Mid-term survivorship results for a rotating-platform knee prosthesis

Interest in mobile-bearing knee prostheses is increasing in the US market. We studied results at 2 to 5 years with a mobile-bearing system that includes a cobalt-chrome tibial tray and femoral component with a polyethylene cruciate-retaining tibial component insert that allows rotation around a central axis and can be used with cruciate-retaining or posterior-stabilized femoral components. The inserts used in this study were cruciate retaining and did not include the posterior-stabilized design. The goal of this study was to demonstrate the function and safety of this prosthesis along with the lack of spinout, which is a major concern in the mobile-bearing knee. Four hundred thirty-five knees constituted the study cohort and underwent survivorship analysis and complication reporting. Routine clinic evaluations included pre- and postoperative radiographs and Knee Society knee and function scores at 6 and 12 weeks and every 2 years. The most recent follow-up data within 2 to 5 years was included for the study along with survey data. Flexion at most recent follow-up averaged 125°. Knee Society score at most recent visit averaged 88 of 100. Knee Society function score averaged 83 of 100. Radiographic results were available for 226 knees, with 97.3% assessed as normal and 6 with these issues: patella stress fracture (3), aseptic tibial loosening (1), patellar osteolysis (1), and patella aseptic loosening (1). In comparison with the fixed-bearing knee equivalent, this mobile-bearing knee demonstrated at least equivalent results in terms of survivorship, function, and patient satisfaction in the short- and mid-term.     

Trastuzumab Beyond Progression for HER2 Positive Metastatic Breast Cancer: Progression‐Free Survival on First‐Line Therapy Predicts Overall Survival Impact

Trastuzumab beyond first progression in the metastatic setting has been adopted based on limited data suggesting improved outcomes compared to second‐line chemotherapy alone although predictive factors for preferential benefit remain elusive. We conducted a retrospective review of all patients receiving trastuzumab for HER2 + metastatic disease between Jan 1, 1999–June 15, 2011. Univariate and time to event analyses described treatment and survival patterns. Median duration of each line of therapy and overall survival times for covariates, including treatment era (pre versus post Jan 1, 2005), lines of trastuzumab‐based therapy (1 versus 2 versus 3 + ), first‐line chemotherapy partner (docetaxel/paclitaxel versus other) and median exposure to first‐line trastuzumab‐based therapy (=/> versus < cohort median) were estimated. A total of 119 patients received a median of two lines of trastuzumab‐based therapy (range 1–8). Median overall survival was 21.8 months (95% CI = 14.5–27.1 m), by era was 15.6 m (95% CI = 9.7–24.8 m) versus 26.1 m (95% CI = 20.0–39.3 m; p = 0.11) and by lines of trastuzumab‐based therapy received was 10.6 m (95% CI = 5.3–17.4 m) versus 13.9 m (95% CI = 9.5–27.6 m) versus 32.5 m (95% CI = 25–49.4 m) (p = 0.0014). Median overall survival was significantly longer for those receiving taxanes with trastuzumab compared to other first line partners (26.1 m, 95% CI = 17.8–31.4 m versus 14.5 m, 95% CI = 9.4–21.9 m, p = 0.02). Median overall survival with duration of first‐line trastuzumab‐based therapy =/> cohort median was 31.9 m (95% CI = 26.2–52.2 m) versus 10.3 m for shorter durations (95% CI = 6.9–15.6 m; p < 0.0001). Our observations support progression‐free survival on first‐line trastuzumab‐based therapy as a clinically relevant predictive factor for overall survival benefit with the adoption of a trastuzumab beyond progression treatment strategy.     

Colonisation with methicillin‐resistant Staphylococcus aureus prior to renal transplantation is associated with long‐term renal allograft failure

Renal transplant recipients are at an increased risk of developing Methicillin‐resistant Staphylococcus aureus due to their immunosuppressed status. Herein, we investigate the incidence of MRSA infection in patients undergoing renal transplantation and determine the effect of MRSA colonisation on renal allograft function and overall mortality. Between January 1st 2007 and December 31st 2012, 1499 consecutive kidney transplants performed in our transplant unit and a retrospective 1:2 matched case‐control study was performed on this patient cohort. The 1‐, 3‐ and 5‐year overall graft survival rates were 100%, 86% and 78%, respectively, in MRSA positive recipients compared with 100%, 100% and 93%, respectively, in the control group (P < 0.05). The 1‐, 3‐ and 5‐year overall patient survival rates were 100%, 97% and 79%, respectively, in MRSA positive recipients compared with 100%, 100% and 95%, respectively, in the control group (P = 0.1). In a multiple logistic regression analysis, colonisation with MRSA pre‐operatively was an independent predictor for renal allograft failure at 5 years (hazard ratio: 4.6, 95% confidence interval: 1–30.7, P = 0.048). These findings demonstrate that the incidence of long‐term renal allograft failure is significantly greater in this patient cohort compared with a matched control population.     

A Clinical Pathway for Total Shoulder Arthroplasty—A Pilot Study

Background

Appropriate pain management after total shoulder arthroplasty (TSA) facilitates rehabilitation and may improve clinical outcomes.

Questions/purposes

This prospective, observational study evaluated a multimodal analgesia clinical pathway for TSA.

Methods

Ten TSA patients received an interscalene nerve block (25 cm³ 0.375% ropivacaine) with intraoperative general anesthesia. Postoperative analgesia included regularly scheduled non-opioid analgesics (meloxicam, acetaminophen, and pregabalin) and opioids on demand (oral oxycodone and intravenous patient-controlled hydromorphone). Patients were evaluated twice daily to assess pain, anterior deltoid strength, handgrip strength, and sensory function.

Results

The nerve block lasted an average of 18 h. Patients had minimal pain after surgery; 0 (median score on a 0–10 scale) in the Post-Anesthesia Care Unit (PACU) but increased on postoperative day (POD) 1 to 2.3 (0.0, 3.8; median (25%, 75%)) at rest and 3.8 (2.1, 6.1) with movement. Half of the patients activated the patient-controlled analgesia four or fewer times in the first 24 h after surgery. Operative anterior deltoid strength was 0 in the PACU but returned to 68% by POD 1. Operative hand strength was 0 (median) in the PACU, but the third quartile (75%) had normalized strength 49% of preoperative value.

Conclusions

Patients did well with this multimodal analgesic protocol. Pain scores were low, half of the patients used little or no intravenous opiate, and some patients had good handgrip strength. Future research can focus on increasing duration of analgesia from the nerve block, minimizing motor block, lowering pain scores, and avoiding intravenous opioids.     

Management of vertebral fragility fractures: a clinical care pathway developed by a multispecialty panel using the RAND/UCLA Appropriateness Method

BACKGROUND CONTEXT

Vertebral fragility fractures (VFFs), mostly due to osteoporosis, are very common and are associated with significant morbidity and mortality. There is a lack of consensus on the appropriate management of patients with or suspected of having a VFF.