Introduction
Recurrent dislocations are still the most frequent reason for revision in total hip arthroplasty (THA). The impact of bearing surfaces on dislocations is still controversial. We ...hypothesized that: (1) bearing surfaces influence the revisions due to dislocations; (2) ceramic-on-ceramic reduced the revisions for dislocations in adjusted models; (3) Delta-on-Delta bearings reduced the revisions for dislocations in comparison to surfaces with cross-linked polyethylene.
Materials and methods
The regional arthroplasty registry was enquired about bearing surfaces and revisions for dislocations and instability. Unadjusted and adjusted rates were provided, including sex, age (<65 years or ≥65 years), head diameter (≤28 mm or >28 mm; <36 mm or ≥36 mm) as variables. 44,065 THAs were included.
Results
The rate of revisions for dislocations was significantly lower in ceramic-on-ceramic and metal-on-metal bearings (unadjusted rates). After adjusting for age, sex, and head size (36 and 28 mm), hard-on-hard bearings were protective (
p
< 0.05): ceramic-on-ceramic had a lower risk of revisions due to dislocation than ceramic-on-polyethylene (HR 1.6, 95% CI 1.2–2.2
p
= 0.0009). The rate of revisions for dislocation was similar in bearings with cross-linked polyethylene and Delta-on-Delta articulations, in unadjusted and adjusted models.
Conclusion
Bearings with conventional polyethylene were more predisposed to dislocations. Currently adopted bearings exerted no significant influence on revisions due to dislocations. These findings could be primarily related to wear, but due to the time distribution, soft tissue envelopes and surface tension may also play a role. Pre-clinical biomechanical evaluations and prospective matched cohort studies are required to draw definitive conclusions.
Introduction
Ceramic-on-ceramic couplings demonstrated to be reliable bearings in primary total hip arthroplasty (THA), with long-term remarkable results. Like-on-like configurations were widely ...described. On the contrary, mixed material combinations from the same manufacturer, Delta-on-Forte or Forte-on-Delta, were poorly studied. In particular, it is unknown whether mixed ceramic combinations are more at risk of ceramic fractures. Thus, a registry study was conducted to investigate the long-term survival rates and reasons for revision of mixed ceramic combinations. A comparison with Delta-on-Delta couplings was also performed.
Materials and methods
The regional arthroplasty registry RIPO was enquired about three cohorts of ceramic bearings (head-on-liner: Delta-on-Forte, Forte-on-Delta, Delta-on-Delta). Demographics, survival rates and reasons for revision were evaluated and compared.
Results
In total, 346 (1.5%) implants had a Delta-on-Forte coupling (mean follow-up: 6.4 years). In total, 1163 (5%) THAs had a Forte-on-Delta articulation (mean follow-up: 8.2 years). Delta-on-Delta surfaces were implanted in 21,874 (93.5%) hips (mean follow-up: 3.9 years). Mixed material combinations were implanted between 2003 and 2007. The survival rates of the three cohorts were similar and were higher than 95% at 10 years. In Forte-on-Delta group, four liners failed (0.3% of the implants), whereas ceramic fractures occurred in 15 cases (0.1%) in Delta-on-Delta couplings (3 heads and 12 liners). Considering ceramic fracture as endpoint, there was no significant difference between the three survival rates.
Conclusions
Mixed ceramic bearing configurations from the same manufacturer in primary THA showed mid-to-longterm dependable outcomes, not inferior to the most recent like-on-like ceramic bearings. No additional risks of ceramic fractures were evident. Thus, closer follow-ups are not required.
Objective
Stem anteversion in total hip arthroplasty (THA) has been measured using two different distal references, the posterior condyle (PC) or the transepicondylar axis (TEA). The reliability, the ...difference in value between these two techniques, and the possible confounding factors are scarcely known. Aims of this work were to assess (1) the intraclass correlation and the difference between the two measurement techniques and (2) the possible influence of condylar dysmorphisms on the anteversion value discrepancy.
Materials and methods
A consecutive series of post-THA CT scans were selected, excluding hip dysplasia, end-stage knee osteoarthritis, and replaced knees. Using a surgical planning software, stem anteversion was measured using the PC or the TEA reference. The intraclass reliability was assessed. The anteroposterior femoral condyle diameters were measured: the difference and the ratio were measured and correlated with the stem anteversion values.
Results
91 CT scans were included. Inter/intra-observer TEA measurements were more reliable than PC. The intraclass correlation between PC and TEA anteversion measurements was good, 0.954 (CI 95% 0.922–0965). The mean difference between PC and TEA anteversion was 5.27 ± 2.41°. The difference and the ratio between the two anteroposterior condyle diameters did not influence the anteversion difference (respectively,
p
0.797 and
p
0.901).
Conclusions
TEA and PC demonstrated to achieve a good correlation, not dependent from the condyle morphology. However, the difference between the two measurements (5°) can severely influence the combined anteversion (10–20%): due to clinical applicability and better inter/intra-observer agreement, TEA should be preferred for measuring stem anteversion.
Sudden cardiac death (SCD) is a pivotal health problem worldwide. The identification of subjects at increased risk of SCD is crucial for the accurate selection of candidates for implantable ...cardioverter defibrillator (ICD) therapy. Current strategies for arrhythmic stratification largely rely on left ventricular (LV) ejection fraction (EF), mostly measured by echocardiography, and New York Heart Association functional status for heart failure with reduced EF. For specific diseases, such as hypertrophic and arrhythmogenic cardiomyopathy, some risk scores have been proposed; however, these scores take into account some parameters that are a partial reflection of the global arrhythmic risk and show a suboptimal accuracy. Thanks to a more comprehensive evaluation, cardiac magnetic resonance (CMR) provides insights into the heart muscle (the so-called
tissue characterization
) identifying cardiac fibrosis as an arrhythmic substrate. Combining sequences before and after administration of contrast media and mapping techniques, CMR is able to characterize the myocardial tissue composition, shedding light on both intracellular and extracellular alterations. Over time, late gadolinium enhancement (LGE) emerged as solid prognostic marker, strongly associated with major arrhythmic events regardless of LVEF, adding incremental value over current strategy in ischemic heart disease and non-ischemic cardiomyopathies. The evidence on a potential prognostic role of mapping imaging is promising. However, mapping techniques require further investigation and standardization. Disclosing the arrhythmic substrate within the myocardium, CMR should be considered as part of a multiparametric approach to personalized arrhythmic stratification.
Late survival of patients having deep sternal wound infection (DSWI) after bilateral internal thoracic artery (BITA) grafting is largely unexplored.
Outcomes of 3391 consecutive BITA patients were ...reviewed retrospectively. Patients with DSWI after surgery (n = 142, 4.2%) were compared with those having no sternal complications (n = 3177). Predictors of DSWI and of mortality during the follow-up period were found with negative-binomial and Cox proportional-hazards regression, respectively. One-to-one propensity score-matched analysis, which considered simultaneously baseline patient characteristics, operative data, and postoperative complications was performed. The resulting matched pairs were compared for non-parametric estimates of late survival. The same comparison was performed in matched pairs having no major complications (except DSWI) early after surgery.
In-hospital mortality was higher in DSWI cohort than in patients having no sternal complications (5.6% vs. 1.8%, p = 0.0035). Almost all of postoperative complications were more frequent in DSWI patients. Female sex, obesity, chronic lung disease, renal impairment, extracardiac arteriopathy, congestive heart failure, and urgent/emergency priority were predictors of DSWI common to two DSWI risk models that were developed. DSWI was independent predictor of reduced late survival (multiple covariates-adjusted hazard ratio HR, 1.91, p < 0.0001). The propensity matching resulted in 135 pairs with same in-hospital mortality (5.2%). Estimates of freedom from all-cause death were lower in DSWI cohort (HR, 1.92, p < 0.0001), even when only pairs (n = 59) having no major postoperative complications (except DSWI) were considered (HR, 1.84, p = 0.026).
DSWI after BITA use seems to reduce late survival even after adjusting for baseline patient characteristics and concomitant postoperative complications.
•Bilateral internal thoracic artery (BITA) grafting is underused primarily because of increased risk of sternal complications.•Deep sternal wound infection (DSWI) is associated with increased morbidity and mortality after surgery.•To date, late survival of patients having DSWI after BITA grafting is largely unexplored.•Based on the results of this study, DSWI in BITA patients seems to be independent predictor of reduced late survival.
Far from being historically considered a primary healthcare problem, tricuspid regurgitation (TR) has recently gained much attention from the scientific community. In fact, in the last years, robust ...evidence has emerged regarding the epidemiological impact of TR, whose prevalence seems to be similar to that of other valvulopathies, such as aortic stenosis, with an estimated up to 4% of people >75 years affected by at least moderate TR in the United States, and up to 23% among patients suffering from heart failure with reduced ejection fraction. This recurrent coexistence of left ventricular systolic dysfunction (LVSD) and TR is not surprising, considered the multiple etiologies of tricuspid valve disease. TR can complicate heart failure mostly as a functional disease, because of pulmonary hypertension (PH), subsequent to elevated left ventricular end-diastolic pressure, leading to right ventricular dilatation, and valve tethering. Moreover, the so-called “functional isolated” TR can occur, in the absence of PH, as a result of right atrial dilatation associated with atrial fibrillation, a common finding in patients with LVSD. Finally, TR can result as a iatrogenic consequence of transvalvular lead insertion, another frequent scenario in this cohort of patients. Nonetheless, despite the significant coincidence of these two conditions, their mutual relation, and the independent prognostic role of TR is still a matter of debate. Whether significant TR is just a marker for advanced left-heart disease, or a crucial potential therapeutical target, remains unclear. Aim of the authors in this review is to present an update concerning the epidemiological features and the clinical burden of TR in the context of LVSD, its prognostic value, and the potential benefit for early tricuspid intervention in patients affected by contemporary TR and LVSD.
We aimed to assess the characteristics, management and long-term prognosis of a cohort of patients with multiple valvular disease, focusing on the context of severe mitral or aortic disease with ...concomitant significant tricuspid regurgitation (TR).
After using a propensity score matching for age, 975 patients with ≥ moderate TR, diagnosed at our centers from 2012 to 2020, were included and divided in four groups, including isolated TR patients as reference group. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization + any valvular intervention.
Patients with isolated TR (356, 37 %) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). Patients with severe mitral regurgitation (MR) + TR (466, 48 %) showed higher rates of concomitant coronary artery disease, advanced functional class symptoms and larger left atrial volumes. Severe aortic stenosis (AS) patients (131, 13 %) were older, with more comorbidities and lower LVEF. Patients with severe aortic regurgitation and TR (22, 2 %) were younger, with larger LV dimensions and higher pulmonary arterial pressures.
After a median follow-up of 2.8 years, both endpoints were univariably more frequent in patients with severe AS + TR (all p < 0.001), but after comprehensive adjustment difference in the primary endpoint became insignificant, underscoring the serious outcomes of all significant TR groups significantly. Overall, in 44 (5 %) patients tricuspid intervention was performed, with no differences between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment.
In the context of severe left-sided VD, concomitant significant TR is common, and each subtype presents with different clinical and echocardiographic features: patients with severe AS and TR have considerable worse prognosis, although comprehensive adjustment reflected the poor outcomes affecting all types of patients with significant TR. In this scenario, TR was profoundly undertreated.
Introduction: Total hip arthroplasty (THA) after proximal femoral fixation is a challenging procedure due to possible hardware-related complications. Case presentation: A 78-year-old female with hip ...osteoarthritis had a proximal femoral osteotomy fixed using a blade plate in the same femur 41 years ago. A two-step approach was planned. After a challenging hardware removal, an iatrogenic subtrochanteric fracture below the degenerated hip occurred after three months. THA with a tapered long stem was successfully performed with no need for additional osteosynthesis, and good results were seen two years later. Discussion: THAs in subtrochanteric fractures are technically demanding but feasible in selected cases. Hardware removal before THA implantation may carry important risks, and the surgical team should be prepared to perform arthroplasty in case of complications. Conclusion: THA in a subtrochanteric fracture below hip osteoarthritis is a feasible option in selected cases.
Background: Periprosthetic hip infections (PHIs) are troublesome complications of hip arthroplasties. The gold standard procedure for treating chronic PHI is a 2-stage approach. Recently, however, ...more conservative approaches have been developed to spare the osseointegrated components and avoid sequestra, bone loss, devascularization, and difficult reconstructions. The partial two-stage approach, which leaves the well-fixed component in situ and removes the loosened component, may be an effective strategy. Objective: This paper, a narrative mini-review, analyzed the preliminary results of a partial 2-stage approach to treating chronic hip arthroplasty infections. Methods: Pertinent papers describing the partial 2-stage approach (leaving the well-fixed component in situ and removing the loosened component) were collected and evaluated. Results: Six main case series were selected. A total of 76 patients were included. Many patients were treated with socket removal and stem retention with quite similar surgical techniques. Many cases included highly virulent bacteria, and no pre-operative selection about comorbidities was performed. The first outcomes of this approach were promising, with a rate of infection control ranging from 81.3% to 100% at mid-term follow-up. Conclusion: This approach proved good at mid-term follow-up; however, many concerns still exist. In particular, the indications are imprecise, and the role of biofilm is still unclear. Despite the first good outcomes, the partial 2-stage approach for chronic PHI should be validated by multicenter prospective studies.
Ghrelin may exert positive effects on cardiac structure and function in heart failure (HF) patients.
We assessed ghrelin levels in 266 dilated cardiomyopathy (DCM) patients and in 200 age, gender and ...body mass index (BMI) matched controls. Further, we evaluated the expression of ghrelin and growth hormone secretagogue-receptor (GHSR) in the myocardium of 41 DCM patients and in 11 controls.
DCM patients had significantly lower levels of total, acylated and unacylated ghrelin when compared to controls (
< 0.05 for all). In controls, we observed a negative correlation of ghrelin with age, male gender and BMI. These correlations were lost in the DCM group, except for male gender. Total ghrelin was higher in patients with more recent diagnosis when compared to patients with longer duration of the DCM (
= 0.033). Further, total ghrelin was higher in patients with lower left ventricular systolic function (<40% LVEF, vs. 40% ≤ LVEF < 49% vs. LVEF ≥ 50%: 480.8, vs. 429.7, vs. 329.5 pg/mL, respectively,
= 0.05). Ghrelin prepropeptide was expressed more in DCM patients than in controls (p = 0.0293) while GHSR was expressed less in DCM patients (p < 0.001). Furthermore, ghrelin showed an inverse correlation with its receptor (= -0.406, p = 0.009), and this receptor showed a significant inverse correlation with Interleukin-1 (= -0.422, p = 0.0103).
DCM duration and severity are accompanied by alterations in the ghrelin-GHSR system.
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