Nonrevision Patients Research Articles

The Calpain Gene is Correlated With Metal-on-Metal Hip Replacement Failures

BackgroundMetal-on-metal (MOM) total hip arthroplasty is associated with unacceptable failure rates secondary to metal ion reactions. Efforts to identify which patients will go on to failure have been limited; recently, there has been a suggestion for a potential genetic basis for the increased risk of revision in MOM hip replacements (MOMHRs). The purpose of this study is to determine whether certain immunologic genotypes are predictive of the need for revision in patients with MOM total hip implants. MethodsThis is a case-control study of all patients undergoing primary MOMHR between September 2002 and January 2012 with a minimum of 5-year follow-up. Our investigational “case” cohort was comprised of patients who underwent revision for MOMHR for a reason other than infection. A single-nucleotide polymorphism (SNP) array analysis was performed to identify a potential genetic basis for failure. ResultsThirty-two patients (15 case and 17 control) were included in our analysis. All patients in the revision group had a chief complain of pain; revision patients were more likely to have a posterior approach (P = .01) and larger head size (P = .04) than nonrevision patients. No patient or implant characteristics were independently associated with revision in a multivariate analysis. Patients with SNP kgp9316441 were identified as having an increased odds of revision for MOM failure (P < .001). ConclusionThis study identified an SNP, kgp9316441, encoding proteins associated with inflammation and macrophage activation. This SNP was associated with significantly increased odds of revision for MOMHR. Future studies are warranted to validate this gene target both in vitro and in vivo. Level of EvidenceIII.

190. Preoperative opioid therapy poorly controls pain in nonrevision adult spinal deformity (ASD) and increases risk for chronic postoperative opioid usage

BACKGROUND CONTEXT Iatrogenic malalignment, nonunion and adjacent segment degeneration are established etiologies for pain in adult spinal deformity (ASD). However, reasons for pain among ASD patients with no prior history of surgery (nonrevision) are incompletely understood. Opioid therapy for pain is controversial and problematic. PURPOSE Compare pain scores in nonrevision ASD patients who preoperatively receive opioids vs no opioids and evaluate pain scores and risk for chronic opioid use following surgical treatment. It is hypothesized that preop opioid therapy poorly controls pain and increases risk for chronic postop opioid use compared to opioid nonusers in nonrevision ASD patients. STUDY DESIGN/SETTING Analysis of a prospective multicenter ASD database. PATIENT SAMPLE ASD patients with no history of prior spine surgery, enrolled into a prospective multicenter database and subsequently surgically treated for ASD. OUTCOME MEASURES Scoliosis Research Society-22r questionnaire (SRS-22r), SF-36, numeric rating scale (NRS) back and leg pain. METHODS ASD patients (age >18 years, no history of spine surgery), were enrolled into a prospective multicenter ASD database and evaluated for opioid use on SRS-22r questionnaire. Patients divided into preop opioid (OPIOID) vs nonopioid (NON) users, organized into SRS deformity types (thoracic, lumbar, double, sagittal and mixed), treated surgically for ASD and evaluated minimum 2 years postop. Pre- and postop demographic, radiographic, and pain values evaluated, and postop opioid usage compared. RESULTS Two hundred twenty-seven of 426 patients, (mean follow-up 3.3 years) were eligible for study and evaluated. Distribution of SRS deformity type for OPIOID vs NON was similar. Comparison of scoliosis patients (thoracic, lumbar or double deformities) demonstrated OPIOID (n=32) had similar preop age, BMI, smoking history, maximal scoliosis, SVA, and sagittal spinopelvic parameters as NON (n=95; p>0.05). However, OPIOID had greater preop NRS back pain (7.3 vs 6.1), leg pain (4.9 vs 3.1), and worse SF-36 bodily pain (31.8 vs 39.8) than NON (p 0.05). However, OPIOID had greater preop NRS back pain (7.8 vs 7.0), leg pain (5.8 vs. 3.8), and worse SF-36 bodily pain (29.3 vs. 35.6) than NON (p CONCLUSIONS Evaluation of 227 surgically treated nonrevision ASD patients demonstrated that despite having similar demographics, spinal deformity and similar surgery OPIOID reported greater preop pain scores, greater postop pain scores and had greater risk for opioid usage than NON. The relative risk of opioid usage at 2 years postop was 5.0 for preop daily users and 2.8 for preop weekly users compared to NON. Preop opioid therapy should be avoided in non-revision ASD. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The 10-year outcomes of the ASR XL Acetabular System: a single-center experience from China

BackgroundThe revision rate of articular surface replacement (ASR) implants continues to rise in China because of metal debris. However, there are few reports on the clinical results of ASR implants with prolonged follow-up time in China. This study investigated the clinical outcomes and the risk factors of revision surgery in patients with ASR implants.MethodsIn total, 74 patients (74 hips) who underwent primary total hip arthroplasty (THA) with ASR implants over the past 4 to 10 years were retrospectively analyzed. Relevant clinical, radiographic, and biochemical data were examined.ResultsThe average follow-up time was 88.46 (range 23–114) months, and the ASR implants of 18 hips (24.3%) were revised. Patients who received revision surgery had worse joint function with significantly lower Harris Hip Score and Western Ontario and McMaster Universities index than non-revision patients (61.11 ± 6.68 vs 85.30 ± 9.16, p < 0.001; 61.00 ± 3.83 vs 79.04 ± 14.49, p < 0.001; respectively). Higher acetabular abduction angle and serum Co and Cr concentration were significantly relevant to worse joint function as measured by HSS (p = 0.018, 0.009, 0.043, respectively). ROC curve analysis was applied to categorize the optimal cutoff values of acetabular abduction angle and serum Cr and Co concentration for revision surgery, which were settled as 47.80°, 98.44 μg/L, and 6.95 μg/L, respectively. Overall survival of the prostheses with high acetabular abduction angle (> 47.80°, HR = 70.145, 95% CI 1.558–3158.213, p = 0.029), high serum Cr concentration (98.44 μg/L, HR = 58.956, 95% CI 1.294–2685.203, p = 0.036), and high serum Co concentration (> 6.95 μg/L, HR = 179.511, 95% CI 2.360–13656.941, p = 0.019) decreased significantly than the lower groups.ConclusionsEvaluation of the DePuy ASR XL articulation demonstrated increased rates of revision following a longer follow-up period. High acetabular abduction angle and serum Cr and Co concentration correlated with worse clinical outcomes and high revision rate. Therefore, we advocate that patients with DePuy ASR XL implants be followed up more closely than those with other implants, especially with high acetabular abduction angle and serum Cr or Co concentration.

Recovery Kinetics of Radiographic and Implant-Related Revision Patients Following Adult Spinal Deformity Surgery

Prior studies have observed similar health-related quality of life (HRQL) in revisions and nonrevision (NR) patients following adult spinal deformity (ASD) correction. However, a novel comparison approach may allow better comparisons in spine outcomes groups. To determine if ASD revisions for radiographic and implant-related complications undergo a different recovery than NR patients. Inclusion: ASD patients with complete HRQL (Oswestry Disability Index, Short-Form-36 version 2 (SF-36), Scoliosis Research Society [SRS]-22) at baseline, 6 wk, 1 yr, 2 yr. Generated revision groups: nonrevision (NR), revised-complete data (RC; with follow-up 2 yr after revision), and revised-incomplete data (RI; without 2-yr follow-up after revision). In a traditional analysis, analysis of variance (ANOVA) compared baseline HRQLs to follow-up changes. In a novel approach, integrated health state was normalized at baseline using area under curve analysis before ANOVA t-tests compared follow-up statuses. Two hundred fifty-eight patients were included with 50 undergoing reoperations (19.4%). Rod fractures (n=15) and proximal joint kyphosis (n=9) were most common. In standard HRQL analysis, comparing RC index surgery and RC revision surgery HRQLS revealed no significant differences throughout the 2-yr follow-up from either the initial index or revision procedure. Using normalized HRQL/integrated health state, RI displayed worse scores in SF-36 Physical Component Score, SRS activity, and SRS appearance relative to NR (P<.05), indicating less improvement over the 2-yr period. RC were significantly worse than RI in SF-36 Mental Component Score, SRS mental, SRS satisfaction, and SRS total (P<.05). ASD patients indicated for revisions for radiographic and implant-related complications differ significantly in their overall 2-yr recovery compared to NR, using a normalized integrated health state method. Traditional methods for analyzing revision patients' recovery kinetics may overlook delayed improvements.

How often is the office visit needed? Predicting total knee arthroplasty revision risk using pain/function scores.

BackgroundMost patients have favorable outcomes after primary total knee arthroplasty (TKA). Well-validated methods to predict the risk of poor outcomes have not been developed or implemented. Several patients have annual clinic visits despite well-funcitoning TKA, as a routine practice, to detect early failure requiring revision surgery. It is not known whether assessment of pain and function can be used as a predictive tool for early failure and revision to guide practice. Our objective was to determine whether pain and function can predict revision after TKA.MethodsWe retrospectively studied data from a large prospectively gathered TKA registry to examine changes in outcome scores for primary TKAs undergoing revision compared to those not requiring revision to determine the factors that are predictive for revision.ResultsOf the 1,012 patients, 721 had had a single-sided primary TKA and had American Knee Society (AKS) Scores for three or more visits. 46 patients underwent revision, 23 acutely (fracture, traumatic component failure or acute infection) and 23 for latent causes (late implant loosening, progressive osteolysis, or pain and indolent infection). Mean age was 70 years for the non-revision patients, and 64 years for those revised. Both AKS Clinical and AKS Function Scores for non-revised patients were higher than in revision patients, higher in acute revision compared to latent revision patients. Significant predictors of revision surgery were preoperative, 3- and 15-month postoperative AKS Clinical Scores and 3-month AKS Function Scores. At 15-month post-TKA, a patient with a low calculated probability of revision, 32 % or less, was unlikely to require revision surgery with a negative predictive value of 99 %.ConclusionTime dependent interval evaluation post-TKA with the AKS outcome scores may provide the ability to assign risk of revision to patients at the 15-month follow-up visit. If these findings can be replicated using a patient-reported measure, a virtual follow-up with patient-reported outcomes and X-ray review may be an alternative to clinic visit for patients doing well.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1669-y) contains supplementary material, which is available to authorized users.

Longitudinal Pilot Analysis of Radiation Exposure During the Course of Growing Rod Treatment for Early-Onset Scoliosis

Study DesignRetrospective consecutive case series. ObjectivesTo estimate the amount of ionizing radiation (IR) exposure in growing rod (GR) surgery for early-onset scoliosis. Summary of Background DataThere is substantial evidence of the health hazards attributed to IR exposure. However, no studies have estimated the amount of IR exposure in GR surgery. Materials and MethodsA consecutive single-center series of GR patients were retrospectively reviewed. Of 28 total patients, 24 had a minimum 2-year follow-up and complete records available for analysis. All spine-related IR imaging studies excluding intraoperative fluoroscopy were tabulated and IR estimated based on historical controls in millisieverts (mSv). ResultsInitial x-ray evaluation for scoliosis was performed at a mean age of 4.0 years (range = birth to 9.7). Mean radiographic period was 8.5 years (range = 2.2 to 19.4). There was a statistically significant inverse correlation between patient age at time of initial IR and total mean IR (p < .05). Total IR was 3.4 times greater than that of estimated background radiation (2.4 mSv per year). Mean IR before index surgery and during the first postoperative year were 22.41 mSv and 10.78 mSv, respectively. Annual IR after the first postoperative year averaged 7.02 mSv (range = 2.25 to 13.45). Patients who underwent at least one revision surgery experienced significantly higher IR than nonrevision patients (79.95 vs. 46.58 mSv; p < .05). Overall, 89% of total IR was attributed to x-rays and 11% from computed tomography. ConclusionsCompared to the general public, GR patients had 3.4 times more IR than the estimated background radiation for the same duration of time. Younger patients and those requiring revision surgery had significantly higher IR doses. This study underscores the importance of recognizing the amount of IR used in the management of GR patients and its potential long-term risks. Level of EvidenceIII.

PSU32 A Comparison of Resource Utilization and Medical Charges Among Lumbar Interbody Fusion Surgical Patients With and Without Revision

2HealthMetrics Outcomes Research, Delray Beach, FL, USA OBJECTIVES: Compare resource utilization and medical charges among patients who had an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLF), or transforaminal posterior lumbar interbody fusion (T-PLIF) and a subsequent revision surgery to those without such a revision surgery. METHODS: The MedStat MarketScan databases from 2006 - 2009 were utilized for this retrospective analysis. Patients were included if had a ALIF, PLF, or T-PLIF and had continuous insurance coverage for 2 years post procedure. Revision patients were then matched to non-revision patients at a 2:1 ratio based upon type of initial procedure, year of birth, sex, and region of residence Medical payments and resource utilization were compared between the two cohorts using t-statistics for continuous variable and chi-square statistics for categorical variables. RESULTS: In the 2 years post procedure, patients with a subsequent revision were significantly more likely to visit a physical therapist (92% v 62%; P0.0001), receive an epidural steroid injection (58% v 47%; P0.0074), or visit the emergency room with a diagnosis of back pain (20% v 9%; P0.0001). The average cost the initial surgery was similar among the two cohorts ($39,925 v $38,341; P0.6422) while the mean cost associated with a revision surgery was $35,296 (std dev$32,814). Total payments for the two cohorts, ignoring the cost of the initial procedure was $33,180 for patients who did not have a subsequent revision, and $89,770 for patients with a subsequent revision (P0.0001). These differences translate into a $56,590 cost premium associated with a revision surgery ‐ 62% of which can be accounted by the revision surgery itself. CONCLUSIONS: Revision surgery was associated with significantly more resource utilization post initial surgery. Comparing costs among the two groups reveal a significant cost premium associated with revision surgery and that such costs extended beyond the cost of the revision surgery itself.

Modification of Perioral Stiffness in Patients with Repaired Cleft Lip and Palate

To measure and compare the perioral stiffness among three groups of pediatric subjects: a group of patients with a repaired cleft lip (and palate) who had a secondary lip revision surgery (revision), another group of patients with repaired cleft lip (and palate) who did not have secondary surgery (nonrevision), and a group of noncleft "normal" patients (noncleft). A parallel, three-group, nonrandomized clinical trial. A total of 16 patients with repaired cleft lip/palate who did not have lip revision, 13 patients with repaired cleft lip/palate who had lip revision surgery and were tested at 18 to 24 months postsurgery, and 27 noncleft patients. Nonparticipatory perioral stiffness was sampled using a recently developed face-referenced measurement technology known as OroSTIFF. Perioral stiffness, derived as a quotient from resultant force and interangle lip span, was modeled with multilevel regression techniques. Real-time calculation of the perioral stiffness function demonstrated a significant quadratic relation between imposed interangle stretch and resultant force for each of the three groups. This nonlinear stiffness growth function was significantly elevated in the nonrevision patients compared with the noncleft controls and is likely due to the presence of scar tissue in the upper lip; it was significantly lower among patients with cleft lip/palate who completed lip revision surgery. This study demonstrates the efficacy of applying an objective measurement to map differences in perioral tissue biomechanics among patients born with orofacial clefts.

Revision Septoplasty: Review of Sources of Persistent Nasal Obstruction

Patients with nasal obstruction from septal deviation commonly undergo septoplasty to improve nasal airflow. Some patients suffer from persistent obstruction after their primary septoplasty and may undergo a revision septoplasty to improve their nasal passageway. Our objective was to identify patients who underwent revision septoplasty and to identify their sources of persistent nasal obstruction. Patients who underwent septoplasty at our institution between 1995 and 2005 were reviewed. Data is collected on demographics, comorbidities, age at septoplasty, associated and concomitant procedures, surgical approach, and anatomic site of obstruction. Five hundred forty-seven patients met inclusion criteria including 477 who underwent primary septoplasty and 70 who underwent revision surgery. Nineteen percent of nonrevision patients underwent nasal valve surgery along with their primary septoplasty versus 4% of patients in the revision group. Fifty-one percent of revision patients had nasal valve surgery at revision surgery. Patients who underwent sinus surgery along with primary septoplasty were less likely to undergo revision septoplasty. History of facial trauma, obstructive sleep apnea, site of deviation, and performance of inferior turbinate surgery did not affect the likelihood of revision septoplasty. A significant number of patients who undergo revision septoplasty also have nasal valve collapse. We recommend that in addition to septal deviation and inferior turbinate hypertrophy, nasal valve function be fully evaluated before performing septoplasty. This will help to ensure a complete understanding of a patient's nasal airway obstruction and, consequently, appropriate and effective surgical intervention.

Factors influencing haemostasis and blood transfusion in cardiac surgery.

To find out the risk factors influencing perioperative bleeding and use of blood products in cardiac surgery so that appropriate interventions can be selected for blood conservation, risk factors were analysed in 343 cardiac surgical patients, retrospectively, by multiple regression technique. The results showed that the factors related to postoperative bleeding were male gender, Higgins score, cardiopulmonary bypass (CPB) time, operation procedures, intraoperative blood loss and use of internal mammary artery (IMA) graft. Factors related to perioperative homologous blood transfusions were emergency surgery, preoperative haemoglobin level, Higgins score, intraoperative blood loss, operation time and operation procedures. The geometric mean of postoperative bleeding in the entire series was 1085 ml and the mean packed red cell, plasma and platelet transfusions were 3.29 +/- 0.4, 1.96 +/- 0.39 and 0.21 +/- 0.05 units respectively. The incidence of homologous blood transfusion during the hospital stay was 58.9% for the entire series and 54.5% in the nonrevision patients. Emergency patients received significantly more blood transfusion (p = 0.0001). Perioperative blood loss and transfusions are still problems in cardiac surgery and certain patient groups in this study were identified as high risk; available blood conservation techniques, therefore, are recommended in these patients.