Outcome of Revision Surgery for the Idiopathic Stiff Total Knee Arthroplasty.

BACKGROUND: Idiopathic stiff total knee arthroplasty (TKA) represents one of the most challenging subsets of the stiff TKA, as the etiology is unknown and there is no consensus on the most appropriate surgical treatment modality. Therefore, the aim of this study is to report on postoperative outcomes of revision surgery for idiopathic stiff TKA. METHODS: We retrospectively reviewed 189 consecutive patients (202 knees) who underwent revision TKA for stiffness: (1) 101 knees in the idiopathic stiffness cohort and (2) 88 in the non-idiopathic stiffness cohort. In the idiopathic stiffness cohort, 42 knees underwent isolated tibial insert exchange and 59 knees underwent component revision. Perioperative knee range of movement and complications were analyzed. RESULTS: The overall revision surgery outcomes of the idiopathic stiffness cohort were worse than those of the non-idiopathic stiffness cohort with regard to maximum flexion (91.7° vs 100.1°, P = .02) and flexion range of motion (ROM) (87.6° vs 97.1°, P = .01). In the idiopathic stiffness cohort, isolated tibial insert exchange demonstrated greater maximum flexion (96.8° vs 88.4°, P = .06) and flexion ROM (93.2° vs 83.9°, P = .07). In terms of re-revision rates, the isolated tibial insert exchange idiopathic stiffness cohort demonstrated lower re-revision rates compared to the component revision idiopathic stiffness cohort (16.7% vs 31.0%, P = .01). CONCLUSION: This study demonstrates that the overall revision surgery outcome of idiopathic stiff TKA is worse than non-idiopathic TKA stiffness. In idiopathic stiffness cohorts, isolated tibial insert exchange was associated with lower re-revision rates than component revision, with similar efficacy in improving ROM, suggesting that isolated tibial insert exchange may be a preferred surgical treatment option in TKA patients with idiopathic stiffness.

Reverse shoulder arthroplasty has higher perioperative implant complications and transfusion rates than total shoulder arthroplasty.

BACKGROUND: Indications for reverse total shoulder arthroplasty (RTSA) have expanded. The purpose of this retrospective cohort study was to evaluate national trends in shoulder arthroplasty utilization and to compare national perioperative complication rates for hemiarthroplasty (HA), total shoulder arthroplasty (TSA), and RTSA in a matched cohort. METHODS: The National Inpatient Sample was queried from 2011-2013 to identify patients who underwent HA, TSA, or RTSA. Age, sex, race, insurance type, Elixhauser comorbidity index, and perioperative complications were identified. A coarsened exact matching algorithm was used to match RTSA patients with TSA and HA patients to compare medical and implant-related perioperative in-hospital complications. Multivariable logistic regression analysis was performed on unmatched data to identify risk factors for development of perioperative complications. RESULTS: Overall, 42,832 shoulder arthroplasties were identified (44% TSAs, 34% RTSAs, 19% HAs). After matching, RTSAs had 6.2 times the odds of a perioperative implant-related complication (P < .001) and 2 times the odds of a red blood cell transfusion compared with TSAs (P < .001). The logistic regression model showed that prior shoulder arthroplasty (odds ratio [OR], 15.1; P < .001), younger age (OR, 0.98; P = .006), earlier year of index surgery (OR, 0.83; P = .002), history of illicit drug use (OR, 6.2; P = .008), and depression (OR, 2.3; P = .003) were risk factors for development of in-hospital implant-related complications after RTSA. CONCLUSION: The perioperative implant-related complication rate and postoperative transfusion rate of RTSAs were significantly higher than those of TSAs. In addition, prior shoulder surgery, younger age, earlier year of index surgery, history of illicit drug use, and depression were risk factors for implant-related complications after RTSA. However, the perioperative RTSA implant-related complications did decline each year, suggesting a growing national proficiency with performing RTSA.

A case of Loeffler's endocarditis after initiation of adalimumab.

Tumor necrosis factor antagonists (anti-TNF) are increasingly prescribed as maintenance therapy for a variety of autoimmune conditions. Therefore, frequent monitoring and awareness of side effects are of the utmost importance. Adalimumab is known to cause peripheral eosinophilia, but there are few reports of more severe adverse events. Loeffler's endocarditis is a rare and fatal disease characterized by eosinophilic infiltration of the endomyocardium leading to fibrosis and restrictive cardiomyopathy. Herein we describe a 72 year old female on adalimumab therapy for two years for rheumatoid arthritis presenting with Loeffler's endocarditis. This case represents a rare case of Loeffler's endocarditis diagnosed rapidly and without myocardial biopsy. Early intervention is crucial in the prevention of permanent fibrosis and mortality in Loeffler's endocarditis. This case demonstrates the need for close monitoring and early recognition in patients on anti-TNF therapy. Abbreviations: tumor necrosis factor (TNF), hypereosinophilic syndrome (HES).

Post-radiotherapy vesicocutaneous fistula presenting as gas/fluid-filled groin swelling.

We report an interesting and rare case of a vesicocutaneous fistula, which was diagnosed only one year following radiotherapy. A 71 year old gentleman presented with a gangrenous swelling of his left thigh. A copius amount of urine was seen to be draining from the site after initial incision and drainage. Computed tomography with contrast confirmed the diagnosis of a vesicocutaneous fistula. Bilateral nephrostomies were inserted to aid spontaneous closure of the fistula. Previous case reports of vesicocutaneous fistulae involving radiotherapy have described the complication of a fistula occurring many years after the intervention.