Periprosthetic Joint Infection: Are Patients With Multiple Prosthetic Joints at Risk?

Patients who present with a periprosthetic joint infection in a single joint may have multiple prosthetic joints. The risk of these patients developing a subsequent infection in another prosthetic joint is unknown. Our purposes were (1) to identify the risk of developing a subsequent infection in another prosthetic joint and (2) to describe the time span and organism profile to the second prosthetic infection. We retrospectively identified 55 patients with periprosthetic joint infection who had another prosthetic joint in place at the time of presentation. Of the 55 patients, 11 (20%) developed a periprosthetic joint infection in a second joint. The type of organism was the same as the first infection in 4 (36%) of 11 patients. The time to developing a second infection averaged 2.0 years (range, 0-6.9 years).     

Inadequate Margins of Excision When Undergoing Mastectomy for Breast Cancer: Which Patients are at Risk?

Background

We analyzed the margin status and risk factors for inadequate margins among patients who underwent skin-sparing mastectomies (SSM) and traditional total mastectomies (TM).

Materials and Methods

Patients undergoing mastectomies from 2003 to 2009 were included. Margins of excision were considered positive if carcinoma was at an inked margin and were considered close if such disease was within 2 mm of an inked margin.

Results

A total of 426 patients were identified. The mean age was 60 years and 90% were white. Mean tumor size was 2.6 cm and 44% had multiple ipsilateral carcinomas. Of 426 patients, 177 (42%) underwent SSM with reconstruction and 249 (58%) TM. The rate of positive or close margins on the initial specimen was 29% for SSM vs. 12% for TM (P < 0.01), and the rate of reoperation for margins was 7% for SSM vs. 2% for TM (P < 0.01). Logistic regression analysis revealed that independent risk factors for initial close or positive margins included SSM (odds ratio 2.36, 95% confidence interval [95% CI] 1.05–5.30), multiple ipsilateral tumors (OR 2.12, 95% CI 1.05–4.24), and upper-inner quadrant location (OR 2.58, 95% CI 1.07–6.19). Mean follow-up time was 28 months, and the local recurrence rate was 0.9%. Local recurrence rates were not different for those undergoing SSM (1.1%) vs. TM (0.8%, P = NS).

Conclusions

Mastectomy patients undergoing SSM, with multiple ipsilateral tumors, and/or upper-inner quadrant disease are at significantly higher risk for inadequate margins of excision. These patients warrant more vigilant intraoperative attention to margin status to ensure adequate margins at the end of the first operation.     

Are Revision Hip Arthroplasty Patients at Higher Risk for Venous Thromboembolic Events Than Primary Hip Arthroplasty Patients?

Background

The purpose of this study is to determine whether revision total hip arthroplasty (THA) is associated with increased rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) when compared to primary THA.

Which Risk Factors Are Associated with Pain and Patient-reported Function in Patients with a Rotator Cuff Tear?

BackgroundPatient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores.Question/purposeAfter controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?MethodsFifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05.ResultsThis model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r² = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r² = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r² = 0.65; p < 0.001).ConclusionOur results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan.Level of EvidenceLevel II, prognostic study.     

Predicting Bariatric Surgical Outcomes: Does Preoperative Weight Gain Correlate with Lesser Postoperative Weight Loss?

Background: This study is a retrospective analysis of 76 patients who underwent vertical banded gastroplasty (VBG), in order to determine whether preoperative weight gain correlates with lesser postoperative weight loss. Methods: Patients were divided into two groups: those patients who did not gain a significant amount of weight during the preoperative period (group 1), and those patients who gained greater than 2.5% of their preoperative BMI during the preoperative period (group 2). There were 59 patients in group 1 and 17 patients in group 2. Results: Patients in group 1 had an average follow-up of 374 days and lost an average of 37.5 kg. The patients in group 2 had an average follow-up of 379 days with an average weight loss of 39.3 kg. Conclusion: Linear regression analysis was performed and supported the finding that preoperative weight gain is not predictive of lesser postoperative weight loss.     

Early Vascular Thrombosis After Kidney Transplantation: Can We Predict Patients at Risk?

Background

Renal transplant is the therapy of choice for patients with chronic renal disease. In recent years, improvement in immunosuppressive drugs reduced early graft loss associated with acute rejection. However, vascular thrombosis, accounting for 5% of early graft loss, can sensitize the recipient for human leukocyte antibodies, reducing the chance for a second transplant. The aim of this study was to identify risk factors for vascular thrombosis in a single transplant center, to design specific prevention protocol.