Above-knee amputation shows higher complication and mortality rates in line with lower functional outcome compared to knee arthrodesis in severe periprosthetic joint infection.

Aims: In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility. Methods: Patients with PJI of the knee and subsequent KA or AKA between June 2011 and May 2021 were included. Demographic data, comorbidities, and patient history were analyzed. Functional outcomes and QoL were prospectively assessed in both groups with additional treatment-specific scores after AKA. Outcomes, complications, and mortality were evaluated. Results: A total of 98 patients were included, 52 treated with arthrodesis and 47 with AKA. The mean number of revision surgeries between primary arthroplasty and arthrodesis or AKA was 7.85 (SD 5.39). Mean follow-up was 77.7 months (SD 30.9), with a minimum follow-up of two years. Complications requiring further revision surgery occurred in 11.5% of patients after arthrodesis and in 37.0% of AKA patients. Positive intraoperative tissue cultures obtained during AKA was significantly associated with the risk of further surgical revision. Two-year mortality rate of arthrodesis was significantly lower compared to AKA (3.8% vs 28.3%), with age as an independent risk factor in the AKA group. Functional outcomes and QoL were better after arthrodesis compared to AKA. Neuropathic pain was reported by 19 patients after AKA, and only 45.7% of patients were fitted or were intended to be fitted with a prosthesis. One-year infection-free survival after arthrodesis was 88.5%, compared to 78.5% after AKA. Conclusion: Above-knee amputation in PJI results in high complication and mortality rates and poorer functional outcome compared to arthrodesis. Mortality rates after AKA depend on patient age and mobility, with most patients not able to be fitted with a prosthesis. Therefore, arthrodesis should be preferred whenever possible if salvage procedures are indicated.

Establishing and clinically validating a machine learning model for predicting unplanned reoperation risk in colorectal cancer.

BACKGROUND: Colorectal cancer significantly impacts global health, with unplanned reoperations post-surgery being key determinants of patient outcomes. Existing predictive models for these reoperations lack precision in integrating complex clinical data. AIM: To develop and validate a machine learning model for predicting unplanned reoperation risk in colorectal cancer patients. METHODS: Data of patients treated for colorectal cancer (n = 2044) at the First Affiliated Hospital of Wenzhou Medical University and Wenzhou Central Hospital from March 2020 to March 2022 were retrospectively collected. Patients were divided into an experimental group (n = 60) and a control group (n = 1984) according to unplanned reoperation occurrence. Patients were also divided into a training group and a validation group (7:3 ratio). We used three different machine learning methods to screen characteristic variables. A nomogram was created based on multifactor logistic regression, and the model performance was assessed using receiver operating characteristic curve, calibration curve, Hosmer-Lemeshow test, and decision curve analysis. The risk scores of the two groups were calculated and compared to validate the model. RESULTS: More patients in the experimental group were ≥ 60 years old, male, and had a history of hypertension, laparotomy, and hypoproteinemia, compared to the control group. Multiple logistic regression analysis confirmed the following as independent risk factors for unplanned reoperation (P < 0.05): Prognostic Nutritional Index value, history of laparotomy, hypertension, or stroke, hypoproteinemia, age, tumor-node-metastasis staging, surgical time, gender, and American Society of Anesthesiologists classification. Receiver operating characteristic curve analysis showed that the model had good discrimination and clinical utility. CONCLUSION: This study used a machine learning approach to build a model that accurately predicts the risk of postoperative unplanned reoperation in patients with colorectal cancer, which can improve treatment decisions and prognosis.

Periprosthetic giant cell tumour of the tibia: en bloc resection and megaprosthesis revision.

We present a case detailing the diagnosis and management of a periprosthetic giant cell tumour in a female patient in her 70s, who had undergone total knee arthroplasty (TKA) for primary osteoarthritis in her right knee 7 years prior. The patient reported 4 months of painful weight-bearing. Various imaging modalities, including plain radiographs, CT scans and MRI, revealed a sizeable lytic lesion beneath the TKA prosthesis, along with loosening of the tibial component.Blood tests and analyses of synovial fluid ruled out periprosthetic joint infection, and a biopsy confirmed the diagnosis of a giant cell tumour of the bone. Treatment entailed en bloc resection of the tumour and revision of the TKA using a hinged, oncological-type megaprosthesis. Surgical procedures involved careful resection of the proximal tibia, preservation of vasculature and the creation of a medial gastrocnemius muscle flap. Following surgery, the patient underwent supervised rehabilitation with a functional brace.

Stoma associated complications after diverting loop ileostomy, end ileostomy or split stoma formation after right sided colectomy-a retrospective cohort study (StoComSplit Analysis).

BACKGROUND: For high-risk patients receiving right-sided colectomy, stoma formation is a safety strategy. Options are anastomosis with loop ileostomy, end ileostomy, or split stoma. The aim is to compare the outcome of these three options. METHODS: This retrospective cohort study included all patients who underwent right sided colectomy and stoma formation between January 2008 and December 2021 at two tertial referral centers in Switzerland. The primary outcome was the stoma associated complication rate within one year. RESULTS: A total of 116 patients were included. A total of 20 patients (17%) underwent primary anastomosis with loop ileostomy (PA group), 29 (25%) received an end ileostomy (ES group) and 67 (58%) received a split stoma (SS group). Stoma associated complication rate was 43% (n = 21) in PA and in ES group and 50% (n = 34) in SS group (n.s.). A total of 30% (n = 6) of patients in PA group needed reoperations, whereas 59% (n = 17) in ES and 58% (n = 39) in SS group had reoperations (P = 0.07). Wound infections occurred in 15% (n = 3) in PA, in 10% (n = 3) in ES, and in 30% (n = 20) in SS group (P = 0.08). A total of 13 patients (65%) in PA, 7 (24%) in ES, and 29 (43%) in SS group achieved stoma closure (P = 0.02). A total of 5 patients (38%) in PA group, 2 (15%) in ES, and 22 patients (67%) in SS group had a stoma-associated rehospitalization (P < 0.01). CONCLUSION: Primary anastomosis and loop ileostomy may be an option for selected patients. Patients with end ileostomies have fewer stoma-related readmissions than those with a split stoma, but they have a lower rate of stoma closure. CLINICAL TRIAL REGISTRATION: Trial not registered.

Impact of leaflet splitting on coronary access after redo-TAVI for degenerated supra-annular self-expanding platforms.

BACKGROUND: Coronary access (CA) is a major concern in redo-transcatheter aortic valve implantation (TAVI) for failing supra-annular self-expanding transcatheter aortic valves (TAVs). AIMS: This ex vivo study evaluated the benefit of leaflet splitting (LS) on subsequent CA after redo-TAVI in anatomies deemed at high risk of unfeasible CA. METHODS: Ex vivo, patient-specific models were printed three-dimensionally. Index TAVI was performed using ACURATE neo2 or Evolut PRO (TAV-1) at the standard implant depth and with different degrees of commissural misalignment (CMA). Redo-TAVI was performed using the balloon-expandable SAPIEN 3 Ultra (TAV-2) at different implant depths with commissural alignment. Selective CA was attempted for each configuration before and after LS in a pulsatile flow simulator. The leaflet splay area was assessed on the bench. RESULTS: In matched comparisons of 128 coronary cannulations across 64 redo-TAVI configurations, the overall feasibility of CA significantly increased after LS (60.9% vs 18.7%; p<0.001). The effect of LS varied according to the sinotubular junction height, TAV-1 design, TAV-1 CMA, and TAV-2 implant depth, given TAV-2 alignment. LS enabled CA for up to CMA 45° with the ACURATE neo2 TAV-1 and up to CMA 30° with the Evolut PRO TAV-1. The combination of LS and a low TAV-2 implant provided the highest feasibility of CA after redo-TAVI. The leaflet splay area ranged from 25.60 mm2 to 37.86 mm2 depending on the TAV-1 platform and TAV-2 implant depth. CONCLUSIONS: In high-risk anatomies, LS significantly improves CA feasibility after redo-TAVI for degenerated supra-annular self-expanding platforms. Decisions on redo-TAVI feasibility should be carefully individualised, taking into account the expected benefit of LS on CA for each scenario.

Evaluating the risk of return to the operating room across all elective orthopaedic procedures.

BACKGROUND: Although elective procedures have life-changing potential, all surgeries come with an inherent risk of reoperation. There is a gap in knowledge investigating the risk of reoperation across orthopaedics. We aimed to identify the elective orthopaedic procedures with the highest rate of unplanned reoperation and the reasons for these procedures having such high reoperation rates. METHODS: Patients in the NSQIP database were identified using CPT and ICD-10 codes. We isolated 612,815 orthopaedics procedures from 2018 to 2020 and identified the 10 CPT codes with the greatest rate of unplanned return to the operating room. For each index procedure, we identified the ICD-10 codes for the reoperation procedure and categorized them into infection, mechanical failure, fracture, wound disruption, hematoma or seroma, nerve pathology, other, and unspecified. RESULTS: Below knee amputation (BKA) (CPT 27880) had the highest reoperation rate of 6.92% (37 of 535 patients). Posterior-approach thoracic (5.86%) or cervical (4.14%) arthrodesis and cervical laminectomy (3.85%), revision total hip arthroplasty (5.23%), conversion to total hip arthroplasty (4.33%), and revision shoulder arthroplasty (4.22%) were among the remaining highest reoperation rates. The overall leading causes of reoperation were infection (30.1%), mechanical failure (21.1%), and hematoma or seroma (9.4%) for the 10 procedures with the highest reoperation rates. CONCLUSIONS: This study successfully identified the elective orthopaedic procedures with the highest 30-day return to OR rates. These include BKA, posterior thoracic and cervical spinal arthrodesis, revision hip arthroplasty, revision total shoulder arthroplasty, and cervical laminectomy. With this data, we can identify areas across orthopaedics in which revising protocols may improve patient outcomes and limit the burden of reoperations on patients and the healthcare system. Future studies should focus on the long-term physical and financial impact that these reoperations may have on patients and hospital systems. LEVEL OF CLINICAL EVIDENCE: IV.

Secondary Meniscectomy Rates and Risk Factors for Failed Repair of Ramp Lesions Performed at the Time of Primary ACL Reconstruction: An Analysis of 1037 Patients From the SANTI Study Group.

BACKGROUND: Studies evaluating secondary meniscectomy rates and risk factors for failure of ramp repair are sparse and limited by small numbers and heterogeneity. PURPOSES/HYPOTHESIS: The purposes were to determine the secondary meniscectomy rate for failure of ramp repair performed using a posteromedial portal suture hook at the time of anterior cruciate ligament reconstruction (ACLR) and to identify risk factors for secondary meniscectomy. It was hypothesized that patients who underwent ACLR combined with a lateral extra-articular procedure (LEAP) would experience significantly lower rates of secondary meniscectomy compared with those undergoing isolated ACLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients undergoing primary ACLR and ramp repair between 2013 and 2020 were included in the study. Final follow-up for each patient was defined by his or her last appointment recorded in a prospective database (with a study end date of March 2023). The database and medical records were used to determine whether patients had undergone secondary meniscectomy for failure of ramp repair. Survivorship of ramp repair (using secondary meniscectomy as an endpoint) was determined using the Kaplan-Meier method. Multivariate analysis was used to investigate possible risk factors. RESULTS: A total of 1037 patients were included in the study. The secondary meniscectomy rate after ramp repair was 7.7% at a mean final follow-up of 72.4 months. Patients without combined ACLR + LEAP were >2-fold more likely to undergo a secondary medial meniscectomy compared with those with combined ACLR + LEAP (hazard ratio, 2.455; 95% CI, 1.457-4.135; P = .0007). Age, sex, preoperative Tegner score, and time between injury and surgery were not significant risk factors for failure. CONCLUSION: The rate of secondary meniscectomy after ramp repair performed through a posteromedial portal at the time of primary ACLR was low. Patients who underwent isolated ACLR (rather than ACLR + LEAP) were >2-fold more likely to undergo a secondary medial meniscectomy for failure of ramp repair. Additional risk factors for failure of ramp repair were not identified.

10-Year Survival and Clinical Improvement of Meniscal Allograft Transplantation in Early to Moderate Knee Osteoarthritis.

BACKGROUND: Meniscal allograft transplantation (MAT) is a viable option for patients experiencing unicompartmental knee pain after total or subtotal meniscectomy. Nonetheless, caution is recommended when suggesting this procedure in the presence of knee osteoarthritis (OA) because of the higher risk of poor survival and outcomes. PURPOSE/HYPOTHESIS: The purpose was to document the long-term survival of MAT performed as a salvage procedure in patients with knee OA. The hypothesis was that MAT would significantly reduce pain and increase the function of the affected joint at a long-term follow-up compared with the preoperative condition, with a low number of failures and knee replacement surgeries. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 47 patients (37 men and 10 women) with symptomatic knee OA (Kellgren-Lawrence grades 2 or 3) treated with MAT were evaluated at baseline, 5 years, and a minimum 10-year final follow-up (11.1 ± 1 years) using the Lysholm score, the visual analog scale for pain, the Knee injury and Osteoarthritis Outcome Score subscales, and the Tegner score. A total of 44 patients had undergone previous surgeries. Patient satisfaction, revision surgeries, and failures were also recorded. RESULTS: A statistically significant improvement was observed in all clinical scores from the baseline assessment to the final follow-up. The Lysholm score improved significantly from 46.4 ± 17.2 at the preoperative assessment to 77.7 ± 20.4 at the intermediate follow-up (P < .001), with a significant decrease at the final follow-up (71 ± 23.3; P = .018). A similar trend was reported for the visual analog scale scale for pain, Knee injury and Osteoarthritis Outcome Score, and Tegner score, with no complete recovery to the previous sports activity level. A total of 33 patients required concurrent procedures, such as anterior cruciate ligament reconstructions, osteotomies, and cartilage procedures. Five patients underwent reoperation and were considered surgical failures, while 15 patients presented a clinical condition of <65 of the Lysholm score and were considered clinical failures. Among these, 4 patients were considered both surgical and clinical failures. CONCLUSION: MAT surgery has proven to be a valid option for improving pain and function even in OA joints (Kellgren-Lawrence grades 2 or 3), yielding satisfactory results despite a worsening clinical outcome in the long-term follow-up. Therefore, based on the data from this study, orthopaedic surgeons may consider recommending MAT as a salvage procedure even in knees affected by early to moderate OA, while advising patients that the need for combined interventions could potentially reduce graft survival.

Arthroscopic Bankart Repair With Remplissage in Anterior Shoulder Instability Results in Fewer Redislocations Than Bankart Repair Alone at Medium-term Follow-up of a Randomized Controlled Trial.

BACKGROUND: A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored. PURPOSE: To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. "Failure" was defined as a redislocation, and "overall recurrent instability" was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed. RESULTS: A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios. CONCLUSION: For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage. REGISTRATION: NCT01324531 (ClinicalTrials.gov identifier).

Salvage Latarjet may provide worse outcomes in terms of recurrent instability and returning to sports compared to primary Latarjet: a systematic review of comparative studies.

BACKGROUND: The Latarjet procedure (LP) is performed as a primary stabilization procedure (primary LP) and a salvage procedure when an earlier shoulder stabilization procedure has failed (salvage LP). However, whether primary LP or salvage LP provides better outcomes for anterior shoulder instability remains unknown. METHODS: Two independent reviewers performed the literature search based on the PRISMA guidelines. A comprehensive search of PubMed, Embase, web of science and Cochrane Library was performed from their inception date to December 4, 2023. Inclusion criteria mainly included the comparison of postoperative outcomes between primary and salvage LP, English language, and full text availability. Two reviewers independently examined the literature, collected data, and evaluated the methodological robustness of the included studies. The Methodological Index for Nonrandomized Studies was used to evaluate the quality of nonrandomized studies. Recurrent instability, complications, reoperations, return to sports, patient-reported outcomes, and range of motion were assessed. Statistical evaluations were conducted using Manager V.5.4.1 (The Cochrane Collaboration, Software Update, Oxford, UK). RESULTS: Twelve studies were included in the systematic review, with 940 shoulders undergoing primary LP and 631 shoulders undergoing salvage LP. Statistically significant differences in favor of primary LP were found in 2 of the 11 and 2 of 4 included studies in terms of recurrent instability and returning to the same sports (RTS) at preinjury level, respectively. In terms of the visual analog scale, subjective shoulder value and the Western Ontario Shoulder Instability Index, 2 of the 4, 1 of the 3 and 1 of the 3 included studies reported statistically significant differences in favor of primary LP. Differences were not noticed regarding complications, reoperations, the time to RTS, the Rowe score, the Athletic Shoulder Outcome Scoring System, and forward flexion. CONCLUSION: Current evidence suggests that compared with primary LP, salvage LP may provide inferior postoperative outcomes in terms of recurrent instability and the rate of RTS at preinjury level. Primary and salvage LP may yield comparable efficacy in terms of complications, reoperations, the rate of RTS, the time to RTS, pain, shoulder function, and range of motion. PROSPERO ID: CRD42023492027.

Displaced Proximal Tibia Fracture After Proximal Tibial Autograft Harvest: A Case Report.

Background: A 60-year-old female underwent proximal tibial autograft harvest for a Cotton osteotomy. Her postoperative course was complicated by psychogenic non-epileptic seizure (PNES) episodes leading to unintentional weightbearing. Knee radiographs at 6 weeks post-procedure demonstrated a displaced proximal tibia fracture through the autograft harvest site. Further clinical review revealed metabolic derangements consistent with secondary hyperparathyroidism. Initial nonoperative treatment led to atrophic varus nonunion requiring definitive treatment with total knee arthroplasty with revision components. Conclusion: This case describes a rare complication of proximal tibial autograft harvest and highlights the importance of preoperative metabolic workup and bone health optimization.Level of Evidence: IV.

Total Hip Arthroplasty After Peri-Acetabular Osteotomy Results in Significant Improvement in Hip Function With Low Revision Rates at Mid-Term Follow-Up.

Background: Bernese periacetabular osteotomy (PAO) improves symptoms and delays degenerative changes in patients with acetabular dysplasia. Yet, eventual total hip arthroplasty (THA) is needed in many of these patients. The impact of PAO on subsequent THA outcomes is not well defined. The purpose of this study is to define: 1) clinical outcomes, 2) post-operative complications and 3) implant survivorship for patients undergoing THA after prior ipsilateral PAO. Methods: A retrospective review was conducted at three institutions to identify individuals undergoing THA after ipsilateral PAO surgery with minimum 1 year follow up. Patient reported outcome measures (PROMs) were collected preoperatively and at final follow-up. Surgical details, radiographic and clinical outcomes, and major complications according to the modified Dindo-Clavien classification system were identified through review of the medical record. Regression analysis and student's t-test were used to compare pre- and post-operative outcome scores. Kaplan-Meier analysis was performed to estimate reoperation-free survivorship. Results: A total of 113 THA in 112 patients were identified with initial review. 103 hips had a minimum of 1-year follow-up and an average follow of 5 ± 4 years (range, 1 to 20). 10 hips (9%) were lost to follow-up leaving 103 (91%) hips available for review with a minimum of 1-year follow-up (mean = 5 years). Mean interval from PAO to THA was 7.7 years (range, 2-15). The average post-operative mHHS improved 37 points (50 to 87, P < 0.001) when compared to pre-operative scores. Eight patients (7.1%) experienced a major grades III-V) surgical complication. These included 2 cases of instability, 2 cases of acetabular loosening, and one case each of periprosthetic fracture, wound dehiscence, periprosthetic infection, acetabular loosening and pneumonia. Failures occurred early at average 3.2 years and survivorship analysis for all-cause revision demonstrated 96% survivorship at both 5 and 10 years. Conclusion: THA after PAO achieves significant clinical improvement and satisfactory survivorship (96%) at mid-term follow-up, with a major complication rate of 7.1%. Level of Evidence: III.

Preoperative CT Scan is not Associated with Shorter Surgical Time or Improved Patient Outcomes for Trimalleolar Ankle Fractures.

Background: Posterior malleolar involvement can drastically affect patient outcomes. Literature has supported the use of preoperative Computed Tomography (CT) to assess posterior malleolar fracture morphology. The purpose of this study is to determine whether preoperative CT is associated with significant improvement in surgical time, postoperative complications, reoperation rates in trimalleolar ankle fractures. Surgeons were also asked to complete survey regarding use of CT scans to gauge utility preoperatively. Methods: Adult patients with trimalleolar ankle fractures who underwent operative fixation between 2018-2020 were retrospectively reviewed. Primary outcomes included surgical time, postoperative complications, and reoperations. Secondary outcome was presence of posterior malleolar fixation. 15 surgeons who performed ankle ORIF were surveyed to gain information regarding why or why not preoperative CT scan was obtained. Results: 288 patients with trimalleolar ankle fractures were included, 94 had preoperative CT scans (32.6%). No significant differences found in patient age, gender, BMI, smoking status between the groups that did and did not have preoperative CT scan. No significant differences were observed in AO/OTA classification between groups. Average surgical time was significantly higher in group that received a preoperative CT (114 without CT vs. 145 with CT, p<0.05). Complications (10.3% no CT vs 7.4% with CT, p=0.55) and reoperations (6.7% without CT vs. 7.4% with CT, p=0.16) not significantly different between groups. No significant difference was observed in rate of posterior malleolus fixation between groups (43.8% without CT vs 39.4% with CT; p=0.52). Of surveyed surgeons, 87% reported they don't routinely obtain preoperative CT scan for trimalleolar ankle fractures. Most common reasons for preoperative scans were deciding on approach/positioning, assessing for impaction, determining the size of the posterior malleolus. Conclusion: Although preoperative CT scans are obtained in one third of patients with operative trimalleolar ankle fractures, we did not find an improvement in surgical time, complications, and reoperation. Level of Evidence: III.

Lag Screw Exchange for Impinging Lateral Hardware Following Intramedullary Nailing of Intertrochanteric Hip Fractures - A Case Series Demonstrating Efficacy.

Background: This study aimed to demonstrate the feasibility of lag screw exchange for painful lateral soft tissue impingement in patients initially treated with cephalomedullary nailing (CMN) for an intertrochanteric hip fracture. Methods: Ten patients initially treated with CMN for unstable intertrochanteric fractures presenting with persistent pain and radiographic evidence of lag screw lateral migration were treated with exchange of original screw with shorter lag screw buried in the lateral cortex to prevent impingement. Patients were evaluated for resolution of pain and achievement of pre-fracture ambulatory status at 6 months post-operatively. Results: Average age was 71.5 years (range: 62-88). Average length of follow-up was 24.9 months. All patients were female, with an average Charlson Comorbidity Index of 1.0 (0-3) and average Body Mass Index of 22.2 (16.0-31.1). Five of ten patients (50.0%) were treated with a cortisone injection in the trochanteric bursa prior to screw exchange with temporary pain relief. Five (50.0%) patients presented with limited range of hip motion. Five (50.0%) had history of prior or current bisphosphonate use. Average lag screw prominence was noted to be 12.2mm (7.9-17.6mm) on radiographic evaluation. Screw exchange was performed at an average of 18.6 months (5.4-44.9 months) following the index procedure. Average operating time of the screw exchange procedure was 45.3 minutes (34-69 minutes) and blood loss was <50mL in all cases. Replacement lag screws were an average of 16.0mm (10-25mm) shorter than the initial screw. All patients achieved complete or significant resolution of lateral thigh pain, and nine (90%) returned to pre-fracture ambulatory status by eight weeks after screw exchange. All patients remained pain free at six months after screw exchange. Conclusion: Lag screw exchange is a efficacious method to address the mechanical irritation of laterally protruding lag screws following IT hip fracture, while also prophylaxing against subsequent femoral neck fractures. Level of Evidence: IV.

Utility of Debridement, Antibiotics, and Implant Retention for Acute Periprosthetic Joint Infection in Revision Total Knee Arthroplasty.

Background: Periprosthetic joint infection (PJI) in revision arthroplasty presents as a challenging complication that is difficult to manage. Debridement, antibiotics, and implant retention (DAIR) is a recognized treatment option, although few studies have investigated success rates in addition to eventual amputation rates for failed cases. Methods: A retrospective review of 365 DAIR cases was performed at a single institution from 2008-2020. Patient records were thoroughly reviewed for inclusion and exclusion criteria by multiple members of the research team, discovering 45 cases met criteria for the study cohort. Demographic information, medical history, culture data, and surgical history, were recorded. DAIR's overall survivorship was evaluated with a Kaplan-Meier (KM) survival curve. Additional KM curves were constructed to compare acute postoperative versus acute hematogenous infections as well as DAIR survivorship relative to infecting organism. Results: DAIR's success rate in revision TKA was 77% at 0.5 years, 56% at 2 years and 46% at 5 years. No significant difference was noted in survivorship when comparing acute postoperative and acute hematogenous cases at 5 years (29 vs 51%, P=0.64). No significance differences in survivorship were noted according to infecting organism (P =0.30). Median follow up duration was significantly lower in the failed DAIR cohort with a median time of 0.5 years in comparison to 1.7 years for the successful DAIR group (P =0.012). There were 20 DAIR cases that failed, 10 of which resulted in eventual amputation. Conclusion: DAIR's success rate for managing acute PJI in revision arthroplasty cases was 46% at 5 years. Of the 20 failed DAIR cases, 10 resulted in eventual amputation. DAIRs utility in managing these complicated PJI cases in the setting of revision arthroplasty is concerning with low success rates and high rates of amputation in failed cases. Level of Evidence: III.

Characteristics and Trends of Strabismus Surgeries at a Tertiary Hospital Over 2 Decades - What Can Be Learned for Years to Come?

PURPOSE: To analyze characteristics and trends of strabismus surgeries in an Israeli hospital over 2 decades. METHODS: A descriptive, retrospective study including all strabismus surgeries (666) performed during 2000-2019 at an Israeli tertiary hospital. Electronic medical records (EMRs) were directly retrieved to produce an anonymized database. RESULTS: No trends were evident for age, sex, or ethnicity (p = .294, 0.914 and p = .167, respectively). The mean number of horizontal muscles remained stable, while an increase was noted in the mean number of muscles operated on to repair vertical strabismus (p < .0001). Among acquired cases, a 2.67-fold increase was noted in the proportion of spontaneous strabismus and a decrease of traumatic causes to a third (p < .001). An increase was noted in the proportion of exotropia among horizontal strabismus corrections (p = .022), and esotropia correction techniques distribution changed (p = .004). Reoperations comprised a third of all cases during both decades (p = .198). Reoperations were more prevalent among younger and Jewish patients (p < .001 and p = .024, respectively). Techniques to correct esotropia and exotropia differed significantly between primary surgeries and reoperations (p < .00001 each). CONCLUSIONS: The complexity of surgical techniques increased over time. Ethnic minorities were less prone to reoperations.

Robotic arm-assisted conversion of unicompartmental knee arthroplasty to total knee arthroplasty.

Aims: Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up. Methods: This prospective study included 16 patients undergoing robotic arm-assisted revision of UKA to TKA versus 35 matched patients receiving robotic arm-assisted primary TKA. In all study patients, the following data were recorded: operating time, polyethylene liner size, change in haemoglobin concentration (g/dl), length of inpatient stay, postoperative complications, and hip-knee-ankle (HKA) alignment. All procedures were performed using the principles of functional alignment. At most recent follow-up, range of motion (ROM), Forgotten Joint Score (FJS), and Oxford Knee Score (OKS) were collected. Mean follow-up time was 21 months (6 to 36). Results: There were no differences between the two treatment groups with regard to mean change in haemoglobin concentration (p = 0.477), length of stay (LOS, p = 0.172), mean polyethylene thickness (p = 0.065), or postoperative complication rates (p = 0.295). At the most recent follow-up, the primary robotic arm-assisted TKA group had a statistically significantly improved OKS compared with the revision UKA to TKA group (44.6 (SD 2.7) vs 42.3 (SD 2.5); p = 0.004) but there was no difference in the overall ROM (p = 0.056) or FJS between the two treatment groups (86.1 (SD 9.6) vs 84.1 (4.9); p = 0.439). Conclusion: Robotic arm-assisted revision of UKA to TKA was associated with comparable intraoperative blood loss, early postoperative rehabilitation, functional outcomes, and complications to primary robotic TKA at short-term follow-up. Robotic arm-assisted surgery offers a safe and reproducible technique for revising failed UKA to TKA.

Surgery for Active Infective Endocarditis on Mitral Valve: Anatomical, Surgical, and Disease Factors as Long-Term Outcome Modifiers.

Background and Objectives: Determinants of long-term outcomes after surgery for native mitral valve endocarditis have not been thoroughly investigated. The aim of this study was to assess anatomical, disease, and surgical risk factors for long-term mortality and need of reintervention, in patients undergoing mitral valve surgery for active endocarditis. Materials and Methods: Patients who underwent surgery for active native mitral valve endocarditis at three academic centres, between 2000 and 2022, were analysed. The primary outcome was long-term survival. The secondary outcome was the freedom from mitral reoperation. Survival curves were constructed with Kaplan-Meier methodology. Multivariable Cox regression was used to identify demographic, anatomical, disease, and surgical factors associated with late mortality and reoperation. Results: 335 consecutive patients with active mitral endocarditis were analysed. Two hundred and one patients (70.5%) had infection confined to the valve cusp whereas 89 (25.6%) had invasive disease extended to the annulus and surrounding tissues. Preoperative neurological events occurred at the diagnosis in 52 cases. Streptococci were the most common causative organisms followed by Staphylococcus aureus, Coagulase-negative Staphylococcus, and Enterococcus. Valve repair was performed in 108 patients (32.2%). Survival at 5 and 10 years was 70.1% and 59.2%, respectively. Staphylococcus emerged as an independent predictor of late mortality, along with age, chronic obstructive pulmonary disease, and previous cardiac surgery. Survival was considerably reduced in patients with S. aureus compared with those without (log rank p < 0.001). The type of surgery (repair vs. replacement) did not emerge as a risk factor for late mortality and reoperation. Seventeen patients underwent mitral reoperation during the follow-up. The 5- and 10-year freedom from reoperation was 94.7% and 91.8%, respectively. Conclusions: Active mitral valve endocarditis remains a life-threatening disease with impaired survival. While lesion characteristics influenced surgical decision-making and intraoperative management, their impact on long-term survival and freedom from reintervention appears to be moderated by other factors such as infecting pathogens and patient comorbidities.

Complex Primary Hyperparathyroidism: Hereditary and Recurrent Disease.

Primary hyperparathyroidism can be sporadic or part of a genetic syndrome, such as MEN1 or HPT-JT. Diagnosis of hereditary HPT requires a thorough history and physical. Parathyroidectomy is curative with greater than 95% success. However, some patients have persistent or recurrent disease requiring reoperation. Reoperative parathyroidectomy is technically challenging, and localizing the pathologic gland can difficult. Patients needing reoperation should undergo evaluation by a high-volume surgeon. Care should be taken to obtain all of the preoperative workup and operative note from the initial surgery. Radioguided parathyroidectomy can be safely and effectively performed in patients with hereditary HPT or undergoing reoperative surgery.