Patients Underwent Revision Surgery Research Articles

Revision anterior cruciate ligament reconstruction with ipsi- or contralateral hamstring tendon grafts

With the increasing number of primary anterior cruciate ligament (ACL) reconstructions, the need for revision ACL surgery has risen over the past few years. The purpose of the present study is to retrospectively compare the clinical outcome of ipsilateral versus contralateral hamstring tendon autografts for ACL revision surgery, specifically with regard to patient satisfaction, post-operative functional outcomes, and return to sports. Between 2004 and 2011, 64 patients underwent ACL revision surgery. Forty-five were successfully recontacted and retrospectively reviewed at an average follow-up of 6.3years. Twenty-two subjects underwent revision ACL reconstruction with ipsilateral autogenous hamstring tendon grafts; in 23 subjects contralateral hamstring were used for reconstruction. Clinical, arthrometric, and functional evaluations were performed. The Tegner activity level, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) Subjective Knee Form were used. Objective evaluation included range of motion, Lachman test, pivot shift test and KT-1000 instrumented laxity testing. No major complications were reported. Follow-up examination showed that there were no significant differences in the IKDC and KOOS scores between the groups. No differences in anterior tibial translation as measured with KT-1000 arthrometer were reported between the groups, although there was a trend for more of the patients undergoing ipsilateral DGST reconstruction to have a glide on the pivot shift test. The percentage of patients returning to pre-injury level was high in both groups. The use of contralateral hamstring tendon autografts for ACL revision surgery produced similar subjective and objective outcomes at 6-years follow-up compared to revision with ipsilateral hamstring tendon autografts. Patients undergoing revision surgery with contralateral autografts experienced a quicker return to sports compared to patients who underwent ipsilateral DGST revision surgery.

Revision Surgery for Zygoma Reduction: Causes, Indications, Solutions, and Results from a 5-Year Review of 341 Cases

Many patients undergo a revision surgery after malar reduction, which is one of the most popular aesthetic surgeries in Asia. We reviewed the leading causes of revision for malar reduction surgery to establish proper indications for revision, seek adequate surgical strategies, and share the results from revision surgical cases. A retrospective review was conducted involving 341 patients who underwent malar reduction reoperation between March 2010 and June 2015. Surgical strategies were decided based upon specific problems and complaints from the previous surgery. Facial photographs, cephalography, and computed tomography images were analyzed, and a patient satisfaction survey was conducted before and after the surgery. A total of 341 patients (321 women, 20 men; average age, 26.6years, range 18-40years) were included. The main causes of reoperations were subjective dissatisfaction and nonunion-related symptoms. Undercorrection of the zygomatic body and arch (n=175, 51.3%) was the most frequent reason for dissatisfaction. The patients underwent revision surgeries via different techniques and strategies based on previous problems from primary surgery, and postoperative patient satisfaction was high. Complications occurred in 35 patients (10.3%) after revision. Based on the results of this study, patient dissatisfaction with the procedure can be minimized beforehand through accurate goal identification and careful planning. Bone nonunion is usually due to excessive bone resection during zygoma reduction surgery. Careful selection of the reposition site and appropriate fixation based on a thorough understanding of masseter action are essential in ensuring satisfactory outcomes without adverse side effects. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

X-tube assisted transforaminal lumbar interbody fusion for treatment of lumbar spinal stenosis with spinal instability

Objective To explore the surgical techniques and effects of X-tube assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF)in treating lumbar spinal stenosis with spinal instability. Methods A total of 33 patients with lumbar spinal stenosis with lumbar instability were admitted to Xuanwu Hospital of Capital Medical University from January 2013 to June 2015 and underwent X-tube assisted MIS-TLIF, whose data were retrospectively summarized in this study. The scores of the Japanese Orthopedic Association (JOA), visual analogue scale (VAS) and Oswestry disability index (ODI) were documented before and after operations to assess the treatment effects, and complications were documented as well.The results of lumber fusions were evaluated according to the Suk standard. Results Thirty-six lumbar segments of 33 patients were dealt with in this study. One patient underwent revision surgery due to displacement of the lumbar fusion cagecausing compression of the nerve root, and the final outcome was good. One patient developed infection in the surgical site 2 weeks post operation, was treated with immediate debridement and recovered well.The follow-up lasted for an average of 12.8±0.4 months. Compared with preoperative conditions, patients' postoperative JOA scores had significant improvement: (16.8±3.2) vs. (20.7±3.2), while the VAS, (4.4±1.4)vs.(1.6±1.3), and ODI, (15.9±7.2) vs.(37.7±16.0), both decreased significantly(P<0.01). The 12-month follow-up indicated that the fusion rate of vertebrae was good in 28 cases(85%)and acceptable in 5 cases(15%)according to the Suk standard. Lumbar computed tomography showed satisfactory effects of the lumber vertebra fusion. Conclusion Lumbar spinal stenosis with instability could be effectively treated by using the MIS-TLIF procedure with X-tube assistance. Key words: Spinal stenosis; Lumbar instability; Microsurgery; Transforaminal lumbar interbody fusion; Tube auxiliary

Elevated Intra-Articular Cobalt and Chromium Levels in Mechanically Assisted Crevice Corrosion in Metal-on-Polyethylene Total Hip Arthroplasty

BackgroundFailed total hip arthroplasty (THA) caused by mechanically assisted crevice corrosion (MACC) has serious consequences such as adverse local tissue reaction (ALTR). Serum cobalt (Co) and chromium (Cr) ion levels have been used to diagnose taper corrosion, but have not been shown to be an accurate measure of the severity of MACC or associated ALTRs. Additionally, elevated serum ions are not specific in patients with multiple artificial joints. MethodsWe examined the relationship between serum and intra-articular (IA) Co and Cr levels in a cohort of 20 patients undergoing revision THA, 16 who had symptomatic MACC. IA Co and Cr levels in MACC patients were compared with demographic, pre-operative, and operative findings. ResultsSerum and IA metal levels were found to be relatively low in THA patients undergoing revision surgery for isolated instability, aseptic loosening, or infection (average serum Co 0.03 ppb [parts per billion], IA Co 1.4 ppb, serum Cr 0.32 ppb, IA Cr 3.3 ppb). In patients with MACC, average IA Co (940 ppb) was significantly higher than serum Co (5.1 ppb) (P = .0003) and IA Cr (491 ppb) was significantly higher than serum Cr (1.3 ppb) (P = .0003). IA Co level was associated with shorter time of hip symptoms to revision surgery (P = .0043). ConclusionSerum levels of Co and Cr correlated with joint levels in the entire cohort, but IA levels of MACC patients were 100 times greater than serum levels. IA Co and Cr levels may be useful in confirming MACC in a specific joint and the striking elevation may explain symptoms and ALTR with relatively low serum values.

Intramedullary and Intra-Osseous Arthrodesis of the Hallux Metatarsophalangeal Joint

To review the outcome of arthrodesis of the hallux metatarsophalangeal (MTP) joint in 23 patients. Records of 9 men and 14 women aged 27 to 88 (mean, 57) years who underwent arthrodesis of the hallux MTP joint using an intramedullary device and an intra-osseous device were reviewed. Indications for surgery were severe hallux valgus (n=15), hallux rigidus (n=6) and rheumatoid arthritis (n=2). Outcome measures included visual analogue score (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, bone union, hallux valgus angle (HVA), dorsiflexion angle (DA), complications, revision, and patient satisfaction. The mean follow-up was 19 (range, 6-38) months. The mean AOFAS score improved from 29 to 75.4 (p<0.0001) and the mean VAS for pain improved from 8.1 to 2.4 (p<0.0001). 20 (86%) of the patients were satisfied with the outcome. The mean HVA was 14º and the mean DA was 22º. 19 (83%) of the toes had a well-aligned hallux. 21 (91%) of the patients achieved arthrodesis of the hallux MTP joint. The remaining 2 patients underwent revision surgery for failed fusion or infected non-union; they continued to have transfer metatarsalgia despite bone union. The intramedullary and intra-osseous devices for arthrodesis of the hallux MTP joint achieved good outcome in terms of AOFAS score, VAS for pain, HVA, DA, bone union, and patient satisfaction.

Lack of stability at more than 12 months of follow-up after anterior cruciate ligament reconstruction using all-inside quadruple-stranded semitendinosus graft with adjustable cortical button fixation in both femoral and tibial sides

IntroductionThe use of the semitendinosus tendon alone for anterior cruciate ligament reconstruction keeps the gracilis muscle intact and decreases anterior pain in comparison with the use of the patellar tendon. Recently, Lubowitz described a new all-inside technique with an ST4 tendon fixed with a cortical button in both femoral and tibial sides. We hypothesized that this type of graft with cortical button fixation provides well-controlled residual anterior tibial translation (<3mm).The aim of this study was to assess the results obtained with this technique in terms of laxity and IKDC score at more than 1 year of follow-up. Material and methodsWe performed a prospective single-center study to evaluate the results with this procedure with at least 1 year of follow-up. The primary endpoint was the objective IKDC score and side-to-side anterior tibial translation difference. The secondary endpoint was the subjective assessment using the subjective IKDC and Lysholm scores. Tunnel positioning was assessed using the Aglietti criteria. ResultsThirty-five patients were included and reviewed with a mean follow-up of 19.7 months. Sixty-three percent of the patients were male and the mean age at the procedure was 28 years. The IKDC score was A or B in 43% of the patients and C or D in 57%; 54% of the patients had a residual side-to-side anterior tibial translation difference less than 3mm and 29% presented significant pivot shift (grade C or D). Five patients underwent revision surgery, including one for rupture of the ACL reconstruction. The meniscal status did not influence postoperative laxity and the IKDC grade. DiscussionOur hypothesis was not verified and the postoperative stability of the knee was insufficient. Postoperative side-to-side anterior tibial translation difference remained greater than 3mm for 16 patients and the analysis seems to indicate that the distal cortical fixation of the graft with an adjusted loop is insufficient. Level of evidenceProspective study – Level IV.

Endoscopic Transretracaruncular-Middle Meteas Tract for Insertion of a Porous Polyethylene-Coated Jones Tube.

The purpose of this article is to describe a modified lacrimal bypass with a porous polyethylene-coated Jones tube. A total of 180 patients (180 eyes) with a nonreconstructable lacrimal obstruction underwent lacrimal bypass with a porous polyethylene-coated Jones tube through a retrocaruncular-middle meatus tract approach with endoscopic assistance. All patients were followed up at least for 24 months. Success rate of lacrimal bypass was analyzed and complications were recorded. A total of 174 patients were finally included. Duration of surgery ranged from 28 to 47 minutes (mean 37.2 ± 4.2 minutes). The mean duration of follow-up was 30.0 ± 6.4 months (range 24-48 months). The mean tube length was 23.2 ± 1.9 mm (range 20-28 mm). At the final review, complete success was achieved in 138 (79.3%) patients. Moderate success was achieved in 23 (13.2%) patients, and 13 (7.5%) patients failed. Of the 161 patients successfully treated, 24 patients underwent revision surgery to excise granulomas (15 patients) or adjust tube position (9 patients). The complications included granuloma proliferation around the openings of the tube (28 eyes), downward displacement of the tube (17 eyes), and ocular discomfort (15 eyes). The majority of downward tube migration occurred in patients who had a prior history of dacryocystorhinostomy. The treatment failed for 5 patients because of repeated granulomas covering the nasal tube openings, and the treatment failed for 8 patients because of downward displacement of the tube. Our procedure appears to be an effective method for closed insertion of a porous polyethylene-coated Jones.

Iatrogenic Hip Instability Is a Devastating Complication After the Modified Dunn Procedure for Severe Slipped Capital Femoral Epiphysis.

The modified Dunn procedure facilitates femoral capital realignment for slipped capital femoral epiphysis (SCFE) through a surgical hip dislocation approach. Iatrogenic postoperative hip instability after this procedure has not been studied previously; however, we were concerned when we observed several instances of this serious complication, and we wished to study it further. The purpose of this study was to evaluate the frequency, timing, and clinical presentation (including complications) associated with iatrogenic instability after the modified Dunn procedure for SCFE. Between 2007 and 2014, eight international institutions performed the modified Dunn procedure through a surgical dislocation approach in 406 patients. During the period in question, indications varied at those sites, but the procedure was used only in a minority of their patients treated surgically for SCFE (31% [406 of 1331]) with the majority treated with in situ fixation. It generally was performed for patients with severe deformity with a slip angle greater than 40°. Institutional databases were searched for all patients with SCFE who developed postoperative hip instability defined as hip subluxation or dislocation of the involved hip during the postoperative period. We reviewed in detail the clinical notes and operative records of those who presented with instability. We obtained demographic information, time from slip to surgery, type of fixation, operative details, and clinical course including the incidence of complications. Followup on those patients with instability was at a mean of 2 years (range, 1-5 years) after the index procedure. Complications were graded according to the modified Dindo-Clavien classification. Radiographic images were reviewed to measure the preoperative slip angle and the presence of osteonecrosis. A total of 4% of patients treated with the modified Dunn procedure developed postoperative hip instability (17 of 406). Mean age of the patients was 13 years (range, 9-16 years). Instability presented as persistent hip pain in the postoperative period or was incidentally identified radiographically during the postoperative visit and occurred at a median of 3 weeks (range, 1 day to 2 months) after the modified Dunn procedure. Eight patients underwent revision surgery to address the postoperative instability. Fourteen of 17 patients developed femoral head avascular necrosis and three of 17 patients underwent THA during this short-term followup. Anterolateral hip instability after the modified Dunn procedure for severe, chronic SCFE is an uncommon yet potentially devastating complication. Future studies might evaluate the effectiveness of maintaining anterior hip precautions for several weeks postoperatively in an abduction brace or broomstick cast to prevent this complication. Level IV, therapeutic study.

Tumorprothesen in der endoprothetischen Revisionschirurgie der unteren Extremität – Ergebnisse von 25 Patienten nach Versorgung mit einem modularen Tumor- und Revisionssystem (MUTARS®)

Introduction/Background: With extended life expectancy, the number of primary joint arthroplasties has also increased. Revision surgery is also more often necessary, due to aseptic or septic loosening of the prosthesis or periprosthetic fracture. Large bone defects often occur in these patients and several non-modular, conventional implants are available to handle this difficult situation. Custom made implants offer an individually designed and defect-adapted shape with perfect covering of the lesion, but may delay the operation. The Modular Universal Tumor And Revision System (MUTARS®) offers the possibility to vary the length and angle of the femoral neck and the antetorsion angle. Thus, it permits intraoperative adaption to the individual patient's defect. The aim of our study is to present clinical, functional results and the rate of complications in a cohort of patients undergoing revision surgery for failed endoprosthetic replacement or failed trauma surgery, using the Modular Universal Tumor And Revision System with short-to midterm follow-up. Patients and Methods: Between August 2005 and September 2014, 25 patients (17 female, 8 male) with an average age of 72 years (min. 56, max. 92 years) were included in a retrospective study using the MUTARS® system. The patients underwent surgical revision of osseous defects that were not susceptible to conventional care. The mean follow-up was 16 months (min. 12, max. 72 months). The indications which led to revision surgery were as follows: loosened metal-on-metal prosthesis with an acetabular defect caused by a metal-induced granuloma (n = 1), pseudoarthrosis after implantation of femur nail (n = 2), cut-out of a femur nail (n = 1), aseptic loosening of an implanted endoprosthesis (n = 4), septic loosening of an implanted endoprosthesis (n = 1), periprosthetic fracture (n = 6) and periprosthetic infection after two stage revision surgery (infection consolidated Girdlestone situation) (n = 10). All patients were followed up at regular intervals, both clinically and radiologically. Apart from comorbidities, clinical and functional parameters were measured, including the Harris Hip Score. An outcome analysis was also performed with respect to peri- and postoperative complications. Serial plain X-rays were followed-up. Results: In all patients, stable reconstruction without the use of an allograft was possible. In total, 23 patients underwent surgery by using a proximal femur prosthesis; three patients also received a custom made acetabular component. One patient was treated by using a distal femur and one patient was treated by implantation of a total femur prosthesis. The average length of hospital stay was 25 days (min.11, max. 47 days). The Harris Hip Score improved from 28 points preoperatively to 81 points after surgery.In total we recorded 24 % of complications after surgery. Two patients suffered recurrent periprosthetic infection and the prosthesis had to be revised in a further two stage exchange; one patient had a tractus gap and was revised by surgery. Two patients suffered periprosthetic fracture due to trauma and the patient with the total femur prosthesis suffered recurrent periprosthetic infection of the silver - coated mega-prosthesis and committed suicide triggered by an episode of major depression. Conclusion: Because of its modular nature, the Modular Tumor And Revision System (MUTARS®) can be used for highly variable intraoperative defect adaption. Good clinical and functional results were achieved in patients with excessive bone defects. However, the high rate of infection, even with silver coated mega-implants, is still a problem and should be studied further.

A Prospective Comparative Study of Arthroscopic Versus Mini-Open Latarjet Procedure With a Minimum 2-Year Follow-up

To compare postoperative pain during the first postoperative week and the position of the coracoid bone block at the anterior aspect of the glenoid after the arthroscopic and the mini-open Latarjet procedure. The secondary purpose was to assess functional results and recurrence after at least 2years of follow-up. This comparative prospective study included patients who underwent a Latarjet-Bristow procedure for anterior shoulder instability in 2012. The Latarjet procedure was performed by a mini-open approach (G1) in one center and by an arthroscopic approach (G2) in the other. The main evaluation criterion was average shoulder pain during the first postoperative week assessed by the patient on a standard 10-cm visual analog scale (0-10). Secondary criteria were consumption of analgesics during the first week, the position of the coracoid bone block on radiograph and computed tomography scan at the 3-month follow-up and clinical outcomes (Western Ontario Score Index and new surgery) after at least 2years of follow-up. Fifty-eight patients were included, 22 G1 and 36 G2, 13 women and 45 men, mean age 26.9 ± 7.7years. The mean follow-up was 29.8 ± 4.4months. There was significantly less pain in the arthroscopic Latarjet group than in the mini-open group during the first postoperative week (2.5 ± 1.4 vs 1.2 ± 1.2, P= .002) with comparable consumption of analgesics (P > .05). The arthroscopic Latarjet procedure resulted in a more lateral coracoid bone block (P= .04) and a better equatorial position than the mini-open technique (P= .02). Three patients underwent revision surgery (1 recurrence [2.8%], 1 block fracture, 1 screw ablation) in the arthroscopic group, none in the mini-open group (P= .54). At the final follow-up, the Western Ontario Score Index score was good in all patients (G1: 78.5 ± 7.5% vs G2: 82.3 ± 7%, P= .03). This prospective comparative study showed that the arthroscopic Latarjet procedure was significantly less painful than the mini-open procedure during the first postoperative week. The clinical outcomes were comparable after at least 2years of follow-up. Level II, prospective comparative study.

Predicting revision sinus surgery in allergic fungal and eosinophilic mucin chronic rhinosinusitis.

Chronic rhinosinusitis consists of several disease processes. Eosinophilic mucin is found in the subtypes of allergic fungal sinusitis (AFS) and eosinophilic mucin chronic rhinosinusitis (EMCRS). These entities frequently require surgical intervention and have high recurrence rates. We aimed to determine factors in patients with AFS and EMCRS that may be associated with a higher rate of revision surgeries. Our hypothesis is that patients who have polyps, high Lund-Mackay score (LMS), and fungus may have higher revision rates. Retrospective cohort study. This is a retrospective analysis of 117 patients identified over a 5-year period (2005-2009) with the diagnosis of AFS or EMCRS. Contingency tables were created to obtain the odds ratios estimates, and 95% confidence intervals were used to access the association between the outcome (having revision surgery or not) and other clinical binary predictors. Twenty-six of 117 (22%) of the study patients underwent revision surgery. Within the 2-year follow-up period, an additional five of 26 (19%) required another revision surgery. Average LMS was slightly higher in those who underwent revision surgery (16 vs. 13) on a scale of 0 to 24, with an overall mean score of 18 and standard deviation of 6.82 for the whole sample (117). Other factors evaluated were the presence of fungus, polyps, eosinophilic mucin, and the eosinophilic count and medical therapy received. The presence of eosinophilic mucin was significantly associated a higher rate of revision surgery. 4. Laryngoscope, 127:59-63, 2017.

Epidemiology of Dislocation Following Direct Anterior Total Hip Arthroplasty: A Minimum 5-Year Follow-Up Study

BackgroundThe cumulative mid- to long-term risk of dislocation following total hip arthroplasty is considerably greater than has been reported in short-term studies. We retrospectively investigated the epidemiology of first-time dislocation following total hip arthroplasty using 28-mm heads through the direct anterior approach in patients with hip dysplasia who were followed up for more than 5 years. MethodsThe operative records of 871 hips in 790 consecutive patients were reviewed to determine the incidence of postoperative first-time dislocation. ResultsThe mean follow-up duration was 7.8 (range, 5.6-11.7) years. The direct anterior approach was used for all hips. Postoperative dislocation was observed in 8 hips (0.92%) in 8 patients. First-time dislocation occurred during the first 3 weeks in 6 hips (75%). The cumulative risk of postoperative dislocation was 0.69% at 1 month, 0.80% at 1 year, and 0.93% at 5 years. One patient underwent revision surgery for recurrent dislocation within the first month due to malalignment of the cup. ConclusionOur findings demonstrated that the direct anterior approach limits the time of dislocation to the very early postoperative period; that is, the risk of a first-time dislocation after the first month is considerably low. Preserving muscular structures may contribute to continuous dynamic stability of the hip, which could explain the slight increase in the cumulative risk of first-time dislocation.

Preoperative Risk Factors Associated With Poor Outcomes of Revision Surgery for “Pseudotumors” in Patients With Metal-on-Metal Hip Arthroplasty

BackgroundRevision surgery of failed metal-on-metal (MoM) total hip arthroplasty (THA) for adverse tissue reaction (pseudotumor) can be challenging as a consequence of soft tissue and muscle necrosis. The aims of this study were to (1) report the revision outcomes of patients who underwent revision surgery for failed MoM hip arthroplasty due to symptomatic pseudotumor and (2) identify preoperative risk factors associated with revision outcomes. MethodsBetween January 2011 and January 2013, a total of 102 consecutive large head MoM hip arthroplasties in 97 patients (male: 62, female: 35), who underwent revision surgery were identified from the database of a multidisciplinary referral center. ResultsAt minimum follow-up of 2 years (range: 26-52 months), at least one complication had occurred in 14 of 102 revisions (14%). Prerevision radiographic loosening (P = .01), magnetic resonance imaging (MRI) findings of solid lesions with abductor deficiency on MRI (P < .001), and intraoperative grading of adverse tissue reactions (P = .05) were correlated with post-revision complications. The reoperation rate of revised MoM THA was 7% (7 of 102 hips). Implant survivorship was 88% at 3 years. Metal ion levels declined in most patients after removal of MoM articulation. ConclusionRevision outcomes of revision surgery for failed MoM THA due to symptomatic pseudotumor demonstrated 14% complication rate and 7% re-revision rate at 30-month follow-up. Our study identified prerevision radiographic loosening, solid lesions/abductor deficiency on MRI, and high grade intraoperative tissue damage as risk factors associated with poorer revision outcomes. This provides clinically useful information for preoperative planning and perioperative counseling of MoM THA patients undergoing revision surgery.

Structural and mechanical characterisation of the peri-prosthetic tissue surrounding loosened hip prostheses. An explorative study

Very little is known about the structure and properties of peri-prosthetic fibrous tissue that is found around loose orthopaedic implants. We describe a method for characterizing the structural organisation (histology, confocal microscopy) as well as the nano- and micro-scale mechanical behaviour (atomic force microscopy, nanoindentation) of peri-prosthetic fibrous tissue. The tissue was collected from 11 patients undergoing revision surgery due to aseptic loosening. Sirius Red and Movat histological staining procedures indicated that the tissue mainly consists of collagen fibres and ground substance. However, large inter- and intra-patient variations in the relative proportions of these tissue components were found, as well as in collagen fibre orientation and possibly also maturation. The nano-scale Young׳s moduli ranged from 0–950kPa, but showed large inter-patient variability. When the results per sample were presented in a probability density function, we could roughly discriminate one peak in the 0–100kPa range and/or one peak in the 100–500Pa range. These nano-scale moduli seem to respectively present the mechanical properties of glycosaminoglycan (GAG) and collagen molecules. The majority of the micro-scale Young׳s moduli ranged between 0.5 and 2.0kPa for all samples. This explorative study provides new insights in (the variations of) structural organisation and mechanical properties of peri-prosthetic tissue.

Ballooning osteolysis in 71 failed total ankle arthroplasties

Background and purpose — Aseptic loosening is a major cause of failure in total ankle arthroplasty (TAA). In contrast to other total joint replacements, large periarticular cysts (ballooning osteolysis) have frequently been observed in this context. We investigated periprosthetic tissue responses in failed TAA, and performed an element analysis of retrieved tissues in failed TAA.Patients and methods — The study cohort consisted of 71 patients undergoing revision surgery for failed TAA, all with hydroxyapatite-coated implants. In addition, 5 patients undergoing primary TAA served as a control group. Radiologically, patients were classified into those with ballooning osteolysis and those without, according to defined criteria. Histomorphometric, immunohistochemical, and elemental analysis of tissues was performed. Von Kossa staining and digital microscopy was performed on all tissue samples.Results — Patients without ballooning osteolysis showed a generally higher expression of lymphocytes, and CD3+, CD11c+, CD20+, and CD68+ cells in a perivascular distribution, compared to diffuse expression. The odds of having ballooning osteolysis was 300 times higher in patients with calcium content >0.5 mg/g in periprosthetic tissue than in patients with calcium content ≤0.5 mg/g (p < 0.001).Interpretation — There have been very few studies investigating the pathomechanisms of failed TAA and the cause-effect nature of ballooning osteolysis in this context. Our data suggest that the hydroxyapatite coating of the implant may be a contributory factor.

Factors regulating bone remodeling processes in aseptic implant loosening.

This study was undertaken to screen periprosthetic tissues (PPTs) under specified conditions for a series of molecular components and describe them in bone remodeling processes within aseptic loosening. PPT samples were obtained from patients undergoing revision surgery of endoprostheses (n = 24) and synovial tissues from patients with OA (control) (n = 18), patients with any form of inflammatory arthritides were excluded. Tissue samples were examined via microbiology, histology (H&E, TRAP), immunohistochemistry (CD68/anti-S100a4), quantitative real-time PCR (ALP, COL1A1, cathepsin K, M-CSF, MMP13, OPG, RANK, RANKL, TNF-α, and TRAP) and an endotoxin-assay. PPT samples contained a variety of cellular components and stained positive for TRAP (56%), CD68 (100%), and S100a4 (100%). Wear debris were found in cells staining positive for CD68 and S100a4. In PPTs significantly higher ALP, COL1A1, MMP-13, RANK, RANKL, and TRAP expression were found along with a significantly higher RANKL/OPG ratio and a significantly lower OPG expression. No significant difference was observed for M-CSF, TNF-α, cathepsin K, and endotoxin levels. In conclusion we found osteogenic proteins (ALP, COL1A1), a proteolytic enzyme (MMP-13), markers for osteoclast differentiation (RANK, RANKL), and osteoclast activity (TRAP) to be increased in PPT, whereas OPG expression decreased significantly in comparison to control. We present data about a large series of molecular components in PPT and describe novel and key findings about their expression levels in regards to aseptic implant loosening. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:248-257, 2017.

Diagnostic performance of swab PCR as an alternative to tissue culture methods for diagnosing infections associated with fracture fixation devices

BackgroundMolecular procedures could potentially improve diagnoses of orthopaedic implant-related infections, but are not yet clinically implemented. Analysis of sonication fluid shows the highest sensitivity for diagnosing implant infections in cases of revision surgery with implant removal. However, there remains controversy regarding the best method for obtaining specimens in cases of revision surgery with implant retention. Tissue culture is the most common diagnostic method for pathogen identification in such cases. Here we aimed to assess the diagnostic performance of swab PCR analysis compared to tissue culture from patients undergoing revision surgery of fracture fixation devices. MethodsWe prospectively investigated 62 consecutive subjects who underwent revision surgery of fracture fixation devices during a two-year period. Tissue samples were collected for cultures, and swabs from the implant surface were obtained for 16S rRNA PCR analysis. Subjects were classified as having an implant-related infection if (1) they presented with a sinus tract or open wound in communication with the implant; or (2) purulence was encountered intraoperatively; or (3) two out of three tissue cultures tested positive for the presence of the same pathogen. Tissue culture and swab PCR results from the subjects were used to calculate the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and area under the ROC curve (AUC) for identifying an orthopaedic implant-related infection. ResultsOrthopaedic implant-related infections were detected in 51 subjects. Tissue culture identified infections in 47 cases, and swab PCR in 35 cases. Among the 11 aseptic cases, tissue culture was positive in 2 cases and swab PCR in 4 cases. Tissue culture showed a significantly higher area under the ROC curve for diagnosing infection (AUC=0.89; 95% CI, 0.67–0.96) compared to swab PCR (AUC=0.66; 95% CI, 0.46–0.80) (p=0.033). ConclusionsCompared to swab PCR, tissue culture showed better performance for diagnosing orthopaedic implant-related infection. Although molecular methods are expected to yield higher diagnostic accuracy than cultures, it appears that the method of obtaining specimens plays an important role. Improved methods of specimen collection are required before swab PCR can become a reliable alternative to tissue-consumptive methods.

Analysis of Risk Factors for Early Adjacent Segment Disease Underwent Revision Surgery within 5 Years after Lumbar Spinal Fusion

Introduction There are many concerns about adjacent segment disease after lumbar spinal fusion using pedicle screws. Of them, we have a question which occurs early adjacent segment disease(EASD) within 5 years. We analyze the risk factors about EASD in patients who underwent revision surgery within 5 years from first operation. Materials and Methods From August 1988 to December 2007, 657 patients underwent lumbar spinal fusion of 3 and less segment to treat degenerative lumbar disease. Among them, 137 patients underwent revision surgery within 5 years due to adjacent segment disease or previously followed more than 5 years were included in this study. Gender, age, fusion method, preoperative diagnosis, number of fusion segments and radiological measurements were analyzed. In radiological measurement, pre-&amp; post-operative lumbar lordotic angle(LLA), pre-&amp; post-operative fusion segment lordotic angle(FSLA), pre-&amp; post-operative FSLA per level, correction of LLA, correction of FSLA, and correction of FSLA per level were estimated. Statistical univariate analysis was performed with the Chi-square test and multivariate logistic regression analysis was done by using SPSS 14.0. Results There were 13 patients with revision surgery due to EASD. 6 patients were operated by decompression or discectomy and 7 patients needed additional fusion. In univatiate analysis, there was little relationship between EASD and gender, age, preoperative diagnosis, number of fusion segments, pre-&amp; post-operative LLA, pre-&amp; post-operative FSLA, pre-&amp; post-operative FSLA per level, correction of FSLA and correction of FSLA per level. However, the frequency of EASD was significantly high in cases where PLIF was more than PLF( p = 0.023), correction of LLA was &gt; 15°( p = 0.021) and correction of FSLA per level was &gt; 5°( p = 0.049). In multivariate logistic regression analysis, the frequency of ESAD was significantly high in case where PLIF was more than PLF(odd ratio = 17.866) and correction of LLA was &gt; 15°(odd ratio = 19.282). Conclusions There was no statistical significance between EASD and gender, age, preoperative diagnosis, number of fusion segments, pre-&amp; post-operative LLA, pre-&amp; post-operative FSLA, pre-&amp; post-operative FSLA per level, correction of FSLA and correction of FSLA per level. However, PLIF and correction of LLA more than 15 degree increased risk of EASD.

Overpowering Posterior Instrumentation and Fusion using a Modified Anterior Lumbar Interbody Fusion Technique, An Experience of 11 Cases

Introduction Restoration of sagittal balance is paramount in any type of spinal reconstructive surgery. Recent work has demonstrated that the failure to maintain lumbar lordosis following fusion not only accelerated adjacent degeneration (Umehara S. et al., Spine. 2000; Rothenfluh D.A. et al., Euro Spine. 2015), but also has a strong correlation to patient's clinical symptomatology, quality of life, and overall function (Glassman S.D. et al., Spine 2005; Schwab F. et al., Spine. 2010). As such, postoperative hypolordosis in the presence of posterior instrumentation and fusion has become a growing problem and presents the operative surgeon with a difficult challenge. In this study we describe our early clinical experience with using a modified anterior lumbar interbody fusion (ALIF) technique for the purposes of increasing lumbar lordosis and improving sagittal imbalance in revision adult spinal deformity patients. Material and Methods We present a retrospective case series of 11 patients that developed pain and disability following previous instrumented posterior lateral spinal fusion. All patients were diagnosed with either a posterior pseudoarthrosis and/or a lumbar segment fused with non-anatomic segmental lordosis. All patients underwent ALIF with either anterior wedge allograft or hyperlordotic cages and posterior instrumentation and fusion. Distraction of the disc space and obtainment of the desired lordosis was achieved by using the jackknife capability of the OR table (the patients lumbosacral junction was positioned at the level of the hinge of the table and during the discectomy the table was “jackknifed” into further lordosis). This provided a gradual, and controlled generation of a more anatomic lordosis. Digital standard upright lateral radiographs were used to measure spinopelvic parameters on all patients both pre-, and post-operatively. Two independent observers reviewed each radiograph. Results From 2014 to 2015, 11 patients underwent revision surgery utilizing this modified ALIF approach with hyperlordotic graft insertion and revision posterior fusion for the treatment of symptomatic sagittal imbalance. Mean patient age was 50.1 years (range 30 – 62). All patients had 30-degree hyperlordotic cages placed while three had an additional standard 20-degree cage placed at an additional lumbar level (average 1.3 per patient). Although preliminary, early postoperative radiographic assessment has shown average increase in L5/S1 segmental and global lumbar lordosis exceeding 20 and 7 degrees, respectively. Additionally, pelvic incidence was found to be increase by an average of 5 degrees. Conclusion The ability to overpower the posterior instrumentation and to generate added lordosis while fusing the anterior spine is an appealing prospect. In our small series, no loosening of the pedicle screws, or fracture of the pedicles/posterior fusion was observed. We hypothesize that the correction occurs due to flexibility of the titanium bars. Although this is a small series and caution should be exercised before widespread uptake, it does illustrate the potential use of this technique to further address this challenging patient population.

Postoperative Complications Within the First Year After Extreme Lateral Interbody Fusion: Experience of the First 108 Patients.

Retrospective chart review. To determine complications within the first year after undergoing extreme lateral interbody fusion (XLIF). There are a growing but limited number of reports in the literature regarding early postoperative complications after XLIF. We performed a retrospective chart review of perioperative complications of a case series of the first 108 patients to undergo XLIF at our institution between 2007 and 2009. We also recorded estimated blood loss, surgical time, and hospital length of stay for each procedure. There were 25 complications (23%) overall in patients who underwent the XLIF procedure. Four patients (3.7%) experienced major complications including: vertebral body fracture, contralateral nerve root injury, dense quadriceps paresis, and persistent stenosis. Three of these patients underwent revision surgery. There were 21 minor (19.4%) complications the vast majority of which consisted of approach-related thigh pain and/or paresthesias that all ultimately resolved. Transient ipsilateral thigh numbness, pain, and/or hip flexor weakness is a frequent postoperative finding most commonly when the L4-L5 level is instrumented. Dense femoral nerve palsy is a debilitating complication that may occur despite intraoperative neurophysiological monitoring. It should be noted that this retrospective study may underreport the true incidence of complications among these patients.