Factors Associated with Reoperation after Pyrocarbon Proximal Interphalangeal Joint Arthroplasty for the Arthritic Joint: A Retrospective Cohort Study.

Introduction The rate of reoperation after pyrocarbon proximal interphalangeal (PIP) joint arthroplasty ranges from 5.9 to 37% and complications such as radiographic loosening, deformity, dislocation, and stiffness are common. Because of the limited amount of knowledge around these problems, we evaluated factors associated with reoperation after pyrocarbon PIP arthroplasty. Materials and Methods We retrospectively included all adult patients that underwent primary PIP pyrocarbon implant arthroplasty between 2002 and 2016 at one institutional system. A total of 45 patients, with a mean age of 55 (standard deviation: 14), underwent 66 PIP arthroplasties. To address for within individual correlations, we only included fingers treated at patients' initial surgery ( n = 54) in our statistical analysis. These patients were predominantly diagnosed with noninflammatory arthritis 73% ( n = 33). Arthroplasty was performed upon 10 index, 22 middle, 20 ring, and 2 small fingers. Results The reoperation rate after pyrocarbon PIP arthroplasty was 30% over a median follow-up of 25 months (interquartile range: 8.7-54). Indications for reoperation consisted of subluxation ( n = 6), stiffness ( n = 5), swan-neck deformity ( n = 3), and soft tissue complications ( n = 2). Younger age ( p = 0.025), male sex ( p = 0.017), and noninflammatory arthritis ( p = 0.038) were associated with a higher reoperation rate. Conclusion In this study, our reoperation rate after pyrocarbon PIP arthroplasty was 30%. This study suggested that younger patients, males, and patients with noninflammatory arthritis are at higher risk of reoperation. We recommend considering these factors when selecting candidates for pyrocarbon arthroplasty. Future studies should focus on prospectively researching these factors in comparison with other implants.

Management of unilateral cervical radiculopathy in the military: the cost effectiveness of posterior cervical foraminotomy compared with anterior cervical discectomy and fusion.

OBJECT: To review the cost effectiveness for the management of a unilateral cervical radiculopathy with either posterior cervical foraminotomy (PCF) or anterior cervical discectomy and fusion (ACDF) in military personnel, with a particular focus on time required to return to active-duty service. METHODS: Following internal review board approval, the authors conducted a retrospective review of 38 cases in which patients underwent surgical management of unilateral cervical radiculopathy. Nineteen patients who underwent PCF were matched for age, treatment level, and surgeon to 19 patients who had undergone ACDF. Successful outcome was determined by return to full, unrestricted active-duty military service. The difference in time of return to active duty was compared between the groups. In addition, a cost analysis consisting of direct and indirect costs was used to compare the PCF group to the ACDF group. RESULTS: A total of 21 levels were operated on in each group. There were 17 men and 2 women in the PCF group, whereas all 19 patients in the ACDF group were men. The average age at the time of surgery was 41.5 years (range 27-56 years) and 39.3 years (range 24-52 years) for the PCF and ACDF groups, respectively. There was no statistically significant difference in operating room time, estimated blood loss, or postoperative narcotic refills. Complications included 2 cases of transient recurrent laryngeal nerve palsy in the ACDF group. The average time to return to unrestricted full duty was 4.8 weeks (range 1-8 weeks) in the PCF group and 19.6 weeks (range 12-32 weeks) in the ACDF group, a difference of 14.8 weeks (p < 0.001). The direct costs of each surgery were $3570 for the PCF and $10,078 for the ACDF, a difference of $6508. Based on the 14.8-week difference in time to return to active duty, the indirect cost was calculated to range from $13,586 to $24,045 greater in the ACDF group. Total cost (indirect plus direct) ranged from $20,094 to $30,553 greater in the ACDF group. CONCLUSIONS: In the management of unilateral posterior cervical radiculopathy for military active-duty personnel, PCF offers a benefit relative to ACDF in immediate short-term direct and long-term indirect costs. The indirect cost of a service member away from full, unrestricted active duty 14.8 weeks longer in the ACDF group was the main contributor to this difference.

Arthroplasty in the military: a preliminary experience with ProDisc-C and ProDisc-L.

OBJECT: The introduction of cervical and lumbar arthroplasty has allowed for management of cervical radiculopathy and lumbar degenerative disease in patients with the preservation of motion at the affected segment. While the early clinical outcomes of this technology appear promising, it remains unclear what activity limitations should be imposed after surgery in patients with these implants. This is of particular interest in military personnel, who may be required to return to a rigorous level of activity after surgery. The goals of the FDA trials evaluating various disc arthroplasty devices were to establish safety, efficacy, and equivalency to arthrodesis. Information regarding the level of physical performance attained and restrictions or limitations is lacking, as these were outside the objectives of these trials. Nevertheless, there data are essential for the military surgeon, who is tasked with guiding the postoperative management of patients treated with arthroplasty and returning them to full duty. While there is a single report of clinical results of lumbar arthroplasty in athletes, at this writing, there are no reports of either cervical or lumbar arthroplasty in active duty military personnel. METHODS: The surgical database at a single, tertiary care military treatment facility was queried for all active-duty patients who underwent placement of either a cervical or lumbar arthroplasty device over a 3-year period. The authors performed a retrospective chart review to collect patient and procedural data including blood loss, length of hospital stay, tobacco use, age, rank, complications, and ability to return to full unrestricted active duty. Arthroplasty cohorts were then compared to historical controls of arthrodesis to ascertain differences in the time required to return to full duty. RESULTS: Twelve patients were identified who underwent cervical arthroplasty. All patients returned to unrestricted full duty. This cohort was then compared with 12 patients who had undergone a single-level anterior cervical discectomy and fusion. The average time to return to unrestricted full duty for the arthroplasty group was 10.3 weeks (range 7-13 weeks), whereas that in the fusion group was 16.5 weeks. This difference between these 2 groups was statistically significant (p = 0.008). Twelve patients were identified who underwent lumbar arthroplasty. Ten (83%) of 12 patients in this group returned to unrestricted full duty. In patients who returned to full duty, it took an average of 22.6 weeks (range 12-29 weeks). This cohort was then compared with one in which patients had undergone anterior lumbar interbody fusion. Eight (67%) of 12 patients in the lumbar arthrodesis group returned to unrestricted full duty. In patients who returned to full duty, it took an average of 32.4 weeks (range 25-41 weeks). This difference was not statistically significant (p = 0.156). CONCLUSIONS: The preliminary experience with cervical and lumbar arthroplasty at the authors' institution indicates that arthroplasty is comparable with arthrodesis and may actually expedite return to active duty. Patients are capable of returning to a high level of rigorous training and physical performance. There are no apparent restrictions or limitations that are required after 3 months in the cervical patient and after 6 months in the lumbar patient. Further prospective studies with long-term follow-up are indicated and will be of value when determining the role of arthroplasty compared to arthrodesis in the active-duty population.

A Single Incision Anterior Approach for Transhumeral Amputation Targeted Muscle Reinnervation.

Targeted muscle reinnervation (TMR) is an evolving technique with promising results for prevention and treatment of neuropathic pain, as well as modulation of control for myoelectric prostheses. The previously described and most commonly used technique for transhumeral TMR combines both an anterior and posterior approach to access the major peripheral nerves of the upper extremity. In this article, we review the literature for transhumeral TMR and describe a more expeditious and efficient anterior-only approach that offers safe access through a single incision.

Rate of Return to Military Active Duty After Single and 2-Level Anterior Cervical Discectomy and Fusion: A 4-Year Retrospective Review.

BACKGROUND: Over the years of rigorous of military service, military personnel may experience cervical spondylosis and radiculopathy. Given the frequency of this occurrence, the capacity to return to unrestricted full duty in the military after anterior cervical discectomy and fusion (ACDF) is worthy of analysis. OBJECTIVE: To identify the rate of return to full, unrestricted active duty after single and 2-level anterior cervical discectomy, and fusion surgery in military personnel. METHODS: A retrospective chart review was performed at a tertiary care military treatment facility for all active duty personnel who underwent a single or 2-level ACDF over a 4-yr period. Patient and procedural data were collected to include single or 2-level fusion, indication for surgery, fusion level, tobacco use, age, and military rank. Fischer's Exact and Wilcoxon Rank Sum tests were used to identify statistically significant differences in the rate of return to active duty. RESULTS: A total of 132 anterior cervical discectomy and fusions were analyzed. One hundred sixteen patients (88%) were able to return to unrestricted full active duty, while the remaining 16 required separation from the military for continued pain or disability. The return to active duty rate was significantly higher in service members with a rank of E7 or above (99%) than those E6 and below (73%). There was a strong association between the presence of a pseudoarthrosis and the capacity to return to full duty (P = .013). CONCLUSION: Both single and 2-level ACDFs have high overall success with an 88% rate of return to full duty.

Rate of return to military active duty after single level lumbar interbody fusion: a 5-year retrospective review.

BACKGROUND: Lumbar interbody fusion has been extensively studied in the civilian population; however, data regarding its efficacy in the military are lacking. OBJECTIVE: To identify the rate of return to unrestricted active military duty after single-level lumbar interbody fusion surgery. METHODS: The surgical database at a single tertiary care military treatment facility was queried for active-duty patients who underwent a single-level lumbar interbody fusion over a 5-year period. A retrospective chart review was performed with backward stepwise logistic regression analysis, and Fisher exact and Wilcoxon rank sum tests were used for statistical analysis. RESULTS: A total of 102 patients met the inclusion criteria. Mean age at surgery was 34.0 years (range, 19-51 years). Most surgeries (59%) were performed for discogenic pain secondary to degenerative disc disease; the remaining patients underwent surgery for spondylolisthesis (39%) or spinal stenosis (2%). Thirty-nine patients (38%) were treated via an anterior approach (anterior lumbar interbody fusion), whereas 63 patients (62%) underwent fusion via a posterior approach (transforaminal or posterior lumbar interbody fusion). Fifty-six patients (55%) were able to return to unrestricted full active duty, and the remaining 46 patients (45%) were separated from the military. The return to active duty rate was significantly higher in older patients and those ranking E7 (Chief Petty Officer) and above (84.8%). CONCLUSION: Fifty-five percent of the service members who underwent a single-level lumbar interbody fusion returned to unrestricted full duty. Older age and higher rank were statistically significant positive predictors of a successful return to active duty.