Reduced 5-Year Risk for Revision of the Oxford UKA Using New Instrumentation versus Conventional Instrumentation: A Registry Study of 12,867 UKAs.

Microplasty instrumentation was introduced for a more consistent surgical implantation technique, especially component alignment and tibial resection level, of the Oxford medial unicompartmental knee arthroplasty (UKA) and thereby aims to improve UKA survival. This study aimed to assess the 5-year risk for revision and reasons for revision of the Oxford medial UKA using the new instrumentation (Microplasty) with its predecessor, that is, conventional instrumentation (Phase 3). Data of all medial UKAs from the Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Implantaten) between 2007 and 2019 were collected. Type of instrumentation was divided into new (Microplasty) and conventional instrumentation. Kaplan-Meier analysis was performed to calculate 5-year cumulative revision percentage with any reason for revision as end point. A multivariable Cox regression with outcome revision of UKA adjusted for age, gender, American Society of Anesthesiologists score, surgical history, and type of fixation was performed. Additionally, reasons for revision at 3-year were assessed and tested through Fisher's exact tests. A total of 12,867 Oxford medial UKAs, 8,170 using new and 4,697 using conventional instrumentation, were included. The 5-year revision percentage was 9.2% (95% confidence interval [CI]: 8.4-10.1%) for UKAs using the conventional and 6.1% (95% CI: 5.4-6.7%) for new instrumentation. The adjusted hazard ratio for revision at 5-year follow-up was 0.74 (95% CI: 0.63-0.87) in favor of UKAs using the new instrumentation. Malalignment was more frequently registered as reason for revision in UKAs using the conventional compared with the new instrumentation (16% versus 7.5%; p = 0.001). Our results show a reduced 5-year risk for revision of the medial Oxford UKAs using the new compared with the conventional instrumentation. This might be the result of a lower revision rate for malalignment in UKAs using the new instrumentation.

Does surgeon volume influence the outcome after hip hemiarthroplasty for displaced femoral neck fractures; early outcome, complications, and survival of 752 cases.

INTRODUCTION: Surgeon volume of hip arthroplasties is of importance with regard to complication and revision rates in total hip arthroplasty. For hip hemiarthroplasty, the effect of surgeon volume on outcome is far less studied. We analyzed the outcome of hip hemiarthroplasties performed by orthopedic surgeons in a retrospective cohort in different volume categories, focusing on early survival of the prosthesis and complications. METHODS: Between March 2009 and January 2014, 752 hemiarthroplasties were performed for intracapsular femoral neck fracture by 27 orthopedic surgeons in a large Dutch teaching hospital. Surgeons were divided into four groups, a resident group and three groups based on the number of total hip arthroplasties and hemiarthroplasties performed per year: a low-volume (< 10 arthroplasties per year), moderate-volume (10-35 arthroplasties per year), and high-volume groups (> 35 arthroplasties per year). Outcome measures were stem survival using a competing risk analysis, complication rates, and mortality. Chi-square tests were used to compare complication rates and mortality between groups. RESULTS: Patients were followed for a minimum of 2 years or until revision or death. Overall 60% of the patients included had died at time of follow-up. We found comparable stem survival rates in the low-volume group (n = 48), moderate-volume group (n = 201), high-volume group (n = 446), and resident group (n = 57). There were no significant differences between the groups with regard to dislocation rate, incidence of periprosthetic fracture, infection, and mortality. CONCLUSION: Surgeon volume and experience did not influence early outcome and complication rates in hip hemiarthroplasty. Hemiarthroplasty can safely be performed by both experienced hip surgeons and low-volume surgeons.

Dementia and delirium, the outcomes in elderly hip fracture patients.

BACKGROUND: Delirium in hip fractured patients is a frequent complication. Dementia is an important risk factor for delirium and is common in frail elderly. This study aimed to extend the previous knowledge on risk factors for delirium and the consequences. Special attention was given to patients with dementia and delirium. METHODS: This is a retrospective cohort study performed in the Amphia Hospital, Breda, the Netherlands. A full electronic patient file system (Hyperspace Version IU4: Epic, Inc., Verona, WI, USA) was used to assess data between January 2014 and September 2015. All patients presented were aged ≥70 years with a hip fracture, who underwent surgery with osteosynthesis or arthroplasty. Patients were excluded in case of a pathological or a periprosthetic hip fracture, multiple traumatic injuries, and high-energy trauma. Patient and surgical characteristics were documented. Postoperative outcomes were noted. Delirium was screened using Delirium Observation Screening Scale and dementia was assessed from medical notes. RESULTS: Of a total of 566 included patients, 75% were females. The median age was 84 years (interquartile range: 9). Delirium was observed in 35%. Significant risk factors for delirium were a high American Society of Anesthesiology score, delirium in medical history, functional dependency, preoperative institutionalization, low hemoglobin level, and high amount of blood transfusion. Delirium was correlated with a longer hospital stay (P=0.001), increased association with complications (P<0.001), institutionalization (P<0.001), and 6-month mortality (P<0.001). Patients with dementia (N=168) had a higher delirium rate (57.7%, P<0.001) but a shorter hospital stay (P<0.001). There was no significant difference in the 6-month mortality between delirious patients with (34.0%) and without dementia (26.3%). CONCLUSION: Elderly patients with a hip fracture are vulnerable for delirium, especially when the patient has dementia. Patients who underwent an episode of delirium were at increased risk for adverse outcomes.

Outcome after osteosynthesis of hip fractures in nonagenarians.

BACKGROUND: Hip fractures in the elderly population are associated with high morbidity and mortality. However, there is still a lack of information on mortality and loss of independence in extremely elderly people with a hip fracture. OBJECTIVE: To study functional outcomes and mortality after osteosynthesis of hip fractures in very old patients in our clinic. PATIENTS AND METHODS: Hospital charts of all patients over 90 years old who were operated for a hip fracture between January 2007 and December 2011 were reviewed. Outcome measures were mortality, preoperative and postoperative mobility, and loss of independence. RESULTS: A total of 149 patients were included; 132 (89%) women, median age 93.5±2.45 years. Thirty-six (24%) patients were classified as American Society of Anesthesiologists (ASA) grade 2, 104 (70%) as ASA grade 3, and nine (6%) as ASA grade 4. The Charlson comorbidity index (CCI) score was 2 or less in 115 (77%) patients and 34 (23%) patients scored 3 or more points. Short-term survival was 91% and 77% at 30 days and 3 months, respectively. Long-term survival was 64%, 42%, and 18% at 1, 3, and 5 years after surgery, respectively. Survival was significantly better in patients with lower ASA scores (P=0.005). No significant difference in survival was measured between patients according to CCI score (P=0.13). Fifty-one percent of patients had to be accommodated in an institution with more care following treatment, and 57% were less mobile after osteosynthesis of a hip fracture. CONCLUSION: Our study shows that short-term mortality rates in very elderly patients with a hip fracture are high and there is no clear predictive value for mortality. ASA classification is the best predictive value for overall mortality. A large proportion of these patients lost their independence after osteosynthesis of a hip fracture.

Total ankle replacement outcome in low volume centers: short-term followup.

BACKGROUND: The indication for total ankle replacement (TAR) as an alternative to ankle fusion continues to be a much-debated topic. The reported survival of TAR at midterm followup is approximately 90%. The aim of this study was to compare functional outcome and survival of TAR in low volume centers versus high volume centers. MATERIALS AND METHODS: A retrospective cohort study was carried out in four low volume centers. Sixty-four Salto TARs were performed between 2003 and 2007 in 60 patients. Fifty-five (59 TAR) patients were eligible for followup with 28 men. Standardized American Orthopaedic Foot and Ankle Society (AOFAS) scores, patient satisfaction, and range of motion (ROM) were measured. Standardized and dynamic radiographs were used for evaluation of radiolucencies, ROM and component alignment. RESULTS: Seven of the 59 ankle prostheses had to be revised: five for loosening and two for deep infection. Three of the five revised for loosening went on to fusion, and in two a revision of one of the components was performed. Both infected ankles were fused. Five patients declined to participate this study, among these two were TAR failures. Survival with revision as the endpoint was 86% at final followup. The average AOFAS score was 75 (SD ± 15). On dynamic radiographs the ROM was 22 degrees (SD ± 8) in the tibiotalar joint. CONCLUSION: This study demonstrated that functional results of total ankle replacement in low volume centers were comparable to most high volume centers but survival was lower especially when we consider our shorter followup than most comparable series.

Provocative discography and lumbar fusion: is preoperative assessment of adjacent discs useful?

STUDY DESIGN: A cohort study of clinical outcomes of lumbar fusion patients with preoperative assessment of adjacent levels by provocative discography. OBJECTIVE: To evaluate whether the preoperative status of the adjacent discs, as determined by provocative discography, has an impact on the clinical outcome of lumbar fusion in chronic low back pain (LBP) patients. SUMMARY OF BACKGROUND DATA: The results of lumbar fusion in chronic LBP patients vary considerably and are hard to predict. It is believed that degenerative levels adjacent to a fused spinal segment may be a cause of continuing pain. In this respect, it is important to know whether preoperative degenerative or symptomatic adjacent levels have an adverse effect on patient outcomes after lumbar fusion. METHODS: In 197 patients with an equivocal indication for lumbar fusion (two thirds were patients with prior spine surgery), the decision for either lumbar fusion or conservative management was determined by a temporary external transpedicular fixation trial. During the diagnostic workup, all patients had undergone provocative discography that included the assessment of the discs adjacent to the intended fusion levels. The individual changes in pain on a visual analog scale, assessed before treatment and at follow-up, and patient satisfaction were the measures of outcome. RESULTS: In the 82 patients who underwent a lumbar fusion, no difference in outcome was found between those patients with degenerative or symptomatic discs adjacent to the fusion and those with normal adjacent discs. CONCLUSION: In this cohort study of chronic LBP patients with an uncertain indication for lumbar fusion, the preoperative status of adjacent levels as assessed by provocative discography did not appear to be related to the clinical outcome after fusion.

The value of a pantaloon cast test in surgical decision making for chronic low back pain patients: a systematic review of the literature supplemented with a prospective cohort study.

The results of lumbar fusion in chronic low back pain (LBP) patients vary considerably, and there is a need for proper patient selection. Lumbosacral orthoses have been widely used to predict outcome, however, with little scientific support. The aim of the present study was to determine the value of a pantaloon cast test in selecting chronic LBP patients for lumbar fusion or conservative management. First, a systematic review of the literature was carried out in which two independent reviewers identified studies in Medline, Cochrane and Current Contents databases. Three papers met the selection criteria. In the only study with a control group, a significantly better outcome after fusion compared to conservative treatment was found in patients who reported significant pain relief while in a cast (i.e. a positive cast test). The results of lumbar fusion, however, were not significantly different for patients with a positive and those with a negative cast test. In addition to the review, a clinical cohort study of 257 LBP patients, who had been allocated to either lumbar fusion or conservative management by a temporary external transpedicular fixation trial, was performed. Prior to allocation, all had undergone a pantaloon cast test. Patients with no history of prior spine surgery and with a positive pantaloon cast test had a better outcome after lumbar fusion than those treated conservatively (P = 0.002, chi (2 )test). In patients with previous spine operations the outcomes were poor and the test was of no value. From the literature and the present patient cohort, it was concluded that only in chronic LBP patients without prior spine surgery, a pantaloon cast test with substantial pain relief suggests a favorable outcome of lumbar fusion compared to conservative management. The test has no value in patients who have had previous spine surgery.

Temporary external transpedicular fixation of the lumbosacral spine: a prospective, longitudinal study in 330 patients.

STUDY DESIGN: In this study, 330 patients with incapacitating low back pain underwent temporary external transpedicular fixation (TETF) of the lumbosacral spine in a prospective trial. OBJECTIVE: To evaluate TETF as a test for selecting suitable candidates for segmental spinal fusion. SUMMARY OF BACKGROUND DATA: Few studies regarding TETF have been published, and contradictory results concerning predictive value and morbidity were reported. METHODS: All patients were tested with the external fixator in two different positions: fixation and nonfixation. Before and during the test and at follow-up examination, pain was assessed on a Visual Analogue Scale (VAS). The TETF test was considered to be positive if the VAS score in the fixation state was 30 or more points lower than in the nonfixation state. Hence, a positive test would imply the decision to perform segmental lumbosacral fusion. When the reduction was less than 30 points, the test was negative. Individual pain reduction and working capacity were taken as measure of outcome. RESULTS: Most of the patients in this study (62%) underwent spinal surgery previously. The positive and negative TETF groups were quite similar, but a large within-group variation was found. Within the fusion group of 123 patients, improvement in VAS scores and improvement in working capacity were not significantly better for the positive TETF group in comparison with the negative TETF group. CONCLUSION: In this heterogeneous group of chronic patients with low back pain, TETF of the spine (including a placebo trial) does not appear to be of value in selecting suitable candidates for spinal fusion.