Tranexamic acid in total hip arthroplasty: An umbrella review on efficacy and safety

Purpose

This comprehensive review was conducted to assess the effects of tranexamic acid (TXA) on blood loss, venous thromboembolism (VTE) risk, and wound complications following total hip arthroplasty (THA). Additionally, it sought to evaluate the effects of various TXA dosages, modes of administration, and combinations with other antifibrinolytic drug.

Methods

In search of systematic reviews and meta-analyses on the use of TXA in THA patients, we searched extensively through databases including Scopus, the Cochrane Library, Embase, Medline, the Web of Science, PubMed, and Google Scholar. We discovered 23 meta-analyses covering 32,442 patients overall that fulfilled our study criteria, spanning the period from the creation of these databases until May 2023.

Results

This comprehensive review's meta-analyses, which together examined over 35,000 patients, repeatedly demonstrated how TXA administration during THA successfully lowers perioperative blood loss and the need for transfusions. TXA reduced total blood loss by an average of 151-370 ml, postoperative hemoglobin levels by 0.5-1.1 g/dL, and transfusion rates by 19-26% on average when compared to control groups. The information gathered did not indicate that using TXA significantly increased the risk of VTE or wound complications. When comparing different TXA doses, administration techniques, or its use in conjunction with other anti-fibrinolytic therapies, no discernible differences were found in terms of efficacy or safety outcomes.

Conclusion

The comprehensive review clearly indicates that TXA improves THA outcomes without increasing the risk of adverse events by lowering blood loss and the requirement for transfusions. This insightful information can help surgeons decide whether to use TXA during THA procedures.

Risks of suboptimal and excessive thyroid hormone replacement across ages

BACKGROUND

Hypothyroidism is prevalent at all ages and represents a non-communicable disease with preventable consequences.

METHOD

Narrative review.

REVIEW

In children and adolescents, the most devastating consequences of undertreatment with levothyroxine (LT4) are poor growth and development. Delayed treatment in congenital hypothyroidism can lead to permanent brain damage. In young to middle-aged adults, symptoms are often overlooked, and treatment delayed by many years. The resulting consequences are also at this age group compromised brain and physical function but less severe and partly reversible with treatment. The under-treated condition often results in a higher risk of, e.g., increased cardiovascular disease burden, obesity, hypertension, poor physical capacity, and poor quality of life. Excessive replacement is at all adult age groups associated with increased risk of cardiac death, osteoporosis, loss of muscle function, psychological instability and poor quality of life. In young fertile women, the consequences of undertreatment with LT4 are subnormal fertility, recurrent pregnancy loss, compromised fetal growth, and neurocognitive development. On the other hand, excessive LT4 treatment has been related to gestational hypertension, preeclampsia and preterm birth. In the elderly, care must be given to avoid confusing a slightly high age-related serum TSH with requirement for LT4 treatment in a truly hypothyroid patient. Excessive LT4 treatment in patients of high age is associated with an increased mortality.

CONCLUSION

Suboptimal and excessive LT4 replacement of the preventable non-communicable disease hypothyroidism requires more focus from the healthcare system and from the global political systems to prevent the personally devastating and socioeconomically challenging consequences.

Spallation and particles infusion into the extracorporeal circuit during CRRT: a preventable phenomenon

Patients in intensive care are exposed to the risk of microparticle infusion via extracorporeal lines and the resulting complications. A possible source of microparticle release could be the extracorporeal circuit used in blood purification techniques, such as continuous renal replacement therapy (CRRT). Disposable components of CRRT circuits, such as replacement bags and circuit tubing, might release microparticles such as salt crystals produced by precipitation in replacement bags and plastic microparticles produced by spallation. In-line filtration has proven effective in retaining microparticles both in in-vitro and in-vivo studies. In our study, we performed an in-vitro model of CRRT-treatment with the aim of detecting the microparticles produced and released into the circuit by means of a qualitative and quantitative analysis, after sampling the replacement and patient lines straddling a series of in-line filters. Working pressures and flows were monitored during the experiment. This study showed that microparticles are indeed produced and released into the CRRT circuit. The inclusion of in-line filters in the replacement lines allows to reduce the burden of microparticles infused into the bloodstream during extracorporeal treatments, reducing the concentration of microparticles from 14 mg/mL pre in-line filter to 11 mg/mL post in-line filter. Particle infusion and related damage must be counted among the pathophysiological mechanisms supporting iatrogenic damage due to artificial cross-talk between organs during CRRT applied to critically ill patients. This damage can be reduced by using in-line filters in the extracorporeal circuit.

Total Hip Arthroplasty in patients under 50 years old: does cementless fixation have better results?

BACKGROUND

Cementless fixation for hip arthroplasties has increased in the last decades, particularly in younger patients. The purpose of this study was to compare the long-term results three different types of fixations in patients under 50 years old.

METHODS

Cemented, hybrid and cementless fixations were assessed in patients under 50 years old with a minimum follow-up of 8 years. Loosening, demarcation, complications, and prosthesis survival were assessed. Functional analysis was performed with the modified Harris Hip Score and Visual analogue scale was collected.

RESULTS

Final series consisted in 222 patients. Significant improvement was observed regarding mHHS and VAS score in each group. We observed statistically significant difference regarding demarcation between the groups (p<0.001). The higher rate of acetabular and femoral stem loosening was observed in the cemented (20.0%) and hybrid (18.9%) group. The lowest prosthesis survival rate after 16 years was observed in hybrid group (p<0.001).

CONCLUSION

Total hip replacement has good long-term clinical and functional outcomes. The lowest rate of prosthesis survival was observed in hybrid group with 84.2% after 16 years.

Impact of preoperative anemia on patients undergoing total joint replacement of lower extremity: a systematic review and meta-analysis

PURPOSE

Preoperative anemia increases postoperative morbidity, mortality, and the risk of allogeneic transfusion. However, the incidence of preoperative anemia in patients undergoing total hip arthroplasty and total knee arthroplasty (TKA) and its relationship to postoperative outcomes has not been previously reported.

METHODS

We conducted a comprehensive literature search through PubMed, Cochrane Library, Web of Sincien, and Embase from inception to July 2023 to investigate the prevalence of preoperative anemia in patients undergoing Total Joint Arthroplasty, comorbidities between anemic and non-anemicpatients before surgery, and postoperative outcomes. postoperative outcomes were analyzed. Overall prevalence was calculated using a random-effects model, and heterogeneity between studies was examined by Cochran's Q test and quantified by the I2 statistic. Subgroup analyses and meta-regression analyses were performed to identify sources of heterogeneity. Publication bias was assessed by funnel plots and validated by Egger's test.

RESULTS

A total of 21 studies with 369,101 samples were included, all of which were retrospective cohort studies. 3 studies were of high quality and 18 studies were of moderate quality. The results showed that the prevalence of preoperative anemia was 22% in patients awaiting arthroplasty; subgroup analyses revealed that the prevalence of preoperative anemia was highest in patients awaiting revision of total knee arthroplasty; the highest prevalence of preoperative anemia was found in the Americas; preoperative anemia was more prevalent in the female than in the male population; and preoperative anemia with a history of preoperative anemia was more common in the female than in the male population. patients with a history of preoperative anemia; patients with joint replacement who had a history of preoperative anemia had an increased risk of infection, postoperative blood transfusion rate, postoperative blood transfusion, Deep vein thrombosis of the lower limbs, days in hospital, readmission within three months, and mortality compared with patients who did not have preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia in patients awaiting total joint arthroplasty is 22%, and is higher in TKA and female patients undergoing revision, while preoperative anemia is detrimental to the patient's postoperative recovery and will increase the risk of postoperative complications, transfusion rates, days in the hospital, readmission rates, and mortality.

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

THE EFFECTS OF DRAINAGE TUBE ON PAIN AND FUNCTIONAL RECOVERY AFTER UNICOMPARTMENTAL KNEE ARTHROPLASTY

Objective

The objective of this study was to evaluate the impact of drainage tube placement on postoperative pain, recovery, and opioid consumption within a 72-hour period following unicompartmental knee arthroplasty (UKA).

Methods

Patients with medial knee osteoarthritis who underwent UKA from January 2019 to August 2020 were enrolled in the study and divided into two groups based on whether they received a drain postoperatively.

Results

The drainage group had significantly lower VAS scores on day 1, day 2, and day 3, in addition to significantly smaller changes in the circumference of the knee joint within 3 days postoperatively (P <0.05). The ROM in the drainage group significantly increased at 3 days and 1 month post-surgery, with a statistically significant difference in morphine consumption between the two groups at 3 days (P<0.05). The incidence of postoperative nausea and vomiting (5 cases) and wound bleeding (1 case) was lower in the drainage group compared to the non-drainage group (P<0.05).

Conclusions

The placement of a drainage tube in UKA may reduce the swelling of knee joint and pain, which not only reduces the use of Opioid but also facilitates early functional activities of the knee joint. Level of Evidence III; Retrospective Comparative Study.

Patient reported outcomes following total shoulder arthroplasty and hemiarthroplasty: An analysis of data from the National Joint Registry

INTRODUCTION

Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are used in the management of end stage glenohumeral arthritis. Improvement in shoulder function and resolution of symptoms are high priorities for patients. The aim of this study was to compare patient-reported outcome measures (PROMs) following TSA and HA.

METHOD

Records from the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man were linked to the PROMs dataset. The study included anatomical shoulder arthroplasties performed for osteoarthritis in patients with an intact rotator cuff. Patients with preoperative and postoperative Oxford Shoulder Scores (OSSs) were included. The improvement in OSS at 6 months and 5 years, and the trend in scores over time were analyzed for each prosthesis. A cohort of 2,002 patients were matched on 10 variables using propensity scores. OSSs at 6 months following TSA versus HA were compared in the matched sample.

RESULTS

There was a significant improvement in the OSS in both groups (p<0.001). At 6 months the OSSs were superior following TSA compared to HA (median 42 vs 36, p<0.001). The median score at 5 years was 44 following TSA and 35 following HA. Score distributions were skewed towards the maximum score. The highest possible score (48) was achieved in 28% (134/478) of TSAs and 9% (20/235) of HAs at 5 years. The improvement in the preoperative to 6-month OSS reached the minimal clinically important difference of 5.5 in 92% (1653/1792) of TSAs and 80% (416/523) of HAs. At 5 years this improvement was maintained in 91% (339/374) of TSAs and 78% (136/174) of HAs.

CONCLUSION

TSA resulted in superior OSSs at 6 months in patients with osteoarthritis. The median OSS improved from 6 months to 5 years following TSA, however there was a small decline in scores following HA. A ceiling effect was shown in the OSS following TSA at 5 years.

BENEFITS OF A CLINICAL PATHWAY IN TOTAL KNEE ARTHROPLASTY

Objective

Demonstrate whether a multiprofessional Clinical Pathway Program in Total Knee Arthroplasty (CPPA) contributesto optimizing hospital care.

Method

Retrospective study of medical data of care indicators in 310 patients divided into two groups: A- who underwent arthroplasty in the last biennium before the introduction of the CPPA (n=144) and group B- who underwent TKA in the biennium after the introduction of the CPPA (n=166).

Results

Postoperative showed a significant difference in favor of group B over group A for hospitalization time in days 4.33 ± 2.79 and 5.4 ± 1.67 (p<0.001), time of prophylactic antibiotic in hours 28.13 ± 33.77 and 81.49 ± 40.91 (p<0.001), referral to the intensive care unit 40.9% and 73.4% (p<0.001), initiation of thromboprophylaxis within 24 hours 97.9% and 82.5% (p<0.001), use of elastic stockings and/or intermittent compression prescribed for thromboprophylaxis 89.5% and 31.2% (p<0.001), initiation of rehabilitation within 24 hours 90.1% and 66.1% (p<0.001), readmissions within 30 days 4.1% and 3% (p = 0.76), readmissions 90 days 2.7% and 6.6% (p = 0.183), transfusions 5.5% and 15.2% (p = 0.033).

Conclusion

The implementation of a multiprofessional CPPA contributed to the implementation of care protocols, favoring greater patient safety. Level of Evidence III; Retrospective Comparative Study.

Transcatheter treatment of the tricuspid valve: current status and perspectives

Transcatheter tricuspid valve interventions (TTVI) are emerging as alternatives to surgery in high-risk patients with isolated or concomitant tricuspid regurgitation. The development of new minimally invasive solutions potentially more adapted to this largely undertreated population of patients, has fuelled the interest for the tricuspid valve. Growing evidence and new concepts have contributed to revise obsolete and misleading perceptions around the right side of the heart. New definitions, classifications, and a better understanding of the disease pathophysiology and phenotypes, as well as their associated patient journeys have profoundly and durably changed the landscape of tricuspid disease. A number of registries and a recent randomized controlled pivotal trial provide preliminary guidance for decision-making. TTVI seem to be very safe and effective in selected patients, although clinical benefits beyond improved quality of life remain to be demonstrated. Even if more efforts are needed, increased disease awareness is gaining momentum in the community and supports the establishment of dedicated expert valve centres. This review is summarizing the achievements in the field and provides perspectives for a less invasive management of a no-more-forgotten disease.

Optimizing periprosthetic fracture management and in-hospital outcome: insights from the PIPPAS multicentric study of 1387 cases in Spain

BACKGROUND

The incidence of all periprosthetic fractures (PPF), which require complex surgical treatment associated with high morbidity and mortality, is predicted to increase. The evolving surgical management has created a knowledge gap regarding its impact on immediate outcomes. This study aimed to describe current management strategies for PPF and their repercussions for in-hospital outcomes as well as to evaluate their implications for the community.

METHODS

PIPPAS (Peri-Implant PeriProsthetic Survival Analysis) was a prospective multicentre observational study of 1387 PPF performed during 2021. Descriptive statistics summarized the epidemiology, fracture characteristics, management, and immediate outcomes. A mixed-effects logistic regression model was employed to evaluate potential predictors of in-hospital mortality, complications, discharge status, and weight-bearing restrictions.

RESULTS

The study encompassed 32 (2.3%) shoulder, 4 (0.3%) elbow, 751 (54.1%) hip, 590 (42.5%) knee, and 10 (0.7%) ankle PPF. Patients were older (median 84 years, IQR 77-89), frail [median clinical frailty scale (CFS) 5, IQR 3-6], presented at least one comorbidity [median Charlson comorbidity index (CCI) 5, IQR 4-7], were community dwelling (81.8%), and had outdoor ambulation ability (65.6%). Femoral knee PPF were most frequently associated with uncemented femoral components, while femoral hip PPF occurred equally in cemented and uncemented stems. Patients were managed surgically (82%), with co-management (73.9%), through open approaches (85.9%) after almost 4 days (IQR, 51.9-153.6 h), with prosthesis revision performed in 33.8% of femoral hip PPF and 6.5% of femoral knee PPF. For half of the patients, the discharge instructions mandated weight-bearing restrictions. In-hospital mortality rates were 5.2% for all PPF and 6.2% for femoral hip PPF. Frailty, age > 84 years, mild cognitive impairment, CFS > 3, CCI > 3, and non-geriatric involvement were candidate predictors for in-hospital mortality, medical complications, and discharge to a nursing care facility. Management involving revision arthroplasty by experienced surgeons favoured full weight-bearing, while an open surgical approach favoured weight-bearing restrictions.

CONCLUSIONS

Current arthroplasty fixation check and revision rates deviate from established guidelines, yet full weight-bearing is favoured. A surgical delay of over 100 h and a lack of geriatric co-management were related to in-hospital mortality and medical complications. This study recommends judicious hypoaggressive approaches. Addressing complications and individualizing the surgical strategy can lead to enhanced functional outcomes, alleviating the economic and social burdens upon hospital discharge. Level of Evidence Level IV case series.

TRIAL REGISTRATION

registered at ClinicalTrials.gov (NCT04663893), protocol ID: PI 20-2041.

Prevalence of Adrenal Insufficiency in Korean Patients undergoing Total Knee Arthroplasty

BACKGROUND

This study investigated the prevalence of adrenal insufficiency among patients admitted for total knee arthroplasty (TKA) due to osteoarthritis and identified factors contributing to adrenal insufficiency.

METHODS

We divided the patients into two groups based on the results of preoperative standard-dose short synchronous stimulation tests: group 1 (adrenal insufficiency) and group 2 (normal adrenal function). We also assessed the prevalence of adrenal insufficiency and compared the numbers of patients who received oral steroids, the frequency of previous steroid injection use, and the frequency of systemic symptoms of steroid depletion such as fatigue and loss of appetite between the two groups. Multiple regression analysis was performed to identify factors related to adrenal insufficiency.

RESULTS

The prevalence of adrenal insufficiency was 60.0% (120/200). Group 1 had higher numbers of previous steroid injections (12.8±10.2 vs. 6.8±7.9) and patients taking oral steroids (18/120 vs. 3/80) (p<0.001 and p=0.011, respectively). The frequency of systemic symptoms of steroid depletion, such as fatigue and loss of appetite, was also higher in group 1 (94/120 vs. 42/80, p<0.001). Recent steroid injections and loss of appetite were associated with adrenal insufficiency (p=0.002 and p=0.009, respectively).

CONCLUSION

The results of this study revealed a high prevalence of adrenal insufficiency in Korean patients hospitalized for TKA due to end-stage osteoarthritis. Recent steroid injections were causally related to the development of adrenal insufficiency. Therefore, adrenal function should be assessed preoperatively to prevent postoperative complications related to adrenal insufficiency.

Global research output and highly-cited publications on prosthetic joint infections: A bibliometric analysis (2003-2022)

Backgroundand aims

Prosthetic Joint Infection (PJI) is a serious clinical problem after Arthroplasty. The research field on PJI is emerging, but there is a paucity of information on the most impactful publications on it. This prompted us to conduct a bibliometric analysis of the global research output, from 2003 to 2022, to identify the growth of publications, the key players in this research field and to evaluate the characteristics of highly-cited publications (HCPs) on the PJI.

Methods

Publications related to PJI research were identified globally from the Scopus database, using specific keywords, covering the literature from 2003 to 2022. The HCPs were considered those with 100 or more citations. Information on publication year, citation count, funding sources, title, author, journal, country, institution, research area, and strategic keywords were collected from these HCPs. Publication data was imported into Microsoft Excel and analyzed further using VOSviewer and R software.

Results

There were 182 HCPs (3.12%), which received a total citation of 124701 (average CPP of 21.41), with the citation range from 100 to 1921. Research articles were the most predominant publications (69.2%), but their average citations per paper (CPP) of 189.78 was lower than that of Review articles (average CPP: 253.17). The USA has been the leading country in terms of total publications (31.58%), and HCPs (36.99%), followed by Switzerland, Spain, UK and China. There were no HCPs from developing countries. J. Parvizi of Thomas Jefferson University, USA (with a total publications of 31 and an average CPP of 315.7), and W. Zimmerli of Basel University, Switzerland (with a TP of 11 and an average CPP of 341.9), were the most productive and impactful authors in PJI global research output.

Conclusion

This bibliometric analysis identified the most productive and impactful authors, organizations, countries, and journals in the research of PJI, of the last two decades.

Effects of changing the head coach on soccer team's performance: A systematic review

The aim of this review was to identify and synthesise the most significant literature addressing the effects of changing the HC on soccer team's performance, identifying the most frequently researched outcomes and characterizing their methodologies. A systematic review of PubMed, Scopus, Web of Science and SPORTDiscus databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, 2020) guidelines. The following keywords and synonyms were entered in various combinations in the title, abstract or keywords: "football*" OR soccer AND "coach*" OR "manager*" AND "replacement" OR "turnover" OR "substitution*" OR "change". Solely original articles written in English that contained data about the effects of the change in the HC on performance in professional male soccer were included. A total of 94 titles were identified, of which 24 met the eligibility criteria. The quality of the studies was considered excellent. The most common topic of analysis was the effects of the HC on match outcomes (i.e., win, draw, loss, points won, goals average). Some studies suggest that the HCs dismissal has small but positive impacts on a team's short-term performance, while other findings suggest that little-to-no impact is observed following HC departure. The dismissal of the HC does not guarantee increase success of an underperforming team. Some studies suggest that hiring an appropriate coach could positively affect match performance in the short-term. Due to limited variations in study designs, further research is needed before robust conclusions can be drawn.

Osteosynthesis, hemiarthroplasty, total hip arthroplasty in hip fractures: All I need to know

Recent data from the UK's National Hip Fracture Database (NHFD) demonstrate an upward trajectory in the incidence of hip fractures, a trend which is expected to persist. In 2023 alone, the NHFD reported 72,160 cases, underscoring the prevalence of these injuries. These fractures are associated with significant morbidity, mortality, and economic costs. National guidelines for the surgical management of these fractures are established, although the implementation of total hip arthroplasty (THA) as a primary treatment modality varies. This review offers a narrative synthesis of contemporary literature on hip fractures, focusing on epidemiology, classification systems, and treatment options, with a particular emphasis on the outcomes of THA.

Learning curve of Persona Partial Knee (PPK) arthroplasty: a clinical trial

BACKGROUND

Unicompartmental knee arthroplasty (UKA) procedures are considered to be more technically demanding than conventional total knee arthroplasty (TKA), requiring a longer learning curve and more expert surgical skills. Despite some clear advantages of UKA over TKA (such as lesser blood loss, greater bone stock, greater knee performances, etc.), UKA evidenced a greater rate of revision.

OBJECT

This study investigated the learning curve of Persona Partial Knee (PPK) arthroplasty for primary medial UKA performed by a single, non-designer surgeon. PPK is a fixed-bearing, compartment-specific implant. The primary outcome of interest for this study was to evaluate the learning curve of the surgical duration. The secondary outcome of interest was to evaluate the learning curve of radiological implant positioning.

METHODS

Patients who underwent primary medial UKA using PPK (Zimmer-Biomet, Warsaw IN, USA) were prospectively enrolled for the study. All surgeries were performed by a single, non-designer surgeon experienced in knee and hip arthroplasty. The primary outcome of interest was to evaluate the surgical duration. The secondary outcome of interest was to evaluate the implant positioning. The learning curve was estimated using an appropriate nonlinear polynomial regression model with a lower Akaike Information Criterion (AIC).

RESULTS

One hundred twenty five patients were enrolled in the study. 59% of them (74 of 125 patients) were women. The patients' mean age at the time of surgery was 70.1 ± 9.5 years and their mean body mass index (BMI) was 27.8 ± 4.2 kg/m2. Curve stabilisation of the surgical time was at the 94th patient, of the tibial angle at the 47th patient, of the tibial slope at the 54th patient, of the anterior protrusion at the 29th patient, and of the posterior protrusion at the 51st patient.

CONCLUSIONS

The learning curve for component positioning was achieved in approximately 50 cases. The curve of the surgical time achieved a plateau at 94 Persona Partial Knee. Additionally, the factors directly correlated with earlier stabilization of the learning curve in terms of component positioning were: male gender, younger age, right side, and larger components.

Artificial intelligence technology improves the accuracy of preoperative planning in primary total hip arthroplasty

OBJECTIVE

Successful total hip arthroplasty relies on accurate preoperative planning. However, the conventional preoperative planning, a two-dimensional method using X-ray template, has shown poor reliability of predicting component size. To our knowledge, artificial intelligence technology assisted three-dimensional preoperative planning is promising to improve the accuracy of preoperative planning but there is a dearth of clinical evidence. Therefore, in this study we compared the prediction accuracy of these two maneuvers.

METHODS

We conducted a prospective study consisting of 117 consecutive patients who underwent a primary cementless total hip arthroplasty to compare the prediction accuracy of these two methods. The two-dimensional and artificial intelligence assisted three-dimensional planning results of the same patient were compared with the definitive implant size respectively.

RESULTS

The prediction accuracy of artificial intelligence assisted three-dimensional planning for cup and the stem sizes were 66.67% (78/117) and 65.81% (77/117), two-dimensional planning was 30.77% (36/117) and 37.61% (44/117) (p < 0.05). There were poor prediction results of two-dimensional planning in patients with hip dysplasia (p = 0.004, OR = 7.143) and excessive femoral anteversion (p = 0.012, OR = 1.052), meanwhile the failure risk of stem side two-dimensional planning increased as patients got older (p = 0.003, OR = 1.118). The accuracy of artificial intelligence assisted three-dimensional planning cannot be affected by above factors.

CONCLUSIONS

We confirmed that artificial intelligence assisted three-dimensional preoperative planning showed higher accuracy and stability than two-dimensional preoperative planning in primary cementless total hip arthroplasty. We believe artificial intelligence assisted three-dimensional preoperative planning technology provides surgeons a new reliable choice and offers advantages whether in simple or complicated cases.

Glenohumeral joint osteoarthritis is not associated with clavicle fractures in a large arthroplasty cohort

Introduction

A recent study based on a large osteological collection reported an association between clavicle fractures and osteoarthritis of the glenohumeral joint. No clinical study has yet addressed this potential association. Other radiographic parameters such as the critical shoulder angle have been associated with the risk of glenohumeral joint osteoarthritis. The primary outcome of this study was to determine if there is an association between glenohumeral joint arthritis and clavicle fractures. The secondary outcome was to determine the association between critical shoulder angle and glenohumeral joint arthritis in our patient cohort.

Methods

We retrospectively analysed 572 consecutive shoulder arthroplasty surgeries. Osteoarthritis was the indication for 343 shoulder arthroplasties. 229 shoulder arthroplasties were performed due to another diagnosis such as trauma or fracture, cuff arthropathy, or revision surgery. Three fellowship trained consultant shoulder surgeons assessed the pre- and post-operative radiographs of all patients.

Results

A clavicle fracture was suspected in 5/343 (1.5 %) shoulder arthroplasties performed due to osteoarthritis and 5/229 (2.1 %) shoulder arthroplasties performed for another diagnosis. Interobserver variability was assessed using a Fisher Exact test and showed no significant relationship between osteoarthritis and a fracture of the clavicle (p = 0.531). Critical shoulder angle results correlated with the previously published literature regarding critical shoulder angle and osteoarthritis and rotator cuff arthropathy.

Conclusion

Clavicle fractures were not associated with glenohumeral osteoarthritis in our patient cohort of shoulder arthroplasty patients. Critical shoulder angle results were consistent with published literature. Further research in the form of prospective long term studies are needed to establish if any association exists between clavicle fractures and osteoarthritis of the glenohumeral joint.

Level of evidence

Level III. Retrospective analysis.

A prospective, randomized trial of liposomal bupivacaine compared to conventional bupivacaine on pain control and postoperative opioid use in adults receiving adductor canal blocks for total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a commonly performed procedure to alleviate pain and improve functional limitations caused by end-stage joint damage. Effective management of postoperative pain following TKA is crucial to the prevention of complications and enhancement of recovery. Adductor canal blocks (ACB) with conventional bupivacaine (CB) provide adequate analgesia after TKA, but carry a risk of rebound pain following block resolution. Liposomal bupivacaine (LB) is an extended-release local anesthetic that can provide up to 72 h of pain relief. The objective of this study was to compare postoperative outcomes between ACBs using LB and CB after TKA.

METHODS

This single institution, prospective, randomized, clinical trial enrolled patients scheduled for TKA. Participants were randomized to receive ACB with either LB or CB. Pain scores up to 72 h postoperatively were assessed as the primary outcome. Opioid consumption and length of stay were evaluated as secondary outcomes.

RESULTS

A total of 80 patients were enrolled. Demographic and clinical characteristics were similar between the two groups. LB group showed significantly lower cumulative opioid use during the 72 h evaluated (P = 0.016). There were no differences in pain scores or length of stay between the groups.

CONCLUSION

The study demonstrated that LB ACBs led to significantly lower opioid consumption in the days following TKA without affecting pain scores or length of stay. This finding has important implications for improving postoperative outcomes and reducing opioid use in TKA patients. Previous studies have reported inconsistent results regarding the benefits of LB, highlighting the need for further research.

TRIAL REGISTRATION

This project was retrospectively registered with clinicaltrials.gov ( NCT05635916 ) on 2 December 2022.

Comparison between Anatomic Total Shoulder Arthroplasty and Reverse Shoulder Arthroplasty for Older Adults with Osteoarthritis without Rotator Cuff Tears

Background

Many older adults with glenohumeral osteoarthritis without rotator cuff tears experience muscle atrophy and fatty degeneration. In these cases, range of motion (ROM) recovery and clinical results after total shoulder arthroplasty (TSA) could be poor, with low subjective satisfaction after surgery. The purpose of this study was to compare the clinical outcomes of anatomic TSA and reverse shoulder arthroplasty (RSA) in patients aged over 70 years with primary glenohumeral osteoarthritis without rotator cuff tears. We hypothesized that the clinical outcomes of anatomical TSA would be better than those of RSA.

Methods

This single-center, retrospective comparative study involved patients who underwent TSA or RSA from 2013 to 2020. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, and active ROM preoperatively and at the follow-up. Walch classification and glenoid version angle were measured using preoperative computed tomography, and fatty infiltration of supraspinatus and infraspinatus muscles were checked through preoperative magnetic resonance imaging.

Results

Of the 67 patients included in this study, TSA was performed in 41 patients (TSA group), and RSA was performed in 26 patients (RSA group). The two groups had no clinical differences in the patients' preoperative demographic and radiographic data. At the final follow-up, both groups showed improved pain, ROM, and functional outcomes. Moreover, the TSA group demonstrated significantly better postoperative ASES (86.8 ± 6.3 vs. 81.6 ± 5.5, p = 0.001) and Constant-Murley (80.4 ± 5.7 vs. 73.4 ± 6.2, p < 0.001) scores than the RSA group. The TSA group showed a significantly better postoperative active ROM than the RSA group regarding forward flexion as well as external and internal rotations (p < 0.001). All patients in the RSA and TSA groups exceeded the minimal clinically important difference.

Conclusions

In older adult patients with degenerative glenohumeral osteoarthritis wherein the rotator cuff is preserved without excessive bone loss, anatomic TSA and RSA can improve pain, ROM, and clinical outcomes. However, clinical results and ROM were better with TSA than with RSA during the short- and mid-term follow-up periods.

Three out of four working-age patients have fulfilled expectations towards paid employment six months after total hip or knee arthroplasty: a multicentre cohort study

To investigate factors associated with fulfilment of expectations towards paid employment after total hip/knee arthroplasty (THA/TKA). Cohort study including preoperatively employed patients aged 18-64 scheduled for THA/TKA. Expectations were collected preoperatively, and 6 and 12 months postoperatively with the paid employment item of the Hospital-for-Special-Surgery Expectations Surveys (back-to-normal = 1; large improvement = 2; moderate improvement = 3; slight improvement = 4; not applicable = 5). Patients scoring not applicable were excluded. Fulfilment was calculated by subtracting preoperative from postoperative scores (< 0: unfulfilled; ≥ 0: fulfilled). Multivariable logistic regression analyses were conducted separately for THA/TKA at 6 and 12 months postoperatively. Six months postoperatively, 75% of THA patients (n = 237/n = 316) and 72% of TKA patients (n = 211/n = 294) had fulfilled expectations. Older age (TKA:OR 1.08, 95% CI 1.01-1.15) and better postoperative physical functioning (THA:OR 1.10, 95% CI 1.06-1.14; TKA:OR 1.03, 95% CI 1.01-1.06) increased the likelihood of fulfilment. Physical work tasks (THA:OR 0.12, 95% CI 0.03-0.44), preoperative sick leave (TKA:OR 0.33, 95% CI 0.17-0.65), and difficulties at work (THA:OR 0.10, 95% CI 0.03-0.35; TKA:OR 0.41, 95% CI 0.17-0.98) decreased the likelihood of fulfilment. Twelve months postoperatively similar risk factors were found. Three out of four working-age THA/TKA patients had fulfilled expectations towards paid employment at 6 months postoperatively. Preoperative factors associated with fulfilment were older age, mental work tasks, no sick leave, postoperative factors were better physical functioning, and no perceived difficulties at work.

Imaging in an academic orthopedic shoulder service: a report on incidental lung pathology findings

INTRODUCTION

Computed tomography (CT) is often utilized for both diagnostic and pre-operative planning purposes in shoulder arthroplasty. Our study reports on the incidence of pulmonary findings in our pre-operative shoulder arthroplasty population over 14 years at our institution.

METHODS

We conducted a retrospective review of all "shoulder CT" exams ordered by two orthopedic upper extremity surgeons between the years of 2008 and 2021. These exams were then further analyzed to include only those ordered for the purpose of pre-operative "shoulder arthroplasty" planning. All incidental findings were documented and those with pulmonary findings were then further analyzed. A detailed chart review was then performed on these patients to determine the impact on their planned shoulder arthroplasty.

RESULTS

A total of 363 shoulder pre-operative CTs were ordered by our two upper extremity orthopedic surgeons at our institution between the years of 2008 and 2021. Primary lung cancer in the form of adenocarcinoma (n = 3) had an incidence of 0.8% of all CT scans and 1.4% of all pulmonary incidental findings. Fifteen patients (4% of all CT scans and 7% of all pulmonary incidental findings) had no concern for malignancy and were appropriately evaluated with further imaging based on their initial shoulder CT.

CONCLUSION

While shoulder arthroplasty and pre-operative planning with CT imaging continue to become more common, so too is the incidence of reported pulmonary findings. From a patient care standpoint, it is important that these findings are accurately identified, appropriately triaged, and communicated clearly to our patients.

Longer term follow up of outcomes following implantation of a modular rotating hinge knee prosthesis: 53 implants at mean 7.6 year follow up

BACKGROUND

Rotating hinge knee replacements are becoming more common but have historically had high complication and failure rates. This study is one of the largest to assess the implant survival and patient outcomes of a third-generation rotating hinge knee replacement at a single tertiary orthopaedic centre.

METHODS

Data for consecutive operations at our tertiary unit between 2006 to 2020 were assessed with review of electronic patient and radiology records. The Oxford Knee Score was used to assess outcomes and the Kaplan Meier method used to estimate survivorship.

RESULTS

53 rotating hinge knees were implanted in 46 patients (13 male, 33 female) at a mean age of 67.8 years. 21 were primary and 32 were revision procedures. Indications for use of this implant included instability, loosening, fracture and infection. Survivorship was 77.8% at the mean follow up of 7.6 years. A total of 29 complications were noted with ongoing pain, stiffness, infection and patellofemoral symptoms being the most common. 8% of unresurfaced patellas required a subsequent secondary resurfacing. The Oxford Knee Score demonstrated a significant improvement from 14.6 preoperatively to 27.5 at one year postoperatively, which was maintained in the longer term.

CONCLUSION

The third-generation rotating hinge knee implant in use at our unit has improved outcomes for patients. The survivorship of the implant is comparable to the published literature, although there is a paucity of data. The complication rates remain relatively high and patients should be counselled appropriately. We advise resurfacing the patella to avoid the need for secondary procedures.

Trends in Isolated Mitral Valve Repair or Replacement Surgery in Australia: A Statewide Cohort Linkage Study

BACKGROUND

Global trends in mitral valve surgery (MVSx) suggest increasing repair compared with replacement, especially in the United States and European countries. The relative use, and outcomes of, MV repair and replacement in Australia are unknown.

METHODS

New South Wales residents who underwent isolated MVSx between 2001 and 2017 were identified from the Admitted-Patient-Data-Collection database. Mortality outcomes were tracked to 31 Dec 2018 and adjusted based on age, sex, urgency of operation, and comorbidity status.

RESULTS

The study cohort comprised 5,693 patients: 2020 (35%) underwent repair (MVr), 1,656 (29%) underwent mechanical replacement (mech.MVR), and 2017 (35%) underwent bioprosthetic replacement (bio.MVR). Respective median ages [interquartile range] were 67 yo [59-75 yo], 64 yo [55-71 yo], and 75 yo [68-80 yo] (p<0.001 across groups). Between 2001 and 2017, total MVSx increased steadily with population growth. Whereas the relative use of MVr remained static (34% to 38%), that for bio.MVR (22% to 50%) and mech.MVR (45% to 13%) changed significantly. MVr had the best outcome with 1.2% in-hospital, 2.5% 1-year, and 21.6% total cumulative mortality during a median follow-up of 6.5 years. Compared to MVr, the adjusted hazard ratio (aHR) for mech.MVR and bio.MVR for long-term mortality were 1.41 (95% confidence interval [CI]=1.24-1.61) and 1.73 (95% CI=1.53-1.95), respectively. Heart failure and sepsis were the main cardiovascular and noncardiovascular causes of death in all groups.

CONCLUSION

In this statewide Australian cohort examined over 17 years, MVr is potentially underutilised despite having superior outcomes to MVR. Access to quality dataset which provides the indication for MVSx and quantitative clinical factors is critical to further improve MVr coverage and outcome MVSx.

A global analysis of implants and replacements of pacemakers and cardioverter-defibrillators before, during, and after the COVID-19 pandemic in Italy

At the beginning of the COVID-19 emergency, non-urgent surgical procedures had to be deferred, but also emergencies were reduced. To assess the global trend of pacemaker (PM) and implantable cardiac-defibrillator (ICD) procedures performed in Italy before, during, and after the first COVID-19 emergency, all the Italian hospital discharge records related to PM/ICD procedures performed between 2012 and 2021, sent to the National Institute of Health, were reviewed. Compared to 2019, in 2020, there was a reduction of first PM implants (52,216 to 43,962, -16%; p < 0.01), but not replacements (16,591 to 17,331, + 4%; p = 0.16). In particular, in April 2020, there was a drop of first implants (- 53,4% vs the average value of April 2018 and April 2019; p < 0.01), while the reduction of replacements was less evident (-32.6%; p = NS). In 2021, PM procedures increased to values similar to the pre-pandemic period. A reduction of ICD procedures was observed in 2020 (22,355, -7% toward 2019), mainly in April 2020 (- 46% vs April 2018/April 2019; p = 0.03). In 2021, the rate of ICD procedures increased (+ 14% toward 2020). A non-significant reduction of "urgent" procedures (complete atrioventricular block for PM and ventricular fibrillation for ICD), even in April 2020, was observed. In 2020, there was a reduction of first PM implants and ICDs, offset by increased activity in 2021. No decrease in PM replacements was observed, and the drop in "urgent" PM and ICD procedures was not statistically significant.

Only Low Patients' Expectations Are Prognostic for Dissatisfaction With Performing Work-Related Knee-Straining Activities After Total Knee Arthroplasty: A Prospective Multicenter Cohort Study

OBJECTIVE

To investigate whether preoperative expectations regarding performing work-related knee-straining activities were associated with being dissatisfied 6 months after total knee arthroplasty (TKA) among working patients, and, to identify prognostic factors for being dissatisfied with performing these work-related knee-straining activities.

DESIGN

Multicenter prospective cohort study.

SETTING

Orthopedic surgery departments of 7 hospitals in the Netherlands.

PARTICIPANTS

A consecutive sample of 175 working patients who were on the waiting list for TKA (median age 59 years, 53% women) and intended to return to work (N=175).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Dissatisfaction with performing work-related knee-straining activities 6 months postoperative was measured using the Work Osteoarthritis or joint-Replacement Questionnaire (score range 0-100). The clinically relevant cut-off points for being satisfied and dissatisfied were ≥71 and ≤50, respectively.

RESULTS

Thirty-three patients (19%) were dissatisfied with performing work-related knee-straining activities 6 months after TKA. Patients who expected to be dissatisfied preoperative had a 5.1 times higher odds (95% CI 1.7-15.5) of being dissatisfied 6 months postoperatively compared with patients who expected to be satisfied preoperative. Regression analyses revealed that only patients' expectations were prognostic for being dissatisfied 6 months postoperatively rather than age, pain level, or having a knee-straining job.

CONCLUSIONS

Two in 10 working patients are dissatisfied with performing work-related knee-straining activities 6 months after TKA. Only preoperative patients' expectations appeared prognostic. Therefore, we should better prepare working patients with low expectations by managing their preoperative expectations and improving their performance of work-related knee-straining activities in rehabilitation.

Effects of Obesity on Cervical Disc Arthroplasty Complications

OBJECTIVE

High body mass index is a well-established modifiable comorbidity that is known to increase postoperative complications in all types of surgery, including spine surgery. Obesity is increasing in prevalence amongst the general population. As this growing population of obese patients ages, understanding how they faire undergoing cervical disc arthroplasty (CDA) is important for providing safe and effective evidence-based care for cervical degenerative pathology.

METHODS

Our study used the Healthcare Cost and Utilization Project's National Inpatient Sample to assess patients undergoing CDA comparing patient characteristics and outcomes in nonobese patients to obese patients from 2004 to 2014.

RESULTS

Our study found a significant increase in the overall utilization of CDA as a treatment modality (p = 0.012) and a statistically significant increase in obese patients undergoing CDA (p < 0.0001) from 2004 to 2014. Obesity was identified as an independent risk factor associated with increased rates of inpatient neurologic complications (odds ratio [OR], 6.99; p = 0.03), pulmonary embolus (OR, 5.41; p = 0.05), and wound infection (OR, 6.97; p < 0.001) in patients undergoing CDA from 2004 to 2014.

CONCLUSION

In patients undergoing CDA, from 2004 to 2014, obesity was identified as an independent risk factor with significantly increased rates of inpatient neurologic complications, pulmonary embolus and wound infection. Large prospective trials are needed to validate these findings.

An updated meta-analysis comparing complications, functional, clinically relevant and radiological outcomes of accelerometer based portable navigation and conventional technique of total knee arthroplasty

Introduction

Since previous studies, including small-scale meta-analyses comparing accelerometer-based portable navigation (APN-TKA) and conventional techniqueof total knee arthroplasty (CONV-TKA), have reported divergent results, there is a need for an updated meta-analysis to compare complications, functional outcomes, clinically relevant outcomes and radiographic alignment of components.

Methods

This meta-analysis was conducted as per PRISMA guidelines. Randomised controlled trials, and non-randomised comparative cohort studies in English language on primary TKA were included. The complications compared were Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), infection, manipulation under anaesthesia (MUA) for postoperative knee stiffness, re-operation and mortality. The functional outcomes compared were the Knee Society Knee Score, Knee Society Score function, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Arthritis Index. The evaluated clinically relevant outcomes were surgical time, blood loss, drop in haematocrit, tourniquet time, postoperative knee flexion and complications). The number of radiological outliers; as well as the absolute values of the alignment of the overall prosthesis, femoral and tibial components in both coronal and sagittal planes, was assessed.

Results

Twenty-five studies were included. Both the groups were comparable in terms of preoperative demographic features. There was no difference in complications and functional outcomes. Operation time was longer in APN-TKA (p < 0.00001) but there was no difference in rest of the clinically relevant outcomes. Restoration of the lower limb mechanical axis (p = 0.003) and coronal femoral alignment angle (p = 0.0002) was better with APN. APN also significantly reduced the risk of the odds of outliers of lower limb mechanical axis (p < 0.0001), coronal femoral alignment (p = 0.03), coronal tibial alignment (p < 0.0001) and sagittal tibial alignment (p = 0.0001).

Conclusion

The improvement in the accuracy of implantation by the use of APN-TKA, as determined by the overall alignments of prosthesis, or femoral and tibial components, does not necessarily translate into lesser complications and better functional and clinical outcomes.

Level of evidence

Therapeutic study, Level II.

Is Posterior Cruciate Ligament Needle Pie-Crusting Safe and Effective in Balancing Cruciate-Retained Total Knee Arthroplasty? A Comparative Study

Background

There is still debate over whether to sacrifice the posterior cruciate ligament (PCL) during total knee arthroplasty (TKA). Several studies reported the costs and benefits of each approach regarding technical difficulties in PCL balancing and postoperation complications. In this study, we aimed to evaluate PCL needling as a safe method for balancing the cruciate-retained TKA (CR-TKA).

Methods

In this comparative study, 120 patients underwent CR-TKA and were divided into 2 groups. Fifty-four patients with an acceptable PCL tightness were included in group A, and 66 cases with a tight PCL were included in group B. In group B, needle pie-crusting of the PCL was performed instead of releasing the PCL from its insertions as the standard procedure. The participants' functional outcomes, pain severity, knee range of motion, and PCL laxity were evaluated during multiple follow-ups in 3 years postoperatively.

Results

The participants' age, weight, and body mass index did not differ between the 2 groups. The mean age of the patients was 69 ± 5.9 years. The functional outcomes and range of motion of the patients in the 2 groups significantly improved after the operation compared to the preoperative status, but the postoperative score was not significantly different between groups (P > .05). Clinical examinations were normal in all patients in both groups in all follow-up stages.

Conclusions

PCL balancing is a time-consuming yet essential step for the outcome of CR-TKA and patient satisfaction. PCL needling technique shows promising results and a few complications for PCL balancing in CR-TKA.

Cost-effectiveness of implant movement analysis in aseptic loosening after hip replacement: a health-economic model

OBJECTIVE

To investigate the cost-effectiveness of using Implant Movement Analysis (IMA) to follow up suspected aseptic loosening when the diagnosis after an initial X-ray is not conclusive, compared with a diagnostic pathway with X-ray follow-up.

METHODS

A health-economic model in the form of a decision tree was developed using quality-adjusted life years (QALY) from the literature, cost-per-patient data from a university hospital and the probabilities of different events from expert physicians' opinions. The base case incremental cost-effectiveness ratio (ICER) was compared with established willingness-to-pay thresholds and sensitivity analyses were performed to account for assumptions and uncertainty.

RESULTS

The base case ICER indicated that the IMA pathway was cost effective (SEK 99,681, compared with the SEK 500,000 threshold). In the sensitivity analysis, the IMA pathway remained cost effective during most changes in parameters. ICERs above the threshold value occurred in cases where a larger or smaller proportion of people receive immediate surgery.

CONCLUSION

A diagnostic pathway using IMA after an inconclusive X-ray for suspected aseptic loosening was cost effective compared with a pathway with X-ray follow-up.

Periprosthetic acetabular fractures as a complication of total hip arthroplasty

Periprosthetic acetabular fractures are rare but potentially devastating complications of total hip arthroplasty. As the number of total hip arthroplasties performed annually increases, so has the incidence of periprosthetic fractures, with the topic being spotlighted more frequently in the orthopaedic community. There is a particular sparsity of literature regarding periprosthetic acetabular fractures, with periprosthetic femoral fractures after total hip arthroplasty being traditionally far more commonly reported. This article aims to provide an up-to-date review of the epidemiology, risk factors, diagnostic challenges, classifications, and management strategies for periprosthetic acetabular fractures after total hip arthroplasty.

Less pain reported 5 years after cementless compared to cemented unicompartmental knee replacement: an analysis of pain, neuropathy, and co-morbidity scores

PURPOSE

To compare patient-reported pain scores and assess the influence of neuropathy and co-morbidity, on knee pain following cemented and cementless medial unicompartmental knee replacement (UKR) 5 years after surgery.

METHOD

In this longitudinal study, 262 cemented and 262 cementless Oxford UKR performed for the same indications and with the same techniques were recruited. Patients were reviewed at five years, evaluating patient-reported pain and association with clinical outcomes. Intermittent and Constant Osteoarthritis Pain (ICOAP), PainDETECT (PD), Charnley score, Oxford Knee Score (OKS) and American Knee Society Score (AKSS) were compared.

RESULTS

In both cohorts, intermittent pain was more common than constant pain (47% vs 21%). Cementless knees reported significantly less pain than cemented (ICOAP-Total 5/100 vs 11/100, p < 0.0001). A greater proportion of cementless knees experienced no pain at all (ICOAP = 0/100, 61% vs 43%, p < 0.0001) and 75% fewer experienced severe or extreme pain. Pain sub-scores in PD, OKS and AKSS follow this trend. Pain was unlikely to be neuropathic (PD positive: 5.26%), but patients reporting high levels of 'strongest' pain were three times more likely to be neuropathic. Patients with co-morbidities (Charnley C) experienced greater pain than those without (Charnley A+B) across all knee-specific scores, despite scores being knee specific.

CONCLUSION

Both cemented and cementless UKR in this study had substantially less pain than that reported in literature following TKR. Cementless UKR had significantly less pain than cemented UKR in all scores. Two-thirds of patients with a cementless UKR had no pain at all at 5 years, and pain experienced was most likely to be mild and intermittent with no patients in severe or extreme pain. Patients with cementless UKR that had higher levels of pain were more likely to have co-morbidity or evidence or neuropathic pain. It is unclear why cementless UKR have less pain than cemented; further study is necessary.

The Ankle Joint: Updates on Ankle Fusion Approaches and Fixation

Ankle fusion is a well-studied, classical procedure for conditions affecting the ankle joint, and has a long history with predictable results. Although there are many different approaches available, a few options are commonly used. The two main focuses of modern literature are on anterior plating versus traditional screw fixation, and on arthroscopic versus open techniques for fusion. This article discusses recent literature and then presents cases and techniques that are commonly used today. This includes arthroscopic ankle arthrodesis, traditional transfibular approach, anterior plating, and the indications and application of external fixation. Standard recovery and complications are discussed.

Revision of Motec Total Wrist Replacement in the Second Metacarpal

Wrist arthroplasty is becoming more commonplace, with various implant choices available. The Motec (Swemac Orthopaedics AB, Linköping, Sweden) cementless ball-and-socket system is being increasingly utilised and is designed for the distal component to be implanted into the third metacarpal. However, distal component failure is a recognised complication. We outline our experience with the revision of this component into the second metacarpal. This technical note is presented through our experience of two patients who underwent revision arthroplasty for the management of peri-prosthetic fracture of the third metacarpal. This technique has demonstrated a safe and viable solution to this complication, achieving good anatomical centre of rotation, function, range of movement and patient satisfaction. Level of Evidence: Level V (Therapeutic).

The effect of body mass index and preoperative weight loss in people with obesity on postoperative outcomes to 6 months following total hip or knee arthroplasty: a retrospective study

BACKGROUND

Few studies have investigated the association between obesity, preoperative weight loss and postoperative outcomes beyond 30- and 90-days post-arthroplasty. This study investigated whether body mass index (BMI) and preoperative weight loss in people with obesity predict postoperative complications and patient-reported outcomes 6 months following total knee or hip arthroplasty.

METHODS

Two independent, prospectively collected datasets of people undergoing primary total knee or hip arthroplasty for osteoarthritis between January 2013 and June 2018 at two public hospitals were merged. First, the sample was grouped into BMI categories, < 35 kg/m2 and ≥ 35 kg/m2. Subgroup analysis was completed separately for hips and knees. Second, a sample of people with BMI ≥ 30 kg/m2 was stratified into participants who did or did not lose ≥ 5% of their baseline weight preoperatively. The presence of postoperative complications, Oxford Hip Score, Oxford Knee Score, EuroQol Visual Analogue Scale and patient-rated improvement 6 months post-surgery were compared using unadjusted and adjusted techniques.

RESULTS

From 3,552 and 9,562 patients identified from the datasets, 1,337 were included in the analysis after merging. After adjustment for covariates, there was no difference in postoperative complication rate to 6 months post-surgery according to BMI category (OR 1.0, 95%CI 0.8-1.4, P = 0.8) or preoperative weight loss (OR 1.1, 95%CI 0.7-1.8, P = 0.7). There was no between-group difference according to BMI or preoperative weight change for any patient-reported outcomes 6 months post-surgery.

CONCLUSION

Preoperative BMI or a 5% reduction in preoperative BMI in people with obesity was not associated with postoperative outcomes to 6 months following total knee or hip arthroplasty.

Integrative analysis of DNA methylome and transcriptome reveals epigenetic regulation of bisphenols-induced cardiomyocyte hypertrophy

Cardiac hypertrophy, a kind of cardiomyopathic abnormality, might trigger heart contractile and diastolic dysfunction, and even heart failure. Currently, bisphenols (BPs) including bisphenol A (BPA), and its alternatives bisphenol AF (BPAF), bisphenol F (BPF) and bisphenol S (BPS) are ubiquitously applied in various products and potentially possess high cardiovascular risks for humans. However, the substantial experimental evidences of BPs on heart function, and their structure-related effects on cardiomyocyte hypertrophy are still urgently needed. DNA methylation, a typical epigenetics, play key roles in BPs-induced transcription dysregulation, thereby affecting human health including cardiovascular system. Thus, in this study, we performed RNA-seq and reduced representation bisulfite sequencing (RRBS) to profile the landscapes of BPs-induced cardiotoxicity and to determine the key roles of DNA methylation in the transcription. Further, the capabilities of three BPA analogues, together with BPA, in impacting heart function and changing DNA methylation and transcription were compared. We concluded that similar to BPA, BPAF, BPF and BPS exposure deteriorated heart function in a mouse model, and induced cardiomyocyte hypertrophy in a H9c2 cell line. BPAF, BPF and BPS all played BPA-like roles in both transcriptive and methylated hierarchies. Moreover, we validated the expression levels of four cardiomyocyte hypertrophy related candidate genes, Psmc1, Piptnm2, Maz and Dusp18, which were all upregulated and with DNA hypomethylation. The findings on the induction of BPA analogues on cardiomyocyte hypertrophy and DNA methylation revealed their potential detrimental risks in heart function of humans.

Cone-Beam Weight-Bearing Computed Tomography of Ankle Arthritis and Total Ankle Arthroplasty

Weight-bearing computed tomography has multiple advantages in evaluating the hindfoot and ankle. It can assess hindfoot and ankle alignment, pathology in ankle arthritis, and complications related to total ankle replacements. It is an essential tool in ankle osteoarthritis diagnostic, preoperative planning, and total ankle replacement outcomes. It allows for better accuracy and reproducibility of alignment and implant size. In addition, it has the potential to more assertively detect complications related to weight bearing.

Automatic classification of experimental models in biomedical literature to support searching for alternative methods to animal experiments

Current animal protection laws require replacement of animal experiments with alternative methods, whenever such methods are suitable to reach the intended scientific objective. However, searching for alternative methods in the scientific literature is a time-consuming task that requires careful screening of an enormously large number of experimental biomedical publications. The identification of potentially relevant methods, e.g. organ or cell culture models, or computer simulations, can be supported with text mining tools specifically built for this purpose. Such tools are trained (or fine tuned) on relevant data sets labeled by human experts. We developed the GoldHamster corpus, composed of 1,600 PubMed (Medline) articles (titles and abstracts), in which we manually identified the used experimental model according to a set of eight labels, namely: "in vivo", "organs", "primary cells", "immortal cell lines", "invertebrates", "humans", "in silico" and "other" (models). We recruited 13 annotators with expertise in the biomedical domain and assigned each article to two individuals. Four additional rounds of annotation aimed at improving the quality of the annotations with disagreements in the first round. Furthermore, we conducted various machine learning experiments based on supervised learning to evaluate the corpus for our classification task. We obtained more than 7,000 document-level annotations for the above labels. After the first round of annotation, the inter-annotator agreement (kappa coefficient) varied among labels, and ranged from 0.42 (for "others") to 0.82 (for "invertebrates"), with an overall score of 0.62. All disagreements were resolved in the subsequent rounds of annotation. The best-performing machine learning experiment used the PubMedBERT pre-trained model with fine-tuning to our corpus, which gained an overall f-score of 0.83. We obtained a corpus with high agreement for all labels, and our evaluation demonstrated that our corpus is suitable for training reliable predictive models for automatic classification of biomedical literature according to the used experimental models. Our SMAFIRA - "Smart feature-based interactive" - search tool ( https://smafira.bf3r.de ) will employ this classifier for supporting the retrieval of alternative methods to animal experiments. The corpus is available for download ( https://doi.org/10.5281/zenodo.7152295 ), as well as the source code ( https://github.com/mariananeves/goldhamster ) and the model ( https://huggingface.co/SMAFIRA/goldhamster ).

Long-term risk of cardiovascular implantable electronic device reinterventions following external cardioversion of atrial fibrillation and flutter: A nationwide cohort study

BACKGROUND

External cardioversion (ECV) is an essential part of rhythm control of atrial fibrillation and flutter in patients with and without cardiovascular implantable electronic devices (CIEDs). Long-term follow-up data on ECV-related CIED dysfunctions are limited.

OBJECTIVE

The purpose of this study was to investigate the risk of CIED reintervention following ECV in a nationwide cohort.

METHODS

We identified CIED implants and surgical reinterventions from 2005 to 2021 in the Danish Pacemaker and ICD Register. We included CIED patients undergoing ECV from 2010 to 2019 from the Danish National Patient Registry. For each ECV-exposed generator, 5 matched generators without ECV were identified, and for each ECV-exposed lead, 3 matched leads were identified. The primary endpoints were generator replacement and lead reintervention.

RESULTS

We compared 2582 ECV-exposed patients with 12,910 matched patients with a pacemaker (47%), implantable cardioverter-defibrillator (ICD) (29%), cardiac resynchronization therapy-pacemaker (6%), or cardiac resynchronization therapy-defibrillator (18%). During 2 years of follow-up, 210 ECV-exposed generators (8.1%) vs 670 matched generators (5.2%) underwent replacements, and 247 ECV-exposed leads (5.6%) vs 306 matched leads (2.3%) underwent reintervention. Unadjusted hazard ratios were 1.61 (95% confidence interval [CI] 1.37-1.91; P <.001) for generator replacement and 2.39 (95% CI 2.01-2.85; P <.001) for lead reintervention. One-year relative risks were 1.73 (95% CI 1.41-2.12; P <.001) for generator replacement and 2.85 (95% CI 2.32-3.51; P <.001) for lead reintervention, and 2-year relative risks were 1.39 (95% CI 1.19-1.63; P <.001) and 2.18 (95% CI 1.84-2.57; P <.001), respectively.

CONCLUSION

ECV in patients with a CIED is associated with a higher risk of generator replacement and lead reintervention. The risks of reinterventions were more pronounced within the first year after cardioversion.

Functional scores and prosthetic implant placement are different for navigated medial UKA left in varus alignment

PURPOSE

The purpose of this study was to analyze the clinical outcomes and radiologic position of the knee in two groups of patients after medial unicompartmental knee arthroplasty (UKA): one group with residual varus axis (RVA) alignment and other one with neutral mechanical axis (NMA) of the lower limb.

METHODS

All patients who underwent UKA between January 2015 and January 2018 were evaluated retrospectively. Inclusion criteria were: medial UKA for isolated medial femoro-tibial osteoarthritis, a varus deformity of < 15°, and a minimal follow-up of 2 years. All patients had a preoperative and postoperative clinical examination with functional scores (New International Knee Score (NewIKS) and Knee injury and Osteoarthritis Outcome Score (KOOS) and radiographs. Preoperative and postoperative values for continuous outcomes were compared using the Student's t test for paired data and differences between the groups were compared with the Mann-Whitney U test. p < 0.05 was considered statistically significant.

RESULTS

The RVA group consisted of 48 cases of medial UKA in 48 patients (22 females). Mean postoperative hip-knee-ankle (HKA) angle was 174.3° ± 2.8 and the corresponding mean AKI angle (tibial mechanical angle) was 82.9° ± 2.9. The NMA group consisted of 35 cases of medial UKA in 35 patients (14 females). Mean postoperative HKA angle was 178.9° ± 3 and the corresponding mean AKI angle was 85.5° ± 3.1. A significant difference was found between the two groups for the KOOS score and for global NewIKS, with a better score in the RVA group.

CONCLUSIONS

RVA alignment after medial UKA results in a significant improvement in functional knee scores at 2-year post-surgery. Return to sport and recreational activities was better than in patients with postoperative NMA.

LEVEL OF EVIDENCE

Level 3; retrospective cohort study.

Distal Interphalangeal Joint Arthroplasty: A Narrative Review

Background: Symptomatic distal interphalangeal (DIP) joint arthritis is frequently treated by arthrodesis, though DIP arthroplasty has been reported as a treatment option since 1977. This study reviews the current evidence on DIP joint arthroplasty for the treatment of arthritis refractory to non-operative management. Methods: A systematic search of PubMed, MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using the ROBINS-I tool. Results: The search yielded 55 records, of which six studies were included in the narrative review. All the included studies were of level IV evidence (case series or cohort studies). DIP arthroplasty was effective in relieving pain and reducing subsequent dysfunction. The average total arc of motion was 30°-40° but with an extension lag of 10°-15°. The overall complication rate was 15% with a re-operation rate of 8%. Joint instability (incidence of 2.5%) and infection (incidence of 2.1%) were the most common complications, while implant fracture was seen in 1% of cases. Joints that failed after DIP arthroplasty were salvaged by DIP arthrodesis. Conclusions: DIP arthroplasty is an effective treatment for painful arthritis but with a complication rate of 15%. Its main advantage over arthrodesis is the preservation of DIP motion. However, due to the limited high-quality evidence available, its use should be limited to circumstances where there is a desire or vocational need to maintain motion at the DIP joint. Level of Evidence: Level V (Therapeutic).

Comparison of Survival Rate between Posterior-Stabilized and Constrained Condylar Articulations in Revision Total Knee Arthroplasty: A Minimum 5-Year Follow-up Analysis

Background

Revision total knee arthroplasty (RTKA) is a technically demanding procedure for failed primary TKA. Posterior-stabilized (PS) and constrained condylar knee (CCK) articulations are commonly used for RTKA, but comparison of these articulations in RTKA is scarce. The aim of this study was to compare survival rates and clinical outcomes of RTKAs using PS articulation and CCK articulation.

Methods

This study conducted a retrospective analysis of 86 RTKAs (PS, n = 41; CCK, n = 45) with a mean follow-up of 9.15 ± 2.79 years. Clinical outcomes were evaluated using the Hospital for Special Surgery score, Knee Society Score, and The Western Ontario and McMaster Universities Osteoarthritis Index at final follow-up. The survival rate of each group was analyzed by Kaplan-Meier survival analysis and Cox-hazard progression model.

Results

Clinical outcomes were improved in both groups without significant difference. Twelve patients had orthopedic complications (4 in PS group and 8 in CCK group). Eight of them underwent re-RTKA (3 in PS group and 5 in CCK group). The articulation design did not influence the failure. The estimated 10-year survival rate was 92.7% in the PS group and 88.2% in the CCK group with no significant difference (p = 0.60). Also in septic failure, there was no significant difference in survival rate (92.7% in PS group and 92.5% in CCK group, p = 0.87). The hazard ratio in the PS group was not significantly different (p = 0.607).

Conclusions

In RTKA, both PS and CCK showed similar survival rates and clinical outcomes at a mean follow-up of 9.2 years. Implant articulation did not affect the outcomes when properly indicated.

Orange molasses as a new energy ingredient for feedlot lambs in Brazil

The objectives of this experiment were to evaluate the effects of increasing levels of orange molasses in replacement of flint corn grain in high-concentrate diets on dry matter intake (DMI), average daily gain (ADG), and feed efficiency (FE) of feedlot lambs. Thirty male lambs without defined racial pattern (30.3 ± 5.3 kg of initial BW; mean ± SD) were used in a randomized complete block design with 10 blocks and 3 treatments. The treatments were defined by partial replacement of flint corn by orange molasses in the diet with 90% of concentrate and 10% of Cynodon spp. hay, as follows: 0OM-control diet without orange molasses; 20OM-20% of orange molasses replacing flint corn; and 40OM-40% of orange molasses replacing flint corn (DM basis). The experiment lasted 72 days divided into 3 subperiods, with 1 subperiod of 16 days and 2 subperiods of 28 days. Animals were weighed after a 16-h fast on days 1, 16, 44, and 72 of the experimental periods to determine the ADG and FE. The DMI, ADG, and FE showed an interaction between treatments and experimental periods. The DMI in the first period decreased linearly (P < 0.01); in the third period, there was no effect of treatments (P > 0.05) on DMI. The ADG decreased linearly (P < 0.01) in the first period as the orange molasses increased. Otherwise, in the third period, ADG increased linearly (P = 0.05) as flint corn was replacement by orange molasses. The FE showed an interaction between treatment and period (P = 0.09). The first period had a decreased linear effect; in the third period, there was a trend (P = 0.07) of increased linear effect. There was no difference between the diets regarding the final BW of the lambs. In conclusion, the orange molasses can replace up to 40% of flint corn in diets for feedlot lambs without affecting final BW. However, it is important to consider the adaptation time proved to be very important for better use of orange molasses as a source of energy in diets for lambs.

Left ventricular assist device exchange: a review of indications, operative procedure, and outcomes

The use of left ventricular assist devices (LVADs) is intended to treat patients with end-stage heart failure. Owing to technological advances, these devices are becoming more durable. However, LVADs may need to be exchanged when complications arise and heart transplantation is not possible. Indications for LVAD exchange (LVADE) include device thrombosis, device infections, and pump component failure. LVADE has historically been associated with a high risk of morbidity and mortality. In this review, we discuss the indications of LVADE, the decisional and technical aspects during surgery, and outcomes.

Novel Aortic Valve Replacement Technique for Reducing Complete Heart Block

Background

Aortic valve replacement (AVR) may complicate conduction abnormalities and require permanent pacemaker (PPM) implantation. New techniques that lessen this challenge may lead to the development of new approaches. Our objective was to evaluate the contemporary incidence of early postoperative PPM implantation in patients undergoing isolated AVR and root disease with the standard AVR surgical technique compared with the novel suture AVR technique.

Methods

The clinical data of 354 patients (250 male, 104 female) who underwent surgery for isolated AVR and root disease in different referral cardiology departments in Tabriz, Iran, over 4 years were analyzed. Patients with preoperative significant conduction abnormalities were excluded from the study. The patients were evaluated for in-hospital mortality, postoperative PPM implantation, and their stay in the ICU after surgery.

Results

The mean age of the patients was 52.46±16.13 years. Totally, 183 patients (51.7%) were operated on with the new suture AVR technique. In-hospital mortality was lower in this group than in the group that underwent the "classic" surgical technique (2.5% vs 3.7%). PPM implantation was required in 3 patients (0.8%) after the novel suture AVR technique, whereas it was needed in 12 patients (3.4%) in the other group (P=0.024). The mortality rate was 9 patients (2.5%) in group 1 and 13 patients (3.7%) in group 2, which was not statistically significant (P=0.296). According to the logistic regression, the survival rate in the group operated on with the classical surgical method was 0.27 times higher than that in the patients operated on with the new method.

Conclusion

Permanent complete AV block is a critical complication after AVR surgery. A lower PPM requirement and higher survival in patients operated on with the new method was the main finding of this study. New techniques with lower PPM requirements may be suitable for cardiac surgery.

The effect of graded motor imagery training on pain, functional performance, motor imagery skills, and kinesiophobia after total knee arthroplasty: randomized controlled trial

Background

The aim was to investigate the effect of graded motor imagery (GMI) added to rehabilitation on pain, functional performance, motor imagery ability, and kinesiophobia in individuals with total knee arthroplasty (TKA).

Methods

Individuals scheduled for unilateral TKA were randomized to one of two groups: control (traditional rehabilitation, n = 9) and GMI (traditional rehabilitation + GMI, n = 9) groups. The primary outcome measures were the visual analogue scale and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcome measures were knee range of motion, muscle strength, the timed up and go test, mental chronometer, Movement Imagery Questionnaire-3, lateralization performance, Central Sensitization Inventory, Pain Catastrophizing Scale, and Tampa Kinesiophobia Scale. Evaluations were made before and 6 weeks after surgery.

Results

Activity and resting pain were significantly reduced in the GMI group compared to the control group (P < 0.001 and P = 0.004, respectively). Movement Imagery Questionnaire-3 scores and accuracy of lateralization performance also showed significant improvement (P = 0.037 and P = 0.015, respectively). The Pain Catastrophizing Scale and Tampa Kinesiophobia Scale scores were also significantly decreased in the GMI group compared to the control group (P = 0.039 and P = 0.009, respectively). However, GMI did not differ significantly in WOMAC scores, range of motion, muscle strength, timed up and go test and Central Sensitization Inventory scores compared to the control group (P > 0.05).

Conclusions

GMI improved pain, motor imagery ability, pain catastrophizing, and kinesiophobia in the acute period after TKA.

Application of machine learning in the prevention of periprosthetic joint infection following total knee arthroplasty: a systematic review

BACKGROUND

Machine learning is a promising and powerful technology with increasing use in orthopedics. Periprosthetic joint infection following total knee arthroplasty results in increased morbidity and mortality. This systematic review investigated the use of machine learning in preventing periprosthetic joint infection.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed was searched in November 2022. All studies that investigated the clinical applications of machine learning in the prevention of periprosthetic joint infection following total knee arthroplasty were included. Non-English studies, studies with no full text available, studies focusing on non-clinical applications of machine learning, reviews and meta-analyses were excluded. For each included study, its characteristics, machine learning applications, algorithms, statistical performances, strengths and limitations were summarized. Limitations of the current machine learning applications and the studies, including their 'black box' nature, overfitting, the requirement of a large dataset, the lack of external validation, and their retrospective nature were identified.

RESULTS

Eleven studies were included in the final analysis. Machine learning applications in the prevention of periprosthetic joint infection were divided into four categories: prediction, diagnosis, antibiotic application and prognosis.

CONCLUSION

Machine learning may be a favorable alternative to manual methods in the prevention of periprosthetic joint infection following total knee arthroplasty. It aids in preoperative health optimization, preoperative surgical planning, the early diagnosis of infection, the early application of suitable antibiotics, and the prediction of clinical outcomes. Future research is warranted to resolve the current limitations and bring machine learning into clinical settings.

Fluid Therapy in Exotic Animal Emergency and Critical Care

Many new concepts are emerging in the understanding of fluid therapy in human and mammalian medicine, including the role of the glycocalyx, increased understanding of fluid, sodium, and chloride overload, and the advantages of colloid administration in the form of albumin. None of these concepts, however, appear to be directly applicable to non-mammalian exotic patients, and careful consideration of their alternate physiology is required when formulating fluid plans for these patients.

Distal Interphalangeal Joint Arthroplasty - A Systematic Review

Background: Arthritis of the distal interphalangeal joint (DIPJ) can result in significant functional limitations and pain. While arthrodesis is the most common surgical intervention, this can decrease grip strength and have other limitations. DIPJ arthroplasty may be an appealing alternative in select patient with this study aiming to review the outcomes of this procedure. Methods: A search was conducted according to PRISMA guidelines using PubMed, Embase and Ovid Medline from date of inception to April 2022. Relevant studies were included if they reported on complications and functional outcomes of DIPJ arthroplasty. Data was then extracted and analysed. Results: Seven studies were included including 171 patients with 269 digits. The mean age was 62.1 years, with 81% of the cohort being female. The indication for surgery was osteoarthritis in 97% of patients. Surgical approaches varied from dorsal transverse, dorsal T-incision, dorsal H-incision to radial incisions. A silicone implant was used in all patients. A total of 97.7% of patients were satisfied with their outcome, and pain improved or eliminated in all patients where it was reported. Joint stability was noted in 97.4% of cases. The mean preoperative DIPJ range of motion was 24° and improved to 36° post-operation. The mean preoperative extensor lag was 24° and reduced to 13° post operation. The rate of re-operation was 7.1%. Conclusions: DIPJ arthroplasty may be a viable alternative to arthrodesis in certain settings, providing high patient satisfaction, improvements in digital range of motion and relief of pain. However, the available literature is sparse, and limited by low-quality studies and heterogenous outcome reporting. Level of Evidence: Level III (Therapeutic).

Mitral repair versus replacement: 20-year outcome trends in the UK (2000-2019)

OBJECTIVES

Using a large national database, we sought to describe outcome trends in mitral valve surgery between 2000 and 2019.

METHODS

The study cohort was split into mitral valve repair (MVr) or replacement, including all patients regardless of concomitant procedures. Patients were grouped by four-year admission periods into groups (A to E). The primary outcome was in hospital mortality and secondary outcomes were return to theatre, postoperative stroke and postoperative length of stay. We investigated trends over time in patient demographics, comorbidities, intraoperative characteristics and postoperative outcomes. We used a multivariable binary logistic regression model to assess the relationship between mortality and time. Cohorts were further stratified by sex and aetiology.

RESULTS

Of the 63 000 patients in the study cohort, 31 644 had an MVr and 31 356 had a replacement. Significant demographic shifts were observed. Aetiology has shifted towards degenerative disease; endocarditis rates in MVr dropped initially but are now rising (period A = 6%, period C = 4%, period E = 6%; P < 0.001). The burden of comorbidities has increased over time. In the latest time period, women had lower repair rates (49% vs 67%, P < 0.001) and higher mortality rates when undergoing repair (3% vs 2%, P = 0.001) than men. Unadjusted postoperative mortality dropped in MVr (5% vs 2%, P < 0.001) and replacement (9% vs 7%, P = 0.015). Secondary outcomes have improved. Time period was an independent predictor for reduced mortality in both repair (odds ratio: 0.41, 95% confidence interval: 0.28-0.61, P < 0.001) and replacement (odds ratio: 0.50, 95% confidence interval: 0.41-0.61, P < 0.001).

CONCLUSIONS

In-hospital mortality has dropped significantly over time for mitral valve surgery in the UK. MVr has become the more common procedure. Sex-based discrepancies in repair rates and mortality require further investigation. Endocarditis rates in MVS are rising.