Successful reverse total shoulder replacement in a patient with Apert syndrome.

Apert syndrome, first described in the literature by a French pediatrician Eugene Apert, is a rare congenital form of acrocephalodactyly with autosomal dominant inheritance. Classically, this syndrome is characterized by craniosynostosis, midface hypoplasia, and symmetrical syndactyly of hands and feet resulting from embryonic anomalies during the third week of gestation. It is also associated with a variety of abnormalities of the viscera, involving the neurological, genitourinary, and cardiorespiratory systems. Glenohumeral manifestations of Apert syndrome include glenoid dysplasia, an oblong humeral head with a prominence of the greater tuberosity, acromial prominence, and inferior subluxation of the glenohumeral joint. This pathological anatomy results in progressive degenerative changes, synchondrosis, and restriction in shoulder joint mobility, particularly in flexion and abduction. While surgical options for the accompanying deformities of the feet and spine are described, interventions for shoulder pathology are not well-defined. Joint replacement surgery could offer such patients pain relief and improved function. Reverse total shoulder arthroplasty is yet to be described in Apert syndrome and this case report presents the outcome in a 48-year-old male. Level of evidence: IV case report.

Association between pre-operative anxiety and/or depression and outcomes following total hip or knee arthroplasty.

PURPOSE: While elective primary total hip (THA) and knee (TKA) arthroplasty are effective procedures for addressing the symptoms associated with advanced osteoarthritis, there is evidence to suggest that patient anxiety and depression are linked to poorer outcomes following surgery. METHODS: A secondary analysis of prospectively-collected data of people undergoing primary elective THA or TKA for osteoarthritis across 19 hospitals was performed. We assessed outcomes at 1 year post-surgery for people with and without medically treated anxiety and/or depression at the time of surgery (A/D and no-A/D). We used unadjusted and adjusted analyses to compare improvement in Oxford Hip or Knee Scores, the incidences of major post-operative complications, satisfaction and index joint improvement by A/D status. RESULTS: 15.2% (254/1669) of patients were identified with anxiety and/or depression at time of surgery. In the unadjusted analysis, the A/D group had greater mean Oxford score improvement by 2.1 points (95% CI 0.8 to 3.4, p = 0.001), increased major complications (OR 1.39, 95% CI 1.05 to 1.85, p = 0.02), were less likely to report a "much better" global improvement for index joint (OR 0.56, 95% CI 0.38 to 0.83, p = 0.003), and there was no statistically significant difference in the rate of satisfaction with the results of surgery (OR 0.64, 95% CI 0.37 to 1.10, p = 0.10). The adjusted analysis found no significant associations between A/D vs. no-A/D and any of the reported outcomes. CONCLUSION: After adjustment for confounding variables, people with anxiety and/or depression pre-operatively, compared to those without, have similar outcomes following hip or knee arthroplasty.

Aspirin for prevention of venous thromboembolism in recipients of major lower-limb orthopedic surgery: a systematic review of Level I evidence.

INTRODUCTION: Major lower-limb orthopedic surgery recipients are at increased risk of venous thromboembolism (VTE). The optimal strategy for preventing VTE is a topic of ongoing debate. The use of aspirin has been implicated in reducing VTE events and is potentially advantageous compared to other agents in respect to cost, access, route of administration and reduced adverse effects such as bleeding. EVIDENCE ACQUISITION: A systematic search for Level I evidence (systematic reviews and meta-analyses of randomised-controlled trials) was performed in April 2019 to evaluate the use of aspirin for primary and secondary VTE prophylaxis compared to alternative chemical and mechanical strategies. This search encompassed three electronic databases (Pubmed, Embase and the Cochrane Database of Systematic Reviews). All references of included studies were screened for additional studies. Data was compiled and compared to the recommendations and guidelines published by major institutions. Included studies were appraised with the aid of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. EVIDENCE SYNTHESIS: In total, 21 studies were included. Interventions and outcomes identified were heterogeneous across studies. Most statistical tests applied found no difference between aspirin and other interventions in regards to deep vein thrombosis, pulmonary embolism, bleeding and mortality outcomes. CONCLUSIONS: Aspirin may be a viable alternative to established thromboprophylactic regimes for primary prevention of VTE, however in the setting of secondary prevention it is generally less efficacious. Future studies should have clearly identified and comparable outcome measures, with direct comparisons and assessment of intervention combination, dosing and treatment duration.

Can Surgeons Reduce the Risk for Dislocation After Primary Total Hip Arthroplasty Performed Using the Posterolateral Approach?

BACKGROUND: Hip dislocation is one of the most common postoperative complications after total hip arthroplasty (THA). Potential contributors include patient- and surgical-related factors. We performed a retrospective cohort study to identify risk factors for postoperative dislocation in patients receiving THA via the posterolateral approach. METHODS: We assessed 1326 consecutive primary THAs performed between 2010 and 2015. Patient information was documented, and plain radiographic films were used to evaluate cup positioning, hip offset, and hip length change. A multiple logistic regression was used to identify risk factors for dislocation. Follow-up was coordinated by the Danish National Patient Registry. RESULTS: Age and American Society of Anesthesiologists scores were higher in dislocating THA compared with those in the nondislocating THA. Cup anteversion was less in dislocating THA compared with that in nondislocating THA. Independent risk factors for cup dislocation were increased age, body mass index <25 and >30 kg/m2, and leg shortening of >5 mm. CONCLUSION: Surgeons should aim for a shortening of leg length <5 mm to reduce the risk of postoperative dislocation in primary THA. Although anteversion was reduced for dislocating THA, there is likely no universal safe zone for cup positioning. Hip stability is multifactorial, and optimal cup positioning may vary from patient to patient.

Acetabular cup position and risk of dislocation in primary total hip arthroplasty.

Background and purpose - Hip dislocation is one of the most common complications following total hip arthroplasty (THA). Several factors that affect dislocation have been identified, including acetabular cup positioning. Optimal values for cup inclination and anteversion are debatable. We performed a systematic review to describe the different methods for measuring cup placement, target zones for cup positioning, and the association between cup positioning and dislocation following primary THA. Methods - A systematic search of literature in the PubMed database was performed (January and February 2016) to identify articles that compared acetabular cup positioning and the risk of dislocation. Surgical approach and methods for measurement of cup angles were also considered. Results - 28 articles were determined to be relevant to our research question. Some articles demonstrated that cup positioning influenced postoperative dislocation whereas others did not. The majority of articles could not identify a statistically significant difference between dislocating and non-dislocating THA with regard to mean angles of cup anteversion and inclination. Most of the articles that assessed cup placement within the Lewinnek safe zone did not show a statistically significant reduction in dislocation rate. Alternative target ranges have been proposed by several authors. Interpretation - The Lewinnek safe zone could not be justified. It is difficult to draw broad conclusions regarding a definitive target zone for cup positioning in THA, due to variability between studies and the likely multifactorial nature of THA dislocation. Future studies comparing cup positioning and dislocation rate should investigate surgical approach separately. Standardized tools for measurement of cup positioning should be implemented to allow comparison between studies.

Data quality audit of the arthroplasty clinical outcomes registry NSW.

BACKGROUND: The Arthroplasty Clinical Outcomes Registry NSW (ACORN) was initiated in 2012. ACORN is a registry piloting within NSW, Australia with several participating hospitals; it aims to monitor patient-centred outcomes and post-surgical complications after total hip and knee arthroplasty. Using retrospective audit methodology, we aimed to investigate the completeness and accuracy of data in ACORN. METHODS: We undertook a reabstracting audit of 100 clinical records of patients who underwent surgery in 2012/2013 (50 each from hospitals A and B). These records represented 27% (100/367) of patient entries in the ACORN registry, all of which were collected at either hospital A or hospital B. Firstly, data completeness was determined by identifying the proportion of missing data in the original data pro forma. Secondly, accuracy of the initial data extraction was determined by comparing these data to reabstracted data collated by an auditor blind to the outcomes of the initial extraction. Inaccuracies were ascertained to be a disagreement between categorical variables and for continuous data, a pre-determined window of error was established. Benchmarks for data completeness and accuracy were set at 95.0%; kappa and intraclass coefficient (ICC) calculations were also utilised to supplement this analysis. In addition, registry completeness (the percentage capture of eligible patients) was also determined as part of the data quality analysis. RESULTS: Completeness and accuracy of submitted datasets were evaluated to be 99.0% (1259/1272) and 94.0% (2159/2296) respectively for Hospital A, and 99.3% (1589/1600) and 96.1% (2444/2542) for Hospital B. The majority of accuracy discrepancies pertained to medical history data. For Hospital A, 57.1% (28/49) of variables met the accuracy benchmark of 95%; 74.5% (38/51) of variables in Hospital B met this benchmark. Of the number of patients eligible for inclusion in the registry, 93.5% (660/706) were found to be included. CONCLUSION: Levels of data completeness and accuracy were found to be high in the submitted datasets for both hospitals. However, important deficits were identified in the accuracy of patient comorbidities. More specific and clear data definitions, and a more thorough examination of medical records would be possible methods to improve the accuracy of deficient areas.