Mid-term Postoperative Period Research Articles

Survivorship, Clinical Outcomes, and Radiographic Complications in the Infinity Total Ankle Arthroplasty at Mid-term (Minimum 5-Year) Follow-up

Category: Ankle Arthritis; Ankle Introduction/Purpose: As the frequency of total ankle arthroplasties (TAA) performed annually has increased significantly over the past decade, several novel TAA implants have entered the market. The Infinity TAA (Stryker, Mahwah, NJ) is a low-profile fixed- bearing implant that was approved for use in the United States in 2014. Although the short-term survivorship and complication rates of the Infinity TAA have been well documented in the literature, mid- to long-term outcome studies of this implant are limited. The aim of this study was to describe the survivorship, reoperation rate, and radiographic and clinical outcomes of the Infinity implant at minimum 5-year follow-up. We hypothesized that there would be no significant drop-off in clinical outcome or alignment from 2-year to 5-year follow-up. Methods: This is a single-institution retrospective review of patients who underwent primary TAA with the Infinity implant from July 2014 to April 2017. Four fellowship-trained foot and ankle surgeons contributed patients. Out of 74 identified ankles, 65 ankles in 64 patients had minimum clinical follow-up of 5 years (mean, 6.5; range, 5.0-8.0) and were included for analysis. Medical records were reviewed to record demographics, surgical data, complications, reoperations, and revisions. Radiographs were assessed to measure preoperative and postoperative alignment, and the incidence of postoperative peri-implant lucencies and cysts. Preoperative, 2-year, and 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscores in the categories of Pain, Symptoms, Activities of Daily Living, Sports, and Quality of Life were obtained. The primary outcome was 5-year survivorship. Secondary outcomes were reoperations with retention of tibial and talar components, radiographic alignment, peri-implant lucencies/cysts, and clinical outcomes (FAOS) scores. Results: Implant survivorship at 5 years was 93.8%, with 4/65 revisions. Three revisions occurred less than 2 years from the index surgery (2/3 for tibial subsidence; 1/3 for tibial and talar subsidence). The fourth revision occurred at 7.1 years due to cystic changes with tibial and talar subsidence. There were 11 reoperations in 10 ankles. Alignment correction achieved surgically (preop coronal deformity 9.0 ± 6.8°; 1Y postop 1.6 ± 1.5°) was maintained at final radiographic follow-up (1.8 ± 1.7°; P = 0.32). There were 16 ankles (24.6%) with peri-implant radiographic abnormalities: 14 cases of lucency (14 tibia, 0 talus) and 3 cases of cysts. FAOS outcomes demonstrated significant improvement from preop to postop in all five domains at 2 years, which were maintained at 5 years. Conclusion: The mid-term outcomes of the Infinity implant in this single-institution study demonstrated good survivorship of 93.8% and improved clinical outcomes at mean 6.3-year follow-up. This was a mid-term follow-up to the 2-year outcome study published at this institution. Radiographic assessment at final follow-up demonstrated that alignment correction was maintained, and there was a 21.5% incidence of asymptomatic periprosthetic lucencies. These results demonstrate that there was no significant change in radiographic or clinical outcomes with this implant after 5 years, which is valuable for surgeons in terms of counseling and following patients in the immediate and mid-term postoperative period.

Effect of quadriceps training at different levels of blood flow restriction on quadriceps strength and thickness in the mid-term postoperative period after anterior cruciate ligament reconstruction: a randomized controlled external pilot study

BackgroundMore than 2 million anterior cruciate ligament (ACL) injuries occur worldwide each year. Most surgeons suggest that athletes and active persons with significant knee functional demands, including cutting motions, require and should be offered ligament reconstruction surgery. Despite concentrated rehabilitation efforts, deficits in quadriceps size and strength can persist for years after surgery. Blood flow restriction (BFR) training can help overcome disuse muscular atrophy in the mid-term postoperative period after anterior cruciate ligament reconstruction (ACLR) surgery. The purpose of this study was to evaluate the effects of quadriceps training with different levels of blood flow restriction on quadriceps strength and thickness of participants after ACLR.MethodsIn this study, 30 post-ACL reconstruction participants were randomly divided into three groups (control, 40% Arterial Occlusion Pressure [AOP] and 80% AOP groups). All patients were subjected to different levels of BFR, combined with conventional quadriceps rehabilitation, for 8 weeks. Assessments included scaled maximal isokinetic knee extension strength at 60°/s and 180°/s, the sum of the thickness of the affected femoris rectus and vastus intermedius, Y-balance test performance, and International Knee Documentation Committee questionnaire responses before and after the intervention.ResultsIn total, 23 participants completed the entire study. The 80% AOP compression group showed an increase in quadriceps femoris muscle strength and muscle thickness (p < 0.01). As compared with the control group, outcome indicators in the 40% AOP and 80% AOP group were improved (p < 0.05). After 8 weeks of experimental BFR intervention, the results were better for the 80% AOP compression group than for the 40% AOP compression group in quadriceps peak torque to body weight at 60°/s and 180°/s angular velocity, as well as the sum of the thickness of the rectus femoris and vastus intermedius.ConclusionThe combination of BFR and low-intensity quadriceps femoris training can effectively improve the muscle strength and thickness of knee extensors in participants with ACLR and help reduce the difference between the healthy and surgical sides of the knee joint while improving knee-joint function. Choosing quadriceps training with 80% AOP compression intensity could provide the most benefits. Meanwhile, BFR can accelerate the rehabilitation process of patients and allow early entry into the next rehabilitation cycle.RegistrationTrial registration Chinese Clinical Trial Registry, registration number ChiCTR2100050011, date of registration: 15/08/2021.

Pituitary stalk changes on magnetic resonance imaging following pituitary adenoma resection using a transsphenoidal approach.

We aimed to investigate the magnetic resonance imaging (MRI) findings and clinical significance of position and changes in morphology of the pituitary stalk following pituitary adenoma (PA) resection using a transsphenoidal approach. We collected clinical and MRI data of 108 patients with PA after transsphenoidal surgery. Diameter, length, and coronal deviation of the pituitary stalk were measured pre-, post-, and mid-term post-operatively, to observe pituitary stalk morphology. Of 108 patients, 53 pituitary stalks were recognisable pre-operatively. The angle between the pituitary stalk and the median line was 7.22°-50.20° (average, 25.85°) in 22 patients with left-sided pituitary stalks and 5.32°-64.05° (average, 21.63°) in 20 patients with right-sided pituitary stalks. Of 42 patients with preoperative pituitary stalk deviation, 41 had an early postoperative recovery and 1 had increased deviation. In the mid-term postoperative period, 21 of 42 patients had pituitary stalks located centrally. In 53 patients, the pituitary stalk length was 1.41-11.74 mm (mean, 6.12 mm) pre-operatively, 3.61-11.63 mm (mean, 6.93 mm) in the early postoperative period, and 5.37-17.57 mm (mean, 8.83 mm) in the mid-term postoperative period. In the early postoperative period, 58 (53.70%) patients had posterior pituitary bright spots (PPBS) and 28 (25.92%) had diabetes insipidus (DI). Pre-operatively, the pituitary stalk was compressed and thinned. Post-operatively, it could be stretched to a "normal state", and its position showed a gradual centring trend. Post-operatively, the length of the pituitary stalk gradually increased. The PPBS in the early postoperative period negatively correlated with postoperative DI.

Influence of lamina vastoadductoria dissection on the outcomes of femoral artery extensive lesion stenting: A pilot randomised investigation

ObjectiveAim of the study was to improve the immediate and long-term results of stenting of the superficial femoral artery in extended lesions with the changing of the biomechanics of superficial ffemoral artery and of the first portion of the popliteal artery. MethodsPilot randomized prospective single-center study were included 70 patients. Patients were randomized into two groups in 1 × 1 format for 35 people using the envelope method. Self-expanding bare metal stents were used in all cases. At the first group standard revascularization procedures with SFA stenting were performed; in the second group, the superficial femoral artery stenting was supplemented with fasciotomy in the Hunter’s canal with the superficial femoral artery intersection. The total observation period was 2 years. During the observation period an assessment of the clinical symptoms of the lower extremities, measurement of the ankle-brachial index and ultrasound duplex scanning of the operated segment were performed. ResultsAll procedures in both groups were successfully performed. Primary patency through 24 months was 28.5% (10 of 35) in group 1 and 60% (21 of 35) in group 2 (p = 0,015). ConclusionsChanging the biomechanical properties of the distal of the superficial femoral artery segment and of the first portion of the popliteal artery is safe and contributes to the primary patency improvement during the stenting of extended of the superficial femoral artery lesions compared to standard SFA stenting.Dissection of the lamina vastoadductoria with transection of the collateral branches of the knee joint network reduces frequent and severe damages of stents after the stenting of the superficial femoral artery extended lesion.According to the frequency of complications in the early and mid-term postoperative period, limb salvage, mortality and the secondary patency rates, the new method is comparable with standard of the superficial femoral artery stenting.

Does MIS-TLIF or TLIF result in better pedicle screw placement accuracy and clinical outcomes with navigation guidance?

BackgroundAlthough previous studies have suggested that navigation can improve the accuracy of pedicle screw placement, few studies have compared navigation-assisted transforaminal lumbar interbody fusion (TLIF) and navigation-assisted minimally invasive TLIF (MIS-TLIF). The entry point of pedicle screw insertion in navigation-assisted MIS-TLIF (NM-TLIF) may deviate from the planned entry point due to an uneven bone surface, which may result in misplacement. The purpose of this study was to explore the pedicle screw accuracy and clinical consequences of MIS-TLIF and TLIF, both under O-arm navigation, to determine which surgical method is better.MethodsA retrospective study of 54 patients who underwent single-segment NM-TLIF or navigation-assisted TLIF (N-TLIF) was conducted. In addition to the patients’ demographic characteristics, intraoperative indicators and complications, the Oswestry Disability Index (ODI) and visual analog scale (VAS) score were recorded and analyzed preoperatively and at the 1-, 6-, and 12-month and final postoperative follow-ups. The clinical qualitative accuracy and absolute quantitative accuracy of pedicle screw placement were assessed by postoperative CT. Multifidus muscle injury was evaluated by T2-weighted MRI.ResultsCompared with N-TLIF, NM-TLIF was more advantageous in terms of the incision length, intraoperative blood loss, drainage volume, time to ambulation, length of hospital stay, blood transfusion rate and analgesia rate (P < 0.05). The ODI and VAS scores for low back pain were better than those of N-TLIF at 1 month and 6 months post-surgery (P < 0.05). There was no significant difference in the clinical qualitative screw placement accuracy (97.3% vs. 96.2%, P > 0.05). The absolute quantitative accuracy results showed that the axial translational error, sagittal translational error, and sagittal angle error in the NM-TLIF group were significantly greater than those in the N-TLIF group (P < 0.05). The mean T2-weighted signal intensity of the multifidus muscle in the NM-TLIF group was significantly lower than that in the N-TLIF group (P < 0.05).ConclusionsCompared with N-TLIF, NM-TLIF has the advantages of being less invasive, yielding similar or better screw placement accuracy and achieving better symptom relief in the midterm postoperative recovery period. However, more attention should be given to real-time adjustment for pedicle insertion in NM-TLIF rather than just following the entry point and trajectory of the intraoperative plan.

Effect of patellar denervation by circumpatellar electrocautery on clinical outcomes of patients with total knee arthroplasty running title: Patellar denervation in knee arthroplasty

Objective: Anterior knee pain may lead to worse outcomes after total knee arthroplasty. The effect of patellar denervation (PD) by electrocautery on postoperative pain and function in patellar nonresurfacing TKA were assessed in this study. Materials and Methods: This retrospective study included patients with a minimum of 24 months follow-up who were operated for TKA between January 2014 and January 2018. Patellar Denervation (PD) group; patients who underwent circumpatellar electrocautery around the patella, and Control (C) group; who did not underwent. Patient demographics, preoperative patellofemoral osteoarthritis grades, Knee Society System (KSS) scores, Feller patella score (PS), Short Form-36 (SF-36) and visual analog scale (VAS) scores at preoperative, postoperative 3. Month and last follow-up examination were noted. Results: There was no difference between groups in terms of gender distribution and age (P &gt; 0.05). At 3rd postoperative month, KSS-Knee was significantly higher and VAS score was significantly lower in the PD patients compared to C group (p=0.026, p=0.023 respectively). At the final follow-up, KSS-Function and PS scores were significantly higher (p=0.031, 0.012 respectively). Some of the QoL scores were better at late follow-up in PD group. However, there was no statistical difference between these two groups in other follow-up examinations (p &gt; 0.05). Conclusion: Circumpatellar electrocautery denervation can be advantageous in reducing early postoperative knee pain. Clinical, functional and some of the QoL scores were better in the midterm postoperative period of patients with gonarthrosis treated by TKA with PD.

Results of the early and mid-term postoperative period after correction of total anomalous pulmonary venous connection

Aim. To compare complications and outcomes in the postoperative period with two different methods for correcting total anomalous pulmonary venous connection.Methods. In this pilot, two-centre, simple, blind, prospective randomised study, the patients’ quality of life after correction of total anomalous pulmonary venous connection in infancy was evaluated using the sutureless (n = 20) and conventional repair methods (n = 20) in 40 patients. The overall mortality and complications in the mid-term were evaluated.Results. The average follow-up was 15 (13; 16) months. Mortality was noted only in the conventional repair group, amounting to 5 (25%) patients (p = 0.018). Severe obstruction of the pulmonary veins anastomosis was also noted only in the conventional repair group (n = 8, 40%; p = 0.0013). Infectious endocarditis was observed in one (6.6%) patient in the conventional repair group (p = 0.42). Arrhythmias were present in 4 (26.6%) patients in the conventional repair group (p = 0.02).Conclusion. The rates of obstruction of the pulmonary vein anastomosis, arrhythmias and death depend on the method of total anomalous pulmonary venous connection correction. The sutureless repair reduces the incidence of early and mid-term postoperative complications compared to conventional repair. Received 16 March 2021. Revised 8 June 2021. Accepted 11 June 2021. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: Yu.N. Gorbatykh, A.V. Bogachev-Prokophiev, M.V. PlotnikovData collection and analysis: M.V. Plotnikov, M.G. Galstyan, D.G. TarasovStatistical analysis: M.V. PlotnikovDrafting the article: M.V. Plotnikov, Yu.N. GorbatykhCritical revision of the article: I.A. SoynovFinal approval of the version to be published: M.V. Plotnikov, Yu.N. Gorbatykh, A.N. Аrkhipov, M.G. Galstyan, A.V. Bogachev-Prokophiev, D.G. Tarasov, I.A. Soynov

Serial change in perfusion\u2013metabolism mismatch after coronary artery bypass grafting

ObjectiveMyocardial ischemia is known to suppress fatty acid metabolism and favor glucose metabolism. However, changes in myocardial metabolism after coronary revascularization are not fully elucidated.MethodsThirty-eight patients with coronary artery disease were retrospectively enrolled. These patients had undergone stress perfusion single photon emission computed tomography (SPECT) and 123I-BMIPP SPECT in both the short-term (6.4 ± 4.7 months) and mid-term (29.9 ± 7.2 months) after isolated coronary artery bypass grafting. Tracer uptake was graded using a 17-segment, 5-point scoring model. Serial changes in SRS (summed rest score), SDS (summed difference score), the BMIPP score (total defect score of BMIPP), and the mismatch score (BMIPP score–SRS) were evaluated. In addition, persistent perfusion–metabolism mismatch (PM) was defined as mismatch score minus SDS of 3 or more during the mid-term postoperative period. The clinical parameters associated with PM were examined.ResultsFrom short- to mid-term postoperative period, the extent of infarcted myocardium (SRS) did not change significantly (7.8 ± 8.0 to 7.1 ± 7.0, P = 0.117). The extent of ischemic myocardium (SDS), the BMIPP score and the mismatch score, which reflects perfusion–metabolism mismatch, were significantly improved (2.0 ± 2.8 to 0.7 ± 1.0, P = 0.010; 12.2 ± 9.0 to 9.5 ± 7.9, P < 0.001; 4.4 ± 3.7 to 2.5 ± 2.6, P < 0.001; respectively). Remarkably, perfusion–metabolism mismatch persisted in 13 patients (34%) even in the mid-term postoperative period. eGFR and SYNTAX score were independent predictors of persistent perfusion–metabolic mismatch in multivariable analysis (OR = 0.951, 95% CI 0.898–0.985, P = 0.010 and OR = 1.126, 95% CI 1.011–1.254, P = 0.031, respectively). The mismatch score both in the short- and mid-term significantly correlated with SYNTAX score (r = 0.400 and r = 0.472, respectively).ConclusionsFatty acid metabolism disturbance improved from short- to mid-term postoperative period in patients with successful reperfusion by coronary artery bypass grafting. However, in patients with severe atherosclerosis, impaired fatty acid metabolism was sustained until the mid-term postoperative period, even though ischemia had resolved.

Type B Acute Aortic Dissection as a Perioperative Complication after an Endovascular Abdominal Aortic Repair.

Type B aortic dissection (TBAD) is a rare but catastrophic complication of endovascular aneurysm repair (EVAR). We report two cases of TBAD occurring in the perioperative period of EVAR. The intraoperative and postoperative courses were unremarkable. Routine postoperative computed tomography angiography (CTA) revealed TBAD. Conservative treatment was successful, and no adverse aortic events occurred. TBAD that occurs in the perioperative period is likely to be iatrogenic in origin, uncomplicated, and managed with medical therapy: its prognosis is better than when the condition develops in the midterm postoperative period.

J-shaped sternotomy in aortic valve repair and ascending aorta replacement. Short-term results

Objective: to evaluate the short-term outcomes of surgical treatment of aortic valve and ascending aorta defects performed through mini-sternotomy using normothermic cardiopulmonary bypass and hyperkalemic cardioplegia via Calafiori technique from May 8, 2019 to May 14, 2020. Materials and methods . The study enrolled 80 patients with isolated aortic valve disease and combined pathology of the aortic root and ascending aorta. It lasted from May 8, 2019 to May 14, 2020. The patients were divided into two groups: Group 1 included 30 patients in whom the upper median J-shaped sternotomy was applied as an access, while Group 2 consisted of 50 patients in whom standard median sternotomy was used as an access. The patients consisted of 43 (53.7%) males and 37 (46.3%) females; the average age was 55.1 ± 11.6 years. All patients were examined before surgery. It revealed no statistically significant differences between the two groups. Results. Group 2 had a 30-day mortality of 2% (n = 1) due to the development of acute heart failure against the background of heart rhythm disturbances. One patient in this group had a late mortality due to acute cerebrovascular accident occurring a month after discharge, which corresponded to 2% (n = 1). There were no deaths in Group 1. In Group 1, there were two conversions (6.7%) to longitudinal median sternotomy. In the first case, it was not possible to restore heart rhythm through repeated defibrillator discharges from mini-sternotomy access due to the presence of an adhesive process in the pericardial cavity. In the second case, ligation of the right internal thoracic artery was required after sternal wire sutures. Artificial ventilation (AV) lasted for 170.9 ± 70.2 minutes in Group 1 and 358.2 ± 169.5 minutes in Group 2. Cardiac activity was independently restored in 23 patients (77%) in Group 1, and in 12 (24%) in Group 2 (p &lt; 0.001). Intraoperative blood loss was 400 ± 150 mL and 850 ± 150 mL (p &lt; 0.05) in Group 1 and Group 2, respectively. In the early postoperative period, it was 200 ± 150 mL in Group 1 and 350 ± 150 mL in Group 2. The length of stay at the intensive care unit and the duration of intensive therapy did not exceed 1 day in both groups. In the early postoperative period, 4 patients in Group 1 (13%) and 27 patients in Group 2 (54%) needed inotropic support (p &lt; 0.001). The need for painkillers and non-steroidal anti-inflammatory drugs was within 3–4 days in Group 1 and 8–10 days in Group 2. In-hospital postoperative period varied from 10 to 16 days in both groups, depending on the severity of the initial condition, presence of concomitant diseases and the need to select an adequate anticoagulant dose. The patients were discharged in satisfactory condition under the supervision of a cardiologist at their homes. There were no inflammatory complications in the access area in both groups during their in-hospital stay. Among the complications in the mid-term postoperative period, two months after discharge, mediastinitis was observed in Group 2. The patient was re-hospitalized, after a course of antibiotic therapy which resolved the mediastinitis; sternal osteosynthesis was performed. Conclusion . Based on the study, it has been shown that this technique reduces the duration of mechanical ventilation, ensures early extubation, decreases blood loss, and, accordingly, ensures the use of replacement therapy, chest stability and a better cosmetic effect. It should be noted that there was no mortality and sternal complications in the patient group with a minimally invasive approach.

Comparative analysis of the effect of steroid therapy and blood pressure maintenance on the mid-term outcomes of spinal cord injury

Objective. To analyze the dynamics of neurological symptoms and the structure of complications when using methylprednisolone and the method of maintaining target values of mean arterial pressure during surgical treatment of patients in the acute period of spinal cord injury (SCI). Material and Methods. The study included 110 patients in the acute period of SCI with compression of spinal cord segments who were admitted to the clinic from January 2012 to March 2018 and underwent decompression and stabilization surgery within the first 2–3 hours after admission. In order to improve the blood supply to the damaged segments of the spinal cord and to prevent multiple organ failure, the main direction of intensive care in two groups of patients was to maintain the target blood pressure at the level of 85–90 mm Hg during the first 7–10 days. The MPD group included 43 patients who received methylprednisolone as a neuroprotector at a dose of 30 mg/kg bolus within the first hour after admission, followed by infusion at a dose of 5.4 mg/kg/h for 23 hours; and the MAP group included 67 patients who did not receive methylprednisolone. Non-invasive monitoring of central hemodynamic parameters was carried out on the basis of impedance cardiography data. The objective status of patients and data of X-ray diagnostics at the time of preoperative examination and during instrumental studies, as well as in 3–14 day intervals and in the mid-term (up to 4–6 months) postoperative period were analyzed. Results. In the MPD group, 22 patients had ASIA type A neurological deficit, and an increase in ASIA grade was observed only in 4 (18 %) of them. There were 18 patients with incomplete injury in this group, and 9 of them (50 %) had a positive trend. In the MAP group, 38 patients had ASIA type A, out of them 11 (29 %) improved, and 28 patients had ASIA type B, C or D, out of them 17 (61 %) showed positive dynamics of neurological symptoms. No statistically significant differences were found. In the MPD group, complications such as nosocomial pneumonia and acute endobronchitis were observed three times more often, pulmonary embolism and decubital soft tissue ulcers – four times more often, and sepsis, acute respiratory distress syndrome and surgical site infection – two times more often. There were statistically significant differences in the incidence of nosocomial pneumonia and acute endobronchitis between MPD and MAP groups (p = 0.004 and p = 0.002, respectively.) Conclusion. Maintaining mean arterial pressure at 85–90 mm Hg during the first 7–10 days after admission to the hospital allowed achieving a greater number of cases of improvement in the neurological status of patients, in contrast to the use of methylprednisolone. The use of methylprednisolone in patients with acute SCI increased the risk of nosocomial pneumonia or acute endobronchitis by 2.91 times (p = 0.003).

Valoración geriátrica integral: influencia en los resultados clínicos de la cirugía colorrectal en pacientes de edad muy avanzada

IntroductionThe objective of this work was to analyse the postoperative clinical results of patients surgically treated for colorectal cancer in relation to the results of the preoperative comprehensive geriatric evaluation. MethodsObservational study in which postoperative morbidity and mortality at 30 and 90 days were analysed in a cohort of patients surgically treated for colorectal cancer according to age groups: group 1) between 75 and 79 years old; group 2) between 80 and 84 years old, and group 3) ≥85 years old. In addition to the anaesthetic risk assessment, patients were assessed with the Karnofsky, Barthel and Pfeiffer indexes. Mortality at 30 and 90 days after surgery was analysed in relation to the results of the comprehensive evaluation. ResultsA total of 227 patients with colorectal cancer were included in the study period: 91 in group 1, 89 in group 2 and 47 in group 3. There were statistically significant differences in mortality at 30 days (p=0,029) but not at 90 days after surgery, according to age groups. Mortality at 90 days was significantly higher in patients with worse scores on the Karnofsky and Barthel scales. ConclusionsComprehensive geriatric assessment using different scales is a good tool to assess postoperative mortality in the mid-term postoperative period.

Early failure of an uncemented femoral stem, as compared to two other stems with similar design, following primary total hip arthroplasty performed with direct anterior approach.

An increased risk of early femoral component loosening has been reported using the direct anterior approach (DAA) compared with other common surgical approaches. However, long-term data are scarce. The purpose of this study is: (1) to determine the incidence of early femoral loosening in a high volume, single surgeon's practice utilising the DAA approach; and (2) to examine the effect of stem design and type of coating on aseptic loosening in the early and mid-term postoperative period. A retrospective review of 1650 consecutive patients (1800 hips) who underwent total hip arthroplasty (THA) using the DAA between August 2011 and December 2017 was conducted at our institution. 3 types of uncemented femoral stems (Quadra-S, Avenir, TwinSys), with similar design, but different coating, were implanted. Patients were evaluated clinically and radiologically at 4 weeks, 3 months, 1 year, and annually thereafter. After a mean follow-up of 46.4 months, the total incidence of revision for aseptic loosening was 0.44% (n = 8). All loose stems were Quadra-S, failing to achieve osseointegration, for an overall incidence of 0.96% (p = 0.002). None of the other stems were loose. Radiolucent lines around the proximal stem portion were visible in 75 Quadra-S stems (4.1%) on radiographs taken at 1 year postoperatively and continued to deteriorate at the latest follow-up. In this specific cohort of patients, the increased rate of femoral stem aseptic loosening was implant-related and was attributed only to a specific type of femoral stem (Quadra-S). No relation to other factors was proven suggesting that the surface characteristics of this femoral stem and the lack of bioactive coating are responsible for the observed early femoral failures. These findings should be confirmed by additional registry work and larger population sample sizes are needed to evaluate the prosthesis performance after implantation through the DAA.

Impact of Substance Use Disorder on Midterm Mortality After Valve Surgery for Endocarditis

Fueled by the burgeoning opioid epidemic, valve surgeries for substance use disorder-related infective endocarditis (SUD-IE) are increasing. The impact of substance use disorder on postvalve replacement morbidity needs further investigation. We queried The Society of Thoracic Surgeons Adult Cardiac Surgery Database for all valve surgeries for infective endocarditis at Tufts Medical Center (2002-2016) and collected demographic and disease-related data, including timing of mortality subclassified as short-term (<6 months including operative), midterm (6 months to 5 years), and extended-term (>5 years). Patients with documentation of illicit drug use before the operation were considered to have SUD-IE. Deaths were confirmed through review of medical record and matching with the Massachusetts Vital Statistics Database. We performed univariate and multivariate proportional hazard regressions examining the impact of substance use disorder mortality in people who received a valve replacement. In the cohort of 228 patients, 80 (35%) had SUD-IE. Eight-six people (38%) died, and overall mortality was higher in people with SUD-IE compared with non-SUD-IE (48% vs 32%, P= .025). SUD-IE was associated with a higher risk of overall mortality (adjusted hazard ratio, 2.41; 95% confidence interval, 1.38-4.20; P= .002). Although the difference between short-term or extended-term mortality wasnot significant, SUD-IE was associated with increased frequency of midterm mortality (53% vs 31%, P= .003). Our data reflect high rates of postvalve surgery morbidity and mortality in people with SUD-IE at a tertiary care center. The midterm postoperative period is a vulnerable period for people with SUD-IE worthy of further investigation.

Postoperative care in patients with DeBakey type I aortic dissection: criteria of aortic remodeling and risk factors of disease progression

To present current treatment modes for DeBakey type I aortic dissection, to compare their early and mid-term postoperative results, to evaluate predictors of negative aortic remodeling after surgery. Retrospective cohort analysis included 78 patients with DeBakey type I aortic dissection who underwent surgical treatment in 2009-2017. Patients were divided into 3 groups depending on type of intervention: group I (n=22) - Elephant Trunk procedure, group II (n=29) - hybrid interventions, group III (n=27) - proximal aortic replacement alone. Early postoperative results and aortic remodeling in mid-term postoperative period were compared. There were no significant differences in postoperative morbidity, in-hospital mortality and freedom from aortic death. However, 7 patients were lost for follow-up in group III. Analysis of false lumen patency showed results in favor of more aggressive approach (groups I and II) with significantly higher rate of false lumen thrombosis in segments 1 and 2 (p<0,001 and p=0,004 respectively). Freedom from negative aortic remodeling was also significantly higher in groups I and II. Risk factors of patent false lumen were residual fenestration, large volume of false lumen in segment 2, dissection of supra-aortic vessels and connective tissue disorders. Risk factors of negative aortic remodeling were connective tissue disorders, patent false lumen and dissection of supra-aortic vessels. Advanced surgical approach (Elephant Trunk procedure or hybrid interventions) should be preferred for DeBakey type I aortic dissection.

Mid-term results of papillary muscles approximation: a retrospective single-center study

Background. Enlargement of the left ventricular chamber and displacement of papillary muscles in the apical and lateral directions increase the tethering forces. Left ventricular and papillary muscle desynchrony and reduced myocardial contractility reduce the closing forces, thus leading to impaired leaflet coaptation and appearance of mitral regurgitation. Therefore, treatment of mitral insufficiency requires an integrated approach, affecting all aspects of the pathogenesis of mitral regurgitation recurrence. Recent publications show that adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation is effective in preventing recurrent regurgitation. One of these procedures is papillary muscle approximation. However, the safety and the positive impact of this method are still open to question. Aim. This study focused on the assessment of mid-term results of papillary muscles approximation and comparison of the obtained results with those of isolated mitral annuloplasty.Methods. Two hundred and twelve patients with ischemic cardiomyopathy and ischemic mitral regurgitation were enrolled in this retrospective single-center study. The patients were randomised to 2 groups by using propensity score matching (a “neighbor” method) according to the following parameters: end diastolic volume, end systolic volume, stroke volume and ejection fraction. The first group included 112 patients with ischemic cardiomyopathy and mitral regurgitation, who underwent coronary artery bypass grafting, mitral annuloplasty and papillary muscle approximation. The second group included 112 patients with ischemic cardiomyopathy who underwent coronary artery bypass grafting and mitral valve annuloplasty. We evaluated early and mid-term results.Results. Two patients in group 1 and three patients in group 2 died of heart failure progression during 31.3±10.4 month follow-up. According to the Kaplan-Meier analysis, no statistically significant differences were noted between the groups (log-rank test = 0.8). Approximation of papillary muscles in patients with ischemic mitral regurgitation improved mitral valve leaflet coaptation as evidenced by the values of coaptation depth, coaptation line and tenting area (p&gt;0.05). During follow-up, 3 cases (2.7%) of mitral insufficiency recurrence were recorded in group 1 and 16 (14.3%) in group 2. The Kaplan-Meier analysis of cumulative probability showed a significant difference in freedom from recurrence of mitral regurgitation ≥2 between groups in the mid-term postoperative period (log-rank test = 0.041).Conclusion. Adjunctive papillary muscle approximation performed at the time of mitral annuloplasty improves the durability of mitral valve repair. Received 18 April 2018. Revised 12 October 2018. Accepted 18 October 2018. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest.

Predictors of adverse events in the mid-term postoperative period in patients who underwent carotid endarterectomy

Aim. Emphasis in the study was placed on the identification of unfavorable prognosis factors associated with carotid endarterectomy (CEE) during mid-term follow-up.Methods. Over a period from 2015 to 2016, 222 CEE operations were performed. Most patients (n = 190; 85.5%) underwent CEE using a patch of xenopericardium, 14.4% (n = 32) received eversion CEE, and a temporary shunt was used in 14.4% (n = 32). Hybrid revascularization in the volume of percutaneous coronary intervention (PCI) + CEE was performed in 9.9% (n = 22) patients. The groups under study were compared by using a chi-square test followed by subsequent analysis of the shares, or if ordinal characters or quantitative traits with a distribution different from the normal one occurred—by using a Mann – Whitney U-test. Correction of multiple comparisons was done by calculating an average fraction of false discoveries of the hypotheses (false discovery rate). The analysis of prognostic factors was done using the odds ratio (OR) by means of the 2 × 2 tables.Results. Among the complications detected in the mid-term follow-up, the most common adverse event was the development of MI in 3.6% (n = 8) of patients. According to color duplex scanning of brachiocephalic arteries, restenosis of the operated ICA was observed in 4.5% of patients. The following risk factors significantly increased the risk of adverse events: angina pectoris II–III functional class (OR = 3.84%, CI = 1.24–11.9), SYNTAX Score &gt;22 (OR = 2.83, CI = 1.137–7.086).Conclusion. Based on the results of a single-center prospective retrospective study, significant risk factors for adverse outcome in the mid-term postoperative period were identified.Received 10 May 2017. Revised 27 September 2017. Accepted 5 October 2017.Funding: The research was done with support of the grant (No. 12090ГУ/2017) awarded by the Fund for Facilitation of Innovations within the framework of the “Umnik-2016” project (Kemerovo).Conflict of interest: The authors declare no conflict of interest.Author contributionsConception and study design: R.S. Tarasov, A.I. Anufriyev Data collection and analysis: A.R. ShabaevDrafting the article: A.N. Kazantsev, N.N. Burkov Critical revision of the article: A.V. MironovFinal approval of the version to be published: L.S. Barbarash

Invited Commentary

Invited Commentary

Beating-Heart Versus Conventional On-Pump Coronary Artery Bypass Grafting: A Meta-Analysis of Clinical Outcomes

Beating-heart on-pump coronary artery bypass grafting (BH-ONCAB) offers a hybrid coronary revascularization technique that may confer the benefits of an "off-pump" operation while maintaining the hemodynamic stability and mechanical support of conventional on-pump CABG (C-ONCAB). This study aimed to identify whether BH-ONCAB confers a morbidity or mortality benefit over C-ONCAB in the immediate and midterm postoperative period. A systematic literature review identified 13 studies incorporating 3,930 patients (937 BH-ONCAB; 2,993 C-ONCAB) fulfilling our inclusion criteria. Outcomes were meta-analyzed using random-effects modelling. Between-study heterogeneity was investigated through quality assessment, subgroup, and risk of bias analysis. No difference was seen in overall 30-day mortality (13 studies; odds ratio, 0.60; 95% confidence interval, 0.32 to 1.14; p = 0.12), or midterm survival (5 studies; hazard ratio, 0.65; 95% confidence interval, 0.22 to 1.88; p = 0.43) between BH-ONCAB and C-ONCAB. BH-ONCAB was associated with significantly fewer postoperative myocardial infarction events (odds ratio, 0.32; 95% confidence interval, 0.11 to 0.92; p = 0.03); however, no significant difference was observed in other postoperative morbidity outcomes. Intraoperatively, BH-ONCAB resulted in significantly less intraaortic balloon pump use, shorter cardiopulmonary bypass time, and less blood loss. The number of anastomoses and vessels grafted were not significantly different between BH-ONCAB and C-ONCAB. BH-ONCAB is a safe and comparable alternative to C-ONCAB in terms of early mortality and late survival. Furthermore, BH-ONCAB may confer a particular advantage in preventing perioperative myocardial infarction and reducing overall blood loss. Future work should focus on larger matched studies and multicenter randomized controlled trials that risk-stratify patients according to preoperative ventricular function and renal insufficiency to allow us to optimize our surgical revascularization strategy in these high-risk patients.

Short stem total hip arthroplasty in patients with rheumatoid arthritis.

Total hip arthroplasty (THA) has proven successful in patients with rheumatoid arthritis (RA). Patients with RA often require multiple revisions, and bone conservation is mandatory. A variety of short stems is currently available with mid-term results for osteoarthritis. This retrospective study evaluated mid-term clinical results of short stem THA in a series of patients with RA. Between 2005 and 2009, a total of 105 cementless short stems were implanted in patients with RA. Average patient age at the time of the index THA was 44.2 years, and average length of follow-up was 5 years. Clinical evaluation included physical examination and documentation of potential adverse events during the postoperative period. No radiographic failures occurred. Femoral and cup components showed some minor radiolucencies with sclerotic lines, but none involved 100% of the bone-prosthesis interface. Complications included femoral component subsidence in 2 hips after initial full weight bearing; 1 case resolved after 3 months, and the other case was revised to a standard shaft. One intraoperative dorsolateral stem tip perforation occurred with revision to a conventional length stem. Migration in 1 cup led to revision without removal of the short stem implant. No infections or joint dislocations were observed. The transfer of the short stem concept to an additional treatment option for patients with RA proved successful in the early to mid-term postoperative period. Complications and revisions were limited to early migration and early loosening of the implants in line with the results reported in the literature of cementless conventional THA in patients with RA.