Tag Archive | reoperation

Complex Reconstructions Call for Creative Solutions

Metastatic disease around the acetabulum often leads to patients needing total hip arthroplasty (THA), plus supplementary acetabular reconstruction. Traditional methods such as the Harrington reconstruction technique have shown good short-term outcomes, but there are concerns that a cemented acetabular component in this setting is at risk for failure in the longer term. Newer approaches, such as using cementless tantalum acetabular components with augments, have also shown promise. Houdek et al. compared these 2 approaches and report the findings in the July 15, 2020 issue of The Journal.

The authors followed 115 patients who underwent THA for metastatic disease at 2 tertiary sarcoma centers, with a mean 4-year follow-up among surviving patients. They compared the outcomes of 78 Harrington reconstructions with those of 37 tantalum reconstructions, with surgeons at each center exclusively performing 1 of the 2 techniques. The cohorts were comparable at baseline regarding age, sex, severity of systemic disease and acetabular defects, and pelvic discontinuity. Functional outcomes improved in both groups, but there were no significant between-group differences. The main statistical finding of the study was that a higher percentage of patients in the Harrington reconstruction group (27%) needed a reoperation than those in the tantalum group (8%), with a hazard ratio of 4.59 (p=0.003).

Historically, there has been an understandable lack of long-term follow-up in this fragile patient population; 94 of the 115 patients in this study died of systemic disease progression at an average of 16 months after surgery. Overall patient survival was only 34% at 2 years and 15% at 10 years. Despite these grim mortality numbers, Houdek et al. claim that with advances in treatments for metastatic cancer, patients are living longer and therefore may benefit from more durable acetabular reconstructions.

This study leaves unanswered the question of whether the theoretic advantage of bony ingrowth with tantalum is what accounted for the decreased reoperation rates. As Albert Aboulafia, MD notes in his Commentary on this study, the authors did not review radiographs or postmortem histology to look for evidence of osseointegration. But Houdek et al. do present a potential avenue for further investigation. And what remains clear is that metastatic disease around the hip is a complex problem, and that we as surgeons should continue to investigate promising treatment strategies to improve patient outcomes (even if only palliative) and enhance biological fixation.

Click here for a 4-minute video in which co-author Matthew Houdek explains the rationale for this study.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Reoperation Rates for Wrist-Arthritis Treatments

With contemporary teaching and advanced-imaging diagnostic protocols, the incidence of advanced wrist arthritis related to scaphoid nonunion and carpal instability seems to be decreasing. When this condition does present, the longstanding debate about treatment pits preserving the carpal bone mass with a 4-corner arthrodesis (FCA) against resecting the proximal row of carpal bones (proximal row carpectomy, or PRC) to provide better motion. At issue have been concerns about the durability and reoperation rates for these two treatment approaches.

In the June 17, 2020 issue of The Journal, Garcia et al. tap into the Veterans Health Administration  data warehouse to help clarify this treatment dilemma. The authors identified 1,168 patients with stage-II SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse) patterns of wrist arthritis. The outcomes of interest were subsequent conversion to total wrist arthrodesis and secondary surgical procedures after FCA and PRC.

Using propensity score analysis, the authors established matched cohorts of 251 cases of each procedure. The rate of conversion to total wrist arthrodesis was virtually identical in both matched groups, but far fewer patients who underwent FCA avoided a subsequent nonarthrodesis operation compared with those who underwent PRC (83.5% vs 99.7%, respectively).

Based on these findings and the evidence in previously published literature, the authors say, “We believe that PRC may be preferable to FCA in patients with symptomatic stage-II SLAC/SNAC wrist arthritis.” I think this choice should always be the result of shared decision making that itemizes the pros and cons of both procedures—especially taking into account patient preferences related to expected functional outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

THA in the Very Young: Midterm Results

Orthopaedic surgeons work hard to find good alternatives to total hip arthroplasty (THA) in patients <50 years old. That’s because the high functional demands and longer remaining lifespan in these patients can result in excessive wear of the bearing surfaces and loosening of the components—both of which have been documented in multiple publications. But what happens when THA is the most viable solution for a posttraumatic or congenital hip problem in a very young patient because arthrodesis or other osteotomies are not feasible?

In the March 18, 2020 issue of The Journal, Pallante et al. report medium-term outcomes of THA in 78 patients who were ≤20 years of age at the time of surgery, with follow-ups ranging from 2 to 18 years. The findings included the following:

  • 10-year survivorship for reoperation of 95.0%
  • 10-year survivorship for revision of 97.2%
  • 10-year survivorship for complications of 89.5%

Overall, the linear articular wear averaged 0.019 mm/yr in the ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene bearings studied, and the average modified Harris hip score in the cohort was 92.

However, despite these impressive clinical and survivorship outcomes, I advise orthopaedists not to lower their resistance to performing THA on these very young patients, many of whom present with hip problems caused by deforming conditions such as Legg-Calve-Perthes disease. We really need 30 to 40 years of outcome data to truly  understand what happens with function, revision rates, and wear characteristics in this population. Having said that, I am confident that this group from Mayo will continue reporting on this patient cohort at 5- to 10-year intervals, so that the worldwide orthopaedic community can keep learning from this experience.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

More Data on Outpatient vs Inpatient Joint Replacement

TKA for OBuzzIn addition to the Pearl Diver-based retrospective study by Arshi et al. on one-year complications after outpatient knee replacement, the December 6, 2017 issue of JBJS contains a NSQIP-based retrospective study by Basques et al. that compares 30-day adverse events and readmissions among 1,236 patients who underwent same-day-discharge hip or knee (total or unicompartmental) arthroplasty with an equal number of propensity score-matched patients who were discharged at least 1 calendar day after the procedure.

When analyzing all three procedures together, the authors found no overall between-group differences in the rates of any adverse event (severe or minor) or readmission. However, when authors analyzed individual adverse events, the same-day group had decreased thromboembolic events and increased 30-day reoperations compared to inpatients. Analysis of individual procedures revealed an increased 30-day reoperation rate for same-day total knee arthroplasty (TKA), compared with inpatient TKA. Overall, infection was the most common reason for reoperation and readmission following same-day procedures.

As with the Arshi et al. study, the limitations of the database prevented these authors from accounting for physician or hospital volume. However, they did identify several preoperative patient characteristics that increased the risk of 30-day readmission among same-day patients, and from those findings Basques et al. concluded that “obese patients, older patients [≥85 years of age], and those with diabetes mellitus may not be appropriate candidates for same-day procedures.”

Smoking Boosts Rate of Reoperation for Infection after TJA

Smoking Image from Nick.jpegHere’s one thing about which medical studies have been nearly unanimous:  Smoking is a health hazard by any measure. In the February 15, 2017 edition of The Journal of Bone & Joint Surgery, Tischler et al. put some hard numbers on the risk of smoking for those undergoing total joint arthroplasty (TJA).

After controlling for confounding factors, the authors of the Level III prognostic study found that:

  • Current smokers have a significantly increased risk of reoperation for infection within 90 days of TJA compared with nonsmokers.
  • The amount one has smoked, regardless of current smoking status, significantly contributed to increased risk of unplanned nonoperative readmission.

In a commentary on the Tischler et al. study, William, G. Hamilton, MD says, “…as physicians, we should work cooperatively with our patients to enhance outcomes by attempting to reduce these modifiable risk factors. We can educate patients and can suggest smoking cessation programs and weight loss regimens that may not only improve the risk profile during the surgical episode, but also improve the patients’ overall health.”