Total hip arthroplasty for rheumatoid arthritis in younger patients: 2,557 replacements in the Finnish Arthroplasty Register followed for 0–24 years

Background?The results of total hip arthroplasty (THA) in young patients with rheumatoid arthritis (RA) have been reported in only a few studies. On a nationwide level, the outcome of THA in these patients is unknown. We evaluated the population-based survival of THA in patients under 55 years of age with RA and factors affecting the survival.

Patients?Between 1980 and 2003, 2,557 primary THAs performed for RA in patients less than 55 years of age were reported to the Finnish Arthroplasty Register.

Results?Proximally circumferentially porous-coated uncemented stems had a 15-year survival rate of 89% (95% CI 83–94) with aseptic loosening as endpoint. The risk of stem revision due to aseptic loosening was higher with cemented stems than with proximally porouscoated uncemented stems implanted during the same period (RR 2.4; p < 0.001). In contrast, Cox regression analysis showed that the risk of cup revision was significantly higher for all uncemented cup concepts than for all-polyethylene cemented cups with any cup revision as endpoint. There were no significant differences in survival between the THR concepts.

Interpretations?Uncemented proximally circumferentially porous-coated stems and cemented all-poly-ethylene cups are currently the implants of choice for young patients with RA.     

Arthroplasty for ochronotic arthritisNo failure of 11 replacements in 3 patients followed 6–12 years

Background?Alkaptonuria is a rare single-gene disorder characterized by black pigmentation of cartilage and other connective tissues. Premature degenerative arthritis affects the large joints in many of these of patients. Medical treatment is limited to a protein-restricted diet (phenylalanine and tyrosine) with surgery reserved for end-stage joint disease. As in other metabolic bone diseases, there are concerns about the quality and strength of affected bones and therefore the suitability and longevity of replacement arthroplasty. The histopathology and outcome of joint replacement for alkaptonuric arthritis is unknown and limited to sporadic case reports.Patients and results?We describe 11 joint replacements in 3 patients with alkaptonuric polyarthropathy, including shoulder and elbow replacements not previously reported. No prosthetic failures occurred in up to 12 years of follow-up.Interpretation?Total joint replacement is an acceptable treatment for degenerative joint disease in alkaptonuric patients, with implant survival comparable to that found in patients with osteoarthritis.     

Revision total hip arthroplasty in juvenile chronic arthritis: 17 revisions in 11 patients followed for 4–12 years

Background Revision total hip arthroplasty (THA) in patients with juvenile chronic arthritis (JCA) is complicated by the young age of the patient, poor bone stock and small physical proportions. We report the complications and outcome of a prospective series of 17 revision THAs in Charnley class C JCA patients.

Methods 15 acetabular components and 10 femoral components were revised. 13 cementless cups, 2 reconstruction/roof rings and cemented cups, and 4 cemented and 6 cementless femoral stems were implanted. 2 proximal femoral allografts and 1 strut allograft were used. Age at revision was 32 (21–53) years. Follow-up averaged 7 (4–12) years.

Results 2 patients with cemented femoral stems developed loosening, osteolysis and fracture. Both were successfully revised to long-stem cementless implants with strut/proximal femoral allografts. 1 loose, worn cementless cup with osteolysis was revised. 1 patient with a peri-operative infection and late acetabular fracture had a loose, non-revised cementless cup. 1 case of sciatic nerve palsy occurred after revision using a reconstruction ring. 1 late infection necessitated resection arthroplasty. Harris hip scores improved from 53 (34–85) to 76 (47–96).

Interpretation Revision THA in JCA has a substantial complication rate, even in experienced hands. The problem of obtaining long-term stable fixation, osteolysis, and replenishment of lost bone stock are major difficulties.     

Outcome of isolated tibial polyethylene insert exchange after uncemented total knee arthroplasty: 27 patients followed for 8–71 months

Background?The outcome of performing isolated tibial polyethylene insert exchange (ITPIE) after total knee arthroplasty (TKA) is under debate. We evaluated the survival probability of ITPE after uncemented TKA.

Method?27 patients (27 knees) with an ITPIE performed mean 9 (0.9–17) years after the initial TKA were included in the study (22 patients also had the patellar component replaced simultaneously). All patients had their exchange performed at our department between 1997 and 2001 and had their latest follow-up examination mean 40 (8–71) months after the exchange.

Results?During the follow-up, 2 patients had total knee revision because of aseptic loosening and 2 patients had isolated patella component exchange (in 1 of the patients, combined with a new ITPIE). Kaplan-Meier survival analysis gave a survival probability of 80% at 34 months of follow-up.

Interpretation?The short-term survival after an ITPIE was similar to that of a total knee revision with exchange of all components. Since the ITPIE is a much smaller operation with fast rehabilitation, we recommend it in elderly patients with a well-fixed and wellaligned prosthesis without surface damage of the components.     

Secondary intramedullary nailing after distraction osteogenesis30 patients followed for 2–12 years

Background?There is no consensus about replacement of an external fixator by reamed intramedullary nailing in fracture cases. Patients and methods?We evaluated the outcome in 30 patients (33 segments) of secondary intramedullary nailing during the consolidation phase after callus distraction using an external device. The main reasons for nailing were docking site nonunion (17 patients), angular deformity or fracture of the lengthened area (8 patients) or intolerance of the external device (5 patients), in 11 patients combined with a delayed distracted callus maturation. The average follow-up time was 4 (2–12) years. Results?Intramedullary infection after nailing occurred in 1 case, and slight loss in callus length in 5 cases. Failure of union at the docking site with nail breakage occurred in 1 case. In the other patients, consolidation in the lengthened callus area and also union at the docking site were achieved on average 6 months after nailing. Interpretation?We believe that intramedullary nailing during the consolidation phase after bone lengthening or bone transport is a treatment option for delayed callus maturation or docking site nonunion, reducing prolonged use of the external fixator.     

Metal ion levels in patients with a lumbar metal-on-metal total disc replacement: should we be concerned?

The purpose of this study was to evaluate whether concerns about the release of metal ions in metal-on-metal total hip replacements (THR) should be extended to patients with metal-bearing total disc replacements (TDR). Cobalt and chromium levels in whole blood and serum were measured in ten patients with a single-level TDR after a mean follow-up of 34.5 months (13 to 61) using inductively-coupled plasma mass spectrometry. These metal ion levels were compared with pre-operative control levels in 81 patients and with metal ion levels 12 months after metal-on-metal THR (n = 21) and resurfacing hip replacement (n = 36). Flexion-extension radiographs were used to verify movement of the TDR. Cobalt levels in whole blood and serum were significantly lower in the TDR group than in either the THR (p = 0.007) or the resurfacing group (p < 0.001). Both chromium levels were also significantly lower after TDR versus hip resurfacing (p < 0.001), whereas compared with THR this difference was only significant for serum levels (p = 0.008). All metal ion levels in the THR and resurfacing groups were significantly higher than in the control group (p < 0.001). In the TDR group only cobalt in whole blood appeared to be significantly higher (p < 0.001). The median range of movement of the TDR was 15.5° (10° to 22°). These results suggest that there is minimal cause for concern about high metal ion concentrations after TDR, as the levels appear to be only moderately elevated. However, spinal surgeons using a metal-on-metal TDR should still be aware of concerns expressed in the hip replacement literature about toxicity from elevated metal ion levels, and inform their patients appropriately.     

Cancer incidence and cause-specific mortality in patients with metal-on-metal hip replacements in Finland: A population-based study with a mean follow-up of 4.6 (1–11) years

Background and purpose

Metal-on-metal hip implants have been widely used, especially in the USA, Australia, England and Wales, and Finland. We assessed risk of death and updated data on the risk of cancer related to metal-on-metal hip replacements.

Patients and methods

A cohort of 10,728 metal-on-metal hip replacement patients and a reference cohort of 18,235 conventional total hip replacement patients were extracted from the Finnish Arthroplasty Register for the years 2001–2010. Data on incident cancer cases and causes of death until 2011 were obtained from the Finnish Cancer Registry and Statistics Finland. The relative risk of cancer and death were expressed as standardized incidence ratio (SIR) and standardized mortality ratio (SMR). SIR/SIR ratios and SMR/SMR ratios, and Poisson regression were used to compare the cancer risk and the risk of death between cohorts.

Results

The overall risk of cancer in the metal-on-metal cohort was not higher than that in the non-metal-on-metal cohort (RR = 0.91, 95% CI: 0.82–1.02). The risk of soft-tissue sarcoma and basalioma in the metal-on-metal cohort was higher than in the non-metal-on-metal cohort (SIR/SIR ratio = 2.6, CI: 1.02–6.4 for soft-tissue sarcoma; SIR/SIR ratio = 1.3, CI: 1.1–1.5 for basalioma). The overall risk of death in the metal-on-metal cohort was less than that in the non-metal-on-metal cohort (RR = 0.78, CI: 0.69–0.88).

Interpretation

The overall risk of cancer or risk of death because of cancer is not increased after metal-on-metal hip replacement. The well-patient effect and selection bias contribute substantially to the findings concerning mortality. Arthrocobaltism does not increase mortality in patients with metal-on-metal hip implants in the short term. However, metal-on-metal hip implants should not be considered safe until data with longer follow-up time are available.Metal-on-metal hip implants have been widely used, especially in the USA, Australia, England and Wales, and Finland (AOANJRR 2010, NJR 2011, Cohen 2012, Seppänen et al. 2012). The theoretical health risks related to chronically elevated blood metal ion concentrations induced by abnormal wear and corrosion of the metal-on-metal implants—apart from local symptoms around the failing implant—include systemic symptoms of poisoning (Steens et al. 2006, Oldenburg et al. 2009, Rizzetti et al. 2009, Tower 2010, 2012, Mao et al. 2011, Sotos and Tower 2013, Zyviel et al. 2013) and carcinogenesis (Mäkelä et al. 2012, Smith et al. 2012, Brewster et al. 2013). Systemic metal ion toxicity cases due to a failed hip replacement are rare. However, there have been several recent reports of systemic cobalt toxicity following revision of fractured ceramic components, and also in patients with a failed metal-on-metal hip replacement (Steens et al. 2006, Oldenburg et al. 2009, Rizzetti et al. 2009, Tower 2010, 2012, Mao et al. 2011, Sotos and Tower 2013, Zyviel et al. 2013). Possible clinical findings include fatigue, weakness, hypothyroidism, cardiomyopathy, polycythemia, visual and hearing impairment, cognitive dysfunction, and neuropathy. Fatal cardiomyopathy due to systemic cobalt toxicity after hip replacement has been reported (Zyviel et al. 2013).Metal debris from hip replacement may be associated with chromosomal aberrations and DNA damage (Case et al. 1996, Bonassi et al. 2000, Daley et al. 2004). However, the risk of cancer is not increased after conventional metal-on-polyethylene total hip replacement or after first-generation metal-on-metal total hip arthroplasty (Visuri et al. 1996, 2010a). The short-term overall cancer risk after modern metal-on-metal hip arthroplasty is not increased either (Mäkelä et al. 2012, Smith et al. 2012, Brewster et al. 2013). However, recent linkage studies of overall cancer risk are based on hospital episode statistics, which may have less quality assurance than cancer registry data (Smith et al. 2012, Brewster et al. 2013). Annual updating of cancer registry data concerning the metal-on-metal issue is advisable.In this paper, we update our earlier published results on risk of cancer (Mäkelä et al. 2012) and give an assessment of the overall and cause-specific mortality in primary metal-on-metal and non-metal-on-metal hip replacement patients who were operated on from 2001 to 2010, by combining data from the Finnish Arthroplasty Register, the Population Register Centre, and the Finnish Cancer Registry. The reason for this early updating of the cancer data was to be able to detect a cancerogenic effect of metal-on-metal implants as early as possible.     

Increased mortality after anterior shoulder dislocation: 255 patients aged 12–40 years followed for 25 years

Background?No data exist regarding mortality rate in young patients with a first–time anterior shoulder dislocation. A cohort of 255 patients aged 12–40 years had a primary anterior shoulder dislocation during the years 1978 and 1979. After 10 years, 9 of the patients had died—which is a high figure for this cohort of patients. The question thus arose as to whether these patients had an increased mortality rate. In this study we have examined the mortality rate in these patients 25 years after the primary dislocation, relative to that of the Swedish population in general.

Patients and methods?In 1978 and 1979, 255 patients aged 12–40 years (257 shoulders) with first–time anterior shoulder dislocation were treated with or without immobilization. During 2003 and 2004, a follow-up of all patients who were alive was undertaken and the certificates of causes of death of 27 deceased patients were also analyzed.

Results?The mortality rate (SMR) for the patients in this study was more than double that of the general Swedish population (p < 0.001). A higher proportion of the deceased patients had etiology other than sportsrelated activity as a cause of their initial dislocation (p = 0.04). 11 of the 27 who were deceased had died from injury or intoxication (S00–T98, ICD10), which was more than expected relative to the causes of death for the general Swedish population in 2003 and 2004 (p < 0.001)

Interpretation?The doubled mortality rate in our cohort of patients is most probably explained by the inclusion of a disproportionate number of patients with alcoholic behavior, which may affect the long-term outcome in trauma series.     

10-year results of the uncemented Allofit press-fit cup in young patients: 121 hips followed for 10–12 years

Background and purpose

Uncemented acetabular components in primary total hip arthroplasty (THA) are commonly used today, but few studies have evaluated their survival into the second decade in young and active patients. We report on a minimum 10-year follow-up of an uncemented press-fit acetabular component that is still in clinical use.

Methods

We examined the clinical and radiographic results of our first 121 consecutive cementless THAs using a cementless, grit-blasted, non-porous, titanium alloy press-fit cup (Allofit; Zimmer Inc., Warsaw, IN) without additional screw fixation in 116 patients. Mean age at surgery was 51 (21–60) years. Mean time of follow-up evaluation was 11 (10–12) years.

Results

At final follow-up, 8 patients had died (8 hips), and 1 patient (1 hip) was lost to follow-up. 3 hips in 3 patients had undergone acetabular revision, 2 for deep infection and 1 for aseptic acetabular loosening. There were no impending revisions at the most recent follow-up. We did not detect periacetabular osteolysis or loosening on plain radiographs in those hips that were evaluated radiographically (n = 90; 83% of the hips available at a minimum of 10 years). Kaplan-Meier survival analysis using revision of the acetabular component for any reason (including isolated inlay revisions) as endpoint estimated the 11-year survival rate at 98% (95% CI: 92–99).

Interpretation

Uncemented acetabular fixation using the Allofit press-fit cup without additional screws was excellent into early in the second decade in this young and active patient cohort. The rate of complications related to the liner and to osteolysis was low.Uncemented acetabular components are widely used all over the world. A variety of these components have been associated with excellent short- to medium-term clinical and radiographic outcomes (Hallan et al. 2010, Howard et al. 2011). During the second decade of use, a number of cementless cup designs have shown durable fixation, but problems related to wear and osteolysis often compromise the results, and the surgeon can face serious problems in revision surgery because of extensive bone loss. This is a particular problem with young and active patients (Kim et al. 2012). Currently, there are few reports on the survival of contemporary uncemented cups that are still in clinical use in young patient cohorts with a minimum of 10 years of follow-up (Akbar et al. 2009, Kim et al. 2012), despite being used frequently in this group of patients.We evaluated the ten- or more-year results of an independent series of the non-porous, uncemented, press-fit Allofit cup in young patients (≤ 60 years old) implanted without any additional fixation (screws) and compared the results with those reported in the literature.     

No increased stem subsidence after arthroplasty in young patients with femoral head osteonecrosis:41 patients followed for 1–9 years

Background?Poor bone stock in patients with osteonecrosis of the femoral head may be a reason for poor outcome after hip replacement. One way of studying bone quality is to measure implant migration. We thus investigated the clinical and radiographic results of cementless THR in younger patients with femoral head osteonecrosis.

Patients and methods?We studied hips in 41 patients (mean age 48 (25–63) years) with a cementless hip arthroplasty after late stage osteonecrosis. Clinical evaluation was by the Harris hip score, the WOMAC score and the SF-36 score. Stem subsidence was measured with the Ein Bild Roentgen Analyse femoral component analysis (EBRA-FCA) at 3, 12, 24, 60, and 72 months after operation. The average duration of follow-up was 7(1–9) years, with less than 2 years for 2 patients.

Results?There was no revision of any hip. No radiographic or clinical stem loosening was seen. After 60 months, the cementless stems showed a median subsidence of –0.7?mm (95% CI: –0.9 to –0.2). No femoral osteolysis occurred. Femoral radiolucent lines, all < 1?mm, were seen in 10 hips. At the latest follow-up the Harris hip score was 83 (23–100) points.

Interpretation?Our findings for porous-coated stems in patients with femoral osteonecrosis indicate no greater risk of stem subsidence and rate of osteolysis after an average of 7 years follow-up. Thus, we continue to use uncemented stems in younger patients with femoral osteonecrosis. However, continued follow-up will be necessary to evaluate the long-term outcome.     

Predictors of loss of follow-up in a prospective registry: which patients drop out 12 months after lumbar spine surgery?

Background ContextLong-term patient-reported outcomes (PROMs) are essential in clinical practice and research. Prospective trials and registries often struggle with high rates of loss of follow-up (LOFU), which may bias their findings. Little is known on risk factors for PROM nonresponse, especially for digitally mailed questionnaires.PurposeTo elucidate which patients are at high risk for LOFU by identifying associated predictors.Study DesignAnalysis of a prospective registry.Patient SamplePatients that underwent surgery for degenerative lumbar disease were included.Outcome MeasuresRate of PROM follow-up response at 12 months postoperatively.MethodsPreoperatively and at 12 months postoperatively, patients were asked to complete a range of PROM questionnaires using a web-based tool. All patients who successfully completed their baseline questionnaire were included. Patients were not actively reminded upon nonresponse. Univariate and independent predictors of LOFU at 12 months were identified.ResultsWe included 1,456 patients, of which 861 (59%) were lost to follow-up at 12 months. Univariately, lower age, American Society of Anesthesiologists (ASA) class 1, smoking, lack of prior surgery, higher pain scores and functional disability, and lower quality-of-life were associated with LOFU (all p<.05). Only lower age (OR: 0.98, p=.001), smoking (OR: 1.46, p=.019), lack of prior surgery (OR: 0.59, p=.019), and spondylolisthesis (OR: 0.47, p=.024) independently predicted LOFU.ConclusionsIn a prospective registry of lumbar spine surgery patients based on web-based outcome capturing, younger age, active smoking status, lack of prior surgery, and nonspondylolisthesis surgery were independent predictors of loss of follow-up. In the future, it may become possible to preoperatively identify patients at high-risk for study dropout. As the implementation of prospective registries and the use of automated follow-up methods are on the rise, it is crucial to ensure efficiency and reduce bias of the methods on which all clinical research is based on.     

Role of MMP-9 and its tissue inhibitor TIMP-1 in human osteosarcomaFindings in 42 patients followed for 1–16 years

Background?The activity of matrix metalloproteinases (MMPs) in degrading extracellular matrix is controlled by activation of proenzymes and inhibition of MMP tissue inhibitors (TIMPs). Patients and methods?To assess the proteolytic cascade imbalance in malignancy progression, tissue expression and serum levels of MMP-2, MMP-9 and of their inhibitors TIMP-2 and TIMP-1 respectively were evaluated in 42 selected patients with high-grade osteosarcoma (OS). MMP-2, MMP-9, TIMP-2 and TIMP-1 were studied in biopsies by immunohistochemistry and in serum by ELISA test. Patients were subdivided into 3 groups according to their follow up: continuously disease-free, diagnosis of metastasis during follow-up, and metastasis at diagnosis. Results?Immunohistochemistry demonstrated an imbalance between MMPs and TIMPs, with a more evident role for MMP-9 than for MMP-2 in tumor progression. TIMP-1 inhibitor in plasma was higher in patients with osteosarcoma than in a control group. This high value of TIMP-1 was particularly evident in the group of patients who later developed metastases and/or local recurrences, and in those with metastases at diagnosis. Interpretation?Our findings confirm the protective action of TIMP-1, as MMP inhibitor, but also show its activity as a growth factor underlining its multifunctional role in OS.     

Is concomitant bone surgery necessary at the time of open reduction in developmental dislocation of the hip in children 12-18 months old? Comparison of open reduction in patients younger than 12 months old and those 12-18 months old

It is controversial to perform bone surgery at the time of open reduction in developmental dislocation of the hip in children 12-18 months old. The purpose of this study is to investigate whether concomitant bone surgery is necessary in patients treated with medial open reduction in this age range. Patients that were under 12 months of age at the time of open reduction were compared with patients that were 12-18 months old. Forty-four hips of 30 patients treated with open reduction through Ferguson's medial approach have been included in the study. Mean follow-up was 19.6 years (13-27.5). Age at the time of open reduction was less than 12 months in 21 hips (group A) and 12 months or more in 23 hips (group B). There was no significant difference between two groups concerning avascular necrosis or unsatisfactory radiological outcome (Severin's groups III and IV). A higher rate of secondary bone surgery was necessary in group B than in group A. Although secondary bone surgery is needed at a higher frequency in children 12-18 months old, the radiological outcome is not significantly different for patients younger than 12 months. Therefore, the recommendation of concomitant bone surgery on a routine basis during open reduction in developmental dislocation of the hip in children 12-18 months old is debatable.     

Corrosion in modular total hip replacements: An analysis of the head–neck and stem–sleeve taper connections

In this retrieval study, modular junctions of retrieved S-ROM^® implants were examined to determine the extent of corrosion at the head–neck and stem–sleeve junctions. Corrosion severity was graded in relation to the bearing surface material over time. It was found that the corrosion at the head–neck taper is greater for cobalt–chrome femoral heads compared to ceramic femoral heads. The stem–sleeve junction had significantly more corrosion damage (p < 0.05) in implants that had hard-on-hard bearing surfaces compared to hard-on-soft bearings. This study suggests that bearing surface materials and head size affect the amount of corrosion that is present at the modular junctions.     

Femoral head diameter affects the revision rate in total hip arthroplasty: An analysis of 1,720 hip replacements with 9–21 years of follow-up

Background?In a previous study concerning 1,660 ScanHip THAs that were followed for up to 12 years, the cumulative revision rate was not found to be dependent on whether a 22-mm or a 32-mm head size had been used. We have re-examined these patients to see whether a longer follow-up time (9–21 years) would disclose an effect of head size on the revision rate.

Patients and methods?We analyzed the cumulative revision rate for 1,720 Scan Hip arthroplasties with either 22-mm or 32-mm femoral heads. The patients were followed for 9–21 years.

Results?Arthroplasties with 32-mm head had 2.8-times higher cumulative revision rate than those with a 22-mm head. Older age reduced the risk of revision while male sex increased the risk.

Interpretation?We found that head size affects revision risk, but that even in a reasonably large material a long follow-up time is required to disclose the effects of head size—and thus wear—on survival.     

Achilles tendon lengthening for ankle equinus deformity in hemophiliacs: 23 patients followed for 1–24 years

Background?Bleeding in the calf or ankle joint may lead to ankle equinus deformity, particularly in childhood and during adolescence. We assessed the long-term functional and radiographic results after Achilles tendon lengthening for ankle equinus deformity in hemophiliacs.

Patients and methods?Between 1975 and 1986, 30 hemophilic patients with pes equinus were surgically managed by Achilles tendon lengthening. Of these, 23 were followed up prospectively twice a year for an average of 13 (1–24) years. The mean age at operation was 29 (12–46) years. The clinical results were documented according to the score of the Advisory Committee of the World Federation of Hemophilia (WFH), while radio-graphs were evaluated using the Pettersson score. On average, preoperative ankle equinus deformity was 21 (5–55) degrees. Mean range of motion was 21 (5–42) degrees prior to surgery.

Results?At the first postoperative examination 1 year after surgery, 21/23 cases were improved, and 9/21 reached dorsiflexion to at least neutral position. At the last follow-up, ankle equinus deformity was 10 (4–20) degrees on average. 20/23 patients still showed significant improvement compared to their condition before surgery. 7 patients still had complete correction of the equinus deformity, while mean range of motion decreased constantly over the observation period. The clinical score was significantly improved 1 year after surgery and diminished only slightly afterwards. Radio-graphic outcome deteriorated, with scores rising from 4.3 (1–10) points preoperatively to 7.3 (3–12) points at last follow-up.

Interpretation?Most patients treated for hemophilic pes equinus by Achilles tendon lengthening experienced long-term benefit concerning the equinus deformity, but gradually lost overall movement of the ankle joint. Progression of the ankle arthropathy cannot be hindered.??     

Cost effectiveness of dual mobility in hip–spine patients: A value-based algorithm of utilization

ObjectivesPrior spinal pathology or surgery may increase the risk of dislocation and revision surgery after total hip arthroplasty. The purpose of this review is to present the etiology of dislocation, evaluate different implants to decrease risk of dislocation, and determine cost effectiveness of use.FindingsDual mobility implants for primary total hip arthroplasty can decrease postoperative dislocation and may result in long-term cost-savings.ConclusionsPrior spinal pathology or lumbar surgery can result in higher dislocation rates after total hip arthroplasty. Preoperative evaluation with patient questionnaires, assessment of previous medical history, and the use of advance imaging can help determine the need for dual mobility implants. The proper use of dual mobility implants may decrease dislocation risk in a cost-effective manner.     

DNA content prognostic in soft tissue sarcoma: 102 patients followed for 1–10 years

In a prospective study of 102 patients with soft tissue sarcoma, the prognostic importance of DNA content and clinicopathologic features was analyzed. Based on DNA flow cytometry, 37 lesions were diploid (normal DNA content) and 65 were nondiploid (abnormal DNA content). The 5-year metastasis-free survival rate of the whole series was 0.59. The survival rate was 0.77 for patients with diploid tumors and 0.48 for those with nondiploid tumors (ρ = 0.01). Multivariate analysis identified two independent metastatic risk factors: increasing tumor size and nondiploidy. Unexpectedly, high malignancy grade (III-IV) was not found to be an independent risk factor for metastasis.

The risk of metastasis was strongly related to the number of risk factors present. Thus, the 5-year survival for the 76 patients with no or one risk factor was 0.69, as compared with 0.30 for the 26 patients with two risk factors (P < 0.0001).

Our study shows that metastatic disease in soft tissue sarcoma is closely related to nondiploidy. A prognostication model based on DNA content and tumor size was found to discriminate between patients with a good and a poor prognosis after surgical treatment. The model can be used to identify patients who should be excluded from trials with adjuvant chemotherapy.     

Health-related quality of life for men with prostate cancer—an evaluation of outcomes 12–24 months after treatment

ObjectiveTo determine the health-related quality of life (HRQoL) impact of prostate cancer interventions at 2 years post-treatment, and between the 12- and 24-month interval, to better characterize this measure.Materials and methodsPatients treated at the Center for Prostate Disease Research between June 2003 and February 2010 were offered enrollment into a HRQoL study that entailed a baseline evaluation before prostate biopsy and at 3, 6, 9, 12, 18, 24, and 30 months thereafter. The instruments used were the Expanded Prostate Cancer Index Composite (EPIC), EPIC Demographic, and Medical Outcomes Study Short-Form 36 (SF-36). A Student's t-test and ANOVA were used to examine the association between HRQoL scores, patient demographic, and disease features. Multivariable regression models were used to analyze change over time. Estimates of risk, corresponding confidence intervals, and P values are presented for these longitudinal findings.ResultsThe study group was comprised of 595 patients. African Americans (AA) had slightly lower baseline raw scores in all EPIC and SF-36 HRQoL domains, but on bivariate analysis, there was no statistical difference in change of scores over time. Radical prostatectomy (RP) led to the greatest decline in urinary function. Bowel function significantly worsened with the addition of hormone therapy (HT) to external beam radiation therapy (EBRT). Sexual bother and function had a marked decline in all active treatment options. Despite these changes, there were no differences in overall satisfaction. SF-36 domains were not affected by RP, whereas EBRT and EBRT + HT had universal impact. For the 12- to 24-month interval, specifically, patients who underwent EBRT fared worse over this time period, showing continued worsening of urinary bother, hormonal function, physical role, physical component summary, and overall satisfaction. Patients who underwent RP did not show any further decline in the 12- to 24-month interval, but instead showed improvement.ConclusionsBecause of the protracted nature of recovery after surgery, delayed onset of effects from radiation, potential interval decline secondary to age-related symptoms, and longevity of patients with prostate cancer, determination of long-term HRQoL outcomes is integral. Counseling with regard to these outcomes should be balanced with oncologic expectations from treatment.