Vascular Injuries in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Vascular injuries associated with total knee arthroplasty can have limb and life-threatening consequences. The aims of this study were to conduct a meta-analysis of the overall rate of vascular injuries after total knee arthroplasty and to conduct a systematic review of specific major and minor vessel injuries. METHODS: All English-language literature published from January 1, 1998, to November 30, 2018, was queried in 4 unique databases using a common search term. This yielded 404 results, of which 270 were unique. Two reviewers then assessed studies for eligibility. All non-human studies, cadaver studies, studies describing only human images, and human studies with non-acute pathology were excluded. The final study included 10 large epidemiological studies and 68 case series or studies. Data from the literature were abstracted into a comma-separated database spreadsheet using Microsoft Excel. A meta-analysis was then performed. Pooled statistics were calculated with weighting by inverse variance assuming a random effect model. I was calculated as a quantifier of heterogeneity and interpreted according to the Cochrane manual. All data analysis was performed using R software. RESULTS: Among the 1,419,557 total knee arthroplasties reported in 10 studies, there were 767 major vascular injuries (0.05% [54 per 100,000 total knee arthroplasties]). Amputation or long-term neurological complications occurred in approximately 21% of patients after major vascular injury. Presentation after 24 hours occurred in 36% of cases. The most frequently injured vessels were the geniculate arteries, popliteal artery, superficial femoral artery, and anterior tibial artery. The injuries that were most likely to result in amputation were femoral artery occlusion, popliteal artery transection, and popliteal artery arteriovenous fistula. CONCLUSIONS: Amputation and long-term neurological complications are common complications after a vascular injury associated with a total knee arthroplasty. Preoperative consultation with vascular surgery physicians may be a prudent approach before a surgical procedure for patients with known peripheral vascular disease, diabetes, hypertension, or smoking; however, more data on risk factors are needed. Awareness by the surgical team and implementation of specific strategies during a surgical procedure such as gentle manipulation of the knee and careful retraction may further reduce the rate of injuries. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Spine radiosurgery in adolescents and young adults: early outcomes and toxicity in patients with metastatic Ewing sarcoma and osteosarcoma.

OBJECTIVE: There are limited data on spine stereotactic radiosurgery (SRS) in treating adolescent and young adult (AYA) patients. SRS has the advantages of highly conformal radiation dose delivery in the upfront and retreatment settings, means for dose intensification, and administration over a limited number of sessions leading to a decreased treatment burden. In this study, the authors report the oncological and toxicity outcomes for AYA patients with metastatic sarcoma treated with spine radiosurgery and provide clinicians a guide for considerations in dose, volume, and fractionation. METHODS: An institutional review board-approved database of patients treated with SRS in the period from October 2014 through December 2018 was queried. AYA patients, defined by ages 15-29 years, who had been treated with SRS for spine metastases from Ewing sarcoma or osteosarcoma were included in this analysis. Patients with follow-ups shorter than 6 months after SRS were excluded. Local control, overall survival, and toxicity were reported. RESULTS: Seven patients with a total of 11 treated lesions were included in this study. Median patient age was 20.3 years (range 15.1-26.1 years). Three patients had Ewing sarcoma (6 lesions) and 4 patients had osteosarcoma (5 lesions). The median dose delivered was 35 Gy in 5 fractions (range 16-40 Gy, 1-5 fractions). The median follow-up was 11.1 months (range 6.8-26.0 months). Three local failures were observed within the follow-up period. No acute grade 3 or greater toxicity was observed. One patient developed late grade 3 toxicity consisting of radiation enteritis. This patient had previously received radiation to an overlapping volume with conventional fractionation. SRS re-irradiation for this patient was also performed concurrently with chemotherapy administration. No late grade 4 or higher toxicities were observed. No pain flare or vertebral compression fracture was observed. Three patients died within the follow-up period. CONCLUSIONS: SRS for spine metastases from Ewing sarcoma and osteosarcoma can be considered as a treatment option in AYA patients and is associated with acceptable toxicity rates. Further studies must be conducted to determine long-term local control and toxicity for this treatment modality.

Posterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

OBJECTIVE: This study was conducted to determine and recommend the most up-to-date information on the indications, complications, and outcomes of posterior surgical treatments for cervical spondylotic myelopathy (CSM) on the basis of a literature review. METHODS: A comprehensive literature search was performed, using the MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and Web of Science databases, for peer-reviewed articles published in English during the last 10 years. RESULTS: Posterior techniques, which include laminectomy alone, laminectomy with fusion, and laminoplasty, are often used in patients with involvement of 3 or more levels. Posterior decompression for CSM is effective for improving patients' neurological function. Complications resulting from posterior cervical spine surgery include injury to the spinal cord and nerve roots, complications related to posterior screw fixation or instrumentation, C5 palsy, spring-back closure of lamina, and postlaminectomy kyphosis. CONCLUSION: It is necessary to consider multiple factors when deciding on the appropriate operation for a particular patient. Surgeons need to tailor preoperative discussions to ensure that patients are aware of these facts. Further research is needed on the cost-to-benefit analysis of various surgical approaches, the comparative efficacy of surgical approaches using various techniques, and long-term outcomes, as current knowledge is deficient in this regard.

Lumbar Spinal Stenosis and Degenerative Spondylolisthesis: A Review of the SPORT Literature.

The Spine Patient-Reported Outcomes Related Trial (SPORT) is arguably one of the most impactful and insightful studies conducted in spine surgery. Designed as a prospective, multicenter study with randomized and observational cohorts, SPORT has provided vast data on the pathogenesis, treatment effects, clinical outcomes, cost effectiveness of disk herniation, lumbar spinal stenosis, and degenerative spondylolisthesis. With regards to spinal stenosis and degenerative spondylolisthesis, SPORT has demonstrated a sustained benefit from surgical intervention at 2, 4, and 8 years postoperatively. Myriad subgroup analyses have subsequently been performed that have also resulted in clinically relevant findings. These analyses have assessed incidence and risk factors for reoperations and intraoperative complications, impact of patient comorbidities and host factors, influence of epidural injections, patient decision-making, and role of nonoperative therapy. This has resulted in significant findings that may allow spine surgeons to optimize patient outcomes while managing expectations appropriately.

Postoperative stroke after anterior cervical discectomy and fusion in patients with carotid artery stenosis: a statewide database analysis.

BACKGROUND: Carotid artery injury and stroke secondary to prolonged retraction remains an extremely rare complication in anterior cervical discectomy and fusion (ACDF). However, multiple studies have demonstrated that carotid artery retraction during the surgical approach may alter the normal blood flow, leading to a significant reduction in the cross-sectional area of the vessel. Others have suggested that dislodgment of atherosclerotic plaques following manipulation of the carotid artery can be a potential risk for intracranial embolus and stroke. PURPOSE: We aimed to evaluate: (1) the incidence of postoperative stroke following ACDF and (2) incidence of other postoperative complications in a cohort of patients who had a diagnosis of carotid artery stenosis (CAS) versus those who did not. PATIENT SAMPLE: This study utilized the Statewide Planning and Research Cooperative System database from January 1, 2009 to December 31, 2013. All patients who underwent (ACDF) and had a preoperative diagnosis of CAS were identified using the International Classification of Disease, ninth revision codes. Those who had a previous history of stroke were excluded. Patients who had CAS were propensity score matched to patients without history of CAS for demographics and Charlson/Deyo comorbidity scores. OUTCOME MEASURES: Incidence of postoperative stroke and other complications were compared between the cohorts. The threshold for statistical significance was set at a p<.05. This study received no funding. The authors report no conflict of interests relevant to this study. RESULTS: There were 34,975 patients who underwent an ACDF in the study time period. After excluding those under the age of 18 and with history of previous stroke, there were 61 patients who had CAS that were compared with a propensity-matched cohort. The CAS cohort had a significantly higher incidence of postoperative stroke during their hospitalization (6.6% vs 0%, p<.042). The CAS cohort also had higher rates of acute renal failure (27.9% vs 4.9%, p = .01) and sepsis (18% vs 4.9%, p = .023). There were no stroke related deaths. CONCLUSIONS: Patients with CAS who underwent ACDF had a statistically significant greater incidence of developing a postoperative stroke. To the best of our knowledge, no previous study has evaluated the development of postoperative stroke in patients with CAS undergoing ACDF. Larger, multicenter studies are needed to estimate the true incidence of stroke in this specific patient population. However, our results may illustrate the importance of preoperative optimization, approach-selection, and postoperative stroke surveillance in patients with a history of CAS who undergoes ACDF.

Hip Osteoarthritis Patients Demonstrated Marked Dynamic Changes and Variability in Pelvic Tilt, Obliquity, and Rotation: A Comparative, Gait-Analysis Study.

INTRODUCTION: Changes in pelvic position has been shown to affect acetabular coverage of the femoral head in total hip arthroplasty (THA) and may contribute to complications such as impingement, dislocation, or early wear. Understanding the kinematic changes of these positions during functional activities may help surgeons reach a consensus regarding stable hip mechanics and ideal implant positioning in THA. Therefore, in this study, we aimed to evaluate the following in patients who had unilateral hip OA: 1) dynamic changes; and 2) variability; in the following pelvic position parameters: A) tilt; B) obliquity; and C) rotation standing position to walking. This same data was also collected from a control cohort of normal subjects with non-arthritic hip joints. Data from both cohorts were then compared. MATERIALS AND METHODS: This study analyzed 50 patients who had unilateral osteoarthritis of the hip. There were 27 men and 23 women who had a mean age of 59 years, a mean height of 173 cm (range, 152 to 200 cm), a mean weight of 84 kg (range, 31.5 to 125 kg), and a mean body mass index (BMI) of 28 kg/m2 [range, 13 to 43 kg/m2). In addition, a cohort of 19 healthy subjects with matching demographics (11 men and 9 women, mean age; 64, mean height; 168 cm, mean weight; 88 kg, mean BMI; 30 kg/m2) served as a control group. Joint marker sets were used for analysis and specific markers were used to assess pelvic position of the participants. In each cohort, mean pelvic tilt, obliquity, and rotation values in standing position, as well as mean minimum and maximum values in walking position were collected and compared. Dynamic change from standing to walking was calculated in both cohorts and then compared. Variability was demonstrated by comparing a graphic representation of individual values from both cohorts. RESULTS: In hip OA patients, wide dynamic changes were demonstrated in pelvic tilt, obliquity, and rotation when going from a standing to a walking position (pelvic tilt; mean standing +8°, [range, -5° to +32°], walking range -13.5° to +33°, obliquity; mean standing +0.4°, [range, -8° to 7°], walking range -14° to +10°, rotation; mean standing -1.5° [range, -16 to +10°], and walking range -28° to +13°). In the non-arthritic cohort, narrower ranges of dynamic changes were recorded (pelvic tilt; mean standing +7°, [range, +4.35° to +9.81°], walking range +4.35° to +9.81°, obliquity; mean standing +0.66° , [range, -0.35° to 1.67°], walking range [-2.8° to 5.1°], rotation; standing mean +0.5° [range, -1.16° to +2.16°], and walking range [-6.8° to +5.1°]). When both cohorts were compared, the hip OA cohort had a three- to four-folds increase in dynamic change relative to the non-arthritic group, and in pelvic tilt, obliquity, and rotation (pelvic tilt; 38.5° vs. 9.3°, obliquity; 23.6° vs. 7.24°, rotation; 39.5° vs. 11.4). In addition, marked variability in pelvic position was also demonstrated when walking ranges of all three parameters for hip OA patients were compared to the non-arthritic subjects. CONCLUSION: This study utilized a novel and innovative approach to analyze the dynamic changes and variability in pelvic position parameters in patients with hip OA in comparison to non-arthritic matching subjects. Hip OA patients showed marked changes in pelvic tilt, obliquity, and rotation when going from standing to walking. Non-arthritic subjects exhibited much less noticeable changes in all three parameters. When dynamic changes in both cohorts were compared, hip OA patients had a three- to four-folds increase relative to the non-arthritic group with marked variability in walking ranges. These findings may have implications on the acetabular spatial orientation and highlight the need for individual planning when undertaking THA to account for the dynamic changes in pelvic position parameters during functional activities.