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PURPOSE: To evaluate the clinical and radiographic outcomes of an all-arthroscopic rotator cuff repair technique involving muscle advancement and double-layer lasso loop (DLLL) repair for massive, retracted posterosuperior cuff tears. METHODS: This was a retrospective case series of patients with massive, retracted posterosuperior cuff tears who underwent the all-arthroscopic muscle advancement technique from March 2017 to September 2021, with a minimum follow-up of 12 months. Key steps included suprascapular nerve release, advancement of the supraspinatus and infraspinatus muscles, and DLLL repair. Preoperative and postoperative visual analog scale score for pain, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant score, University of California, Los Angeles (UCLA) shoulder score, active range of motion, and strength were compared. Preoperative and postoperative structural radiologic characteristics were analyzed. RESULTS: We evaluated 43 shoulders in 38 patients with a mean follow-up period of 18.8 months (range, 12-55 months). Of the 43 shoulders, 4 showed repair failure (9.3% retear rate). Visual analog scale, ASES, Constant, and UCLA scores significantly improved (P < .001) in patients who showed healing on postoperative magnetic resonance imaging (n = 39). ASES, Constant, and UCLA scores were significantly better in the healed group, with 100% exceeding the minimal clinically important difference for the ASES score and UCLA score and 84.2%, for Constant score. A lower proportion of patients in the retear group achieved the minimal clinically important difference. Active range of motion in all planes significantly improved for patients who had healed repairs (P < .001). Relative abduction strength, supraspinatus strength, and infraspinatus strength were at least 90% of those on the contralateral side. The recovery rate of pseudoparalysis (7 patients) was 100%. CONCLUSIONS: All-arthroscopic muscle advancement, coupled with DLLL repair, leads to a high healing rate with excellent clinical outcomes and recovery of strength to at least 90%, even in patients with pseudoparalysis. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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BACKGROUND: Surgically repairing rotator cuff tears with a higher extent of fatty infiltration is controversial. Current evidence supports performing rotator cuff repair in patients exhibiting Goutallier stage 3-4 fatty infiltration. However, the presence of retraction complicates accurate assessment using the Goutallier Classification, particularly on the lateral Y-view. A shift towards classifying fatty infiltration in more medial regions may enhance the precision of tissue quality quantification. The objective of this study was to analyze the uniformity of fatty infiltration within the entire supraspinatus muscle using the Goutallier Classification across three scapular Y-view sections and to examine the association between Goutallier grade, tangent sign, and modified Patte stage. METHODS: A retrospective evaluation was conducted on preoperative magnetic resonance imaging (MRI) scans from a consecutive series of 97 patients who had previously undergone arthroscopic rotator cuff repairs. Three supraspinatus sections on the MRI sagittal plane were identified: the lateral Y-view (section one), a medial section at the suprascapular notch anatomical landmark (section two), and a section 3 cm medial from the suprascapular notch Medial Scapular Body (section three). Goutallier grade, tangent sign, and modified Patte stage were used to evaluate fatty infiltration, muscle atrophy, and tendon retraction, respectively. RESULTS: Section one had the highest Goutallier grade, while section three had the lowest. Intra-observer rest retest reliability analysis showed excellent consistency in all sections with section one (ICC=0.920, 95% CI), section two (ICC=0.917, 95% CI), and section three (ICC=0.923, 95% CI) for Goutallier grade. Inter-observer reliability analysis also revealed excellent consistency in sections one (ICC=0.951, 95% CI), section two (ICC=0.949, 95% CI), and section three (ICC=0.922, 95% CI) for Goutallier grade. A strong correlation was observed between Goutallier grade and modified Patte stage (τb=0.43-0.56, p=0.001), and between Goutallier grade and tangent sign (τb=0.43-0.54, p=0.001) across all sections. CONCLUSION: The severity of fatty infiltration within the supraspinatus muscle belly is inconsistent, with the lateral portion being the most severe and the medial portion the least severe. Goutallier grade demonstrates a strong correlation with tangent sign and modified Patte stage. This suggests that tendon retraction results in a potential overestimation in the amount of fatty infiltration defining some tears unjustly irreparable when measuring at the traditionally described lateral Y-view position compared with 3cm medial.
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BACKGROUND: The degree of atrophy and fatty infiltration of rotator cuff muscle belly is a key predictor for cuff repairability. Traditionally, Goutallier grading of fatty infiltration is assessed at sagittal scapular Y-view. Massive rotator cuff tears are associated with tendon retraction and medial retraction of cuff musculature, resulting in medialization of the muscle bulk. Thus, standard Y-view can misrepresent the region of interest and may misguide clinicians when assessing repairability. It is hypothesized that by assessing the muscle belly with multiple medial sagittal magnetic resonance imaging (MRI) sections at the medial scapular body, the Medial Scapular Body-Goutallier Classification (MSB-GC) will improve reliability and repeatability, giving a more representative approximation to the degree of fatty infiltration, as compared with the original Y-view. METHODS: Fatty infiltration of the rotator cuff muscles were classified based on the Goutallier grade (0-4) at 3 defined sections: section 1, original Y-view; section 2, level of suprascapular notch; and section 3, 3 cm medial to the suprascapular notch on MRI scans. Six subspecialist fellowship-trained shoulder surgeons and 3 musculoskeletal radiologists independently evaluated deidentified MRI scans of included patients. RESULTS: Of 80 scans, 78% (n = 62) were massive cuff tears involving the supraspinatus, infraspinatus, and subscapularis tendons. Interobserver reliability (consistency between observers) for Goutallier grade was excellent for all 3 predefined sections (range: 0.87-0.95). Intraobserver reliability (repeatability) for Goutallier grade was excellent for all 3 sections and 4 rotator cuff muscles (range: 0.83-0.97). There was a moderate to strong positive correlation of Goutallier grades between sections 1 and 3 and between sections 2 and 3 and these were statistically significant (P < .001). There was a reduction in the severity of fatty infiltration on the Goutallier classification from sections 1 to 3 across all muscles: 42.5% of both supraspinatus and infraspinatus were downgraded by 1, 20% of supraspinatus and 3.8% of infraspinatus were downgraded by 2, and 2.5% of supraspinatus were downgraded by 3. CONCLUSION: This study found that applying the Goutallier classification to more medial MRI sections (MSB-GC) resulted in assignment of lower grades for all rotator cuff muscles. Additionally, this method demonstrated excellent test-retest reliability and repeatability. Inclusion of a more medial view or whole scapula on MRI, especially in advanced levels of tear retraction, could be more reliable and representative for assessment of the degree of fatty infiltration within the muscle bulk that could help predict tear repairability and therefore improve clinical decision making, which should be studied further in clinical studies.
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BACKGROUND: The deltopectoral approach is well accepted for shoulder arthroplasty procedures. The extended deltopectoral approach with detachment of the anterior deltoid from the clavicle allows increased joint exposure and can protect the anterior deltoid from traction injury. The efficacy of this extended approach has been demonstrated in anatomic total shoulder replacement surgery. However, this has not been shown in reverse shoulder arthroplasty (RSA). The primary aim of this study was to evaluate the safety of the extended deltopectoral approach in RSA. The secondary aim was to evaluate the performance of the deltoid reflection approach in terms of complications and surgical, functional, and radiologic outcomes up to 24 months after surgery. METHODS: A prospective, nonrandomized comparative study was performed between January 2012 and October 2020 including 77 patients in the deltoid reflection group and 73 patients in the comparative group. The decision for inclusion was based on patient and surgeon factors. Complications were recorded. Patients were followed up for ≥24 months to evaluate their shoulder function and undergo ultrasound evaluation. Functional outcome measures included the Oxford Shoulder Score, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, pain intensity (rated on visual analog scale [VAS] from 0 to 100), and range of motion (forward flexion, abduction, and external rotation). A regression analysis was performed to evaluate any factors of influence on the VAS score. RESULTS: There were no significant differences in the complication rate between the 2 groups (14.5% in deltoid reflection group and 13.8% in comparative group, P = .915). Ultrasound evaluation was available in 64 patients (83.1%), and no proximal detachment was observed. In addition, there were no significant differences in functional outcome measures both preoperatively and at 24 months after surgery between the groups assessed based on the mean VAS pain score, Oxford Shoulder Score, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, forward flexion, abduction, and external rotation. Adjustment for possible confounders in a regression model indicated that only prior surgery significantly influenced the VAS pain score after surgery (P = .031; 95% confidence interval, 0.574-11.67). Deltoid reflection (P = .068), age (P = .466), sex (P = .936), use of glenoid graft (P = .091), prosthesis manufacturer (P = .382), and preoperative VAS score (P = .362) were not of influence. DISCUSSION: The results of this study show that an extended deltopectoral approach for RSA is safe. Selected reflection of the anterior deltoid muscle improved exposure and prevented anterior deltoid muscle injury followed by reattachment. Patients had similar functional scores preoperatively and at 24 months postoperatively compared with a comparative group. Furthermore, ultrasound evaluation showed intact reattachments.
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Artroplastia do Ombro , Artroplastia de Substituição , Músculo Deltoide , Articulação do Ombro , Humanos , Artroplastia de Substituição/métodos , Artroplastia do Ombro/métodos , Músculo Deltoide/cirurgia , Dor , Estudos Prospectivos , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Ombro/cirurgia , Articulação do Ombro/diagnóstico por imagem , Articulação do Ombro/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The Latarjet coracoid transfer procedure reliably stabilizes the glenohumeral joint for shoulder instability. However, complications such as graft osteolysis, nonunion and fracture continue to affect patient clinical outcomes. The double-screw (SS) construct is regarded as the gold standard method of fixation. SS constructs are associated with graft osteolysis. More recently, a double-button technique (BB) has been suggested to minimize graft-related complications. However, BB constructs are associated with fibrous nonunion. To mitigate this risk, a single screw combined with a single button (SB) construct has been proposed. It is thought that this technique incorporates the strength of the SS construct and allows micromotion superiorly to mitigate stress shielding-related graft osteolysis. AIMS: The primary aim of this study was to compare the failure load of SS, BB, and SB constructs under a standardized biomechanical loading protocol. The secondary aim was to characterize the displacement of each construct throughout testing. METHODS: Computed tomography scans of 20 matched-pair cadaveric scapulae were performed. Specimens were harvested and dissected free of soft tissue. SS and BB techniques were randomly assigned to specimens for matched-pair comparison with SB trials. A patient-specific instrument (PSI)-guided Latarjet procedure was performed on each scapula. Specimens were tested using a uniaxial mechanical testing device under cyclic loading (100 cycles, 1 Hz, 200 N/s) followed by a load-to-failure protocol (0.5 mm/s). Construct failure was defined by graft fracture, screw avulsion, and/or graft displacement of more than 5 mm. RESULTS: Forty scapulae from 20 fresh frozen cadavers with a mean age of 69.3 years underwent testing. On average, SS constructs failed at 537.8 N (SD 296.8), whereas BB constructs failed at 135.1 N (SD 71.4). SB constructs required a significantly greater load to fail compared with BB constructs (283.5 N, SD 162.8, P = .039). Additionally, SS (1.9 mm, IQR 0.87) had a significantly lower maximum total graft displacement during the cyclic loading protocol compared with SB (3.8 mm, IQR 2.4, P = .007) and BB (7.4 mm, IQR 3.1, P < .001) constructs. CONCLUSION: These findings support the potential of the SB fixation technique as a viable alternative to SS and BB constructs. Clinically, the SB technique could reduce the incidence of loading-related graft complications seen in the first 3 months of BB Latarjet cases. The study is limited to time-specific results and does not account for bone union or osteolysis.
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Instabilidade Articular , Osteólise , Articulação do Ombro , Humanos , Idoso , Articulação do Ombro/cirurgia , Instabilidade Articular/cirurgia , Escápula/cirurgia , Parafusos Ósseos , Complicações Pós-OperatóriasRESUMO
The aim is to review clinical and radiological outcomes for all cases of primary and revision THA, combining a cemented stem (Exeter V40) with a dual mobility component from a different manufacturer (SERF Novae), to evaluate whether concerns regarding mixing components from different manufacturers are justified. We identified 72 hip replacements performed between May 2010 and December 2015 using the SERF Novae dual mobility cup with an Exeter V40 stem, the majority of which were cemented (90%) and revisions (58%). Patients were evaluated clinically and radiologically at a minimum of two years. There were five (6.9%) dislocations; three (4.2%) requiring revision - one of which was an intra-prosthetic disarticulation and two infections. No cases were lost to follow-up and 49 surviving cases were reviewed at a mean of 4.0 (range 1.8-8.1) years following surgery. Pain and functional outcome scores all improved. There were no radiological failures and no revisions for aseptic loosening of stem or cup. The combination of Exeter cemented stem with a dual mobility bearing from a different manufacturer results in acceptable short-term outcomes in terms of hip stability, revision rates and patient-reported measures.
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Artroplastia de Quadril , Prótese de Quadril , Humanos , Desenho de Prótese , Falha de Prótese , Estudos Retrospectivos , Reoperação , SeguimentosRESUMO
The land application of biosolids can be subject to questions and concerns, suggesting a gap exists with public perception of biosolids. There is opposition amongst a segment of the population regarding the land application of biosolids in the Southern Interior of British Columbia in Canada. Kamloops and Merritt communities were assessed through a mailout survey to understand better public perceptions of biosolids risks and factors that influence attitudes towards biosolids management. Two thousand surveys were distributed proportionately between the communities. Response rates for Kamloops and Merritt were 22 and 24 percent, respectively. Kamloops and Merritt respondents generally identified differing risk perceptions around biosolids management. Kamloops respondents relative to Merritt were more accepting of the risks associated with biosolids. This acceptance is a likely result of Merritt residents' recent experience with application sites and proximity to biosolids projects, and the associated negative local media attention. Results from Kamloops highlighted that there is general support to find a productive use of biosolids. This research supports the notion that the 'beyond compliance' approach of conducting early engagement to obtain community support proactively may be valuable for any potentially controversial natural resource project, such as with biosolids land application projects.
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Percepção , Opinião Pública , Atitude , Biossólidos , Colúmbia BritânicaRESUMO
BACKGROUND: The use of smartphones and multimedia messaging service (MMS) continues to increase in day to day orthopaedic clinical practice. However, there is limited evidence to support the safe utilisation of MMS. OBJECTIVES: The aim of this study was to correlate the performance of MMS imaging to picture archiving and communication systems (PACS) imaging within the setting of diagnosis and management of ankle fractures. METHODS: The ankle fracture radiograph series of 82 consecutive patients were evaluated by five orthopaedic consultant specialists. A questionnaire regarding diagnosis and preferred management was completed separately for each patient using smartphone and PACS images. Statistical analysis was performed using Intraclass Correlation Coefficient (ICC). RESULTS: Ankle fracture diagnosis showed strong to excellent correlation both inter- and intraobserver MMS vs PACS when using the Weber (0.815, 0.988), Anatomical (0.858, 0.988), and AO classification systems (0.855, 0.985). MMS was less reliable than PACS in determining many management options. CONCLUSION: The reliability of ankle fracture classification using MMS image viewing was not significantly different to interpretation on PACS workstations. Smartphone use in ankle fracture classification is supported by this study. Smartphone use was less accurate than PACS in devising management plans and future use should be limited to making only initial plans that must be corroberated with PACS and intraoperative findings prior to definitive fixation.
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Fraturas do Tornozelo , Smartphone , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Humanos , Multimídia , Radiografia , Reprodutibilidade dos TestesRESUMO
BACKGROUND: To review on-table, day 0, day 1, day 7, and day 30 mortality after hemiarthroplasty or total hip arthroplasty (THA) using cemented femoral stems for femoral neck fractures in order to evaluate risk factors for perioperative and short-term mortality. METHODS: The medical records of 751 consecutive cases with neck of femur fractures who underwent hemiarthroplasty (n = 602) or THA (n = 149) with cemented stems between January 2011 and December 2016 were retrospectively reviewed from a prospectively gathered database. The primary outcome measures were on-table, day 0, day 1, day 7, and day 30 mortality. Univariate and multivariate analyses were performed in order to identify various contributing patient and surgical variables. RESULTS: There were 2 on-table deaths (0.27%): one patient had a cardiorespiratory arrest at the time of inserting the femoral stem and the other had a cardiorespiratory arrest at the end of wound closure some 20 minutes after cementing. There were 3 further day 0 deaths meaning the day 0 mortality rate was 0.67% (5/751). All 5 patients were older than 80 years and had an American Society of Anesthesiologists grade 3 or more. The 1-day, 7-day, and 30-day mortality rates were 0.93% (7 patients), 2.7% (20 patients), and 6.8% (51 patients), respectively. There is significantly higher 30-day mortality risk associated with increasing American Society of Anesthesiologists grade (P < .001) when adjusted for age, gender, and type of surgery (hemiarthroplasty compared with THA). CONCLUSION: In our neck of femur fracture patients who were operated with cemented stems, 7-day and 30-day mortality rates were 2.7% and 6.8%, respectively. Cemented stems should be used with caution in elderly hip fracture patients with multiple comorbidities who are at high risk of perioperative mortality.
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Artroplastia de Quadril , Fraturas do Colo Femoral , Hemiartroplastia , Prótese de Quadril , Idoso , Artroplastia de Quadril/efeitos adversos , Cimentos Ósseos , Fraturas do Colo Femoral/cirurgia , Fêmur , Hemiartroplastia/efeitos adversos , Humanos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Total hip arthroplasty (THA) is an effective procedure for relieving pain and restoring function in osteoarthritis. A significant proportion of patients have severe disease bilaterally. Consensus regarding safety and selection of patients for simultaneous bilateral THA or the optimal timing for staged THA has not been reached. The aim of this study is to compare rates, causes of revision, and 30-day mortality between simultaneous and staged bilateral THA using data from the Australian Orthopedic National Joint Replacement Registry. METHODS: Data for 12,359 bilateral THA procedures were collected from September, 1999 to December, 2017. Rates and causes of revision and 30-day mortality were obtained for simultaneous bilateral and staged procedures with intervals of 1 day-6 weeks, 6 weeks-3 months, and 3 months-6 months. Yearly cumulative percent revision or cumulative percent survival with 95% confidence intervals calculated by the Kaplan-Meier method, and adjusted hazard ratios were used for comparisons. RESULTS: Thirty-day mortality is lower in patients who have bilateral procedures within 6 months, regardless of timing, than those who have unilateral procedures (0.06% vs 0.18%). Staged bilateral THA had a significantly lower mortality than simultaneous bilateral THA (odds ratio 0.175, 95% confidence interval = 0.04-0.78, P = .022). When separate time intervals were compared, no significant differences were seen. Bilateral 6 week-3 months has a higher rate of revision from 1.5 years-2years compared with same day bilaterals (hazard ratio = 2.39, 95% confidence interval = 1.12, 5.09, P = .024). There were no other significant differences in the rate of revision between groups. The most common reasons for revision were fracture, loosening, and infection. Simultaneous bilateral procedures have a significantly higher rate of revision for fracture compared with staging 3-6 months (hazard ratio = 1.96 [1.27, 3.03], P = .002). CONCLUSION: This study demonstrates that bilateral THA has a low mortality rate regardless of time interval between procedures. Simultaneous and staged bilateral THA have similar rates of revision.
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Artroplastia de Quadril , Prótese de Quadril , Artroplastia de Quadril/efeitos adversos , Austrália/epidemiologia , Prótese de Quadril/efeitos adversos , Humanos , Modelos de Riscos Proporcionais , Sistema de Registros , Reoperação , Resultado do TratamentoRESUMO
BACKGROUND: Patellar resurfacing in total knee arthroplasty (TKA) remains a controversial issue after more than 4 decades of TKA. Despite a growing body of evidence from registry data, resurfacing is still based largely on a surgeon's preference and training. The purpose of this study is to provide long-term outcomes for patellar resurfaced compared to when the patella is not resurfaced. METHODS: Data from the Australian Orthopaedic Association National Joint Replacement Registry (1999-2017) were used for this study. The analysis included 570,735 primary TKAs undertaken for osteoarthritis. Hazard ratios (HRs) and 17-year cumulative percent revision rates were used to compare revision rates between 4 subgroups: minimally stabilized (MS) patellar resurfacing, posterior stabilized (PS) patellar resurfacing, MS unresurfaced, and PS unresurfaced patella. Additional analyses of the patellar implant type and a comparison of inlay and onlay patellar resurfacing were also performed. RESULTS: For all primary TKA, procedures where the patella was not resurfaced have a higher rate of revision compared to procedures where the patella was resurfaced (HR, 1.31; confidence interval, 1.28-1.35; P < .001). Unresurfaced PS knees have the highest cumulative percent revision at 17 years (11.1%), followed by MS unresurfaced (8.8%), PS resurfaced (7.9%), and MS resurfaced (7.1%). Inlay patellar resurfacing has a higher rate of revision compared to onlay patellar resurfacing (HR, 1.27; confidence interval, 1.17-1.37; P < .001). CONCLUSION: Resurfacing the patella reduces the rate of revision for both MS and PS knees. MS knees with patellar resurfacing have the lowest rate of revision. Onlay patella designs are associated with a lower revision rate compared to inlay patella designs.
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Artroplastia do Joelho , Prótese do Joelho , Ortopedia , Osteoartrite do Joelho , Austrália/epidemiologia , Humanos , Articulação do Joelho/cirurgia , Osteoartrite do Joelho/cirurgia , Patela/cirurgia , Sistema de Registros , Resultado do TratamentoRESUMO
BACKGROUND: Hip arthroplasty is increasing in Australia. The number of procedures for fractured neck of femur was 7500 in 2017. Best practices for fixation method and procedure type require scrutiny. This paper is about the costs and health outcomes of cemented and uncemented hemiarthroplasty and total hip arthroplasty at a national level. METHODS: We created a Markov model for patients <75, aged 75-85, and over 85. Expected costs and health outcomes over 5 years from a decision to change from existing practice to a best practice policy in which all patients with fractured neck of femur received the same fixation method based on age and type of arthroplasty are estimated. The model was populated using prevalence and incidence data from the Australian Orthopedic Association National Joint Replacement Registry, costs from Metro North Hospital and Health Service in Queensland, and probabilities and utilities from the literature. We simulated the uncertainties in outcomes with probabilistic sensitivity analysis. RESULTS: We found that uncemented stem procedures were more costly and provided worse health outcomes compared to cemented stem fixation for hemiarthroplasty and total hip arthroplasty for all age groups. Moving from existing practice to cemented stem arthroplasty could save the Australian health system $2.0 million over 5 years with a gain of 203 quality-adjusted life years. CONCLUSION: We suggest that consideration be given to cemented fixation of the femoral stem for patients receiving both hemiarthroplasty and total hip arthroplasty for fractured neck of femur. Best practice guidelines focused on cost-effectiveness should recommend cemented stem fixation to both save costs and improve patient quality of life.
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Artroplastia de Quadril , Fraturas do Colo Femoral , Hemiartroplastia , Prótese de Quadril , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Análise Custo-Benefício , Fraturas do Colo Femoral/epidemiologia , Fraturas do Colo Femoral/cirurgia , Serviços de Saúde , Humanos , Qualidade de Vida , Reoperação , Resultado do TratamentoRESUMO
BACKGROUND: There is variable evidence regarding survivorship beyond 20 years of total hip arthroplasties in young patients. We report the long-term results of the Exeter cemented hip system in patients ≤50 years at minimum of 20 years. METHODS: Clinical and radiological outcomes of 130 consecutive total hip arthroplasties in 107 patients aged 50 years or younger at primary operation were reviewed; 77% had a diagnosis other than osteoarthritis. All patients were followed at 5-year intervals, no patients were lost to follow-up, and the status of every implant is known. RESULTS: Mean age at surgery was 41.8 (17-50) years. Mean follow-up was 22.0 (20.0-26.1) years. There were 79 hips surviving, 14 hips (11 patients) deceased, and 37 hips revised. Reasons for revision: 29 hips for aseptic cup loosening (26 stems revised using cement-in-cement, three left in-situ); three stems for femoral osteolysis, two related to acetabular polyethylene wear (14.1 and 17.0 years), one with Gaucher's disease (21.1 years); one broken stem (12.9 years); one cup for instability (4.3 years-stem revised using cement-in-cement); and two hips with infection (8.5 and 23.8 years). There were no cases of aseptic loosening of the Exeter stem. There were no radiologically loose stems although eight patients had radiological evidence of loosening of the cemented cup. Survivorship at 22 years was 74.9% for revision for all causes and 96.3% for revision of the stem for aseptic loosening or lysis. CONCLUSION: The Exeter cemented stem has excellent survivorship at minimum 20 years in young patients. Acetabular component survivorship was less favorable, but the advent of highly cross-linked polyethylene may improve this in the long term.
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Artroplastia de Quadril , Prótese de Quadril , Adulto , Artroplastia de Quadril/efeitos adversos , Seguimentos , Humanos , Pessoa de Meia-Idade , Desenho de Prótese , Falha de Prótese , Reoperação , Resultado do TratamentoRESUMO
BACKGROUND: Cement-in-cement femoral revision is a proven technique in revision total hip arthroplasty, with excellent results reported using standard-sized Exeter stems. The Exeter 44/00/125 short revision stem was introduced in 2004 to facilitate cement-in-cement revision. The stem is 25-mm shorter and has a slimmer body than standard stems to facilitate adjustment of depth of insertion and stem version. It is not known if this change in stem size affects its long-term performance. We therefore reviewed the outcome of all Exeter short revision stems used for cement-in-cement revision in our unit, with a minimum of 5 years of follow-up. METHOD: One hundred sixty-six cases were performed between 2004 and 2010. Mean follow-up of surviving patients was 8.1 years (range 5.0-11.7). The fate of all 166 hips were known and included in the survival analysis. RESULTS: Median clinical scores improved significantly. Sixteen hips required re-revision (infection 6, loose cup 3, periprosthetic fracture 3, instability 2, stem fracture with chronic infection 1, and pain 1). Kaplan-Meier survival analysis at 10 years revealed 100% survival for aseptic stem loosening, 96.8% survival for stem failure, and 88.9% survival for all causes. CONCLUSION: The Exeter short revision stem performed as well as standard length stems for cement-in-cement revision in this the largest and longest review of their use. Larger registry-based studies may provide additional information on the performance of this stem.
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Cimentos Ósseos , Prótese de Quadril , Reoperação/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril , Feminino , Fêmur/cirurgia , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Dor/cirurgia , Fraturas Periprotéticas/cirurgia , Desenho de Prótese , Falha de Prótese , Reoperação/métodos , Análise de SobrevidaRESUMO
BACKGROUND: The declining popularity of cemented acetabular components is incongruous, given the published results of prostheses implanted using contemporary techniques. The outcome of arthroplasty has previously been demonstrated to correlate with surgeon experience and volume of practice. We aim to explore if surgeon volume alters outcomes of cemented acetabular components based on survivorship data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). METHODS: An observational study was undertaken using a cohort of 22,956 patients with a primary diagnosis of osteoarthritis in the period 2003-2016 in whom cemented acetabular components were implanted. The cohort was stratified by age (greater than or less than 65 years) and annualized surgical volume of ≤10, >10-≤25, and >25 cases. RESULTS: Stratified by age and volume, there was a protective benefit against revision conveyed at volume thresholds of 10 cases per annum and 25 cases per annum for patients ≥65 years of age and <65 years of age, respectively. CONCLUSION: Cemented total hip arthroplasty has excellent survivorship out to 15 years based on AOANJRR data. This survivorship is further improved if surgeons perform a higher volume of cases, with >25 cases conferring the greatest benefit. The AOANJRR data set is used to define best practice; surgeons who choose to utilize cemented acetabular fixation should be encouraged to perform this technique in adequate volumes to minimize revision risk and ensure the preservation of this important surgical skill set.
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Acetábulo/cirurgia , Artroplastia de Quadril , Cimentos Ósseos , Prótese de Quadril , Osteoartrite do Quadril/cirurgia , Idoso , Austrália/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ortopedia , Osteoartrite do Quadril/epidemiologia , Modelos de Riscos Proporcionais , Falha de Prótese , Sistema de Registros , Reoperação , Estudos RetrospectivosRESUMO
Background and purpose - No difference in outcome has been demonstrated comparing cemented taper-slip and composite beam designs in short-term randomised trials; we assessed outcome differences using a registry analysis. Patients and methods - All cemented stems with > 100 implantations were identified in the National Joint Registry of England and Wales from April 1, 2003 to September 31, 2013 and categorised as taper-slip or composite beam. Survival analyses using Kaplan-Meier and Cox regression were performed. Results - We identified 292,987 cemented arthroplasties, of which 16% (47,586) were composite beam stems, with taper-slip stems making up the remainder (n = 245,401). There was a statistically significant increased chance of revision in the composite beam group compared with the taper-slip group (1.7% vs 1.3%, p < 0.001) but statistically no significant differences of survival estimates (p = 0.06). When the 2 groups were segregated to delineate the most implanted model in each category, the differences became more profound with the most implanted taper-slip stem (Exeter V40) showing statistically and clinically significant superior 8-year survival: 97.9% compared with 97.6% for all other taper-slip; 97.5% for the most implanted composite beam (Charnley cemented stem); and 97.7% for all other composite beam. Interpretation - There was an increased incidence of revision for composite beam stems. The most implanted taper-slip stem demonstrated significant survival advantage vs. all other stems.
Assuntos
Artroplastia de Quadril , Prótese de Quadril/estatística & dados numéricos , Falha de Prótese , Infecções Relacionadas à Prótese/epidemiologia , Reoperação/estatística & dados numéricos , Idoso , Cimentação , Estudos de Coortes , Inglaterra/epidemiologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Modelos de Riscos Proporcionais , Desenho de Prótese , Estudos Retrospectivos , Resultado do Tratamento , País de Gales/epidemiologiaRESUMO
OBJECTIVES: This study aimed to determine whether the timing of an interview relative to the recruitment season was associated with being ranked or matched at an academic medical center. METHODS: Eleven specialties (anesthesiology, diagnostic radiology, emergency medicine, family medicine, general surgery, internal medicine, neurology, neurosurgery, obstetrics-gynecology, orthopedic surgery, and psychiatry) that participated in the National Resident Matching Program were included in the study. Each program's total number of interview days during the October 2014-January 2015 interview season were divided equally into three interview time periods. The Cochran-Armitage trend test was used to evaluate associations among the three interview time periods (early, middle, and late) and interviewee outcomes (ranked or matched at our institution) for all subjects combined for each of the 11 programs and for specialty groups (medical, surgical, and hospital). RESULTS: Of 1034 applicants included in the analyses, 60% were men. Most were graduated from US medical schools (59.8%; a total of 103 applicants obtained first-year training positions through the Match [95.4% combined fill rate]). Twenty-nine interviewed early, 38 in the middle, and 36 in the late period (P = 0.3877). A total of 864 applicants were ranked by 1 of the 11 residency programs at the study site: 267 in the early period, 319 in the middle, and 278 in the late period (P = 0.4184). Being ranked in association with specialty classification also showed no significant differences. CONCLUSIONS: Interview timing had no relation to the likelihood of a match or being ranked by 1 of the 11 programs studied at our institution. These findings help dispel misconceptions about the importance of the interview date for a successful match.
Assuntos
Centros Médicos Acadêmicos , Internato e Residência , Entrevistas como Assunto , Critérios de Admissão Escolar , Adulto , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estações do Ano , Fatores de Tempo , Estados UnidosRESUMO
BACKGROUND: Total knee arthroplasty (TKA) is an effective procedure for relieving pain and restoring function in osteoarthritis, with a significant proportion of patients having severe disease bilaterally. However, although there are differences in patient selection criteria for bilateral procedures, there is no consensus regarding the optimal timing for bilateral TKA. The aim of this study was to compare rates and causes of revision and 30-day mortality between simultaneous and staged bilateral TKA using data from the Australian Orthopaedic Association National Joint Replacement Registry. METHODS: Data for over 36,000 bilateral TKAs were collected from September 1999 to December 2015. Rates and causes of revision and 30-day mortality rates were obtained for simultaneous bilateral and staged procedures with intervals of 1 day-6 weeks, 6 weeks-3 months, and 3-6 months. Yearly cumulative percent revision or cumulative percent survival with 95% confidence intervals calculated using the Kaplan-Meier method and adjusted hazard ratios were used for comparisons. RESULTS: There was no significant difference between revision rates or reasons for revision between staged bilateral and simultaneous TKA (hazard ratio 1.09 [95% confidence interval {CI} 0.85-1.40; P = .511] for 1 day-6 weeks, 0.93 [95% CI 0.77-1.14; P = .494] for 6 weeks-3 months, and 1.10 [95% CI 0.98-1.23; P = .115] for 3-6 months). The most common reasons for revision were loosening/lysis and infection. The 30-day mortality rates were lower in the 6 weeks-3 months group than simultaneous bilaterals (P = .007). CONCLUSION: This study demonstrates that simultaneous and staged bilateral TKA have similar rates of revision over the medium term but that 30-day mortality is reduced in the 6 weeks-3 months group.
Assuntos
Artroplastia do Joelho/mortalidade , Artroplastia do Joelho/métodos , Osteoartrite do Joelho/cirurgia , Idoso , Artroplastia do Joelho/estatística & dados numéricos , Austrália/epidemiologia , Feminino , Humanos , Prótese do Joelho/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/epidemiologia , Falha de Prótese , Sistema de Registros/estatística & dados numéricos , Reoperação/mortalidade , Reoperação/estatística & dados numéricosRESUMO
Background and purpose - The hip-related timeline of patients following a total hip arthroplasty (THA) can vary. Ideally patients will live their life without need for further surgery; however, some will undergo replacement on the contralateral hip and/or reoperations. We analyzed the probability of mortality and further hip-related surgery on the same or contralateral hip. Patients and methods - We performed a multi-state survival analysis on a prospectively followed cohort of 133,654 Swedish patients undergoing an elective THA between 1999 and 2012. The study used longitudinally collected information from the Swedish Hip Arthroplasty Register and administrative databases. The analysis considered the patients' sex, age, prosthesis type, surgical approach, diagnosis, comorbidities, education, and civil status. Results - During the study period patients were twice as likely to have their contralateral hip replaced than to die. However, with passing time, probabilities converged and for a patient who only had 1 non-revised THA at 10 years, there was an equal chance of receiving a second THA and dying (24%). It was 8 times more likely that the second hip would become operated with a primary THA than that the first hip would be revised. Multivariable regression analysis reinforced the influence of age at operation, sex, diagnosis, comorbidity, and socioeconomic status influencing state transition. Interpretation - Multi-state analysis can provide a comprehensive model of further states and transition probabilities after an elective THA. Information regarding the lifetime risk for bilateral surgery, revision, and death can be of value when discussing the future possible outcomes with patients, in healthcare planning, and for the healthcare economy.
Assuntos
Artroplastia de Quadril/mortalidade , Prótese de Quadril/estatística & dados numéricos , Osteoartrite do Quadril/cirurgia , Idoso , Feminino , Humanos , Masculino , Osteoartrite do Quadril/mortalidade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sistema de Registros , Reoperação/mortalidade , Fatores de Risco , Fatores Sexuais , Suécia/epidemiologiaRESUMO
The SecY/61 complex forms the protein-channel component of the ubiquitous protein secretion and membrane protein insertion apparatus. The bacterial version SecYEG interacts with the highly conserved YidC and SecDF-YajC subcomplex, which facilitates translocation into and across the membrane. Together, they form the holo-translocon (HTL), which we have successfully overexpressed and purified. In contrast to the homo-dimeric SecYEG, the HTL is a hetero-dimer composed of single copies of SecYEG and SecDF-YajC-YidC. The activities of the HTL differ from the archetypal SecYEG complex. It is more effective in cotranslational insertion of membrane proteins and the posttranslational secretion of a ß-barreled outer-membrane protein driven by SecA and ATP becomes much more dependent on the proton-motive force. The activity of the translocating copy of SecYEG may therefore be modulated by association with different accessory subcomplexes: SecYEG (forming SecYEG dimers) or SecDF-YajC-YidC (forming the HTL). This versatility may provide a means to refine the secretion and insertion capabilities according to the substrate. A similar modularity may also be exploited for the translocation or insertion of a wide range of substrates across and into the endoplasmic reticular and mitochondrial membranes of eukaryotes.