The Surgical Options and Clinical Evidence for Treatment of Wear or Corrosion Occurring With THA or TKA

Background

Wear and corrosion occurring in patients with hip and knee arthroplasty are common causes of failure leading to revision surgery. A variety of surgical approaches to these problems have been described, with varying efficacy. Polyethylene wear, metal-on-metal (MoM) hip bearing wear, and problems associated with modular taper corrosion are the areas of greatest clinical impact; results of revisions for these problems are likely to dictate a large portion of revision resources for the foreseeable future, and so they call for specific study.

Questions/purposes

We identified the most frequently reported procedures to treat hip polyethylene wear, knee polyethylene wear, MoM wear after THA, and modular taper corrosion and determined the timing and reasons these failed.

Methods

We performed systematic reviews of the published literature on the four topics using MEDLINE^® and Embase in October 2013; searches were supplemented by hand searches of bibliographies. Prespecified criteria resulted in the identification of 38 relevant articles, of which 33 were either case reports or Level IV evidence. Followup was generally at short term and ranged from 0.2 to 8 years.

Results

The most frequently reported procedures for treating clinically important wear were a partial or complete revision. When treating polyethylene wear, the more frequently reported reasons for hip and knee rerevisions were loosening, continued wear, and instability. Soft tissue reactions were more common and occasionally extensive in patients with MoM or modular taper corrosion. Patients with soft tissue reactions had more complications and higher rerevision rates.

Conclusions

Studies with longer followup and higher levels of evidence are needed to direct the treatment of wear and corrosion. When soft tissue damage secondary to MoM wear or taper corrosion is present, the results of treatment can be poor. There is an urgent need to better understand these two mechanisms of failure.     

A comparison of the validity of two indirect utility instruments as measures of postoperative recovery

Background

Cost-effectiveness analyses of surgical interventions require valid measures of postoperative recovery. The objective of this study was to compare the validity of two indirect utility instruments, the Short Form 6D (SF-6D) and EuroQol 5D (EQ-5D), as measures of postoperative recovery.

Materials and methods

A prospective cohort of patients undergoing elective colorectal resection at two university-affiliated institutions from October 2012–October 2013 completed the SF-6D and EQ-5D (including the EQ-visual analog scale [EQ-VAS]) at baseline (before surgery), and at 4 and 8 wk after surgery. Responsiveness and construct validity were assessed through a priori hypotheses.

Results

A total of 165 patients were included. The SF-6D was the most responsive to the expected postoperative changes at 4 and 8 wk compared with the EQ-5D and the EQ-VAS. The 4-wk SF-6D, EQ-5D, and EQ-VAS discriminated between patients with and without complications after controlling for confounders with adjusted mean differences of −0.070 (95% confidence interval [CI] −0.126 to −0.015), −0.133 (95% CI −0.231, −0.030), and −7.91 (95% CI −14.77, −1.04), respectively. Mean SF-6D and EQ-5D values were significantly different from the US population norms at all time points, but the magnitude of change was highest for the SF-6D. The strength of correlation between all three instruments was moderate at all time points (r = 0.550–0.684, all P < 0.05).

Conclusions

The SF-6D preference-based health index appears to be a more valid measure of postoperative recovery than the EQ-5D and EQ-VAS in surgical cost-effectiveness analyses.     

Venous thromboembolism during combat operations: a 10-y review

Background

This article examines the incidence of venous thromboembolism (VTE) in combat wounded, identifies risk factors for pulmonary embolism (PE), and compares the rate of PE in combat with previously reported civilian data.

Methods

A retrospective review was performed of all U.S. military combat casualties in Operation Enduring Freedom and Operation Iraqi Freedom with a VTE recorded in the Department of Defense Trauma Registry from September 2001 to July 2011. The Military Amputation Database of all U.S. military amputations during the same 10-y period was also reviewed. Demographic data, injury characteristics, and outcomes were evaluated.

Results

Among 26,634 subjects, 587 (2.2%) had a VTE. This number included 270 subjects (1.0%) with deep venous thrombosis (DVT), 223 (0.8%) with PE, and 94 (0.4%) with both DVT and PE. Lower extremity amputation was independently associated with PE (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.07–2.69). A total of 1003 subjects suffered a lower extremity amputation, with 174 (17%) having a VTE. Of these, 75 subjects (7.5%) were having DVT, 70 (7.0%) were having PE, and 29 (2.9%) were found to have both a DVT and a PE. Risk factors found to be independently associated with VTE in amputees were multiple amputations (OR, 2; 95% CI, 1.35–3.42) and above the knee amputation (OR, 2.11; 95% CI, 1.3–3.32).

Conclusions

Combat wounded are at a high risk for thromboembolic complications with the highest risk associated with multiple or above the knee amputations.     

Decision making in the management of recurrent head and neck cancer

Despite substantial improvements in head and neck squamous cell carcinoma (HNSCC) treatment, the major obstacle to long‐term survival remains disease recurrence. Salvage options are often limited due to prior therapy and the escalated morbidity of retreatment. The costs of treatment must be measured against the anticipated quality and quantity of life recovered, even with resectable disease. This review surveys the recurrent HNSCC literature to better guide decision making. Across multiple studies, negative prognostic factors include impaired performance status, advanced recurrent stage, brief disease‐free interval, previous chemotherapy, and nonlaryngeal sites of recurrence. When possible, surgical salvage remains the principal option for durable disease control, quality of life preservation, and cure. Nonsurgical therapies have also demonstrated measurable improvements in locoregional control. Interpretation of salvage literature must be tempered by recognition of significant selection bias. The decision for salvage therapy must be individualized, with management that involves well‐informed patients resulting in the best outcomes. © 2013 Wiley Periodicals, Inc. Head Neck 36 : 144–151, 2014