A Rare Case of Ruptured Appendicitis Secondary to Metastatic Ovarian Cancer.

BACKGROUND Patients with advanced stage ovarian cancer typically have vague non-specific abdominal symptoms related to pelvic tumor, metastasis, and ascites. When these patients present with more acute abdominal pain, appendicitis is rarely considered. Acute appendicitis due to metastatic ovarian cancer has been sparsely documented in the medical literature; only twice, to our knowledge. CASE REPORT A 61-year-old woman with a 3-week history of abdominal pain, shortness of breath, and bloating was diagnosed with ovarian cancer after computed tomography (CT) demonstrated a large pelvic cystic and solid mass. Five weeks later she underwent an omental biopsy to determine cell type and potential upstaging of the ovarian cancer to stage IV, as other aggressive cancers such as breast cancer can also involve the pelvis/omentum. Seven hours after her biopsy, she presented with increasing abdominal pain. Post-biopsy complications such as hemorrhage or bowel perforation were initially suspected to be the cause of her abdominal pain. However, CT demonstrated ruptured appendicitis. The patient underwent an appendectomy and histopathologic examination of the specimen revealed infiltration by low-grade ovarian serous carcinoma. CONCLUSIONS Given the low incidence of spontaneous acute appendicitis in this patient's age group, and the lack of any other clinical, surgical, or histopathological evidence to suggest another cause, metastatic disease was ruled to be the likely source of her acute appendicitis. Providers should be aware of appendicitis in a broad differential diagnosis and have a low threshold for ordering abdominal pelvis CT when advanced stage ovarian cancer patients present with acute abdominal pain.

Risk Factors for Repeat Debridement, Spacer Retention, Amputation, Arthrodesis, and Mortality After Removal of an Infected Total Knee Arthroplasty With Spacer Placement.

BACKGROUND: Chronic periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is most commonly addressed with a 2-stage exchange procedure. The purpose of this study is to examine the natural history of patients who have undergone prosthesis removal and spacer placement and evaluate risk factors for outcomes other than reimplantation. METHODS: Patients who underwent removal of an infected TKA and placement of an antibiotic spacer for PJI were identified in a Medicare database. Patients with a study outcome within 1 year were then identified: (1) in hospital mortality, (2) knee arthrodesis, (3) amputation, (4) repeat debridement procedure without reimplantation, and (5) reimplantation. Independent risk factors for these outcomes were evaluated with a multivariate logistic regression analysis. RESULTS: A total of 18,533 patients were included. Within 1 year postoperatively, 691 patients (3.7%) died in a hospital setting, 852 patients (4.5%) underwent a knee arthrodesis, 574 patients (3.1%) underwent an amputation, 2683 patients (14.5%) underwent a repeat debridement procedure without being reimplanted, 2323 patients (12.5%) retained their spacer, and 11,420 patients (61.6%) underwent spacer removal and reimplantation within 1 year. Numerous independent patient-related risk factors for these outcomes were identified. CONCLUSION: A large number of patients (38.4%) do not undergo reimplantation within 1 year of prosthesis removal and spacer placement. Outcomes after prosthesis removal and antibiotic spacer placement are variable, and there are several independent risk factors for such outcomes that may be used to develop and improve existing treatment strategies for patients presenting with chronic PJI after TKA.

Narcotic Use and Total Knee Arthroplasty.

BACKGROUND: Although the United States is in the midst of a narcotic epidemic, risk factors for use and the impact of perioperative narcotic use on total knee arthroplasty (TKA) outcomes is ill-defined. METHODS: A national database was queried for patients who underwent primary TKA from 2007 to 2015. Patients taking narcotics in the preoperative, and for a prolonged period of time postoperatively, were identified. The risk factors for prolonged narcotic use were analyzed with a regression analysis, in addition to evaluating preoperative and prolonged postoperative use as independent risk factors for short-term and long-term complications. RESULTS: In total, 113,337 patients met inclusion criteria, of which 31,733 patients were prescribed narcotics preoperatively and 35,770 patients were prescribed narcotics more than 3 months postoperatively. There are several independent risk factors for prolonged narcotic use postoperatively, the most significant being the number of narcotic prescriptions prescribed preoperatively. Preoperative narcotic use was independently associated with an increased risk of emergency room visits, readmission, infection, stiffness, and aseptic revision. Prolonged postoperative use was also associated with significantly increased rates of infection, stiffness, and aseptic revision. CONCLUSION: Preoperative and prolonged narcotic use following TKA was associated with an increased risk of short-term and long-term complications following TKA. The liberal use of narcotics in the perioperative period should be considered a modifiable risk factor when considering elective TKA.