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BACKGROUND: A 2-stage revision continues to be the standard treatment for periprosthetic joint infection (PJI) in hip arthroplasty. The use of "functional" spacers may allow patients to return to daily living while optimizing their health for revision surgery. We aimed to evaluate the clinical outcomes of different spacer types regarding infection eradication, mechanical complications, and functional outcomes. METHODS: Patients who have complete Musculoskeletal Infection Society criteria for diagnosis of PJI that underwent one-stage or 2-stage revision were queried in an institutional surgical database between 2002 and 2022. Out of 286 patients, 210 met our inclusion criteria and were retrospectively reviewed for demographics, laboratory values, functional and patient-reported outcomes, and subsequent revisions. The study population had 54.3% women, a mean age of 61 years old, and a mean follow-up of 3.7 ± 3.2 years. There was no difference between age, body mass index, or Charlson Comorbidity Index scores between each cohort. Spacers were categorized as nonfunctional static, nonfunctional articulating, or functional articulating. Functional spacers were defined as those that allowed full weight bearing with no restrictions. Delphi criteria were used to define revision success, and failure was defined as a recurrent or persistent infection following definitive surgery. RESULTS: There was a significantly lower reoperation rate after a definitive implant in the functional articulating cohort (P = .003), with a trending higher infection eradication rate and a lower rate of spacer failure compared to the nonfunctional spacer cohort. At 5 years, functional articulating spacers had a 94.1% survivorship rate, nonfunctional articulating spacers had an 81.2% survival rate, and nonfunctional static spacers had a 71.4% survival rate. In the functional articulating spacer cohort, 14.6% had yet to get reimplanted, with an average follow-up time of 1.4 years. CONCLUSIONS: Within this large cohort of similar demographics, functional articulating spacers may result in better clinical outcomes and infection eradication during 2-stage revision arthroplasty for PJI.
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Artroplastia de Quadril , Prótese de Quadril , Infecções Relacionadas à Prótese , Reoperação , Humanos , Feminino , Pessoa de Meia-Idade , Reoperação/estatística & dados numéricos , Masculino , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/instrumentação , Infecções Relacionadas à Prótese/cirurgia , Infecções Relacionadas à Prótese/etiologia , Estudos Retrospectivos , Idoso , Prótese de Quadril/efeitos adversos , Resultado do Tratamento , Desenho de Prótese , Falha de PróteseRESUMO
PURPOSE: The vertebral bone quality (VBQ) score based on magnetic resonance imaging (MRI) was introduced as a bone quality marker in the lumbar spine. Prior studies showed that it could be utilized as a predictor of osteoporotic fracture or complications after instrumented spine surgery. The objective of this study was to evaluate the correlation between VBQ scores and bone mineral density (BMD) measured by quantitative computer tomography (QCT) in the cervical spine. METHODS: Preoperative cervical CT and sagittal T1-weighted MRIs from patients undergoing ACDF were retrospectively reviewed and included. The VBQ score in each cervical level was calculated by dividing the signal intensity of the vertebral body by the signal intensity of the cerebrospinal fluid on midsagittal T1-weighted MRI images and correlated with QCT measurements of the C2-T1 vertebral bodies. A total of 102 patients (37.3% female) were included. RESULTS: VBQ values of C2-T1 vertebrae strongly correlated with each other. C2 showed the highest VBQ value [Median (range) 2.33 (1.33, 4.23)] and T1 showed the lowest VBQ value [Median (range) 1.64 (0.81, 3.88)]. There was significant weak to moderate negative correlations between and VBQ Scores for all levels [C2: p < 0.001; C3: p < 0.001; C4: p < 0.001; C5: p < 0.004; C6: p < 0.001; C7: p < 0.025; T1: p < 0.001]. CONCLUSION: Our results indicate that cervical VBQ scores may be insufficient in the estimation of BMDs, which might limit their clinical application. Additional studies are recommended to determine the utility of VBQ and QCT BMD to evaluate their potential use as bone status markers.
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Densidade Óssea , Tomografia Computadorizada por Raios X , Humanos , Feminino , Masculino , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Imageamento por Ressonância Magnética , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Vértebras LombaresRESUMO
OBJECTIVE: Radiotherapy is an important component of soft tissue sarcoma management. Radiation osteitis is a common radiographic finding identified in the setting of radiotherapy on magnetic resonance imaging (MRI). This study aims to identify the incidence of radiation osteitis in patients who received radiotherapy for soft tissue sarcoma and if a further workup, including a biopsy, was performed for concerning MRI findings. MATERIALS AND METHODS: Medical records of patients with soft tissue sarcoma who received radiotherapy from 2008 to 2020 were retrospectively reviewed. Patients with at least one MRI of the sarcoma site following radiotherapy and information regarding radiotherapy treatments were included. MRIs of these patients were reviewed for the presence of radiation osteitis by two musculoskeletal radiologists. The clinical course of these patients including biopsy for concerning MRI findings, local recurrence, and metastasis was recorded. RESULTS: Thirty soft tissue sarcoma patients who received radiation for soft tissue sarcoma were included. Radiation osteitis was present in 18 patients. The time to osteitis present on MRI following radiotherapy completion was a median of 4.5 months. Biopsy for concerning MRI findings was performed in eight patients, five for local recurrence, and three for regional osseous metastasis. Three patients had confirmed osseous metastases. CONCLUSION: Although radiation osteitis is often a benign imaging finding, it can be difficult to discern these lesions from potentially malignant sites of disease. We recommend multidisciplinary management of soft tissue sarcoma at sarcoma centers to appropriately identify benign from malignant lesions and decide the necessity of a biopsy.
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Osteíte , Sarcoma , Neoplasias de Tecidos Moles , Humanos , Osteíte/diagnóstico por imagem , Incidência , Estudos Retrospectivos , Sarcoma/diagnóstico por imagem , Sarcoma/radioterapia , Neoplasias de Tecidos Moles/diagnóstico por imagem , Neoplasias de Tecidos Moles/radioterapiaRESUMO
BACKGROUND: The safety of postoperative colonoscopy and endoscopy following total joint arthroplasty (TJA) remains largely unknown. The objective of this study was to characterize the effect of gastrointestinal endoscopic procedures after TJA on the risk of postoperative periprosthetic joint infection (PJI). METHODS: Using a large national database, patients who underwent an endoscopic procedure (colonoscopy or esophagogastroduodenoscopy (EGD)) within 12 months after primary TJA were identified and matched in a 1:1 fashion based on procedure (primary total knee arthroplasty (TKA) versus total hip arthroplasty (THA)), age, sex, Charlson Comorbidity Index (CCI), and smoking status with patients who did not undergo endoscopy. A total of 142,055 patients who underwent endoscopy within 12 months following TJA (96,804 TKAs and 45,251 THAs) were identified and matched. The impact of timing of endoscopy relative to TJA on postoperative outcomes was assessed. Preoperative comorbidity profiles and 1-year complications were compared. Statistical analyses included Chi-squared tests and multivariate logistic regressions with outcomes considered significant at P < .05. RESULTS: Multivariate analyses revealed that endoscopy within 2 months following TKA and 1 month of THA was associated with a significantly increased odds of periprosthetic joint infection (odds ratio (OR): 1.29 [1.08-1.53]; P = .004; OR: 1.41 [1.01-1.90]; P = .033, respectively). Patients who underwent endoscopy greater than 2 months from the timing of their TKA and 1 month from THA were not at significantly greater risk of developing PJI. CONCLUSION: These data suggest that invasive endoscopic procedures should be delayed if possible by at least 2 months following TKA and 1 month following THA to minimize the risk of PJI.
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Artrite Infecciosa , Artroplastia de Quadril , Artroplastia do Joelho , Infecções Relacionadas à Prótese , Humanos , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/complicações , Estudos Retrospectivos , Artroplastia do Joelho/efeitos adversos , Artroplastia de Quadril/efeitos adversos , Artrite Infecciosa/cirurgia , Endoscopia Gastrointestinal/efeitos adversos , Fatores de RiscoRESUMO
PURPOSE: To systematically screen the literature in an effort to critically examine the effect of tranexamic acid (TXA) in patients undergoing arthroscopic surgery, specifically pertaining to pain, blood loss, length of surgery, and both major and minor complications. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines, 3 databases (MEDLINE, EMBASE, and Cochrane) were searched April 2020 and screened in duplicate using inclusion and exclusion criteria for studies on the given subject. Study findings were reviewed, and meta-analysis was then performed on sufficiently congruent data using a random-effects model. RESULTS: There were 7 eligible randomized controlled trials, with 724 total patients, undergoing anterior cruciate ligament reconstruction (4 studies, 537 patients), meniscectomy (1 study, 45 patients), femoroacetabular impingement (1 study, 70 patients), or rotator cuff repair (1 study, 72 patients). The mean age throughout the included studies was 33.9 years, with a mean of 27.7% female patients. There was a 1% drop out rate at 3 months postoperatively. There were significantly lower visual analog scale scores at 2 weeks postoperatively in the TXA groups (mean difference: -1.65, 95% confidence interval [CI] -3.41 to 0.10, P = .06, I2 = 97%). Furthermore, there was a significant decrease in the number of patients requiring joint aspiration in the TXA groups (risk ratio 0.27, 95% CI 0.12-0.56, I2 = 0%, P = .0006). The drainage output in TXA groups was also significantly decreased (mean difference: -61.14 mL, 95% CI -104.43 to -17.85, I2 = 94%, P = .006). Furthermore, there was a statistically significant decrease in hemarthrosis grade (Coupens & Yates) at 2 weeks postoperatively (Mean difference: -0.76, 95% CI -0.97 to -0.54, I2 = 0%, P < .0001). Finally, there was no significant difference in operating time, across all studies (Mean difference: 0.53, 95% CI -3.43 to 4.50, I2 = 57%, P < .79). The use of TXA showed no increased incidence of deep vein thrombosis, infection, arthrofibrosis, or other major complications or adverse reactions between the TXA and control groups. CONCLUSIONS: This systematic review and meta-analysis of randomized controlled trialss found that the use of TXA significantly improves pain scores up to 6 weeks postoperatively, decreases drainage output, decreases the need for joint aspirations, decreases incidence of hemarthrosis, increases visual clarity and technical ease, and has no increased incidence of other complications, at no loss to operative time. These findings indicate that TXA may be a useful adjunct in arthroscopic knee and shoulder surgery. LEVEL OF EVIDENCE: II.
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Reconstrução do Ligamento Cruzado Anterior , Ácido Tranexâmico , Adulto , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Artroscopia/efeitos adversos , Perda Sanguínea Cirúrgica/prevenção & controle , Feminino , Hemartrose/etiologia , Humanos , Masculino , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Ácido Tranexâmico/uso terapêuticoRESUMO
PURPOSE: High body mass index (BMI) is positively correlated with bone mineral density (BMD) in healthy adults; however, the effect of BMI on regional segmental BMDs in the axial skeleton is unclear. In addition, obese patients often have glucose intolerance and patients with lumbar spine pathology commonly have a history of epidural steroid injections (ESIs). The purpose of this study is to evaluate the effect of these patient factors on regional differences in BMD measured by quantitative computed tomography (QCT) in a lumbar fusion patient cohort. METHODS: The data were obtained from a database comprised of clinical and preoperative CT data from 296 patients who underwent primary posterior lumbar spinal fusion from 2014 to 2017. QCT-vBMDs of L1 to L5, S1 body, and sacral alae were measured. Multivariate linear regression analyses were performed with setting vBMDs as the response variables. As explanatory variables, age, sex, race, current smoking, categorized BMI, diabetes, and ESI were chosen a priori. RESULTS: A total of 260 patients were included in the final analysis. Multivariate analyses demonstrated that obese and morbidly obese patients had significantly higher vBMD in the sacral alae (SA). Diabetes showed independent positive associations with vBMDs in L1, L2, and the SA. Additionally, patients with an ESI history demonstrated significantly lower vBMD in the SA. CONCLUSIONS: Our results demonstrate that obesity, diabetes, and epidural steroids affected vBMD differently by lumbosacral spine region. The vBMD of the SA appeared to be more sensitive to various patient factors than other lumbar regions.
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Diabetes Mellitus , Obesidade Mórbida , Adulto , Densidade Óssea , Humanos , Vértebras Lombares/diagnóstico por imagem , Esteroides/efeitos adversos , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: Quantitative computed tomography (QCT) is an alternate imaging method to dual X-ray absorptiometry to measure bone mineral density (BMD). One advantage of QCT is that it allows site-specific volumetric BMD (vBMD) measurements in a small region. In this study, we utilized site-specific, endplate vBMD (EP-vBMD) as a potential predictive marker of severe cage subsidence in standalone lateral lumbar interbody fusion (SA-LLIF) patients and conducted a retrospective comparative study between EP-vBMD and trabecular vBMDs (Tb-vBMD) in the vertebrae. METHODS: Patients undergoing SA-LLIF from 2007 to 2016 were retrospectively reviewed. EP-vBMD was defined as the average of the upper and lower endplate volumetric BMDs measured in cortical and trabecular bone included in a 5-mm area of interest beneath the cage contact surfaces. We compared Tb-vBMDs and EP-vBMDs between disk levels that had severe cage subsidence and levels with no severe subsidence. RESULTS: Both EP-vBMD and Tb-vBMD could be measured in 210 levels of 96 patients. Severe cage subsidence was observed in 58 levels in 38 patients. Median (IQR) Tb-vBMD was 120.5 mg/cm3 (100.8-153.7) in the non-severe subsidence group and 117.9 mg/cm3 (90.6-149.5) in the severe subsidence group (p = 0.393), whereas EP-vBMD was significantly lower in the severe subsidence group than the non-severe subsidence group (non-severe subsidence 257.4 mg/cm3 (216.3-299.4), severe subsidence 233.5 mg/cm3 (193.4-273.3), p = 0.026). CONCLUSION: We introduced a novel site-specific vBMD measurement for cage subsidence risk assessment. Our results showed that EP-vBMD was a reproducible measurement and appeared more predictive for severe cage subsidence after SA-LLIF than Tb-vBMD. These slides can be retrieved under Electronic Supplementary Material.
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Densidade Óssea , Fusão Vertebral , Humanos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Região Lombossacral , Estudos RetrospectivosRESUMO
BACKGROUND: To the authors' knowledge, social network status in adolescent and young adult (AYA) cancer survivors has not been adequately studied to date. The authors developed and validated a functional social network index (FSNI) for AYA survivors, and compared its performance with that of 2 traditional indices (density and betweenness centrality). METHODS: A total of 102 AYA survivors and 102 noncancer controls who were matched for age, sex, and race were recruited from an Internet panel. Each participant reported relationships with up to 25 close friends and/or relatives. The authors developed a FSNI with reported marital status, contact frequency with friends/relatives, available resources for emotional and tangible support, and available resources for physical activity and weight management advice. Linear regression was used to analyze associations between the FSNI and cancer diagnoses, treatments, and coping skills. RESULTS: Based on the FSNI, survivors were found to have more available resources for emotional support (beta [b] = 3.02; P = .003), tangible support (b = 4.17; P<.001), physical activity advice (b = 3.94; P<.001), and weight management advice (b = 4.10; P<.001) compared with noncancer controls. Survivors of lymphoma had the largest FSNI, whereas survivors of central nervous system malignancies had the smallest (b = 2.77; P = .02). A higher FSNI was associated with better coping skills: less denial (b = 0.10; P = .01), using emotional support (b = 0.08; P = .04), using instrumental support (b = 0.12; P<.001), less behavioral disengagement (b = 0.08; P = .04), venting of emotions (b = 0.10; P = .004), positive reframing (b = 0.12; P = .003), planning for the future (b = 0.08; P = .03), and religious engagement (b = 0.16; P<.001). Density and betweenness centrality indices demonstrated neither significant differences in social networks between cancer survivors and controls (all P values >.05) nor significant associations with coping skills (all P values >.05). CONCLUSIONS: The FSNI appears to provide a better social network assessment for AYA cancer survivors than traditional indices. Cancer 2018;124:2220-7. © 2018 American Cancer Society.
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Sobreviventes de Câncer/psicologia , Quimiorradioterapia/efeitos adversos , Neoplasias/psicologia , Redes Sociais Online , Psicometria/métodos , Adaptação Psicológica/efeitos dos fármacos , Adaptação Psicológica/efeitos da radiação , Adolescente , Adulto , Emoções , Feminino , Humanos , Masculino , Neoplasias/terapia , Qualidade de Vida , Apoio Social , Adulto JovemRESUMO
PURPOSE: To compare importance ratings of patient-reported outcomes (PROs) items from the viewpoints of childhood cancer survivors, parents, and clinicians for further developing short-forms to use in survivorship care. METHODS: 101 cancer survivors, 101 their parents, and 36 clinicians were recruited from St. Jude Children's Research Hospital. Participants were asked to select eight items that they deemed useful for clinical decision making from each of the four Patient-Reported Outcomes Measurement Information System Pediatric item banks. These item banks were pain interference (20 items), fatigue (23 items), psychological stress (19 items), and positive affect (37 items). RESULTS: Compared to survivors, clinicians rated more items across four domains that were statistically different than did parents (23 vs. 13 items). Clinicians rated five items in pain interference domain (ORs 2.33-6.01; p's < 0.05) and three items in fatigue domain (ORs 2.22-3.80; p's < .05) as more important but rated three items in psychological stress domain (ORs 0.14-0.42; p's < .05) and six items in positive affect domain (ORs 0.17-0.35; p's < .05) as less important than did survivors. In contrast, parents rated seven items in positive affect domain (ORs 0.25-0.47; p's < .05) as less important than did survivors. CONCLUSIONS: Survivors, parents, and clinicians viewed importance of PRO items for survivorship care differently. These perspectives should be used to assist the development of PROs tools.
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Sobreviventes de Câncer/psicologia , Neoplasias/mortalidade , Medidas de Resultados Relatados pelo Paciente , Adolescente , Criança , Feminino , Humanos , Masculino , Qualidade de Vida/psicologia , Inquéritos e QuestionáriosRESUMO
PURPOSE: Search for evidence pertaining to the effectiveness of drains used in spinal surgeries. METHOD: PubMed and EMBASE databases were searched for articles pertaining to the use of drains in all types of spinal surgery. The bibliographies of relevant studies were searched for additional papers that met the initial inclusion criteria. Level I and II studies were scored according to guidelines in the Cochrane Collaboration Back Review Group. We utilised the Population, Intervention, Comparison, Outcomes and Study design (PICOS) method to define our study eligibility criteria. RESULTS: Nineteen papers were identified: four level I studies, eight level III studies and seven level IV studies. The four level I, involving the randomization of patients into 'drain' and 'non-drain' groups, identified a total of 363 patients. Seven of the eight level III retrospective studies concluded that the use of drains did not reduce complications. Two of the seven level IV studies agreed with this conclusion. The remaining five level IV studies reported the benefits of lumbar drainage following dural tears. CONCLUSIONS: There is a paucity of published literature on the use of drains following spinal surgery. This is the first study to assess the evidence for the benefits of drains post-operatively in spinal surgery. The identified studies have shown that drains do not reduce the incidence of complications in anterior cervical discectomy and fusion, one and two level posterior cervical fusions, lumbar laminectomies, lumbar decompressions or discectomies and posterior spinal fusion for adolescent scoliosis. Further level I and II studies are needed.
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Drenagem/estatística & dados numéricos , Procedimentos Ortopédicos , Coluna Vertebral/cirurgia , Humanos , Procedimentos Ortopédicos/métodos , Procedimentos Ortopédicos/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologiaRESUMO
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare relapsing-remitting autoimmune polyneuropathy that targets peripheral nerves and has been associated in the literature with sarcoidosis. The goal of this study is to report the clinical case of a 61-year-old man with sarcoidosis who developed CIDP following lumbar spine surgery. The patient presented at their clinic visit with lumbar back pain and underwent a dome laminoplasty at L2-3, L3-4, and L4-5 with no known complications. Approximately four hours postoperatively, he developed bilateral lower extremity weakness most prominent along the tibialis anterior and extensor hallucis longus (L4-S1) as well as saddle anesthesia. An MRI revealed no acute changes concerning compression. Electromyography (EMG) was performed six months postoperatively, which revealed absent F waves along the peroneal and tibial nerves as well as decreased amplitude consistent with an underlying axonal neuropathy. He was referred to a neurologist for a second opinion where a diagnosis of CIDP was made. Intravenous immune globulin treatment was initiated, and the patient felt improvement in his symptoms. This case highlights the association between sarcoidosis and CIDP and discusses the pathophysiology of the disease. In patients with sarcoidosis and weakness following lumbar surgery with a negative MRI, CIDP should be on the differential.
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INTRODUCTION: Periprosthetic joint infection (PJI) remains a serious complication after total knee arthroplasty (TKA). While debridement, antibiotics, and implant retention (DAIR) are considered for acute PJI, success rates vary. This study aims to assess a new scoring system's accuracy in predicting DAIR success. METHODS: 119 TKA patients (2008-2019) diagnosed with PJI who underwent DAIR were included for analysis. Data were collected on demographics, laboratory values, and clinical outcomes. This was used for validation of the novel classification system consisting of PJI acuteness, microorganism classification, and host health for DAIR indication. Statistical analysis was carried out using SPSS programming. RESULTS: Mean follow-up was 2.5 years with an average age of 65.5 ± 9.1 years, BMI of 31.9 ± 6.2 kg/m2, and CCI of 3.04 ± 1.8. Successful infection eradication occurred in 75.6% of patients. The classification system demonstrated 61.1% sensitivity, 72.4% specificity, and 87.3% positive predictive value (PPV) when the DAIR cutoff was a score less than 6. For a cutoff of less than 8, sensitivity was 100%, specificity was 37.9%, and PPV was 83.3%. CONCLUSIONS: To date, no consensus exists on a classification system predicting DAIR success. This novel scoring system, with high PPV, shows promise. Further refinement is essential for enhanced predictive accuracy.
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PURPOSE: Radiation induced changes in bone such as radiation osteitis are commonly identified on magnetic resonance imaging (MRI) in patients who receive radiotherapy for soft tissue sarcoma (STS) management. This study proposes a novel MRI scoring system to assess osseous lesions and predict potential for malignancy based on MRI score in STS patients who received radiotherapy. METHODS: The MRI score consisted of 3 parameters: morphology, signal intensity, and progression. Interobserver reliability between MRI scores were analyzed with Cohen's kappa coefficient. Receiver operating curve (ROC) analysis was performed to determine a predictive MRI score for malignancy. RESULTS: 156 MRI's from 30 STS patients who received radiotherapy were retrospectively reviewed. Two (6.7 %) patients developed regional osseous metastasis identified on MRI. The kappa coefficient of the scoring system was 0.785 demonstrating substantial interobserver agreement (p < 0.001). ROC analysis demonstrated that the optimal cut-off value for malignant lesion on MRI was 5.5 (area under the curve 0.998; p < 0.001). CONCLUSIONS: This novel MRI scoring system recommends lesions with a score of six and above to be biopsied to distinguish if malignancy is present. We believe this scoring system can be utilized by multidisciplinary care teams to guide clinical recommendations for patients with STS and MRI findings concerning for malignancy versus radiation induced changes.
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Neoplasias Ósseas , Imageamento por Ressonância Magnética , Sarcoma , Humanos , Feminino , Masculino , Sarcoma/diagnóstico por imagem , Sarcoma/radioterapia , Imageamento por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/radioterapia , Adulto , Idoso , Reprodutibilidade dos Testes , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Neoplasias de Tecidos Moles/diagnóstico por imagem , Neoplasias de Tecidos Moles/radioterapia , Sensibilidade e Especificidade , Neoplasias Induzidas por Radiação/diagnóstico por imagem , Neoplasias Induzidas por Radiação/etiologiaRESUMO
INTRODUCTION: Periprosthetic femoral fractures (PPFFs) represent an important healthcare problem, with a rising incidence noted due to an increase in the number of arthroplasty surgeries being performed. There is a current lack of national consensus as to how these complex, often frail patients are managed. AIMS: Our primary aim was to present the epidemiology of PPFFs in England and Wales over the first two years of data collection by the National Hip Fracture Database (NHFD). Secondary aims included how well the NHFD Key Performance Indicators (KPIs) are met for PPFF patients, whether centres reporting a higher burden of PPFF patients are more likely to meet KPIs compared to lower volume centres, and to also identify if regional variation in care for these patients exist. METHODS: Patients aged 60 years or over, admitted to any acute hospital in England or Wales with a PPFF within the period 1st January 2020 to 31st December 2021 were included. Fractures were classified using the Vancouver system. The primary outcome of interest was the incidence of PPFF in England and Wales. Secondary outcomes included i) geographical distribution, ii) pattern of injury, iii) treatment received, iv) KPI performance nationally, v) KPI performance by top 5 highest volume hospitals vs the rest, vi) KPI performance by region and vii) KPI performance compared with native hip fracture patients. RESULTS: A total of 5,566 PPFFs were reported during our study period. A 31 % increase in cases was seen between 2020 and 2021 (2,405 to 3,161). The South-West of England reported the highest burden of PPFFs (14 % of all cases reported in 2021). Vancouver B subtypes were most common around hip replacements (62 %) and C subtype around knee replacements (55 %). A total of 4,598 patients (82.6 %) underwent operative management. There was regional variation in KPI attainment. When compared to KPI attainment for native hip fractures PPFF care under performed in most regions and domains. High volume PPFF centres were not associated with improved attainment of KPIs. CONCLUSION: We have described the incidence, nature, and management of PPFF at national and regional levels using routinely collected NHFD data. Both numerically and due to case complexity, PPFF are a considerable challenge to patients and health services alike. This epidemiology is not captured by other existing datasets and increased case contribution to the NHFD is encouraged to improve understanding and enable prioritisation and delivery of further care and research.
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Artroplastia de Quadril , Bases de Dados Factuais , Fraturas Periprotéticas , Humanos , País de Gales/epidemiologia , Inglaterra/epidemiologia , Feminino , Masculino , Fraturas Periprotéticas/epidemiologia , Fraturas Periprotéticas/cirurgia , Idoso , Incidência , Idoso de 80 Anos ou mais , Pessoa de Meia-Idade , Fraturas do Fêmur/cirurgia , Fraturas do Fêmur/epidemiologia , Fraturas do Quadril/cirurgia , Fraturas do Quadril/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVES: Undifferentiated pleomorphic sarcoma (UPS) is a frequent subtype within the heterogeneous group of soft tissue sarcomas (STS). The use of radiotherapy (RT) has become an important component of a multimodal approach to treating STS. Key studies have demonstrated that the addition of RT improves rates of local control in STS, though the effect on overall survival (OS) is less clear. Furthermore, there is very limited and conflicting evidence regarding effect of RT on overall survival in UPS. The purposes of this investigation were to examine the association between RT and OS in UPS patients undergoing surgical resection and to determine independent prognostic indicators of OS in this patient population. METHODS: This was a retrospective review of patients who underwent surgical treatment for primary UPS from 1993 to 2021. Associations between RT and OS were analyzed with Kaplan-Meier curves and log-rank testing. Cox proportional hazards regression analysis was used to determine independent prognostic factors of OS. RESULTS: One hundred and fourteen patients who underwent surgical resection of primary UPS were included in the study. Ninety-six (84.2 %) patients received RT perioperatively. Use of RT was associated with improved OS on log-rank testing (hazard ratio (HR) 0.20; 95 % confidence interval (CI) 0.11-0.36; p < 0.001). On multivariate analysis, RT was an independent predictor of improved OS (HR 0.18; 95 % CI 0.09-0.39; p < 0.001) while metastasis at presentation (HR 4.82; 95 % CI 2.26-10.27; p < 0.001) and older age (HR 1.92; 95 % CI 1.20-3.36; p = 0.02) were predictive of decreased OS. Use of RT was not significantly associated with a lower rate of local recurrence in our cohort (p = 0.49). CONCLUSIONS: Use of RT in combination with surgery was an independent prognostic indicator of improved overall survival in UPS patients. Older age and metastasis at presentation were associated with worse overall survival. Based on this and other available studies, treatment for UPS should involve limb-sparing resection when feasible with RT to ensure optimal survival.
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Cerebral palsy (CP) is a neurodevelopmental condition that can result in altered gait biomechanics, joint dysfunction, and imbalance. The complications associated with total knee arthroplasty (TKA) in patients with CP have not yet been well described. Therefore, our analysis sought to compare the 90-day and 2-year complications following TKA in patients with and without CP. The PearlDiver Mariner database was utilized to identify patients with CP undergoing primary TKA between 2010 and 2020. This cohort was matched 1:4 to a control cohort without neurodegenerative disorders based on age, sex, Elixhauser Comorbidity Index (ECI), tobacco use, obesity, and diabetes. A total of 3,257 patients (657 CP patients 2,600 controls) were included in our final analysis. A multivariable logistic regression analysis was utilized to determine the risk of CP on medical and surgical complications at 90 days and all-cause revision rates at 2 years. Patients with CP had an increased risk of acute kidney injury (odds ratio [OR]: 1.66; 95% confidence interval [CI]: 1.07-2.5; p = 0.019), pneumonia (OR: 5.63; 95% CI: 3.69-8.67; p < 0.001), urinary tract infection (OR: 5.01; 95% CI: 3.85-6.52; p < 0.001), and transfusion (OR: 2.21; 95% CI: 1.50-3.23; p < 0.001). CP patients additionally had a higher incidence of emergency department (ED) visits (OR: 5.24; 95% CI: 3.76-7.32; p < 0.001) and readmissions (OR: 5.24; 95% CI: 2.57-4.96; p < 0.001). There were no differences in rates of periprosthetic joint infection (PJI; OR: 1.23; 95% CI: 0.69-2.10; p = 0.463), surgical site infection (SSI; OR: 0.51; 95% CI: 0.12-1.46; p = 0.463), and reoperation (OR: 1.35; 95% CI: 0.71-2.43; p = 0.339) at 90 days postoperatively. The all-cause revision rates at 2 years were comparable (OR: 1.02; 95% CI: 0.67-1.51; p = 0.927). In this database review, we found that CP patients have a higher risk of medical complications in the acute postoperative period following TKA. The 90-day surgical complication and 2-year revision rates in CP patients were comparable to matched controls.
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PURPOSE: Machine learning (ML) models have been used to predict cancer survival in several sarcoma subtypes. However, none have investigated extremity leiomyosarcoma (LMS). ML is a powerful tool that has the potential to better prognosticate extremity LMS. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for cases of histologic extremity LMS (n = 634). Patient, tumor, and treatment characteristics were recorded, and ML models were developed to predict 1-, 3-, and 5-year survival. The best performing ML model was externally validated using an institutional cohort of extremity LMS patients (n = 46). RESULTS: All ML models performed best at the 1-year time point and worst at the 5-year time point. On internal validation within the SEER cohort, the best models had c-statistics of 0.75-0.76 at the 5-year time point. The Random Forest (RF) model was the best performing model and used for external validation. This model also performed best at 1-year and worst at 5-year on external validation with c-statistics of 0.90 and 0.87, respectively. The RF model was well calibrated on external validation. This model has been made publicly available at https://rachar.shinyapps.io/lms_app/ CONCLUSIONS: ML models had excellent performance for survival prediction of extremity LMS. Future studies incorporating a larger institutional cohort may be needed to further validate the ML model for LMS prognostication.
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Robotic Roux-en-Y gastric bypass (RRYGB) is an innovative alternative to traditional laparoscopic approaches. Literature has been published investigating its safety/efficacy; however, the quality of reporting is uncertain. This systematic review used the Idea, Development, Exploration, Assessment and Long-term follow-up (IDEAL) framework to assess the reporting quality of available literature. A narrative summary was formulated, assessing how comprehensively governance/ethics, patient selection, demographics, surgeon expertise/training, technique description and outcomes were reported. Forty-seven studies published between 2005 and 2024 were included. There was incomplete/inconsistent reporting of governance/ethics, patient selection, surgeon expertise/training and technique description, with heterogenous outcome reporting. RRYGB reporting was poor and did not align with IDEAL guidance. Robust prospective studies reporting findings using IDEAL/other guidance are required to facilitate safe widespread adoption of RRYGB and other surgical innovations.
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Derivação Gástrica , Obesidade Mórbida , Procedimentos Cirúrgicos Robóticos , Humanos , Derivação Gástrica/normas , Procedimentos Cirúrgicos Robóticos/normas , Obesidade Mórbida/cirurgia , Laparoscopia/normas , Resultado do Tratamento , Seleção de Pacientes , FemininoRESUMO
OBJECTIVES: To evaluate a population of children with non-refluxing primary megaureter (NRPM), we investigated spontaneous resolution of ureteral dilation and the pattern (proximal to distal or distal to proximal) in which it occurs. METHODS: From our prospectively collected prenatal hydronephrosis (HN) database (0-24 months, 2008-2017), selecting those with NRPM (n = 92). We excluded patients who underwent surgery (n = 20), children with <6 months follow-up (n = 2) and without a voiding cystourethrogram (VCUG) (n = 4). Images were segregated into 198 ureteric segments (proximal/mid/distal). We defined resolution as Society for Fetal Urology (SFU) (0/1), anteroposterior diameter (APD) <10 mm, and ureteric dilatation <5 mm. Descriptive statistics and Kaplan-Meier curves were created for time-to-resolution analyses. RESULTS: Of 66 patients and 198 ureteral segments, median age at presentation was 2 months (0-12), 83% were male (33% circumcised). Mean APD at baseline was 11 ± 4 mm, and 79% had (SFU 3/4) HN. Mean dilatation of ureteral segments (mm) at baseline was: 9 ± 2 proximal, 9 ± 2 mid, and 11 ± 3 distal. At a median follow-up time of 26 (7-83) months, dilation of 55 (83%) proximal, 48 (72%) mid, and 22 (33%) distal ureteric segments had resolved. Overall, HN resolution occurred in 76% of patients. Resolution rates were similar for proximal/mid-ureters (83% vs 72%; P = .20); however, they were significantly different from distal segments (83% proximal vs 33% distal; 72% mid vs 33% distal, P <.01). CONCLUSION: Our data suggest that spontaneous resolution of NRPM follows a proximal to distal progression. Distal ureteric dilatation takes up to 10 months longer to resolve compared to that of proximal and mid-ureteric segments, as well as that of the renal pelvis.
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Hidronefrose , Ureter , Obstrução Ureteral , Criança , Gravidez , Feminino , Humanos , Masculino , Lactente , Recém-Nascido , Pelve Renal , Ureter/diagnóstico por imagem , Ureter/cirurgia , Dilatação Patológica , Estudos RetrospectivosRESUMO
Aims: The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement. Methods: This work used data freely available from the National Hip Fracture Database (NHFD) facilities survey in 2021, which asked 21 questions about the care of patients with PPFFs, and nine relating to clinical decision-making around a hypothetical case. Results: Of 174 centres contributing data to the NHFD, 161 provided full responses and 139 submitted data on PPFF. Lack of resources was cited as the main reason for not submitting data. Surgeon (44.6%) and theatre (29.7%) availability were reported as the primary reasons for surgical delay beyond 36 hours. Less than half had a formal process for a specialist surgeon to operate on PPFF at least every other day. The median number of specialist surgeons at each centre was four (interquartile range (IQR) 3 to 6) for PPFF around both hips and knees. Around one-third of centres reported having one dedicated theatre list per week. The routine discussion of patients with PPFF at local and regional multidisciplinary team meetings was lower than that for all-cause revision arthroplasties. Six centres reported transferring all patients with PPFF around a hip joint to another centre for surgery, and this was an occasional practice for a further 34. The management of the hypothetical clinical scenario was varied, with 75 centres proposing ORIF, 35 suggested revision surgery and 48 proposed a combination of both revision and fixation. Conclusion: There is considerable variation in both the organization of PPFF services England and Wales, and in the approach taken to an individual case. The rising incidence of PPFF and complexity of these patients highlight the need for pathway development. The adoption of networks may reduce variability and improve outcomes for patients with PPFF.