Porous Tantalum Tibial Metaphyseal Cones in Revision TKA: Excellent 10-Year Survivorship.

BACKGROUND: Highly porous metal tibial metaphyseal cones (TMCs) are commonly utilized in revision total knee arthroplasty (TKA) to address bone loss and obtain biologic fixation. Mid-term (5 to 10 year) studies have previously demonstrated excellent survivorship and high rates of osseointegration, but longer-term studies are lacking. We aimed to assess long-term (≥ 10 year) implant survivorship, complications, and clinical and radiographic outcomes after revision TKA with TMCs. METHODS: Between 2004 and 2011, 228 revision TKAs utilizing porous tantalum TMCs with stemmed tibial components were performed at a single institution and were retrospectively reviewed. The mean age at revision was 65 years, the mean BMI was 33, and 52% were women. Implant survivorship, complications, and clinical and radiographic outcomes were assessed. The mean follow-up was 6.3 years. RESULTS: The 10-year survivorship free of aseptic loosening leading to TMC removal was 97%, free of any TMC removal was 88%, free of any re-revision was 66%, and free of any reoperation was 58%. The most common indications for re-revision were periprosthetic joint infection (PJI), instability, and aseptic femoral component loosening. The 10-year non-operative complication rate was 24%. The mean Knee Society scores increased from 38 preoperatively to 69 at 10 years. There were eight knees that had evidence of partial, progressive tibial radiolucencies at 10 years. CONCLUSIONS: Porous tantalum TMCs demonstrated persistently durable longer-term survivorship with a low rate of implant removal. The rare implant removals for component loosening or instability were offset by those required for PJI, which accounted for 80% of cone removals. Porous tantalum TMCs provide an extremely reliable tool to address tibial bone loss and achieve durable long-term fixation in revision TKA.

Depression and anxiety are associated with an increased risk of infection, revision, and reoperation following total hip or knee arthroplasty.

The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation. Between January 2000 and March 2019, 21,469 primary and revision arthroplasties (10,011 THAs; 11,458 TKAs), which were undertaken in 15,504 patients at a single academic medical centre, were identified from a 27-county linked electronic medical record (EMR) system. Depressive and anxiety disorders were identified by diagnoses in the EMR or by using a natural language processing program with subsequent validation from review of the medical records. Patients with mental health diagnoses other than anxiety or depression were excluded. Depressive and/or anxiety disorders were common before THA and TKA, with a prevalence of 30% in those who underwent primary THA, 33% in those who underwent revision THA, 32% in those who underwent primary TKA, and 35% in those who underwent revision TKA. The presence of depressive or anxiety disorders was associated with a significantly increased risk of any infection (primary THA, hazard ratio (HR) 1.5; revision THA, HR 1.9; primary TKA, HR 1.6; revision TKA, HR 1.8), revision (THA, HR 1.7; TKA, HR 1.6), re-revision (THA, HR 2.0; TKA, HR 1.6), and reoperation (primary THA, HR 1.6; revision THA, HR 2.2; primary TKA, HR 1.4; revision TKA, HR 1.9; p < 0.03 for all). Patients with preoperative depressive and/or anxiety disorders were significantly less likely to report "much better" joint function after primary THA (78% vs 87%) and primary TKA (86% vs 90%) compared with those without these disorders at two years postoperatively (p < 0.001 for all). The presence of depressive or anxiety disorders prior to primary or revision THA and TKA is common, and associated with a significantly higher risk of infection, revision, reoperation, and dissatisfaction. This topic deserves further study, and surgeons may consider mental health optimization to be of similar importance to preoperative variables such as diabetic control, prior to arthroplasty.

Modular Proximal Body Exchange for Re-Revision Total Hip Arthroplasty: Rarely Utilized and Moderately Successful.

BACKGROUND: Modular fluted tapered stems (MFTSs) are commonly used in revision total hip arthroplasty (THA) and provide the option of exchanging the proximal modular portion to address future surgical problems without complete femoral revision. We are unaware of any data documenting the frequencies, indications, and outcomes of modular proximal body exchange in re-revision THA. METHODS: Between 1997 and 2019, we performed 57 modular proximal body exchanges among 8,079 revision THAs at our institution. Indications and outcomes were documented at a mean follow-up of 3.4 years (range, 0 to 12.8). RESULTS: Modular proximal body exchange was performed on 47 of 1,375 (3%) of MFTSs implanted. The indications for all 57 modular proximal body exchanges performed during the study period were dislocation in 30 (53%), partial resection for periprosthetic joint infection (PJI) in 13 (23%), modular junction failure in 8 (14%), surgical exposure in 4 (7%), and concurrently with trochanteric osteotomy nonunion fixation in 2 (4%). At the final follow-up, subsequent re-revisions occurred in 10 of 30 (33%) of modular proximal body exchanges indicated for dislocation and in 5 of 13 of those indicated for PJI. One modular junction subsequently fractured after modular proximal body exchange. CONCLUSION: Modular proximal body exchange of a MFTS is an uncommon procedure most often performed for treatment of hip dislocation or PJI. It is moderately successful with approximately one-third of cases requiring subsequent re-revision. This procedure is often performed with modular component exchange alone, but can also be helpful to facilitate complex acetabular exposure. These data provide useful information to surgeons and patients undergoing this procedure. LEVEL OF EVIDENCE: IV.

Changing Surgical Approach From Primary to Revision Total Hip Arthroplasty Is Not Associated With Increased Risk of Dislocation or Re-Revisions.

BACKGROUND: No prior studies have examined outcomes based on approach concordance between primary and revision total hip arthroplasty (THA). There is theoretical concern that performing surgery through multiple planes could potentiate dislocation risk. This study aimed to assess the impact of utilizing concordant vs discordant surgical approaches between primary and revision THA on incidence of dislocation, re-revision, reoperation, and nonoperative complications. METHODS: Between 2000 and 2018, 705 revision THAs were retrospectively identified in patients who underwent primary THA at the same academic center. Surgical approach was determined for primary and revision THA from operative notes with dislocations, re-revisions, reoperations, and complications determined from our total joint registry. Complication rates were compared between those with concordant and discordant surgical approaches. Mean age was 65 years, 50% were female, mean body mass index was 31 kg/m2, and mean follow-up was 4 years. RESULTS: Surgical approach discordance occurred in 97 cases (14%), which was more frequent when the direct anterior approach was used for primary THA (72%, P < .001) compared to lateral (12%) or posterior (10%) approaches. There were no statistically significant differences in the incidence of dislocations, re-revisions, reoperations, and nonoperative complications among those with concordant and discordant approaches for the overall cohort and when analyzed by primary approach (P > .05 for all). CONCLUSION: Comparable dislocation and complication rates were observed among revision THAs with concordant and discordant approaches between primary and revision THA. These data provide reassurance that changing vs maintaining the surgical approach from primary to revision THA does not significantly increase dislocation or re-revision risk. LEVEL OF EVIDENCE: IV.

Impact of Perioperative Pain Control on Knee Range of Motion and Development of Arthrofibrosis Following Primary Total Knee Arthroplasty.

BACKGROUND: Inadequate pain control following total knee arthroplasty (TKA) has been postulated to negatively impact knee range of motion (ROM). We sought to determine the association between perioperative pain levels and knee ROM at 3-month follow-up or need for manipulation under anesthesia (MUA). METHODS: We retrospectively reviewed 2243 primary TKAs performed from 2002 to 2019 at a single academic center using an institutional total joint registry. Mean age was 68, mean body mass index was 32.8, and 59% were female. Knee ROM was measured preoperatively and 3 months postoperatively. Change in knee ROM, rates of soft tissue contracture, and MUA were assessed in relation to in-hospital 10-point pain visual analog scale (VAS) measurements. RESULTS: Overall, 44% had improved ROM at 3-month follow-up, 29% had no change in ROM, and 27% had worsened ROM. There was no significant difference in mean VAS scores of patients with improved, unchanged, or worsened ROM postoperatively (3.0 vs 2.8 vs 3.0; P = .068). There was no significant difference in mean VAS scores of patients who developed a soft tissue contracture or required MUA vs those who did not develop these complications (2.7 vs 2.9; P = .24). Similarly, no significant relationship with these outcomes was identified when maximum and discharge VAS scores were analyzed. CONCLUSION: Comparable ROM and rates of MUA based on in-hospital pain levels were observed in this large series of primary TKA patients. While significant early pain may limit participation in ROM exercises initially, this does not appear to have a marked impact on ROM-related complications for most patients. LEVEL OF EVIDENCE: III, Therapeutic.

Unfavorable Outcomes Following Surgical Treatment of Hallux Valgus Deformity: A Systematic Literature Review.

BACKGROUND: Surgical correction of deformity plays a central role in the treatment of hallux valgus deformity. However, complications or unintended outcomes are frequently noted in clinical series. There has been no rigorous systematic review of studies reporting outcomes of surgical treatment for hallux valgus deformity, to the best of our knowledge. METHODS: We performed a systematic review of studies reporting the outcomes of surgical correction for hallux valgus deformity. RESULTS: A total of 229 studies met the inclusion criteria. The pooled rates of postoperative patient dissatisfaction and postoperative first metatarsophalangeal pain were 10.6% and 1.5%, respectively. The overall rate of recurrent deformity was 4.9%. CONCLUSIONS: Hallux valgus surgery has been reported to have fairly consistent results and rates of complications or unfavorable outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes in adults with cerebral venous sinus thrombosis: A retrospective cohort study.

Most patients with cerebral venous sinus thrombosis (CVST) treated with anticoagulation have good outcomes. We examined which factors were associated with poor outcomes after treatment. We retrospectively reviewed patients ≥18 years old who were diagnosed with CVST between 1997 and 2015. Good (modified Rankin score [mRS] ≤2) and poor outcomes were dichotomized. Demographic, historical, clinical, imaging, and treatment characteristics were compared. Eighty-nine patients received treatment for CVST (52.8% males, 74.2% Caucasian). Sixty-eight (76.4%) had good outcomes and 21 (23.6%) had poor outcomes. Poor outcome was associated with systemic or central nervous system (CNS) infection (p = 0.002), lower use of heparin-only therapy than interventional-only treatments (p = 0.003), and increased use of craniectomy (p = 0.002). Good outcomes were associated with migrainous headache on presentation (p = 0.01) and involvement of superficial cortical vessels only (p = 0.02). No prothrombotic or imaging findings correlated with poor outcome. Multivariable analysis showed that any clinical risk factor (p = 0.02) and headache (p = 0.02) predicted improved outcome whereas systemic or CNS infection (p = 0.02) and craniectomy (p = 0.02) predicted poor outcome. A published risk score showed a moderate ability to predict good outcome but not poor outcome. Overall sensitivity (23.8%), specificity (75.0%), and positive (24.0%) and negative (77.0%) predictive value suggested moderate prediction of good outcome and limited prediction of poor outcome. Rates of poor outcomes in CVST were comparable with previous investigations (23.6%), but prediction of poor outcome remains challenging in patients with CVST. Our results suggested that systemic infection and craniectomy were the most robust predictors of poor outcome.

Neutrophil-to-lymphocyte ratio as prognostic indicator in gastrointestinal cancers: a systematic review and meta-analysis.

An accurate, time efficient, and inexpensive prognostic indicator is needed to reduce cost and assist with clinical decision making for cancer management. The neutrophil-to-lymphocyte ratio (NLR), which is derived from common serum testing, has been explored in a variety of cancers. We sought to determine its prognostic value in gastrointestinal cancers and performed a meta-analysis of published studies using the Meta-analysis Of Observational Studies in Epidemiology guidelines. Included were randomized control trials and observational studies that analyzed humans with gastrointestinal cancers that included NLR and hazard ratios (HR) with overall survival (OS), disease-free survival (DFS), progression-free survival (PFS), and/or cancer-specific survival (CSS).We analyzed 144 studies comprising 45,905 patients, two-thirds of which were published after 2014. The mean, median, and mode cutoffs for NLR reporting OS from multivariate models were 3.4, 3.0, 5.0 (±IQR 2.5-5.0), respectively. Overall, NLR greater than the cutoff was associated with a HR for OS of 1.63 (95% CI, 1.53-1.73; P < 0.001). This association was observed in all subgroups based on tumor site, stage, and geographic region. HR for elevated NLR for DFS, PFS, and CSS were 1.70 (95% CI, 1.52-1.91, P < 0.001), 1.64 (95% CI, 1.36-1.97, P < 0.001), and 1.83 (95% CI, 1.50-2.23, P < 0.001), respectively.Available evidence suggests that NLR greater than the cutoff reduces OS, independent of geographic location, gastrointestinal cancer type, or stage of cancer. Furthermore, DFS, PFS, and CSS also have worse outcomes with elevated NLR.