Revision Surgery Research Articles

Re-excision rates after breast-conserving surgery for invasive breast cancer: an Albertan perspective.

Re-operation after breast-conserving surgery for invasive breast cancer is variable among centres and individual surgeons. In this study, we aimed to characterize the current landscape of practice regarding re-operation for invasive breast cancer in the province of Alberta. This study was a retrospective review of the Synoptec database for patients undergoing primary breast-conserving surgery for invasive breast cancer or reoperation in the province of Alberta in the year 2020. We extracted data on demographic and tumour characteristics, use of intraoperative margin-assessment strategies, and surgical facility. We conducted univariate and multivariate logistic model analyses. We included 1391 breast surgeries in the study. A total of 158 patients underwent re-operation during the study period. The median time to first reoperation was 34 days. The overall re-operation rate was 11.4% (range 5.4%-18.5%) among surgical facilities. The completion mastectomy rate was 5.2%, and 1.5% of patients underwent multiple revisional surgeries. Tumour multifocality was associated with increased revisional surgery rates on multivariate analysis (odds ratio 2.80). The results of this study are consistent with the published literature. We have identified heterogeneity among sites in Alberta for revisional surgery after breast-conserving surgery for invasive breast cancer. This highlights an opportunity for ongoing education and quality improvement in breast cancer care in the province of Alberta.

Multifidus Degeneration: The Key Imaging Predictor of Adjacent Segment Disease.

Retrospective cohort study. To identify imaging predictors on pre- and perioperative imaging that are associated with a future revision surgery for adjacent segment disease (ASD) following lumbar fusion. Patients undergoing open posterior lumbar fusion between 2014-2022 were followed-up for >2-year. The initial MRI was evaluated for disc degeneration by Pfirrmann (grade 1-5); Modic changes (0-3); as well as fatty infiltration and functional cross-sectional area (fCSA) of the multifidus, erector spinae, and psoas. Spinopelvic alignment was measured pre- and postoperatively. Of 216 patients, 14.8% (n = 32) required revision surgery for ASD in the further course. There were no significant differences in Modic changes or Pfirrmann grades between the ASD group and controls. Fatty infiltration was significantly higher in the ASD group for both the erector spinae (40.5% vs 36.9%, P = 0.043) and multifidus muscles (61.0% vs 53.9%, P = 0.003). Additionally, the multifidus fCSA was smaller in patients who developed ASD (5.7cm2 vs 6.7cm2). Pre- and postoperative spinopelvic parameters were not significantly different between groups, and no other MRI measurements showed a significant difference. In a multivariable logistic regression model adjusting for age and sex, multifidus fatty infiltration emerged as the only significant predictor of ASD revision surgery (P = 0.004). Patients with more than 58% multifidus fatty infiltration had over double the risk of developing ASD (OR 2.7, 95% CI: 1.1-6.5, P = 0.032). Multifidus fatty infiltration is the key imaging predictor for the development of ASD requiring surgical revision. Disc degeneration and spinopelvic alignment appear to have less impact.

Functional Outcome and Patient Satisfaction After Primary vs Secondary Arthrodesis for Lisfranc Injuries: Toward a Single-Surgery Approach.

The choice between primary arthrodesis (PA) and open reduction and internal fixation (ORIF) for acute Lisfranc injuries remains contentious. Apart from primary treatment, arthrodesis is often used for treating chronic Lisfranc injuries, including patients in whom initial ORIF or nonoperative treatment failed. The aim of this study was to compare PA and secondary arthrodesis (SA) in terms of complications and functional outcome. A retrospective cohort study was conducted on trauma patients with Lisfranc injuries treated at a level 1 trauma center between July 1, 2010, and July 1, 2020. Selected patients were evaluated at the outpatient clinic and received a survey. Demographics, injury characteristics, management, complications, and patient-reported outcomes (American Orthopaedic Foot & Ankle Society midfoot score, Foot Function Index) were analyzed. Twenty-nine of 37 potential patients (78.4%; PA n = 11, SA n = 18) completed the survey with a median follow-up of 7.1 (PA) to 9.3 (SA) years (P = .01). The majority were female (n = 18, 62.1%); the mean age of PA patients was 57.1 years (SD 14.2) compared with 43.5 years (SD 17.1) in SA patients (P = .04). In the PA group, there was no infection, 100% union, and implants were removed in 5 of 11 patients. In the SA group, 11.1% (n = 2) developed infection, malunion rate was 11.1%, implants were removed in 33.3% (n = 6), and 22.2% required revision surgery. AOFAS was "good" in PA (77.7, SD 17.3) compared with rated "fair" in SA (67.1, SD 21.3, P = .19). FFI was better in PA (26.0, SD 26.2) than SA (37.6, SD 30.8, P = .32), which exceeded the minimally important clinical difference. Although this study was limited by sample size, the overall results suggest equivalent functional outcome, pain and treatment satisfaction in primary arthrodesis compared with secondary arthrodesis patients for treatment of Lisfranc injury.

Efficacy of endoscopic interlaminar decompression in lumbar spinal stenosis: a retrospective study.

This retrospective study evaluated the clinical effectiveness of endoscopic interlaminar decompression for lumbar spinal stenosis in 40 patients treated from February 2020 to January 2022. The procedure was successful in all cases, with only one dural sac injury reported and no other complications. Postoperative Visual Analogue Scale (VAS) and Japanese Orthopaedic Association (JOA) scores improved significantly (P<0.05), and the modified Macnab criteria showed an 87.5% rate of excellent and good outcomes at follow-up. No patients required revision surgery. Overall, the endoscopic interlaminar approach proved to be effective, safe, and supported early recovery.

Retromuscular, periprosthetic drainage after hernioplasty with sublay mesh reinforcement in ventral hernias results in less retromuscular fluid collections but longer hospital stay and analgetic use with unclear effect on clinical outcome - a randomized controlled trial

PurposeTo determine whether periprosthetic drain insertion for hernioplasty using sublay mesh augmentation influences retromuscular fluid collections (RFC) and the clinical course.MethodsForty-two patients with open repair of midline hernias (M2-4, W1, European Hernia Society classification) were allocated to groups with or without retromuscular drains. Subcutaneous drainages were used in both groups to avoid confounding from surgical site occurrences due to superficial, subcutaneous fluid collections. The participants underwent clinical and ultrasound assessments on postoperative days (POD) 14 and 30 to detect RFC, subcutaneous seromas, and wound complications. The sample size was estimated using the RFC of a test cohort with drainage; the assumed relevant volume (5 ml) was calculated comprising 84% (mean + 1 SD) of these patients.ResultsIn the retromuscular drainage group, the RFC median volume was reduced by 75.2% on POD 14, and by POD 30, no RFC were found [0.2 vs. 25.8 (p < 0.001) and 0 vs. 4.0 (p = 0.02) on PODs 14 and 30, respectively]. The number of patients with RFC ≥ 5 mL was also significantly lower in the drainage group [4 vs. 12 (p = 0.02) and 1 vs. 8 (p = 0.02) on PODs 14 and 30, respectively]. No surgical site infections occurred in either group, but retromuscular hematoseroma led to one revision surgery and one needle aspiration in the group without drainage. In the drainage group, a significantly longer hospital stay (6.5 days vs. 4 days; p = 0.01) and longer regular analgetic intake (6 vs. 3 days; p = 0.03) were observed. Multivariable regression revealed that retromuscular drainage usage was the only independent predictor of the RFC volume.ConclusionWe found that the use of retromuscular drains after hernioplasty with sublay hernia repair reduced periprosthetic fluid collections in our population but prolonged hospital stay. Whether the reduction of RFC can prevent SSO or revision surgery cannot be determined from our data, the relevance is therefore not assessable. Hence, further larger studies are required to determine the clinical relevance of drains.

Is MAGEC X better than earlier designs of magnetically controlled growing rod: an explant study.

Determine the performance of MAGEC X rods through retrieval analysis and comparison with clinical data. A multicentre explant database was searched to identify cases using MAGEC X device. Clinical and surgical data was gathered prospectively. Prior to rod disassembly, rods underwent testing with an external remote controller to measure the force output. Eleven cases from 6 centres were identified. Implantation occurred at mean age 6.9years with mean duration of implantation 42months. Dual rod constructs were used in all but one case, providing 21 MAGEC X rods for explant analysis. Tissue metallosis was identified at revision surgery in 8/11 cases (73%). Of the 21 rods, 13/21 (62%) produced no force while 8/21 (38%) produced the force stated by the manufacturer. Endcap separation was seen in 5/21 (24%) rods. Where full disassembly was possible, 13/14 (93%) rods had an intact locking pin. Average rod growth was 18mm (range 2-45mm), equivalent to 5.1mm per year. Wear debris was found within 20/21 (95%) MAGEC X rods. Despite the substantial design changes with MAGEC X tissue metallosis was seen in most cases; most explanted MAGEC X rods had lengthened only partially and produced no force output. While the previous issue of locking pin fracture appears to have been mitigated with MAGEC X, there are multiple other and new failure modes, such as endcap separation. Overall MAGEC X appears to give little improvement over earlier iterations of the rod.

Outpatient versus inpatient total shoulder arthroplasty: A meta-analysis of clinical outcomes and adverse events.

In recent years, orthopaedic procedures have increasingly shifted from inpatient to outpatient settings. This trend includes total shoulder arthroplasty (TSA), which is being performed more frequently in outpatient facilities and ambulatory surgical centres. The purpose of this study was to compare the clinical outcomes and rates of adverse events between outpatient and inpatient TSA. PubMed, Cochrane, and Google Scholar (pages 1-20) databases were screened for articles comparing outpatient to inpatient TSA through June 2024, using relevant and holistic search terms. Non-comparative articles and those utilizing national databases were excluded from our study. Data on complications, myocardial infarction (MI), thromboembolic events, anaemia/transfusions, infections, readmissions, emergency department (ED) visits, revision surgery, and patient reported outcome measures at one year (Visual Analog Scale [VAS] and American Shoulder and Elbow Surgeons [ASES] score) were extracted. A total of 14 articles were included in our study, involving 1070 outpatient and 1330 inpatient TSA patients. Patients in the inpatient group were older and had a higher ASA compared to the patients in the outpatient group. The outpatient TSA group was found to have significantly lower rates of overall complications (odds ratio [OR] = 0.59, p = 0.001), medical complications (OR = 0.43, p < 0.001), and readmissions (OR = 0.47, p = 0.008), as well as higher mean ASES scores (81.4 vs. 78.5, p = 0.01) when compared to the inpatient TSA group. There were no significant differences in rates of ED visits (p = 0.27), revisions (p = 0.06), and VAS scores (p = 0.15) between inpatient and outpatient TSA groups. TSAs performed in the outpatient setting had a lower rate of overall adverse events, medical complications, readmissions, and a higher ASES score compared to inpatient TSAs. However, since patients in the inpatient group had higher ASA and were older, our results support the safety of the outpatient TSA based on the current selection criteria.

Approaches to Cheek Reconstruction following Mohs Surgery

AbstractThe native features of the cheek allow for a variety of approaches when considering reconstruction following Mohs surgery. Selecting the best approach requires consideration of deficit size and location, skin laxity, surrounding anatomy, aesthetic outcomes, and specific patient factors. Reconstruction options vary based on the zone of the cheek affected, but direct closure remains the gold standard. When direct closure is not suitable, the use of the cervicofacial advancement flap, biologic agents, or a combination of the two should adequately address the majority of cheek deficits resulting from Mohs surgery. During cheek reconstruction, great care should be taken to maintain and support the surrounding anatomy, most notably the lower eyelid. Postoperative management is mostly comprised of scar management, as immediate, urgent complications are rare. Options to address postoperative scarring range from silicone sheeting to revisional surgery, but most deficits will settle well if given adequate time and are properly cared for with noninvasive measures.

Antithrombotic Agents After Free Tissue Transfer in the Pediatric and Adolescent Population.

Even for the experienced microsurgeon, free tissue transfer in pediatric patients is challenging, and large patient series remain scarce in the literature. Moreover, the added value of antithrombotic agents in pediatric free tissue transfer remains unclear. We conducted a retrospective outcome analysis of pediatric free tissue transfer with respect to postoperative antithrombotic treatment at our tertiary academic center. All patients aged 0 to 18 years who underwent free tissue transfer from 1998 to 2022 were included in the study. Seventy patients received 73 free tissue transfers. The most common indications were facial paralysis, trauma, and tumor (49.3%, 21.9%, and 20.5%, respectively). The most common recipient sites were the head and neck (56.1%) and lower extremity (32.8%). We observed a flap revision rate of 12.5% of the cases and one flap loss (1.4%). 58.9% of the population received post-operative antithrombotic agents. The rate of flap revision surgery was similar (11.6% and 10.0%, respectively), with and without antithrombotic treatment (p>0.05). There were no major bleeding complications or deep vein thrombosis. The antithrombotic treatment did not seem to affect the flap revision rate or the bleeding complications in our cohort. Hence, the data do not support the routine administration of antithrombotic treatment in pediatric free flap reconstruction. However, these findings should be solidified in prospective randomized trials.

Patient-Reported Esthetic Outcomes Following Secondary Rhinoplasty in Adult Patients with a Cleft lip and Palate.

Secondary rhinoplasty is a frequently requested revision procedure in patients with a history of cleft lip and palate (CLP). The satisfaction of patients with the esthetic outcome of the procedure has been infrequently studied. Adult patients with CLP who had undergone a secondary rhinoplasty between 2009 and 2019 were identified in a cross-sectional cohort that had filled the FACE-Q rhinoplasty module. The effect of the cleft type and the number and timing of the nasal revision surgeries were evaluated. Forty participants were included, median age of 26 years (range 18-59 years). Nine (23%) participants had a history of bilateral CLP. The median time form the last nasal operation to the study was 4.5 years (range 16 days to 10 years). The participants reported being satisfied with the appearance of the nose (median score 52, interquartile range [IQR] 44-60) but the satisfaction with the appearance of the nostrils (median score 44, IQR 30-64) was below the normative value for the scale. Patients with a history of bilateral CLP reported worse satisfaction across all the aspects of health-related quality of life assessed (P < .05 for all). No association was observed between the age at the first open rhinoplasty and satisfaction with the appearance of the nose or the nostrils. Following secondary rhinoplasty, adults with CLP are, in general, satisfied with their nose but less so with nostrils. Compared to unilateral CLP, bilateral CLP is associated with a worse health-related quality of life.

Challenges and Long-Term Outcomes of Cementless Total Hip Arthroplasty in Patients Under 30: A 24-Year Follow-Up Study with a Minimum 8-Year Follow-Up, Focused on Developmental Dysplasia of the Hip

Background: Total hip arthroplasty (THA) is a well-established and effective treatment for advanced osteoarthritis (OA) of the hip joint. While commonly performed in older patients, THA is increasingly used in younger individuals, especially in cases of secondary coxarthrosis. Technological advances have led to the development of specialized implants, which allow surgeons to address severe post-inflammatory or dysplastic deformities. Younger patients undergoing THA, often in their 20s or 30s, present higher functional expectations. Despite limited long-term studies, research indicates a higher rate of revision surgeries in this age group compared to older populations, making these procedures a unique challenge. Methods: This retrospective study analyzed 5263 primary total hip arthroplasties (THAs) performed at our center between May 1985 and December 2016. After excluding cemented and hybrid implants, as well as patients lost to follow-up or with other etiologies, 101 uncemented THA procedures in 92 patients aged 30 years or younger were included. The majority (64.4%) were due to dysplastic coxarthrosis (DDH), while avascular necrosis (26.7%) and juvenile rheumatoid arthritis (8.9%) accounted for the rest. The average patient age was 25.6 years, with a mean follow-up period of over 24 years. Surgical technique involved the anterolateral approach, with implants placed in the true acetabular region. Implants included Munich/Plasmacup, Mittelmeier, and P-M designs. Implant survival was estimated using the Kaplan–Meier estimator to determine the probability of implant longevity over the follow-up period. Outcomes were assessed using Merle d’Aubigné and Postel scores, modified by Charnley, alongside radiographic evaluations based on the Crowe, De Lee, and Gruen classifications. Results: Preoperatively radiological assessment of all hips was classified as grade IV according to the Kellgren–Lawrence scale. Over an average follow-up of 24 years, final outcomes using the modified Merle d’Aubigné and Postel (MAP) classification were excellent in 24%, good in 37%, satisfactory in 8%, and poor in 32% of cases. Results compared between DDH group and control group indicate significantly more poor results for the DDH group compared to the control group (p-value &lt; 0.05). All poor outcomes were associated with prosthesis loosening, primarily involving P-M and Mittelmeier acetabular components. Complications included intraoperative fractures in five cases, peripheral nerve dysfunction in six cases, and heterotopic ossification in eight cases. Postoperative pain scores on the VAS scale improved from 6.8 to 1.7. The Kaplan–Meier estimator indicated 10-year survival rates of 85.2% for the entire prosthesis, with 69.8% survival at 15 years and 54.5% at 20 years. For each period the bio-functionality according to Kaplan–Meier estimator was in favor of the control group. Conclusions: Cementless THA in patients aged 30 or younger has demonstrated itself to be an efficacious treatment for hip osteoarthritis, yielding favorable bio-functional outcomes in both short- and long-term follow-up. Nevertheless, THA performed in the context of developmental dysplasia of the hip (DDH) carries a significantly elevated risk of postoperative complications, most notably aseptic loosening, which critically undermines implant survival rates. Given the young demographic and the anticipated prolonged functional lifespan of the prosthesis, there is an increased propensity for loosening over time, necessitating vigilant and sustained postoperative surveillance.

Treatment of subcutaneous lipomas in the horse.

To describe the treatment of subcutaneous lipomas in the horse. 3 horses. The horses were aged 1 to 2 years old, with lipoma of the abdomen, prepuce, and tarsus. All cases had surgical removal of the masses under general anesthesia. Recurrence of an invasive abdominal lipoma occurred in case 1 at the exit site of a passive drain. The recurrence was treated unsuccessfully with injectable cisplatin, and a second revision surgery with the use of an active drain resulted in resolution. In case 2, complete resection of an encapsulated lipoma of the lateral prepuce was successful with no recurrence. In case 3, incomplete resection of a tarsal lipoma resulted in a sound horse, with no further growth. Histopathologic analysis revealed that all masses were composed of well-differentiated adipocytes with no evidence of malignancy. Subcutaneous lipomas are relatively rare and affect horses primarily ≤ 2 years of age. They are benign, although their presence can be deleterious due to invasion of local structures or the impact on normal locomotion. The margins of invasive tumors are difficult to identify due to their integration with normal tissue. Incomplete removal may allow for mass recurrence. Active suctions drains are beneficial if dead space is a concern.

Efficacy of Diagnostic In-Office Shoulder Ultrasound in the Surgical Treatment of Full-Thickness Rotator Cuff Tears.

Early surgical management of full-thickness traumatic rotator cuff tears (RCTs) may optimize functional outcomes, prioritizing timely diagnoses. Ultrasound and magnetic resonance imaging (MRI) are highly sensitive and specific modalities for RCT diagnosis, yet MRI remains the gold standard diagnostic tool despite increased costs and potential delays in care. Ultrasound can provide same-day diagnosis, thus possibly expediting care. The use of diagnostic shoulder ultrasound alone in the orthopaedic surgeon's office could increase the efficiency of diagnosis and care of traumatic full-thickness RCTs compared with MRI. Cohort study; Level of evidence, 3. A retrospective chart review of patients with full-thickness traumatic RCT diagnosed via ultrasound or MRI who subsequently underwent rotator cuff repair with 1 of 2 ultrasound-trained surgeons between January 1, 2014, and December 31, 2019, was performed. Inclusion criteria included patients ≥18 years old, documentation of a first-time traumatic event, and the patient's desire to have immediate surgical management. Revision surgeries, long-term shoulder instability, and nontraumatic injuries were excluded. Basic demographic data were collected, and the number of preoperative office visits and the timing from initial evaluation to diagnosis and surgery were calculated for the ultrasound and the MRI cohorts. A power analysis of 0.8 with an alpha of .05 required 38 patients per group. Overall, 133 patients were diagnosed via MRI compared with 76 via ultrasound. Besides body mass index, there were no significant differences in demographic variables or insurance status. Compared with the MRI cohort, patients in the ultrasound cohort received their diagnosis almost 2 weeks faster (P < .0001), were scheduled for surgery almost 3 weeks faster (P < .0001), and underwent surgery 2 weeks faster after initial evaluation (P < .0001) while requiring nearly half as many clinical visits (P < .0001). Regression analysis confirmed that ultrasound significantly reduced time to imaging, scheduling, and surgery after initial evaluation while requiring fewer clinical visits (P < .05). The study findings indicated that ultrasound was a time-saving alternative diagnostic modality for traumatic RCT compared with MRI without compromising standard of care. These results were achieved independent of patient insurance status, disability index, or other demographic variables.

Long-Term Survival of Bladder Augmentation is Influenced by its Shape and Mucosal Lining

IntroductionBladder augmentation in the UK has been largely by enterocystoplasty or ureterocystoplasty (UC). Ileocystoplasty can be simple patch placement (SPP), or formation of an ileal cup (IC). Urothelium is the “right” mucosa, whereas intestinal mucosa exhibits absorption, mucus production, malignancy. On videourodynamics it can be shown that SPP fills with a poor conformation (irregular shape), while IC was good, and UC adequate.Our aim was to measure the long-term outcomes of augmentation, comparing UC (“right” mucosa and adequate conformation), to SPP (“wrong” mucosa and poor conformation) to IC (“wrong mucosa” and good conformation). MethodsSingle-centre retrospective review. Patients were identified from operative logs for the period 2005 to 2022. Registered as an audit (CARMS 31503). Data collected included: demographics, dates: operation, redo-surgery, imaging, stones(renal/bladder) and any intervention. Data were given as numbers (%), median (range) analysed by Fisher exact test where P<0.05 was taken as significant. ResultsThere were 168 bladder augmentations: UC (n = 24), SPP (n = 72), and IC (n = 72). Follow-up was no different for IC 4.23(0.05-11.50) vs SPP 4.43(0.15-13) yrs, but was longer for UC at 6.2 (4.1-8.9) yrs. Age at augmentation was 6.7 (2.5-17.1) vs 8.1 (2-17) vs 11.6 (5.9-17) yrs respectively (UC vs IC vs SPP, P=0.0001).Revision surgery was required in 3/24 (12.5%) UC, 6/72 (8.3%) SPP, and 0/72(0%) IC. IC had fewer redos than SPP, P=0.028. Long-term survival was significantly better for IC (100% at 10 years, vs UC 85% at 10 years and SPP 96% at 5 yrs and 75% at 10 yrs, log-rank P<0.05).Imaging follow-up was available in SPP (n = 56) IC (n = 62), UC (n=24) with renal stones identified in 7/56 (%) SPP, 2/62 (%) IC, and 0 in UC. Bladder stones were present in SPP 5/56 (8.9%) vs IC 2/62(3.2%), NS. Stone-free survival was 100% at 10yrs in UC, 95% in IC, and 62% in SPP, P=0.028.Combining bladder failure leading to reaugmentation and bladder stones requiring surgery, allows comparison between SPP and IC: In SPP bladder stones and augment failure occurred in 15.3%, vs 2.8% in IC. There is a 6.3-fold increase in bladder stones and augment redo with SPP [irregular filling bladder (poor conformation) and the “wrong” mucosa] vs IC (good confirmation, but “wrong” mucosa). ConclusionAugmentation survival is influenced by conformation and presence of the “right” mucosa. UC is only possible in 14% of cases, and an IC is preferable to SPP when an enterocystoplasty is needed.

Outcomes following revision of a failed primary reverse shoulder arthroplasty.

Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA. MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews were searched. Studies involving adult patients who underwent revision of a primary RSA for any indication were included. Those who underwent a RSA for failure of a total shoulder arthroplasty or hemiarthroplasty were excluded. Pre- and postoperative shoulder scores were evaluated in a random effects meta-analysis to determine the mean difference. The rates of re-revision and complications were also calculated. The initial search elicited 3,166 results and, following removal of duplicates and screening, 13 studies with a total of 1,042 RSAs were identified. An increase in shoulder scores pre- to postoperatively was reported in all the studies. Following revision of a RSA to a further RSA, there was a significant increase in the American Shoulder and Elbow Surgeons Score (mean difference 20.78 (95% CI 8.16 to 33.40); p = 0.001). A re-revision rate at final follow-up ranging from 9% to 32%, a one-year re-revision rate of 14%, and a five-year re-revision rate of 23% were reported. The complication rate in all the studies was between 18.5% and 36%, with a total incidence of 29%. This is the largest systematic review of the outcomes following revision of a RSA. We found an improvement in functional outcomes after revision surgery, but the rates of re-revision and complications are high and warrant consideration when planning a revision procedure.

Comparison of Implant Placement Accuracy Between Manual, Robot-Assisted, Computer-Navigated, Augmented Reality Navigated, Patient-Specific Instrumentation, and Accelerometer Navigated Total Hip Arthroplasty: A Systematic Review and Network Meta-Analysis.

Malpositioning of the acetabular cup during total hip arthroplasty (THA) can lead to complications. Robotic surgery and navigation techniques aim to address this issue, but there is limited evidence regarding which method can achieve better clinical outcomes. Therefore, this network meta-analysis (NMA) aimed to compare the efficacy of various navigation methods. This NMA of prospective randomized controlled trials compared robot-assisted systems (RAS), computer-assisted navigation systems (CAS), augmented reality-based portable navigation (AR), patient-specific instrumentation (PSI), portable accelerometer-based navigation (PN), and conventional methods (C) for THA procedures. We searched MEDLINE, EMBASE, Cochrane, Central Register of Controlled Trials, International Clinical Trials Platform Search Portal, and ClinicalTrials.gov. databases. The primary outcomes included revision surgery and postoperative clinical scores, and the secondary outcomes encompassed cup placement accuracy, acetabular cup placement outliers from the Lewinnek safe zone, surgical time, and complications. We used a Bayesian random-effects NMA, and confidence of evidence was assessed using confidence in NMA. We identified 45 studies including 2,122 patients. We did not find large differences in revision surgery, clinical outcome scores, cup inclination, or anteversion angle accuracy among the modalities. AR, CAS, and PSI exhibited a lower risk of outliers from safe zones than C. In addition, RAS and CAS had a longer surgical time than C. Robotic and navigation tools did not reduce the revision risk or enhance clinical outcomes. AR, CAS, PSI, and PN may decrease the risk of cup placement outliers in safe zones. However, the cup placement accuracy was equivalent, and the surgical time may be longer in RAS and CAS than in C. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Anterior column realignment better restores sagittal alignment but carries higher risk of mechanical failures than lateral lumbar interbody fusion in patients with degenerative sagittal imbalance

Background of contextAnterior column realignment (ACR), a modified lateral lumbar interbody fusion (LLIF), is an emerging, less invasive technique that allows greater lordosis correction by releasing anterior longitudinal ligament. However, long-term results have been poorly documented with regard to mechanical failure, such as proximal junctional kyphosis (PJK) and rod fracture (RF), and clinical outcomes. PurposeTo compare the outcomes, primarily mechanical failure, in patients with degenerative sagittal imbalance (DSI) treated with ACR versus LLIF alone. Study design/settingRetrospective study Patient samplePatients ≥ 60 years of age; severe DSI defined by pelvic incidence (PI) - lumbar lordosis (LL) ≥ 20°; performance of ≥ 2-level LLIF; and ≥ 5 total fused levels including the sacrum. Outcome measuresMechanical failure such as PJK and RF; radiographic results; clinical outcomes MethodsEnrolled patients were divided into two groups, based on whether their anterior reconstruction was accomplished with ACR or LLIF alone: ACR and LLIF groups. Mechanical failures were compared between the two groups as a composite outcome including PJK and /or RF. PJK was defined as proximal junctional angle (PJA) >28° and Δ PJA >22°. Only RFs developing at the level with corresponding procedures (ACR or LLIF) were included in the analysis. Logistic regression was performed to compare the relative risk of mechanical failure between the ACR and LLIF groups. The radiographic and clinical outcomes were also compared between the groups. ResultsThe final study cohort consisted of 210 patients. The mean age was 69.6 years, and there were 190 females (90.5%). There were 124 patients in the ACR group and 86 patients in the LLIF group. Perioperative changes for all sagittal parameters were significantly greater in the ACR group than in the LLIF group. Overall mechanical failure rates were significantly higher in the ACR group than in the LLIF group (32.3% vs. 14.0%, P = 0.003). Multivariate regression analysis with adjusting potential confounders revealed that ACR carried a significantly higher risk of mechanical failure than LLIF (Odds ratio = 5.6, 95% confidence interval = 2.0 – 15.6, P < 0.001). The final clinical outcomes were worse in the ACR group than in the LLIF group. ConclusionACR restored the sagittal malalignment more powerfully than did LLIF. However, compared to the LLIF, ACR was associated with a greater risk of mechanical failures and revision surgery. The final clinical outcomes in the ACR group were inferior to those in the LLIF group. Therefore, ACR should be left as a last resort for the cases where it is expected that an adequate correction cannot be achieved using LLIF alone. If ACR has to be performed, it is necessary to establish feasible surgical strategies to avoid mechanical failures.

Failed radial head arthroplasty treated by removal of the implant.

In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow. A total of 11 patients in whom removal of a RHA without reimplantation was undertaken as a revision procedure were reviewed at a mean follow-up of 8.4 years (6 to 11). The range of motion (ROM) and stability of the elbow were recorded. Pain was assessed using a visual analogue scale (VAS). The functional outcome was assessed using the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Radiological examination included the assessment of heterotopic ossification (HO), implant loosening, capitellar erosion, overlengthening, and osteoarthritis. Complications and the rate of further surgery were also recorded. The indications for removal of the implant were stiffness in five patients, aseptic loosening in five, and pain attributed to the RHA in three. The mean time interval between RHA for trauma to removal was ten months (7 to 21). Preoperatively, three patients had overlengthening of the implant, three had capitellar erosion, six had HO, and four had radiological evidence of loosening. At the final follow-up, the mean the flexion-extension arc improved significantly by 38.2° (95% CI 20 to 59; p = 0.002) and the mean arc of prono-supination improved significantly by 20° (95% CI 0 to 72.5; p = 0.035). The mean pain VAS score improved significantly by 3.5 (95% CI 2 to 5.5; p = 0.004). The mean MEPS improved significantly by 27.5 (95% CI 17.5 to 42.5; p = 0.002). The mean OES improved significantly by 9 (95% CI 2.5 to 14; p = 0.012), and the mean DASH score improved significantly by 23.5 (95% CI 7.5 to 31.6; p = 0.012). Ten patients (91%) had HO and osteoarthritis. Two patients underwent further surgery due to stiffness and pain, respectively. Simple removal of the implant at revision surgery following a failed RHA introduced following trauma provides satisfactory mid-term results with an acceptable risk of complications. Osteoarthritis, instability, and radioulnar impingement were not problems in this series.

Improved clinical and radiographic outcomes with expandable cages in transforaminal lumbar interbody fusion: a propensity-matched cohort analysis.

The restoration of sufficient overall lumbar lordosis (LL) and segmental LL (SL) is associated with achieving optimal sagittal balance, decreasing back pain, and enhancing functional outcomes for patients. Expandable cages were developed in hopes of improving radiographic parameters and clinical outcomes, although current clinical evidence is inconclusive. Here, the authors aimed to evaluate the clinical and radiographic outcomes in patients undergoing one- or two-level open transforaminal lumbar interbody fusion (TLIF) with expandable versus static cage placement, using propensity-matched cohorts. An institutional retrospective cohort of patients who underwent one- or two-level open TLIF with either expandable cage or static cage placement was identified. Using relevant preoperative covariates, including age, primary versus revision operation, number of cages implanted, and surgical level implanted, the authors built propensity-matched cohorts. They identified clinical outcomes in both cohorts, including operative characteristics and complication rates, along with pain, weakness, and sensory deficits over follow-up. Furthermore, they extracted and examined preoperative, postoperative, and last follow-up radiographic parameters. A total of 148 patients were included, and they were followed for a mean of 1.7 years (range 0.5-4.3 years). Propensity matching was used to create cohorts of patients who were similar with respect to age, surgical indication, revision status, number of cages implanted, surgical level implanted, and length of follow-up. Patients in both groups had similar preoperative radiographic parameters. Patients with expandable cages saw larger increases in SL, both postoperatively (5.3° ± 7.5° vs 1.6° ± 5.6°, p = 0.006) and at last follow-up (5.7° ± 7.4° vs 1.0° ± 6.1°, p = 0.003). They also saw significant improvements in pelvic incidence minus LL mismatch at last follow-up (-4.4° ± 13.2° vs 5.8° ± 13.8°, p = 0.009). No differences in intraoperative or perioperative complications were found, but patients with expandable cages were less likely to require readmission, develop adjacent-segment disease, or require revision surgery. They were also more likely to be symptom free at 1 month after surgery and at last follow-up. Expandable cages lead to better restoration of radiographic features, including SL and improvements in clinical outcomes, compared with static cages in propensity-matched cohorts in patients undergoing one- or two-level open TLIFs.

Outcome, Complications, and Follow-Up in Dogs Treated with Pancarpal Arthrodesis Stabilized with Orthogonal Plates.

Pancarpal arthrodesis was performed in 21 dogs, using orthogonal (cranial/dorsal and medial) plates without postoperative rigid external coaptation. Short-term and long-term outcomes, arthrodesis progression, and complications were assessed using a retrospective review of case records and radiographs. Three of 21 (14.2%) dogs required a revision surgery: 2 had total implant explantation and 1 had a screw removed. Other complications were managed successfully medically. One of 21 (4.8%) dogs had confirmed deep surgical site infection requiring implant removal, and 4 of 21 (19%) had suspected (not confirmed on microbiology) superficial surgical site infections that resolved with medical management. Long-term outcomes were assessed via owner questionnaire (Canine Brief Pain Inventory) and were available for nine dogs at a mean of 26.78 mo after surgery. The mean score for the first part (assessment of pain) was 7.83/40, which is classified as no pain to mild pain. The mean score for the second part (assessment of function) was 12.67/60, which is classified as very good. The last part (overall impression) was defined as excellent in four dogs (44.44%), very good in one dog (11.11%), and good in the other four dogs (44.44%). This retrospective study documents a suitable technique for pancarpal arthrodesis in dogs with carpal injuries.