Patients Underwent Revision Surgery Research Articles

Fragment specific fixation technique using 2.7mm VA LCP for comminuted posterior wall acetabular fractures: a novel surgical technique.

The purposes of the study were to introduce surgical technique of fragment-specific fixation technique using multiple 2.7-mm variable-angle locking compression plates (VA LCPs) in comminuted posterior wall acetabular fractures and reported its clinical results. Among the 68 patients, 23 with comminuted posterior wall factures with ≥ 3 fragments in the CT scan and no column involvement with a minimum follow-up duration of 12months were enrolled in this study. We evaluated the clinical results after the treatment of comminuted posterior wall acetabular fractures via the fragment-specific fixation technique using 2.7-mm variable-angle locking compression plates (VA LCPs) retrospectively. The average duration of follow-up was 26.8months. Anatomical reduction was achieved in eighteen patients. Imperfect reduction was achieved in five patients. 22 patients achieved fracture union and one patient underwent revision surgery owing to acute postoperative infection. There were no complications, including loss of reduction, fixative failures, sciatic nerve palsy, heterotopic ossification, and early posttraumatic arthritis among 22 patients. The average functional outcome was measured as 'very good'. Fragment-specific fixation technique using 2.7-mm VA LCPs for comminuted posterior wall acetabular fractures could be an acceptable alternative means of surgical fixation.

Posterior revision surgery using an intraarticular distraction technique with cage grafting to treat atlantoaxial dislocation associated with basilar invagination.

The treatment of atlantoaxial dislocation (AAD) and basilar invagination (BI) is challenging, especially in symptomatic patients with a history of previous surgery. Although seldom reported, posterior revision surgery to revise prior constructs can be advantageous over an anterior or combined approach. The authors describe their experience in performing posterior revision surgery using Goel's technique. The authors reviewed patients with AAD and BI who had undergone previous posterior surgery at the cranio-cervical junction between January 2016 and September 2017. All of these patients underwent revision surgery from a posterior approach. The Japanese Orthopaedic Association (JOA) score was used to assess clinical symptoms before and after surgery. The distance from the tip of the odontoid to Chamberlain's line, atlantodental interval (ADI), and clivus-canal angle (CCA) were used for radiographic assessment before and after surgery. Twelve consecutive patients were reviewed. Prior surgeries were as follows: 4 patients (4/12) with posterior osseous decompression without fusion, 7 (7/12) with reduction and fusion without decompression, and 1 (1/12) with posterior osseous decompression and reduction and fusion. With the use of Goel's technique for revision in these cases, distraction using facet spacers afforded release of the anterior soft tissue from a posterior approach. The occiput was fixated to C2 using a cantilever technique, and autologous cancellous bone was grafted into the intraarticular joints. In all 12 patients, complete reduction of BI and AAD were achieved without injury to nerves or vessels. All patients had evidence of bony fusion on CT scans within 18 months of follow-up. Posterior revision surgery using Goel's technique is an effective and safe revision salvage surgery for symptomatic patients with AAD and BI.

The Utility of In-Hospital Postoperative Radiographs Following Surgical Treatment of Traumatic Thoracolumbar Injuries.

A retrospective cohort study. The objective of this study was to assess the utility of routine in-hospital postoperative radiographs for identifying hardware failure following surgical treatment of traumatic thoracolumbar (TL) injuries. Postoperative radiographs following spine surgery are considered standard of care despite a lack of evidence supporting their utility. Previous studies have concluded that postoperative radiographs following lumbar fusion for degenerative conditions have limited clinical value. A retrospective chart review was performed on patients who underwent surgical treatment of traumatic TL injuries between December 2006 and October 2015 at a level I trauma center. Before discharge, postoperative upright anteroposterior and lateral radiographs were obtained and reviewed by 1 surgeon and 1 radiologist as per protocol. Patients who subsequently underwent revision surgery during their initial hospital stay were identified. These patients were further analyzed to identify the indications for surgery and determine if the results of the radiographs obtained led to the subsequent revision surgery. A total of 463 patients were identified who underwent surgical treatment following TL trauma. The rate of revision surgery during the initial hospitalization was 1.3% (6/463). Three patients underwent revision surgery due to worsening neurological status. One patient underwent reoperation because of advance imaging obtained for abdominal trauma. Two patients underwent revision surgery due to abnormal findings on postoperative radiographs. The overall sensitivity and specificity of routine postoperative radiographs was 33.3% and 100%, respectively. In the absence of new clinical signs and symptoms, obtaining routine in-hospital postoperative radiographs following surgical treatment of TL injuries provides minimal value. Clinical assessment should help determine if additional imaging is indicated for the patient. Avoiding unnecessary inpatient tests such as routine postoperative radiograph may offer multitude of benefits including lowering patient radiation exposure, reducing health care costs and better allocation of hospital resources. Level III.

Risk Factors of Postoperative Spinal Epidural Hematoma After Biportal Endoscopic Spinal Surgery

Although postoperative spinal epidural hematoma is a rare complication, it can cause severe neurologic complications. Studies regarding biportal endoscopic spinal surgery, a type of minimally invasive spinal surgery technique, have been recently reported. The purpose of our study is to report the incidence and risk factors of postoperative hematoma after biportal endoscopic spinal surgery. The subjects included 310 patients that underwent biportal endoscopic spinal surgery from 2015 to 2017. Magnetic resonance imaging (MRI) was performed in all patients before surgery, and also after surgery to identify epidural hematoma. Using electronic medical records, perioperative factors such as age, sex, operation name, operation level, water infusion pump usage, thrombin-containing hemostatic agent, and anticoagulant medication were statistically analyzed in the aspect of postoperative hematoma. The overall occurrence rate of postoperative hematoma was 23.6% (n= 94). A total of 304 levels (76.4%) were without hematoma according to the postoperative MRI among the total 398 levels. Six patients underwent revision surgery of hematoma evacuation. Female sex, old age (>70 years), preoperative anticoagulation medication, and usage of intraoperative water infusion pump were significantly correlated to the occurrence of postoperative hematoma. Although symptomatic postoperative hematoma was extremely rare at 1.9%, radiologic hematoma confirmed by postoperative MRI was higher at 23.6%. The perioperative risk factors of postoperative hematoma after biportal endoscopic spinal surgery include female sex, older age (>70 years), preoperative anticoagulation medication, usage of intraoperative water infusion pump, and surgery requiring more bone work (laminectomy or interbody fusion).

Ulnar head replacement and sigmoid notch resurfacing arthroplasty with minimum 12-month follow-up.

Our study aimed to report the short-term outcomes of patients who underwent partial ulnar head replacement and distal radial ulnar joint interposition arthroplasty. From 2012 to 2016, nine patients underwent this procedure with mean follow-up of 27 months (range 12-55). Seven of the nine patients had previously undergone surgical intervention on the ipsilateral wrist. The procedure resulted in substantial improvements in pain and function. Mayo Wrist Score improved from 37 preoperatively to 73 postoperatively, and six patients achieved a good or excellent outcome. Visual analogue pain scores decreased from 7 preoperatively to 1 postoperatively. Grip improved from 20 kg preoperatively to 30 kg postoperatively. There was no significant change in wrist range of motion. Two patients underwent revision surgery to improve wrist motion. We conclude that over short-term follow-up the procedure provides a feasible option for distal radial ulnar joint arthritis. Level of evidence: IV.

Is pseudarthrosis after spinal instrumentation caused by a chronic infection?

To assess whether a chronic bacterial infection is present in a subset of patients with pseudarthrosis after instrumented spinal fusion. This was a prospective diagnostic study including adult patients with previous instrumented spinal fusion. Patients underwent revision surgery for either pseudarthrosis or other causes (e.g. implant removal, curve progression or junctional kyphosis) (control group). Five separate biopsies were randomly collected, intraoperatively, from the pseudarthrosis site and cultivated under both aerobic (5days) and anaerobic (14days) conditions. If cultivation was positive in at least 2/5 tissue samples, the biopsy was sectioned and stained using peptide nucleic acid fluorescence in situ hybridization (PNA-FISH). Confocal laser scanning microscopy was used to examine the sections and visualize bacterial aggregates. The study included 32 pseudarthrosis and 32 control patients. Cultivation yielded bacteria in at least 1/5 biopsies in 52% of patients with no difference between the groups (p = 1.0). Bacteria of the same species was found in at least 2/5 samples in seven pseudarthrosis patients and four controls (p = 0.509). Propionibacterium acnes was found in 8 of these 11 samples. Microscopy demonstrated tissue-embedded bacterial aggregates in two of these patients but with no inflammatory cells indicating an active infection. The presence of bacteria was not associated with the number of previous spinal procedures or the pre-revision fusion length (p ≥ 0.503). Pseudarthrosis after instrumented spinal surgery was not significantly associated with the presence of bacteria at the pseudarthrosis site. Positive cultivation results are common after spinal instrumentation, but our results indicate that they rarely represent an organized infection. These slides can be retrieved under Electronic Supplementary Material.

Long-term results of the Global Modular Replacement System tumor prosthesis for reconstruction after limb-sparing bone resections in orthopedic oncologic conditions: Results from a national cohort.

We investigated implant revision, implant failure, and amputation risk after limb-sparing bone tumor surgery using the Global Modular Replacement System (GMRS) tumor prosthesis in patients suffering from bone sarcomas (BS), giant cell tumors (GCT), or metastatic bone disease (MBD). A retrospective study of a nationwide consecutive cohort (n = 119, 47 [12-81] years, M/F = 65/54) having limb-sparing surgery and reconstruction using the GMRS tumor prosthesis due to bone tumors (BS/GCT/MBD = 70/8/41) from 2005 to 2013. Anatomical locations were as followed: distal femur (n = 49), proximal femur (n = 41), proximal tibia (n = 26), or total femur (n = 3). Kaplan-Meier survival analysis and competing risk analysis with death as a competing risk were used for statistical analysis. For BS and GCT patients, 5-year patient survival was 72% (95% confidence interval [CI]: 59-85%) and for MBD 33% (95% CI: 19-48%). Thirty-two patients underwent revision surgery (5-year revision incidence 14%; 95% CI: 8-21%). Twelve patients had revision of bone-anchored parts (implant failure) with a 5-year revision incidence 6% (95% CI: 2-10%). Ten amputations were performed due to local relapse (n = 9) or recurrent infections (n = 1) with a 5-year incidence of amputation: 8% (95% CI: 3-13%). We identified a low risk of revision and amputation when using the GMRS tumor prosthesis for limb-sparing bone tumor.

Cost Implications of Varying the Surgical Setting and Anesthesia Type for Trigger Finger Release Surgery.

Trigger finger release (TFR) is a common surgical procedure, representing a financial burden to the healthcare system. Our null hypothesis is that the choice surgical setting [operating room (OR) versus procedure room (PR)] and anesthetic type [local-only or monitored anesthesia care (MAC)] do not affect surgical encounter costs for TFR. Adult patients undergoing isolated unilateral TFR between May 2014 and December 2017 by 5 fellowship-trained hand surgeons at a single academic medical center were identified by Current Procedural Terminology (CPT) code (26055). We excluded patients undergoing revision surgery, tenosynovectomy, or additional procedures. Using our institution's information technology value tools, we calculated total direct costs for each surgical encounter, which were compared between groups. Univariate and multivariable gamma regression were used to model costs. Of 210 included patients, 54% (113/210) of cases were performed in the PR and 46% (97/210) in the OR. No significant differences in demographics were observed between PR and OR groups. Compared to local-only in the PR, the OR with local-only, and OR with MAC, demonstrated 2.2- and 3.2-fold greater median costs. Multivariable models suggested that use of the OR independently led to 221% [95% Confidence interval: 137%-345%; P < 0.01] greater mean costs than the PR, and use of MAC was associated with 30% (95% confidence interval: 13%-49%; P < 0.01) greater mean costs for OR cases than local-only, while controlling for other confounders. Performing TFR in the PR setting under local-only anesthesia minimizes surgical encounter direct costs for this common procedure.

Fever and Erythema are Specific Findings in Detecting Infection Following Total Knee Arthroplasty.

Current diagnostic modalities are based almost exclusively on laboratory findings and the role of clinical presentation remains unknown. The purpose of this study was to examine the diagnostic value of clinical presentation in detecting periprosthetic joint infection (PJI). This study evaluated 279 patients undergoing revision surgery for failed total knee arthroplasty (TKA) between 2001-2016. Patients were classified as undergoing septic revisions based on major MSIS criteria. Aseptic revisions were defined as cases of single stage revision that did not have suspected PJI, fulfill MSIS criteria, or subsequently fail within one year of follow-up. Clinical presentation included pain, fever, presence of joint effusion or erythema, and reduced range of motion. Serum and synovial laboratory markers were also evaluated. The diagnostic value of each test was assessed and a Fagan's nomogram was constructed. A subset of MSIS-negative patients was used to demonstrate the value of various clinical presentations in detecting PJI. Post-test probability for infection was calculated taking into account clinical presentation together with serum and synovial markers. Our results show that fever and erythema are the most important signs for diagnosing PJI with a positive likelihood ratio (LR) of 10.78 and 8.08, respectively. Effusion had a LR of 2.42. Pain and reduced ROM were not as strongly correlated with PJI diagnosis; LR was 1.02 and 1.51. Of the 35 MSIS-negative patients treated for PJI, 33 had a post-test probability of infection greater than 90% when taking clinical presentation into account. Clinical presentation should be used to guide which future diagnostic tests should be ordered and in the interpretation of their results. Our results indicate that pain, fever, presence of joint effusion or erythema, and reduced range of motion should prompt further workup for infection. We propose a nomogram that may be used in interoperating their individual weight together with laboratory findings. Fever and erythema are highly specific findings in patients with PJI and future studies should assess whether they may be added as minor criteria to current definitions for infection.

Evaluation of Postoperative Spinal Epidural Hematoma After Biportal Endoscopic Spine Surgery for Single-Level Lumbar Spinal Stenosis: Clinical and Magnetic Resonance Imaging Study

Symptomatic postoperative spinal epidural hematoma is a serious complication that may occur after lumbar spine surgery. We analyzed epidural hematoma using postoperative magnetic resonance imaging (MRI) after biportal endoscopic spinal surgery and its impact on clinical outcome. The subjects of this study were 158 patients who underwent single-level decompression using the biportal endoscopic spinal surgery technique from 2015 to 2017. MRI was performed in all patients before and after surgery, and postoperative MRI was used to identify epidural hematoma. The preoperative and postoperative visual analog scale (VAS) score for leg and back pain, Oswestry Disability Index (ODI), and modified Macnab criteria were recorded for evaluation of clinical outcome. The group with postoperative spinal epidural hematoma (group A) and without hematoma (group B) were comparatively analyzed, both radiologically and clinically. The mean age of the patients was 67.9 ± 11.1 years (range, 49-89). The total number with grade 0 (no hematoma) was 119 levels patients (75.3%) on the T2 axial image of postoperative MRI. The total number of patients with hematoma was 39 (24.7%) according to T2-weighted axial postoperative MRI. Two patients underwent revision surgery because of hematoma-related symptoms. The improvement of clinical outcome measures including VAS leg, VAS back, and ODI was significantly different between group A and B (P < 0.05). The incidence of postoperative spinal epidural hematoma after biportal endoscopic spinal surgery according to postoperative MRI was higher than expected, regardless of the patients' postoperative symptoms. Postoperative hematoma has a decisive influence on postoperative results, and revision surgery might be necessary if canal encroachment is >50% with concomitant symptoms.

Allergy in total knee replacement surgery: Is it a real problem?

Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.

Outcome of revision UKR to TKR when compared to a matched group of TKR of same total arthroplasty lifespan

AimTo compare outcomes of revision uni-compartmental knee replacement (UKR) with a defined revision cause with a matched group of primary total knee replacements (TKR). BackgroundUKR accounts for 8.7% of knee arthroplasty in the UK each year. It has better functional outcome than total knee replacement for isolated single compartment arthritis but can result in complex surgery when revision is required. This is feared to result in poorer patient reported outcomes when compared to primary TKR. We aim to compare the clinical results of revised UKR with primary TKR, taking into account the survival length of the UKR. Patients and methodsForty-five patients (27 female) were retrospectively identified from our arthroplasty database that had undergone revision from UKR to TKR (1999–2014) and had a minimum of two years of follow-up post-revision. These patients were then matched with regards to age at primary procedure, sex, BMI and total arthroplasty life (UKR + Revision TKR) up to point of follow-up. ResultsIn the UKR revision group (mean arthroplasty life 8.6 years) the mean Oxford knee score (OKS) was 31.8. In the primary knee group (mean arthroplasty life 8.4 years) the mean OKS was 32.8. This difference was not statistically significant. Fifteen out of 45 patients undergoing revision surgery required stemmed components. ConclusionUKR provides comparable clinical outcome even after revision surgery to TKR as primary TKRs and should be considered in all patients meeting the selection criteria. Revision is complex and revision components should be available.

The risk factors of rod fracture after correction surgery with satellite rod in severe spinal deformity

Objective To investigate the incidence and risk factors for rod fracture after correction surgery with satellite rod in severe spinal deformity. Methods A retrospective analysis was made including 234 cases who underwent correction surgery using satellite rod technique for severe spinal deformity in our hospital from July 2012 to June 2017. At the last follow-up, a total of 6 patients were found to have rod fracture. All the patients had complete clinical and imaging data at the time of preoperation, postoperation, rod fracture occurring, post-revision and the last follow-up. The Cobb angle, the Global kyphosis (GK), the coronal balance (distance between C7 plumb line and center sacral vertical line, C7PL-CSVL) and the sagittal vertical axis (SVA) were measured respectively in the 6 patients with rod fracture during the follow-up process. The time, incidence and position of the broken rod were recorded, and the reasons of rod fracture were analyzed for each patient. Results The incidence of rod fracture was 2.6% (6/234) in the current study. The 6 patients included 3 males and 3 females with an average age of 34.5±15.4 years at initial surgery. The mean time of rod fracture was 24.0±17.7 months, of which 3 cases (50%) occurred within 1 years after operation. A total of 7 rods were broken, including 4 (57%) rods located at the single-rod-fixed side with stress concentration and 3 (50%) rods at the adjacent segment of the satellite rod. The average loss of correction was 20.8°±29.4° for Cobb angle and 34.0°±21.4° for GK. The potential reasons for rod fracture were listed as follows: 3 cases for residual kyphosis; 2 cases for pseudarthrosis; 3 cases for long fusion construct crossing lumbosacral junction; 1 case for trauma. Of the 6 patients with rod fracture, 3 (43%) patients underwent revision surgery by replacing the broken rods, adding satellite rod at the opposite side of pre-existing satellite rod and bone graft at the rod-breakage area. The other 3 patients underwent observation and no deterioration was found during follow-up. Conclusion The incidence of rod fracture after correction for severe spinal deformity with satellite rod is 2.6%. The broken rods are mainly located at the single-rod-fixed side with stress concentration or the adjacent segment of the satellite rod. Residual kyphosis, pseudarthrosis, long fusion construct crossing lumbosacral junction and trauma are the significant risk factors of rod fracture. Key words: Scoliosis; Kyphosi; Osteotomy; Internal fixators; Risk factors

Transforaminal Endoscopic Decompression for Lumbar Lateral Recess Stenosis: An Advanced Surgical Technique and Clinical Outcomes

The clinical application of endoscopic techniques for lumbar lateral recess stenosis (LRS) is still challenging. This study aimed to describe a transforaminal endoscopic decompression (TED) technique for LRS and to demonstrate its clinical results. Two-year follow-up data were collected from 45 consecutive patients who underwent TED for LRS. Full-scale endoscopic decompression was performed in the dorsal and ventral aspects of the lateral recess with combined partial pediculectomy using an articulating bone burr and endoscopic instruments. Surgical outcomes were evaluated using the Visual Analog Pain Score (VAS), Oswestry Disability Index (ODI), and modified Macnab criteria. The mean age of the 27 female and 18 male patients was 64.9 years. The mean VAS for leg pain and mean ODI improved from 7.93 and 75.87 at baseline to 1.71 and 17.87, respectively, at 2 years after surgery (P < 0.001 and P < 0.001, respectively). Based on the modified Macnab criteria, excellent or good results were obtained in 86.7% of the patients, and symptomatic improvements were obtained in 97.8%. One patient underwent revision surgery because of incomplete decompression, and 2 experienced transient dysesthesia. TED with the patient under local anesthesia can be effective for the treatment of LRS, especially for the elderly or patients at a high risk for general anesthesia.

Unicondylar knee arthroplasty using cobalt-chromium implants in patients with self-reported cutaneous metal hypersensitivity.

The treatment of patients with allergies to metal in total joint arthroplasty is an ongoing debate. Possibilities include the use of hypoallergenic prostheses, as well as the use of standard cobalt-chromium (CoCr) alloy. This non-designer study was performed to evaluate the clinical outcome and survival rates of unicondylar knee arthroplasty (UKA) using a standard CoCr alloy in patients reporting signs of a hypersensitivity to metal. A consecutive series of patients suitable for UKA were screened for symptoms of metal hypersensitivity by use of a questionnaire. A total of 82 patients out of 1737 patients suitable for medial UKA reporting cutaneous metal hypersensitivity to cobalt, chromium, or nickel were included into this study and prospectively evaluated to determine the functional outcome, possible signs of hypersensitivity, and short-term survivorship at a minimum follow-up of 1.5 years. At a mean follow-up of three years (1.5 to 5.7), no local or systemic symptoms of hypersensitivity to metal were observed. One patient underwent revision surgery to a bicondylar prosthesis due to a tibial periprosthetic fracture resulting in a survival rate of 98.8% (95% confidence interval (CI) 91.7 to 99.8; number at risk, 28) at three years with the endpoint of revision for any reason and a survival rate of 97.6% (95% CI 90.6 to 99.3; number at risk, 29) for the endpoint of all reoperations. Clinical outcome was good to excellent with a mean Oxford Knee Score of 42.5 (sd 2.5; 37 to 48). This study is the first demonstrating clinical results and survival analysis of UKA using a CoCr alloy in patients with a history of metal hypersensitivity. Functional outcome and survivorship are on a high-level equivalent to those reported for UKA in patients without a history of metal hypersensitivity. No serious local or systemic symptoms of metal hypersensitivity could be detected, and no revision surgery was performed due to an adverse reaction to metal ions.

Outcome After Surgical Treatment of Calcaneal Osteomyelitis.

Surgical procedures for calcaneal osteomyelitis are partial calcanectomy (PC), total calcanectomy (TC), and below-knee amputation (BKA). With calcaneal osteomyelitis, limb-saving surgery was described to have secondary BKA rates of 4% to 20%, while secondary amputation rates after BKA are unknown. The aim of this study was to describe and compare overall revision and secondary amputation rates for each surgical option in our institution's cohort and to identify risk factors for secondary amputation. Fifty patients treated between 2002 and 2017 were included. Revisions, secondary amputations, and possible risk factors for secondary amputation and overall revision were statistically analyzed. Minor revisions rates were 57.1% in PCs, 100% in TCs, and 27.8% in BKAs. Secondary amputation was performed in 28.6% of the PCs, in 50% of the TCs, and in 5.6% of the BKAs. No statistically significant differences between overall revision and secondary amputation rates were found. C-reactive protein values greater than 5 mg/L at the index procedure were significantly associated with overall revision while we could not identify risk factors for secondary amputation. This study represents the largest group of patients treated for calcaneal osteomyelitis in the literature. In limb-preserving surgical options, secondary BKA rates are higher than previously known. Primary BKA is a procedure with a low reamputation rate of 5.6%. PC can be considered, with 28.6% needing more proximal amputation. In TC, all patients underwent revision surgery and 50% had to undergo secondary BKA. Therefore, we hesitate to consider total calcanectomy as a surgical option in calcaneal osteomyelitis anymore. Level IV, case series.

Sterile particle-induced inflammation is mediated by macrophages releasing IL-33 through a Bruton’s tyrosine kinase-dependent pathway

Initiation of the innate sterile inflammatory response that can develop in response to microparticle exposure is little understood. Here, we report that a potent type 2 immune response associated with the accumulation of neutrophils, eosinophils and alternatively activated (M2) macrophages was observed in response to sterile microparticles similar in size to wear debris associated with prosthetic implants. Although elevations in interleukin-33 (IL-33) and type 2 cytokines occurred independently of caspase-1 inflammasome signalling, the response was dependent on Bruton's tyrosine kinase (BTK). IL-33 was produced by macrophages and BTK-dependent expression of IL-33 by macrophages was sufficient to initiate the type 2 response. Analysis of inflammation in patient periprosthetic tissue also revealed type 2 responses under aseptic conditions in patients undergoing revision surgery. These findings indicate that microparticle-induced sterile inflammation is initiated by macrophages activated to produce IL-33. They further suggest that both BTK and IL-33 may provide therapeutic targets for wear debris-induced periprosthetic inflammation.

Timing and prevalence of revision and removal surgeries after spinal cord stimulator implantation

We performed a retrospective study to characterize the timing and prevalence of revision and removal surgeries after spinal cord stimulator (SCS) implantation in patients with chronic pain. In our analysis of 100 patients who had SCS implants, we found that 34% of patients underwent revision surgery and 53% of patients had their implant removed. Of the patients who required revision surgeries, the majority (56%) eventually opted for removal of their SCS system. The median time to the first revision surgery was 16 months post implantation and the median time to removal was 39 months post implantation. Our findings demonstrate that most SCS systems are removed within a few years post implantation, highlighting the clinical need for a more complete understanding of SCS technology in order to refine patient selection criteria.

Anatomical Reconstruction of the Acromion Using an Autologous Iliac Crest Graft for Treatment of Recurrent Chondroblastoma

A 38-year-old man presented with recurrent chondroblastoma of the acromion after primary curettage and bone grafting. The patient underwent revision surgery with resection of the acromion and reconstruction using an autologous iliac crest graft. He had regained normal shoulder function without recurrence at a follow-up of 17 months. This case demonstrates a rare location of chondroblastoma and successful anatomical and functional reconstruction. The described surgical procedure could be considered for large tumorous lesions of the acromion, for which curettage would be insufficient, and to preserve and reconstruct a functionally intact shoulder girdle.

Type I thyroplasty: A safe outpatient procedure.

Overnight hospitalization is routinely advocated following type I thyroplasty (TP) because of concerns for airway compromise. Hospitalization increases cost and patient inconvenience, and may not necessarily be appropriate. This study evaluated complications following surgery and identified predictors for same to assess which patients benefit most from hospitalization. Retrospective chart review. A study was conducted on patients who underwent TP with or without arytenoid repositioning procedures between June 2008 and March 2017. The demographic data of the subjects, characteristics, etiology of glottic insufficiency, interventions performed, and subsequent complications were evaluated. Of 147 patients reviewed, 100 underwent TP alone, 41 underwent TP with arytenoid adduction, and six patients underwent TP with adduction arytenopexy. Iatrogenic vocal fold paralysis was the most common indication. Major complications, which included transient airway compromise and hematoma requiring reoperation, occurred in 7% of patients. Revision surgery and thyroplasty combined with arytenoid repositioning maneuvers were associated with increased risk of major complications. In general, TP is a safe procedure, with a major complication rate that is lower than that of outpatient thyroidectomy. Overnight hospitalization should be considered in patients undergoing revision surgery and in those requiring concurrent arytenoid repositioning procedures. 4 Laryngoscope, 129:1640-1646, 2019.