Patients Underwent Revision Surgery Research Articles

Radiographic Correction of Bunionette Deformity using Minimally Invasive Fifth Metarsal and Akinette Osteotomy

Category: Midfoot/Forefoot; Lesser Toes; Other Introduction/Purpose: Bunionette Deformity is defined as a painful lateral prominence of the fifth metatarsal head. Conservative treatment entails footwear and activity modification. Symptoms can be exacerbated in the athletic population and activities with specific footwear such as cycling, winter sports and water sports. In refractory cases, patients may pursue operative intervention. Historically, open surgical correction carried risks of wound complications, prolonged recovery time, and nonunion risk. Minimally invasive techniques have gained popularity due to the decreased risk of wound complications, preservation of blood supply and healing potential, and faster operative and recovery times. The purpose of the current study is to examine radiographic and clinical outcomes of minimally invasive bunionette correction with a sliding distal 5th metatarsal osteotomy and lateral closing wedge proximal phalanx (Akinette) osteotomy. Methods: A retrospective review examined 36 feet in 28 patients who underwent minimally invasive bunionette correction from 01/2021 to 12/2021. The study patients were treated at a single center by 3 participating providers trained in minimally invasive techniques. All patients underwent a distal 5th metatarsal osteotomy and Akinette osteotomy of the proximal phalanx. Length of follow up ranged from 3 to 12 months. Radigraphic measurements including 4,5 intermetatarsal angle (IMA), 5th metatarsophalangeal angle, and osteotomy displacement (mm) were compared pre and postoperatively. Patients were asked to complete postoperative satisfaction survey and lesser toe American Orthopaedic Foot & Ankle Society (AOFAS) score. Results: Preliminary analysis shows a radiographic 4,5 IMA correction of 4.9 degrees to 3.4 degrees. Fifth metatarsophalangeal angle was corrected from 20.3 degrees preoperatively to 5.3 degrees postoperatively. Average medial displacement of the metatarsal osteotomy was 2.64 mm. There was one nonunion of the 5th metatarsal in a revision case that had previously been treated at an outside facility with open techniques, which was treated with bone grafting. Two other patients underwent revision surgery for complications from concomitant procedures that were performed (1 lapidus nonunion and 1 lapidus wound dehiscence). There were no wound or neurovascular complications involving the 5th ray. Conclusion: Our data shows that minimally invasive bunionette correction with sliding 5th metatarsal and Akinette osteotomy leads to reliable radiographic correction and clinical improvement. This operation has favorable safety profile with low incidence of complications and a high union rate.

Factors Associated with Revision Surgery in Long Bones Metastases

Background. Bones as an organ are one of the most common targets for tumor metastasis. Currently, the number of patients undergoing surgical treatment for metastatic bone lesions is steadily increasing. In most patients, after surgical treatment, the manifestation of clinical symptoms decreases, primarily pain syndrome, which improves their quality of life. However, it should be noted that the number of patients with bone metastases who underwent revision surgery is also increasing. This article retrospectively analyzes the factors leading to revision after surgical treatment of metastases in long bones.
 The aim of this study was to identify factors leading to revision after surgical treatment of patients with metastases in long bones.
 Methods. A retrospective medical records analysis of 247 patients who underwent surgical treatment for metastases in long bones on the basis of the P.A. Herzen Moscow Research Institute of Oncology in 20062020 was performed. Of these, 33 patients underwent revision surgery. The median age was 62 years. The localization of the primary tumor was as follows: breast cancer 10 cases, kidney cancer 13, lung cancer 3, prostate cancer 2, rectal cancer 3, liver cancer and Ewings sarcoma with bone metastases 1 case each.
 Results. The following factors led to revision surgery: mistakes in preoperative diagnosis (3 patients); postoperative infectious complication (6 patients); dislocation of the endoprosthesis (4 patients); continued growth of solitary metastasis after osteosynthesis (5 cases); aseptic instability after intramedullary osteosynthesis (14 patients); traumatic fracture of the endoprosthesis stem (1 patient).
 Conclusions. Revision after surgical treatment of metastases in long bones, in addition to postoperative complications, lead to mistakes in diagnosis and incorrect choice of surgical treatment method. To reduce the risk of revision surgical interventions, a multidisciplinary approach is needed with the development of surgical treatment tactics in consultation and the use of specialized scales of oncological prognosis.

The Benefit of Addressing Malalignment in Revision Surgery for Proximal Junctional Kyphosis Following ASD Surgery.

Retrospective cohort study. Understand the benefit of addressing malalignment in revision surgery for proximal junctional kyphosis (PJK). PJK is a common cause of revision surgery for adult spinal deformity patients. During a revision, surgeons may elect to perform a proximal extension of the fusion, or also correct the source of the lumbopelvic mismatch. Recurrent PJK following revision surgery was the primary outcome. Revision surgical strategy was the primary predictor (proximal extension of fusion alone compared with combined sagittal correction and proximal extension). Multivariable logistic regression determined rates of recurrent PJK between the two surgical groups with lumbopelvic surgical correction assessed through improving ideal alignment in one or more alignment criteria [Global Alignment and Proportionality (GAP), Roussouly-type, and Sagittal Age-Adjusted Score (SAAS)]. A total of 151 patients underwent revision surgery for PJK. PJK occurred at a rate of 43.0%, and PJF at 12.6%. Patients proportioned in GAP postrevision had lower rates of recurrent PJK [23% vs. 42%; odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8, P =0.024]. Following adjusted analysis, patients who were ideally aligned in one of three criteria (Matching in SAAS and/or Roussouly matched and/or achieved GAP proportionality) had lower rates of recurrent PJK (36% vs. 53%; OR: 0.4, 95% CI: 0.1-0.9, P =0.035) and recurrent PJF (OR: 0.1, 95% CI: 0.02-0.7, P =0.015). Patients ideally aligned in two of three criteria avoid any development of PJF (0% vs. 16%, P <0.001). Following revision surgery for PJK, patients with persistent poor sagittal alignment showed increased rates of recurrent PJK compared with patients who had abnormal lumbopelvic alignment corrected during the revision. These findings suggest addressing the root cause of surgical failure in addition to proximal extension of the fusion may be beneficial.

Characteristics of patients undergoing revision surgery for proximal junctional failure after adult spinal deformity surgery: revalidation of the Hart-International Spine Study Group proximal junctional kyphosis severity scale.

Score on the proximal junctional kyphosis severity scale (PJKSS) has been validated to show good correlations with likelihood of revision surgery for proximal junctional failure (PJF) after surgical treatment of adult spinal deformity (ASD). However, if the patient has progressive neurological deterioration, revision surgery should be considered regardless of severity based on PJKSS score. This study aimed to revalidate the correlation of PJKSS score with likelihood of revision surgery in patients with PJF but without neurological deficit. In addition, the authors provide the cutoff score on PJKSS that indicates need for revision surgery. A retrospective study was performed. Among 360 patients who underwent fusion of more than 4 segments including the sacrum, 83 patients who developed PJF without acute neurological deficit were included. Thirty patients underwent revision surgery (R group) and 53 patients did not undergo revision surgery (NR group). All components of PJKSS and variables other than those included in PJKSS were compared between groups. The cutoff score on PJKSS that indicated need for revision surgery was calculated with receiver operating characteristic curve analysis. Multivariate analysis with logistic regression was performed to identify which variables were most predictive of revision surgery. The mean patient age at the time of index surgery was 69.4 years, and the mean fusion length was 6.1 segments. All components of PJKSS, such as focal pain, instrumentation problem, change in kyphosis, fracture at the uppermost instrumented vertebra (UIV)/UIV+1, and level of UIV, were significantly different between groups. The average total PJKSS score was significantly greater in the R group than in the NR group (6.0 vs 3.9, p < 0.001). The calculated cutoff score was 4.5, with 70% sensitivity and specificity. There were no significant between-group differences in patient, surgical, and radiographic factors (other than the PJKSS components). Three factors were significantly associated with revision surgery on multivariate analysis: instrumentation problem (OR 8.160, p = 0.004), change in kyphosis (OR 4.809, p = 0.026), and UIV/UIV+1 fracture (OR 6.462, p = 0.002). PJKSS score positively predicted need for revision surgery in patients with PJF who were neurologically intact. The calculated cutoff score on PJKSS that indicated need for revision surgery was 4.5, with 70% sensitivity and specificity. The factor most responsible for revision surgery was bony failure with > 20° focal kyphotic deformity. Therefore, early revision surgery should be considered for these patients even in the absence of neurological deficit.

201. Intraoperative placement of analgesic calcium sulfate beads improves functional outcomes in thoracolumbar spine surgery

201. Intraoperative placement of analgesic calcium sulfate beads improves functional outcomes in thoracolumbar spine surgery

Obstetric anal sphincter injuries (OASIS): using transperineal ultrasound (TPUS) for detecting, visualizing and monitoring the healing process

PurposeThe aim of this study was to examine whether OASIS, and its extent, can be confirmed or excluded using transperineal ultrasound (TPUS). A further objective of this study was to monitor the healing process over a period of 6 months and to establish a connection between the sonographic appearance of obstetric anal sphincter injury (OASIS) and anal incontinence.Materials and methodsIn this retrospective clinical study, women with OASIS who gave birth between March 2014 and August 2019 were enrolled. All the patients underwent TPUS 3 days and 6 months after delivery. A GE E8 Voluson ultrasound system with a 3.5–5 MHz ultrasound probe was used. The ultrasound images showed a third-degree injury, with the measurement of the width of the tear and its extent (superficial, partial, complete, EAS and IAS involvement). A positive contraction effect, a sign of sufficient contraction, was documented. Six months after delivery, a sonographic assessment of the healing (healed, scar or still fully present) was performed. A Wexner score was obtained from each patient. The patients’ medical histories, including age, parity, episiotomy and child’s weight, were added.ResultsThirty-one of the 55 recruited patients were included in the statistical evaluation. Three patients were excluded from the statistical evaluation because OASIS was excluded on TPUS 3 days after delivery. One patient underwent revision surgery for anal incontinence and an inadequately repaired anal sphincter injury, as shown sonographic assessment, 9 days after delivery. Twenty patients were excluded for other reasons. The results suggest that a tear that appears smaller (in mm) after 3 days implies better healing after 6 months. This effect was statistically significant, with a significance level of alpha = 5% (p = 0.0328). Regarding anal incontinence, women who received an episiotomy had fewer anal incontinence symptoms after 6 months. The effect of episiotomy was statistically significant, with a significance level of alpha = 5% (p = 0.0367).ConclusionTPUS is an accessible, non-invasive method for detecting, quantifying, following-up and monitoring OASIS in patients with third-degree perineal tears. The width, as obtained by sonography, is important with regard to the healing of OASIS. A mediolateral episiotomy seems to prevent anal incontinence after 6 months.

Dorsal Augmentation Using a Glued Diced Cartilage Graft Fashioned with a Newly Developed Mold in Asian Rhinoplasty.

In dorsal augmentation, costal cartilage can be used in a number of different ways: monobloc, fascia wrapped, or glued diced cartilage grafting (GDCG). The authors developed a mold to make the use of GDCG more convenient. This report describes their experience with GDCG using a novel mold for dorsal augmentation. The study involved 80 patients who underwent dorsal augmentation with the molded GDCG. Facial photographs and medical records were reviewed to assess patient satisfaction and postoperative complications. For the 23 patients who had three-dimensional scanned imaging, dorsal widths and dorsal heights at the radix and rhinion levels were measured to investigate changes in the implants over time. Resorption of the graft was assessed comparing the 3-month postoperative photograph with the latest photograph taken at the last follow-up (at least 1 year after the surgery). Serial changes of the dorsum were assessed with three-dimensional scanned images. A total of 66 patients (82.5 percent) were satisfied with their surgical outcomes. Complications were encountered in 19 patients (23.8 percent) and eight revision procedures (10 percent) were performed. One patient underwent revision surgery because of resorption of the GDCG. Analysis using a three-dimensional scanning device showed a significant increment of the dorsal height ( p < 0.05) without dorsal widening when comparing preoperative with 1-year postoperative follow-up data. There were no significant reductions in dorsal height between postoperative 3 months and 1 year. The use of a novel mold for shaping glued diced cartilage appears to be a useful technique for dorsal augmentation in rhinoplasty. Therapeutic, IV.

Long-term functional outcomes after total wrist arthrodesis

Current literature surrounding functional outcomes after total wrist arthrodesis is limited by short follow-up or limited use of validated patient reported outcome measures (PROMs). The primary aim of this study was to describe long-term functional outcomes following wrist arthrodesis. Secondary aims were to describe the incidence of complications and patient satisfaction. This was a retrospective single-center study. Patients with a minimum of 10-year follow-up completed a questionnaire including the Patient-Rated Wrist Evaluation (PRWE), the Quick version of the Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score, the EQ-5D-5L score, and a question assessing satisfaction. Presence of a complication was also assessed. During the study period 66 patients underwent total arthrodesis. At a median follow-up of 15 years, complete patient reported outcomes were available for 34 patients. Thirty-two patients were lost to follow-up. Mean age at surgery was 49 and 16 patients were female. Mean PRWE and Quick-DASH scores were 44.8 (SD 27.7; range 0–96) and 41.9 (SD 23.6; range 2.3–97.7) respectively. Twenty-eight patients were satisfied. Nine patients reported complications. There were six cases of hardware removal and two cases of prominent metalwork. One patient underwent revision surgery for non-union. Presence of a complication did not affect the Quick-DASH or PRWE scores. Median EQ-5D-5L score was 0.7. This long-term follow-up suggests high levels of patient satisfaction and health related quality of life, despite significant functional disability. The complication rates are not insignificant, although the presence of a complication did not affect functional outcomes.

Short-term clinical outcomes of Kyocera Modular Limb Salvage System designed cementless stems for the endoprosthetic reconstruction of lower extremities: a Japanese Musculoskeletal Oncology Group multi-institutional study

BackgroundThe high rate of aseptic loosening of cemented stems has led to their frequent use in endoprosthetic reconstruction. However, problems, such as stem breakage and stress shielding at the insertion site, remain. The Japanese Musculoskeletal Oncology Group (JMOG) has developed Kyocera Modular Limb Salvage System (KMLS) cementless stems with a unique tapered press-fit and short fixation design. This study aimed to clarify the short-term postoperative outcomes of this prosthesis and validate the stem design.MethodsOne hundred cases of KMLS cementless stems (51 male patients; median age, 49 years; mean follow-up period, 35 months), with a minimum follow-up of 2 years, for the proximal femur (PF), distal femur (DF), and proximal tibia were prospectively registered for use. Prosthesis survival, complication rates, postoperative functional, and radiographical evaluation were analyzed. Complications or failures after insertion of the KMLS endoprostheses were classified into five types and functional results were analyzed according to the MSTS scoring system at postoperative 1 year. The diaphyseal interface and anchorage were graded by the ISOLS system at postoperative 2 years.ResultsThe overall prosthesis survival rates at 2 and 4 years were 88.2 and 79.6%, respectively. The prosthesis-specific survival rate excluding infection and tumor recurrence was 90.2 and 87.9%, respectively. Younger age (p = 0.045) and primary tumor (p = 0.057) were associated with poor prognosis of prosthesis-specific survival excluding infection and tumor recurrence. Complications were observed in 31 patients, 13 patients underwent revision surgery. The mean MSTS functional score at 1 year postoperatively was 68%. Early implant loosening was significantly more common in the DF (p = 0.006) and PF/DF straight stem (p = 0.038). The ISOLS radiographic evaluation at 2 years after surgery revealed good bone remodeling and anchorage in most cases (bone remodeling: 90% / excellent and good, anchorage: 97% / excellent and good).ConclusionsTumor endoprosthesis long-term fixation to the diaphysis of the lower extremity remains challenging. The KMLS cementless stem with a unique tapered press fit design showed good short-term results in maintaining bone stock. To prevent early loosening, a curved stem should be used in PF and DF, but long-term follow-up is necessary.

Clinical application of three-dimensional printed osteotomy guide plate and personalized prosthesis in knee-preserving tumor resection

To investigate the mid-term effectiveness of three-dimensional (3D) printed osteotomy guide plate and personalized prosthesis in knee-preserving tumor resection. The clinical data of 12 patients who underwent knee-preserving tumor resection and reconstruction with 3D printed osteotomy guide plate and personalized prosthesis between September 2016 and October 2018 were retrospectively analyzed. There were 7 males and 5 females. The age ranged from 7 to 59 years, with a median of 44.5 years. There were 11 cases of osteosarcoma and 1 case of fibrosarcoma, all of which were Enneking grade ⅡB. The distance from the tumor to the joint surface was 5.5-8.2 cm, with an average of 6.94 cm. Incision healing, tumor recurrence, periprosthetic fracture, and aseptic loosening were observed after operation. The Musculoskeletal Tumor Society (MSTS) scoring system was used to evaluate the function of the patients, and the knee flexion range of motion was measured. The 12 patients were followed up 41-66 months, with an average of 54.5 months. The length of osteotomy ranged from 14 to 26 cm, with an average of 22.08 cm. Except for 2 patients with superficial infection of incision tissue, no deep infection involving the prosthesis occurred, no patient underwent revision surgery because of prosthesis infection. During the follow-up, local recurrence occurred in 2 cases and distant metastasis occurred in 3 cases. The overall disease-free survival rate was 58.3%. Two patients died of lung metastasis, and the overall survival rate was 83.3%. One patient underwent amputation due to local recurrence, and 1 patient underwent total knee arthroplasty due to prosthesis rupture. No aseptic loosening of the prosthesis and periprosthetic fracture occurred during the follow-up, and the overall prosthesis survival rate was 83.3%. At last follow-up, 10 patients obtained satisfactory knee flexion range of motion that ranged from 95° to 125°, with an average of 110°. Two children could not cooperate with early rehabilitation treatment due to pain, and the knee flexion range of motion was not ideal (50°, 75°). All patients achieved acceptable lower limb function with MSTS scores ranged from 26 to 30, with an average of 28. All patients walked without crutches. The treatment of malignant bone tumors around the knee joint with 3D printed osteotomy guide plate and personalized prosthesis can preserve the articular surface, obtain good limb function, reduce the risk of aseptic loosening of prosthesis, and achieve better mid-term effectiveness.

Poster 161: Consequence Athletes with Anterior Shoulder Instability: Consider Latarjet

Objectives:The Latarjet procedure has been shown to be effective in treating recurrent shoulder instability, especially in the setting of glenoid bone loss and after failed previous Bankart repair. Several studies have additionally shown a significant reduction in recurrent instability rates when compared to Bankart repair in contact athletes when the Latarjet procedure is performed in a primary setting. We have identified an additional population of patients that provides greater challenges beyond the common athlete including those involved in contact sports. Termed “consequence athletes,” these patients are defined as athletes who perform in high risk, uncontrolled environments for whom an injury is likely to threaten life or livelihood. This population includes elite military forces, law enforcement and federal agents, motocross, elite skiers/snowboarders, whitewater kayak and rafters, and rock climbers. The purpose of this study is to evaluate minimum 2-year outcomes of primary Latarjet procedure in consequence athletes with anterior shoulder instability.Methods:Consequence athletes who underwent open Latarjet by one of the three sports medicine trained senior surgeons between August 2006 and January 2018 were retrospectively reviewed from prospectively collected data. Minimum 24 follow up was obtained on all patients. Those younger than 18 at follow up, history of concomitant or prior remplissage procedure, glenoid reconstruction with allograft, severe glenohumeral arthritis, or hyperlaxity were excluded. Glenoid bone loss (GBL) was evaluated on preoperative MRI and the cohort divided into GBL 0-14% and ≥15%. Patient-reported outcome scores (PROs) were collected and included the American Shoulder and Elbow Surgeons (ASES) score, Single Numeric Assessment Evaluation (SANE) score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Short Form–12 (SF-12) Physical Component Summary (PCS), and numeric rating scale (NRS) for pain score (0 - 10, 10 = worst pain). Postoperative patient satisfaction (1 - 10, 10 = very satisfied) was evaluated. Complications and revision surgeries were recorded. Failure was defined as a postoperative dislocation or a revision surgery.Results:Sixty-five consequence athletes were included (54 males, 11 females). The mean age at surgery was 28.5 ± 8.7 years (range 15.8-56.4). The most frequent professions included 17 skiers (26.2%), 17 rock climbers (26.2%), 10 snowboarders (15.4%), 9 white water kayakers/rafters (13.8%), and 8 federal agents/military (12.3%). Primary latarjet was performed in 30 (46.2%) without prior history of soft tissue stabilization procedures. Mean GBL was 13.7%; 27 (41.5%) had 0-14% GBL and 32 (49.2%) had ≥15% GBL. Significant improvement in PROs at minimum 2-year follow was demonstrated for SANE (57.9 ± 24.5 to 91.0 ± 9.5), SF12 PCS (45.5 ± 8.7 to 54.4 ± 7.1), ASES pain (41.5 ± 9.7 to 47.4 ± 5.3), ASES function (31.8 ± 12.6 to 46.2 ± 6.8), ASES total (73.0 ± 19.8 to 93.7 ± 10.0), and quickDASH (27.0 ± 14.0 to 10.0 ± 28.8). Median patient satisfaction was 10. One patient sustained a recurrent dislocation (1.5%), 2 (3%) patients underwent revision surgery. There was no significant correlation between PROs and GBL, number of previous dislocations, or prior soft tissue stabilization procedures.Conclusions:The latarjet procedure a reliable and safe treatment for shoulder instability in the high demand “consequence athlete” population with a post-operative dislocation rate of 1.5% and revision rate of 3%. Significant improvement in PROs was demonstrated for SANE, SF12 PCS, ASES, and DASH with median patient satisfaction score of 10. These findings support treatment of this population with the latarjet procedure, even in the setting of minimal preoperative GBL, where a recurrent instability event could be catastrophic to the individual patient or those working or participating along with them.

Treatment patterns and clinical and economic burden of hip dislocation following primary total hip arthroplasty in England.

AimsThe aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England.MethodsThis retrospective evaluation used data from the UK Clinical Practice Research Datalink database. Patients were eligible if they underwent a primary THA (index date) and had medical records available 90 days pre-index and 180 days post-index. Bilateral THAs were excluded. Healthcare costs and resource use were evaluated over two years. Changes (pre- vs post-THA) in generic quality of life (QoL) and joint-specific disability were evaluated. Propensity score matching controlled for baseline differences between patients with and without THA dislocation.ResultsAmong 13,044 patients (mean age 69.2 years (SD 11.4), 60.9% female), 191 (1.5%) had THA dislocation. Two-year median direct medical costs were £15,333 (interquartile range (IQR) 14,437 to 16,156) higher for patients with THA dislocation. Patients underwent revision surgery after a mean of 1.5 dislocations (1 to 5). Two-year costs increased to £54,088 (IQR 34,126 to 59,117) for patients with multiple closed reductions and a revision procedure. On average, patients with dislocation had greater healthcare resource use and less improvement in EuroQol five-dimension index (mean 0.24 (SD 0.35) vs 0.44 (SD 0.35); p < 0.001) and visual analogue scale (0.95 vs 8.85; p = 0.038) scores, and Oxford Hip Scores (12.93 vs 21.19; p < 0.001).ConclusionThe cost, resource use, and QoL burden of THA dislocation in England are substantial. Further research is required to understand optimal timing of revision after dislocation, with regard to cost-effectiveness and impact on QoL.Cite this article: Bone Joint J 2022;104-B(7):811–819.

Unplanned return to the operating room after arthroscopic procedures: a need to consider 12months after the initial surgery.

The purpose of this study was to report the proportion and cause of unplanned revision surgery rates within 1year following arthroscopic procedures. Our hypothesis was that there is a significant rate of unplanned returns (URs) occurring between 3 and 12months after the initial procedure and that causes of revision are different when considering the delay after the index surgery. Among 4142 consecutive patients who underwent an arthroscopic procedure in a single department of orthopedics and traumatology, patients undergoing revision surgery for any reasons directly related to the primary procedure were included. Cause for revision, surgical site, delay from index procedure, and number of revisions were screened. Seventy-eight patients underwent 97 revision surgeries (2.3%) for reasons directly related to the primary procedure. Most revision surgeries were performed after month 3 following index surgery (59 patients, 60.8%). Mean time to revision surgery was 5.3 ± 4.3months (range 0-365days). Usual early-onset (< 3months) reasons for unplanned revision were surgical site infection (17 patients, 0.41%), wound-healing defect (12 patients, 0.29%), and hemorrhagic complication (7 patients, 0.17%). Reasons for delayed unplanned revision (> 3months) were index procedure failure (21 patients, 0.51%), stiffness (18 patients, 0.43%), and removal of hardware (16 patients, 0.41%). Reasons for return to the operating room (OR) are different depending on the timepoint from index procedure. Patients should receive relevant information accordingly when scheduling any arthroscopic procedure, including up to 1-year potential complications. Prognostic study, Case series, Level IV.

Minimum 5-Year Outcomes of Osteochondral Autograft Transplantation with a Concomitant High Tibial Osteotomy for Spontaneous Osteonecrosis of the Knee with a Large Lesion.

The purpose of this study was to evaluate the mid-term clinical outcomes of osteochondral autograft transplantation (OAT) with concomitant high tibial osteotomy (HTO) in spontaneous osteonecrosis of the knee (SONK) with a large lesion. A total of 48 knees of 48 consecutive patients with SONK (lesion size ≥4 cm2, no age criteria) who underwent opening wedge HTO and concomitant OAT were retrospectively investigated, and those who were followed up postoperatively for at least 5 years were included in this case series study. Clinical outcomes were evaluated using knee and function scores of Knee Society Score, radiographic outcomes were evaluated using the anatomical femorotibial angle (FTA), and these outcomes were compared between patients aged ≥70 years and <70 years. Of the 48 cases, a total of 43 cases were available for review at a minimum of 5 years, and 5 cases were excluded from the analysis. Overall, the mean knee score improved from preoperative 48.8 ± 13.3 to postoperative 87.9 ± 8.6 at 1 year (P < 0.05) and 85.0 ± 10.4 at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). The mean function score also improved from preoperative 60.1 ± 10.9 to postoperative 87.3 ± 12.2 at 1 year (P < 0.05) and 84.2 ± 12.4 at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). The mean standing FTA was corrected significantly from 181.1° ± 2.7° preoperatively to 169.7° ± 2.4° at 1 year (P < 0.05) and 169.4° ± 3.1° at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). There were no significant differences in clinical and radiographic outcomes between patients aged ≥70 years and <70 years. There were 4 cases of lateral hinge fracture around the osteotomy site and 1 case of delayed union. None of the patients underwent revision surgery during the follow-up period (survival rate of 100%). Mid-term clinical outcomes of patients with SONK who underwent HTO and OAT with a relatively large lesion were good.

Cost-effectiveness analysis of routine follow-up for hip fracture patients after dynamic hip screw and intramedullary nail fixation

• Determining the appropriate outpatient management for patients following IM Nail or DHS for neck of femur fractures should be directed by clear objectives. • Routine post-operative surgical encounters with these patients rarely alter their clinical management. • We propose more selective follow-up protocols and adequately resourcing virtual alternatives. • The current outpatient hip fracture care pathway should be optimised to focus on comprehensive multidisciplinary treatment such as rehabilitation, fracture prevention and bone health optimisation. The rising number of hip fractures has incentivised several quality improvement initiatives aimed at improving outcomes. These include the national hip fracture audit and the best practice tariff. Whilst there is an established standard of care for inpatients, the optimal outpatient management of patients after hip fracture fixation remains undefined. We aim to evaluate the cost-effectiveness of routine surgical appointments and provide evidence to support an improved outpatient hip fracture care pathway that focuses on more comprehensive multidisciplinary treatment. This study retrospectively examined all patients who underwent either dynamic hip screw or intramedullary nail fixation for hip fragility fracture at our hospital over a 3-year period. Data was obtained from the Irish Hip Fracture Database (IHFD), the national integrated imaging system (NIMIS) and the medical charts. The number of outpatient appointments, postoperative radiographs and estimated cost of these patient encounters was examined. The rate of revision surgery as well as the type and timing of these interventions was also analysed. We included 272 patients. The mean number of inpatient and outpatient radiographs was 1.13 and 1.54 per patient respectively. There were 428 outpatient appointments scheduled, an average of 1.6 (SD 1.5) per patient. The median length of stay was 12 days (IQR 8-17). Only 16 (5.8%) patients had abnormal X-ray findings and only 8 (2.9%) patients underwent revision surgery. The majority (15/16, 94%) of patients with surgical complications presented with significant symptoms. There was a 13.1% DNA rate resulting in a cost to the health service of €1,400. The combined total cost of follow-up for all patients over the 3 year period was €92,252. Routine postoperative surgical encounters rarely alter a patient's management and contribute significantly to healthcare costs, resources and time loss for patients and their carers. We propose more selective follow-up protocols, adequately resourcing virtual alternatives and an improved outpatient hip fracture care pathway that focuses on comprehensive multidisciplinary treatment such as rehabilitation, fracture prevention and bone health optimisation.

Instability after reverse total shoulder arthroplasty: risk factors and how to avoid them.

Instability after RTSA (4'7%) remains a complication with limited salvage options... or not? We conducted a study of the incidence, predisposing factors, and treatment of RTSA instability to risk stratify patient and identify the most reliable treatment methods. We retrospectively searched for RTSAs performed between 2008 and 2017 at our institution by one surgeon using the same technique. We identified post- operative dislocations or symptoms of instability. 103 patients underwent 103 RTSAs (97 primary, 6 revision). 6 patients had 5 dislocations (3 in primary RTSAs, 3 in revision RTSAs). Mean time from surgery to diagnosis was 32.6 days (range, 10-60 days). One dislocation occurred immediately after surgery, 0 after falls, 3 from low-energy mechanisms of injury, and 2 without known inciting events. All dislocations were treated in the operating room; no dislocation was successfully treated with simple closed reduction in the clinic. Although dislocation after RTSA is uncommon, the risk is higher for patients with higher BMI and for patients undergoing revision surgery. The highest risk of instability occurs in RTSAs done for severe proximal humerus fracture; where the anatomy of the shoulder is changed. In these cases, approximately one in four patients will have a recurrent dislocation. In patients with persistent instability or with risk factors for instability, consideration should be given for use of larger glenospheres and increasing the lateral offset at the time of RTSA. Besides, peri- glenoid release, the suitable tension of the soft tissues tend to be the key of the stability.

Perioperative myocardial injury and mortality after revision surgery for orthopaedic device-related infection.

Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery. In total, 911 consecutive patients were included. The overall perioperative myocardial injury (PMI) rate was 15.4% (n = 140). Septic revision surgery for PJI was associated with a significantly higher PMI rate (43.8% (14/32) vs 14.5% (57/393); p = 0.001) and one-year mortality rate (18.6% (6/32) vs 7.4% (29/393); p = 0.038) compared to aseptic revision or primary arthroplasty. The association with PMI persisted in multivariable analysis with an adjusted odds ratio (aOR) of 4.7 (95% confidence interval (CI) 2.1 to 10.7; p < 0.001), but was not statistically significant for one-year mortality (aOR 1.9 (95% CI 0.7 to 5.4; p = 0.240). PMI rate (15.2% (5/33) vs 14.1% (64/453)) and one-year mortality (15.2% (5/33) vs 9.1% (41/453)) after FRI revision surgery were comparable to aseptic long-bone fracture surgery. Patients undergoing revision surgery for PJI were at a risk of PMI and death compared to those undergoing aseptic arthroplasty surgery. Screening for PMI and treatment in specialized multidisciplinary units should be considered in major bone and joint infections. Cite this article: Bone Joint J2022;104-B(6):696-702.

Skeletal Status in Patients Scheduled for Elective Lumbar Spine Surgery: Comparison of Discectomy, Decompression, Fusion, and Revision.

Retrospective Cohort Study. To investigate and compare the prevalence of low bone mineral density (BMD) and abnormal laboratory bone metabolism parameters in patients undergoing elective primary discectomy, decompression, and fusion and to outline possible differences in these parameters between patients undergoing revision for skeletal vs non-skeletal complications. We retrospectively evaluated BMD measurements by dual-energy x-ray absorptiometry (DXA) in 389 consecutive patients scheduled for elective lumbar spine surgery. Next to demographic characteristics, laboratory bone metabolism parameters were assessed. Group comparisons were performed between primary discectomy, decompression, and fusion. In patients scheduled for revision surgery after fusion, potential differences in the skeletal status between those with skeletal vs non-skeletal complications were analyzed. Osteoporosis by T-score was detected in 6.7%, 11.0% and 14.7% of the patients undergoing discectomy, decompression and fusion, respectively. While vitamin D deficiency (67.6%) and hyperparathyroidism (16.4%) were frequently detected, no differences in laboratory bone metabolism markers could be found between the groups. Female sex (P<.001), higher age (P=.01) and lower BMI (P<.001) were associated with lower BMD. In the cohort of patients undergoing revision surgery due to complications after fusion, those with skeletal complications did not differ in BMD or bone metabolism from those with non-skeletal complications. Osteoporosis represents a relevant comorbidity in patients scheduled for elective spine surgery, which is why DXA should be routinely performed in these patients. However, DXA may provide limited information in identifying patients at increased risk for skeletal complications after fusion.

Intercalary and geographic lower limb tumor resections with the use of 3D printed Patient Specific Instruments- when less is more

BackgroundPrimary bone sarcomas are associated with critically sized bone defects and require complete resection with negative margins. Recent advancements in health care have pioneered novel approaches such as the implementation of 3D surgical technologies. This study presents oncological and functional outcomes following tumor resections of long bones with the use of customized 3D-printed Patient Specific Instruments (PSIs). MethodsThis single-center retrospective study is comprised of seventeen patients who underwent either intercalary (N = 12) or geographic (N = 5) resections with various reconstruction methods including allograft (N = 8), vascularized fibula (Capanna) (N = 7), and 3D printed customized titanium implants (N = 2), between the years 2016–2020. All patients were operated on with a 3D surgical workflow, including intraoperative PSIs, and were followed up postoperatively for at least 12 months (average 31.40 ± 12.13 months) to assess oncological and functional outcomes. ResultsAll patients demonstrated negative surgical margins, apart from one patient who had planned positive margins. Three patients suffered from short-term complications, and three patients underwent revision surgery due to graft non-union or pathological fracture. One patient suffered from local recurrence and underwent above-knee amputation. Three patients suffered from lung metastasis. MSTS at 12-month follow-up was 26.9.±5.87. ConclusionCustomized 3D-printed osteotomy PSIs provide surgeons with a novel tool for optimizing bone resection and reconstruction in long bones surgeries, thus minimizing overall tissue trauma and reducing the risk of damage to nervous and vascular structures. This study demonstrates that the use of PSIs has the potential to improve functional and oncological outcomes. We believe that this technique will become increasingly popular in the future as a widely applicable, highly accurate, cost-effective optimization tool.

Osseointegrated device placement with minimally invasive surgery: Experience and audiological outcome.

Objectives:To evaluate the clinical and audiological outcomes of percutaneous bone conduction device placement by minimally invasive Ponto surgery (MIPS).Methods:This was a retrospective descriptive study of patients who underwent MIPS from March-November 2019 at King Abdullah Ear Specialist Center, Collage of Medicine, King Saud University, Riyadh, Saudi Arabia. We reviewed all the clinical data of patients, including preoperative data, postoperative surgical results, and audiological performance (aided and unaided pure tone audiometry and aided and unaided speech tests).Results:A total of 9 patients with 10 implants were enrolled in this study. One patient underwent revision surgery because of infection and loss of the abutment. We followed the patients from 1-2 years, with a mean of 16.8 months. A significant difference was found between the unaided air conduction pure tone average, with a mean of 72.6±28.4 decibel (dB), and the postoperative aided threshold, with a mean of 20.8±12.2 dB/hectoliter (p=0.008), indicating a functional gain of 51.8 dB. The mean unaided speech discrimination at 65 dB sound pressure level was 34.7±24.8, which was significantly improved to 88.4±11.7 after implantation (p=0.007).Conclusion:minimally invasive Ponto surgery is a suitable minimally invasive surgical method for bone-anchored implant placement. This technique has an advantage in terms of skin sensitivity, cosmetic outcomes, and operative duration.