Transvenous Embolization for Cerebrospinal Fluid-Venous Fistula. A Case Series from a Single Community-Academic Center.

BACKGROUND: Transvenous embolization is a new treatment for spinal cerebrospinal fluid (CSF)-venous fistula, with only 1 reported large case series from the center that invented this technique. METHODS: We report the clinical and radiographic data of 5 consecutive patients who were diagnosed with CSF-venous fistula at a single community-academic medical center and were treated with transvenous embolization. All patients provided consent for this report. Institutional review board approval was not required because of the retrospective nature of this study describing standards of care. RESULTS: Five patients, 3 men and 2 women, with a median age of 57 years, were diagnosed between March and December 2021with spontaneous intracranial hypotension (SIH) as a result of CSF-venous fistula. Two patients were originally referred for middle meningeal artery embolization for chronic subdural hematoma. All fistulae were in the thoracic spine at a single level in 3 patients, 2 levels in 1 patient, and multiple levels in 1 patient. Transvenous embolization was technically successful in all cases, with no significant complications. Four patients (80%) had complete or near-complete resolution of clinical symptoms and returned to baseline function and employment status. One patient (20%) has had a remitting relapsing course. Posttreatment brain magnetic resonance imaging showed resolution of spontaneous intracranial hypotension findings in 4 patients (80%) and minimal changes in 1 patient (20%), who had significant clinical improvement. CONCLUSIONS: Transvenous embolization for the treatment of CSF-venous fistula is feasible and seems effective in the short-term. The results reported by the previous case series can be reproduced in other centers with available expertise and adherence to published diagnostic and treatment protocols.

The efficacy and cost-effectiveness of enoxaparin versus rivaroxaban in the prevention of venous thromboembolism following total hip or knee arthroplasty: A meta-analysis.

INTRODUCTION: Thromboprophylaxis following total hip and knee arthroplasty is variable across institutions, but commonly consists of enoxaparin, and more recently rivaroxaban. We aimed to analyze the current evidence on the efficacy, safety and cost-effectiveness of rivaroxaban versus enoxaparin for thromboprophylaxis following TKA or THA. METHODS: This study was conducted according to PRISMA guidelines. Electronic database searches were performed using three databases from their dates of inception to June 2020. Relevant randomized controlled studies were identified, with data extracted and analyzed. RESULTS: From eight studies, 13,384 patients were included, with 5700 undergoing TKA and 7684 undergoing THA. There were 6629 patients receiving rivaroxaban and 6755 patients receiving enoxaparin. From the total cohort, rivaroxaban was associated with significantly lower rates of major VTE (p = 0.009) and DVT (p < 0.001) when compared to enoxaparin. There was no significant difference in bleeding complications between rivaroxaban and enoxaparin groups (p = 0.14). Subgroup analysis of patients undergoing THA demonstrated that rivaroxaban reduced risk of major VTE (p = 0.002) and DVT (p = 0.01) with no significant differences in any other complications. For those undergoing TKA, rivaroxaban significantly reduced the risk of DVT (p < 0.001) but was associated with higher rates of post-operative blood transfusion (p = 0.03). Cost-analysis revealed that rivaroxaban was superior to enoxaparin, with the medication cost needed to prevent one DVT being $1081 and $432 less with rivaroxaban for THA and TKA respectively. CONCLUSIONS: Rivaroxaban may be a safe and cost-effective alternative to enoxaparin for routine thromboprophylaxis following total knee or hip arthroplasty.

Comparison of outpatient versus inpatient total hip and knee arthroplasty: A systematic review and meta-analysis of complications.

INTRODUCTION: Patients undergoing TKA or THA have traditionally been managed post-operatively as inpatients. However, with current surgical techniques and pain management, there is evidence that outpatient joint arthroplasty can be safely performed in selected patient. This systematic review and meta-analysis aimed to compare the post-operative complication rates of outpatient and inpatient TJA with subgroup analysis of TKA and THA. METHODS: Electronic searches were performed using five databases from their date of inception to October 2018. Relevant studies were identified, with data extracted and meta-analyzed from the studies. RESULTS: From seven included studies, 176,179 patients were inpatient TJA and 1613 were outpatient TJA. The outpatient and inpatient TJA cohorts had similar mean age and BMI, with a greater proportion of females in the inpatient group. For TJA we found no significant difference in total complications (P = 0.06), major complications (P = 0.59), readmissions (P = 0.60), DVT (P = 0.94), UTI (P = 0.50), pneumonia (P = 0.42) and wound complications (P = 0.50) between the outpatient and inpatient groups. However, there were fewer transfusions (P = 0.05) but increased reoperations (P = 0.02) in the outpatient TJA group. Subgroup analysis of TKA (P = 0.25) and THA (P = 0.39) also found no significant differences in total complications between the outpatient and inpatient groups. CONCLUSION: Outpatient TJA had comparable total complication rates to inpatient TJA. Along with that outpatient TJA can significantly reduce costs to healthcare systems but careful pre-operative patient selection is required to optimize outcomes. More quality randomized controlled trials with longer follow-up periods are needed to add to this body of evidence.

The Association Between Anxiety, Depression, and Locus of Control With Patient Outcomes Following Total Knee Arthroplasty.

BACKGROUND: We aimed to determine how preoperative anxiety, depression, and locus of control (LoC) might predict patient outcomes following total knee arthroplasty (TKA). METHODS: Patients undergoing TKA were prospectively recruited over an 18-month period. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to assess TKA outcomes. The Short Form-12, Hospital Anxiety and Depression Score, and LoC surveys were completed by the patients to assess their psychosocial state. These scores were collected preoperatively and at 6 weeks, 18 weeks, and 1 year postoperation. RESULTS: The final cohort consisted of 136 patients. Greater preoperative depression (P = .004) and anxiety (P = .001) scores were correlated with worse total WOMAC score at 6 weeks and 18 weeks postoperatively, respectively. A poorer preoperative Short Form-12 mental score was also correlated with a worse total WOMAC score at 6 weeks postoperatively (P = .007). Greater tendency toward an internal LoC preoperatively was correlated with better WOMAC pain (P < .001) and function (P = .003) scores at 18 weeks postoperatively. However, there was no correlation between preoperative external LoC and postoperative WOMAC score. There was also no correlation between any of the preoperative psychosocial measures and WOMAC score at 1 year postoperatively. CONCLUSION: We identified a group of patients whose psychosocial markers predicted them to have worse outcomes in the short to medium term even though they normalized to satisfactory outcomes at 1 year postoperatively. Identifying this group could allow for targeted intervention with an adjustment of expectations and thus more effective recovery.

Validity and reliability of the Nintendo Wii Fit Stillness score for assessment of standing balance.

BACKGROUND/OBJECTIVE: Standing balance has become an important clinical measure in patient populations who are at risk of falls or have osteoarthritis. With custom-written software, the Wii Balance Board (WBB) has been shown to be a valid and reliable force platform that can be used to assess standing balance. However, no studies to date have assessed the use of the more readily available Wii Stillness Score (WSS) as a measure of balance. METHODS: Twenty-four individuals without lower limb pathology performed a combination of unilateral and double leg standing balance tests with eyes open or closed on two separate occasions. At each session, data from the WBB were acquired on a laptop computer running custom software and then by Wii-Fit software on a Wii console. The reliability of the WSS was determined by assessing reproducibility, while the validity of the WSS was determined by comparing the results of the WSS to that of the custom-written software. RESULTS: We found that the WSS exhibited excellent intra and inter device reliability in three out of four stances tested. The Bland-Altman plots also showed good concurrent validity for the three analysed stances. However, there remain significant limitations with the use of the WSS such as its rigid thirty-second time parameter and single score result. CONCLUSION: The readily available WBB may be a used as a portable and inexpensive device to assess standing balance with custom written software. However, with the current limitations of the WSS, we would discourage its use as a clinical measure of balance.

Single-Stage Revision Arthroplasty for Infection-An Underutilized Treatment Strategy.

BACKGROUND: The burden of revision arthroplasty surgery for infection is rising as the rate of primary arthroplasty surgery increases. Infected arthroplasty rates are now relatively low, but the sheer increase in volume is leading to considerable patient morbidity and significant increases in costs to the health care system. Single-stage revision for infection is one of the several accepted treatment options, but the indications and results are debated. This review aims to clarify the current evidence. METHODS: MEDLINE/PubMed databases were reviewed for studies that looked at single- or one-stage revision knee or hip arthroplasty for infection. RESULTS: There is increasing evidence that single-stage revision for infection can control infection and with decreased morbidity, mortality, and health care costs compared with a staged approach. However, the indications are still debated. Recently, there has been a determined effort to define an infected arthroplasty in a manner that will allow for standardization of reporting in the literature. The evidence supporting single stage for knee arthroplasty is catching up with the result with hip arthroplasty. High-quality data from randomized controlled trials are now pending. CONCLUSION: After the gradual evolution of using the single-stage approach, with the widespread acceptance of this definition, we can now standardize comparisons across the world and move toward a refined definition of the ideal patient population for single-stage arthroplasty revision in both the hip and the knee population.