, estimated blood loss, duration of hospital stay, and complications. The cadaveric study demonstrated adequate decompression of the spinal cord. For the operative cases, the post-operative imaging demonstrated excellent separation for safe stereotactic radiosurgery. The mean incision length was 4.9 cm. The average operative time was 6 hours and 48 minutes, the mean length of stay was 12.8 days and the mean surgical blood loss was 458 mL. The median Spine Instability Neoplastic Score score was 10 with a range of 6-16. All patients remained or improved their neurologic baseline with excellent pain control. One patient incurred a perioperative complication. Minimally invasive separation surgery for spinal metastasis allows for circumferential decompression of the spinal cord and safe post-operative stereotactic radiosurgery. In addition, we demonstrated the efficacy of intra-operative navigation in guiding the resection.

Circumferential Fusion through All-Posterior Approach in Andersson Lesion.

Study DesignRetrospective case series.PurposeTo assess safety and efficacy of single stage, posterior stabilisation and anterior cage reconstruction through the transforaminal or lateral extra-cavitary route for Andersson lesions.Overview of LiteraturePseudoarthrosis in ankylosing spondylitis (Andersson lesion, AL) can cause progressive kyphosis and neurological deficit. Management involves early recognition and surgical stabilisation in patients with instability. However, the need and safety of anterior reconstruction of the vertebral body defect remains unclear.MethodsTwenty consecutive patients with AL whom presented with instability back pain and or neurological deficit were managed by single stage posterior approach with long segment pedicle screw fixation and anterior vertebral reconstruction. Radiological evaluation included- the regional kyphotic angle, measurement of anterior defect in computed tomography (CT) scan and the spinal cord status in magnetic resonance imaging. Radiological outcomes were assessed for fusion and kyphosis correction. Functional outcomes were assessed with visual analogue scale (VAS), ankylosing spondylitis quality of life (ASQoL) and Oswestry disability index (ODI).ResultsThe mean age of the patients was 50.1 years (male, 18; female, 2). The levels affected include thoracolumbar (n=12), lower thoracic (n=5) and lumbar (n=3) regions. The mean level of fixation was 6.2±2.4 vertebrae. The mean anterior column defect was 1.6±0.6 cm. The mean surgical duration, blood loss and hospital stay were 112 minutes, 452 mL and 6.2 days, respectively. The mean followup was 2.1 years. At final follow up, VAS for back pain improved from 8.2 to 2.4 while ODI improved from 62.7 to 18.5 (p <0.05) and ASQoL improved from 14.3±2.08 to 7.90±1.48 (p <0.05). All patients had achieved radiological union at a mean 7.2±4.6 months. The mean regional kyphotic angle was 27° preoperatively, 16.7° postoperatively and 18.1° at the final follow-up.ConclusionsPosterior stabilisation and anterior reconstruction with cage through an all-posterior approach is safe and can achieve good results in Andersson lesions.

Delayed Total Hip Arthroplasty for Failed Acetabular Fractures: The Influence of Initial Fracture Management on Outcome After Arthroplasty

BackgroundTotal hip arthroplasty (THA) provides a successful salvage option for failed acetabular fractures. The complexity of arthroplasty for a failed acetabular fracture will depend on the fracture pattern and the initial management of the fracture. Our objective was to compare the midterm outcome of THA between patients who presented with failed acetabular fractures following initial surgical or nonsurgical treatment. MethodsForty-seven patients underwent cementless THA ± acetabular reconstruction following failed treatment of acetabular fractures. Twenty-seven were initially treated by surgery (group A) and 20 had nonsurgical treatment (group B). Intraoperative measures, preoperative and follow-up clinical, radiological, and functional outcomes were compared between the 2 groups. ResultsThe mean surgical time, blood loss, and need for blood transfusion were significantly less in group A (P < .05). Acetabular reconstruction to address cavitary or segmental defects was needed in a significantly higher number of patients in group B (P = .006). Significant improvement in modified Merle d'Aubigne and Oxford scores was seen postsurgery in both groups. Acetabular component survival with aseptic loosening as end point was 98%. Overall survival rate with infection, revision, or loosening as end point was 93% at a mean follow-up of 7 years ± 17 months. ConclusionTHA for a failed acetabular fracture is greatly facilitated by initial surgical treatment. Although functional results and survivorship were similar in both groups, failed nonsurgical treatment in complex fractures is associated with migrated femoral head and extensive acetabular defects requiring complex acetabular reconstruction.

A Multicenter Prospective Randomized Controlled Clinical Trial to Evaluate the Effectiveness and Safety of a Standalone Percutaneous Interspinous Spacer versus Decompressive Surgery in Degenerative Lumbar Spinal Stenosis with Neurogenic Intermittent Claudication

Introduction The objective of this study is to show that a minimally invasive percutaneous IPD is safe and non-inferior to SDS with regards to clinical outcomes in patients suffering from Degenerative Lumbar Spinal Stenosis with NIC (Neurogenic Intermittent Claudication), relieved by flexion. (Design: Multicenter international randomized controlled trial) Methods One hundred and sixty three patients enrolled by 19 sites across 10 countries (mean age 65 ± 11 years, 51% female, mean duration of leg symptoms 2.5 years) were randomly assigned to IPD or SDS group and are followed until 24 months. Physical function, symptom severity and patient satisfaction were assessed by Zurich Claudication Questionnaire (ZCQ) at baseline, 14days, 6 weeks, 6 months and 12 months follow-ups. Leg, buttock/groin and back pain were assessed by VAS scores. SF-36v2 questionnaire was used to assess quality of life. In addition, physical examination data was collected at all-time points. Percentage of re-operations at index level at follow-up was determined. (Trial registration NTC00905359) Results ZCQ physical function mean percentage change from baseline to 12 months (primary outcome variable) decreased equally and without statistically significant difference over all points in time for IPD and SDS group (respectively, −32 ± 32%, −37 ± 23%, p = 0.158, CI −5, +15). As for secondary outcomes the IPD group showed lower mean surgical time and mean blood loss (respectively, 24 ± 11 minutes and 6 ± 10 ml, p &lt; 0.001) compared with the SDS group (70 ± 39 minutes and 157 ± 145 ml, p &lt; 0.001). Symptom severity improved in both groups equally (−31 ± 27%, −36 ± 25%, p = 0.140, CI −4, +14). No differences in patient satisfaction were observed. VAS leg pain score improved with 59% for the IPD and 66% for the SDS group from baseline to 12 months follow-up. SF-36 v2 physical and mental aggregated score improved equally over time for both treatment groups. At 12 months, 47 SAEs were reported, in 36 patients. Re-operations at index level occurred in 9% of the patients in the IPD group and in 7% in the SDS group. In 6 patients the IPD was explanted. Conclusions This study confirms two prior recent RCTs. Implantation of an IPD as well as open decompression achieve both equally satisfying results in patients with NIC. Both seem to be appropriate procedures with an advantage in some secondary outcomes for IPDs. So far the significantly higher reoperation rate for IPDs could not be confirmed in this study, which opens a window of indication in a subset of patients with NIC, i.e., those with cardiac or other comorbidities.

Does Surgical Approach Affect Patient-reported Function After Primary THA?

Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach. We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA? Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon's direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques. After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, -9; 95% CI, -13 to -5; standard error, 2), compared with the posterior approach (3-month score change, -9; 95% CI, -14 to -3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2-10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79-160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3-10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events. With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively. Level III, therapeutic study.

Modified partial pedicle subtraction osteotomy for the correction of post-traumatic thoracolumbar kyphosis

Background contextPedicle subtraction osteotomy (PSO) is the most commonly recommended technique for the correction of local post-traumatic thoracolumbar deformity; however, the surgical results are not always satisfactory because the possibly damaged upper disc is preserved, and all the posterior elements are resected. PurposeThe aim was to compare the results of standard PSO and modified PSO in the treatment of post-traumatic thoracolumbar kyphosis. Study designThis was a retrospective multicenter comparative clinical study. Patient sampleA total of 86 patients were included in the final analysis. Outcome measuresThe outcome measures included local Cobb angle of the kyphosis, visual analog scale (VAS) score, and Oswestry disability index (ODI) score. MethodsThe upper disc was resected, and the inferior wall of the index pedicle and the lower facet joint were preserved in the modified PSO. Patients with focal kyphosis greater than 30° who were treated with one-level osteotomy, without the presence of spine neoplasm, infection, or previous surgery, were included. The measurements included the VAS score, ODI score, and preoperative and postoperative Cobb angles. ResultsForty-two patients in the modified PSO group and 44 in the standard PSO group were included in the final analysis. The mean surgical time and blood loss were similar between the two groups. Both the VAS and ODI scores had improved significantly at the final follow-up in the two groups. The mean Cobb angle significantly improved from 39.6° to 5.6° in the modified PSO group and from 39.1° to 4.8° in the standard PSO group, with no significant difference between the two groups preoperatively or at the final follow-up. ConclusionsThe modified PSO provides an alternative method with which to correct kyphotic deformity in patients with post-traumatic thoracolumbar kyphosis.

Patient-specific polyetheretherketone implants for repair of craniofacial defects.

Large cranial defects represent reconstructive challenges. Polyetheretherketone (PEEK) implants are preoperatively tailored to the exact size of the defect and exhibit an excellent combination of strength, durability, and environmental resistance. This study presents our experience with patient-specific PEEK implants with computer modeling. A retrospective chart review was conducted on all patients who underwent cranioplasty treated by a PEEK implant between 2007 and 2012. Analysis of the preoperative and perioperative data as well as outcome analysis was performed. A total of 11 patients were included. Mean age was 46 years. The indication for cranioplasty was bone flap infection and subsequent removal in 8 patients, traumatic bone loss in 2 patients, and acquired defect due to cancer resection in 1 patient. The mean time to PEEK cranioplasty since the patient's last operation was 16 months. The mean defect size was 74 cm(2). The mean surgical blood loss was 124 mL. The mean length of stay was 3 days. Complications included 1 postoperative bleeding that required reoperation, but the PEEK implant was successfully salvaged. The mean time to follow-up was 6 months. Use of patient-specific PEEK implants is a good alternative for alloplastic cranioplasty. It is associated with low morbidity as reported in our series, with additional advantages including strength, stiffness, durability, and inertness. It would be beneficial to assess the longer-term outcomes; however, it appears at first glance that PEEK implants show great promise in calvarial reconstruction.