Is Tibial Bone Mineral Density Related to Sex, Age, Preoperative Alignment, or Fixation Method in Primary Total Knee Arthroplasty?

BACKGROUND: Cementless total knee arthroplasty (TKA) has regained interest for its potential for long-term biologic fixation. The density of the bone is related to its ability to resist static and cyclic loading and can affect long-term implant fixation; however, little is known about the density distribution of periarticular bone in TKA patients. Thus, we sought to characterize the bone mineral density (BMD) of the proximal tibia in TKA patients. METHODS: We included 42 women and 50 men (mean age 63 years, range: 50 to 87; mean body mass index 31.6, range: 20.5 to 49.1) who underwent robotic-assisted TKA and had preoperative computed tomography scans with a BMD calibration phantom. Using the robotic surgical plan, we computed the BMD distribution at 1 mm-spaced cross-sections parallel to the tibial cut from 2 mm above the cut to 10 mm below. The BMD was analyzed with respect to patient sex, age, preoperative alignment, and type of fixation. RESULTS: The BMD decreased from proximal to distal. The greatest changes occurred within ± 2 mm of the tibial cut. Age did not affect BMD for men; however, women between 60 and 70 years had higher BMD than women ≥ 70 years for the total cut (P = .03) and the medial half of the cut (P = .03). Cemented implants were used in 1 86-year-old man and 18 women (seven < 60 years, seven 60 to 70 years, and four ≥ 70 year old). We found only BMD differences between cemented or cementless fixation for women < 60 years. CONCLUSIONS: To our knowledge, this is the first study to characterize the preoperative BMD distribution in TKA patients relative to the intraoperative tibial cut. Our results indicate that while sex and age may be useful surrogates of BMD, the clinically relevant thresholds for cementless knees remain unclear, offering an area for future studies.

Comparison of Early Complication Rates After High Tibial Osteotomy Versus Unicompartmental Knee Arthroplasty for Knee Osteoarthritis.

Background: Although both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) can be utilized to treat unicompartmental osteoarthritis (OA) in select patients, the early complication rates between the 2 procedures are not well understood. Understanding of the complication profiles for both procedures would help clinicians counsel patients with unicompartmental knee OA who may be eligible for either treatment option. Purpose: To compare the 30-day complication rates after HTO versus UKA for the treatment of knee OA using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Study Design: Cohort study; Level of evidence, 3. Methods: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing HTO and UKA for knee OA. Patients >60 years of age were excluded. Patient demographics, preoperative comorbidities, and intraoperative data were collected. Postoperative 30-day complications, including venous thromboembolism (VTE), urinary tract infection (UTI), transfusion, surgical-site infection (SSI), and reoperations were recorded. Complication rates between treatment groups were compared using a multivariate logistic regression model adjusted for sex, age, body mass index, steroid use, respiratory status (smoking/dyspnea/chronic obstructive pulmonary disease), diabetes, and hypertension. Results: A total of 156 patients treated with HTO and 4755 patients treated with UKA for knee OA were identified. Mean patient ages were 46 years for the HTO group and 53.4 years for the UKA group. Operative time was significantly longer in the HTO group versus the UKA group (112 minutes vs 90 minutes; P < .001). Multivariate analyses found no significant differences in VTE (1.3% vs 0.6%), UTI (0.6% vs 0.3%), transfusion (0.6% vs 0.2%), deep SSI (0.6% vs 0.1%), and reoperation (1.3% vs 1%) rates between HTO and UKA groups. The HTO group had a higher rate of superficial SSI compared with the UKA group (2.6% vs 0.6%; P = .006) (adjusted odds ratio, 4.2; 95% CI, 1.4-12.5; P = .01). Conclusion: There were no differences in 30-day VTE, UTI, transfusion, deep SSI, and reoperation rates for HTO versus UKA in the treatment of knee OA. HTO was associated with a higher rate of superficial SSI compared with UKA. These findings serve to guide clinicians in counseling patients regarding the early risks after HTO and UKA.

Low early complication rates after arthroscopic meniscus repair and meniscectomy.

PURPOSE: To evaluate the 30-day complication rates after arthroscopic meniscus repair and meniscectomy using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, with subgroup analysis of patients aged > 40 years. METHODS: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing arthroscopic meniscus repair (CPT 29882, 29883) and meniscectomy (29880, 29881). The following 30-day complications were assessed: pulmonary embolism (PE), venous thromboembolism (VTE), surgical site infection (SSI), reoperation, and readmission. Complications rates between treatment groups were compared using multivariate logistic regression analyses adjusted for sex, age, steroid use, and smoking/dyspnoea/COPD. A subgroup analysis was performed for patients aged > 40 years. RESULTS: A total 6354 meniscus repairs and 99,372 meniscectomies were identified. Complication rates were < 1% for both meniscus repair and meniscectomy. Meniscus repair was associated with significantly higher rates of PE, VTE, and readmission compared to meniscectomy: PE (0.2% vs 0.1%, p < 0.001), VTE (0.8% vs 0.4%, p < 0.001), superficial SSI (0.1% vs 0.2%, n.s), deep SSI (0.07% vs 0.1%, n.s), reoperation (0.5% vs 0.4%, n.s), and readmission (0.9% vs 0.8%, p = 0.003). Among patients aged > 40 years, complication rates were < 1.3% for both meniscus repair and meniscectomy. Similar trends and rates were found in patients aged > 40 years undergoing meniscus repair versus meniscectomy: PE (0.38% vs 0.12%, p < 0.001), VTE (1.07% vs 0.46%, p < 0.001), superficial SSI (0.03% vs 0.19%, n.s), deep SSI (0.1% vs 0.06%, n.s), reoperation (0.48% vs 0.43%, n.s), and readmission (1.2% vs 0.85%, p = 0.01). CONCLUSION: Arthroscopic meniscus repair and meniscectomy are both low-risk procedures with 30-day complication rates < 1% overall and < 1.3% among patients aged > 40 years. These findings support meniscus repair whenever feasible in the setting of preserved articular cartilage. Understanding of the short-term complication rates after arthroscopic meniscus repair and meniscectomy can aid surgeons in providing comprehensive preoperative counselling to patients considering such treatments, specifically when discussing the risks and benefits of meniscus repair. LEVEL OF EVIDENCE: III.

Outcomes of Arthroscopic Lysis of Adhesions for the Treatment of Postoperative Knee Arthrofibrosis: A Systematic Review.

Background: Postoperative knee arthrofibrosis is a common and potentially detrimental complication affecting knee function and gait. Several cohort studies have reported good outcomes after arthroscopic lysis of adhesions (LOA) with manipulation under anesthesia (MUA). Purpose: To review the literature assessing the efficacy and complications of arthroscopic LOA and MUA for postoperative arthrofibrosis of the knee and evaluate whether any relevant subgroups are associated with different clinical presentation and outcomes. Study Design: Systematic review; Level of evidence, 4. Methods: This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies published from January 1, 1990, to April 1, 2021, were identified through a search of the US National Library of Medicine (PubMed/MEDLINE), EMBASE, and Cochrane databases. All studies included in this analysis included pre- and postoperative range of motion measurements for their treated patients. Studies reporting outcomes for patients with isolated cyclops lesions after anterior cruciate ligament reconstruction were excluded. Results: Eight studies comprising 240 patients were included. The mean time from index surgery to arthroscopic LOA and MUA was 8.4 months, and the mean postoperative follow-up was at 31.2 months. All studies demonstrated a significant improvement (41.6°) in arc of motion after arthroscopic LOA. Clinically significant improvements in outcome measures, including the International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score, were reported after arthroscopic LOA across all applicable studies. Of 240 patients, a single complication (synovial fistula) occurred after LOA and MUA, which resolved without intervention. Conclusion: The results of this review indicated that arthroscopic LOA and MUA is a safe and efficacious treatment for postoperative arthrofibrosis of the knee.

Cryoneurolysis Is a Safe, Effective Modality to Improve Rehabilitation after Total Knee Arthroplasty.

Although long term pain and mobility outcomes in total knee arthroplasties (TKA) are successful, many patients experience significant amount of debilitating pain during the immediate post-operative period that necessitates narcotic use. Percutaneous cryoneurolysis to the infrapatellar saphenous and anterior femoral cutaneous nerves may help to better restore function and rehabilitation after surgery while limiting narcotic consumption. A retrospective chart review of primary TKA patients receiving pre-operative cryoneurolysis from 2019 to 2020 was performed to assess total opioid morphine milligram equivalents (MME) consumed inpatient and at interval follow-up. Demographics and medical comorbidities were compared between cryoneurolysis and age-matched control patients to assess baseline characteristics. Functional rehabilitation outcomes, including knee range of motion (ROM), ambulation distance, and Boston AM-PAC scores, as well as patient reported outcomes using the KOOS JR and SF-12 scores were analyzed using STATA 17 Software. The analysis included 29 cryoneurolysis and 28 age-matched control TKA patients. Baseline demographics and operative technique were not significant between groups. Although not statistically significant, cryoneurolysis patients had a shorter length of stay (2.5 vs. 3.5 days) and overall less inpatient and outpatient MME requirements. Cryoneurolysis patients had statistically significant improved 6-week ROM and 1-year follow-up KOOS JR and SF-12 mental scores compared to the control. There were no differences in complication rates. Cryoneurolysis is a safe, effective treatment modality to improve active functional recovery and patient satisfaction after TKA by reducing MME requirements. Patients who underwent cryoneurolysis had on average fewer MME prescribed during the perioperative period, improved active ROM, and improved patient-reported outcomes with no associated increased risk of infections, deep vein thrombosis, or neurologic complications.

Anatomic study of an anterior portal for percutaneous internal fixation of capitellum fractures.

BACKGROUND: Fractures of the capitellum are uncommon and difficult to treat surgically. Capitellar open reduction-internal fixation uses a lateral open approach with posterior-to-anterior or anterior-to-posterior screw fixation. We investigated the use of an anterior portal for placement of anterior-to-posterior screw fixation through cadaveric measurement of the anatomic relationships from an anteriorly to posteriorly placed Kirschner wire (K-wire) to anterior elbow structures and calculated the percentage of articular surface accessed from the anterior portal. METHODS: Eight fresh-frozen cadaveric elbows without radiographic or cutaneous evidence of prior trauma or surgery were used for this study. An arthroscopic proximal anteromedial portal was cannulized, and the radiocapitellar joint was evaluated. A single 1-cm portal was placed 1 cm distal to the elbow flexion crease and based lateral to the biceps tendon. The location of the portal was confirmed with a spinal needle, and blunt dissection with a hemostat was performed down to capsular tissue and for arthrotomy. A spinal needle sheath was threaded over a blunt switching stick and served as a cannula for placement of a 0.062 K-wire. Articular mapping was performed with cartilage scraping by the K-wire; the K-wire was then placed at the perceived center along the proximal-to-distal and radial-to-ulnar axis of the capitellum. Fluoroscopic confirmation of the wire's location was performed. Under loupe magnification, anatomic dissection was performed and the shortest distance measurements were recorded with digital calipers from the K-wire to the dissected structures. Capitellar articular measurements were recorded, in addition to the articular area defined by the K-wire. Data analysis was performed, and the average distance and standard deviation (in millimeters) were calculated. For structures that were pierced by or touching the K-wire, the distance was recorded as 0.1 mm. RESULTS: The average distance from the K-wire to the radial, lateral antebrachial cutaneous, and median nerves was 1.8 mm, 11.5 mm, and 28.0 mm, respectively. The average distance from the median cubital vein and biceps tendon was 3.7 mm and 13.4 mm, respectively. The pin track pierced the brachioradialis and supinator muscles in all but 1 specimen. The average capitellar articular surface marked was 39.1% of the calculated articular footprint of the capitellum. CONCLUSIONS: The anterior portal to the capitellum is directly adjacent to the radial nerve and lateral antebrachial cutaneous nerve, where each is susceptible to injury. We recommend blunt dissection and insertion of a cannula to allow drilling and placement of internal fixation in a relatively safe manner with respect to neurovascular structures.

Highly cross-linked polyethylene in primary total knee arthroplasty is associated with a lower rate of revision for aseptic loosening: a meta-analysis of 962,467 cases.

BACKGROUND: The evolution in total knee arthroplasty (TKA) includes the highly cross-linked polyethylene (HXLPE) which has been reported as an effective manner to reduce the wear of the polyethylene and the osteolysis. The purpose of the present study is to synthesize the results of comparative studies between HXLPE and conventional polyethylenes and determine their effect in primary TKA. METHODS: The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: "cross-linked", "polyethylene", "HXLPE", "conventional", "total knee arthroplasty", "TKA", "total knee replacement" and "TKR" combined with Boolean operators AND and OR. RESULTS: Ten studies met the inclusion criteria and were included in the present meta-analysis with 962,467 patients. No significant difference was found regarding the revision rate for any reason between the patients who received HXLPE and those with conventional liner (OR 0.67; 95% CI 0.39-1.18; I2: 97.7%). In addition, there was no difference regarding the radiolucent lines between the two types of liners (OR 0.54; 95% CI 0.20-1.49; I2: 69.4%). However, with data coming from seven studies enrolling a total of 411,543 patients, it was demonstrated that patients who received HXLPE were less likely to be revised due to aseptic loosening compared to the patients with conventional liners (OR 0.35; 95% CI 0.31-0.39; I2: 0.0%). CONCLUSION: The present meta-analysis showed that regarding the overall revision rate and radiographic outcomes there was no significant difference between the two types of liners. On the other hand, the significantly less revision rate due to loosening supports the routine continued use of HXLPE in primary TKA.

Use of elevated liners in primary total hip arthroplasty: a systematic review of the literature.

PURPOSE: Instability remains one of the most frequent complications requiring revision surgery after primary total hip arthroplasty (THA). Elevated liners are often utilized to reduce the risk of dislocation; however, the literature is inconclusive, with no systematic reviews summarizing the data. Thus, this systematic review aimed to establish a consensus for the efficacy of elevated liners in primary THA by determining rates of overall revision and revision specifically for recurrent dislocation. MATERIALS AND METHODS: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible randomized-controlled trials and observational studies reporting on the use of elevated liners in primary total hip arthroplasty were identified through May 2020. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess for heterogeneity. RESULTS: Eight studies met inclusion criteria, and overall, 26,507 patients undergoing primary THA with use of an elevated liner were included. In aggregate, the most common cause of revision was recurrent hip dislocation (1.3%, N = 82/6,267) followed by joint infection (1.2%, N = 45/3,772) and acetabular loosening (0.3%, N = 10/3,772). Notably, elevated liners were associated with a lower risk of revision for recurrent dislocation compared to neutral liners (HR: 0.74; 95% CI: 0.55-1.00; p = 0.048). CONCLUSION: This review found that after primary THA with the use of elevated liners, hip dislocation and prosthetic joint infection continued to be the most frequent reasons for revision surgery. However, elevated liners had a lower risk of revision for recurrent dislocation compared to neutral liners.

Platelet-Rich Plasma Combined With Hyaluronic Acid Improves Pain and Function Compared With Hyaluronic Acid Alone in Knee Osteoarthritis: A Systematic Review and Meta-analysis.

PURPOSE: To evaluate the efficacy of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) injections versus HA injections alone for the management of knee osteoarthritis (OA). METHODS: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible randomized-controlled trials and observational studies directly comparing combined PRP-HA injections with HA injections alone were identified through a search of PubMed, Scopus, and Cochrane Central databases from inception to May 2020. A random effects model meta-analysis was conducted and the I2 statistic was used to assess for heterogeneity. RESULTS: Four studies comprising 377 patients (PRP-HA: 193, HA: 184) with knee OA ranging from I-IV Kellgren-Lawrence grading scale were included. The final follow-up was 12 months in 3 studies and 6 months in 1 study. Patients who received PRP combined with HA had significantly greater improvements compared with those injected with HA alone in terms of visual analog scale scores at 3-month (standardized mean difference [SMD] 1.13; 95% confidence interval [CI] 0.56-1.70; I2 = 56.7%; P < .001), 6-month (SMD 1.08; 95% CI 0.54-1.62; I2 = 67.9%; P < .001), and 12-month (SMD 1.13; 95% CI 0.74-1.52; I2 = 0.0%; P < .001) and 12-month Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical functioning (SMD 0.91; 95% CI 0.65-1.17; I2 = 0.0%; P < .001) and 12-month WOMAC stiffness (SMD 1.09; 95% CI 0.80-1.38; I2 = 0.0%; P < .001) scores. No difference was identified in terms of 12-month WOMAC pain score (SMD 0.36; 95% CI -0.19 to 0.91; I2 = 74.1%; P = .195). CONCLUSIONS: Symptomatic patients with knee OA who were injected with a combination of PRP and HA demonstrated greater improvement in pain and function compared with patients who received HA injections only, as assessed by 3-, 6-, and 12-month visual analog scale scores and 12-month WOMAC physical function and stiffness scores. This study provides encouraging evidence for the use of the combined PRP-HA injections in the management of symptomatic patients with knee OA. LEVEL OF EVIDENCE: III (meta-analysis of randomized and non-randomized comparative trials).

Does Ureteral Stenting Increase the Risk of Metachronous Upper Tract Urothelial Carcinoma in Patients with Bladder Tumors? A Systematic Review and Meta-analysis.

PURPOSE: Ureteral stenting in patients with bladder cancer may become necessary in order to protect the ureteral orifice during transurethral resection of the tumor or for relief of upper urinary tract obstruction. However, it is believed to increase metachronous upper tract urothelial carcinoma risk. MATERIALS AND METHODS: We performed a systematic review and meta-analysis of studies comparing ureteral stenting versus nephrostomy or no drainage with regard to the risk of metachronous upper tract urothelial carcinoma. Records were identified through database searches and sources of grey literature up to October 2020 (PROSPERO: CRD42020178298). RESULTS: Five studies (3,309 individuals) were included. Overall, 278 ureteral stents were placed and 20 (7.2%) patients developed metachronous upper tract urothelial carcinoma, while 131 patients were treated with nephrostomy and 3 (2.3%) cases of metachronous upper tract urothelial carcinoma occurred. Patients treated with ureteral stents had a higher likelihood of metachronous upper tract urothelial carcinoma compared to no stents (OR: 3.49, 95% CI: 1.43-8.48, I2=52%) and no upper urinary tract drainage (OR: 3.37, 95% CI: 1.49-7.63, I2=45%). No difference with regard to metachronous upper tract urothelial carcinoma was observed between stent and nephrostomy (OR: 3.07, 95% CI: 0.41-22.98, I2=54%). For the same outcomes, no difference was noted for patients with hydronephrosis. The level of evidence for all measures was evaluated as low. CONCLUSIONS: Stenting as a preventive measure after resection of tumors involving the orifice should be avoided, when possible, as it increases the risk of metachronous upper tract urothelial carcinoma. In cases of hydronephrosis, drainage with either nephrostomy or stent is recommended depending on individual patient cases as both interventions do not differ regarding metachronous upper tract urothelial carcinoma risk.

Home-based management of knee osteoarthritis during COVID-19 pandemic: literature review and evidence-based recommendations.

PURPOSE: To provide evidence-based recommendations for patients with severe knee osteoarthritis (OA), who had their knee surgery postponed due to the COVID-19 pandemic. METHODS: PubMed/Medline, Scopus and Cochrane Central databases were systematically reviewed for studies reporting outcomes of home-based treatments for knee OA. Due to between-study differences in treatment strategy and reporting methods the results were not pooled and findings of the current review were presented in a narrative manner. RESULTS: The comprehensive literature search yielded 33 eligible studies that were included in this review. Management is performed at home and consists of exercise, proper nutrition, physical therapy and use of corrective and assistive orthotics. Virtual education on self-management strategies should be part of coping with knee OA. Initiating an exercise programme involving gymnastics, stretching, home cycling and muscle strengthening is highly recommended. Obese patients are encouraged to set weight loss goals and adopt a healthy diet. Potential benefits but weak evidence has been shown for the use of knee braces, sleeves, foot orthotics or cushioned footwear. Walking aids may be prescribed, when considered necessary, along with the provision of instructions for their use. CONCLUSION: When bridging the time to rescheduled surgery, it is essential to use appropriate home-based tools for the management of knee OA if pain is to be reduced and need for analgesics or opioid use is to be diminished while maintaining or even improving the functioning and avoiding further limitation of range of motion and subsequent muscular atrophies. Finally, none of these treatments may completely substitute for the life-changing effect of a total knee arthroplasty in patients with severe knee OA. Hence, the subsequent goal is to gradually and safely reinstate elective surgery.

Endovascular reconstruction of extracranial traumatic internal carotid artery dissections: a systematic review.

Extracranial internal carotid artery dissection (ICAD) is a potential source of morbidity and mortality in trauma patients and requires high degree of suspicion for diagnosis after the initial presentation. Occasionally, if standard therapy is contraindicated, endovascular reconstruction is a treatment option. The aim of this systematic review was to report clinical and radiographic outcomes following endovascular repair of ICAD of traumatic and iatrogenic etiology. A comprehensive systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed and Cochrane Library databases were searched. Twenty-four studies comprising 191 patients (204 lesions) were included; 179 underwent traditional carotid artery stenting (CAS), whereas 12 patients underwent flow diversion with the pipeline embolization device (PED). In total, 75.7% of the CAS group and 66.6% of the PED group presented with ICAD-related symptomatology. Concomitant pseudoaneurysms were identified in 61.9% and 78.5% of lesions in the CAS and PED group, respectively. Adverse event rates among CAS-treated lesions after 30-day follow-up were below 2.2% for stroke, transient ischemic attack, and mortality. During follow-up in the CAS group, there was no incidence of ICAD-related stroke or death and 2.2% of patients underwent a repeat CAS procedure. In the PED group, no patient suffered stroke or death in the reported follow-up. In the PED cohort, there was an adequate occlusion rate and no patient had to be retreated. Endovascular reconstruction of traumatic or iatrogenic ICAD appears safe. This approach demonstrated acceptable short- and long-term clinical and radiographic outcomes in both groups.

A meta-analysis of randomized trials comparing bovine pericardium and other patch materials for carotid endarterectomy.

OBJECTIVE: Patch angioplasty during carotid endarterectomy is commonly used to treat symptomatic and asymptomatic carotid artery stenosis. The objective of the present study was to compare the different patch materials that are currently available (synthetic vs venous vs bovine pericardium) in terms of short- and long-term outcomes. METHODS: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and eligible randomized control trials were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until September 2017. A meta-analysis was conducted with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. The primary study end point was the incidence of long-term restenosis. Secondary study end points were 30-day stroke, transient ischemic attack (TIA), myocardial infarction, neck wound infection, local hematoma, carotid artery thrombosis, cranial nerve injury, long-term stroke incidence, and death. RESULTS: Eighteen studies and 3234 patients were included. The risk of 30-day stroke (relative risk [RR], 1.00; 95% confidence interval [CI], 0.45-2.19; I2 = 0%), TIA (RR, 1.14; 95% CI, 0.41-3.19; I2 = 0%), myocardial infarction (odds ratio, 0.75; 95% CI, 0.14-3.97; I2 = 0%), death (RR, 0.53; 95% CI, 0.21-1.34; I2 = 0%), wound infection (RR, 1.84; 95% CI, 0.43-7.81; I2 = 0%), carotid artery thrombosis (RR, 1.47; 95% CI, 0.44-4.97; I2 = 0%), cranial nerve palsy (RR, 1.21; 95% CI, 0.53-2.77; I2 = 0%), and long-term stroke (RR, 2.33; 95% CI, 0.76-7.10; I2 = 0%), death (RR, 1.09; 95% CI, 0.65-1.83; I2 = 0%) and restenosis of greater than 50% (RR, 0.48; 95% CI, 0.19-1.20; I2 = 0%) were similar between the synthetic vs venous patch groups. Also, no differences in terms of 30-day stroke (RR, 0.31; 95% CI, 0.02-5.16; I2 = 63.1%), TIA (RR, 0.49; 95% CI, 0.14-1.76; I2 = 0%), death (RR, 0.74; 95% CI, 0.05-10.51; I2 = 31.7%), carotid artery thrombosis (RR, 0.13; 95% CI, 0.02-1.07; I2 = 0%), and long-term restenosis of greater than 70% (RR, 0.15; 95% CI, 0.01-2.29; I2 = 70.9%) were detected between the synthetic polytetrafluoroethylene and Dacron patch groups. The comparison between the bovine pericardium vs synthetic patch did not yield any statistically significant results in terms of 30-day stroke (RR, 1.44; 95% CI, 0.19-10.79; I2 = 12.7%), TIA (RR, 1.05; 95% CI, 0.11-10.27; I2 = 0%), local neck hematoma (RR, 4.01; 95% CI, 0.46-34.85; I2 = 0%), and death (RR, 4.01; 95% CI, 0.46-34.85; I2 = 0%). CONCLUSIONS: Closure of the carotid arteriotomy with any of the studied patch materials seems to be similar in terms of short- and long-term end points. However, additional randomized trials with adequate follow-up periods are needed to compare bovine pericardium patches with other patch materials.

Revascularization of radiation-induced carotid artery stenosis with carotid endarterectomy vs. carotid artery stenting: A systematic review and meta-analysis.

OBJECTIVE: The incidence of carotid artery stenosis after head and neck radiation is anticipated to rise due to the increasing survival of patients with head and neck malignancies. It remains unclear whether carotid artery stenting (CAS) or endarterectomy (CEA) is the best treatment strategy for radiation-induced carotid artery stenosis. MATERIALS & METHODS: This study was performed according to the PRISMA and MOOSE guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 20, 2017. A meta-analysis of random effects model was conducted. The I-square statistic was used to assess for heterogeneity. RESULTS: Five studies and 143 patients were included. Periprocedural stroke, myocardial infarction (MI) and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR: 7.09; 95% CI: 1.17-42.88; I2 = 0%). CEA was associated with lower mortality rates after a mean follow-up of 50 months (OR: 0.29; 95% CI: 0.09-0.97; I2 = 0%). No difference was identified in long-term restenosis rates between CEA and CAS. CONCLUSIONS: Patients with radiation-induced carotid artery stenosis can safely undergo both CAS and CEA with similar risks of periprocedural stroke, MI and death. However, patients treated with CEA have a higher risk for periprocedural CN injuries and a lower risk for long-term mortality.