Risk Of Further Surgery Research Articles

The Microbiology of Knee Prosthetic Joint Infection and its Influence on Persistent Infection.

Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a severe complication causing a significant burden. The study aims were to establish the epidemiology of microorganisms in TKA PJI, the rate of persistent infection requiring further surgery, and the risk factors for this. Microbiological specimens between June 2002 and March 2017 at five regional hospital sites were identified with revision TKA procedures in the National Joint Replacement Registry. The time between procedures, type of revision strategy, and any subsequent further revision operations were collected. At minimum 2-year follow-up, 174 revision TKA were identified, with a mean patient age of 69 ± 11 years. A broad range of pathogens were identified. Fifty cases (29%) had persistent infection requiring at least one further operative procedure, 13 cases required 3 or more. Coagulase-negative Staphylococcus species (CNS) was seen most with failed surgery, polymicrobial infections also posing a significant risk factor. The best chance of a successful PJI surgical strategy was < 12 months from primary TKA, with the greatest risk between 3 and 5 years (p < 0.05). Younger age significantly increased the risk of further surgery (p < 0.05). Management varied; 103 (59%) debridement, antibiotic therapy and implant retention, with further surgery in 29%; 45 (17%) single-stage revision, with further surgery in 13%; and 26 (15%) two-stage revision, with further surgery in 12%. This study presents the most common causative pathogens for PJI in TKA, and the high rate of persistent infection after initial revision surgery. Risk factors for persistent infection and further revision surgery were polymicrobial and CNS infections, patients who presented between 3 and 5 years following primary TKA, and younger age. This study therefore raises important risk factors and areas for future research to reduce the burden of multiple operations after PJI.

Surgical versus non-surgical treatment for carpal tunnel syndrome.

Surgical versus non-surgical treatment for carpal tunnel syndrome.

Risk of further surgery after decompression in patients with diffuse idiopathic skeletal hyperostosis extending to the lumbar segments: focus on the number of residual lumbar/lumbosacral and sacroiliac mobile segments.

Patients with diffuse idiopathic skeletal hyperostosis (DISH) that extends to the lumbar segments (L-DISH) have a high risk of further surgery after lumbar decompression. However, few studies have focused on the ankylosis status of the residual caudal segments, including the sacroiliac joint (SIJ). We hypothesized that patients with more ankylosed segments beside the operated level, including the SIJ, would be at a higher risk of further surgery. A total of 79 patients with L-DISH who underwent decompression surgery for lumbar stenosis at a single academic institution between 2007 and 2021 were enrolled. The baseline demographics and radiological findings by CT imaging focusing on the ankylosing condition of the residual lumbar segments and SIJ were collected. Cox proportional hazard analysis was conducted to investigate the risk factors for further surgery after lumbar decompression. The rate of further surgery was 37.9% during an average of 48.8months of follow-up. Cox proportional hazard analysis demonstrated that the presence of fewer than three segments of non-operated mobile caudal segments was an independent predictor for further surgery (including both the same and adjacent levels) after lumbar decompression (adjusted hazard ratio 2.53, 95%CI [1.12-5.70]). L-DISH patients with fewer than three mobile caudal segments besides index decompression levels are at a high risk of further surgery. Ankylosis status of the residual lumbar segments and SIJ should be thoroughly evaluated using CT during preoperative planning.

P301 Outcomes following colectomy for patients with Ulcerative Colitis, ten years of data from a tertiary referral centre

Abstract Background Patients who undergo subtotal colectomy for Ulcerative Colitis (UC) have a persistent risk of colorectal cancer (CRC) in the retained rectum and this increases overtime. There are currently no guidelines for rectal surveillance in this group. We aimed to assess the outcome following colectomy for patients with UC over a ten year period. Methods We conducted a retrospective analysis of patients with UC who underwent colorectal surgery in a tertiary referral centre. The Hospital In-Patient Enquiry system and the St Vincent's Hospital IBD Database were used to identify patients. Patients with colorectal cancer were excluded. Results In a six year period one-hundred and seventy six bowel surgeries were carried out for patients with Inflammatory Bowel Disease. Sixty five of these procedures were performed on patients with UC, eight of which would subsequently be re-diagnosed with Crohn’s Disease. 73.6% (n=42) had a completion proctectomy within ten years, 12% (n=7) were lost to follow up and 5% (n=3) died from non-gastrointestinal disorders. 8.7% (n=5) retained their rectum after ten years. For patients who had a completion proctectomy the median time to surgery was two years. Most of these patients did not have surveillance within the twenty four month time frame. Patients who had a completion proctectomy between three and ten years underwent surveillance endoscopy on average two occasions. All patients in the retained rectum group had surveillance proctoscopy with a median frequency of 2.4 years. The risk of further surgery was a factor for two patients due to obesity and decompensated liver disease. A third patient had an ileorectal anastamosis abroad and continues to have active rectal disease. Dysplasia was found in the rectum of the fourth patient thirteen years post colectomy. The final patient refused surgery but agreed to endoscopic surveillance. A rectal adenocarcinoma was diagnosed ten years post-operation. Conclusion Despite the absence of guidelines for completion proctectomy and/or surveillance of the retained rectal stump, three quarters of our UC patients had undergone completion proctectomy within ten years. A small but significant number of patients have a residual rectal stump after ten years, they require CRC surveillance and clear guidelines on this are needed.

Complications From Postmastectomy Radiation Therapy in Patients Undergoing Immediate Breast Reconstruction: A Population-Based Study

PurposePrevious studies have shown an increase in the number of women electing for immediate breast reconstruction at the time of mastectomy. Although often not known at the time, some of these women will require postoperative radiation therapy. The purpose of this study was to investigate if exposure to radiation therapy after mastectomy with immediate breast reconstruction is associated with an increased risk of further surgery to manage complications arising from radiation. Methods and MaterialsThis retrospective, population-based cohort study included all patients who underwent mastectomy with immediate reconstruction from 2007 to 2014 in the province of Ontario, Canada. Exposure to adjuvant radiation therapy was captured using data from Ontario Health. The study outcome was reoperation for breast reconstruction performed during the follow-up window. Cox proportional hazard models were used to assess the effect of radiation therapy exposure on risk of breast reconstruction reoperation. ResultsWe identified 2342 patients who underwent mastectomy with immediate reconstruction over an 8-year period in Ontario, of whom 378 (16.1%) underwent adjuvant radiation therapy. Patients who received radiation were significantly more likely to undergo reoperation during follow-up (hazard ratio, 1.76; 95% confidence interval, 1.49-2.08; P < .0001). Patients with implant-based reconstructions (n = 1629, 69.6%) were not more likely to undergo reoperation than those with flap-based procedures (n = 713, 30.4%) (hazard ratio, 1.01; 95% confidence interval, 0.85-1.21; P = .885). ConclusionsAdjuvant radiation therapy initiated after mastectomy with immediate breast reconstruction is associated with an increased risk of additional breast reconstruction surgery, regardless of the type of reconstruction used. Patients with breast cancer who choose to undergo immediate reconstruction after mastectomy should be advised that additional reconstruction procedures may be required.

The risk of subsequent surgery following bowel resection for Crohn's disease in a national cohort of 19 207 patients.

Surgery is required for most patients with Crohn's disease (CD) and further surgery may be necessary if medical treatment fails to control disease activity. The aim of this study was to characterize the risk of, and factors associated with, further surgery following a first resection for Crohn's disease. Hospital Episode Statistics from England were examined to identify patients with CD and a first recorded bowel resection between 2007 and 2016. Multivariable logistic regression was used to examine risk factors for further resectional surgery within 5 years. Prevalence-adjusted surgical rates for index CD surgery over the study period were calculated. In total, 19 207 patients (median age 39 years, interquartile range 27-53 years; 55% women) with CD underwent a first recorded resection during the study period. 3141 (16%) underwent a further operation during the study period. The median time to further surgery was 2.4 (interquartile range 1.2-4.6) years. 3% of CD patients had further surgery within 1 year, 14% by 5 years and 23% by 10 years. Older age (≥58), index laparoscopic surgery and index elective surgery (adjusted OR 0.65, 95% CI 0.54-0.77; 0.77, 0.67-0.88; and 0.77, 0.69-0.85; respectively) were associated with a reduced risk of further surgery by 5 years. Prior surgery for perianal disease (1.60, 1.37-1.87), an extraintestinal manifestation of CD (1.51, 1.22-1.86) and index surgery in a high-volume centre for CD surgery (1.20, 1.02-1.40) were associated with an increased risk of further surgery by 5 years. A 25% relative and 0.3% absolute reduction in prevalence-adjusted index surgery rates for CD was observed over the study period. Further surgery following an index operation is common in CD. This risk was particularly seen in patients with perianal disease, extraintestinal manifestations and those who underwent index surgery in a high-volume centre.

Promotive effects of four herbal medicine ARCC on wound healing in mice and human.

BackgroundTraditional Chinese medicine (TCM) had been extensively used in China for wound management and had shown great potential in wound treatment while its mechanism is still needed to be addressed.ObjectiveThe present study sought to investigate the therapuetic effect of the TCM ARCC on acute and chronic wounds.MethodsHere, using the ultra‐low temperature preparation method, the mixed ultramicro powder prepared with Angelica (A), Angelica (R), Calcined Gypsum (C) and Caleramide (C) named as ARCC. The effects of ARCC on wound healing in adult and aged mice were comparatively evaluated through a full‐thickness skin defect model. In addition, we randomly selected 10 patients aged 55 to 70 years from a cohort of 500 patients with diabetic feet to assess their prognosis.ResultsAs the results showed that the healing rate had delayed in aged mice compared to adult mice, while ARCC prominently augmented the healing process in aged mice. Moreover, ARCC treatment wounds in aged mice showed accelerated re‐epithelization, enhanced granulation tissue formation, and increased vascularization, which was similar to that of adult mice. Furthermore, ARCC also achieved therapeutic effects in diabetic foot patients, accelerating wound healing. The results found that foot ulcers improved significantly 7 days after the ARCC administration, and 80% of patients were healed within 1 month.DiscussionIn the present study, ARCC was found to have therapeutic effects on both acute and chronic wounds in animal models. ARCC also demonstrated therapeutic effects in diabetic feet, which promoted wound healing, prevented wound infection, and avoided the risk of further surgery or amputation. All these evidences suggested ARCC was a promising approach for wound treatment.ConclusionsARCC might be recommended as a promising therapeutic medication in diabetic and chronic refractory wounds.

Adding a tibial tubercle osteotomy with anteromedialisation to medial patellofemoral ligament reconstruction does not impact patient-reported outcomes in the treatment of patellar instability

ObjectivesAn isolated medial patellofemoral ligament (MPFL) reconstruction (MPFLR) has been demonstrated to be an effective treatment option in the prevention of patellar instability, but there is growing support for performing a tibial tubercle osteotomy (TTO) in patients with an elevated tibial tubercle-trochlear groove distance. The purpose of this study was to evaluate the impact of adding a TTO to MPFLR on patient-reported outcomes. MethodsA retrospective review of patients who underwent MPFLR with or without TTO with a minimum of 12-month follow-up was performed. Patients in both groups were matched based on age, gender, and follow-up time. Recurrent instability (including redislocation and subluxation), visual analogue scale (VAS) score, Kujala score, and satisfaction were evaluated. ResultsThere were 59 patients who underwent MPFLR with concomitant TTO performed at our institution and met our inclusion and exclusion criteria. These patients were then matched to patients undergoing isolated MPFLR based on demographics and follow-up time. The mean age was 25.0 years, 76.3% were female, and the mean follow-up time was 49 months. There was a significant difference in mean tibial tubercle-trochlear groove distance (19.8 ± 3.9 vs. 14.1 ± 2.8) between groups. There was no significant difference in VAS (1.48 ± 2.0 vs. 1.49 ± 2.1, p = 0.972), satisfaction (86.1% ± 24.2% vs. 81.2% ± 27.9, p = 0.311) or revision surgeries (10.2% vs. 10.2%) between groups. ConclusionMatched patients undergoing MPFLR with TTO compared with isolated MPFLR demonstrate no statistically significant difference in patient-reported outcomes, levels of pain, and satisfaction postoperatively. Furthermore, the addition of a TTO does not increase the risk of further surgery or complications. Level of evidenceIII, retrospective comparative study.

Distal Femoral Replacement as a Primary Treatment Method for Distal Femoral Fractures in the Elderly.

Distal femoral fractures account for 3-6% of all femoral fractures with a similar demographic as patients suffering from proximal femoral fractures. The mortality risk can be high in such injuries, which has prompted NHS England to extend the scope of the Best Practice Tariff to include all fragility fractures of the femur. Poor bone quality, intra-articular extension, and significant comminution can make these fractures difficult to manage with fixation techniques, while early mobilisation is a key outcome in the treatment of this injury.In this study, a comprehensive literature search was performed based on keywords, and abstracts were reviewed to identify relevant articles. The following factors were analysed: time to surgery, time to full weight-bearing, the average hospital stay, post-operative mobility status, and complications.A total of 233 abstracts were identified using the pre-determined search criteria, and, subsequently, articles were excluded following author review. A total of 10 relevant articles were included in this review, with five used for review and comparison between distal femoral replacement (DFR) and fixation. This resulted in a sample of 200 patients treated with DFR with over 87% ambulatory at follow-up and a re-operation rate of 13.3% compared to 78% and 13.5%, respectively, in those treated with open reduction internal fixation (ORIF) procedure.Despite a limited pool of evidence, the literature suggests that DFR offers an option that potentially allows immediate weight-bearing and leaves most patients ambulatory at follow-up. Although DFR is more costly than other operative techniques, it avoids complications associated with fixation such as non-union and can reduce the risk of further surgery through direct complications or a need for delayed arthroplasty, which is deemed more complex secondary to fixation. Early mobilisation is a key step in reducing morbidity and mortality among this cohort of patients, and a procedure such as DFR should be more widely considered to help achieve this outcome.

Long-term evaluation of pediatric ACL reconstruction: high risk of further surgery but a restrictive postoperative management was related to a lower revision rate

IntroductionThe guidelines regarding rehabilitation after pediatric anterior cruciate ligament reconstruction (ACLR) are sparse. The aim of the study was to retrospectively describe the long-term outcome regarding further surgery and with special emphasis on the revision rate after two different postoperative rehabilitation programs following pediatric ACLR.Material and methods193 consecutive patients < 15 years of age who had undergone ACLR at two centers, A (n = 116) and B (n = 77), in 2006–2010 were identified. Postoperative rehabilitation protocol at A: a brace locked in 30° of flexion with partial weight bearing for 3 weeks followed by another 3 weeks in the brace with limited range of motion 10°–90° and full weight bearing; return to sports after a minimum of 9 months. B: immediate free range of motion and weight bearing as tolerated; return to sports after a minimum of 6 months.The mean follow-up time was 6.9 (range 5–9) years. The mean age at ACLR was 13.2 years (range 7–14) years.The primary outcome measurement in the statistical analysis was the occurrence of revision. Multivariable logistic regression analysis was performed to investigate five potential risk factors: surgical center, sex, age at ACLR, time from injury to ACLR and graft diameter.ResultsThirty-three percent had further surgery in the operated knee including a revision rate of 12%. Twelve percent underwent ACLR in the contralateral knee. The only significant variable in the statistical analysis according to the multivariable logistic regression analysis was surgical center (p = 0.019). Eight percent of the patients at center A and 19% of the patients at B underwent ACL revision.ConclusionsFurther surgery in the operated knee could be expected in one third of the cases including a revision rate of 12%. The study also disclosed a similar rate of contralateral ACLR at 12%. The revision rate following pediatric ACLR was lower in a center which applied a more restrictive rehabilitation protocol.Level of evidenceCase-control study, Level III.

Arthroscopic treatment for femoroacetabular impingement syndrome (FAIS) in adolescents—5-year follow-up

ABSTRACTTo report the minimum 5-year outcome after hip arthroscopy with labral repair in adolescents. From 2011 to 2014, 29 consecutive patients with a mean age 16.3 years (range 12.7–19.8 years) underwent hip arthroscopy treatment for femoroacetabular impingement syndrome. Patient-related outcome measures (PROMs) including modified Harris Hip Score (mHHS), Visual Analog Scale (VAS) for pain and Copenhagen Hip and Groin Outcome Score (HAGOS) were used preoperatively and at follow-up (FU). Percentage of patients achieving minimum clinically important difference (MCID) and substantial clinical benefit (SCB) for mHHS and HAGOS were determined. Mean FU was 6.7 years (range 5–9.6 years), and a 100% FU was accomplished. Significant improvements were seen for all PROMs at FU in patients not having a periacetabular osteotomy (PAO) with VAS pain score improving from mean 62 to 9, mHHS from 58 to 94 and HAGOS improved in all subgroups. For mHHS, SCB changes were achieved by 76% and MCID by 76% of the patients. Percentage of patients achieving MCID for HAGOS subgroups were 81% for pain, 67% for symptoms, 76% for physical function in daily living, 76% for physical function in sport and recreation, 81% for participation in physical activities and 81% for hip-related quality of life. Two patients had revision hip arthroscopy. PAO was later performed in three patients. The risk of further surgery with center edge (CE) bony edge (CEB) <30° was 42% and 0% with CEB ≥30°. Adolescents having hip arthroscopy with labral repair and resection of cam and pincer morphology achieve significant improvements at mean 6.7 years of FU. CEB < 30° increases the risk of further surgery.

Factors which predict adverse events following surgery in adults with cervical spinal deformity.

The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults. We identified adult patients who underwent corrective cervical spinal surgery between 1 January 2007 and 31 December 2015 from the MarketScan database. The baseline comorbidities and characteristics of the operation were recorded. Adverse events were defined as the development of a complication, an unanticipated deleterious postoperative event, or further surgery. Patients aged < 18 years and those with a previous history of tumour or trauma were excluded from the study. A total of 13,549 adults in the database underwent primary corrective surgery for a cervical spinal deformity during the study period. A total of 3,785 (27.9%) had a complication within 90 days of the procedure, and 3,893 (28.7%) required further surgery within two years. In multivariate analysis, male sex (odds ratio (OR) 0.90 (95% confidence interval (CI) 0.8 to 0.9); p = 0.019) and a posterior approach (compared with a combined surgical approach, OR 0.66 (95% CI 0.5 to 0.8); p < 0.001) significantly decreased the risk of complications. Osteoporosis (OR 1.41 (95% CI 1.3 to 1.6); p < 0.001), dyspnoea (OR 1.48 (95% CI 1.3 to 1.6); p < 0.001), cerebrovascular accident (OR 1.81 (95% CI 1.6 to 2.0); p < 0.001), a posterior approach (compared with an anterior approach, OR 1.23 (95% CI 1.1 to 1.4); p < 0.001), and the use of bone morphogenic protein (BMP) (OR 1.22 (95% CI 1.1 to 1.4); p = 0.003) significantly increased the risks of 90-day complications. In multivariate regression analysis, preoperative dyspnoea (OR 1.50 (95% CI 1.3 to 1.7); p < 0.001), a posterior approach (compared with an anterior approach, OR 2.80 (95% CI 2.4 to 3.2; p < 0.001), and postoperative dysphagia (OR 2.50 (95% CI 1.8 to 3.4); p < 0.001) were associated with a significantly increased risk of further surgery two years postoperatively. A posterior approach (compared with a combined approach, OR 0.32 (95% CI 0.3 to 0.4); p < 0.001), the use of BMP (OR 0.48 (95% CI 0.4 to 0.5); p < 0.001) were associated with a significantly decreased risk of further surgery at this time. The surgical approach and intraoperative use of BMP strongly influence the risk of further surgery, whereas the comorbidity burden and the characteristics of the operation influence the rates of early complications in adult patients undergoing corrective cervical spinal surgery. These data may aid surgeons in patient selection and surgical planning. Cite this article: Bone Joint J2021;103-B(4):734-738.

Arthroscopic outcomes in TMJ internal derangement and surgical progression in a single centre in New Zealand

This study aims to examine outcomes for temporomandibular joint (TMJ) arthroscopy in different Wilkes stages of internal derangement (ID) and factors relevant in relapse in those requiring further surgical management. A review was undertaken of patients who underwent TMJ arthroscopy from June 2017 until August 2019 at St George's Medical Centre, Christchurch, New Zealand. Those with a primary diagnosis of ID with adequate follow up were reviewed. Gender, pre-and post-operative visual analogue scale (VAS) pain scores and maximum incisal opening (MIO) according to Wilkes stages were statistically analysed. Parameters of those who underwent further surgery were assessed. Ninety-nine patients were reviewed with follow up time between 3 and 27 months. No difference in pre- and post-operative VAS pain scores occurred between Wilkes stages (p = 0.9527). Wilkes II patients had the lowest re-operation rates (6.7%). Twenty-one percent of patients underwent further surgery with either re-arthroscopy, arthrotomy or total joint replacement. Gender did not influence the risk of further surgery (p = 0.3451). Four Wilkes IV and 5 Wilkes V patients underwent TJR, with none from Wilkes II or III. This study shows TMJ arthroscopy should be considered a first line intervention in treating symptomatic ID regardless of initial Wilkes stage. A significant improvement in pain and functional levels occurred across all stages. No specific factors were identified for those undergoing further surgery. However, a trend towards open surgery and total joint replacement was seen in Wilkes IV and V patients.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding.

The risk of later surgery at the anastomotic site following right hemicolectomy for Crohn's disease in a national cohort of 12 230 patients

Crohn's disease (CD) has a high-risk of bowel resection and later surgery for recurrent disease. Recent guidelines recommend colonoscopy 6-12months following surgery to reduce further surgical intervention through medical therapy intensification. To investigate the risk of further surgery at the anastomosis following right hemicolectomy for CD. Hospital Episode Statistics were used to identify patients with CD and a right hemicolectomy between 2007 and 2016. Adherence to post-resection colonoscopy guidance timing and risk of further surgery at the anastomosis were examined. Cox proportional hazards models assessed risk factors for further surgery. 12230 patients were identified: 45% male; median age 36 (IQR 26-49) years. Median follow-up was 5.9 (IQR 3.6-8.6) years: totalling 74960 person-years. Median time to further surgery was 2.9 (IQR 1.2-5.3) years. By 5 years 9% and by 10 years 16.9% of those with sufficient follow-up had at least one further surgery involving the anastomotic site. Older, less deprived patients and those whose index surgery took place on an elective admission had a reduced risk of further surgery. The annual number of right hemicolectomies increased over the study from 1063 to 1317, driven by the increasing prevalence of CD. Overall, 78% of patients did not have a colonoscopy, as recommended, within 6-12months following index resection. Further surgery involving the anastomotic site remains common following index right hemicolectomy for CD. Post-surgical colonoscopy was only undertaken in 22% of patients within suggested timeframes. Increased colonoscopy may lead to a reduced need for surgery if early optimisation of medical therapy is undertaken for recurrence.

Risk of adjacent segment disease after 'topping-off' multi-level lumbar fusions with posterior dynamic stabilisers: an observational cohort study.

To determine whether 'topping-off' lumbar fusions, using posterior dynamic stabilising devices (PDSs) with specific biomechanical parameters, reduces the risk of adjacent segment disease (ASD). Survival analysis of two non-randomised cohorts, with or without 'topping-off' (T/O or NoT/O), compared the risk of further surgery for ASD following multi-level posterior lumbar interbody fusion (PLIF). The study sample comprised consecutive patients, aged 55 + years, with degenerative pathology at 2, 3 or 4 levels. The NoT/O cohort underwent surgery between August 1993 and September 2019 (n = 425) and the T/O cohort between September 2011 and September 2019 (n = 146). Comparison of ASD risk between cohorts used Cox proportional hazards (CPH) modelling and Kaplan-Meier survivorship analysis. Analysis was completed on 571 operations across 507 patients. Median follow-up was 63months (range 0.3-196) and 37months (range 1.7-98) for the NoT/O and T/O cohorts, respectively. Of 423 patients, 125 (29.6%) patients in the NoT/O cohort underwent further surgery for ASD and 16/145 (11.03%) in the T/O cohort. The hazard ratio (T/O: NoT/O) from the CPH model was 0.42 (95% CL: 0.24-0.74, P = 0.003). Mean annual incidence across the first 5years was 5.0% in the NoT/O cohort compared with 2.8% in the T/O cohort (P = 0.029). No patient required surgery or developed ASD at a 'topped-off' level. Two patients developed asymptomatic pedicle screw loosening at the level of the PDS device. PROMs were similar between cohorts. This large, non-randomised, observational study found an approximately 60% reduction in further surgery for ASD with the use of the PDS to 'top-off' PLIF fusions. PDS device-related complications were very low.

Is Aspirin as Effective as the Newer Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Total Hip and Knee Arthroplasty? An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man

BackgroundFew studies have compared aspirin with direct oral anticoagulants (DOACs) (DOACs = direct thrombin inhibitors and factor Xa inhibitors) for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We assessed the efficacy and safety of aspirin compared with DOACs for VTE prophylaxis after THA and TKA using the world's largest joint arthroplasty registry. MethodsWe studied the National Joint Registry linked to English hospital inpatient episodes for 218,650 THA and TKA patients. Patients receiving aspirin were matched separately to patients receiving direct thrombin inhibitors and factor Xa inhibitors using propensity scores. Outcomes assessed at 90 days included VTE, length of stay, and adverse events. ResultsAfter THA, there was a significantly lower risk of VTE associated with the use of direct thrombin inhibitors (0.44%; odds ratio [OR], 0.69; 95% confidence interval [95% CI], 0.55-0.87; P = .002) and factor Xa inhibitors (0.37%; OR, 0.63; 95% CI, 0.47-0.85; P = .003) compared with aspirin (0.63%). After THA, direct thrombin inhibitors (coefficient, −0.37 days; 95% CI, −0.43 to −0.31; P < .001) and factor Xa inhibitors (coefficient, −0.80 days; 95% CI, −0.87 to −0.74; P < .001) were associated with a reduced length of stay compared with aspirin. Similar findings for both outcomes were observed after TKA. Compared with aspirin, DOACs were not associated with an increase in the risk of short-term revision surgery, reoperation, major hemorrhage, wound disruption, surgical site infection, and mortality. ConclusionAfter THA and TKA, DOACs were associated with a reduced risk of VTE compared with aspirin. DOACs were associated with a reduced length of stay, and DOACs were not associated with an increase in the risk of further surgery, wound problems, bleeding complications, or mortality compared with aspirin.

Role of Postoperative Patient-Reported Outcomes to Predict Ankle Arthroplasty and Arthrodesis Revision.

Patient-reported outcomes are becoming common for measuring patient-centric outcomes in surgery. However, there is little known about the relationship between postoperatively collected patient-reported outcomes and objective clinical outcomes. The objective of this study was to measure whether postoperative Ankle Osteoarthritis Scale (AOS) values were associated with risk of revision among patients having ankle arthrodesis or total ankle arthroplasty for treatment of symptomatic end-stage ankle arthritis. This is a retrospective analysis of a longitudinal cohort of ankle arthrodesis and total ankle arthroplasty patients. A single center recruited patients between 2003 and 2013 and follow-up was at least 4 years. Patients completed the AOS preoperatively and annually following surgery. An extended Cox regression model incorporating time-varying AOS values was used to model risk of failure. A total of 336 patients and 348 ankles were included, representing 139 ankle arthrodesis procedures and 209 total ankle arthroplasties. The median follow-up time for revisions was 8.2 years and 46 patients had a revision. Higher values of patients' AOS scores in the postoperative period were associated with a higher likelihood of revision (hazard ratio, 1.04 per 1-point increase; 95% confidence interval, 1.03-1.05). Ankle arthrodesis was associated with a reduced risk of revision compared with ankle fusion (hazard ratio, 0.12; 95% confidence interval, 0.03-0.49). This study showed that persistent pain and poor function after fusion or replacement surgery, as measured by elevated values of the AOS, were associated with higher risk of further surgery. Level III, retrospective cohort study.

CORR Insights®: High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years.

CORR Insights®: High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years.

High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years.

The evidence for treating acute, unreconstructable radial head fractures in unstable elbows with radial head replacement predominantly consists of short- to mid-term follow-up studies with a heterogenous mix of implants and operative techniques. Data on longer-term patient-reported outcomes after radial head replacement is lacking. (1) What proportion of patients undergo revision or implant removal after radial head replacement? (2) At a minimum of 8 years follow-up, what are the patient-reported outcomes (QuickDASH, Oxford Elbow Score, and EuroQol-5D)? (3) What factors are associated with a superior long-term patient-reported outcome, according to the QuickDASH? Between September 1994 and September 2010, we surgically treated 157 patients for acute radial head fractures. We excluded patients where the radial head was excised (n = 21), internally fixed (n = 15), or replaced as a secondary procedure after failed internal fixation (n = 2). A total of 119 patients who underwent radial head replacement surgery for an acute unreconstructable fracture were included, with a mean age of 50 years (range 15 to 93 ± 19 years), and 53% of patients (63) were women. All but two implants were uncemented, loose-fitting, monopolar prostheses, of which 86% (102) were metallic and 14% (17) were silastic. Implants were only cemented if they appeared unstable within the proximal radius. Silastic implants were used in the earlier series and replaced by metallic implants starting in 2000. We reviewed electronic records to document postoperative complications and prosthesis revision and removal. A member of the local research team (THC, CDC) who was not previously involved in patient care contacted patients to confirm complications, reoperations and to obtain long-term patient-reported outcomes scores. Nineteen patients had died at the point of outcome score collection. Of the remaining 100 patients, 80 were contacted (67% of total cohort), at a median of 11 years (range 8 to 24 years) after injury. The primary outcome measure was the QuickDASH score. Of 119 patients, 25% (30) underwent reoperation, with three patients undergoing revision and 27 patients undergoing prosthesis removal at a median of 7 months (range 0 to 125 months). Twenty-one of 30 procedures (70%) occurred within 1 year after implantation. Kaplan-Meier survivorship analysis demonstrated a cumulative implant survival rate of 71%. In the 80 patients contacted, the mean QuickDASH score was 13 ± 14, the mean Oxford Elbow Score was 43 ± 6, and the median EuroQol-5D score was 0.8 (-0.3 to 1.0). After controlling for covariates, we found that prothesis revision or removal (p = 0.466) and prosthesis type (p = 0.553) were not associated with patient-reported outcome, according to the QuickDASH. The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperation. Patients must be counselled regarding this risk of secondary intervention, of which the peak risk appears to be within 1 year after implantation. Despite this, patients report low disability according to the QuickDASH at a minimum follow-up of 8 years. Level IV, therapeutic study.