Complications and Survivorship After Aseptic Revision Total Hip Arthroplasty: Is There a Difference by Surgical Approach?

BACKGROUND: Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior-based approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA. METHODS: We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (Direct Anterior Approach [DAA], Anterior Based Muscle Sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected. RESULTS: The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index THA was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PL groups (9.55% versus 5.3% versus 11.4%, respectively, P = 0.11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of post-operative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = 0.31). CONCLUSIONS: This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, AMBS approach, or PA, nor between anterior or posterior-based approaches.

Extracorporeal Membrane Oxygenation for Graft Dysfunction Early After Heart Transplantation: A Systematic Review and Meta-analysis.

INTRODUCTION: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a prevailing option for the management of severe early graft dysfunction. This systematic review and individual patient data (IPD) meta-analysis aims to evaluate (1) mortality, (2) rates of major complications, (3) prognostic factors, and (4) the effect of different VA-ECMO strategies on outcomes in adult heart transplant (HT) recipients supported with VA-ECMO. METHODS AND RESULTS: We conducted a systematic search and included studies of adults (≥18 years) who received VA-ECMO during their index hospitalization after HT and reported on mortality at any timepoint. We pooled data using random effects models. To identify prognostic factors, we analysed IPD using mixed effects logistic regression. We assessed the certainty in the evidence using the GRADE framework. We included 49 observational studies of 1477 patients who received VA-ECMO after HT, of which 15 studies provided IPD for 448 patients. There were no differences in mortality estimates between IPD and non-IPD studies. The short-term (30-day/in-hospital) mortality estimate was 33% (moderate certainty, 95% confidence interval [CI] 28%-39%) and 1-year mortality estimate 50% (moderate certainty, 95% CI 43%-57%). Recipient age (odds ratio 1.02, 95% CI 1.01-1.04) and prior sternotomy (OR 1.57, 95% CI 0.99-2.49) are associated with increased short-term mortality. There is low certainty evidence that early intraoperative cannulation and peripheral cannulation reduce the risk of short-term death. CONCLUSIONS: One-third of patients who receive VA-ECMO for early graft dysfunction do not survive 30 days or to hospital discharge, and one-half do not survive to 1 year after HT. Improving outcomes will require ongoing research focused on optimizing VA-ECMO strategies and care in the first year after HT.

A case series: the outcomes, support duration, and graft function recovery after VA-ECMO use in primary graft dysfunction after heart transplantation.

Primary graft dysfunction (PGD) is a rare complication associated with high mortality after heart transplantation, which may require veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) support. A standardized definition for PGD was developed by the International Society of Heart and Lung Transplantation in 2014. Due to limited reports using this definition, the detailed outcomes after VA-ECMO support remain unclear. Therefore, we retrospectively analyzed our single-center outcomes of PGD following VA-ECMO support. Between September 2014 and August 2018, 160 patients underwent heart transplantation in our single center. Nine PGD patients required VA-ECMO support, with an incidence of 5.6%. Pre-operative recipient/donor demographics, intra-operative variables, timing of VA-ECMO initiation and support duration, graft function recovery during 30 days after heart transplant, VA-ECMO complications, and survival were analyzed. The indication for VA-ECMO support was biventricular failure for all nine patients. Six patients had severe PGD requiring intra-operative VA-ECMO, while two patients had moderate PGD and one patient had mild PGD requiring post-operative VA-ECMO. All cohorts were successfully decannulated in a median of 10 days. Survival to discharge rate was 88.9%. One-year survival rate was 85.7%. Left ventricular ejection fraction recovered to normal within 30 days in all PGD patients. Our study showed VA-ECMO support led to high survival and timely graft function recovery in all cohorts. Further larger research can clarify the detailed effects of VA-ECMO support which may lead to standardized indication of VA-ECMO support for PGD patients.

Psychological Impact and Posttraumatic Stress Disorder Symptomatology After Ulnar Collateral Ligament Injuries in Baseball Players.

Background: Significant psychological impact and prevalence of posttraumatic stress disorder (PTSD) have been well documented in patients sustaining anterior cruciate ligament injury. Purpose: To examine PTSD symptomatology in baseball players after sustaining elbow ulnar collateral ligament (UCL) injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Male baseball players of various competition levels (high school through Minor League Baseball [MiLB]) who underwent surgery for a UCL injury between April 2019 and June 2022 participated in the study. Before surgery, patients completed the Impact of Event Scale-Revised (IES-R) to assess PTSD symptomatology. Subgroup analysis was conducted according to level of play and player position. Results: A total of 104 male baseball players with a mean age of 19.4 years (range, 15-29 years) were included in the study; 32 players (30.8%) were in high school, 65 (62.5%) were in college, and 7 (6.7%) were in MiLB. There were 64 (61.5%) pitchers, 18 (17.3%) position players, and 22 (21.2%) 2-way players (both pitching and playing on the field). A total of 30 (28.8%) patients scored high enough on the IES-R to support PTSD as a probable diagnosis, and another 22 patients (21.2%) scored high enough to support PTSD as a clinical concern. Nineteen patients (18.3%) had potentially severe PTSD. Only 4 players (3.8%) were completely asymptomatic. Subgroup analysis revealed college players as significantly more symptomatic than high school players (P = .02), and 2-way players were found to be significantly less susceptible to developing symptoms of PTSD compared with pitchers (P = .04). Conclusion: Nearly 30% of baseball players who sustained a UCL injury qualified for a probable diagnosis of PTSD based on the IES-R. Pitchers and college athletes were at increased risk for PTSD after UCL injury compared with 2-way players and high school athletes, respectively.

Patients With Posterior Cruciate Ligament Injuries Obtain Information Regarding Diagnosis, Management, and Recovery from Low-Quality Online Resources.

OBJECTIVES: This study investigates the most common online patient questions pertaining to posterior cruciate ligament (PCL) injuries and the quality of the websites providing information. METHODS: Four PCL search queries were entered into the Google Web Search. Questions under the 'People also ask' tab were expanded in order and 100 results for each query were included (400 total). Questions were categorized based on Rothwell's Classification of Questions (Fact, Policy, Value). Websites were categorized by source (Academic, Commercial, Government, Medical Practice, Single Surgeon Personal, Social Media). Website quality was evaluated based on the Journal of the American Medical Association (JAMA) Benchmark Criteria. Pearson's chi-squared was used to assess categorical data. Cohen's kappa was used to assess inter-rater reliability. RESULTS: Most questions fell into the Rothwell Fact category (54.3%). The most common question topics were Diagnosis/Evaluation (18.0%), Indications/Management (15.5%), and Timeline of Recovery (15.3%). The least common question topics were Technical Details of Procedure (1.5%), Cost (0.5%), and Longevity (0.5%). The most common websites were Medical Practice (31.8%) and Commercial (24.3%), while the least common were Government (8.5%) and Social Media (1.5%). The average JAMA score for websites was 1.49 ± 1.36. Government websites had the highest JAMA score (3.00 ± 1.26) and constituted 42.5% of all websites with a score of 4/4. Comparatively, Single Surgeon Personal websites had the lowest JAMA score (0.76 ± 0.87, range [0-2]). PubMed articles constituted 70.6% (24/34) of Government websites, 70.8% (17/24) had a JAMA score of 4 and 20.8% (5/24) had a score of 3. CONCLUSION: Patients search the internet for information regarding diagnosis, treatment, and recovery of PCL injuries and are less interested in the details of the procedure, cost, and longevity of treatment. The low JAMA score reflects the heterogenous quality and transparency of online information. Physicians can use this information to help guide patient expectations pre- and post-operatively.

What are our patients asking Google about acromioclavicular joint injuries?-frequently asked online questions and the quality of online resources.

Background: Management of acromioclavicular (AC) joint injuries has been an ongoing source of debate, with over 150 variations of surgery described in the literature. Without a consensus on surgical technique, patients are seeking answers to common questions through internet resources. This study investigates the most common online patient questions pertaining to AC joint injuries and the quality of the websites providing information. Hypothesis: 1) Question topics will pertain to surgical indications, pain management, and success of surgery and 2) the quality and transparency of online information are largely heterogenous. Methods: Three AC joint search queries were entered into the Google Web Search. Questions under the "People also ask" tab were expanded in order and 100 results for each query were included (300 total). Questions were categorized based on Rothwell's classification. Websites were categorized by source. Website quality was evaluated by the Journal of the American Medical Association (JAMA) Benchmark Criteria. Results: Most questions fell into the Rothwell Fact category (48.0%). The most common question topics were surgical indications (28.0%), timeline of recovery (13.0%), and diagnosis/evaluation (12.0%). The least common question topics were anatomy/function (3.3%), evaluation of surgery (3.3%), injury comparison (1.0%), and cost (1.0%). The most common websites were medical practice (44.0%), academic (22.3%), and single surgeon personal (12.3%). The average JAMA score for all websites was 1.0 ± 1.3. Government websites had the highest JAMA score (4.0 ± 0.0) and constituted 45.8% of all websites with a score of 4/4. PubMed articles constituted 63.6% (7/11) of government website. Comparatively, medical practice websites had the lowest JAMA score (0.3 ± 0.7, range [0-3]). Conclusion: Online patient AC joint injury questions pertain to surgical indications, timeline of recovery, and diagnosis/evaluation. Government websites and PubMed articles provide the highest-quality sources of reliable, up-to-date information but constitute the smallest proportion of resources. In contrast, medical practice represents the most visited websites, however, recorded the lowest quality score. Physicians should utilize this information to answer frequently asked questions, guide patient expectations, and help provide and identify reliable online resources.

Radially Based Extensor Retinacular Sling Reconstruction for Extensor Carpi Ulnaris Subsheath Injuries in Elite Athletes.

BACKGROUND: Extensor carpi ulnaris (ECU) subsheath injuries are an increasingly recognized cause of ulnar-sided wrist pain in elite athletes. There is a lack of surgical outcome data in elite athletes, and unique considerations exist for these patients. METHODS: We performed a retrospective review of our hand center experience of 14 elite professional or collegiate athletes who prospectively underwent radially based extensor retinacular sling ECU subsheath reconstruction by 3 hand surgery-fellowship-trained surgeons between April 2011 and April 2021. Clinical, magnetic resonance imaging (MRI), and intraoperative findings were cataloged. Subgroup analyses of elite hockey players and acute subsheath injuries were also conducted. Statistical analysis was performed via a 2-tailed paired t test. RESULTS: Mean age at the time of surgery was 21.3 years (range, 18-34). Mean time from symptom onset to surgery was 102.1 ± 110.7 days. All 14 patients underwent preoperative MRI. Five patients (35.7%) had intrinsic ECU tendinopathy, 9 patients (64.3%) had ECU tenosynovitis, 6 patients (42.9%) had triangular fibrocartilage complex tears, and 9 patients (64.3%) had ulnocarpal synovitis. Mean postoperative pain on a Visual Analog Scale was 0.25 ± 0.43. Grip strength (P = .001), wrist flexion-extension (P = .037), and pronosupination arcs (P = .093) showed excellent recovery postoperatively. Mean time to unrestricted return to sports was 92.5 ± 21.0 days. There were no complications. Subgroup analyses found similar functional improvement and characterized injury patterns. CONCLUSIONS: Overall, our findings suggest surgical management of ECU subsheath injuries is a viable option in both acute and chronic settings in elite athletes and may be favorable compared with nonoperative management.

Radially Based Extensor Retinacular Sling Reconstruction for Extensor Carpi Ulnaris Subsheath Injuries.

Purpose: Extensor carpi ulnaris (ECU) subsheath injuries result in ulnar-sided wrist pain and often present concurrently with intrinsic ECU pathology and ulnocarpal compartment injuries. There is a lack of surgical outcome data despite the variety of described ECU subsheath pathologies and reconstructive strategies. Methods: We retrospectively reviewed our hand-center experience of 33 patients who prospectively underwent radially based extensor retinacular sling ECU subsheath reconstruction by 4 hand surgery-fellowship-trained surgeons between April 2010 and April 2021. Preoperative clinical and magnetic resonance imaging findings, along with intraoperative findings, were cataloged. Statistical analysis was conducted via a 2-tailed paired t test. Results: The median age at the time of surgery was 44 years (range, 18-63 years). Twenty (60.6%) patients underwent reconstruction on their dominant wrist. The median time between symptom onset and surgery was 6.5 months (range, 4 days-16.1 years). Eight (18%) patients were collegiate-level or professional athletes. Ten (30.3%) patients had frank ECU snapping on the preoperative examination with no recurrence or apprehension on the postoperative examination. All 33 patients underwent a preoperative magnetic resonance imaging. Fifteen (45.4%) patients had intrinsic ECU tendinopathy, 19 (57.6%) patients had ECU tenosynovitis, 18 (54.5%) patients had triangular fibrocartilage complex tears, 20 (60.6%) patients had ulnocarpal synovitis, and 2 (6.1%) patients had lunotriquetral interosseous ligament tears. The mean postoperative pain on a visual analog scale was 0.39 ± 0.55. Grip strength, wrist flexion-extension, and pronosupination arcs (P < .05) showed excellent recovery after surgery. The mean time to unrestricted return to sports was 97.3 ± 19.7 days for the athletes in this study. There were no major complications. Conclusions: Radially based extensor retinacular sling ECU subsheath reconstruction resulted in satisfactory improvements in range of motion and grip strength. Although the mean improvements in these parameters were statistically significant, the clinical significance of these postoperative improvements remains to be defined. Type of study/level of evidence: Therapeutic, Level IV.

Posteromedial Osteophyte Resection in Baseball Players Undergoing Ulnar Collateral Ligament Reconstruction Has no Effect on Return to Play but Decreases Patient-Reported Satisfaction and Throwing Control.

Purpose: The purpose of this study was to compare patient-reported outcomes and return to play (RTP) rates following ulnar collateral ligament reconstruction (UCLR) in patients with and without posteromedial elbow impingement (PI) treated with concomitant arthroscopic posteromedial osteophyte resection. Methods: Baseball players who underwent UCLR performed by the senior surgeon with minimum follow-up of 2 years were surveyed in this retrospective cohort study. Primary outcomes included Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score, Andrews-Timmerman score, and RTP rate. Secondary outcomes included patient satisfaction scores. Results: 35 baseball players were included. Eighteen had no preoperative impingement (mean age: 19.06 ± 3.28 years), while 17 had PI treated with concomitant arthroscopic osteophyte resection (mean age: 20.06 ± 2.68 years). Following surgery, there was no difference in mean Andrews-Timmerman score (no impingement = 91.67 ± 8.04 vs PI = 92.06 ± 7.92, P = .89) nor KJOC score (no impingement = 83.36 ± 11.72 vs PI = 79.88 ± 12.35, P = .40), but there was a decreased mean KJOC throwing control sub-score in the PI group (7.65 ± 2.40 vs 9.11 ± 1.32, P = .04). There was no difference in RTP rate between the groups (no impingement = 72.22%, PI = 94.12%, χ2 = 1.28; P = .26). There was significantly higher mean satisfaction score in the no impingement group (96.67 ± 4.58 vs 90.12 ± 11.91; P = .04), and those patients were also more likely to pursue surgical treatment again (94.44% vs 52.94%, χ2 = 7.88; P = .005). Conclusions: There was no difference in RTP rate following ulnar collateral ligament reconstruction in baseball players with and without posteromedial impingement treated with arthroscopic resection. Outcomes on the KJOC and Andrews-Timmerman scores were good to excellent in both groups. Players in the posteromedial impingement group were less satisfied with their outcome, however, and less likely to elect for surgery if they were to sustain the injury again. Additionally, players in the posteromedial impingement group were found to have decreased throwing control on the KJOC questionnaire, which may suggest that the presence of posteromedial osteophytes represent adaptive changes to stabilize the elbow while throwing. Level of Evidence: Level III, retrospective cohort study.