Sequential changes to intraocular lens dislocation caused by vigorous ocular massage: A case report.

RATIONALE: Although intraocular lens (IOL) dislocations have been reported after uneventful cataract surgeries, no sequential changes have ever been demonstrated. Our case showed the sequential changes to IOL dislocation caused by vigorous ocular massage. PATIENT CONCERNS: A 42-year-old man complained of blurred vision in the left eye 8 years after uneventful phacoemulsification. The IOL was still well-centered, but curvilinear tears of the anterior and posterior capsule along the optic border of IOL and vitreous herniation were noted. In the following month, the IOL subluxated inferiorly. A careful history taking revealed a recent habit of vigorous ocular massage. The subluxation was stable for 2 years after avoiding ocular massage, but dislocation into vitreous occurred after taking a spring water bath (spa) bath with massage. DIAGNOSIS: IOL dislocation. INTERVENTIONS: Pars plana vitrectomy to remove the dislocated IOL and implantation of a 3-piece IOL into sulcus were performed. OUTCOMES: The IOL was well-centered. The visual acuity returned to 20/20. LESSONS: Ocular massage might cause tear of the intact fibrotic capsule and dislocation of IOL. The capsule along the border of the optics might be a weak point against ocular massage.

Patterns of tined lead migration in sacral nerve modulation.

AIM: Lead migration is a common cause of loss of efficacy in sacral nerve modulation. Our aim was to systematically study the migration pattern of tined leads in sacral nerve modulation. Our hypothesis was that tined leads may promote forward migration because of their configuration. METHOD: Consecutive patients treated with sacral nerve modulation with a tined lead electrode, who had experienced loss of efficacy and had radiographs both at baseline and after loss of efficacy between 2005 and 2016 were eligible for inclusion. RESULTS: Twenty-five patients out of 70 with loss of efficacy were studied. Lead migration was measured as percent electrode movement in relation to sacral cortex at lateral projection. All had some degree of lead migration, ranging from 35% backward to 74% forward migration. Sixteen (64%) had forward migration while nine (36%) had backward migration. In seven patients (28%), loss of efficacy was associated with an episode of perceived mechanical strain on the electrode. Fifty percent (4/8) who associated their loss of efficacy with an adverse event had forward migration of the electrode. CONCLUSIONS: Forward lead migration with concomitant loss of efficacy seems to be a common event in patients with tined leads, hence supporting our hypothesis. The retrospective design and that some of the patients with loss of efficacy could not be included because of incomplete data, which is a limitation to the study. Further studies are needed to confirm to what extent the direction and magnitude of the migration relate to loss of efficacy.

Cutting the subconjunctival fragment of the XEN gel implant during needling procedure.

PURPOSE: To describe the case and the follow-up of an inadvertently damaged XEN gel implant during needling procedure. METHODS: Case report. RESULTS: A 60-year-old African American patient underwent an uncomplicated combined phacoemulsification with the insertion of a XEN gel implant. Two months postoperatively, a needling procedure was required. During the needling procedure, a fragment of the XEN gel implant was inadvertently damaged. One month postoperatively, the intraocular pressure was still controlled and the bleb was functioning well. CONCLUSION: This case report reveals a previously unreported complication concerning XEN gel implant. It is important for the surgeon to pay attention during needling procedure, especially if there is a subconjunctival hemorrhage impairing the view, to defer the procedure until good visibility exists.

XEN Implant Fracture During Needling Procedure.

PURPOSE: The XEN implant is a small hydrophilic stent designed to be implanted permanently for the treatment of glaucoma. As with other bleb-forming surgical procedures, needling is part of postoperative care. We describe 3 cases of XEN fracture of the subconjunctival portion that occurred during the needling procedure. METHODS: The purpose of this study was to describe the clinical and anatomic outcomes in 3 cases of XEN fracture caused by the needling procedure. RESULTS: In our case series of XEN procedures (n=170), bleb needling has been performed in 98 cases (57.6%). In 3 cases (3.1%), we observed unintentional damage to the implant after the procedure.The mean distal segment length of the fractured XEN measured 0.83 (range: 0.7 to 1) mm. Despite the adverse event, the mean IOP changed from 25.0 (range: 21 to 30) mm Hg before needling to 12.0 (range: 10 to 14) after needling, with a mean follow-up of 15.3 (range: 11 to 18) months. No vision-threatening complications were recorded during the entire follow-up. CONCLUSIONS: XEN fracture related to the needling procedure should be considered as a possible adverse event of bleb management. Because XEN is composed of a soft and flexible gelatin material, it could be easily damaged by the needle. The fracture does not seem to impair the efficacy of the draining device. As a matter of fact, according to Poiseuille's laws, shortening of the implant's length decreases the resistance while increasing the flow rate. Despite our positive results, it is recommended to preserve the integrity of the implant.

Hounsfield units as predictor for cage subsidence and loss of reduction: following posterior-anterior stabilization in thoracolumbar spine fractures.

STUDY DESIGN: A retrospective, longitudinal cohort study. OBJECTIVE: The purpose of this study was to examine whether Hounsfield units (HUs), as an alternative bone mineral density measurement to dual-energy X-ray absorptiometry and quantitative computed tomography, which lead to additional radiation exposure for patients, has an effect on the maintenance of reduction in bisegmental Cobb angle (CA) and cage subsidence in patients who receive bisegmental spine stabilization after traumatic thoracolumbar spine fractures. METHODS: A total of 81 patients with a mean follow-up of 12 months were analyzed. CAs and cage subsidence were measured intraoperatively and at follow-up. HU was measured, and patients were subsequently assigned based on HU to three HU subgroups (group 1: HU < 110 [poor bone quality (BQ)]; group 2: HU 180-110 [diminished BQ]; group 3: HU > 180 [good BQ]). RESULTS: Following anterior stabilization, loss of reduction and cage subsidence differed between patients with poor and diminished BQ but not significantly, and both groups showed significantly more loss of reduction and cage subsidence than patients with good BQ. CONCLUSION: BQ, estimated with HU, had significant effects on cage subsidence and loss of reduction. We recommend measuring HU before surgery and applying additional treatment strategies, such as polymethylmethacrylate augmentation of endplates or anterior plates, for patients with HU < 180. These slides can be retrieved under Electronic Supplementary Material.

[Handling of retrieved implants in orthopedic surgery : Results of a survey within the framework of the EndoCert initiative]. / Bestandsaufnahme zum Umgang mit ausgebauten Implantaten in der orthopädischen Chirurgie : Ergebnisse einer Umfrage im Rahmen der EndoCert-Initiative.

BACKGROUND: Although investigations of retrieved medical implants can provide valuable information about the cause of the revision, there is a lack of information, which could be avoided by consequent failure analyses. In the framework of the EndoCert certification system it is obligatory to record and report incidents. OBJECTIVES: The present work examines how the willingness to report has developed in certified arthroplasty centers and which method of handling retrievals is preferred and actually used. MATERIALS AND METHODS: On the basis of a questionnaire for handling retrievals, all 508 arthroplasty centers that were certified till June 1, 2016, were included (return rate = 97.2%). RESULTS: A total of 93.3% of the centers have established an algorithm for handling of retrievals and 83.0% of the centers prefer to hand out the retrieval to the patient, while only 25.7% wish to store it in the center for research purposes. In the case of a potential incident as the cause of revision, centers prefer to forward the retrieval to damage analysis, whereby the centers act in different ways, depending on the case. An implant fracture is, e.g., considered a reportable event in most cases without temporal limitation. On the other hand, breakage or failure of surgical instruments is considered not to be reported in the case of more than half of the centers. In 2014 and 2015, approximately 71% of EPZs reported no incidents. CONCLUSIONS: According to our survey, many certified arthroplasty centers are sensitized to careful handling of retrievals. The treatment of the explanted components is conducted in different ways. The assessment of whether an incident is to be reported shows large differences. In view of the relatively high number of revision surgeries, the number of reports to the authorities appears to be low.

The evolution of an uncemented acetabular component in alumina-on-alumina total hip arthroplasty has improved clinical outcome: a prospective, comparative five- to 15-year follow-up study.

AIMS: To determine the effect of a change in design of a cementless ceramic acetabular component in fixation and clinical outcome after total hip arthroplasty PATIENTS AND METHODS: We compared 342 hips (302 patients) operated between 1999 and 2005 with a relatively smooth hydroxyapatite coated acetabular component (group 1), and 337 hips (310 patients) operated between 2006 and 2011 using a similar acetabular component with a macrotexture on the entire outer surface of the component (group 2). The mean age of the patients was 53.5 (14 to 70) in group 1 and 53.0 (15 to 70) in group 2. The mean follow-up was 12.7 years (10 to 17) for group 1 and 7.2 years (4 to 10) for group 2. RESULTS: No hips were revised due to complications related to bearing fracture or to stem loosening. A total of 15 acetabular components were revised for aseptic loosening in group 1 and two in group 2. The survival rate for acetabular component aseptic loosening at eight years was 96.8% (95% confidence interval (CI) 94.8 to 98.7) for group 1 and 99.2% (95% CI 98.0 to 100) for group 2. The risk for aseptic loosening of the acetabular component was higher in group 1 (p = 0.04, Hazard Ratio (HR) 4.99), dysplastic acetabula (p = 0.01, HR 4.12), components outside Lewinnek´s zone (p < 0.001, HR 6.13) and in those with a hip rotation centre distance greater than 5 mm (p = 0.005, HR 4.09). CONCLUSION: Alumina ceramic-on-ceramic THA is an excellent option for young patients. Although newer components appeared to improve fixation, acetabular reconstruction is essential to obtain a satisfactory outcome. Cite this article: Bone Joint J 2017;99-B:749-58.

Self-Expanding Metal Stents Improve Swallowing and Maintain Nutrition During Neoadjuvant Therapy for Esophageal Cancer.

BACKGROUND: Patients with locally advanced esophageal cancer can have significant dysphagia. Nutritional support during neoadjuvant therapy is often delivered via nasoenteric or percutaneous feeding tubes. These approaches do not allow for per-oral feeding. AIMS: Evaluate the safety and efficacy of fully covered self-expanding metal esophageal stents for nutritional support during neoadjuvant therapy. METHODS: This was a pilot, prospective study at a single tertiary center. From March 2012 to May 2013, consecutive patients with esophageal cancer eligible for neoadjuvant therapy were enrolled. Metal stents were placed prior to starting neoadjuvant therapy. Data were collected at baseline and predetermined intervals until an endpoint (surgery or disease progression). Outcomes included dysphagia grade, satisfaction of swallowing score, nutritional status (weight, serum albumin), impact on surgery, and adverse events. RESULTS: Fourteen stents were placed in 12 patients (59.1 ± 9.5 years, 11 men, 1 woman). Dysphagia grade (pre 3.4 ± 0.5 vs post 0.2 ± 0.4, p < 0.0001) and swallowing scores (20.2 ± 5.9 vs 6.3 ± 4.7, p < 0.0001) significantly improved after stent placement. Improvements were sustained throughout neoadjuvant therapy. Body weight and serum albumin levels remained stable. Adverse events included severe chest pain (2), food impaction (1), and delayed stent migration (2). Five patients underwent surgical resection. No significant chemoradiation or operative adverse events occurred due to the presence of a stent. CONCLUSIONS: During neoadjuvant therapy for esophageal cancer, self-expanding metal stents are safe and effective in relieving dysphagia and maintaining nutrition. They allow patients to eat orally, thereby improving patient satisfaction. The presence of an in situ stent did not interfere with surgery.

A comparison of polyethylene wear between cobalt-chrome ball heads and alumina ball heads after total hip arthroplasty: a 10-year follow-up.

STUDY DESIGN: This is a retrospective study comparing polyethylene wear between ceramic ball heads and metal ball heads in total hip arthroplasty. BACKGROUND: The ceramic-on-polyethylene bearing option has been introduced as an alternative to metal-on-polyethylene to minimize polyethylene wear debris and reduce subsequent osteolysis and aseptic loosening. However, the reported data were debatable. We designed this retrospective study to compare polyethylene wear between alumina ceramic ball heads and cobalt-chrome ball heads. METHODS: Bilateral simultaneous primary total hip arthroplasty was performed in 22 patients between January 2002 and December 2002, with one side using metal-on-polyethylene bearing surface and the other side using alumina ceramic-on-polyethylene bearing surface. After 10 years of follow-up, the wear rate of polyethylene liner on both sides was measured using the Dorr method and compared. RESULTS: The annual wear rate of the polyethylene liner was 0.133 mm with a standard deviation of 0.045 in the metal-on-polyethylene group and 0.056 mm with a standard deviation of 0.032 in the ceramic-on-polyethylene group. The wear rate per year was significantly lower in the ceramic-on-polyethylene group (p < 0.001). CONCLUSIONS: Although the implication is still controversial, our study showed that the use of ceramic head lowered the liner wear rate. CLINICAL RELEVANCE: Ceramic is harder and more resistant to scratching than cobalt-chrome. By increasing polyethylene liner survivorship and decreasing potential osteolytic response and aseptic loosening, ceramic head is a better alternative than cobalt-chrome head.

Polyethylene wear and osteolysis after cementless total hip arthroplasty with alumina-on-highly cross-linked polyethylene bearings in patients younger than thirty years of age.

BACKGROUND: We asked whether cementless total hip arthroplasties that made use of alumina-on-highly cross-linked polyethylene bearings would improve hip score and functional activity and reduce the prevalence of polyethylene wear, osteolysis, and aseptic loosening. METHODS: Consecutive primary total hip arthroplasties were performed in fifty patients (a total of sixty hips among thirty-four men and sixteen women) who were younger than thirty years of age. The average age at the time of the index arthroplasty was 28.3 years (range, twenty-one to twenty-nine years). The average follow-up was 10.8 years (range, ten to twelve years). Osteolysis and polyethylene wear rates were evaluated with use of radiography and computed tomography. RESULTS: The mean Harris hip score, which was 38 points (range, 6 to 45 points) preoperatively, had improved to 95 points (range, 85 to 100 points) at a mean follow-up time of 10.8 years. The mean penetration (and standard error of the mean) of the polyethylene liner was 0.031 ± 0.004 mm per year. No hip had osteolysis or aseptic loosening. CONCLUSIONS: At a minimum of ten years and an average of 10.8 years postoperatively, the current generation of cementless acetabular and femoral components with alumina-on-highly cross-linked polyethylene bearings was functioning well and was not associated with the development of osteolysis in our group of patients younger than thirty years of age. While the long-term prevalence of polyethylene wear and osteolysis remains unknown, the midterm data are promising.

A tale of early Reel syndrome caused by an over-enthusiastic masseuse.

Twiddler syndrome is a form of pacemaker lead dislocation caused by the coiling of the pacemaker leads due to pulse generator rotation on its long axis. Similar to Twiddler syndrome, Reel syndrome occurs due to rotation of the pulse generator on its transverse axis, leading to lead dislocation or fracture, followed by clinical symptoms of dislodged leads. We report a case of 75 years old woman with Reel syndrome presenting with syncope.

The ureteroscope-assisted "Mini-Perc" technique of placement of peritoneal dialysis catheters with a 16-Fr Peel-Away sheath: 3-year results in 47 patients.

OBJECTIVES: This study was undertaken to evaluate the clinical feasibility, safety and effect of the ureteroscope-assisted "Mini-Perc" technique with a 16-Fr Peel-Away sheath for insertion of peritoneal dialysis catheters in end-stage renal disease (ESRD) patients. PATIENTS AND METHODS: 47 consecutive ESRD patients underwent ureteroscope-assisted placement of peritoneal dialysis catheters via a 16-Fr Peel-Away sheath. Informed consent form was signed by patients under principle of voluntary. RESULTS: The mean duration of the operation was 40 min (range, 21-75 min). Seven patients (14.9 %) experienced mechanical complications: catheter tip migration in 1 patient (2.1 %), slightly bloody ascites in 4 patients (8.5 %) and catheter-related peritonitis in 2 patients (4.3 %). Two catheters (4.3 %) were removed after renal transplantation. One patient (2.1 %) died from heart failure. One catheter (2.1 %) was explanted because of malfunction. After a mean follow-up time of 15 months (range, 2-36 months), 42 catheters are still functioning properly. CONCLUSIONS: The ureteroscope-assisted "Mini-Perc" technique with a 16-Fr Peel-Away sheath is a simple, safe and effective method for placement of peritoneal dialysis catheters in ESRD patients.

Alumina-on-alumina hip implants: A wear study of retrieved components.

Alumina-alumina bearings are among the most resistant to wear in total hip replacement. Examination of their surfaces is one way of comparing damage caused by wear of hip joints simulated in vitro to that seen in explanted bearings. The aim of this study was to determine whether second-generation ceramic bearings exhibited a better pattern of wear than those reported in the literature for first-generation bearings. We considered both macro- and microscopic findings. We found that long-term alumina wear in association with a loose acetabular component could be categorised into three groups. Of 20 specimens, four had 'low wear', eight 'crescent wear' and eight 'severe wear', which was characterised by a change in the physical shape of the bearing and a loss of volume. This suggests that the wear in alumina-alumina bearings in association with a loose acetabular component may be variable in pattern, and may explain, in part, why the wear of a ceramic head in vivo may be greater than that seen after in vitro testing.

High survival in young patients using a second generation uncemented total hip replacement.

PURPOSE: Whilst excellent long-term results with contemporary uncemented stems have been reported for total hip arthroplasty in young patients, the survival rates for the whole reconstruction are often compromised by high failure rates on the acetabular site due to peri-acetabular osteolysis and accelerated wear. METHODS: In patients 60 years old or younger, we retrospectively reviewed the results at a minimum of ten years of 89 consecutive uncemented total hip replacements in 88 patients using the press-fit Fitmore acetabular component in combination with the CLS Spotorno stem and a 28-mm Metasul metal-on-metal articulation or a 28-mm alumina ceramic on conventional polyethylene bearing. The mean age at the time of surgery was 49 years (range, 25-60). The mean clinical and radiological follow-up was 12 years (range, 10-15). RESULTS: Six patients (six hips) died and two patients (two hips) were lost to follow-up. Five hips were revised: one for deep infection, one for peri-prosthetic femoral fracture, and one for aseptic stem loosening. In two hips an isolated revision of the acetabular liner was performed (one for recurrent dislocation and one for unexplained pain). No revision was performed for accelerated wear, osteolysis or aseptic loosening of the acetabular shell. We could not detect peri-acetabular osteolysis visible on plain radiographs in those hips evaluated radiographically. The Kaplan-Meier survival with revision for any reason as the endpoint was 94% (95% confidence interval, 86-97) at 12 years. CONCLUSIONS: The survival rates and the radiological outcomes with this implant combination in this young and active patient group are encouraging when compared to the results reported for other uncemented cups in this age group.

Less wear with aluminium-oxide heads than cobalt-chrome heads with ultra high molecular weight cemented polyethylene cups: a ten-year follow-up with radiostereometry.

PURPOSE: Wear is a major contributor to osteolysis and aseptic loosening of total hip replacements (THR). Both alumina (Al(2)O(3)) and cobalt-chrome (CoCr) femoral heads are commonly used. We investigated wear comparing alumina heads to cobalt-chrome heads against conventional cemented polyethylene (PE) cups for up to ten years. METHODS: Linear wear was measured with radiostereometry (RSA). Our material was derived from two prospective randomised trials that investigated fixation of femoral stems, not wear, and was evaluated retrospectively (Level III). RESULTS: The mean (95% CI) proximal head penetration was 0.96 mm (0.68-1.23) in the cobalt-chrome group and 0.42 mm (0.30-0.53) in the alumina group at ten years (P = 0.001). The mean (95% CI) 3D penetration was 1.07 mm (0.79-1.35) and 0.53 mm (0.38-0.63), respectively, at ten years (P = 0.001). CONCLUSION: Alumina heads performed better than cobalt-chrome heads in this study after ten-year follow-up.

Circadian rhythm and cartilage extracellular matrix genes in osseointegration: a genome-wide screening of implant failure by vitamin D deficiency.

BACKGROUND: Successful dental and orthopedic implants require the establishment of an intimate association with bone tissue; however, the mechanistic explanation of how biological systems accomplish osseointegration is still incomplete. We sought to identify critical gene networks involved in osseointegration by exploring the implant failure model under vitamin D deficiency. METHODOLOGY: Adult male Sprague-Dawley rats were exposed to control or vitamin D-deficient diet prior to the osteotomy surgery in the femur bone and the placement of T-shaped Ti4Al6V implant. Two weeks after the osteotomy and implant placement, tissue formed at the osteotomy site or in the hollow chamber of T-shaped implant was harvested and total RNA was evaluated by whole genome microarray analyses. PRINCIPAL FINDINGS: Two-way ANOVA of microarray data identified 103 genes that were significantly (>2 fold) modulated by the implant placement and vitamin D deficiency. Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses assigned the highest z-score to the circadian rhythm pathway including neuronal PAS domain 2 (NPAS2), and period homolog 2 (Per2). NPAS2 and Aryl hydrocarbon receptor nuclear translocator-like (ARNTL/Bmal 1) were upregulated around implant and diminished by vitamin D deficiency, whereas the expression pattern of Per2 was complementary. Hierarchical cluster analysis further revealed that NPAS2 was in a group predominantly composed of cartilage extracellular matrix (ECM) genes. Whereas the expression of bone ECM genes around implant was not significantly affected by vitamin D deficiency, cartilage ECM genes were modulated by the presence of the implant and vitamin D status. In a proof-of-concept in vitro study, the expression of cartilage type II and X collagens was found upregulated when mouse mesenchymal stem cells were cultured on implant disk with 1,25D supplementation. CONCLUSIONS: This study suggests that the circadian rhythm system and cartilage extracellular matrix may be involved in the establishment of osseointegration under vitamin D regulation.

Lead migration after sacral neuromodulation: surgical revision in fascial versus tined anchoring systems.

INTRODUCTION AND HYPOTHESIS: Our objective was to compare risk of surgical revision after sacral neuromodulator lead migration based on the type of anchoring system. METHODS: We performed a retrospective cohort study of patients receiving sacral neuromodulation over 7 years. We compared surgical revision due to loss of efficacy accompanied by radiographic lead migration in fascial-anchored versus tined leads. RESULTS: Of 112 patients, 28 (25%) underwent fascial anchoring, and 84 (75%) received tined leads. Within 2 years of implantation, lead migration occurred in 26% of fascial and 10% of tined anchoring systems (RR, 2.25 (95% confidence interval, 0.85-5.93)). Patients with fascial anchors were followed for a longer period of time. Therefore, Kaplan-Meier curves were compared showing no difference in risk of lead migration (p = 0.09). Four of eight (50%) lead migrations in tined leads occurred within the first 3 months after implantation. CONCLUSIONS: Two years after sacral neuromodulator implantation, lead migration is similar between fascial-anchored and tined leads.

Tranexamic acid reduces allogenic transfusion in revision hip arthroplasty.

BACKGROUND: Revision THA is associated with high blood loss and a high probability of blood transfusion in the perioperative period. In November 2003, government legislation established the Blood Utilization Program at our center to reduce the rate and risks associated with allogenic transfusion. QUESTIONS/PURPOSES: The purposes of this study were to (1) determine whether the allogenic transfusion rate in patients undergoing revision THA decreased in those who were reviewed preoperatively by the Blood Utilization Program versus those who were not; (2) determine whether tranexamic acid reduced the rate of transfusion; and (3) identify potential perioperative clinical parameters that are associated with an increased risk of blood transfusion. METHODS: We included all 159 patients who underwent revision THA from January 2006 to October 2008 having either a socket and/or femoral stem revision except those having only a liner exchange. One hundred and one patients attended the Blood Utilization Program preoperatively and 58 patients did not (ie, they required urgent/emergency surgery). RESULTS: The Blood Utilization Program referral made no difference in transfusion rate or transfusion amount; however, the transfusion rates and amount were decreased by 8% and one unit, respectively. In patients referred to the Blood Utilization Program, the intraoperative use of tranexamic acid (an antifibrinolytic) was associated with reduced transfusions, regardless of dosage; preoperative erythropoietin tended to reduce transfusions while preoperative oral iron supplements did not. CONCLUSIONS: To further increase the relevance of the blood utilization program, the guidelines for patients undergoing revision hip arthroplasty need to be redefined. LEVEL OF EVIDENCE: Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.