Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Surgical results for prosthetic versus native valve endocarmus: A multicenter analysis

Objectives: Prosthetic valve endocarditis is associated with worse outcomes compared with native valve endocarditis. Our aim was to evaluate the impact of native valve endocarditis versus prosthetic valve endocarditis on postoperative outcomes and long-term survival and to identify preoperative risk factors in a large cohort of 4300 patients with infective endocarditis. Methods: This retrospective cohort study was conducted in 5 German Cardiac Surgery Centers: the Clinical Multicenter Project of Analysis of Infective Endocarditis in Germany. Data of 4300 patients undergoing valve surgery for native valve endocarditis and prosthetic valve endocarditis were retrospectively analyzed. Univariable and multivariable analyses were used for risk stratification, Kaplan-Meier analysis for long-term survival. In addition, we performed Cox proportional hazards regression with multivariable adjustment. Results: Between 1994 and 2016, 3143 patients (73.1%) underwent surgery for native valve endocarditis and 1157 patients (26.9%) underwent surgery for prosthetic valve endocarditis. Patients with prosthetic valve endocarditis were older (69 [60-75] vs 63 [52-72] years; P < .001) and had more comorbidities, such as hypertension (55 degrees A vs 46%; P < .001), diabetes (28% vs 25%; P = .020), coronary artery disease (32% vs 23%; P < .001), and preoperative acute kidney injury (41% vs 32%; P < .001 ). Kaplan-Meier analysis revealed significantly decreased long-term survival of patients undergoing surgery for prosthetic valve endocarditis compared with native valve endocarditis (P < .001). However, after multivariable adjustment, there was no significant difference in long-term survival between patients undergoing cardiac surgery with prosthetic valve endocarditis compared with native valve endocarditis. Conclusions: After adjusting for preoperative comorbidities, long-term survival for prosthetic valve endocarditis and native valve endocarditis is comparable. Thus, our large cohort study provides evidence that prosthetic valve endocarditis alone should not be a contraindication for redo operations

Impact of the 2009 ESC Guideline Change on Surgically Treated Infective Endocarditis

BACKGROUND In 2009, updated European Society of Cardiology guidelines on the prevention, diagnosis, and treat-ment of infective endocarditis (IE) were released and restricted the use of antibiotic prophylaxis to high-risk patients only. The aim of this study was to analyze the effect of the restrictive antibiotic regimen on the incidence and mani-festations of surgically treated IE before and after the guideline change.METHODS This study retrospectively analyzed data of 4917 patients who underwent valve surgical procedures for IE between 1994 and 2018 in 6 German cardiac surgery centers. Potential risk factors for 30-day mortality were assessed using logistic regression. Interrupted time series regression was used to evaluate the effect of the guideline change on the manifestation of IE.RESULTS A total of 2014 patients (41%) underwent surgical procedures before the guideline change, and 2903 patients (59%) underwent surgical procedures after the change. After 2009, patients were older (67.0 years [interquartile range, 56.0-74.0 years] vs 64.0 years [interquartile range, 52.0-71.0 years]; P < .001), and they presented with more comorbidities, such as hypertension (56.9% vs 41.7%; P < .001), diabetes (27.4% vs 24.4%; P = .020), peripheral artery disease (8.5% vs 6.5%; P = .011), and preoperative acute kidney injury (42.8% vs 31.9%; P< .001). Patients had worse clinical outcomes with respect to 30-day mortality (18.1% vs 14.3%; P = .001) and 1-year mortality (37.1% vs 29.1%; P < .001). An increase in Streptococcus-related IE (P = .002) and an increase in mitral valve IE (P = .035) were observed after the guideline change.CONCLUSIONS Since 2009, there has been a significant increase in the incidence of mitral valve IE and Streptococcus -related IE. Patients undergoing surgical procedures for IE present with more comorbidities, which contribute to high mortality rates.(Ann Thorac Surg 2022;114:1349-57)(c) 2022 by The Society of Thoracic Surgeon

Locked Plating vs. Nailing for Proximal Tibia Fractures: A Multicenter RCT

OBJECTIVES: The main two forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing and locked lateral plating. The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: Sixteen academic trauma centersPatients/Participants: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to intramedullary nailing (IMN) and 47 patients were randomized to locked lateral plating (LLP). INTERVENTION: Intramedullary nailing or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including SMFA, Bother Index, EQ-5DIndex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months post injury. Similarly, there was no difference in terms of time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support or complications. CONCLUSIONS: Both intramedullary nailing and locked lateral plating provide for similar outcomes following these fractures. Patients continue to improve over the course of the year following injury but remain impaired even one year later

Role of Concomitant Coronary Artery Bypass Grafting in Valve Surgery for Infective Endocarditis

Background: It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis (IE) who have relevant coronary artery disease (CAD). However, CABG may add complexity to the operation. We aimed to investigate the impact of concomitant CABG on perioperative outcomes in patients undergoing surgery for IE. Methods: We retrospectively used data of surgically treated IE patients between 1994 and 2018 in six German cardiac surgery centers. We performed inverse probability weighting (IPW), multivariable adjustment, chi-square analysis, and Kaplan-Meier survival estimates. Results: CAD was reported in 1242/4917 (25%) patients. Among them, 527 received concomitant CABG. After adjustment for basal characteristics between CABG and no-CABG patients using IPW, concomitant CABG was associated with higher postoperative stroke (26% vs. 21%, p = 0.003) and a trend towards higher postoperative hemodialysis (29% vs. 25%, p = 0.052). Thirty-day mortality was similar in both groups (24% vs. 23%, p = 0.370). Multivariate Cox regression analysis after IPW showed that CABG was not associated with better long-term survival (HR: 1.00, 95% CI: 0.82-1.23, p = 0.998). Conclusion: In endocarditis patients with CAD, adding CABG to valve surgery may be associated with a higher likelihood of postoperative stroke without adding long-term survival benefits. Therefore, in the absence of critical CAD, concomitant CABG may be omitted without impacting outcome. The results are limited due to a lack of data on the severity of CAD, and therefore there is a need for a randomized trial

Soft self-expandable metal stent to treat painful pancreatic duct strictures secondary to chronic pancreatitis: a prospective multicenter trial

Background and aims: Fully covered self-expandable metal stents (FCSEMSs) may offer a treatment option for pain associated with a dilated pancreatic duct (PD) in chronic pancreatitis (CP), but optimal patient selection and FCSEMS design, efficacy, and safety remain uncertain. We studied an investigational pancreatic FCSEMS for treatment of CP-associated pain. Methods: Patients with painful CP, a dominant distal PD stricture, and PD dilation upstream were enrolled in a prospective, multicenter, single-arm trial studying 6-month indwell of a 4- to 6-cm-long soft pancreatic FCSEMS. Primary efficacy and safety endpoints were pain reduction 6 months after FCSEMS indwell (performance goal ≥53%) and PD stenting-related serious adverse events (SAEs), respectively (performance goal <32%). The primary efficacy endpoint was assessed in patients with sufficiently severe and frequent pain at FCSEMS placement as a first stent or in exchange of a plastic stent. Results: Among 67 patients (mean age, 52.7 ± 12.5 years; mean time since CP diagnosis, 6.4 ± 6.4 years), 34 (50.7%) had plastic stent placement within 90 days of FCSEMS placement, and 46 patients were eligible for the primary efficacy endpoint analysis. Technical success was 97.0% (65/67). The observed primary efficacy (26.1%, 12/46) and safety endpoints (31.3%, 21/67) failed to meet the a priori study hypotheses. Study stent migration occurred in 47.7% of patients (31/65). Conclusions: Six-month treatment with an FCSEMS did not lead to an expected degree of pain reduction, and migrations and SAEs were common. Further study is needed to clarify optimal decompressive strategy, FCSEMS design, and patient selection