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1.
J Arthroplasty ; 35(2): 353-357, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31668526

RESUMO

BACKGROUND: To better define the optimal alignment target for medial fixed-bearing unicompartmental knee arthroplasty (UKA), this study compares the postoperative mechanical alignment of well-functioning UKAs against 2 groups of failed UKAs, including revisions for progression of lateral compartment osteoarthritis ("Progression") and revisions for aseptic loosening or subsidence ("Loosening"). METHODS: From our prospective institutional database of 3351 medial fixed-bearing UKAs performed since 2000, we identified 37 UKAs revised for Progression and 61 UKAs revised for Loosening. Each of these revision cohorts was matched based on age at surgery, gender, body mass index, and postoperative range of motion with unrevised UKAs that had at least 10 years of follow-up and a Knee Society Score of 70 or greater without subtracting points for alignment ("Success" groups). Postoperative alignment was quantified by the hip-knee-ankle (HKA) angle measured on long-leg alignment radiographs. RESULTS: The mean HKA angle at 4-month follow-up for the Progression group was 0.3° ± 3.6° of valgus compared to 4.4° ± 2.6° of varus for the matched Success group (P < 0.001). For the Loosening group, the mean HKA angle was 6.1° ± 3.1° of varus versus 4.0° ± 2.7° of varus for the matched Success group (P < 0.001). CONCLUSIONS: Patients with well-functioning UKAs at 10 years exhibited mild varus mechanical alignment of approximately 4°, whereas patients revised for progression of osteoarthritis averaged more valgus and those revised for loosening or subsidence averaged more varus. The optimal mechanical alignment for medial fixed-bearing UKA survival with contemporary polyethylene is likely slight varus.

2.
J Arthroplasty ; 34(12): 2861-2865, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31445867

RESUMO

BACKGROUND: Outpatient total hip arthroplasty (THA) utilization continues to grow. Literature suggests outpatient THA may result in low rates of complications and readmission. There are no studies comparing safety profiles of THA performed at ambulatory surgery centers (ASC) vs hospital outpatient (HOP) settings. METHODS: Prospectively collected data were reviewed on all patients who underwent THA from 2013 to 2018. ASC and HOP subgroups were compared, investigating difference in demographics, comorbidities, American Society of Anesthesiologists subgroups, all complications, revisions, emergency department (ED) visits, and readmissions within the first 90 days of surgery. An additional subgroup analysis of patients younger than 65 years was performed. RESULTS: Two surgeons performed 3063 THAs during the study period, including 965 outpatient cases (ASC = 335; HOP = 630). Thirty-seven (3.8%) complications occurred within 90 days. No differences were found between groups for 90-day complication rates (ASC = 13, 3.9%; HOP = 24, 3.8%; P = .48), revision rates (ASC = 0, 0%; HOP = 2, .3%; P = .30), all-cause reoperation rates (ASC = 1, 0.3%; HOP = 5, 0.8%; P = .35), ED visits (ASC = 3, 0.9%; HOP = 2, 0.3%; P = .23), or readmission rates (ASC = 2, 0.6%; HOP = 9, 1.4%; P = .25). CONCLUSION: THA can be safely performed in both ASC and HOP settings with low 90-day postoperative complication, revision, reoperation, ED visit, and readmission rates. Based on the populations studied, we identified no statistically significant differences in rates of complications between ASC and HOP groups.

3.
J Arthroplasty ; 34(7): 1369-1373, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30930159

RESUMO

BACKGROUND: Preoperative planning for total knee arthroplasty (TKA) is essential for streamlining operating room efficiency and reducing costs. Digital templating and patient-specific instrumentation have shown some value in TKA but require additional costs and resources. The purpose of this study was to validate a previously published algorithm that uses only demographic variables to accurately predict TKA tibial and femoral component sizes. METHODS: Four hundred seventy-four consecutive patients undergoing elective primary TKA were prospectively enrolled. Four surgeons were included, three of which were unaffiliated with the retrospective cohort study. Patient sex, height, and weight were entered into our published Arthroplasty Size Prediction mobile application. Accuracy of the algorithm was compared with the actual sizes of the implanted femoral and tibial components from 5 different implant systems. Multivariate regression analysis was used to identify independent risk factors for inaccurate outliers for our model. RESULTS: When assessing accuracy to within ±1 size, the accuracies of tibial and femoral components were 87% (412/474) and 76% (360/474). When assessing accuracy to within ±2 sizes of predicted, the tibial accuracy was 97% (461/474), and the femoral accuracy was 95% (450/474). Risk factors for the actual components falling outside of 2 predicted sizes include weight less than 70 kg (odds ratio = 2.47, 95% confidence interval [1.21-5.06], P = .01) and use of an implant system with <2.5 mm incremental changes between femoral sizes (odds ratio = 5.50, 95% confidence interval [3.33-9.11], P < .001). CONCLUSIONS: This prospective series of patients validates a simple algorithm to predict component sizing for TKA with high accuracy based on demographic variables alone. Surgeons can use this algorithm to simplify the preoperative planning process by reducing unnecessary trays, trials, and implant storage, particularly in the community or outpatient setting where resources are limited. Further assessment of components with less than 2.5-mm differences between femoral sizes is required in the future to make this algorithm more applicable worldwide.

4.
J Arthroplasty ; 33(8): 2613-2615, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29636248

RESUMO

BACKGROUND: Early wound healing complications and persistent drainage are associated with an increased risk of infection following knee arthroplasty. However, the scenario in which a patient sustains an acute, traumatic wound dehiscence has not been investigated. The purpose of this study is to determine the outcomes of an acute traumatic wound dehiscence following arthroplasty treated with an urgent irrigation and debridement and primary wound closure. METHODS: Using a single institution's arthroplasty registry, patients sustaining an acute, traumatic wound dehiscence within 30 days of undergoing a primary knee arthroplasty were identified. Patients experiencing chronic wound drainage without injury or a history of prior infection were excluded. Patients were followed for the occurrence of complications and clinical outcomes using the Knee Society Score. RESULTS: From 2006 to 2016, 14 of 25,819 eligible patients (0.05%) were identified as having a traumatic wound dehiscence. The mean time from arthroplasty to wound dehiscence was 9.3 days. All but one patient was treated operatively within 24 hours of dehiscence. Postoperative antibiotics were administered for a mean of 21 days. At a mean of 6.5 years, 6 patients were considered failures (43%) including 2 deep infections, 3 revisions for instability, and 1 patient with a Knee Society Score <60 points. CONCLUSION: Despite emergent incision and drainage and wound closure, patients experiencing an acute traumatic wound dehiscence following knee arthroplasty subsequently exhibit high rates of reoperation for instability, periprosthetic infection, and clinical failure. Further work is required to better understand the optimal modes of treatment for this complication.


Assuntos
Artroplastia do Joelho/efeitos adversos , Articulação do Joelho/cirurgia , Complicações Pós-Operatórias/etiologia , Reoperação , Adulto , Idoso , Idoso de 80 Anos ou mais , Drenagem , Feminino , Humanos , Pessoa de Meia-Idade , Período Pós-Operatório , Sistema de Registros , Índice de Gravidade de Doença , Ferida Cirúrgica , Cicatrização
5.
J Am Acad Orthop Surg ; 26(9): 295-302, 2018 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-29620609

RESUMO

Wound complications and surgical site infections after orthopaedic procedures result in substantial morbidity and costs. Traditional postoperative wound care consists of applying sterile, dry gauze and abdominal pads to the surgical site, with more frequent dressing changes performed in cases in which wound drainage is excessive. Persistent incisional drainage is of particular concern because it increases the risk of deep infection. The use of closed incision negative-pressure wound therapy (ciNPWT) to manage delayed wound healing was first reported a decade ago, and the benefits of this treatment modality include wound contraction with diminished tensile forces, stabilization of the wound environment, decreased edema and improved removal of exudate, and increased blood and lymphatic flow. Numerous trauma, plastic surgery, and general surgery studies have demonstrated that ciNPWT improves wound healing. In orthopaedic surgery, ciNPWT has been shown to be clinically effective for incisions at high risk for perioperative complications. However, specific indications for ciNPWT continue to be defined.


Assuntos
Tratamento de Ferimentos com Pressão Negativa , Procedimentos Ortopédicos/efeitos adversos , Infecção da Ferida Cirúrgica/etiologia , Ferida Cirúrgica/terapia , Artroplastia/efeitos adversos , Mãos/cirurgia , Humanos , Coluna Vertebral/cirurgia , Ferida Cirúrgica/complicações , Deiscência da Ferida Operatória/etiologia , Deiscência da Ferida Operatória/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle
6.
J Arthroplasty ; 33(5): 1552-1556.e1, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29289445

RESUMO

BACKGROUND: Little is known regarding the occurrence of pneumonia after hip fracture surgery. The purpose of this study is to determine the incidence, risk factors, and clinical implications of pneumonia after surgery for geriatric hip fracture. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was used to retrospectively study geriatric patients undergoing surgery for hip fracture during 2006-2014. Independent risk factors for developing pneumonia within 30 days of surgery were identified using multivariate regression. RESULTS: Of the 29,377 patients meeting inclusion criteria, 13,736 (46.8%) underwent hemiarthroplasty, 9468 (32.2%) intramedullary fixation, 4294 (14.6%) plate and/or screw fixation, 1299 (4.4%) total joint arthroplasty, and 580 (2.0%) percutaneous fixation. In total 1191 patients developed pneumonia, an incidence of 4.1%. The strongest risk factors for pneumonia were male sex, older age (especially ≥90 years), low body mass index, and chronic obstructive pulmonary disease. Patients who developed pneumonia had a higher readmission rate (79.1% vs 8.2%, P < .001), a higher rate of sepsis (16.6% vs 1.7%, P < .001), and a higher mortality rate (29.2% vs 5.7%, P < .001). Among 1602 total mortalities, 348 (17.9%) occurred in patients with pneumonia. CONCLUSION: Pneumonia is a serious complication after geriatric hip fracture surgery, which increases the readmission and mortality risks. Evidence-based pneumonia prevention programs should be implemented among high-risk patients-males, patients ≥90 years, body mass index <18.5 kg/m2, and/or patients with chronic obstructive pulmonary disease-to decrease morbidity and mortality.


Assuntos
Hemiartroplastia/efeitos adversos , Fraturas do Quadril/cirurgia , Pneumonia/complicações , Complicações Pós-Operatórias/etiologia , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Placas Ósseas/efeitos adversos , Parafusos Ósseos/efeitos adversos , Feminino , Fraturas do Quadril/complicações , Humanos , Incidência , Masculino , Análise Multivariada , Complicações Pós-Operatórias/diagnóstico , Doença Pulmonar Obstrutiva Crônica/complicações , Melhoria de Qualidade , Estudos Retrospectivos , Fatores de Risco , Sepse/mortalidade
7.
J Arthroplasty ; 33(2): 345-349, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28993087

RESUMO

BACKGROUND: Little research has focused on the influence of gender on postoperative morbidity following total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study aimed to compare operative time, length of stay, 30-day complications, and readmissions based on patient gender. METHODS: The prospectively collected National Surgical Quality Improvement Program registry from 2005 to 2014 was queried to identify primary elective THA and TKA patients. Multivariate regression was used to compare the rates of 30-day adverse events, rates of readmission, operative time, and postoperative length of stay between men and women. Multivariate analyses were controlled for baseline patient characteristics and procedure type. RESULTS: A total of 173,777 patients were included (63.5% TKA and 36.5% THA). Male gender increased the risk of multiple adverse events, including death (relative risk [RR] 1.1, P < .001), surgical site infection (RR 1.2, P < .001), sepsis (RR 1.4, P < .001), cardiac arrest (RR 1.8, P < .001), and return to the operating room (RR 1.3, P < .001). Men had decreased overall adverse events (RR 0.8, P < .001) secondary to a lower risk of urinary tract infection (RR 0.5, P < .001) and blood transfusion (RR 0.7, P < .001), which were prevalent adverse events. Men had an increased risk of 30-day readmission (RR 1.2, P < .001), slightly increased operative time (+6 minutes, P < .001), and slightly decreased length of stay (-0.2 days, P < .001). CONCLUSION: Men had increased risk of multiple individual adverse events including death, surgical site infection, cardiac arrest, return to the operating room, and readmission. Conversely, women had increased risk of urinary tract infection and blood transfusion.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/estatística & dados numéricos , Fatores Sexuais , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Morbidade , Análise Multivariada , Duração da Cirurgia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Melhoria de Qualidade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
8.
J Shoulder Elbow Surg ; 27(2): e38-e44, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29128376

RESUMO

BACKGROUND: We report the long-term results of a cohort of patients after radial head replacement with a bipolar design and a smooth cementless stem at a mean follow-up of 10.4 years. METHODS: Of 17 possible patients from a previous minimum 2-year follow-up study, 16 were available for review. Patients were assessed using clinical and radiographic examination and with standardized outcome measures. Range of motion, stability, and radiographic evaluation of implant loosening and joint degeneration were assessed. Comparisons were performed using the Wilcoxon signed rank test for unequal groups. RESULTS: The average follow-up was 10.5 years (range, 8.5-12 years). The median visual analog scale was 1 (range, 0-5), Minnesota Elbow Performance Index was 93 (range, 70-100), and the Disabilities of the Arm, Shoulder and Hand was 7.5 (range, 0-53). Range of motion was decreased on the operative side compared with the nonoperative side for flexion/extension (P = .005) and pronation/supination (P = .015). Grip strength was decreased on the affected side (P = .045). No patients had elbow instability. Significant arthritic changes developed in 2 patients at the ulnohumeral joint. The median cantilever quotient was 0.4 (range, 0.30-0.50). Osteolysis in zones 1 to 7 was found in all but 2 patients. The median stem radiolucency was 0.5 mm (range, 0.2-0.9 mm). No reoperations occurred since our previous report. Implant survival in this cohort was 97%. CONCLUSION: Bipolar radial head prosthesis with a smooth cementless stem effectively restores elbow stability and function after comminuted radial head fractures with or without concomitant elbow instability. Our study demonstrates excellent long-term implant survival.


Assuntos
Artroplastia de Substituição do Cotovelo/métodos , Articulação do Cotovelo/cirurgia , Prótese de Cotovelo , Previsões , Fraturas Cominutivas/cirurgia , Fraturas do Rádio/cirurgia , Rádio (Anatomia)/cirurgia , Adulto , Idoso , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/fisiopatologia , Feminino , Seguimentos , Fraturas Cominutivas/diagnóstico , Fraturas Cominutivas/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Rádio (Anatomia)/diagnóstico por imagem , Fraturas do Rádio/diagnóstico , Fraturas do Rádio/fisiopatologia , Amplitude de Movimento Articular , Resultado do Tratamento
9.
J Arthroplasty ; 32(10): 3004-3008, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28583760

RESUMO

BACKGROUND: As health care reform drives providers to reduce costs and improve efficiencies without compromising patient care, preoperative planning has become imperative. The purpose of this study is to determine whether height, weight, and gender can accurately predict total knee arthroplasty (TKA) sizing. METHODS: A consecutive series of 3491 primary TKAs performed by 2 surgeons was reviewed. Height, weight, gender, implant, preoperative templating sizes, and final implant sizes were collected. Implant-specific dimensions were collected from vendors. Using height, weight, and gender, a multivariate linear regression was performed with and without the inclusion of preoperative templating. Accuracy of the model was reported for commonly used implants. RESULTS: There was a significant linear correlation between height, weight, and gender for femoral (R2 = 0.504; P < .001) and tibial sizes (R2 = 0.610; P < .001). Adding preoperative templating to the regression analysis increased the overall model fit for both the femoral (R2 = 0.756; P < .001) and tibial sizes (R2 = 0.780; P < .001). Femoral and tibial sizes were accurately predicted within 1 size of the final implant 71%-92% and 81%-97% using demographics alone or 85%-99% and 90%-99% using both templating and demographics, respectively. CONCLUSION: This novel TKA templating model allows final implants to be predicted to within 1 size. The model allows for simplified preoperative planning and potential implementation into a cost-savings program that limits inventory and trays required for each case.


Assuntos
Artroplastia do Joelho/instrumentação , Prótese do Joelho/estatística & dados numéricos , Algoritmos , Peso Corporal , Redução de Custos , Demografia , Feminino , Fêmur/cirurgia , Humanos , Modelos Lineares , Masculino , Estudos Retrospectivos , Tíbia/cirurgia
10.
J Arthroplasty ; 32(8): 2462-2465, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28434694

RESUMO

BACKGROUND: We previously described the results of a randomized controlled trial of mini-posterior vs 2-incision total hip arthroplasty and were unable to demonstrate significant differences in early outcomes. As less-invasive anterior approaches remain popular, the purpose of this report was to re-examine the outcomes at a minimum 5-year follow-up. METHODS: Seventy-two patients undergoing primary total hip arthroplasty were randomized to a mini-posterior or 2-incision approach. Complications, revisions, and clinical outcome measures were compared. Radiographs were reviewed for implant loosening. A power analysis using a minimal clinically important difference value of 6 points for the Harris hip score revealed 28 patients required per group. RESULTS: At a mean of 8.2 years (range, 5-10 years), 6 patients died without revision surgery and 63 of 66 living patients were reviewed. There were 6 total failures, 3 in each group. For unrevised patients, there were no significant differences between groups (posterior vs 2-incision) in the Harris hip score (95.5 ± 3.5 vs 95.7 ± 6.3; P = .88), 12-item Short Form Survey physical composite score (50.5 ± 8.5 vs 49.0 ± 9.1; P = .53), 12-item Short Form Survey mental composite score (57.3 ± 4.1 vs 55.4 ± 8.0; P = .25), or single assessment numeric evaluation score (97.1 ± 3.7 vs 97.8 ± 5.2; P = .55). CONCLUSION: We found no differences in midterm outcomes between the 2 approaches. Given the increased complexity, operative time, and need for fluoroscopy with the 2-incision approach combined with equivalent early and midterm outcomes, the 2-incision approach has been abandoned in the senior author's practice.


Assuntos
Artroplastia de Quadril/métodos , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/estatística & dados numéricos , Chicago/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Duração da Cirurgia , Estudos Prospectivos , Radiografia , Recuperação de Função Fisiológica , Inquéritos e Questionários , Resultado do Tratamento
11.
J Arthroplasty ; 32(6): 1991-1995.e1, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28161137

RESUMO

BACKGROUND: The purpose of this study is to determine the incidence, risk factors, and clinical implications of pneumonia following total joint arthroplasty (TJA). METHODS: The American College of Surgeons National Surgical Quality Improvement Program was used to conduct a retrospective cohort study of patients undergoing TJA. Independent risk factors for the development of pneumonia within 30 days of TJA were identified using multivariate regression. Mortality and readmission rates were compared between patients who did and did not develop pneumonia. Multivariate regression was used to adjust for all demographic, comorbidity, and procedural characteristics. RESULTS: In total, 171,200 patients met inclusion criteria, of whom 66,493 (38.8%) underwent THA and 104,707 (61.2%) underwent TKA. Of the 171,200 patients, 590 developed pneumonia, yielding a rate of 0.34% (95% confidence interval = 0.32%-0.37%). Independent risk factors for pneumonia were chronic obstructive pulmonary disease, diabetes mellitus, greater age (most notably ≥80 years), dyspnea on exertion, dependent functional status, lower body mass index, hypertension, current smoker status, and male sex. The subset of patients who developed pneumonia following discharge had a higher readmission rate (82.1% vs 3.4%, adjusted relative risk [RR] = 16.6, P < .001) and a higher mortality rate (3.7% vs 0.1%, adjusted RR = 19.4, P < .001). Among 124 total mortalities, 22 (17.7%) occurred in patients who had developed pneumonia. CONCLUSION: Pneumonia is a serious complication following TJA that occurs in approximately 1 in 300 patients. Approximately 4 in 5 patients who develop pneumonia are subsequently readmitted, and approximately 1 in 25 die. Given the serious implications of this complication, evidence-based pneumonia prevention programs including oral hygiene with chlorhexidine, sitting upright for meals, elevation of the head of the bed to at least 30°, aggressive incentive spirometry, and early ambulation should be considered for patients at greatest risk.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Complicações do Diabetes , Pneumonia/etiologia , Doença Pulmonar Obstrutiva Crônica/complicações , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Estudos de Coortes , Comorbidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Alta do Paciente , Readmissão do Paciente , Pneumonia/complicações , Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
12.
J Arthroplasty ; 32(3): 1024-1026, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-27776900

RESUMO

BACKGROUND: Digital templating is becoming more prevalent in orthopedics. Recent investigations report high accuracy using digital templating in total hip arthroplasty (THA); however, the effect of body mass index (BMI) on templating accuracy is not well described. METHODS: Digital radiographs of 603 consecutive patients (645 hips) undergoing primary THA by a single surgeon were digitally templated using OrthoView (Jacksonville, FL). A 25-mm metallic sphere was used as a calibration marker. Preoperative digital hip templates were compared with the final implant size. Hips were stratified into groups based on BMI: BMI <30 (315), BMI 30-35 (132), BMI 35-40 (97), and BMI >40 (101). RESULTS: Accuracy between templating and final size did not vary by BMI for acetabular or femoral components. Digital templating was within 2 sizes of the final acetabular and femoral implants in 99.1% and 97.1% of cases, respectively. CONCLUSION: Digital templating is an effective means of predicting the final size of THA components. BMI does not appear to play a major role in altering THA digital templating accuracy.


Assuntos
Artroplastia de Quadril , Índice de Massa Corporal , Articulação do Quadril/diagnóstico por imagem , Cuidados Pré-Operatórios , Radiografia/normas , Acetábulo/cirurgia , Calibragem , Fêmur/cirurgia , Articulação do Quadril/cirurgia , Prótese de Quadril , Humanos , Radiografia/estatística & dados numéricos , Estudos Retrospectivos
13.
JBJS Rev ; 4(7)2016 07 12.
Artigo em Inglês | MEDLINE | ID: mdl-27509328

RESUMO

More than 60% of the talar surface area consists of articular cartilage, thereby limiting the possible locations for vascular infiltration and leaving the talus vulnerable to osteonecrosis. Treatment strategies for talar osteonecrosis can be grouped into four categories: nonsurgical, surgical-joint sparing, surgical-salvage, and joint-sacrificing treatments. Nonoperative and joint-sparing treatments include restricted weight-bearing, patellar tendon-bearing braces, bone-grafting, extracorporeal shock wave therapy, internal implantation of a bone stimulator, core decompression, and vascularized or non-vascularized autograft, whereas joint-sacrificing or salvage procedures include talar replacement (partial or total) and arthrodesis. In patients with a Ficat and Arlet grade-I through III osteonecrosis, evidence in favor of a specific treatment is poor, although tibiotalar or tibiotalocalcaneal arthrodesis may represent a suitable salvage operation.


Assuntos
Artrodese , Osteonecrose/terapia , Tálus/patologia , Transplante Ósseo , Humanos , Transplante Autólogo
14.
J Arthroplasty ; 31(12): 2875-2879.e2, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27378644

RESUMO

BACKGROUND: Sepsis is a rare but serious complication following total joint arthroplasty (TJA). Common sources include urinary tract infection (UTI), surgical site infection (SSI), and pneumonia. The purpose of this study is to characterize the incidence, risk factors, and sources of sepsis following TJA. METHODS: Patients undergoing primary total hip arthroplasty or total knee arthroplasty during 2005-2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Independent associations were tested for using multivariate regression adjusting for baseline characteristics. RESULTS: A total of 117,935 patients were identified (45,612 undergoing total hip arthroplasty and 72,323 undergoing total knee arthroplasty). Of these, 402 (0.34%) developed sepsis following surgery. Patients who developed sepsis had an elevated mortality rate (3.7% vs 0.1%, P < .001). Among the 402 patients who developed sepsis, 124 (31%) had concomitant UTI, 110 (27%) SSI, and 60 (15%) pneumonia. Twenty-one patients (5%) had multiple infectious sources and 129 patients (32%) had no identifiable source. Independent risk factors for sepsis included greater age, male sex, functional dependence, insulin-dependent diabetes, hypertension, chronic obstructive pulmonary disease, current smoker, and greater operative time. CONCLUSION: These findings suggest that the rate of sepsis following TJA is about 1 in 300, and that sepsis is associated with a high risk of mortality. The most common sources of sepsis are UTI, SSI, and pneumonia, potentially accounting for at least two-thirds of cases. The information provided here can be used to guide the diagnostic workup of sepsis in patients following TJA.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Sepse/etiologia , Infecção da Ferida Cirúrgica/complicações , Infecções Urinárias/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Pneumonia/complicações , Melhoria de Qualidade , Fatores de Risco , Sepse/mortalidade , Estados Unidos/epidemiologia , Adulto Jovem
15.
Spine (Phila Pa 1976) ; 41(9): 816-21, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27128255

RESUMO

STUDY DESIGN: Retrospective analysis of a prospectively maintained surgical registry. OBJECTIVE: To examine the association between body mass index (BMI) and the risk for undergoing a revision procedure following a single-level minimally invasive (MIS) lumbar discectomy (LD). SUMMARY OF BACKGROUND DATA: Studies conflict as to whether greater BMI contributes to recurrent herniation and the need for revision procedures following LD. Patients and surgeons would benefit from knowing whether greater BMI is a risk factor to guide the decision whether to pursue an operative versus non-operative treatment. METHODS: Patients undergoing a single-level MIS LD were retrospectively identified in our institution's prospectively maintained surgical registry. BMI was categorized as normal weight (<25 kg/m), overweight (25-30 kg/m), obese (30-40 kg/m), or morbidly obese (≥40 kg/m). Multivariate analysis was used to test for association with undergoing a revision procedure during the first 2 postoperative years. The model was demographics, comorbidities, and operative level. RESULTS: A total of 226 patients were identified. Of these, 56 (24.8%) were normal weight, 80 (35.4%) were overweight, 66 (29.2%) were obese, and 24 (10.6%) were morbidly obese. A total of 23 patients (10.2%) underwent a revision procedure in the first 2 postoperative years. The 2-year risk for revision procedure was 1.8% for normal weight patients, 12.5% for overweight patients, 9.1% for obese patients, and 25.0% for morbidly obese patients. In the multivariate-adjusted analysis model, BMI category was independently associated with undergoing a revision procedure (P = 0.038). CONCLUSION: These findings indicate that greater BMI is an independent risk factor for undergoing a revision procedure following a LD. These findings conflict with recent studies that have found no difference between obese and non-obese patients in regards to risk for recurrent herniation and/or revision procedures. Patients with greater BMI undergoing LD should be informed they could have an elevated risk for revision procedures. LEVEL OF EVIDENCE: 4.


Assuntos
Índice de Massa Corporal , Discotomia/efeitos adversos , Vértebras Lombares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Reoperação , Adulto , Discotomia/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Sobrepeso/diagnóstico , Sobrepeso/epidemiologia , Sobrepeso/cirurgia , Complicações Pós-Operatórias/diagnóstico , Estudos Prospectivos , Reoperação/tendências , Estudos Retrospectivos , Fatores de Risco
16.
J Shoulder Elbow Surg ; 23(4): 485-91, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24090980

RESUMO

BACKGROUND: Little is known about the role that a torn superior labrum (SLAP) plays in glenohumeral stability after biceps tenodesis. This biomechanical study evaluated the contribution of a type II SLAP lesion to glenohumeral translation in the presence of biceps tenodesis. The authors hypothesize that subsequent to biceps tenodesis, a torn superior labrum does not affect glenohumeral stability and therefore does not require anatomic repair in an overhead throwing athlete. METHODS: Baseline anterior, posterior, and abduction and maximal external rotation glenohumeral translation data were collected from 20 cadaveric shoulders. Translation testing was repeated after the creation of anterior (n = 10) and posterior (n = 10) type II SLAP lesions. Translation re-evaluation after biceps tenodesis was performed for each specimen. Finally, anatomic SLAP lesion repair and testing were performed. RESULTS: Anterior and posterior SLAP lesions led to significant increases in glenohumeral translation in all directions (P < .0125). Biceps tenodesis showed no significance in stability compared with SLAP alone (P > .0125). Arthroscopic repair of anterior SLAP lesions did not restore anterior translation compared with the baseline state (P = .0011) but did restore posterior (P = .823) and abduction and maximal external rotation (P = .806) translations. Repair of posterior SLAP lesions demonstrated no statistical difference compared with the baseline state (P > .0125). CONCLUSIONS: With no detrimental effect on glenohumeral stability in the presence of a SLAP lesion, biceps tenodesis may be considered a valid primary or revision surgery for patients suffering from symptomatic type II SLAP tears. However, biceps tenodesis should be considered with caution as the primary treatment of SLAP lesions in overhead throwing athletes secondary to its inability to completely restore translational stability.


Assuntos
Traumatismos em Atletas/cirurgia , Instabilidade Articular/cirurgia , Articulação do Ombro/cirurgia , Tenodese , Adulto , Idoso , Artroscopia , Traumatismos em Atletas/fisiopatologia , Fenômenos Biomecânicos , Cadáver , Feminino , Humanos , Instabilidade Articular/fisiopatologia , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/cirurgia , Amplitude de Movimento Articular , Rotação , Articulação do Ombro/lesões , Articulação do Ombro/fisiopatologia , Traumatismos dos Tendões/fisiopatologia , Traumatismos dos Tendões/cirurgia , Adulto Jovem
17.
J Shoulder Elbow Surg ; 23(3): 395-400, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24129052

RESUMO

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has been indicated primarily for patients aged older than 65 years with symptomatic rotator cuff deficiency, poor function, and pain. However, conditions that benefit from RTSA are not restricted to an elderly population. This study evaluates a consecutive series of RTSA patients aged younger than 60 years. METHODS: We evaluated 36 shoulders (mean age, 54 years) at a mean follow-up of 2.8 years (range, 24-48 months). Of these shoulders, 30 (83%) had previous surgery, averaging 2.5 procedures per patient. The preoperative conditions compelling RTSA were as follows: failed rotator cuff repair (12), fracture sequelae (11), failed arthroplasty (5), instability sequelae (4), cuff tear arthropathy (CTA) (4), and rheumatoid arthritis (2). Follow-up examinations included range-of-motion and strength testing, as well as Single Assessment Numeric Evaluation, visual analog scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES), and Constant scores. Preoperative and postoperative radiographs were reviewed for component loosening and scapular notching. Failure criteria were defined as undergoing revision, having gross loosening, or having an ASES score below 50. RESULTS: The mean Single Assessment Numeric Evaluation score improved from 24.4 to 72.0; the visual analog scale pain score improved from 6 to 2.1. The Simple Shoulder Test score improved from 1.4 to 6.2, and the ASES score improved from 31.4 to 65.8. Active forward elevation improved from 56° to 121°. The normalized postoperative mean Constant score was 54.3. In 9 patients (25.0%), we recorded an ASES score below 50, and these cases were considered failures. CONCLUSION: RTSA can improve shoulder function in a younger, complex patient population with poor preoperative functional ability. This study's success rate was 75% at 2.8 years. This is a limited-goals procedure, and longer-term studies are required to determine whether similar results are maintained over time.


Assuntos
Artroplastia de Substituição/estatística & dados numéricos , Lacerações/cirurgia , Lesões do Manguito Rotador , Atividades Cotidianas , Adulto , Fatores Etários , Artralgia/etiologia , Artroplastia de Substituição/efeitos adversos , Estudos de Coortes , Análise de Falha de Equipamento , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Radiografia , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Reoperação , Manguito Rotador/diagnóstico por imagem , Manguito Rotador/cirurgia , Ruptura/cirurgia , Articulação do Ombro/diagnóstico por imagem , Articulação do Ombro/lesões , Articulação do Ombro/fisiopatologia , Articulação do Ombro/cirurgia , Inquéritos e Questionários , Resultado do Tratamento
18.
Acta Orthop ; 84(5): 479-82, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24171683

RESUMO

BACKGROUND: Magnetic resonance imaging (MRI) is considered to be a valuable tool for the diagnosis of rotator cuff tears in patients with severe glenohumeral osteoarthritis who are indicated for total shoulder arthroplasty (TSA). We determined the sensitivity, specificity, and positive predictive value of MRI in diagnosing rotator cuff tears in such patients. METHODS: MRI reports of 100 patients who had completed a shoulder MRI prior to TSA were reviewed to determine the radiologists' interpretation of the MRI including the diagnosis, presence of a full-thickness cuff tear, and the presence of atrophy and/or fatty infiltration within the rotator cuff muscle bellies. Operative reports were used as a gold standard to determine whether a full-thickness rotator cuff tear was present. RESULTS: Preoperative MRI reports noted 33 of the 100 patients as having a full-thickness rotator cuff tear, 17 of which had multiple tendon tears. 2 of the 33 patients with full tears on MRI were found to have full-thickness tears at surgery. The sensitivity, specificity, and positive predictive value for MRI detection of full-thickness tears were 100%, 68%, and 6% respectively, with a false-positive rate of 32% and an accuracy of 69%. INTERPRETATION: The study suggests that although MRI is highly sensitive, it has a low positive predictive value and moderately low specificity and accuracy in detecting full-thickness rotator cuff tears in patients with severe glenohumeral osteoarthritis.


Assuntos
Imagem por Ressonância Magnética , Osteoartrite/patologia , Radiologia/normas , Lesões do Manguito Rotador , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Substituição/métodos , Competência Clínica/normas , Feminino , Humanos , Imagem por Ressonância Magnética/normas , Masculino , Pessoa de Meia-Idade , Osteoartrite/cirurgia , Cuidados Pré-Operatórios , Estudos Retrospectivos , Manguito Rotador/cirurgia , Ruptura/diagnóstico , Ruptura/cirurgia , Sensibilidade e Especificidade , Articulação do Ombro , Tempo para o Tratamento
19.
Am J Sports Med ; 41(2): 283-90, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23239668

RESUMO

BACKGROUND: Suture anchor fixation has become the preferred method for arthroscopic repairs of rotator cuff tears. Recently, newer arthroscopic repair techniques including transosseous-equivalent repairs with anchors or arthroscopic transosseous suture passage have been developed. PURPOSE: To compare the initial biomechanical performance including ultimate load to failure and localized cyclic elongation between transosseous-equivalent repair with anchors (TOE), traditional transosseous repair with a curved bone tunnel (TO), and an arthroscopic transosseous repair technique utilizing a simple (AT) or X-box suture configuration (ATX). STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-eight human cadaveric shoulders were dissected to create an isolated supraspinatus tear and randomized into 1 of 4 repair groups (TOE, TO, AT, ATX). Tensile testing was conducted to simulate the anatomic position of the supraspinatus with the arm in 60° of abduction and involved an initial preload, cyclic loading, and pull to failure. Localized elongation during testing was measured using optical tracking. Data were statistically assessed using analysis of variance with a Tukey post hoc test for multiple comparisons. RESULTS: The TOE repair demonstrated a significantly higher mean ± SD failure load (558.4 ± 122.9 N) compared with the TO (325.3 ± 79.9 N), AT (291.7 ± 57.9 N), and ATX (388.5 ± 92.6 N) repairs (P < .05). There was also a significantly larger amount of first-cycle excursion in the AT group (8.19 ± 1.85 mm) compared with the TOE group (5.10 ± 0.89 mm). There was no significant difference between repair groups in stiffness during maximum load to failure or in normalized cyclic elongation. Failure modes were as follows: TOE, tendon (n = 4) and bone (n = 3); TO, suture (n = 6) and bone (n = 1); AT, tendon (n = 2) and bone (n = 3) and suture (n = 1); ATX, tendon (n = 7). CONCLUSION: This study demonstrates that anchorless repair techniques using transosseous sutures result in significantly lower failure loads than a repair model utilizing anchors in a TOE construct. CLINICAL RELEVANCE: Suture anchor repair appears to offer superior biomechanical properties to transosseous repairs regardless of tunnel or suture configuration.


Assuntos
Manguito Rotador/cirurgia , Traumatismos dos Tendões/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroscopia , Fenômenos Biomecânicos , Cadáver , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manguito Rotador/fisiopatologia , Lesões do Manguito Rotador , Ombro/fisiopatologia , Âncoras de Sutura , Técnicas de Sutura , Traumatismos dos Tendões/fisiopatologia
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