Patients Underwent Revision Surgery Research Articles

Multilevel Arthrodesis for Adult Spinal Deformity: When Should We Anticipate Major Blood Loss?

Study DesignRetrospective study. ObjectivesTo analyze predictors of major blood loss (MBL) during multilevel arthrodesis for adult spinal deformity (ASD). Summary of Background DataASD surgery is associated with substantial blood loss. MethodsWe identified 237 patients with ASD who underwent spinal arthrodesis of five or more levels by one surgeon and who had complete data on blood loss. MBL was defined as normalized blood loss above the 75th percentile (ie, >49%). Patients with MBL were compared with those without MBL with respect to baseline characteristics, preoperative laboratory values, and surgical factors. Alpha level = 0.05. ResultsA total of 176 patients (74%) had MBL. On univariate analysis, the MBL and non-MBL groups differed with respect to diagnosis of osteoporosis (p = .002), curve type (p = .012), number of levels fused (p < .001), and presence/type of osteotomy (p < .001). The groups were similar in age (p = .605) and proportion of patients undergoing revision surgery (p = .410). Multivariate analysis identified the following predictors of MBL: three-column osteotomy (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 1.7, 9.7), arthrodesis of 11 or more levels (OR = 3.2, 95% CI = 1.4, 7.6), malalignment in both coronal and sagittal planes (OR = 3.2, 95% CI = 1.4, 7.3), and osteoporosis (OR = 2.4, 95% CI = 1.1, 5.4). ConclusionPatients with ASD undergoing spinal arthrodesis of five or more levels are at risk for MBL. Three-column osteotomy, arthrodesis of ≥11 levels, malalignment in both coronal and sagittal planes, and osteoporosis appear to be risk factors for MBL. Level of EvidenceLevel III.

Outcomes of Revisions for Failed Trapeziometacarpal Joint Arthritis Surgery

We compare outcomes of revision surgery for trapeziometacarpal (TM) arthritis with outcomes for both primary and revision surgery for TM arthritis reported in the literature. We hypothesized that patients undergoing revision surgery for TM arthritis would demonstrate pain and functional outcome scores that were worse than those of patients undergoing primary TM surgery. A retrospective analysis of all patients undergoing revision TM surgery at a single institution from 1995 to 2015 was performed. Eighty-three patients (86 hands) met the inclusion criteria. Of these, 25 patients (27 hands) were available for follow-up via phone survey or clinical examination; 58 patients (59 hands) were available for chart review only. Patients available for phone survey or clinical examination were evaluated with the visual analog scale, Disabilities of the Arm, Shoulder, and Hand score, and the Conolly-Rath evaluation method. Patients available for clinical examination were also evaluated with grip strength, pinch strength, and radiographs. Median follow-up was 8.5 years (range, 2.0-21.2 years). Twenty percent of patients experienced postoperative complications, most commonly pin problems (7%). Of the 27 hands available for interview or clinical examination, 15 were dominant and 12 were nondominant. The average visual analog scale was 28.2 (SD, 29.7). Disabilities of the Arm, Shoulder, and Hand scores averaged 32.0 (SD, 20.8). According to the Conolly and Rath criteria, 10 patients had a good outcome, 7 were fair, and 10 were poor. For the group of 13 patients who underwent physical examination, average adduction was 42° in the affected side versus 51° in the nonaffected side. Radial abduction was 58° in the affected side versus 65° in the nonaffected side. Palmar abduction was 53° versus 85° in each group, respectively. Tip finger pinch was 3.4 kg for the affected hand versus 4.0 kg for the nonaffected side. Key pinch was 4.7 and 5.5 kg, respectively. Grip strength was measured as 22.1 kg in the affected side versus 27.6 kg in the contralateral side when adjusted for dominance. In our study group, revision surgery for unsuccessful primary TM surgery demonstrated results inferior to those previously reported for primary surgery for TM arthritis but similar to prior studies of revision TM surgery. Revision surgery, however, can result in satisfactory long-term outcomes particularly when metacarpophalangeal joint pathology is addressed and complications are avoided. Therapeutic IV.

Intravenous and local steroid use in the management of dysphagia after anterior cervical spine surgery: a systematic review of prospective randomized controlled trails (RCTs).

To conduct a high-level systematic review of the literature to evaluate intravenous and local steroid use in the management of dysphagia after anterior cervical spine surgery. We searched the database PubMed, EMBASE, Clinical key, the Cochrane library and Wiley Online Library without time restriction using the terms 'dysphagia' or 'odynophagia' or 'swallowing disorder,' 'steroid,' 'anterior cervical spine surgery.' Randomized controlled trails (RCTs) were selected, and effects of intravenous and local steroids were investigated from these studies. The initial search yielded 67 citations. Six of these studies met the inclusion and exclusion criteria. All of them were prospective RCTs which were evaluated as level 1 evidence. One study found that perioperative intravenous steroid use is not effective in reducing severity of early postoperative dysphagia after one-level ACDF, while five studies suggested that perioperative intravenous and local steroid use seemed to be more effective on reducing incidence and severity of early dysphagia after multilevel ACSS. One double-blinded study still found that locally administered depomedrol on a collagen sponge significantly decreases early dysphagia incidence and severity after ACSS using low-dose BMP. Perioperative intravenous and local steroid use could reduce incidence and severity of early dysphagia after ACSS postoperatively, especially for multilevel surgeries. For the patients underwent revision surgery or at high risk for pseudarthrosis having to use BMP during surgery, locally administered depomedrol on a collagen sponge was suggested to decrease early dysphagia incidence and severity after ACSS. These slides can be retrieved under Electronic Supplementary Material.

Causes and prevention of revision surgery for preauricular sinus: A histopathological analysis

ObjectiveRecurrence rates following preauricular sinus (PAS) surgery vary. Few studies have investigated recurrence after primary PAS surgery in histopathological terms. We performed a histopathological analysis of the causes of revision surgery for PAS, with a view to reducing the recurrence rate after primary surgery. MethodsWe reviewed the medical records of patients who underwent revision surgery after primary excision of a PAS between 2002 and 2017. A pathologist reviewed the histopathology slides. ResultsIn total, 24 patients underwent revision surgery; of those, histopathology slides were available for 18 patients (19 revisions). The mean interval between primary and revision surgery was 50.4 months. We detected lumen with stratified squamous epithelium in 14 of the 19 (73.7%) revisions. Cartilage tissue was attached to the epithelial lining of the lumen in 14 of the 17 (82.4%) slides containing lumen. Inflammatory changes were found in all slides, and granulation tissue was detected in 10 of 19 revision surgery slides. ConclusionsTo prevent PAS recurrence after primary surgery, we recommend a wide local excision including the inflammatory soft tissue, with concomitant partial removal of the cartilage of the ascending helix adjacent to the PAS.

Revision total hip arthroplasty with metal on metal bearing for ceramic bearing fractures

BackgroundDue to concern of potential metallosis caused by residual microscopic ceramic particles, metal-on-metal (MoM) bearing is deemed undesirable in revision total hip arthroplasty (THA) for ceramic bearing fracture. We determined whether MoM bearing is suitable to be used in revision THA for ceramic fractures and also evaluated whether this treatment increases serum iron levels compared with MoM bearing revision THA for polyethylene failure. MethodsBetween 2006 and 2012, 22 patients underwent revision surgery using MoM bearing (28 mm femoral head in 18 hips and 32 mm in 4 hips) for ceramic bearing fracture and followed average 52.1 months. We assessed radiological parameter and functional outcome using Harris hip score (HHS) and WOMAC score. Also, serum cobalt (Co) and chromium (Cr) blood tests were performed and compared with the result obtained from age, sex- and follow-up duration-matched patients with MoM revision THA for failed polyethylene bearing. ResultsThe mean HHS improved from 60.6 preoperatively to 90.3 at final follow-up. There were no changes in cup position, progression of osteolytic lesions, and measurable wear of MoM bearing articulation at final follow-up radiographs. There was one case of recurrent dislocation after surgery, which was treated with greater trochanter distal advancement and one case of deep infection, which underwent two-stage revision. Mean serum Co level (1.7 vs. 1.4 μg/dl; p = 0.211) and Cr level (0.70 vs. 1.01 μg/dl; p = 0.327) showed no significant difference. ConclusionsMoM articulation with liner cementation into the acetabular cup along with total synovectomy can be chosen in revision surgery for ceramic fracture with good midterm follow-up. However, the use of MoM bearing is indicated when the stem and metal shell can be retained and ceramic on ceramic or ceramic on polyethylene bearing cannot be selected. Also long-term outcome needs to be further evaluated.

Contribution of Lateral Interbody Fusion in Staged Correction of Adult Degenerative Scoliosis.

ObjectiveLateral interbody fusion (LIF) is attractive as a less invasive technique to address anterior spinal pathology in the treatment of adult spinal deformity. Its own uses and benefits in treatment of adult degenerative scoliosis are undefined. To investigate the radiographic and clinical outcomes of LIF, and staged LIF and posterior spinal fusion (PSF) for the treatment of adult degenerative scoliosis patients, we analyzed radiographic and clinical outcomes of adult degenerative scoliosis patients who underwent LIF and posterior spinal fusion. MethodsForty consecutive adult degenerative scoliosis patients who underwent LIF followed by staged PSF at a single institution were retrospectively reviewed. Long-standing 36” anterior-posterior and lateral radiographs were taken preoperatively, at inter-stage, 3 months, 1 year, and 2 years after surgery were reviewed. Outcomes were assessed through the visual analogue scale (VAS), 36-Item Short Form Health Survey (SF-36), and Oswestry Disability Index (ODI). ResultsForty patients with a mean age of 66.3 (range, 49–79) met inclusion criteria. A mean of 3.8 levels (range, 2–5) were fused using LIF, while a mean of 9.0 levels (range, 3–16) were fused during the posterior approach. The mean time between stages was 1.4 days (range, 1–6). The mean follow-up was 19.6 months. Lumbar lordosis was significantly restored from 36.4º preoperatively up to 48.9º (71.4% of total correction) after LIF and 53.9º after PSF. Lumbar coronal Cobb was prominently improved from 38.6º preoperatively to 24.1º (55.8% of total correction) after LIF, 12.6º after PSF respectively. The mean pelvic incidence-lumbar lordosis mismatch was markedly improved from 22.2º preoperatively to 8.1º (86.5% of total correction) after LIF, 5.9º after PSF. Correction of coronal imbalance and sagittal vertebral axis did not reach significance. The rate of perioperative complication was 37.5%. Five patients underwent revision surgery due to wound infection. No major perioperative medical complications occurred. At last follow-up, there were significant improvements in VAS, SF-36 Physical Component Summary and ODI scores. ConclusionLIF provides significant corrections in the coronal and sagittal plane in the patients with adult degenerative scoliosis. However, LIF combined with staged PSF provides more excellent radiographic and clinical outcomes, with reduced perioperative risk in the treatment of adult degenerative scoliosis.

Vissage ilio-sacré postérieur pelvien navigué basé sur le scanner 3D

IntroductionPosterior pelvic ring fractures frequently pose a problem of stability with an elevated risk of complications. The traditional method of percutaneous sacro-iliac (SI) stabilization with the use of fluoroscopic image amplifiers demands a high degree of experience and has an elevated risk of screws’ malpositioning. HypothesisIntraoperative 3D-CT scan coupled with a navigation system (O-Arm©) can allow screw fixation accuracy while limiting the risk of complications for the treatment of posterior pelvic ring fractures. Material and methodsPatients with posterior pelvic ring fractures stabilized with percutaneous SI screws through O-Arm© navigation from August 2008 to December 2017 were analyzed. A modified Gras classification was used to determine screws’ positioning under CT visualization, and intra-operative and early postoperative complications were documented. ResultsAmong the 21 patients evaluated, 14 men and 7 women with a mean age of 57.8 years (range 25–91), receiving 39 screws, the rate of misplacement was low: 82%, grade I, 15.4%, grade II, and only 2.6% grade III. Only one patient underwent revision surgery, not because of misplacement but rather for a secondary implant loosening. No complications occurred in this series. DiscussionThis study documented a large series of patients treated for pelvic ring fractures using the intraoperative 3D-CT O-Arm© guided navigation. This surgical approach provided a precise and safe SI screw positioning with no complications. Level of evidenceIV, Retrospective study.

Medicaid Insurance Correlates With Increased Resource Utilization Following Total Hip Arthroplasty

BackgroundWith increased restraints and efforts to contain costs in total hip arthroplasty (THA), an emphasis has been placed on risk stratification. The purpose of this study was to determine whether Medicaid patients have increased resource utilization (including 90-day emergency department [ED] visits and readmissions) compared to Medicare or commercial insurance carriers. The study hypothesized that the Medicaid population would represent a high-risk cohort with increased resource utilization. MethodsThe institutional database was retrospectively queried for primary THAs from 2013 to 2017 based on Current Procedural Terminology codes and patients undergoing revision surgery were excluded. Demographic information including age, sex, and body mass index (BMI) and medical comorbidities including American Society of Anesthesiologists (ASA) scores were evaluated. Patients were stratified by insurance type and length of stay (LOS), and 90-day ED visits and 90-day readmissions were assessed in univariable and multivariable analysis. ResultsA total of 3674 primary THA patients were included in the analysis (including 116 with Medicaid, 1713 with Medicare, and 1845 with other insurance providers). Medicaid patients had significantly higher ASA scores (P < .001) and BMI (P < .001), with corresponding increase in procedure duration (115 vs 99 vs 105 minutes; P < .001). They had a prolonged LOS (2.5 vs 2.5 vs 1.5 days; P < .001) compared with other insurances, but similar to Medicare patients. Following discharge, in multivariable analysis controlling for age, BMI, and ASA score, Medicare patients were significantly more likely to return to the ED (odds ratio, 3.15; 95% confidence interval, 1.88-5.27; P < .001) and be readmitted (odds ratio, 2.46; 95% confidence interval, 1.26-4.81; P = .009). ConclusionMedicaid patients represent a higher risk cohort with increased resource utilization perioperatively, including longer LOS, and more 90-day ED visits and readmissions. This should be considered in outcome assessments and alternative expectations for the episode of care should be set for this population.

Manipulation Rate Is Not Increased After Customized Total Knee Arthroplasty

Introduction Manipulation under anesthesia (MUA) is a standard treatment for arthrofibrosis after total knee arthroplasty (TKA), with reported rates of 1.5-6%. Customized TKA may have better outcomes by matching individual patient anatomy. However, a previous study reported an unacceptably high rate of MUA for customized TKAs. This study reports the incidence of MUA in a large cohort of second generation customized TKAs. Methods:Data was collected prospectively on 360 2nd generation ConforMIS iTotal cruciate retaining TKAs. MUA was performed for clinically significant arthrofibrosis. Range of motion (ROM) and New Knee Society Scores (KSS) were evaluated at regular intervals for two years. Results: 11/360 (3.05%) knees underwent MUA. ROM overall improved from 115° to 125°, and from 112° to 122° in patients undergoing MUA. KSS objective and functional scores in MUA patients increased from 57 to 98 and 41 to 90, respectively, and in the entire cohort increased from 65 to 96 and 45 to 86 at 2 years (p&lt;0.05). No MUA patients underwent revision surgery. Discussion and Conclusion:Customized TKA with second generation ConforMIS iTotal implants results in a MUA rate consistent with the literature for all designs. Additionally, patients exhibit significant increases in ROM and Knee Society Scores.

Outcomes of Surgical Repair of Skull Base Defects Following Endonasal Pituitary Surgery: A Retrospective Observational Study.

Skull base defects following endonasal surgery for pituitary macroadenoma need to be addressed during the surgery to prevent serious postoperative complications like cerebrospinal fluid (CSF) leak. The objective of this study is to assess the incidence of CSF leak following pituitary surgery and the methods of effective skull base repair. This is a retrospective observational study conducted in a tertiary care hospital after obtaining due clearance from the Institutional ethics committee. The charts of patients who underwentendonasal pituitary surgery between 2013 and 2018 were studied and details noted. Patients undergoing revision surgery or with history of preoperative radiotherapy were excluded from the study. 52 patients were included in the study.Based on the type of CSF leak, the patients were grouped into four. 19 patients (36.5%) had an intraoperative CSF leak. 3 patients developed a postoperative CSF leak. Based on the histopathology, 4 patients had ACTH secreting tumor. 8 patients had growth hormone secreting tumor, 22 had gonadotropin secreting tumor, 9 patients had a non-functioning tumour and 9 patients had prolactinoma. The type of skull base repair performed in these patients were grouped into 4.18 patients underwent type I repair, 21 patients underwent type II repair, 8 patients underwent type III repair and 5 patients underwent type IV repair. We have observed that the pedicled nasoseptal flap is particularly advantageous over other repair techniques, especially in low pressure leaks. The strategy for skull base repair should be tailored to suit each patient to minimise the occurrence of morbidity and the duration of hospital stay.

Incidence for Tip Foldover During Cochlear Implantation.

Incidence and clinical presentation of tip foldover during cochlear implantation (CI). Retrospective case review. Tertiary referral university hospital. One thousand three hundred twenty CI recipients who underwent postoperative Stenvers view, digital computed tomography (CT), or digital volume tomography (DVT). Tip foldover rates were evaluated with regard to perimodiolar (PM), lateral wall (LW), and mid-scalar (MS) electrode carriers; the electrode insertion angle was estimated and postoperative complications and the necessity for revisions were described. One thousand three hundred twenty CI recipients (1,722 ears) had detailed surgery reports and postoperative imaging available for review. Tip foldover occurred in 15 ears (0.87%) with the highest rate (1.67%) for PM electrodes. In three patients tip foldover was accompanied by costimulation of the facial nerve and one patient reported vertigo. Eleven patients underwent revision surgery. In two of them revision was performed in the same surgical intervention due to abnormality in spread of excitation measurement. In four patients no revision was conducted due to uncompromised aided speech perception. In a large academic center with experienced surgeons, tip foldover verified by CT/DVT arose at a rate of 0.87%. PM electrode carriers inherited the highest risk for this electrode malposition. Revision surgery was feasible in these cases.

Mid- and long-term effects and related factors of metal-on-metal hip resurfacing arthroplasty

Objective To investigate the mid- and long-term effects of metal-on-metal hip resurfacing arthroplasty(HRA), and to analyze its related factors. Methods A total of 64 patients (81 hips) who underwent metal-on-metal HRA from June 2005 to January 2013 were recruited in the present study. There were 35 males (44 hips) and 29 females (37 hips) with the mean age of 48.26±10.45 years (20-65 years), including 47 unilateral and 17 bilateral HRAs. The cohort consisted of osteoarthritis secondary to the developmental dysplasia of the hip (23 cases, 29 hips), necrosis of the femoral head (19 cases, 22 hips), osteoarthritis (8 cases, 10 hips), rheumatoid arthritis (5 cases, 9 hips), ankylosing spondylitis (6 cases, 8 hips), pigmented villonodular synovitis (2 cases, 2 hips) and Otto's disease (1 case, 1 hip). During the follow-up duration, radiographic features, including acetabular inclination angle, stem-femoral shaft angle, component loosening, osteolysis, femoral neck narrowing and heterotopic ossification, were evaluated by hip X-rays in straight and froglike position. The size and type of pseudotumor were assessed by MRI and ultrasonography. Clinical efficacy was evaluated by Harris hip score and the University of California at Los Angeles (UCLA) hip score. Considering revision surgery as the end point, the component survivorship was calculated. Results The mean follow-up was 7.98±2.21 years, ranging from 5.0 to 12.8 years. The mean postoperative Harris hip score (92.01±5.69) was higher than the preoperative score (41.93±9.09). The mean postoperative UCLA pain, walking, function, activity scores (9.37±0.86, 9.14±1.01, 8.77±1.09, 6.47±1.27, respectively) were improved when compared with the preoperative UCLA scores (3.57±1.23, 5.99±1.30, 5.00±1.01, 3.84±1.41, respectively). The postoperative flexion, abduction and adduction, medial and lateral rotation of the hip was larger than the preoperative ones. Complications occurred in 10 hips (12.3%, 10/81). Seven patients (8 hips) experienced early and intermediate complications, including one intraoperative femoral nerve injury, one deep femoral artery and saphenous nerve injuries during the same surgery, one unexplained pain of hip, one femoral neck fracture, three hips of heterotopic ossification, and one pseudotumour. There were mid- and long-term complications in two hips, including one narrowing of the neck and one pseudotumour which was occurred at 9 years. There was one patient (2 hips) underwent revision surgery twice at 5 months and 9 years. The former cause of revision was femoral neck fracture and the latter one was pseudotumour. The Kaplan-Meier survivorship was98.8% at five years, and 95.0% at ten years. Conclusion Patients who underwent metal-on-metal HRA could obtain good mid- and long-term results. Pseudotumour and unexplained pain of the hip are critical factors which can affect the mid- and long-term results and survivorship of metal-on-metal HRA. Key words: Arthroplasty, replacement, hip; Postoperative complications; Treatment outcome

FA07.06: PERSISTENT DYSPHAGIA IS A RARE PROBLEM AFTER LAPAROSCOPIC NISSEN FUNDOPLICATION

Abstract Background Although around 30% of patients with gastroesophageal-reflux disease (GERD) are insufficiently treated with medical therapy, only 1% opt for surgical therapy. One of the reasons behind this multifactorial phenomenon is the described adverse effect of long term dysphagia or gastric bloating syndrome after surgical treatment. Aim of this study was to evaluate the most common side effects associated with anti-reflux surgery, as well as long term outcomes in a large cohort of highly surgically standardized patients after laparoscopic Nissen fundoplication (LNF). Methods Out of a prospective patients database including all patients that underwent anti-reflux surgery between 01/2003 and 01/2017 at our institution, 350 consecutive patients after highly standardized LF were included in this study. A standardized interview was performed by one physician assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD-Health-related-Quality-of-Life (GERD-HRQL), Alimentary Satisfaction (AS), and patients overall satisfaction. Results After a median follow-up of 4 years, persistent dysphagia (PD) after LNF was observed in 8 (2%) patients, while postoperative gas-bloat syndrome in 45 (12.7%) cases. Endoscopic dilatation was needed in 7 (2%) patients due to dysphagia, and 19 (5%) patients underwent revision surgery due to recurrence of GERD. The postoperative GERD-HRQL total score was significantly reduced (2 (IQR, 0–4.3) vs. 19 (IQR, 17–32); P &lt; 0.000) and the median alimentary satisfaction (AS) was 9/10. Heartburn relief was achieved in 83% of patients. Eighty-three percent of patients were free of PPI intake after follow up, whereas 4% of the patients reported irregular PPI-use. Conclusion LNF is a safe and effective surgical procedure with low postoperative morbidity rates and efficient GERD-related symptom relief. PD does not represent a relevant clinical issue when LNF is performed in a surgical standardized way. These results should be the benchmark to which long-term outcomes of new surgical anti-reflux procedures are compared. Disclosure All authors have declared no conflicts of interest.

Persistent dysphagia is a rare problem after laparoscopic Nissen fundoplication

BackgroundAlthough around 30% of patients with gastroesophageal reflux disease (GERD) are insufficiently treated with medical therapy, only 1% opt for surgical therapy. One of the reasons behind this multifactorial phenomenon is the described adverse effect of long-term dysphagia or gastric bloating syndrome after surgical treatment. Aim of this study was to evaluate the most common side effects associated with anti-reflux surgery, as well as long-term outcomes in a large cohort of highly surgically standardized patients after laparoscopic Nissen fundoplication (LNF).MethodsOut of a prospective patients’ database including all patients that underwent anti-reflux surgery between 01/2003 and 01/2017 at our institution, 350 consecutive patients after highly standardized LNF were included in this study. A standardized interview was performed by one physician assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD-Health-Related-Quality-of-Life (GERD-HRQL), Alimentary Satisfaction (AS), and patients’ overall satisfaction.ResultsAfter a median follow-up of 4 years, persistent dysphagia (PD) after LNF was observed in 8 (2%) patients, while postoperative gas-bloat syndrome in 45 (12.7%) cases. Endoscopic dilatation was needed in 7 (2%) patients due to dysphagia, and 19 (5%) patients underwent revision surgery due to recurrence of GERD. The postoperative GERD-HRQL total score was significantly reduced (2 (IQR 0–4.3) vs. 19 (IQR 17–32); p < 0.000) and the median AS was 9/10. Heartburn relief was achieved in 83% of patients. Eighty-three percent of patients were free of PPI intake after follow-up, whereas 13% and 4% of the patients reported daily and irregular PPI use, respectively.ConclusionLNF is a safe and effective surgical procedure with low postoperative morbidity rates and efficient GERD-related symptom relief. PD does not represent a relevant clinical issue when LNF is performed in a surgical standardized way. These results should be the benchmark to which long-term outcomes of new surgical anti-reflux procedures are compared.

A Comparative Study Between Uncemented and Hybrid Total Hip Arthroplasty in Octogenarians

BackgroundThe aim of this prospective cohort study is to evaluate the outcome of octogenarian patients undergoing uncemented total hip arthroplasty (THA) with a control group of similarly aged patients undergoing hybrid THA with a minimum 5-year follow-up. MethodsClinical outcomes including intraoperative and postoperative complications, blood transfusion, revision rate, and mortality were recorded. Radiological analysis of preoperative and postoperative radiographs assessed bone quality, implant fixation, and any subsequent loosening. ResultsOne hundred forty-three patients (mean age 86.2 years) were enrolled in the study. Seventy-six patients underwent uncemented THA and 67 underwent hybrid THA. The uncemented cohort had a significantly lower intraoperative complication rate (P = .017) and also a lower transfusion rate (P = .002). Mean hospital stay (P = .27) was comparable between the 2 groups. Two patients underwent revision surgery in each cohort. ConclusionOur study demonstrates that uncemented THA is safe for the octogenarian patient and we recommend that age should not be a barrier to the choice of implant. However, intraoperative assessment of bone quality should guide surgeons to the optimum decision regarding uncemented and hybrid implants. Level of evidence3.

Posterior pelvic ring fractures: Intraoperative 3D-CT guided navigation for accurate positioning of sacro-iliac screws.

Posterior pelvic ring fractures frequently pose a problem of stability with an elevated risk of complications. The traditional method of percutaneous sacroiliac (SI) stabilization with the use of fluoroscopic image amplifiers demands a high degree of experience and has an elevated risk of screws' malpositioning. Intraoperative 3D-CT scan coupled with a navigation system (O-Arm©) can allow screw fixation accuracy while limiting the risk of complications for the treatment of posterior pelvic ring fractures. Patients with posterior pelvic ring fractures stabilized with percutaneous SI screws through O-Arm© navigation from August 2008 to December 2017 were analyzed. A modified Gras classification was used to determine screws' positioning under CT visualization, and intraoperative and early postoperative complications were documented. Among the 21 patients evaluated, 14 men and 7 women with a mean age of 57.8 years (range 25-91), receiving 39 screws, the rate of misplacement was low: 82% grade I, 15.4% grade II, and only 2.6% grade III. Only one patient underwent revision surgery, not because of misplacement but rather for a secondary implant loosening. No complications occurred in this series. This study documented a large series of patients treated for pelvic ring fractures using the intraoperative 3D-CT O-Arm© guided navigation. This surgical approach provided a precise and safe SI screw positioning with no complications. IV, Retrospective study.

An Age and Activity Algorithm for Treatment of Type II SLAP Tears.

Background:Type II SLAP tears predominantly occur in males between their third and fifth decades of life. The mechanism of injury is often repeated overheard activity but can also occur due to direct compression loads and traction injuries. The treatment options have changed over the years and include non-operative therapy, direct labral-biceps complex repair, and labral debridement with biceps tenodesis or tenotomy.Objective:To review the existing literature on the management of Type II SLAP tears and provide clinical recommendations based on patient age and activity level.Methods:A review of the existing literature through October 2017 investigating the management of Type II SLAP tears was performed. Emphasis was placed on distinguishing the outcomes based on age and activity level to provide an appropriate treatment algorithm.Results:Patients with Type II SLAP tears should first be trialed with non-operative management and many patients will have a successful result with ability to return to their respective sports or activities. Surgical management should be considered if non-operative management does not provide symptomatic relief. Young, athletic, or high-demand patients should be treated with a SLAP repair while biceps tenodesis should be considered for older or worker’s compensation patients. Patients undergoing revision surgery for a failed SLAP repair should be managed with biceps tenodesis.Conclusion:Type II SLAP tears remain a difficult pathology to manage clinically, but the treatment indications are narrowing. The age and activity algorithm described in this review provides an effective method of managing this complex clinical condition.

The Incidence of Glenohumeral Bone and Cartilage Lesions at the Time of Anterior Shoulder Stabilization Surgery: A Comparison of Patients Undergoing Primary and Revision Surgery

Background: Intra-articular glenohumeral joint changes frequently occur after shoulder instability events. Purpose: (1) To compare demographic characteristics, baseline patient-reported outcomes, and intraoperative findings for patients undergoing primary or revision shoulder stabilization surgery and (2) to determine the incidence of glenohumeral bone and cartilage lesions in this population while identifying factors independently associated with these lesions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group shoulder instability database was used to identify all prospectively enrolled patients undergoing shoulder stabilization surgery for anterior instability between October 2012 and September 2016. Any patient who underwent surgery for posterior or multidirectional shoulder instability or concomitant rotator cuff repair surgery was excluded. Patient demographic characteristics, preoperative patient-reported outcomes, and intraoperative findings, including glenohumeral bone and cartilage lesions, were compared for patients undergoing primary and revision shoulder stabilization surgery. Additionally, patients with and without glenohumeral bone and cartilage lesions were compared and independent associations determined using multivariate analysis. Results: There were 545 patients available for analysis (461/545 [84.6%] primary; 84/545 [15.4%] revision). Patients undergoing revision surgery were older (P = .001), were more frequently smokers (P = .022), had a greater number of instability events before surgery (P = .047), more frequently required reduction assistance (P < .001), and had lower Short Form–36 (SF-36) Mental Component Summary (P = .020) and Western Ontario Shoulder Instability Index (WOSI) (P = .026) scores preoperatively. Additionally, patients undergoing revision surgery had a higher frequency of bone and cartilage lesions than those undergoing primary surgery (47.6% vs 18.4%, respectively; P < .001). Male sex, revision surgery, black race, increasing body mass index, increasing patient age, and lower preoperative SF-36 Physical Component Summary score were independently associated with the presence of glenohumeral bone and cartilage lesions at the time of shoulder stabilization surgery. Revision surgery was strongly associated with the presence of glenohumeral bone and cartilage lesions (odds ratio [OR], 4.381 [95% CI, 2.591-7.406]) and glenoid bone loss greater than 10% (OR, 9.643 [95% CI, 5.128-18.134]) or 20% (OR, 13.076 [95% CI, 5.113-33.438]) of the glenoid width. Conclusion: Glenohumeral bone and cartilage lesions are common at the time of shoulder stabilization surgery, occurring more frequently in patients undergoing revision surgery as compared with primary surgery. On the basis of these findings, future prospective studies should aim to compare the clinical outcomes in these 2 groups.

Latissimus Dorsi Tendon Transfer with or Without Superior Capsular Reconstruction for Treatment of Irrepairable Rotator Cuff Tears

Objectives:Treatment options for massive irreparable rotator cuff tears, in middle aged adults, consists of tendon transfer or superior capsular reconstruction (SCR). The purpose of this study was to evaluate if transfer of the latissimus dorsi tendon transfer is enhanced with combination of superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.Methods:At a single institution, all consecutive patients undergoing transfer of the latissimus dorsi tendon with or without superior capsular reconstruction, between 2013 and 2016, for treatment of irreparable rotator cuff tears were evaluated. SCR, was indicated, in addition to latissimus transfer, for patients with impaired preoperative active abduction. All clinical notes, diagnostic imaging, and operative reports were reviewed in detail. Demographics, operative techniques, and radiographic parameters were collected and measured. Functional outcome scores were prospectively collected from patients. The primary outcome of the study was the Disability of Arm, Shoulder, Hand (DASH) score. The secondary outcomes of the study were the Visual Analog Scale (VAS) pain score, Single Assessment Numeric Evaluation (SANE) score, and the American Shoulder and Elbow Society (ASES) score.Results:At 3 years, there were a total of 26 latissimus dorsi tendon transfers performed in patients with irreparable rotator cuff tears. Of these, 8 patients underwent only latissimus dorsi tendon transfer and 18 patients underwent latissimus dorsi tendon transfer combined with a superior capsular reconstruction. Average age was 53 years old with the majority of patients being male (88%). The dominant extremity was involved in 22 (85%) of latissimus transfers and 14 (53%) of patients had previous surgery to address a rotator cuff tear. Follow-up, for the entire cohort, was on average 29 months. At final follow-up, there was no significant difference in physical examination or radiographic measurements between patients with latissimus transfer alone and those with latissimus transfer with SCR. All patients, undergoing either technique, showed significant improvement in both the DASH score (preoperative DASH=59.6, postoperative DASH=39.9, P=0.049) and VAS score (preoperative VAS=6.6, postoperative VAS=3.3, P=0.0006). However, those patients undergoing revision surgery, regardless of technique, showed significantly less improvement in the DASH score (P=0.005), VAS score (P=0.002), SANE score (P=0.005), and the ASES score (P=0.001). Transfer of the Latissimus tendon with SCR, in comparison to only tendon transfer, did not show any significant difference in the final DASH score (p-value=0.72). At the same time, there was no significant difference between latissimus transfer, with or without SCR, in the secondary outcomes of the VAS score(P=0.97), the SANE score(P=0.63), or the ASES score (P=0.74).Conclusion:This is the first study to report the outcomes of latissimus dorsi tendon transfer with superior capsular reconstruction in comparison to only latissimus dorsi tendon transfer for treatment of irreparable rotator cuff tears. The study suggests that transfer of the latissimus dorsi tendon in combination with superior capsular reconstruction, at short term follow-up of 2 years, may not significantly influence functional outcome. Rather, patients undergoing revision surgery, regardless of technique, may demonstrate smaller improvements in functional outcomes.Table 2.Range of Motion & Physical Examination in Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8) Lat + SCR (n=18) Preoperative Postoperative P-Value Preoperative Postoperative P-Value Range of Motion (Active) Abduction135 ± 21.276.4 ± 180.0475.4 ± 26.071.5 ± 220.80Forward Flexion106.9 ± 36.7135.7 ± 32.20.15103.5 ± 32.2110.6 ± 45.40.35External Rotation36 ± 11.442.9 ± 150.8025.3 ± 18.638.5 ± 16.30.04Internal Rotation65 ± 22.959.3 ± 12.40.5554.4 ± 13.363.1 ± 13.00.08Hornblower Sign2 (25%)2 (25%)0.9814 (78%)2 (11%)0.07External Rotation Lag6 (75%)2 (25%)0.3417 (94%)3 (17%)0.01Continuous data are reported as mean ± standard deviation. Categorical data reported as number (%).Table 4.Functional Outcomes at Final Follow-Up of Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8) Lat + SCR (n=18) Mean (Std Dev)Mean (Std Dev)P-Value Primary Outcome DASH47.0 ± 39.842.5 ± 27.50.72 Secondary Outcome Vas3.14 ± 3.53.4 ± 3.50.97SANE54.7 ± 38.560.9 ± 22.10.63ASES65.8 ± 36.360.6 ± 30.90.74Constance63.8 ± 31.050.3 ± 23.30.34

Pre-operative and Post-Operative Alpha Angles are Significant Independent Predictors of Patient-Reported Outcome Measures at Two Years After Hip Arthroscopy

Objectives:Residual impingement after hip arthroscopy for femoroacetabular impingement (FAI) is a common cause for re-operation; however, the relationship between preoperative and postoperative radiographic parameters and patient-reported outcomes has not been defined.Methods:749 consecutive patients were reviewed two years after primary hip arthroscopy. Patients undergoing revision surgery were excluded. Pre-operative and post-operative radiographs were analyzed to measure the alpha angle on standardized anteroposterior (AP) pelvis, Dunn-lateral, and false profile (FP) views and anterior and lateral center-edge angles (ACEA, LCEA). Univariate analysis evaluated the association between demographic variables, radiographic measures and hip outcome scores (Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports Specific (SS), and Modified Harris Hip Score (mHHS)). Multivariate modeling was subsequently performed. Significance was defined as p<0.05.Results:706 patients with mean age of 33.2±12.3 years and mean BMI 25.1± 5kg/m2 were included for final analysis. The alpha angle on the AP, Dunn-lateral, and FP views and the ACEA and LCEA decreased after surgery (p<0.001 for all). Significant univariate correlations with the postoperative HOS-ADL included age, BMI, pre-operative AP, FP, and Dunn and postoperative FP alpha angles. Postoperative HOS-SS was correlated with age, BMI, medial post-operative joint space width (JSW), pre-operative AP, FP, and Dunn and postoperative FP alpha angles, and pre-operative and post-operative (ACEA). Postoperative mHHS correlated with age, BMI, post-operative lateral JSW, pre-operative AP, FP, and Dunn and postoperative FP and Dunn alpha angles, and post-operative ACEA. Multivariate modeling (Table 2) demonstrated that preoperative and postoperative FP alpha angles were independent predictors of postoperative outcomes.Conclusion:Pre-operative and post-operative alpha angles were negatively correlated with the HOS-ADL, HOS-SS, and mHHS at 2 years after arthroscopic surgery for FAI. Specifically, pre-operative and postoperative FP alpha angles were independent predictors of postoperative outcomes. These results highlight the importance of resecting anterior cam lesions to prevent residual impingement and inferior outcomes.Table 2:Multivariate Regression Results for Association Between Radiographic Measurements and Patient-Reported Outcome ScoresVariableCoefficientP Value HOS-ADL at 2 Years Pre-op HOS-ADL score0.29<0.001Workmen's compensation-8.510.045Pre-op AP alpha angle-0.180.039Post-op false profile alpha angle-0.420.030 HOS-SS at 2 Years Pre-op HOS-SS score0.33<0.001Workmen's compensation-18.70.016Pre-op AP alpha angle-0.430.005Pre-op false profile alpha angle-0.300.039 Modified Harris Hip Score at 2 Years Pre-op MHHS0.32<0.001Age-0.210.025Workmen's compensation-11.30.044Pre-op false profile alpha angle-0.170.046Post-op false profile alpha angle-0.520.040