Objectives We sought to characterize factors and outcomes associated with postoperative acute kidney injury in infants undergoing cardiac surgery. Methods We retrospectively studied 430 infants (<90 ...days) who underwent heart surgery for congenital defects. With a pediatric modified version of the Acute Kidney Injury Network classification, we performed statistical analyses to detect factors and outcomes associated with postoperative acute kidney injury. Results Postoperative acute kidney injury occurred in 225 patients (52%): 135 patients (31%) reached maximum acute kidney injury stage I, 59 (14%) reached stage II, and 31 (7%) reached stage III. On multivariable analysis, single-ventricle status (odds ratio, 1.6; 95% confidence interval, 1.08–2.37; P = .02), cardiopulmonary bypass (odds ratio, 1.2; 95% confidence interval 1.01–1.47; P = .04), and higher reference serum creatinine (odds ratio, 5.1; 95% confidence interval, 1.94–13.2; P = .0009) were associated with postoperative acute kidney injury. Thirty-two (7%) patients died in the hospital. Multivariable logistic regression showed that more severe acute kidney injury was associated with in-hospital mortality (maximum acute kidney injury stage II odds ratio, 5.1; 95% confidence interval, 1.7–15.2; P = .004; maximum acute kidney injury stage III odds ratio, 9.46; 95% confidence interval, 2.91–30.7; P = .0002) and longer mechanical ventilation and inotropic support. All acute kidney injury stages were associated with longer intensive care durations. Stage III acute kidney injury was associated with systemic ventricular dysfunction at hospital discharge. Conclusions Perioperative acute kidney injury is common in infant heart surgery and portends a poor clinical outcome.
Abstract Systemic cobaltism related to metal-on-metal total hip arthroplasty has been published in case reports and series with effects on the cardiac, neurologic, endocrine, and immunologic systems. ...This case report presents a 46-year-old male who underwent bilateral metal-on-metal total hip arthroplasty and subsequently developed cardiomyopathy requiring left ventricular assist device implantation. Intervention with bilateral revision to non-cobalt-containing implants resulted in improved cardiac function. This case report will alert clinicians to the presentation of this rare but devastating complication while also displaying improvement following revision total hip arthroplasty. It is our hope this case will aid in early recognition and intervention of this condition.
Abstract Controversy surrounds the safety of bilateral total knee arthroplasty (TKA) and whether staging the procedures one week apart represents a safer option. A consecutive series of 234 patients ...underwent either a simultaneous (103 patients) or staged bilateral TKA (131 patients) from 2007 to 2012 and were compared to a matched control group of unilateral TKA (131 patients). Staged patients had no difference in one-year complication rate when compared to simultaneous bilateral TKA and the matched unilateral TKA control group (15% vs. 19% vs. 15%, P = 0.512). There was also no difference in perioperative complications (10% vs. 14% vs. 7%, P = 0.231) or 90-day readmissions (8% vs. 4% vs. 4%, P = 0.295). In selected patients with bilateral knee OA, TKA staged at a one-week interval is a safe alternative.
Abstract Health care reform is directing clinical practice towards improving outcomes and minimizing complications. Preoperative identification of high-risk patients and modifiable risk factors ...present opportunity for clinical research. A total of 49,475 total hip arthroplasty patients were identified from National Surgical Quality Improvement Program between 2006 and 2013. We compared morbidly obese patients (BMI ≥ 40 kg/m2 ) and non-morbidly obese patients (BMI 18.5–40 kg/m2 ). We also compared patients with hypoalbuminemia (serum albumin < 3.5 g/dL) against those with normal albumin. Our study demonstrates that hypoalbuminemia is a significant risk factor for mortality and major morbidity among total hip arthroplasty patients, while morbid obesity was only associated with an increased risk of superficial surgical site infection. Impressively, hypoalbuminemia patients carried a 5.94-fold risk of 30-day mortality.
Objective With improving operative mortality for staged palliation of hypoplastic left heart syndrome, interstage death accounts for an increasing proportion of hypoplastic left heart syndrome ...mortality. We investigated risk factors for death or cardiac transplantation during the interstage period between bidirectional Glenn and Fontan procedures in children with hypoplastic left heart syndrome. Methods Patients with hypoplastic left heart syndrome who underwent bidirectional Glenn between August 1995 and June 2007 were screened. Standard risk patients, defined by having been discharged after both Norwood and bidirectional Glenn, were included for analysis. Patient demographic, echocardiographic, cardiac catheterization, and operative data were reviewed. Interstage attrition was defined as death or cardiac transplantation more than 30 days after bidirectional Glenn and before the Fontan procedure. Statistical analysis was carried out using the Student t test, Pearson chi-square correlation, and Cox proportional hazard modeling for multivariable analysis. Results Ninety-two patients with hypoplastic left heart syndrome were alive at 30 days after bidirectional Glenn. Of these patients, 8 died and 3 underwent cardiac transplantation at a median of 391 days (range, 59–1175 days) after bidirectional Glenn, yielding an interstage attrition rate of 12%. Removing the 7 patients who are still awaiting Fontan (but all of whom are at least 3.5 years after bidirectional Glenn) adjusts the attrition rate to 13%. Interstage attrition did not correlate with hemodynamic data obtained at cardiac catheterization, aortic arch obstruction, or right ventricular dysfunction. Multivariable analysis demonstrated that the presence of moderate or severe tricuspid valve regurgitation (hazard ratio, 6.02; 95% confidence interval, 1.56–23.24; P < .01) and weight z score (hazard ratio, 0.38; 95% confidence interval, 0.16–0.88; P = .02) were independent preoperative risk factors for interstage attrition. Conclusions Interstage attrition between bidirectional Glenn and Fontan procedures occurred in 12% of our study population. Moderate or greater tricuspid valve regurgitation and low weight z score at the time of bidirectional Glenn are important risk factors for interstage attrition between the bidirectional Glenn and Fontan procedures in children with hypoplastic left heart syndrome.
Abstract The purpose of this study is to evaluate the efficacy of trabecular metal (TM) shells and augments in acetabular revisions with significant pelvic bone loss. We retrospectively reviewed 97 ...cases of consecutive loose total hip arthroplasty with a minimum of Paprosky grade IIA pelvic bone loss treated with a TM revision acetabular component with or without modular augments. The average Harris hip score improved from 55 preoperatively to 76 postoperatively. At the most recent radiographic evaluation, 88 cups demonstrated no lucent lines, 1 cup had lucent lines but remained well fixed, and 8 cups underwent resection arthroplasty for infection. One cup was revised for chronic instability. There were no aseptic failures in this series. Trabecular metal acetabular cups and shells with or without the use of modular augments can be effectively used to revise failed acetabular components in patients with substantial pelvic bone loss.
Abstract We present a technique of femoral impaction grafting used for the treatment of periprosthetic femur fractures with severe bone loss after total hip arthroplasty. Seven patients with femoral ...fractures with compromise of the femoral isthmus were treated with femoral component revision using the impaction grafting bone technique. The average age was 64 years (range, 44-72 years), and 2 patients required mesh augmentation at the time of surgery. The average follow-up for this group of patients was 56 months (range, 39-92 months). Radiographic evaluation revealed healed fractures in all patients and no evidence of implant loosening at a mean of 56 months (range, 39-92 months). There were no cases of infections or dislocations in this series. Impaction grafting technique can be useful in the treatment of periprosthetic femur fractures when bone loss and canal geometry preclude the use of fully coated femoral components.
Abstract Refractory angina (RFA) is a debilitating disease characterized by cardiac pain resistant to conventional treatments for coronary artery disease including nitrates, calcium-channel and ...β-adrenoceptor blockade, vasculoprotective agents, percutaneous coronary interventions, and coronary artery bypass grafting. The mortality rate of patients living with RFA is not known but is thought to be in the range of approximately 3%. These individuals suffer severely impaired health-related quality of life with recurrent and sustained pain, poor general health status, psychological distress, impaired role functioning, and activity restriction. Effective care for RFA sufferers in Canada is critically underdeveloped. These guidelines are predicated upon a 2009 Canadian Cardiovascular Society (CCS) Position Statement which identified that underlying the problem of RFA management is the lack of a formalized, coordinated, interprofessional strategy between the cardiovascular and pain science/clinical communities. The guidelines are therefore a joint initiative of the CCS and the Canadian Pain Society (CPS) and make practice recommendations about treatment options for RFA that are based on the best available evidence. Concluding summary recommendations are also made, giving direction to future clinical practice and research on RFA management in Canada.
Abstract The concept of staging during the same hospitalization for bilateral total knee arthroplasty (BTKA) has emerged as a practice to minimize perioperative risks, although with few data ...providing an evidence base. A total of 41,664 BTKA patients from Nationwide Inpatient Sample data between 1998 and 2010 were identified, and categorized into three groups, same day, staging 1–3 days, and staging 4–7 days BTKA. Staging BTKA 1–3 days apart was associated with increased rates for complications compared to same day BTKA, while staging 4–7 days BTKA was associated with similar complication profiles compared to same day BTKA. Our study suggests that same day BTKA for selective patient population is preferable, and staging BTKA either 1–3 days or 4–7 days apart should be discouraged.
Abstract Total hip arthroplasty (THA) is not commonly performed in adolescents. However, it may be the only option for pain control with continued mobility for advanced disease. We report our ...experience with modern alternative-bearing THA in patients younger than 21 years. Twenty-one THAs (18 patients) were followed. Preoperative and postoperative Harris hip scores were recorded, and radiographs were reviewed. Average follow-up was 49 months (range, 25-89). Underlying etiology was chemotherapy-induced osteonecrosis (33%), steroid-induced osteonecrosis (29%), sickle cell disease (24%), and chronic dislocation (14%). Articulation bearings were ceramic/ceramic (67%), metal/highly cross-linked polyethylene (29%), and metal resurfacing (5%). Mean age was 18 years (range, 13–20). Harris hip scores improved from 43.6 to 83.6 ( P < .001). At final follow-up, there was no radiographic loosening; 1 THA was revised for a cracked ceramic liner. At intermediate-term follow-up, clinical and radiographic results are favorable after alternative-bearing THA in patients younger than 21 years.
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