Patients Underwent Revision Surgery Research Articles

BS SO03 - Revisional bariatric surgery following sleeve gastrectomy, a meta-analysis comparing RYGB and OAGB

Abstract Background The number of bariatric operations is on the rise each year. Sleeve gastrectomy is the most popular procedure however often requires a revision surgery because of insufficient weight loss, weight regain or GERD. The most popular procedures are RYGB and OAGB. Our primary outcome was to look at the effect on weight loss in patients undergoing revision surgery and the secondary outcomes were gastro-oesophageal reflux, BMI difference, operative time, bleeding and anastomotic leak Method A systematic electronic search was undertaken using PubMed, MEDLINE®, Ovid®, Cochrane Library and Google Scholar™ according to PRISMA. Initial search identified 2,546 articles, after screening seven papers met the inclusions criteria, six retrospective studies and one RCT. Results There were a total of 802 patients that fit the inclusion criteria. 390 patients had a OAGB and another 412 had a RYBG. All patients previously had sleeve gastrectomy for weight loss. The length of follow-up was 12 months for our primary outcome. We found no statistically significant difference in %EWL between OAGB and RYGB (p=0.11). The incidence of post-operative reflux was statistically significantly higher in the OAGB group (16% vs 10.1%, p<0.003). Operative time was statistically significantly lower in the OAGB group (p=0.04). Conclusion Our meta-analysis showed no statistically significant difference between the two revision bariatric surgery procedure for %EWL. RYGB was superior to OAGB in reducing the incidence of symptomatic GERD while OAGB had a significant shorter operative time.

Combined Use of External Iliac Lymph Node Count and Bone Scintigraphy for PJI Diagnosis: A Prospective Study

Background: The reactive enlargement of external iliac lymph nodes and increased blood flow in the infected region are commonly observed in lower limb infections. We aimed to differentiate between aseptic loosening and periprosthetic joint infection (PJI) after joint replacement surgery by quantifying the number of enlarged external iliac lymph nodes and using bone scintigraphy to monitor blood flow. Methods: We recruited 124 patients undergoing revision surgery for aseptic loosening or PJI. All the patients underwent preoperative dual-energy computed tomography (DECT) imaging for external iliac lymph nodes and bone scintigraphy. The diagnostic value was evaluated using ROC curve analysis. Results: The number of enlarged external iliac lymph nodes was significantly higher in the PJI group than in the aseptic failure group (4.0 versus. 1.0, p value < 0.001). The median affected/unaffected side ratio in the blood pool phase of ECT in the PJI group was 1.49, significantly higher than the aseptic failure group’s median ratio of 1.04 (p value < 0.001). The AUC for diagnosing PJI using the number of enlarged lymph nodes alone was 0.91, and when using the bone scintigraphy blood pool phase alone, the AUC was 0.89. When both metrics were combined, the AUC increased to 0.95, which was higher than the AUCs for the ESR (AUC = 0.83), CRP (AUC = 0.76), and synovial fluid PMN% (AUC = 0.62). Conclusions: Combining the enlargement of the lymph node count with the bone scintigraphy blood pool phase is a promising approach for diagnosing PJI.

Predictive value of a positive pocket swab for the occurrence of device infection in implantable cardioverter defibrillator patients undergoing generator replacement or lead revision

Abstract Introduction Bacterial colonization of generator pockets in implantable cardioverter defibrillator (ICD) patients plays a key role in the development of device infection after revision surgery. Pocket swabs taken at revision may be useful for predicting device infection, but their prognostic value is not precisely known. Aim of the study was to evaluate the predictive value of positive pocket swabs for cardiac device infection in ICD patients undergoing revision surgery. Methods A total of 646 consecutive ICD patients from a prospective single-centre ICD-registry who underwent elective device replacement, system upgrade or lead revision between 2014 and 6/2023 were analyzed. Independent predictors for device infection were evaluated by a Cox regression analysis adjusting for age, gender, EF, insulin dependent diabetes, anticoagulation, multiple leads, revision surgery and the PADIT score. Results Positive pocket swabs were obtained in 12% of patients. The baseline characteristics of ICD patients with positive versus negative pocket swabs were similar (Table 1). With an average follow-up of 3 years, the infection rate in patients with positive pocket swabs was around 5 times higher than in patients with negative swabs (19% versus 4%, p < 0.001). In a Cox regression analysis, a positive pocket swab was the strongest independent predictor for device infection during follow-up (hazard ratio 4.26, 95% confidence interval 2.15 – 8.45, Table 2). Conclusion A positive swab from ICD-pockets in patients undergoing generator replacement or lead revision is an independent predictor of device infection during follow-up. These results support the routine collection of pocket swabs from patients undergoing revision surgery.Table 1Table 2

Microbial specturm and antibiotic sensitivity of pocket swabs in ICD patients undergoing device replacement or lead revision surgery- findings from a ICD registry observational study

Abstract Introduction Infection is a serious complication of implantable cardioverter defibrillator (ICD) therapy, necessitating effective preventive measures during implantation or revision surgery. The intraoperative use of antibacterial envelopes containing rifampicin and minocycline has shown promising results in reducing infection, yet, it is expensive and not cost-effective. Gentamicin sponges might be an alternative to the antibacterial envelope, however its efficacy on targeting the specific microbial spectrum found in device infection must be further investigated. Aim of the study was to identify the bacterial species obtained from pocket swabs of ICD patients undergoing revision surgery, and assess their sensitivity to gentamicin, rifampicin and minocycline. Methods A total of 459 intraoperative pocket swabs were collected from consecutive ICD patients who underwent elective device replacement, system upgrade or lead revision between 2017 and 6/2023. The baseline characteristics were similar in both groups (Table 1). Results Out of the 459 swabs analysed: 416 (90.6%) were negative for microbial growth. The remaining 43 swabs (9.4%) were tested positive for microbial growth (Table 2). Coagulase-negative- staphylococci (CoNS) were the most commonly isolated bacteria, accounting for 56% of cases. Bacteria with available antibiograms exhibited a sensitivity of 92% to gentamicin, 96% to rifampicin and 96% to Minocycline (Table 2). Conclusion The antibiotic sensitivity of the bacteria obtained from the pocket swabs to gentamycin, rifampicin and minocycline was similar. Thus, gentamicin sponges might be an alternative to the antibacterial envelope in patients with ICD undergoing generator replacement or revision surgery.

Classification of Emerging Scoliosis in Congenital Scoliosis After Hemivertebra Resection and Short Segmental Fusion.

Emerging scoliosis (ES) is a rare phenomenon after hemivertebra (HV) resection and short segmental fusion. Since the introduction of the ES, there have been rare in-depth studies. The aim of the present study was to further analyze the characteristics, risk factors, treatment, and prognosis of ES. A retrospective study analyzed patients with congenital scoliosis due to a single HV who underwent posterior correction and short fusion from 2002 to 2022. ES was defined as a Cobb angle ≥20° from its initial value and an apical vertebra located ≥2 levels away from the fusion region. ES patients and non-ES patients were matched at a 1:2 ratio. Both demographics and radiological parameters were compared. Univariate analysis and multivariate logistic analysis were used to identify the risk factors of ES. Among 261 patients, 13 patients (5.0%) experienced ES. There were eight females and five males. The mean age of the ES patients at the time of primary surgery was 6.6 ± 3.7 years old (2.0-13.2 years old), with a mean follow-up of 64.2 ± 47.9 months (12-156 months). The ES could be further divided into three types: balance-related ES, complication-related ES, and separated ES. There were three balance-related ESs, six complication-related ESs, and four separated ESs. At the last follow-up, six patients were under observation, six patients underwent brace treatment, and one patient underwent revision surgery. Multivariate logistic analysis showed that the magnitude of postoperative compensatory curve (CC) was an independent risk factor for ES (OR = 1.172, p = 0.014). ES is an extraordinary phenomenon after HV resection and short fusion, and it can be divided into three types. The magnitude of postoperative CC was an independent risk factor for ES. According to the severity of ES, observation, brace, or surgery can be chosen.

Matched comparison of non-fusion surgeries for adolescent idiopathic scoliosis: posterior dynamic distraction device and vertebral body tethering.

Two non-fusion devices for adolescent idiopathic scoliosis (AIS) received HDE approval for clinical use in 2019: posterior dynamic distraction device (PDDD) and vertebral body tethering system (VBT). Although indications are similar, there is no comparative study of these devices. We hypothesize that curve correction will be comparable, but PDDD will have better perioperative metrics. AIS PDDD patients were prospectively enrolled in this matched multicenter study. Inclusion criteria were Lenke 1 or 5 curves, preoperative curves 35°-60°, correction to ≤30° on bending radiographs, and kyphosis <55°. Patients were matched by age, sex, Risser, curve type and curvemagnitude to a single-center cohort of VBT patients. Results were compared at 2years. 20 PDDD patients were matched to 20 VBT patients. Blood loss was higher in the VBT cohort (88 vs. 36ml, p < 0.001). Operative time and postoperative length of stay were longer in the VBT cohort, 177 vs. 115min (p < 0.001) (2.9 vs. 1.2days, p < 0.001). Postoperative curve measurement and correction at 6months were better in the PDDD cohort (15° vs. 24°, p < 0.001; 68% vs. 50%, p < 0.001). At 1-year, PDDD patients had improved Cobb angles (14° vs. 21°, p = 0.001). At 2years, a correction was improved in the PDDD cohort, with a curve measurement of 17° for PDDD and 22° for VBT (p = 0.043). At the latest follow-up, 3 PDDD patientsand 1 VBT patient underwent revision surgery. Early results showPDDD demonstrates better index correction, reduced operative time, less blood loss, and shorter length of stay but higher rates of revision compared to a matched cohort of VBT patients at two-year follow-up. Level II, prospective cohort matched comparative study.

Arthroscopic Chondral Nail Fixation for Treating Acetabular Cartilage Delamination Results in Improved Pain Relief at Minimum 2-year Follow-up in Patients with Femoroacetabular Impingement Syndrome: A Propensity-Matched Study

PurposeTo investigate the clinical outcomes following arthroscopic chondral nail fixation for acetabular cartilage delamination (ACD) in patients with femoroacetabular impingement syndrome (FAIS), and the presentation of ACD on MRI at follow-up. MethodsA retrospective review was performed between March 2021 and March 2022 at our institute. Patients undergoing primary hip arthroscopy for FAIS and diagnosed with ACD intraoperatively were included. Exclusion criteria were incomplete data or loss of minimum 2-year follow-up, and concomitant hip conditions including hip osteoarthritis with a Tönnis grade > 1, avascular necrosis, Legg-Calvé-Perthes disease, osteoid osteoma, synovial chondromatosis, pigmented villonodular synovitis, and developmental dysplasia of the hip (DDH). Patients who underwent chondral nail fixation were matched 1:1 with a control cohort of patients who only underwent simple debridement. Preoperative and minimum 2-year postoperative patient-reported outcome (PRO) scores including Visual Analog pain Scale (VAS), modified Harris Hip Score (mHHS), and percentage of achieving minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were collected and compared. MRI was performed preoperatively and at final follow-up to assess ACD. ResultsFifty-eight patients were included in the study (29 patients in each group). Both groups demonstrated improved VAS and mHHS following surgery (all with P < .05). The chondral nail group demonstrated better postoperative VAS (P = .022) compared to the control group, while the postoperative mHHS was comparable between the two groups (P = .852). No significant difference was found in the achievement of MCID between the two groups (all with P > .05). More patients in the chondral nail group achieved PASS of VAS compared to the control group (75.9% vs 48.3%, P = .030). No patient underwent revision surgery or conversion to total hip arthroplasty (THA). The chondral nail group demonstrated significantly higher rate of ACD healing on MRI compared to the control group (P < .001). ConclusionPatients undergoing arthroscopic chondral nail fixation for treating ACD demonstrated significant pain relief, more achievement of PASS of VAS, and higher rate of ACD healing on MRI compared to those undergoing simple debridement. Level of EvidenceLevel III; retrospective cohort study.

Outcomes of tracheal resection and anastomosis in patients with tracheal stenosis: a clinical perspective

BackgroundTracheal stenosis results from an altered inflammatory response to mucosal damage, which leads to impairment of breathing and can even be fatal if not treated promptly (Ind J Otolaryngol Head Neck Surg 73(4):447–454, 2020). ENT and head and neck surgeons face difficulties while treating tracheal stenosis. Mechanical stress from extended endotracheal intubation or tracheostomy, combined with hypoxic metabolic disturbances during an underlying event, is the most frequent cause of tracheal stenosis (Al-Azhar Int Med J 3(10):149-57, 2022). The main objective of the study is to assess the outcomes of tracheal resection and anastomosis in patients who presented with tracheal stenosis. This emphasizes the need for proper case selection and timely surgical intervention to relieve the airway obstruction and to ensure the effectiveness of tracheal resection and anastomosis as the less morbid approach by avoiding a midline sternotomy.The study was conducted in a tertiary care center on 25 patients who were admitted in ENT ward from the year 2011 to year 2021. Case records of those patients who underwent tracheal resection and anastomosis were analyzed on a retrospective basis. Detailed history taking and clinical examination with appropriate investigations like flexible bronchoscopy, computed tomography with 3-dimensional reconstruction, video laryngoscopy, direct laryngoscopy, and lung function tests were carried out for all the patients in the study as required. An evaluation of GERD was also done. Appropriate surgical procedure was done with regular post-operative follow-up for 18 months.ResultsIn our study, 92% of patients had satisfactory outcomes following tracheal resection and anastomosis, while some patients experienced minor complications. In 8% of patients, the primary surgery failed, among whom one patient underwent revision surgery and is doing well. The other patient with post-traumatic stenosis with a long stenotic segment underwent Shiann Yann Lee procedure in an outside center which resulted in failure following which T tube insertion was done. The patient showed improvement and was decannulated after a month.In our study of 25 patients with tracheal stenosis, postoperative complications occurred and were managed accordingly. However, there was no significant correlation between these complications and patient age, sex, extent of stenosis, preoperative Cotton-Myer grading, or the type of surgical procedure performed. This lack of correlation may be attributed to the limited sample size.ConclusionTracheal resection and anastomosis are challenging procedures and should be done only in centers with experience. Standard treatment consists of resection of the stenotic segment with end-to-end anastomosis. The geometry of the ends to be anastomosed is matched properly to avoid gaps or weak points and for air-tight seal anastomosis.

A high-flexion design total knee prosthesis: a ten to twelve-year follow-up study

BackgroundThe purpose of this study was to investigate the clinical and radiographic outcomes and to determine the survivorship of a high-flexion design total knee arthroplasty (TKA) prosthesis, the LOSPA knee system, over a follow-up period of 10–12 years.MethodsThe study included 386 patients (503 TKAs) who were treated with TKA from 2011 to 2013 (follow-up period 10–12 years).The patients were assessed clinically using range of motion (ROM) of the knee, the Knee Society scoring system (KSS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). For radiographic analysis, the positions of femoral and tibial implants as α, β, γ, and δ angles, hip knee ankle (HKA) angle, and radiolucent lines were used. Kaplan–Meier survival analysis was performed.ResultsMean ROM improved significantly from the preoperative baseline of 117.3° to 126.5° at the final follow-up (p < 0.001). The mean KSS and WOMAC scores also both showed significant improvement after surgery (all p < 0.001). A non-progressive radiolucent line less than 2 mm was observed in 23 cases (4.7%). Nine patients underwent revision surgery on the knee during the follow-up period. Revision surgery was performed on four patients due to aseptic loosening, three patients due to infection, one patient due to ankylosis, and one patient due to instability. When the endpoint of survival was the entire surgical cases, the survival rate was 96.2%. The survival rate, with revision for any reason as the endpoint, was 97.2%, and 97.8% for aseptic causes.ConclusionsThe LOSPA knee system, a high-flexion design total knee prosthesis, showed excellent long-term survivorship and improvements in clinical outcomes at 10- to 12-year follow-up.

Intrathecal placement of percutaneous spinal cord stimulation leads: illustrative cases.

Spinal cord stimulation (SCS), including the percutaneous placement of epidural stimulation leads, has been increasingly utilized to treat chronic pain. Although lead migration is a well-characterized complication, few studies have reported on malpositioned leads in the intrathecal space. Here, the authors discuss two cases of intrathecal lead placement necessitating surgical revision. This report is a two-case series on the inadvertent placement of percutaneous SCS leads in the intrathecal space. The authors describe the identification of malpositioned leads, describe the clinical presentation, characterize stimulation parameters, and report improvement following neurosurgical revision for each case. Two patients originally presenting with chronic low-back pain underwent percutaneous SCS lead implantation. Both patients presented with atypical pain symptoms in the acute to subacute postprocedural period, raising suspicion for malpositioned leads. Imaging was consistent with intrathecal malpositioning. Both patients underwent revision surgery resulting in symptomatic improvement. Indicators of malpositioned thoracic SCS leads in the intrathecal space include thoracoabdominal or flank pain exacerbated by movement, insufficient pain relief versus that in the SCS trial, very low electrode impedances, direct visualization on imaging, and lack of epidural lead visualization following laminectomy. Revision options include removal of the intrathecal leads and the surgical placement of a paddle electrode in the epidural space. https://thejns.org/doi/10.3171/CASE24275.

Laparoscopic revisional antireflux and hiatal hernia surgery results in a higher rate of complications and severity at 90 days than primary surgery

ObjectiveData on graded complications and their frequency after laparoscopic revisional antireflux and hiatal hernia surgery compared with primary surgery are lacking. We describe 30- and 90-day morbidity using the Clavien-Dindo classification. MethodsA total of 298 patients underwent revision surgery between 2003 and 2020 and were propensity matched to primary surgeries (1:2 ratio) based on age, sex, body mass index, American Society of Anesthesiology classification, Los Angeles grade esophagitis, presence of Barrett's, and indication for surgery. Complications were graded using the Clavien-Dindo classification, with the highest grade of complication reported per patient. ResultsAfter matching, both groups had a majority of female patients, with a median age of 60 years and a median body mass index of 29.5 kg/m2. Most were healthy, with nonerosive esophagitis and modest levels of Barrett's esophagus. A laparoscopic Nissen fundoplication was most common; however, a partial fundoplication was more common in revisions. Mesh, relaxing incisions, and Collis were more common in revisional surgery. At 30 days, total complications were similar (23.5% [70/298] vs 20.6% [123/596], P = .373) with 1 death in each group. Minor complications (less than Clavien-Dindo 3A) were comparable. Patients undergoing revisional surgery experienced Clavien-Dindo 3B complications (4.7% [14] vs 0.8% [5], P > .001) more frequently, with esophageal obstruction requiring revision and esophageal/gastric leak being most common. Grade Clavien-Dindo 4 A/B complications were comparable in both groups. At 90 days, patients undergoing revisional surgery experienced overall complications (7.1% [21] vs 2.0% [12], P = .003), and Clavien-Dindo 3B complications (1.0% [3] vs 0, P = .037) more frequently, with intra-abdominal abscess washout being the most common Clavien-Dindo 3B complication. ConclusionsRevisional surgery results in similar total complications at 30 days, but additional complications can occur out to 90 days.

Infrahyoid myocutaneous flap for reconstruction in head and neck cancer patients

Background: Reconstruction of head and neck defects following tumor excision is one of the most challenging surgeries due to multiple reasons, such as associated cosmetic and functional impairments. The three-dimensional aspect of the defect makes it more difficult. Although in modern settings, microvascular surgery is preferred in many conditions, it requires the presence of resources and expertise. Locoregional flaps are workhorse flaps in head and neck reconstruction. In this article, we present an uncommonly used flap with high acceptability and success rate in head and neck reconstruction. Aim: To find outcomes of using infrahyoid flap reconstruction in head and neck defects following cancer excision. Materials and Methods: The retrospective study was conducted in the surgical oncology department of our institute. Patients with squamous cell carcinoma of the oral cavity, clinically T1–T3 and N0–N1 stage, with anticipated defects of small to medium defects were included in the study. The study was conducted from July 2020 to June 2022, including a follow-up of 1 year. A total of 14 patients were included in the study. All patients had squamous cell carcinoma of the oral cavity involving different subsites. Patients were operated on by a single surgeon, using the same technique. Result: A total of 14 patients were included with a male-to-female ratio of 11:3 and age between 45 and 60 years. None of the patients underwent revision surgery, and none of the patients had total flap loss. Four patients had minor flap complications, of which three patients had partial, superficial skin necrosis of the flap which was managed conservatively and epithelized later. None of the patients developed major complications, oro-cutaneous fistula, or radiation necrosis. None of the patients developed recurrence after 1 year of surgery. Conclusion: The infrahyoid myocutaneous flap (IHF) is a fairly reliable and easy-to-perform flap for small- and medium-sized defects of the oral cavity, without requiring additional incisions and donor site reconstruction.

Graft choice to decrease the revision rate of anterior cruciate ligament reconstruction: a nationwide retrospective cohort study

There are many graft choices for anterior cruciate ligament (ACL) reconstruction, including autografts and allografts. The choice of graft has been identified as a significant factor affecting the outcome of ACL reconstruction. This study aimed to determine whether allograft or autograft is better for avoiding revisional ACL reconstruction. The National Health Insurance Service-Health screening database analyzed 146,122 patients who underwent ACL reconstruction surgery from Jan. 1, 2002, to Dec. 31, 2021. The study was conducted in two groups, autograft or allograft, and the rates of revision ACL reconstruction between the two groups were compared. Propensity score matching and multivariable Cox Proportional Hazard model analysis were used. The significant predictors for complications (p < 0.05) were as follows. The total of patients with ACL reconstruction was 146,122. Allograft was used in 121,148 patients, and autograft was used in 24,974 patients. 9.2% of the allograft group and 8.7% of the autograft group underwent revision ACL reconstruction. (P < .0001) 70.0% & 63.6% of patients underwent revision surgery within 1 year in the allograft & autograft groups, respectively. In summary, using autograft in primary ACL reconstruction is helpful in lowering the rate of revision surgery.

Easy and safe: A new surgical fixation -technique for acute and chronic anterior instabilities of the sternoclavicular joint: technique and results

Instabilities of the SC joint are a rare injury, accounting for only 3% of all injuries of the shoulder-girdle. While acute posterior dislocations are an emergency and require immediate surgical intervention, anterior instabilities (first and second degree according to Allman) can mostly be treated conservatively. Chronic and highly instable acute anterior instabilities often imposes a significant limitation on the lives of affected patients. Currently, there is no established therapeutic algorithm in place. This retrospective case series with prospective collection of data was performed at a level-I trauma centre. Patients treated surgically for anterior SC joint instabilities between January 2013 and December 2019 and with a minimum follow-up of 24 months were included. The injuries comprised of six acute anterior dislocations treated with tape-cerclage in a "figure-of-8" configuration; twelve patients with chronic anterior SC instabilities were treated with autologous tendon grafts. For one highly unstable chronic anterior instability in addition to the tendon graft synthetic suture material was applied. The clinical evaluation consisted of a physical examination and a standardized questionnaire, which included subjective and objective shoulder scores. Out of 24, 19 patients (79%) with an average age of 32 years ± 15 were available for follow-up. 63% of the patients were male. After a mean follow-up of 57 months, the mean age- and sex-adapted Constant-Murley Shoulder Score (CS) of acute anterior luxations amounted to 90 points ± 20, Nottingham Clavicle Score (NCS) to 81 points ± 22 and DASH Score to 11 points ± 18. Chronic anterior instabilities had a mean CS of 90 points ± 12, NCS of 83 points ± 17 and DASH Score of 4 points ± 5. The study shows a complication rate of 10%. Two patients underwent revision surgery. To conlude, monocortical SCJ fixation in a "figure-of-8" fashion presents a low risk for complication and a low revision rate and can achieve equally good functional outcome after the treatment of highly unstable acute and chronic anterior SCJ instabilities than other published techniques. Our approach presents less risk to the neurovascular structures of the mediastinum than other published techniques requiring bicortical drilling, therefore making the technique more accessible to hospitals without a cardiothoracic surgical background.

Use of Hinged Implants for Multistage Revision Knee Arthroplasty for Severe Periprosthetic Joint Infection: Remission Rate and Outcomes After a Minimum Follow-Up of 5 Years

BackgroundIn severe periprosthetic joint infection after total knee arthroplasty (TKA), multistage procedures are indicated for ongoing signs of infection after implant removal during the spacer interval of an intended 2-stage exchange. In these cases, several additional debridement and spacer exchange surgeries may be necessary. Herein, we analyzed the complications, remission rates, and functional outcomes after multistage revision arthroplasty using hinged TKAs. MethodsPatients (n = 79) treated with multistage revision arthroplasty after chronic periprosthetic joint infection of the knee were included (2010 to 2018). During the prosthesis-free interval, a static spacer containing antibiotic-loaded bone cement was implanted. The mean number of surgeries, including implant removal and revision arthroplasty, was 3.8 (range, 3 to 8). The mean duration from implant removal to revision arthroplasty was 83 days (range, 49 to 318). Complications, remission, and mortality were analyzed after a minimum follow-up of 5 years. Outcomes were assessed based on the Knee Society Score (KSS) and the Western Ontario McMasters University Osteoarthritis Index. ResultsDuring follow-up, 24 (30.4%) patients underwent revision surgery, with a mean time to surgical revision of 99 weeks (range, 1 to 261). After follow-up, the infection-free remission rate and overall mortality were 87.3 and 11.4%, respectively. The mean KSS was 74.3 (range, 24 to 99), the KSS Function Score was 60.8 (range, 5 to 100), and the Western Ontario McMasters University Osteoarthritis Index 30.2 (range, 5 to 83). ConclusionsIn difficult-to-treat cases, multistage revision arthroplasty showed high remission rates and low mortality after a follow-up of 5 years. The overall revision rate was comparably high, accounting for early and late reinfections most of the time. In cases of implant survival, functional outcomes comparable to those of revision hinge TKA reported in the literature can be achieved. Therefore, multistage procedures with additional debridement steps should be performed in cases of ongoing infections in intended 2-stage procedures.

Poster 283: Revision Patellofemoral Surgery: A Retrospective Cohort Analysis

Objectives: To report demographic and radiologic data, and clinical outcomes of patients undergoing revision surgery for patellar instability Methods: This is a retrospective cohort study. We included patients undergoing revision surgery for patellar instability between January 2010 and January 2022 in our institution. Exclusion criteria included patients with missing information regarding their primary surgery, patients with congenital disorders and patients with a history of distal femoral or proximal tibial osteotomy. Statistical analysis was performed using SPSS v. 20. Results: Ninety-six patients underwent revision surgery for patellofemoral instability. Eight patients were excluded based on exclusion criteria (Figure 1). Of the 88 patients included in final analysis, 44 (50%) had their primary surgery in our institution and revision rate in our institution was 3.8%. Primary surgeries included lateral retinacular release (LRR):18, medial patellofemoral ligament (MPFL) reefing: 19, MPFL reconstruction (MPFLR): 33, Tibial tubercle osteotomy (TTO): 24 (Table 1). Revision surgeries included: Lateral patellofemoral ligament reconstruction for iatrogenic medial instability: 6, MPFL release for persistent pain: 3, MPFLR: 36, MPFLR with Patellar tendon shortening: 5, MPFLR with Trochleoplasty: 4, Revision of femoral screw: 1, TTO: 19, TTO+MPFLR: 10, TTO+Trochleoplasty: 1, TTO+MPFLR+Trochleoplasty: 3 (Table 2). Patients having LRR as primary surgery had more female patients and higher patellar tilt, MPFLR patients had higher incidence of trochlear dysplasia, MPFL reefing patients were younger (Table 1). In our cohort of patients undergoing revision surgery for patellar instability, the mean tibial tubercle-trochlear groove (TT-TG) distance was 17.2 mm and the mean Caton-Deschamps Index (CDI) was 1.42. The incidences of trochlear dysplasia and skeletally immature patients were 61% and 68.2%, respectively (Table 1). The Median follow up period after revision surgery was 81 months. The overall complication rate after revision surgery was 12.5% (11/88) and occurred at a median of 31.5 months. Ten patients had recurrent patellar instability and one patient had tibial tubercle fracture (Table 3). Conclusions: The overall incidence of revision surgery was 3.8 after a primary surgery for patellar instability at a median of 31.5 months. Complications occur in 12.5% of patients after the revision surgery with the majority (10/11) being recurrent patellar instability. In our cohort, CDI and the incidences of trochlear dysplasia and skeletally immature patients were increased while the mean TT-TG distance was not.

Aggressive granulomatous pseudotumor following total hip prosthesis: Diagnostic and therapeutic strategies from a single institution experience

IntroductionGranuloma formation following total hip arthroplasty (THA) can occur regardless of the bearing surface. In very rare cases, extensive granulomas mimicking tumors may develop which are known as pseudotumors. The aim of this study is to report on these rare yet complex situations to stimulate reflection in diagnostic and therapeutic approaches. MethodsA retrospective case series study of 5 patients (2 females, 3 males) of aggressive granulomatous lesions on primary prostheses and 4 revision prostheses for aseptic loosening, implanted at a mean age of 74.8 years (range 64–83). A clinical, functional, radiographic, and anatomopathological analysis were conducted. ResultsFour patients underwent revision surgery, while one died before intervention. Functional impairment was significant with a mean pre-reintervention Postel-Merle d'Aubigné (PMA) score of 8.2 (range 4–11). Femoral involvement was constant, associated with acetabular involvement in only one case. bony involvement was major, with a minimum of 5 Gruen zones affected, showing complete cortical lysis. Histopathological analysis consistently revealed multinucleated giant cells and macrophages, predominantly with metallic wear particles. In 2 cases, vascular involvement was suspected without a clearly delineated tumor. Two cases required femoral resection prostheses, one necessitated inter-ilio-abdominal amputation due to extensive soft tissue involvement, one underwent implant removal which failed to prevent progression, and one patient died before reoperation. ConclusionThe volume of lesions in these 5 cases appears markedly larger than reported cases.Extensive pseudo-tumoral granulomatous lesions following THA are rare but carry poor functional prognosis. Evaluation to rule out infection and neoplastic pathology is imperative. Surgical management often resembling tumor treatment should be considered. Early diagnosis is crucial to allow intervention before reaching the stage of massive prosthetic replacement. Level of evidenceIV retrospective study.

Multiple surgical revisions in patients with anastomotic leakage: A retrospective cohort analysis

BackgroundThe occurrence of an anastomotic leakage is a serious and potentially life-threatening complication in visceral surgery, affecting up to 20% of patients with a newly created gastrointestinal anastomosis. Most patients with anastomotic leakage require revision surgery, but little is known about factors affecting the mortality and morbidity of these patients leading eventually to multiple revision surgeries. Based on the results of a previous pilot study, we hypothesized that one influencing factor might be the perioperative blood transfusion. Study designWe performed a monocentric, retrospective cohort analysis of all patients with a verified anastomotic leakage being treated at the Department for General and Visceral Surgery of the University Medical Center Freiburg between 2007 and 2017. ResultsOverall, 160 patients were eligible for inclusion (58% male, on average 64.0 ± 14.3 years of age). Diagnosis was benign in 83 patients, and 105 patients had an open surgical approach. Ninety-four patients had an anastomosis of the lower gastrointestinal tract. Most of the patients (n = 128) developed further postoperative complications. Thirty-five patients died during their hospital stay, mostly due to abdominal sepsis. One hundred and twenty-seven patients underwent revision surgery, 57 patients even more than once. Forty-five patients received pre- or intraoperative blood products. Multiple logistic regression revealed that the frequency of surgical revisions was affected by emergency surgery and by the application of intraoperative packed red blood cells during the initial operation. Patients’ mortality was associated with blood transfusion and patients’ pre-existing illnesses. ConclusionThe results of our retrospective cohort analysis underline the need for a responsible approach to blood transfusions. Blood transfusions appear to lead not only to increased morbidity and mortality, but also to a higher number of revision surgeries.

The relationship between pseudotumours and infected complications in patients who have undergone metal-on-metal total hip arthroplasty.

This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years' clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery. The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively. Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low.

Effects of socioeconomic burden on opioid use following total shoulder arthroplasty

Preoperative opioid users experience worse outcomes and higher complication rates compared to opioid-naïve patients following shoulder arthroplasty. This study evaluates the effects of socioeconomic status, as measured by the Distressed Communities Index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery. A retrospective review of patients who underwent primary shoulder arthroplasty (Current Procedural Terminology code 23472) from 2014 to 2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index, DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents was gathered. Individuals from distressed communities used more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations, respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared with prosperous, comfortable, and mid-tier, respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs. 21.3%, P<.001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs. 21.7%, P=.002). Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.