Publications by authors named "Aaron M Gazendam"

10 Publications

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Assessment of Risk of Bias in Osteosarcoma and Ewing's Sarcoma Randomized Controlled Trials: A Systematic Review.

Curr Oncol 2021 09 28;28(5):3771-3794. Epub 2021 Sep 28.

Department of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada.

Aim: The aim of this study was to systematically assess the risk of bias in osteosarcoma and Ewing's sarcoma (ES) randomized controlled trials (RCT) and to examine the relationships between bias and conflict of interest/industry sponsorship.

Methods: An OVID-MEDLINE search was performed (1976-2019). Using the Cochrane Collaboration guidelines, two reviewers independently assessed the prevalence of risk of bias in different RCT design domains. The relationship between conflicts of interest and industry funding with the frequency of bias was examined.

Results: 73 RCTs met inclusion criteria. Prevalence of low-risk bias domains was 47.3%, unclear-risk domains 47.8%, and 4.9% of the domains had a high-risk of bias. Domains with the highest risk of bias were blinding of participants/personnel and outcome assessors, followed by randomization and allocation concealment. Overtime, frequency of unclear-risk of bias domains decreased (χ = 5.32, = 0.02), whilst low and high-risk domains increased (χ = 8.13, = 0.004). Studies with conflicts of interest and industry sponsorships were 4.2 and 3.1 times more likely to have design domains with a high-risk of bias ( < 0.05).

Conclusion: This study demonstrates that sources of potential bias are prevalent in both osteosarcoma and ES RCTs. Studies with financial conflicts of interest and industry sponsors were significantly more likely to have domains with a high-risk of bias. Improvements in reporting and adherence to proper methodology will reduce the risk of bias and improve the validity of the results of RCTs in osteosarcoma and ES.
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http://dx.doi.org/10.3390/curroncol28050322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8534836PMC
September 2021

The Surgical Management of Proximal Femoral Metastases: A Narrative Review.

Curr Oncol 2021 09 28;28(5):3748-3757. Epub 2021 Sep 28.

Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON L8N 4A6, Canada.

The proximal femur is a common location for the development of bony metastatic disease. Metastatic bone disease in this location can cause debilitating pain, pathologic fractures, reduced quality of life, anemia or hypercalcemia. A thorough history, physical examination and preoperative investigations are required to ensure accurate diagnosis and prognosis. The goals of surgical management is to provide pain relief and return to function with a construct that provides stability to allow for immediate weightbearing. Current surgical treatment options include intramedullary nailing, hemiarthroplasty or total hip arthroplasty and endoprosthetic reconstructions. Oligometastatic renal cell carcinoma must be given special consideration as tumor resection and reconstruction has survival benefit. Both tumor and patient characteristics must be taken into account before deciding on the appropriate surgical intervention.
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http://dx.doi.org/10.3390/curroncol28050320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8534449PMC
September 2021

Are Functional Outcomes of a Total Hip Arthroplasty Predictive of a Contralateral Total Hip Arthroplasty: A Retrospective Cohort Study.

J Arthroplasty 2021 Oct 8. Epub 2021 Oct 8.

Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.

Background: Current literature suggests that 8%-35% of patients undergoing total hip arthroplasty (THA) undergo a subsequent contralateral THA. This study aims to determine if functional outcomes after primary THA predict outcomes in the subsequent primary THA of the contralateral side.

Methods: A retrospective cohort of patients undergoing staged bilateral primary THA was reviewed. The Oxford Hip Score (OHS) was utilized as the functional outcome measurement tool and was assessed preoperatively and at one year postoperatively. The minimal clinically important difference (MCID) was assessed. Based on the first-side THA one-year outcomes, the odds of maintaining an MCID, or not, for the second-side THA were determined.

Results: The study cohort consisted of 551 patients and 1102 primary THAs. The average postoperative OHSs were similar after the first and second THA. Patients achieving the MCID with the first-side surgery were 2.6 times (95% confidence interval 1.0 to 6.64, P = .04) more likely to achieve the MCID for the second-side surgery than patients failing to reach the MCID for their first-side surgery. After the first THA, 29 (5.3%) patients failed to reach the predefined MCID for the OHS compared with 54 (9.8%) patients undergoing their second THA (odds ratio: 1.96 [95% confidence interval: 1.23 to 3.1], χ = 8.14, P = .005).

Conclusions: Functional outcomes after the first THA are predictive of functional outcomes of the second THA. Patients are more likely to achieve a clinically significant improvement after their first THA related to higher preoperative OHSs before the second THA.
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http://dx.doi.org/10.1016/j.arth.2021.09.024DOI Listing
October 2021

Synovial Sarcoma: A Clinical Review.

Curr Oncol 2021 05 19;28(3):1909-1920. Epub 2021 May 19.

Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON L8V 1C3, Canada.

Synovial sarcomas (SS) represent a unique subset of soft tissue sarcomas (STS) and account for 5-10% of all STS. Synovial sarcoma differs from other STS by the relatively young age at diagnosis and clinical presentation. Synovial sarcomas have unique genomic characteristics and are driven by a pathognomonic t(X;18) chromosomal translocation and subsequent formation of the SS18:SSX fusion oncogenes. Similar to other STS, diagnosis can be obtained from a combination of history, physical examination, magnetic resonance imaging, biopsy and subsequent pathology, immunohistochemistry and molecular analysis. Increasing size, age and tumor grade have been demonstrated to be negative predictive factors for both local disease recurrence and metastasis. Wide surgical excision remains the standard of care for definitive treatment with adjuvant radiation utilized for larger and deeper lesions. There remains controversy surrounding the role of chemotherapy in the treatment of SS and there appears to be survival benefit in certain populations. As the understanding of the molecular and immunologic characteristics of SS evolve, several potential systematic therapies have been proposed.
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http://dx.doi.org/10.3390/curroncol28030177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8161765PMC
May 2021

Postoperative Outcomes Following Total Hip and Knee Arthroplasty in Patients with Pain Catastrophizing, Anxiety, or Depression.

J Arthroplasty 2021 06 11;36(6):1908-1914. Epub 2021 Feb 11.

Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.

Background: The relationship among pain catastrophizing, emotional disorders, and total joint arthroplasty (TJA) outcomes is an emerging area of study. The purpose of this study is to examine the association of these factors with 1-year postoperative pain and functional outcomes.

Methods: A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Postoperative outcomes included Visual Analog Scale (VAS) pain, Oxford, Harris Hip (HHS) and Knee Society (KSS) scores. Median regression was used to assess the pattern of relationship among preoperative clinically relevant catastrophizing (CRC) pain, abnormal HADS, and 1-year postoperative outcomes.

Results: We recruited 463 TJA patients, all of which completed 1-year follow-up. At 1 year, CRC-rumination (adjusted median difference 1; 95% confidence interval [CI] 0.31-1.69, P = .005) and abnormal HADS-A (adjusted median difference 1; 95% CI 0.36-1.64, P = .002) were predictors of VAS pain, CRC magnification a predictor of HHS/KSS (adjusted median difference 1.3; 95% CI 5.23-0.11, P = .041), and abnormal HADS-A a predictor of Oxford (adjusted median difference 3.68; 95% CI 1.38-5.99, P = .002). CRC patients demonstrated inferior VAS pain (P = .001), Oxford (P < .0001), and HHS/KSS (P = .025). Abnormal HADS patients demonstrated inferior postoperative VAS (HADS-A, P = .025; HADS-D, P = .030) and Oxford (HADS-A, P = .001; HADS-D, P = .030). However, patients with CRC experienced significant improvement in VAS, Oxford, and HHS/KSS (P < .05) from preoperative to 1 year. Similarly, patients with abnormal HADS showed significant improvement in VAS pain and HHS/KSS (P < .05).

Conclusion: TJA patients who are anxious, depressed, or pain catastrophizing have inferior preoperative and postoperative pain and function. However, as compared to their preoperative status, clinically significant improvement can be expected following hip/knee arthroplasty.
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http://dx.doi.org/10.1016/j.arth.2021.02.018DOI Listing
June 2021

Quantifying the Level of Evidence of Podium Presentations at the American Association of Hip and Knee Surgeons From 2015 to 2019.

J Arthroplasty 2021 06 4;36(6):2219-2222. Epub 2021 Feb 4.

Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.

Background: The American Association of Hip and Knee Surgeons (AAHKS) Annual Scientific Meeting is a leading forum for the presentation and dissemination of research regarding the management of hip and knee pathology making research presented at these meetings a representation of the current literature in the field. The purpose of this study was to quantify the level of evidence of podium presentations presented at the AAHKS annual meeting from 2015 to 2019.

Methods: Two reviewers evaluated the abstracts for the available presentations. Basic science and biomechanical studies were excluded from the review. Economic studies that were not able to be evaluated based on the American Academy of Orthopedic Surgeon guidelines were also excluded. The two reviewers then independently evaluated each abstract and assigned a level of evidence (level I-V) based on the American Academy of Orthopedic Surgeon classification scheme.

Results: A total of 258 podium presentations were included. In total, 17 (7%) abstracts were graded level I evidence, 57 (22%) were graded level II, 85 (33%) were graded level III, and 98 (38%) were graded level IV (Table 1). There was a significant change in the distribution of the level of evidence of podium presentations over time (χ = 24.6, P = .02). The proportion of level I studies has increased between 2015 and 2019 (from 3.9% to 11.8%) with a concomitant decrease in level IV studies (from 42.3% to 21.6%) over that time period.

Conclusions: There has been a significant improvement in the levels of evidence of podium presentations at the AAHKS Annual Meeting from 2015 to 2019.
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http://dx.doi.org/10.1016/j.arth.2021.01.083DOI Listing
June 2021

The Fragility of Statistically Significant Findings From Randomized Controlled Trials in Hip and Knee Arthroplasty.

J Arthroplasty 2021 06 13;36(6):2211-2218.e1. Epub 2020 Dec 13.

Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

Background: The Fragility Index (FI) is a method for evaluating the robustness of statistically significant findings from randomized controlled trials (RCTs) beyond the P value in trials with dichotomous outcomes. The FI is defined as the number of patients in one arm of a trial that would have to have a different outcome to change the results of the trial from statistically significant to nonsignificant. This review assessed the FI in arthroplasty RCTs.

Methods: A systematic search was conducted in MEDLINE, Embase, and Web of Science for RCTs related to primary total joint arthroplasty (TJA) from 2010 to 2020. Trials with a statistically significant dichotomous primary outcome were included. The FI was calculated using Fisher's exact test to determine how many events would need to be reversed to change a study from statistically significant to nonsignificant.

Results: A total of 34 RCTs were included. The median sample size was 103 patients (range 24-791). The median FI was 1 (range 0-45), meaning that reversing the outcome of just one patient in either treatment group of each trial would change it from a significant to a nonsignificant result.

Conclusion: Hip and knee arthroplasty RCTs with statistically significant dichotomous outcomes in TJA are fragile. The median FI in TJA is lower than the FI in any of the other previously reported orthopedic subspecialties. Fragility is another reason to be cautious when conducting or interpreting small trials, and to continue to strive toward large trials to answer important questions in TJA.

Level Of Evidence: Level I.
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http://dx.doi.org/10.1016/j.arth.2020.12.015DOI Listing
June 2021

Risk Factors for Postoperative Coronal Balance in Adult Spinal Deformity Surgery.

Global Spine J 2018 Oct 27;8(7):690-697. Epub 2018 Mar 27.

University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada.

Study Design: A retrospective case-control study.

Objectives: To determine factors influencing the ability to achieve coronal balance following spinal deformity surgery.

Methods: Following institutional ethics approval, the radiographs of 47 patients treated for spinal deformity surgery with long fusions to the pelvis, were retrospectively reviewed. The postoperative measurements included coronal balance, L4 tilt, and L5 tilt, levels fused, apical vertebral translation and maximum Cobb angle. L4 and L5 tilt angles were measured between the superior endplate and the horizontal. Sagittal parameters including thoracic kyphosis, lumbar lordosis, pelvic incidence, and sagittal vertical axis were recorded. Coronal balance was defined as the distance between the central sacral line and the mid body of C7 being ≤40 mm. Surgical factors, including levels fused, use of iliac fixation with and without connectors, use of S2A1 screws, interbody devices, and osteotomies. Statistical tests were performed to determine factors that contribute to postoperative coronal imbalance.

Results: Of the 47 patients reviewed, 32 were balanced after surgery and 14 were imbalanced. Coronal balance was 1.30 cm from center in the balanced group compared to 4.83 cm in the imbalanced group ( < .01). Both L4 and L5 tilt were statistically different between the groups. Gender and the use of transverse connectors differed between the groups but not statistically.

Conclusions: In adult spinal deformity patients undergoing primary fusions to the pelvis, the ability to level the coronal tilt of L4 and L5 had the greatest impact on the ability to achieve coronal balance in this small series. A larger prospective series can help validate this important finding.
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http://dx.doi.org/10.1177/2192568218764904DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232708PMC
October 2018

Posterior column reconstruction improves fusion rates at the level of osteotomy in three-column posterior-based osteotomies.

Eur Spine J 2018 03 21;27(3):636-643. Epub 2017 Sep 21.

Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Room 442, First Floor, East Wing, Toronto, ON, M5T 2S8, Canada.

Purpose: To determine the incidence of pseudarthrosis at the osteotomy site after three-column spinal osteotomies (3-COs) with posterior column reconstruction.

Methods: 82 consecutive adult 3-COs (66 patients) with a minimum of 2-year follow-up were retrospectively reviewed. All cases underwent posterior 3-COs with two-rod constructs. The inferior facets of the proximal level were reduced to the superior facets of the distal level. If that was not possible, a structural piece of bone graft either from the local resection or a local rib was slotted in the posterior column defect to re-establish continual structural posterior bone across the lateral margins of the resection. No interbody cages were used at the level of the osteotomy.

Results: There were 34 thoracic osteotomies, 47 lumbar osteotomies and one sacral osteotomy with a mean follow-up of 52 (24-126) months. All cases underwent posterior column reconstructions described above and the addition of interbody support or additional posterior rods was not performed for fusion at the osteotomy level. Among them, 29 patients underwent one or more revision surgeries. There were three definite cases of pseudarthrosis at the osteotomy site (4%). Six revisions were also performed for pseudarthrosis at other levels.

Conclusion: Restoration of the structural integrity of the posterior column in three-column posterior-based osteotomies was associated with > 95% fusion rate at the level of the osteotomy. Pseudarthrosis at other levels was the second most common reason for revision following adjacent segment disease in the long-term follow-up.
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http://dx.doi.org/10.1007/s00586-017-5299-9DOI Listing
March 2018

Posterior Versus Three-Column Osteotomy for Late Correction of Residual Coronal Deformity in Patients With Previous Fusions for Idiopathic Scoliosis.

Spine Deform 2017 05;5(3):189-196

University Health Network, Toronto Western Hospital, Department of Surgery, Division of Orthopaedics, 399 Bathurst St. Toronto, ON M5T2S8, Canada.

Study Design: Retrospective case series.

Objective: To compare the early results of posterior column (PCO) and three-column (3CO) osteotomies performed in patients with previously fused idiopathic scoliosis and review their abilities to achieve coronal correction of residual deformities.

Summary Of Background Data: Residual deformity of previously fused AIS can accelerate adjacent segment degeneration secondary to lowest instrumented vertebra (LIV) tilt and rotation. Many of these patients are not satisfied with their cosmetic appearance and would choose revising the deformity when future surgery is indicated.

Methods: The data from 29 consecutive patients who underwent PCOs or 3COs for late revisions of idiopathic scoliosis were reviewed. Measurements included Cobb angle, focal osteotomy angle, and coronal balance. Perioperative data, complications, and patient-reported outcomes were also reviewed.

Results: Fourteen patients were treated with PCOs and 15 with 3COs. Global coronal correction was equal between the two groups. In the PCO group, where patients underwent a mean of 2.4 osteotomies, 20.2° of correction was obtained compared to 19.5° in the 3CO group (p = .33), which all underwent single osteotomies. The average coronal correction was 9.2°/osteotomy for the PCO group and 14.1°/osteotomy for the 3CO group (p < .01). Estimated blood loss was 1,417.5 mL in the PCO group compared to 3,199.3 in the 3CO group (p < .01). Five patients (36%) had intraoperative complications in the PCO group compared to 12 (80%) in the 3CO group (p < .05). There were no differences in operative times, length of stay, or patient-reported outcomes between groups.

Conclusion: PCOs and 3COs performed in patients with previously fused spines for idiopathic scoliosis are effective in achieving residual deformity correction. In cases of posterior fusions, where the patient has a mobile anterior column, PCOs should be considered over 3COs because of their decreased risk of blood loss and complications.
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http://dx.doi.org/10.1016/j.jspd.2017.01.004DOI Listing
May 2017
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