Revision Strategies Research Articles

Autologous bone cylinder transplantation with cannulated screw re-stabilisation: a new treatment option for delayed fracture healing of the femoral neck

Delayed fracture healing and non-unions of the femoral neck after lag screw osteosynthesis occur particularly in multiply injured young patients, and then surgical revision is often required. Currently no evidence-based treatment guidelines exist and therapeutic options include both hip arthroplasties and femoral head-maintaining operations. Here we report on young patients with delayed fracture healing of the femoral neck. Patients underwent revision surgery by autologous bone cylinder transplantation with mechanical re-stabilisation by cannulated lag screws. We reviewed all patients after femoral neck screw osteosynthesis and identified eight patients at 7.3 [3-24] months after initial osteosynthesis with persisting, or reoccurring postoperative pain. Average patient age was 43 [35-57] years and patient Harris Hip Score (HHS) numbers were low (52 ± 19). Before revision surgery the preoperative CT scans showed a partial bone consolidation (anterior and/or posterior cortices) in the absence of a complete bone consolidation of all cortices. Seven patients were treated by bone cylinder transplantation from the patient's own iliac crest; one patient underwent an inverse bone cylinder procedure. Seven patients were additionally treated by re-insertion of 1-2 lag screws to increase mechanical stability. After revision surgery the average patient follow-up period was 42 [12-89] months. Five patients achieved favourable clinical and radiographic outcome with both complete bone union and return to work within 7.2 ± 2.75 months. One patient showed fracture healing but developed an aseptic femoral head osteonecrosis. Two patients failed to achieve complete bone consolidation. The postoperative HHS was 92 ± 4 in patients with favourable clinical outcome (n = 5) and 89 ± 2 after second revision surgery (2 hip arthroplasties; 1 valgus osteotomy). Both groups had significantly better HHS numbers compared with before surgical revision (p < 0.05). These data show that in this difficult-to-treat subset of young patients with delayed fracture healing of the femoral neck, autologous bone cylinder transplantation with mechanical re-stabilisation should be considered as a promising surgical revision strategy before hip arthroplasty.

Subtrochanteric fracture non-unions with implant failure managed with the diamond concept

Background The management of non-unions of subtrochanteric femoral fractures with associated implant failure is challenging. This study assessed the outcome of a cohort of patients treated according to the diamond concept. Methods Between 2005–2010 all patients with subtrochanteric aseptic non-unions presented post implant failure (Gamma Nail breakage) were eligible in the absence of severe systemic pathologies and comorbidities. Demographics, initial fracture pattern, method of stabilisation, mode of failure of metal work, time to revision of fixation, complications, time to union, and functional outcome were recorded over a minimum period of follow-up of 12 months. The revision strategy was based on the “diamond concept;” optimising the mechanical and biological environment (revision of fixation, osteoinduction/BMP-7, osteoconduction/RIA harvested graft, and osteogenicity/concentrate of bone marrow aspirate). Results Out of 280 nailing procedures 12 (4.3%) cases met the inclusion criteria. A consistent mode of metalwork failure was recorded with initial breakage of the proximal distal locking screw followed by nail breakage at the lag screw level. Biomechanical SEM analysis of the nails revealed no structural damage besides the standard fatigue striation. Varus mal-reduction was present in all cases, with an average of 7.3 degrees (5–11). The average time to screw failure was 4.3 months (2–6) and nail failure was 5.9 months (4–10). All but one of the cases were revised to a 95 degrees blade plate and one to an Affixus nail. Time to union was 6.5 months (5–10). All but one of the cases by 12 months have returned to their preinjury level of mobilisation. Conclusion Varus mal-reduction must be avoided in the initial stabilisation of subtrochanteric fractures. Proximal distal screw failure is predictive of future fracture non-union and subsequent nail breakage. The diamond concept for optimising mechanics and bone biology is a successful method for managing complex sub-trochanteric non-unions with failed metalwork.

Late Diagnosis of Pedicle Screw Malplacement With Perforation of the Thoracic Aorta After Posterior Stabilization in a Patient With Multiple Myeloma

A case report. To demonstrate delayed diagnosis of screw malpositioning with perforation of the thoracic aorta after posterior stabilization of a Th7-vertebral collapse due to multiple myeloma. Relevant diagnostic and therapeutic strategies are outlined in the context of a rather unfortunate series of interventional events. Pedicle screw instrumentation has become a well-established standard in the surgical treatment of various disorders of the spinal column. Particularly at the upper-thoracic level, the close anatomic relationship of the spine to the aorta places it and other major structures at high risk. Although iatrogenic vascular injuries are rare, a few cases have been described. A 64-year-old female patient remarked progressive back pain after 2 years of uneventful recovery from a multilevel posterior stabilization by pedicle screw and rod instrumentation because of an osteolytic collapse of the Th7 vertebra. The subsequent computed tomographic scan demonstrated kyphotic deformity of the thoracic spine with transspinal and periaortic screw malplacement. The revision strategy was an interdisciplinary single session two-phase operation. The primary phase included a left-sided thoracotomy, mobilization of the thoracic aorta, and posterior implant removal under vascular monitoring in right lateral position. The initially planned corporectomy of Th7 and subsequent vertebral body replacement by cage implantation via the anterior approach was dismissed because of critical tissue adhesions of the thoracic aorta to the anterior vertebral column. Finally, the thoracotomy was closed, the patient transferred into prone position and stabilized by a multilevel posterior reinstrumentation under fluoroscopy guidance. Although the clinical course in malpositioned pedicle screw instrumentation may stay unremarkable, this case illustrates that in a proven injury to the thoracic aorta revision is mandatory to prevent further vascular damage. The appropriate strategy demands exact and provident planning using a preferably interdisciplinary approach.

Biomechanical Analysis of Revision Strategies for Rod Fracture in Pedicle Subtraction Osteotomy

Pseudoarthrosis after pedicle subtraction osteotomy (PSO) can require revision surgery due to posterior rod failure, and the stiffness of these revision constructs has not been quantified. To compare the multidirectional bending stiffness of 7 revision strategies following rod failure. Seven fresh-frozen human spines (T11-pelvis) were tested as follows: (1) posterior instrumentation from T12-S1 (excluding L3) with iliac fixation and L3 PSO; (2) inline connectors after rod breakage at L3 (L2 screws removed for access); (3) cross-links connecting rods above and below inline connectors; satellite rods (4) parallel, (5) 45° anterior, and (6) 45° posterior to original rods; 45° posterior with cross-links connecting (7) original and (8) satellite rods. Groups 3 to 8 were tested in random order. Nondestructive pure moment flexion-extension (FE), lateral bending (LB), and axial rotation (AR) tests were conducted to 7.5 Nm; 3D motion tracking monitored the primary range of motion. Addition of inline connectors alone restored stiffness in FE and LB (P > .05), but not in AR (P < .05). Satellite rods (groups 4 to 6) restored stiffness in FE and LB (P > .05), but not in AR (P < .05) and were not significantly different from one another (P > .05). The addition of cross-links (groups 3, 7, and 8) restored stiffness in all bending modes (P > .05) and were significantly greater than inline connectors alone in AR (P < .05). The results suggest that these revision strategies can restore stiffness without entire rod replacement. Failure of AR stiffness restoration can be mitigated with cross-links. The positioning of the satellite rods is not an important factor in strengthening the revision.

Revisionsstrategien bei ventralem Implantatversagen an der LWS am Beispiel von „stand-alone cages“

This article gives a review of the possible revision strategies after repeated operative treatment of degenerative spinal diseases using stand-alone cages. Own clinical experiences and reports from the literature were taken into consideration. Dorsal stabilization is the main consideration for all access routes even if it can be discussed, albeit controversially, whether ventral removal of an installed cage is justified, because this contains a significantly higher perioperative risk. The increased risk of neurological complications by dorsal revision and for vascular complications by ventral access, especially at the L4/5 level must be particularly considered. Clinical data and own experience have shown that in the majority of cases an additional dorsal stabilization should be favored for revision surgery. Currently large clinical studies which deal with the revision problematic of stand-alone cages with respect to the access route are still lacking.

Infection in total hip replacement: meta-analysis

While total hip arthroplasty has progressed to become one of the most successful surgical procedures ever developed, infection remains a serious complication. We have conducted a review of the literature pertaining to management of deep infection in total hip arthroplasty, specifically focusing on clinically relevant articles published in the last fiveyears. A search was conducted using MEDLINE and PubMed, as well as a review of the Cochrane database, using the terms "total hip arthroplasty", "total hip replacement" and "infection". References for all selected articles were cross-checked. While the so-called two-stage revision is generally considered to be the gold standard for management, numerous studies now report outcomes for implant retention and reassessing one-stage revision strategies. There are encouraging reports for complex reconstruction options in patients with associated severe bone stock loss. The duration of antibiotic therapy remains controversial. There is concern about increasing bacterial resistance especially with the widespread use of vancomycin and ertapenem (carbapenem).

Iranian EFL Students’ Writing Strategies for Error Correction: An MI Approach

This study tries to shed some light on the Iranian EFL students’ writing strategies at the revision stage of the process of writing in relation to students’ interpersonal or intrapersonal intelligences. A total of 73 students majoring in English participated in this investigation. The results indicated that there was a significant relationship between the participants’ writing revision strategies and their dominant MI profiles. An analysis of covariance also indicated that the type of revision did not have any significant effect on the participants’ writing achievement.

Revisional bariatric surgery at a single institution

BackgroundBariatric surgery, although safe, can have long-term complications that require revision. Our series illustrates the spectrum of primary procedures, indications for surgery, and strategies for revision. MethodsThe study was a retrospective chart review. Sixty-three patients were identified. Of specific interest were complications and percentage of excess weight loss (EWL) during the follow-up period. ResultsEighteen patients had a previous vertical banded gastroplasty (VBG), 26 had a Roux-en-Y gastric bypass (RYGB), 18 had a laparoscopic adjustable gastric banding (LAGB), and 1 had a jejunal-ileal bypass. All VBG patients were revised to RYGB. Seventeen RYGB patients were revised with RYGB. Eight LAGB patients were revised with RYGB. Eight RYGB patients had placement of LAGB. Two LAGB patients were revised with LAGB because of a slipped band. Eight LAGB patients had the band removed. The morbidity rate was 30% with a major morbidity rate of 11%. There were 2 leaks, neither required reoperation. Other major complications included 3 pneumonias, 2 reoperations, and 2 intra-abdominal abscesses. There were no mortalities. In the 15 patients who had conversion of VBG to RYGB, the mean EWL was 50%, with 60% of patients achieving more than 50% EWL. In the 10 patients who had revision of their RYGB, the mean EWL was 51%, with 60% of patients achieving more than 50%. In the 6 patients who had revision of LAGB to RYGB, the mean EWL was 39%, with 33% of patients achieving more than 50% EWL. In the 8 patients who had LAGB after RYGB the mean EWL was −2%, with 0% of patients achieving more than 50%. ConclusionsRevisional surgery is effective, although complication rates are higher than primary bariatric surgery. The type of initial and revisional procedure affects EWL.

Revision Strategy for Posterior Extrusion of the CHARITÉ Polyethylene Core

This is a case report of a posterior extrusion of the polyethylene core from a CHARITÉ arthroplasty. This is the first reported case of posterior dislocation of the polyethylene and the revision strategies used to correct this problem. To report a novel failure mechanism and revision strategy for CHARITÉ total disc arthroplasty (TDA). Case report at a Level 1 tertiary care referral center in the northeastern United States. This is a case report and review of the literature of a patient who sustained posterior dislocation of the polyethylene core from a CHARITÉ TDA several months after the index procedure. Core dislocation is a known complication of TDA. However, of the known reported dislocations all have been anterior. This case describes the first known occurrence of posterior core dislocation and the revision strategy for this problem. This case report highlights the first known case of a posterior dislocation of a CHARITÉ core. It is likely that altered biomechanical forces generated over time attributed to device failure. An instrumented posterior fusion with removal of the core is what ultimately led to a stable revision construct.

Revision total hip arthroplasty for focal pelvic osteolysis with well-fixed cementless acetabular component retention by focus clearance and bone graft

Objective To evaluate the results of using focus clearance and morselized bone graft to treat a well-fixed socket osteolysis after total hip arthroplasty (THA) during cementless acetabular revisions.Methods From March 2006 to March 2009, 23 patients (23 hips) who had an acetabular revision hip arthroplasty of well-fixed socket for osteolysis were retrospectively reviewed, including 13 males and 10 females with an average age of 46.6 years (range, 39-54), and the mean interval from primary to revision THA was 5.5 years (range, 4.6-7.4). The preoperative Harris hip score was 74. The operative technique included debridement of soft tissues with removal of granulomata and packed tightly with morselized cancellous allograft through ilioinguinal approach, and exchanging the liner and femoral head through the posterior-lateral approach of the hip. Results The mean duration of follow-up after revision was 28 months (range, 8-38). At final follow-up, all hip were functioning well and the average Harris hip score was 93.8. Osteogenesis in bone graft were well-developed in 16 patients. Twelve bone grafts were completely incorporated into surrounding bone through creeping substitution. All acetabular components remain radiographically well-fixed and no loosening and shifting. There were no new osteolytic lesions, ectopic ossification, deep venous thrombosis, hip dislocation or infection during follow-up. Conclusion Our revision strategies included debridement and bone grafting, a revision of femoral heads and polyethylene liner and retention of the cups and femoral stems. The method can reduce the amount of the wear particle from polyethylene. The short-term outcome is excellent. Key words: Arthroplasty, replacement, hip; Osteolysis; Reoperation

Revision strategy after failure of Magerl-Gallie fusion procedure

For failure of an implant after a Magerl-Gallie stabilization procedure and detection of pseudarthrosis with instability of segments C1 and C2, operative revision and restabilization are necessary in the majority of cases. The following case report summarizes a revision strategy using a modified Goel-Harms procedure to restabilize a persisting C1-C2 instability after a failed Magerl-Gallie fusion procedure. This was necessary because of breakage of both transarticular C1-C2 screws with incompletely consolidated atlanto-axial fusion and persisting C1-C2 instability.

The problems and strategy of acetabular revision

自1972年以来,人工全髋关节置换术在我国得到广泛开展,接受手术的患者越来越多.随着患者数量以及假体使用年限的增加,由于各种原因引发假体失败而需要接受翻修的患者也在增多.本期专门就有关问题刊登了几篇与人工髋关节翻修术相关的临床研究,希望为读者提供一定的指导和帮助。

A Belief Revision Framework for Revising Epistemic States with Partial Epistemic States

Belief revision performs belief change on an agent's beliefs when new evidence (either of the form of a propositional formula or of the form of a total pre-order on a set of interpretations) is received. Jeffrey's rule is commonly used for revising probabilistic epistemic states when new information is probabilistically uncertain. In this paper, we propose a general epistemic revision framework where new evidence is of the form of a partial epistemic state. Our framework extends Jeffrey's rule with uncertain inputs and covers well-known existing frameworks such as ordinal conditional function (OCF) or possibility theory. We then define a set of postulates that such revision operators shall satisfy and establish representation theorems to characterize those postulates. We show that these postulates reveal common characteristics of various existing revision strategies and are satisfied by OCF conditionalization, Jeffrey's rule of conditioning and possibility conditionalization. Furthermore, when reducing to the belief revision situation, our postulates can induce most of Darwiche and Pearl's postulates.

Developing Students as Writers Through Collaboration

Revision is recognised as a key and complex element of the writing process. Despite this, research shows that students find it difficult effectively to revise their own writing due to a lack of metacognitive awareness and understanding of the processes they undertake when writing. The first part of this inquiry studies nine students’ understanding of the writing process and the revision strategies they employ using think‐aloud protocols and follow‐up interviews. Although the students all agreed that revision was an important part of improving their writing, they could not, or found it difficult to, articulate reasons for the changes they made to their writing. Therefore, the second part of the study explores the potential of collaborative writing to encourage and facilitate metacognitive talk through the implementation of a strategy where students are paired with a ‘writing buddy’. Observations of classroom work and interview responses of students showed that the scheme was successful in providing students with an experience of writing which was social, flexible and holistic, where talk is used to externalise thinking in order to develop a metacognitive understanding of the writing process.

Attendance and exam performance at university: a case study

The link between absenteeism and students’ academic performance at university is perpetually a hot topic for teaching academics. Most studies suggest the effect is negative, although the strength of this effect is in dispute. The issue is complicated further when researchers draw their inferences from different angles, such as the removal of a mandatory attendance policy or the implementation of a module‐specific attendance policy. Although previous studies have suggested the effect on exam performance of removing a mandatory attendance policy is weak, this study investigates the effect of implementing a module‐specific attendance policy and finds a strong effect on exam performance. We also identify that student‐specific factors are important, including revision strategies and peer‐group effects and that not taking account of these factors will result in biased estimates of the effect of an attendance policy on exam performance. Furthermore, this paper suggests that the effect of absenteeism on exam performance is non‐linear and further research is needed to identify when attendance policy is a justifiable tool.

Revising Matumo's "Setswana–English–Setswana dictionary"

The aim of this article is to design a revision strategy for the Setswana to English side of the Setswana–English–Setswana Dictionary compiled by Z.I. Matumo in 1993. An existing general organic Setswana corpus as well as a dedicated corpus compiled for the purposes of the revision will be used as a basis for macro- and microstructural aspects of the proposed revision. Lemma candidate lists for inclusion in and omission from the existing dictionary will be generated from these corpora, existing articles will be critically analysed and models for revised/updated articles will be presented. Key components of the revision strategy include the design and use of a multidimensional Ruler and Block System for the measurement and balancing of alphabetical stretches for the revised dictionary in terms of time, average length of articles and number of pages per alphabetical category. It is not possible to present all aspects of the revision within the scope of a journal article but the most prominent ones as well as a selection of typical issues will be dealt with. Keywords: lexicography, lemmatisation, revision, information retrieval, macrostructure, microstructure, ruler, block system, dictionary, african languages, setswana (tswana)

A Forecast for Blackness: The Work of Victor LaValle

A Forecast for BlacknessThe Work of Victor LaValle Aisha Sabatini Sloan When Nina Simone and Weldon Irvine, Jr. wrote the song, "To be Young, Gifted, and Black," I wonder if they had any idea what kind of monsters they were spawning. I don't mean this derogatorily. That sweet, earnest song created in honor of the playwright and activist Lorraine Hansberry garnered a spirit of love and support for generations of black children to come, but it also opened up the possibility for the kind of offspring that could defy, embarrass, and dishonor the best intentions of their creators. They will be young, gifted for sure, and in some way or another black (or, as LaValle calls Obama, "blackish.") But will their gifts match the sweet hopes, aesthetic tendencies, and social vision of the elders who made their privilege possible? Absolutely not. Who even knew that a black sci-fi nerd was possible in 1970? To be young, gifted, and black in the work of Victor LaValle, as it turns out, is to be a kind of compassionate Frankenstein, a patchwork quilt of cultural influences and coping mechanisms no civil rights activist in his or her right mind could have imagined. Victor LaValle's most recent novel stars a protagonist, Ricky Rice, who we see in a series of terrifying, and periodically unethical, stances: standing in a dark stairwell listening to the screams of his childhood friends as they are shot at close range; stealing the gun off of an injured cop to sell for heroin; dying in a basement while wild cats gnaw at his body. I take great pleasure imagining Nina Simone's face responding to some of these scenarios. Her face and, more importantly, the mumbling under her breath. LaValle himself is the son of a Ugandan mother and a white American father. He grew up headbanging to heavy metal music alongside "a Persian kid, a Korean, a couple of white guys" in one of the most internationally diverse areas in the world: Queens, New York. His influences include horror films and his website bears the approval of hip hop artistcum-actor Mos Def, who sees Big Machine as "the first great book of the next America." What kind of book is this? One where, three quarters of the way through, you find yourself nodding along without the slightest shiver of disbelief as the protagonist realizes he is pregnant with an angel. The fetus is growing between the man's shoulder blades. To be young, gifted, and black to Victor LaValle means taking a risk: no longer portraying the most flattering sides of blackness, not worried whether or not his work will be taken seriously. LaValle tells one interviewer that he wanted to create black characters engaged in the plot of a Bruce Willis film, and that his revision strategy is to remove any section of work that was not fun to write. Only the most virulent, well-groomed, robustly nourished self-esteem could get away with such a thing. And get away he does. The result feels like a culturally legitimate accident. [End Page 979] The history of pain in black culture is on par with the ridiculous violence in a bad action film—and so it makes sense that these characters endure this degree of torture while still pulling through. He creates a startlingly accurate portrayal of all that pain while admitting in an article for Bookforum that he is tired of all the dourness and doomsaying; of the grimace that's required whenever we discuss [black nationalism] and blackness in general; of the countless humorless men and women who scold every impulse toward comfort or laughter or, dare I say it, optimism. I'm sick of the same old forecast for blackness: gloom followed by clouds of hail. ("Beyond the Skin Trade") I began reading Big Machine at the bar of a Detroit eatery called Cass Café. Here, in the ruins of what the media likes to deem America's most dejected wasteland, a waitress placed a plate of wasabi-garnished vegetarian egg rolls with a side of sautéed Swiss chard in front of me, along with a bottle of micro-brewed...

Retrieval analysis of motion preserving spinal devices and periprosthetic tissues

This article reviews certain practical aspects of retrieval analysis for motion preserving spinal implants and periprosthetic tissues as an essential component of the overall revision strategy for these implants. At our institution, we established an international repository for motion-preserving spine implants in 2004. Our repository is currently open to all spine surgeons, and is intended to be inclusive of all cervical and lumbar implant designs such as artificial discs and posterior dynamic stabilization devices. Although a wide range of alternative materials is being investigated for nonfusion spine implants, many of the examples in this review are drawn from our existing repository of metal-on-polyethylene, metal-on-metal lumbar total disc replacements (TDRs), and polyurethane-based dynamic motion preservation devices. These devices are already approved or nearing approval for use in the United States, and hence are the most clinically relevant at the present time. This article summarizes the current literature on the retrieval analysis of these implants and concludes with recommendations for the development of new test methods that are based on the current state of knowledge of in vivo wear and damage mechanisms. Furthermore, the relevance and need to evaluate the surrounding tissue to obtain a complete understanding of the biological reaction to implant component corrosion and wear is reviewed.

Adjustable gastric banding as revisional bariatric procedure after failed gastric bypass—intermediate results

Background Although gastric bypass is the most common bariatric procedure in the United States, it is has been associated with a failure rate of 15% (range 5–40%). The addition of an adjustable gastric band to Roux-en- Y gastric bypass has been reported to be a useful revision strategy in a small series of patients with inadequate weight loss after proximal gastric bypass. Methods We report on 22 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an adjustable silicone gastric band around the proximal gastric pouch. The bands were adjusted at 6 weeks postoperatively and beyond, as needed. Complications and weight loss at the most recent follow-up visit were evaluated. Results The mean age and body mass index at revision was 41.27 years (range 25–58) and 44.8 ± 6.34 kg/m 2, respectively. Patients had experienced a loss of 19%, 27%, 47.3%, 42.3%, 43%, and 47% of their excess weight at 6, 12, 24, 36, 48, and 60 months after the revisional procedure, respectively. Three major complications occurred requiring reoperation. No band erosions have been documented. Conclusion The results from this larger series of patients have also indicated that the addition of the adjustable silicone gastric band causes significant weight loss in patients with poor weight loss outcomes after gastric bypass. That no anastomosis or change in absorption is required makes this an attractive revisional strategy. As with all revisional procedures, the complication rates appear to be increased compared with a similar primary operation.

Estratégias de escrita em L1 e L2: EXISTEM DIFERENÇAS? pesquisar

The following paper discusses the L1 and L2 writing strategies of a group of 'Licenciatura' Students. The in-class study focused on revision strategies. It was observed that in the L2, there was more revision at the lexical and sintactic level; whereas, in the L1, there was more revision at the level of the paragraph and idea organization. It was concluded, however, that more research needs to be done in this area in order to come to firmer conclusions.