Radiographic assessment of radiolucent lines around a highly porous titanium cup (Tritanium) using digital tomosynthesis, after total hip arthroplasty.

BACKGROUND: The objectives of this study were to assess radiolucent lines around a highly porous titanium cup (Tritanium) using digital tomosynthesis and to investigate the clinical and radiographic factors associated with radiolucent lines on tomosynthesis. METHODS: Fifty-five patients underwent total hip arthroplasty using a Tritanium cup, and digital tomosynthesis and plain radiography were performed at 1 week, 6 months, 1 year, and 2 years after surgery. The radiolucent lines around the cup were measured on both DTS and plain radiography at each postoperative period. Clinical evaluations were performed by the Japanese Orthopaedic Association hip disease evaluation questionnaire (JHEQ), and revision surgeries were examined. Based on the presence of radiolucent lines on digital tomosynthesis at 2 years postoperatively, patients were divided into RL (+) and RL (-) groups and investigated for related factors. RESULTS: There were 20 cases in the RL (+) group and 35 cases in the RL (-) group, and no revision surgeries were required. Statistically, there were more cases with radiolucent lines on digital tomosynthesis (45.4% at 1 week and 36.3% at 2 years) than on plain radiography (9.1% at 1 week and 9.1% at 2 years) at each postoperative point. Logistic analysis showed no significant associations between the presence of radiolucent lines at 2 years on digital tomosynthesis, and the JHEQ parameters of pain (p = 0.937), movement (p = 0.266), or mental status (p = 0.404). CONCLUSION: In a short-term evaluation up to 2 years, digital tomosynthesis detected more radiolucent lines around the titanium cups than plain radiography. The occurrence of radiolucent lines was not related to the postoperative clinical evaluation.

A traditional hip implant is as effective as newer types for people over 65.

The studyFawsitt C, Thom H, Hunt L. Choice of prosthetic implant combinations in total hip replacement: cost-effectiveness analysis using UK and Swedish hip joint registries data. Value Health 2019;22:303-12.This study was funded by the NIHR Research for Patient Benefit Programme (project number PB-PG-0613-31032).To read the full NIHR Signal, go to https://discover.dc.nihr.ac.uk/content/signal-000771/a-traditional-hip-implant-is-as-effective-as-more-expensive-newer-types-for-older-people.

Single-Anesthetic Versus Staged Bilateral Total Hip Arthroplasty: A Matched Cohort Study.

BACKGROUND: There is debate regarding the role of single-anesthetic versus staged bilateral total hip arthroplasty (THA) for patients with end-stage bilateral osteoarthritis. Studies have shown that single-anesthetic bilateral THA is associated with systemic complications, but there are limited data comparing patient outcomes in a matched setting of bilateral THA. METHODS: We identified 94 patients (188 hips) who underwent single-anesthetic bilateral THA. Fifty-seven percent of the patients were male. Patients had a mean age of 52.2 years and body mass index of 27.1 kg/m. They were matched 1:1 on the basis of sex, age (±1 year), and year of surgery (±3 years) to a cohort of patients undergoing staged bilateral THA. In the staged group, there was <1 year between procedures (range, 5 days to 10 months). Mean follow-up was 4 years for each group. RESULTS: Patients in the single-anesthetic group experienced shorter total operating room time and length of stay. There was no difference (hazard ratio [HR] = 0.73, p = 0.50) in the overall revision-free survival in patients undergoing single-anesthetic or staged bilateral THA. The risks of reoperation (HR = 0.69, p = 0.40), complications (HR = 0.83, p = 0.48), and mortality (HR = 0.47, p = 0.10) were similar. Single-anesthetic bilateral THA reduced the total cost of care (by 27%, p = 0.0001). CONCLUSIONS: In this matched cohort analysis, single-anesthetic bilateral THA was not associated with an increased risk of revision, reoperation, or postoperative complications, while decreasing cost. In our experience, single-anesthetic bilateral THA is a safe procedure that, for certain patients, offers an excellent means to deal with bilateral hip osteoarthritis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Development and validation of an automated and marker-free CT-based spatial analysis method (CTSA) for assessment of femoral hip implant migration: In vitro accuracy and precision comparable to that of radiostereometric analysis (RSA).

BACKGROUND AND PURPOSE: We developed a marker-free automated CT-based spatial analysis (CTSA) method to detect stem-bone migration in consecutive CT datasets and assessed the accuracy and precision in vitro. Our aim was to demonstrate that in vitro accuracy and precision of CTSA is comparable to that of radiostereometric analysis (RSA). MATERIAL AND METHODS: Stem and bone were segmented in 2 CT datasets and both were registered pairwise. The resulting rigid transformations were compared and transferred to an anatomically sound coordinate system, taking the stem as reference. This resulted in 3 translation parameters and 3 rotation parameters describing the relative amount of stem-bone displacement, and it allowed calculation of the point of maximal stem migration. Accuracy was evaluated in 39 comparisons by imposing known stem migration on a stem-bone model. Precision was estimated in 20 comparisons based on a zero-migration model, and in 5 patients without stem loosening. RESULTS: Limits of the 95% tolerance intervals (TIs) for accuracy did not exceed 0.28 mm for translations and 0.20° for rotations (largest standard deviation of the signed error (SD(SE)): 0.081 mm and 0.057°). In vitro, limits of the 95% TI for precision in a clinically relevant setting (8 comparisons) were below 0.09 mm and 0.14° (largest SD(SE): 0.012 mm and 0.020°). In patients, the precision was lower, but acceptable, and dependent on CT scan resolution. INTERPRETATION: CTSA allows detection of stem-bone migration with an accuracy and precision comparable to that of RSA. It could be valuable for evaluation of subtle stem loosening in clinical practice.

The Poly Implant Prothèse breast prostheses scandal: Embodied risk and social suffering.

This article examines the 2010 scandal surrounding the use and subsequent recall of adulterated Poly Implant Prothèse (PIP) silicone breast prostheses in France. It uses a mixed method approach that includes 12 interviews with French PIP prosthesis recipients, analyses of medical literature, policy documents of French and EU regulatory agencies, and an online forum for PIP recipients. These data are used to explain how the definition of "acceptable risk" in the silicone implants controversy of the 1990s in the US influenced the PIP scandal later on in France. Additionally, PIP recipients had an embodied experience of risk that clashed with the definition of risk used by authorities and some surgeons. The coverage of re-implantation was also defined at different policy levels, leading to variation in patients' suffering. The combination of fraud and lack of recognition from part of the medical system constitutes an example of social suffering for the patients involved. The PIP scandal is a useful case for analyzing the interconnection of embodied experience and professional and public policy definitions of medical risk through the concepts of moral economy and biological citizenship.

Endovascular aneurysm repair (EVAR) follow-up imaging: the assessment and treatment of common postoperative complications.

Endovascular abdominal aortic aneurysm repair (EVAR) is a well-established procedure, which has long-term mortality rates similar to that of open repair. It has the additional benefit of being less invasive, making it the favoured method of treating abdominal aortic aneurysms in elderly and high-risk patients with multiple co-morbidities. The main disadvantage of EVAR is the higher rate of re-intervention, due to device-related complications, including endoleaks, limb occlusion, stent migration, kinking, and infection. As a result lifelong surveillance is required. In order to avoid missing these complications, intricate knowledge of stent graft design, good-quality diagnostic ultrasound skills, multiplanar reformatting of CT images, and reproducible investigations are important. Most of these complications can be treated via an endovascular approach using cuff extensions, uncovered stents, coils, and liquid embolic agents. Open surgery is reserved for complex complications, where an endovascular approach is not feasible.

Echocardiographic and clinical factors related to paravalvular leak incidence in low-gradient severe aortic stenosis patients post-transcatheter aortic valve implantation.

BACKGROUND: Paravalvular leak (PVL) following transcatheter aortic valve implantation (TAVI) is associated with poor outcomes. The association of clinical and echocardiographic parameters in the occurrence of even mild PVL in patients with low-gradient severe aortic stenosis (LGSAS) after TAVI and predictors of all-cause mortality and re-hospitalization during 2-year follow-up was studied, as data are sparse in the literature. METHODS: Seventy-five consecutive LGSAS patients (age 80 ± 8 years, 68% male, 89% Caucasians) were enrolled and followed-up for PVL development at hospital discharge, as well as mortality or re-hospitalization for cardiovascular disease, during a 2-year follow-up period. Patients' characteristics were retrospectively extracted from hospital's database. Mortality was determined either by chart review or the Social Security Death Index. RESULTS: PVL was evident in 29 out of 75 patients. Patients with PVL had higher death rates at 6-month, 1-year of follow-up (27 vs. 7%, P = 0.05, 32 vs. 8%, P = 0.04, respectively) and lower stroke rates (0 vs. 7%, P = 0.009), compared with those who had no PVL. Patients with PVL were older, had lower BMI, higher prevalence of atrial fibrillation, higher brain natriuretic peptide (BNP), lower rest left ventricular ejection fraction, higher aortic cross-sectional area (Aa), lower stroke volume index, higher aortic resistance, stroke work, and higher energy loss index at rest and during dobutamine stress. Multivariable predictors of PVL post-TAVI were pre-procedural BNP levels and Aa. CONCLUSIONS: PVL remains a common complication after TAVI, related to adverse events in LGSAS patients. Aa and BNP levels remain the most important predictors of PVL.

Indocyanine green video angiography-assisted surgical management of coil migration resulting from the endovascular treatment of anterior communicating artery aneurysm: technical case report and instrumentation assessment.

We describe surgical management of herniated coil using indocyanine green video angiography (ICGA) following failure of endovascular retrieval methods in a patient who had endovascular treatment for anterior communicating artery aneurysm. The interdisciplinary cooperation between the endovascular and neurosurgical teams proved to be crucial for obtainment of a desirable outcome in this case. ICGA technology applied in such difficult cases may improve the surgical outcome.

AQUILA: assessment of quality in lower limb arthroplasty. An expert Delphi consensus for total knee and total hip arthroplasty.

BACKGROUND: In the light of both the importance and large numbers of case series and cohort studies (observational studies) in orthopaedic literature, it is remarkable that there is currently no validated measurement tool to appraise their quality. A Delphi approach was used to develop a checklist for reporting quality, methodological quality and generalizability of case series and cohorts in total hip and total knee arthroplasty with a focus on aseptic loosening. METHODS: A web-based Delphi was conducted consisting of two internal rounds and three external rounds in order to achieve expert consensus on items considered relevant for reporting quality, methodological quality and generalizability. RESULTS: The internal rounds were used to construct a master list. The first external round was completed by 44 experts, 35 of them completed the second external round and 33 of them completed the third external round. Consensus was reached on an 8-item reporting quality checklist, a 6-item methodological checklist and a 22-item generalizability checklist. CONCLUSIONS: Checklist for reporting quality, methodological quality and generalizability for case series and cohorts in total hip and total knee arthroplasty were successfully created through this Delphi. These checklists should improve the accuracy, completeness and quality of case series and cohorts regarding total hip and total knee arthroplasty.

Comparative assessment of sacral screw loosening augmented with PMMA versus a calcium triglyceride bone cement.

STUDY DESIGN: A calcium triglyceride bone cement (CTBC) was compared with the gold-standard polymethylmethacrylate (PMMA) to assess the stability of augmented sacral screw fixation under cyclic loading. OBJECTIVE: To determine whether CTBC augmentation of a pedicle screw would provide a similar level of fixation in the S1 pedicles compared with PMMA augmentation. SUMMARY OF BACKGROUND DATA: Numerous studies have shown the advantages of using PMMA to augment screw fixation; however, its biomechanical properties are not ideal. CTBC offers potential benefits such as being low exothermic, a modulus of elasticity closer to bone, and the potential for osteoconductivity, but its comparative performance in this situation has not been previously evaluated. METHODS: Six cadaveric sacra were used in this study; 3.0 mL volumes of PMMA (Simplex P) and CTBC (Kryptonite™ Bone Cement) were injected into contralateral screw tracts, with the screw immediately inserted after cement injection. After a 12-hour setting period, the sacrum was potted in a custom fixture and mounted to the frame of a materials testing machine. Alternating flexion and extension bending moments were applied at 1 Hz. Flexion moments were applied starting at 0.5 Nm and increased by 1 Nm after every 1000 cycles until the screw had reached 6° of rotation relative to its starting position. Extension moments were maintained at 0.5 Nm. Screw rotation relative to bone was determined in real time by a custom optical tracking system and was analyzed using two-way repeated-measures analyses of variance (ANOVAs) and post hoc Student-Newman-Keuls tests (α = 0.05). RESULTS: To reach 6° of screw rotation, the PMMA-augmented screw required more loading cycles (15,464 ± 2526 vs. 10,277 ± 1762 cycles; P = 0.006) and a larger applied moment (15.3 ± 2.2 vs. 10.5 ± 1.7 Nm; P = 0.010) than CTBC-augmented screw. CONCLUSION: The PMMA augmentation provided increased resistance to cyclic loading compared with the CTBC augmentation for sacral pedicle screw fixation, but both augmentations well exceeded previously published findings for nonaugmented screws.

Early- and late-term dislocation risk after primary hip arthroplasty in the Medicare population.

From 1998 to 2007 Medicare 5% national sample dataset, 39 271 primary total hip arthroplasty (THA) patients were identified. Dislocations within 2 years (early) and after 2 years (late) of primary THA were identified. Cox regression was used to evaluate patient, hospital, and procedure characteristics for risk of dislocation, and 1540 (3.92%) and 451 (1.15%) patients were diagnosed with early and late dislocations, respectively. Dislocation rate at 6 months' follow-up decreased steadily between 1998 and 2007 from 4.21% to 2.14%. Early and late dislocation risks were lower by 35% (P < .001) and 43% (P = .01), respectively, for patients operated during 2004 and 2007 compared with 1998 and 2003. Higher Charlson index scores (i.e., more comorbid conditions) and surgeon volume were significant risk factors (P < or = .04). Decrease in dislocation risks after primary THA seems to coincide with increasing use of larger diameter femoral heads. An awareness of risk factors for dislocation can help surgeons identify high-risk patients so as to prescribe appropriate intervention strategies.