RESUMEN
BACKGROUND: Although hinged prostheses have been used successfully in complex revision total knee arthroplasty (TKA), concerns exist regarding early failure due to aseptic loosening and other mechanical complications. The use of metaphyseal cones and hybrid cement fixation have been studied in unlinked constrained primary or revision TKA, but their impact on the survivorship of hinged prostheses has yet to be investigated. METHODS: We identified a consecutive series of 164 hinged prostheses and collected data on demographics, indications, complications, and re-revisions in patients who had fully cemented versus hybrid stems, with and without metaphyseal cones. A multivariate analysis was performed to identify independent variables associated with re-revision as the primary end point. RESULTS: In total, 84 patients (51.2%) had fully cemented stems, and 80 patients (48.8%) had hybrid stems. Cones were used in 73 patients (44.5%). At a mean follow-up of 3.4 ± 2.2 years, 42 patients underwent re-revision (25.8%), most commonly for infection (12.2%), followed by loosening (6.7%) and periprosthetic fracture (3.7%). Patients who had fully cemented stems had lower re-revision rates than hybrid fixation constructs (19 versus 26%, P = .043). Using multivariable regression, a construct with hybrid fixation with cones (odds ratio = 2.39; P = .037) was an independent risk factor for failure. Utilization of cones alone did not have an effect on re-revision rates at 3.4-year follow-up. CONCLUSIONS: While we found no difference with the use of cones, patients undergoing revision TKA with a hinge prosthesis and fully cemented stems had better overall survivorship than hybrid stems.
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Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Diseño de Prótesis , Falla de Prótesis , Reoperación , Humanos , Artroplastia de Reemplazo de Rodilla/instrumentación , Artroplastia de Reemplazo de Rodilla/métodos , Reoperación/estadística & datos numéricos , Femenino , Masculino , Anciano , Persona de Mediana Edad , Resultado del Tratamiento , Estudios Retrospectivos , Cementos para Huesos , Anciano de 80 o más Años , Estudios de SeguimientoRESUMEN
CASE: A 74-year-old man presented with septic shock with infection of his heart transplant and bilateral prosthetic knee joints simultaneously. He underwent bilateral knee resection arthroplasties with placement of articulating spacers. At 3-year follow-up, the patient was alive and ambulating independently. CONCLUSION: This case represents the first report of bilateral hematogenous prosthetic knee infections associated with concomitant enterococcal endocarditis of a heart transplant treated successfully and definitively with radical debridement and placement of articulating spacer with regular implants.
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Artritis Infecciosa , Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Masculino , Humanos , Anciano , Antibacterianos/uso terapéutico , Reoperación , Articulación de la Rodilla/cirugía , Prótesis de la Rodilla/efectos adversos , Artritis Infecciosa/cirugíaRESUMEN
CASE: A 43-year-old woman with dermatomyositis presented with Mycobacterium avium complex (MAC) knee septic arthritis with superimposed polymicrobial infection. After poor infection control with antibiotic therapy, she underwent debridement and antibiotic cement spacer placement, followed by knee arthrodesis 6 months later. At 2-year follow-up, she had no pain and was ambulating without assistive devices. CONCLUSION: As far as we know, this is the first reported case of MAC native-knee septic arthritis successfully treated with antibiotic cement spacer followed by knee arthrodesis. This case sheds insight on treatment strategies for a rare native-knee infection.
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Artritis Infecciosa , Dermatomiositis , Infección por Mycobacterium avium-intracellulare , Adulto , Antibacterianos/uso terapéutico , Artritis Infecciosa/complicaciones , Artritis Infecciosa/tratamiento farmacológico , Artritis Infecciosa/cirugía , Artrodesis/efectos adversos , Desbridamiento , Dermatomiositis/complicaciones , Femenino , Humanos , Complejo Mycobacterium avium , Infección por Mycobacterium avium-intracellulare/complicaciones , Infección por Mycobacterium avium-intracellulare/tratamiento farmacológicoRESUMEN
BACKGROUND: Owing to COVID-19, arthroplasty fellowship programs will be required to interview virtually for the current application cycle. Unrelated to COVID-19, our arthroplasty fellowship offered the 2019-2020 interviewees the option of an in-person or virtual interview. The purpose of the present study is to compare interviewee perceptions regarding in-person vs virtual interview formats from that application cycle at a single institution. METHODS: A 17-question survey was sent to all 26 interviewees (13 in-person and 13 virtual) shortly after the rank-list submission deadline. Interviewees were asked to what extent they agreed or disagreed with several statements, ranging from whether the interview was enjoyable to whether interviewees felt they were being adequately evaluated. In this Likert scale rating system, "strongly agree" was given 5 points (more positive outlook), and "strongly disagree" was given 1 point (more negative outlook). Chi-square analyses were performed. RESULTS: Seventeen interviewees (8 in-person and 9 virtual) returned questionnaires (response rate: 65%). Both in-person and virtual interview ratings were similar when averaged across all statements (4.5 vs 4.4, P = .67). In-person and virtual ratings were also similar for each individual statement (all P > .05). On average, interviewees spent $557/in-person interview. Fifteen (88%) said virtual interviews were more convenient, and 14 (94%) said they were more cost-effective. CONCLUSION: At a single institution, perceptions on interview format, as quantified through Likert scale ratings, were similar between in-person and virtual groups. The vast majority also viewed virtual interviews as more convenient and cost-efficient. These findings have immediate implications for future fellowship application cycles.
RESUMEN
Patellar position and alignment may be measured on routine axial radiographs by various techniques; however, the agreement and reliability of such measurements with a resurfaced patella remain unknown. This study evaluated the range and reliability of lateral patellar tilt and lateral patellar displacement following total knee arthroplasty (TKA) with a resurfaced patella among three observers on 45° Merchant view in 139 TKAs. Intraclass correlation coefficient (ICCs) were used to evaluate intraobserver agreement (IOA) and inter-rater reliability (IRR). IRR was high between each of the observers for lateral patellar tilt (ICC = 0.8) and lateral patellar displacement (ICC = 0.87). IOA was also high upon repeat measurement for the same observer for lateral patellar tilt (ICC ≥ 0.90) and lateral patellar displacement (ICC ≥ 0.86). Therefore, lateral patellar tilt and lateral patellar displacement are reproducible measurements of patellar position on a Merchant axial radiograph following a well-functioning TKA with a resurfaced patella.
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Artroplastia de Reemplazo de Rodilla/métodos , Rótula/cirugía , Anciano , Humanos , Articulación de la Rodilla/cirugía , Persona de Mediana Edad , Radiografía , Reproducibilidad de los Resultados , TriazolesRESUMEN
BACKGROUND: The changing demographics of our society will lead to an increasing number of patients presenting for orthopedic surgery with increasing comorbidity. We investigated the association between comorbidity and both the risks (complications) and benefits (improved function) of total hip arthroplasty (THA) for primary hip osteoarthritis, whilst controlling for potential confounders including age. METHODS: One thousand five hundred and eighty-four patients (67.1 ± 10.6 years; 54% men) in our tertiary care orthopedic hospital completed the Oxford Hip Score before and 12 months after THA. Comorbidity was assessed using the American Society of Anesthesiologists (ASA) grade and Charlson Comorbidity Index (CCI). Details regarding perioperative complications (hospital stay plus 18 days after discharge; mean 27 ± 3 days) were extracted from the clinic information system and graded for severity. RESULTS: For ASA1, 2, and ≥3, respectively, there were 3.1%, 3.0%, and 6.6% surgical/orthopedic complications; 3.7%, 12.5%, and 27.4% general medical complications; and 6.7%, 14.5%, and 29.8% complications of either type. ASA was associated with complication severity (P < .001). In multiple regression, increasing ASA grade (OR 1.74; 95% CI, 1.33-2.29) and age (OR 1.06; 95% CI, 1.05-1.08), both showed an independent association with increased risk of a complication; CCI explained no further significant variance. CCI, but not age, was associated with the 12-month Oxford Hip Score (beta coefficient, -0.742; 95% CI, -1.130 to -0.355; P = .002) while ASA grade explained no further variance. CONCLUSION: Greater comorbidity was associated with increased odds of a complication and (independently) slightly worse patient-rated outcome 12 months after THA. Comorbidity indices can be easily obtained for all surgical patients and may assist with preoperative counseling regarding individual risks and benefits of THA.
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Artroplastia de Reemplazo de Cadera , Osteoartritis de la Cadera , Artroplastia de Reemplazo de Cadera/efectos adversos , Comorbilidad , Femenino , Humanos , Masculino , Osteoartritis de la Cadera/epidemiología , Osteoartritis de la Cadera/cirugía , Alta del Paciente , Complicaciones Posoperatorias/epidemiología , Factores de RiesgoRESUMEN
BACKGROUND: Cementation of a constrained liner is a viable option for treating instability after total hip arthroplasty (THA) when the acetabular component is well fixed and well aligned. However, concerns regarding long-term mechanical failure and recurrent instability remain. The aim of this study was to evaluate the long-term survivorship, complications, and clinical and radiographic outcomes of constrained polyethylene liners cemented into well-fixed acetabular components at the time of revision THA. METHODS: We identified 125 cases in which a constrained liner of 1 design was cemented into a retained, osseointegrated acetabular component during revision THA between 1998 and 2006. The mean patient age at revision was 70 years. Mean follow-up was 7 years. Survivorship data, risk of instability, and clinical and radiographic outcomes were analyzed. RESULTS: Survivorship free from revision for instability was 86% at 5 years and 81% at 10 years. Survivorship free from aseptic acetabular component revision was 78% at 5 years and 65% at 10 years, with the most common failure mechanism being dissociation of the constrained liner from the acetabular component. Survivorship free from revision for any reason was 76% at 5 years and 60% at 10 years. The most common complications were instability and periprosthetic joint infection, with cumulative incidences at 7 years of 18% and 11%, respectively. Harris hip scores did not significantly improve. Cup position did not affect implant survivorship or risk of dislocation. CONCLUSIONS: Cementing a constrained liner into a retained acetabular shell at the time of revision THA has durable long-term results, with 8 in 10 patients free from instability at 10 years. Aseptic acetabular survivorship was worse (65%) at 10 years, primarily due to dissociation of the constrained liner from the acetabular component. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/instrumentación , Cementación , Prótesis de Cadera , Diseño de Prótesis , Falla de Prótesis , Acetábulo , Adulto , Anciano , Anciano de 80 o más Años , Índice de Masa Corporal , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Factores de Tiempo , Resultado del TratamientoRESUMEN
Trauma, surgery, and other inflammatory conditions can lead to debilitating joint contractures. Adjunct pharmacologic modalities may permit clinical prevention and treatment of recalcitrant joint contractures. We investigated the therapeutic potential of rosiglitazone by intra-articular delivery via oligo[poly(ethylene glycol)fumarate] (OPF) hydrogels in an established rabbit model of arthrofibrosis. OPF hydrogels loaded with rosiglitazone were characterized for drug elution properties upon soaking in minimum essential media (MEM) with 10% fetal bovine serum and measurements of drug concentrations via High Performance Liquid Chromatography (HPLC). Drug-loaded scaffolds were surgically implanted into 24 skeletally mature female New Zealand White rabbits that were divided into equal groups receiving OPF hydrogels loaded with rosiglitazone (1.67 mg), or vehicle control (10 µl DMSO). After 8 weeks of joint immobilization, rabbits were allowed unrestricted cage activity for 16 weeks. Contracture angles of rabbit limbs treated with rosiglitazone showed statistically significant improvements in flexion compared to control animals (mean angles, respectively, 64.4° vs. 53.3°, p < 0.03). At time of sacrifice (week 24), animals in the rosiglitazone group continued to exhibit less joint contracture than controls (119.0° vs. 99.5°, p = 0.014). The intra-articular delivery of rosiglitazone using implanted OPF hydrogels decreases flexion contractures in a rabbit model of arthrofibrosis without causing adverse effects (e.g., gross inflammation or arthritis). Statement of Clinical Significance: Post-traumatic joint contractures are common and debilitating, with limited available treatment options. Pharmacologic interventions can potentially prevent and treat such contractures. This study is translational in that a commercially approved medication has been repurposed through a novel delivery device. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2949-2955, 2018.
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Contractura/tratamiento farmacológico , Hipoglucemiantes/administración & dosificación , Rosiglitazona/administración & dosificación , Andamios del Tejido , Animales , Células Cultivadas , Modelos Animales de Enfermedad , Evaluación Preclínica de Medicamentos , Femenino , Fibroblastos/efectos de los fármacos , Fibrosis , Humanos , Poliésteres , Polietilenglicoles , ConejosRESUMEN
BACKGROUND: The use of chemoprophylaxis to prevent thromboembolic disease after primary THA and TKA can be associated with postoperative bleeding complications. Mechanical prophylaxis has been studied as an alternative to chemoprophylaxis with greater safety in patients undergoing THA, but no data have been published comparing the safety of chemoprophylaxis versus mechanical methods for patients undergoing TKA. The risk of readmission resulting from bleeding and venous thromboembolism (VTE) has also not been determined for patients undergoing THA or TKA when treated with low-molecular-weight heparin (LMWH) alone compared with mechanical prophylaxis plus aspirin (ASA). QUESTION/PURPOSES: We sought to answer four questions: For the THA and TKA cohorts, respectively, (1) was the incidence of readmission resulting from VTE and bleeding complications higher with LMWH than mobile compression plus ASA; and (2) was the incidence of wound bleeding complications higher with LMWH than mechanical compression plus ASA? For the TKA cohort specifically, (3) was the frequency of systemic bleeding events and complications related to chemical prophylaxis higher with LMWH compared with mechanical compression plus ASA? (4) Was there a difference in symptomatic VTEs between LMWH and mechanical compression plus ASA? METHODS: Between November 2008 and April 2011, 632 patients underwent primary THA and TKA. Seventy-two patients (11%) were identified before surgery as being at high risk for VTE (31 patients) or bleeding (41 patients) and were excluded from the study. Five hundred sixty patients (89%) were considered to be at standard risk for VTE and bleeding and comprise the study cohort. Between November 2008 and November 2009, 252 patients (76 THAs, 176 TKAs) underwent THA and TKA and were treated with LMWH (5 mg dalteparin given subcutaneously daily for 14 days) and in-hospital nonmobile mechanical compression. Between November 2009 and April 2011, a total of 308 patients undergoing THA and TKA (108 THAs, 200 TKAs) were treated using a mobile compression device plus oral aspirin once daily for 2 weeks after surgery. All complications and readmissions that occurred within 6 weeks of surgery were noted. There were no differences between the VTE treatment groups with regard to age, sex, or body mass index. RESULTS: For the THA cohort, there was no difference in the frequency of readmission for a bleeding complication (wound or systemic) between the two groups (2.6% for LMWH versus 0.9% for mobile compression; p = 0.57; odds ratio [OR], 2.9). Patients undergoing TKA treated with LMWH had higher readmission rates within 6 weeks of surgery because of a bleeding complication, a wound infection, or the development of a VTE (6.8% for LMWH versus 1.5% for mobile compression; p = 0.015; OR, 4.8). For the THA cohort, there was higher wound bleeding complication frequency with LMWH (9.2% for LMWH versus 0.9% for mechanical compression; p = 0.009; OR, 10.9). Patients undergoing TKA treated with LMWH had a higher frequency of wound bleeding complications or infection (3.9% for LMWH versus 0.5% for mobile compression; p = 0.028; OR, 8.2). Patients undergoing TKA treated with LMWH had higher rates of systemic bleeding or a complication secondary to LMWH administration (2.8% for LMWH versus 0% for mobile compression; p = 0.022; OR, 12.8). No difference was noted in the rate of symptomatic VTEs between either group (for THA: 2.6% for the LMWH group versus 1.9% for the mechanical compression group; p = 1; for TKA: 1.1% versus 0%, respectively; p = 0.22). CONCLUSIONS: Based on these results, we advocate for routine use of mobile mechanical compression devices in the prevention of VTEs and complications associated with more potent chemical anticoagulants. However, more focused randomized clinical trials are needed to validate these findings. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Aspirina/efectos adversos , Dalteparina/efectos adversos , Fibrinolíticos/efectos adversos , Técnicas Hemostáticas , Heparina de Bajo-Peso-Molecular/efectos adversos , Readmisión del Paciente , Hemorragia Posoperatoria/prevención & control , Tromboembolia Venosa/prevención & control , Cicatrización de Heridas , Adulto , Anciano , Anciano de 80 o más Años , Aspirina/administración & dosificación , Dalteparina/administración & dosificación , Diseño de Equipo , Femenino , Fibrinolíticos/administración & dosificación , Técnicas Hemostáticas/efectos adversos , Técnicas Hemostáticas/instrumentación , Heparina de Bajo-Peso-Molecular/administración & dosificación , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/inducido químicamente , Hemorragia Posoperatoria/diagnóstico , Hemorragia Posoperatoria/epidemiología , Presión , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologíaRESUMEN
OBJECTIVE: To evaluate the outcomes of a single-stage surgical protocol to treat a presumed aseptic long-bone nonunion with positive intraoperative cultures obtained at the time of surgery. DESIGN: Retrospective comparative series. SETTING: Orthopaedic specialty hospital. PATIENTS AND METHODS: We retrospectively identified 77 patients with long-bone nonunions thought to be aseptic preoperatively, which grew bacteria from cultures obtained at the time of index nonunion surgery. INTERVENTION: Fifty (65%) patients underwent open debridement of the nonunion site followed by surgical stabilization through plates and screws. Twenty-seven (35%) patients underwent exchange nailing with canal reamings used for cultures. MAIN OUTCOME MEASUREMENT: Rate of radiographic union, time to clinical and radiographic union, nonunion rate after index nonunion surgery, and final union rate after revision procedures. RESULTS: Osseous union after the index nonunion surgery was achieved in 84% of the patients (65 of 77). Time to clinical union was 6.3 months (range, 1-24 months), and time to radiographic union was 7.4 months (range, 2-24 months). Eighteen percent (14 of 77 patients) did not heal after the index nonunion surgery and required additional surgeries. The final union rate after revision surgery was 99% (76 of 77 patients). CONCLUSIONS: Eighty-four percent of presumed aseptic nonunions of long-bone fractures with positive intraoperative cultures fully healed after a single-stage surgical protocol and long-term antibiotic when appropriate. When patients are diagnosed with a subclinical infected nonunion, they should be counseled about the higher likelihood of reoperation, but in most cases can expect excellent union rates after 1 additional surgery. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Fijación Interna de Fracturas/efectos adversos , Curación de Fractura/fisiología , Fracturas Óseas/cirugía , Fracturas no Consolidadas/microbiología , Fracturas no Consolidadas/cirugía , Cuidados Intraoperatorios/métodos , Adulto , Anciano , Antibacterianos/uso terapéutico , Placas Óseas , Tornillos Óseos , Estudios de Cohortes , Desbridamiento/métodos , Femenino , Fracturas del Fémur/diagnóstico por imagen , Fracturas del Fémur/cirugía , Estudios de Seguimiento , Fijación Interna de Fracturas/métodos , Fracturas Óseas/diagnóstico por imagen , Fracturas no Consolidadas/diagnóstico por imagen , Fracturas no Consolidadas/tratamiento farmacológico , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Reoperación/métodos , Estudios Retrospectivos , Medición de Riesgo , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/cirugía , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Opioids have been the mainstay of treatment in the physiologically young geriatric hip fracture patient undergoing total hip arthroplasty (THA). However opioid-related side effects increase morbidity. Regional anesthesia may provide better analgesia, while decreasing opioid-related side effects. The goal of this study was to examine the effect of perioperative continuous femoral nerve blockade with regards to pain scores, opioid-related side effects and posthospital disposition in hip fracture patients undergoing THA. METHODS: Twenty-nine consecutive geriatric hip fracture patients (22 women/7 men) underwent THA. Average follow-up was 8.3 months (6 weeks-39 months). Fifteen patients were treated with standard analgesia (SA). Fourteen patients received an ultrasound-guided insertion of a femoral nerve catheter after radiographic confirmation of a hip fracture. All complications and readmissions that occurred within 6 weeks of surgery were noted. RESULTS: Continuous femoral nerve catheter (CFNC) patients were discharged home more frequently than SA patients (43% for CFNC vs 7% for SA; P = .023). CFNC patients reported lower average pain scores preoperatively (P < .0001), on postoperative day 1 (P = .005) and postoperative day 2 (P = .037). Preoperatively, CFNC patients required 61% less morphine equivalent (P = .007). CFNC patients had a lower rate of opioid-related side effects compared with SA patients (7% vs 47%; P = .035). CONCLUSION: CFNC patients were discharged to home more frequently. Use of a CFNC decreased daily average patient-reported pain scores, preoperative opioid usage, and opioid-related side effects after THA for hip fracture. Based on these data, we recommend routine use of perioperative CFNC in hip fracture patients undergoing THA.
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Artroplastia de Reemplazo de Cadera/efectos adversos , Nervio Femoral , Fracturas de Cadera/cirugía , Bloqueo Nervioso/efectos adversos , Dimensión del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Anciano , Analgesia , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Anestesia de Conducción , Artroplastia de Reemplazo de Cadera/métodos , Catéteres , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Manejo del Dolor , Alta del Paciente , Estudios Retrospectivos , AutoinformeRESUMEN
OBJECTIVE: To evaluate the effect of continuous femoral nerve catheter (CFNC) for postoperative pain control in geriatric proximal femur fractures compared with standard analgesia (SA) treatment. DESIGN: Retrospective comparative study. SETTING: Academic Level 1 trauma center. PATIENTS/PARTICIPANTS: We retrospectively identified 265 consecutive geriatric hip fracture patients who underwent surgical treatment. INTERVENTION: One hundred forty-nine patients were treated with standard analgesia without nerve catheter whereas 116 patients received an indwelling CFNC. MAIN OUTCOME MEASUREMENT: Daily average preoperative and postoperative pain scores, daily morphine equivalent consumption, opioid-related side effects and discharge disposition. RESULTS: Patients with CFNC patients reported lower average pain scores preoperatively (1.9 ± 1.7 for CFNC vs. 4.7 ± 2 for SA; P < 0.0001), on postoperative day 1 (1.5 ± 1.6 for CFNC vs. 3 ± 1.7 for SA; P < 0.0001) and postoperative day 2 (1.2 ± 1.5 for CFNC vs. 2.6 ± 2.1 for SA; P < 0.0001). CFNC group consumed 39% less morphine equivalents on postoperative day 1 (4.4 ± 5.8 mg for CFNC vs. 7.2 ± 10.8 mg for SA; P = 0.005) and 50% less morphine equivalent on postoperative day 2 (3.4 ± 4.4 mg for CFNC vs. 6.8 ± 13 mg for SA; P = 0.105). Patients with CFNC had a lower rate of opioid-related side effects compared with patients with SA (27.5% for CFNC vs. 47% for SA; P = 0.001). More patients with CFNC were discharged to home with or without health services than patients with SA (15% for CFNC vs. 6% for SA; P = 0.023). CONCLUSION: Continuous femoral nerve catheter decreased daily average patient-reported pain scores, narcotic consumption while decreasing the rate of opioid-related side effects. Patients with CFNC were discharged to home more frequently. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Analgésicos Opioides/administración & dosificación , Nervio Femoral/diagnóstico por imagen , Fracturas de Cadera/epidemiología , Bombas de Infusión Implantables/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/epidemiología , Anciano , California/epidemiología , Cateterismo Periférico/estadística & datos numéricos , Femenino , Fracturas de Cadera/tratamiento farmacológico , Fracturas de Cadera/cirugía , Humanos , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/estadística & datos numéricos , Manejo del Dolor/métodos , Manejo del Dolor/estadística & datos numéricos , Dimensión del Dolor/efectos de los fármacos , Dolor Postoperatorio/prevención & control , Alta del Paciente , Prevalencia , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Addressing recurrent instability in patients with poor bone stock and inadequate abductor tensioning remains a challenge in revision total hip arthroplasty. One treatment method is implantation of a constrained liner. The purpose of this study was to determine clinical outcomes, redislocation rate, and revisions of a focally constrained liner in a high-risk patient cohort. METHODS: Fifty-eight hips between 2008 and 2011 underwent implantation of a focally constrained liner. Nineteen were placed concurrent with acetabular component revision and 39 were placed into a well-fixed acetabular shell. Mean age was 69 years and mean number of previous ipsilateral hip surgeries was 4.2. At mean follow-up of 3.5 years, we analyzed clinical outcomes, redislocation, and revisions. RESULTS: Mean Harris Hip Scores was 74. Fourteen hips (24%) were revised and 3 hips (5%) required reoperation at final follow-up. Eleven hips (19%) redislocated at a mean time to dislocation of 12.2 months; 31% (11 of 36 patients) that underwent modular exchange specifically for instability redislocated. Risk factors for redislocation included number of previous surgeries (P = .013), implantation of a 28 mm femoral head (hazards ratio 12.8), revision indication of instability (P = .04), and modular exchange with constrained liner implantation without acetabular shell revision (P = .01). CONCLUSION: Implantation of a focally constrained liner in revision total hip arthroplasty for recurrent instability has a high failure rate, especially with a modular exchange. Although concurrent acetabular revision had a lower redislocation rate, the decision to revise a well-fixed cup should be weighed with potential complications associated with cup revision.
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Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Prótesis de Cadera , Reoperación , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Falla de Prótesis , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Dupuytren's disease is an inherited disorder in which patients develop fibrotic contractures of the hand. Current treatment strategies include surgical excision or enzymatic digestion of fibrotic tissue. MicroRNAs, which are key posttranscriptional regulators of genes expression, have been shown to play an important regulatory role in disorders of fibrosis. Therefore in this investigation, we apply high throughput next generation RNA sequencing strategies to characterize microRNA expression in diseased and healthy palmar fascia to elucidate molecular mechanisms responsible for pathogenic fibrosis. METHODS: We applied high throughput RNA sequencing techniques to quantify the expression of all known human microRNAs in Dupuytren's and control palmar fascia. MicroRNAs that were differentially expressed between diseased and healthy tissue samples were used for computational target prediction using the bioinformatics tool ComiR. Molecular pathways that were predicted to be differentially expressed based on computational analysis were validated by performing RT-qPCR on RNA extracted from diseased and non-diseased palmar fascia biopsies. RESULTS: A comparison of microRNAs expressed in Dupuytren's fascia and control fascia identified 74 microRNAs with a 2-fold enrichment in Dupuytren's tissue, and 32 microRNAs with enrichment in control fascia. Computational target prediction for differentially expressed microRNAs indicated preferential targeting of collagens and extracellular matrix related proteins in control palmar fascia. RT-qPCR confirmed the decreased expression of microRNA targeted collagens in control palmar fascia tissues. DISCUSSION: Control palmar fascia show decreased expression of mRNAs encoding collagens that are preferentially targeted by microRNAs enriched in non-diseased fascia. Thus alterations in microRNA regulatory networks may play an important role in driving the pathogenic fibrosis seen in Dupuytren's disease via direct regulatory effects on extracellular matrix protein synthesis. CONCLUSION: Dupuytren's fascia and healthy palmar fascia can be distinguished by unique microRNA profiles, which are predicted to preferentially target collagens and other extracellular matrix proteins.
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Colágeno/genética , Contractura de Dupuytren/genética , MicroARNs/genética , Análisis de Secuencia de ARN , Biología Computacional , Secuenciación de Nucleótidos de Alto Rendimiento , HumanosRESUMEN
The results of total hip arthroplasty in 42 primary total hip arthroplasties in super-obese patients (BMI ≥ 50) were reviewed. The mean body mass index for the study group was 53.2 kg/m(2) (range 50-64). The mean preoperative Harris hip score improved from 35 to 74.8 postoperatively (P<0.001). Twenty-four of the THAs had at least one complication. At least one major complication occurred in 11 of the THAs and at least one minor complication in 14 THAs When compared to matched 2:1 control group the super-obese patient had a significantly increased risk to experience a complication (HR 5.6 , CI = 2.8-11.0). Caution should be used when proceeding with primary total hip arthroplasty with a BMI greater than 50.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Índice de Masa Corporal , Articulación de la Cadera/cirugía , Artropatías/cirugía , Obesidad Mórbida/complicaciones , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Artropatías/complicaciones , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: We observed isolated tibial component debonding from the cement in one modern primary TKA design (NexGen LPS 3° tibial tray; Zimmer, Warsaw, IN, USA). This failure mechanism is sparsely reported in the literature. QUESTIONS/PURPOSES: We (1) assessed survivorship of this tibial tray with special emphasis on debonding; (2) described clinical and radiographic features associated with tibial failure; and (3) compared patient and radiographic features of the failures with a matched cohort. METHODS: A total of 1337 primary TKAs were performed with a cemented NexGen LPS 3° tibial tray over an 11-year period. Twenty-five knees (1.9%) were revised for tibial debonding. BMI and radiographic alignment in the tibial debonding group were compared with a matched control group. Implant survivorship was assessed using tibial debonding as the end point. RESULTS: Survival free of revision from tibial debonding was 100% at 1 year and 97.8% at 5 years. The tibial failures shared a typical radiographic pattern with debonding at the cement-implant interface and subsidence into varus and flexion. We found no link between limb alignment or individual component alignment and failure because 22 of the 25 failures occurred in well-aligned knees. CONCLUSIONS: Our standardized followup of patients undergoing TKA at routine intervals allowed us to discover a higher rate of revision resulting from tibial debonding. We have discontinued the use of this particular tibial tray for primary TKA and surveillance for patients undergoing TKA continues to be warranted.