Publications by authors named "Jie J Yao"

17 Publications

  • Page 1 of 1

Surface Roughness of Titanium Orthopedic Implants Alters the Biological Phenotype of Human Mesenchymal Stromal Cells.

Tissue Eng Part A 2021 Aug 16. Epub 2021 Aug 16.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Metal orthopedic implants are largely biocompatible and generally achieve long-term structural fixation. However, some orthopedic implants may loosen over time even in the absence of infection. fixation failure is multifactorial, but the fundamental biological defect is cellular dysfunction at the host-implant interface. Strategies to reduce the risk of short- and long-term loosening include surface modifications, implant metal alloy type, and adjuvant substances such as polymethylmethacrylate cement. Surface modifications (e.g., increased surface rugosity) can increase osseointegration and biological ingrowth of orthopedic implants. However, the localized responses of cells to implant surface modifications need to be better characterized. As an model for investigating cellular responses to metallic orthopedic implants, we cultured mesenchymal stromal/stem cells on clinical-grade titanium disks (Ti6Al4V) that differed in surface roughness as high (porous structured), medium (grit blasted), and low (bead blasted). Topological characterization of clinically relevant titanium (Ti) materials combined with differential mRNA expression analyses (RNA-seq and real-time quantitative polymerase chain reaction) revealed alterations to the biological phenotype of cells cultured on titanium structures that favor early extracellular matrix production and observable responses to oxidative stress and heavy metal stress. These results provide a descriptive model for the interpretation of cellular responses at the interface between native host tissues and three-dimensionally printed modular orthopedic implants, and will guide future studies aimed at increasing the long-term retention of such materials after total joint arthroplasty.
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http://dx.doi.org/10.1089/ten.TEA.2020.0369DOI Listing
August 2021

Direct Inpatient Medical Costs of Operative Treatment of Periprosthetic Hip and Knee Infections Are Twofold Higher Than Those of Aseptic Revisions.

J Bone Joint Surg Am 2021 Feb;103(4):312-318

Departments of Orthopedic Surgery (M.H., D.G.L., D.J.B., and H.M.K.) and Health Sciences Research (S.L.V., J.E.R., and H.M.K.), Mayo Clinic, Rochester, Minnesota.

Background: Periprosthetic joint infections (PJIs) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are associated with substantial morbidity. A better understanding of the costs of PJI treatment can inform prevention, treatment, and reimbursement strategies. The purpose of the present study was to describe direct inpatient medical costs associated with the treatment of hip and knee PJI.

Methods: At a single tertiary care institution, 176 hips and 266 knees that underwent 2-stage revisions for the treatment of PJI from 2009 to 2015 were compared with 1,611 hips and 1,276 knees that underwent revisions for aseptic indications. In addition, 84 hips and 137 knees that underwent irrigation and debridement (I&D) with partial component exchange were compared with 39 hips and 138 knees that underwent partial component exchange for aseptic indications. Line-item details of services billed during hospitalization were retrieved, and standardized direct medical costs were calculated in 2018 inflation-adjusted dollars.

Results: The mean direct medical cost of 2-stage revision THA performed for the treatment of PJI was significantly higher than that of aseptic revision THA ($58,369 compared with $22,846, p < 0.001). Similarly, the cost of 2-stage revision TKA performed for the treatment of PJI was significantly higher than that of aseptic revision TKA ($56,900 compared with $24,630, p < 0.001). Even when the total costs of aseptic revisions were doubled for a representative comparison with 2-stage procedures, the costs of PJI procedures were 15% to 28% higher than those of the doubled costs of aseptic revisions (p < 0.001). The mean direct medical cost of I&D procedures for PJI was about twofold higher than of partial component exchange for aseptic indications.

Conclusions: The direct medical costs of operative treatment of PJI following THA and TKA are twofold higher than the costs of similar aseptic revisions. The high economic burden of PJI warrants efforts to reduce the incidence of PJI. Reimbursement schemes should account for the high costs of treating PJI in order to ensure sustainable patient care.

Level Of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.00550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8327701PMC
February 2021

What Is the Survivorship After Hip Arthroscopy for Femoroacetabular Impingement? A Large-database Study.

Clin Orthop Relat Res 2020 10;478(10):2266-2273

Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, WA, USA.

Background: Patients with femoroacetabular impingement (FAI) may experience lasting clinical improvement after hip arthroscopy; however, some patients will still eventually undergo early conversion to THA due to unresolved symptoms and progression of arthritis. However, the risk of this has been only incompletely characterized in prior studies.

Questions/purposes: Using a large healthcare claims database over a 5-year period (2011-2016), we asked: (1) What is the survivorship free from THA after arthroscopic osteoplasty performed for FAI? (2) What identifiable demographic factors and patient characteristics are associated with early conversion to THA after hip arthroscopy performed for FAI?

Methods: We included all patients who underwent hip arthroscopy for FAI, between the ages of 12 years and 63 years, with 3 months of claims data before hip arthroscopy and minimum 2-year follow-up. A total of 4730 hip arthroscopy patients from 2011 to 2014 were retrieved from a US commercial claims database. Hip arthroscopy incidence doubled over time from 1.2 to 2.1 persons per 100,000. Temporal trends, patient demographics, diagnoses at time of arthroscopy, and patient comorbidities were retrieved and logistic regression performed. Survivorship analysis on 11,323 patients (lifting the 2-year follow-up requirement) was also performed to identify independent variables associated with early risk of conversion to THA.

Results: In patients undergoing hip arthroscopy for FAI, the overall proportion of conversion to THA within 2 years after hip arthroscopy was 7% (338 of 4730). After controlling for confounding variables such as sex, obesity, and depression, we found the following were independently associated with increased odds of conversion to THA: older age (odds ratio 1.08 [95% CI 1.01 to 1.10]; p < 0.001), osteoarthritis (OR 2.91 [95% CI 2.27 to 3.77]; p < 0.001), joint inflammation (OR 1.89 [95% CI 1.16 to 3.09]; p = 0.01), and a history of opioid use (OR 2.17 [95% CI 1.69 to 2.79]; p < 0.001). Survivorship analysis similarly revealed that older age (hazard ratio 1.08 [95% CI 1.07 to 1.09]; p < 0.001), osteoarthritis (HR 2.53 [95% CI 2.13 to 3.01]; p < 0.001), joint inflammation (HR 1.53 [95% CI 1.10 to 2.11]; p = 0.01), a history of opioid use (HR 2.02 [95% CI 1.71 to 2.38]; p < 0.001), and smoking (HR 1.55 [95% CI 1.14 to 2.11]; p = 0.005), were independently associated with increased odds of conversion to THA within 2 years after hip arthroscopy for FAI.

Conclusions: Although the findings of this study are limited and should not be taken in isolation, patients with FAI who are older, carry diagnoses of inflammatory or degenerative articular disease, or who use opioids or smoke should be counseled about a potentially increased risk of undergoing early conversion to THA after hip arthroscopy. Future studies to further examine the effect of these diagnoses in prospectively collected cohorts, incorporating radiographic and patient-reported outcome measures, are needed.

Level Of Evidence: Level III, prognostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491898PMC
October 2020

The Use and Adverse Effects of Oral and Intravenous Antibiotic Administration for Suspected Infection After Revision Shoulder Arthroplasty.

J Bone Joint Surg Am 2020 Jun;102(11):961-970

Department of Orthopaedic Surgery and Sports Medicine (J.J.Y., B.M.W., A.J.W., F.A.M., and J.E.H.), Division of Allergy and Infectious Diseases, Department of Medicine (P.S.P.), and School of Medicine (K.J.), University of Washington, Seattle, Washington.

Background: When performing revision shoulder arthroplasty, surgeons do not have access to the results of intraoperative culture specimens and will administer empiric antibiotics to cover for the possibility of deep infection until the culture results are finalized. The purpose of this study was to report the factors associated with the initiation, modification, and adverse events of 2 different postoperative antibiotic protocols in a series of revision shoulder arthroplasties.

Methods: In this study, 175 patients undergoing revision shoulder arthroplasty were treated with either a protocol of intravenous (IV) antibiotics if there was a high index of suspicion for infection or a protocol of oral antibiotics if the index of suspicion was low. Antibiotics were withdrawn if cultures were negative and were modified as indicated if the cultures were positive. Antibiotic course, modification, and adverse effects to antibiotic administration were documented.

Results: On univariate analysis, factors significantly associated with the initiation of IV antibiotics were male sex (p < 0.001), history of infection (p < 0.001), intraoperative humeral loosening (p = 0.003), and membrane formation (p < 0.001). On multivariate analysis, male sex (p = 0.003), history of infection (p = 0.003), and membrane formation (p < 0.001) were found to be independent predictors of the initiation of IV antibiotics. On the basis of preoperative and intraoperative characteristics, surgeons anticipated the culture results in 75% of cases, and modification of antibiotic therapy was required in 25%. The modification from oral to IV antibiotics due to positive culture results was made significantly more often in male patients (p < 0.001). Adverse effects of antibiotic administration occurred in 19% of patients. The rates of complications were significantly lower in the patients treated with oral antibiotics and a shorter course of antibiotics (p < 0.001).

Conclusions: Complications associated with antibiotic administration after revision shoulder arthroplasty are not infrequent and are more common in patients whose initial protocol is IV antibiotics. Further study is needed to balance the effectiveness and risks of post-revision antibiotic treatment given the frequency of antibiotic-related complications.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.00846DOI Listing
June 2020

Challenges in the Measurement and Interpretation of Serum Titanium Concentrations.

Biol Trace Elem Res 2020 Jul 6;196(1):20-26. Epub 2019 Nov 6.

Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55905, USA.

The measurement of circulating metal ion levels in total hip arthroplasty patients continues to be an area of clinical interest. National regulatory agencies have recommended measurement of circulating cobalt and chromium concentrations in metal-on-metal bearing symptomatic total hip arthroplasty patients. However, the clinical utility of serum titanium (Ti) measurements is less understood due to wide variations in reported values and methodology. Fine-scale instrumentation for detecting in situ Ti levels continues to improve and has transitioned from graphite furnace atomic absorption spectroscopy to inductively coupled plasma optical emission spectrometry or inductively coupled plasma mass spectrometry. Additionally, analytical interferences, variable sample types, and non-standardized sample collection methods complicate Ti measurement and underlie the wide variation in reported levels. Normal reference ranges and pathologic ranges for Ti levels remain to be established quantitatively. However, before these ranges can be recognized and implemented, methodological standardization is necessary. This paper aims to provide background and recommendations regarding the complexities of measurement and interpretation of circulating Ti levels in total hip arthroplasty patients.
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http://dx.doi.org/10.1007/s12011-019-01891-4DOI Listing
July 2020

assessment of high-molecular-weight polyethylene core suture tape for intra-articular ligament reconstruction: an animal study.

Bone Joint J 2019 10;101-B(10):1238-1247

Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Aims: Options for the treatment of intra-articular ligament injuries are limited, and insufficient ligament reconstruction can cause painful joint instability, loss of function, and progressive development of degenerative arthritis. This study aimed to assess the capability of a biologically enhanced matrix material for ligament reconstruction to withstand tensile forces within the joint and enhance ligament regeneration needed to regain joint function.

Materials And Methods: A total of 18 New Zealand rabbits underwent bilateral anterior cruciate ligament reconstruction by autograft, FiberTape, or FiberTape-augmented autograft. Primary outcomes were biomechanical assessment (n = 17), microCT (µCT) assessment (n = 12), histological evaluation (n = 12), and quantitative polymerase chain reaction (qPCR) analysis (n = 6).

Results: At eight weeks, FiberTape alone or FiberTape-augmented autograft demonstrated increased biomechanical stability compared with autograft regarding ultimate load to failure (p = 0.035), elongation (p = 0.006), and energy absorption (p = 0.022). FiberTape-grafted samples also demonstrated increased bone mineral density in the bone tunnel (p = 0.039). Histological evaluation showed integration of all grafts in the bone tunnels by new bone formation, and limited signs of inflammation overall. A lack of prolonged inflammation in all samples was confirmed by quantification of inflammation biomarkers. However, no regeneration of ligament-like tissue was observed along the suture tape materials. Except for one autograft failure, no adverse events were detected.

Conclusion: Our results indicate that FiberTape increases the biomechanical performance of intra-articular ligament reconstructions in a verified rabbit model at eight weeks. Within this period, FiberTape did not adversely affect bone tunnel healing or invoke a prolonged elevation in inflammation. Cite this article: 2019;101-B:1238-1247.
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http://dx.doi.org/10.1302/0301-620X.101B10.BJJ-2018-1282.R2DOI Listing
October 2019

Weight changes after total knee arthroplasty in Chinese patients: a matched cohort study regarding predictors and outcomes.

J Orthop Surg Res 2019 Jul 2;14(1):200. Epub 2019 Jul 2.

Department of Orthopedic Surgery, The Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Rd, Shanghai, 200072, People's Republic of China.

Background: The purpose of this study was to compare 2-year BMI changes between patients undergoing simultaneous bilateral total knee arthroplasty (TKA), staged bilateral TKA, and unilateral TKA. We also sought to determine the predictors of weight change and whether clinically meaningful weight changes affected outcomes.

Patients And Methods: This retrospective, single-institution study included 202 Chinese patients who received simultaneously bilateral TKA, staged bilateral TKA, or unilateral TKA from 2008 to 2015. There were 49 simultaneous bilateral TKAs, 52 staged bilateral TKAs, and a matched 101 unilateral TKAs.

Results: 66.8% (135/202) of patients lost weight after TKA surgery. However, 20.7% (42/202) of patients experienced clinically meaningful weight loss (a BMI decrease of more than 5%). Paired t test showed that 2-year BMI was significantly lower than preoperative BMI (p < 0.001). Weight loss was significantly different between the surgical strategy (p < 0.001). Preoperative BMI and age were predictive of clinically significant weight loss or gain (p < 0.05). Multiple linear regression showed that post-operative weight loss was associated with better Western Ontario and McMaster Universities Osteoarthritis Index and SF-36 scores (p < 0.001).

Conclusion: Patients after TKA experience weight loss. Age and preoperative BMI predict clinically meaningful weight change. Simultaneous bilateral TKA is associated with higher likelihood of weight loss. Clinically meaningful weight loss experiences better patient-reported outcomes.
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http://dx.doi.org/10.1186/s13018-019-1184-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604226PMC
July 2019

Revision Total Hip Arthroplasty for the Treatment of Fracture: More Expensive, More Complications, Same Diagnosis-Related Groups: A Local and National Cohort Study.

J Bone Joint Surg Am 2019 May;101(10):912-919

Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota.

Background: Revision total hip arthroplasty (revision THA) occurs for a wide variety of indications and in the United States it is coded under Diagnosis-Related Groups (DRGs) 466, 467, and 468, which do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision THA costs and 30-day complications by indication, both locally and nationally.

Methods: Hospitalization costs and complication rates for 1,422 aseptic revision THAs performed at a high-volume center between 2009 and 2014 were retrospectively reviewed. Additionally, charges for 28,133 revision THAs in the National Inpatient Sample (NIS) were converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratios, and 30-day complication rates for 3,224 revision THAs were obtained with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Costs and complications were compared between revision THAs performed for fracture, wear/loosening, and dislocation/instability with use of simultaneous and pairwise comparisons and a multivariable model accounting for American Society of Anesthesiologists (ASA) score, age, and sex.

Results: Local hospitalization costs for fracture (median, $25,672) were significantly higher than those for wear/loosening ($20,228; p < 0.001) or dislocation/instability ($17,911; p < 0.001), with differences remaining significant even after adjusting for patient comorbidities (p < 0.001). NIS costs for fracture (median, $27,596) were higher than those for other aseptic indications (wear/loosening: $21,176, p < 0.001; dislocation/instability: $16,891, p< 0.001). Local 30-day orthopaedic complication rates for fracture (20.7%) were higher those than for dislocation/instability (9.0%; p = 0.007) and similar to those for wear/loosening (17.6%; p = 0.434). Nationally, combined medical and surgical complication rates for fracture (71.3% of patients with ≥1 complication) were significantly higher than those for wear/loosening (35.2%; p < 0.001) or dislocation/instability (35.1%; p < 0.001).

Conclusions: Hospitalization costs for revision THA for fracture were 33% to 48% higher than for all other aseptic revision THAs, both locally and nationally. This increased cost persisted even after multivariable comorbidity adjustment, the current DRG basis for stratifying revision THA reimbursement. Additionally, 30-day complication rates suggest that increased resource utilization for fracture patients continues even after discharge. Indication-specific coding and reimbursement systems are necessary to maintain sustainable access to revision THA for all patients.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.18.00523DOI Listing
May 2019

Long-Term Mortality Trends After Revision Total Knee Arthroplasty.

J Arthroplasty 2019 03 1;34(3):542-548. Epub 2018 Dec 1.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.

Background: Long-term mortality following primary total knee arthroplasty (TKA) is lower than the general population. However, it is unknown whether this is true in the setting of revision TKA. We examined long-term mortality trends following revision TKA.

Methods: This retrospective study included 4907 patients who underwent 1 or more revision TKA between 1985 and 2015. Patients were grouped by surgical indications and followed until death or October 2017. The observed number of deaths was compared to the expected number of deaths using standardized mortality ratios (SMR) and Poisson regression models.

Results: Compared to the general population, patients who underwent revision TKA for infection (SMR, 1.45; 95% confidence interval [CI], 1.33-1.57; P < .0001) and fracture (SMR, 1.16; 95% CI, 1.00-1.34; P = .04) experienced a significantly higher mortality risk. Patients who underwent revision TKA for infection and fracture experienced excess mortality soon after surgery which became more pronounced over time. In contrast, the mortality risk among patients who underwent revision TKA for loosening and/or bearing wear was similar to the general population (SMR, 0.95; 95% CI, 0.89-1.02; P = .16). Aseptic loosening and/or wear and instability patients had improved mortality initially; however, there was a shift to excess mortality beyond 5 years among instability patients, and beyond 10 years among aseptic loosening and/or wear patients.

Conclusion: Mortality is elevated soon after revision TKA for infection and fracture. Mortality is lower than the general population after revision TKA for loosening and/or bearing wear but gets worse than the general population beyond the first postoperative decade.
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http://dx.doi.org/10.1016/j.arth.2018.11.031DOI Listing
March 2019

Perioperative Inpatient Use of Selective Serotonin Reuptake Inhibitors Is Associated With a Reduced Risk of THA and TKA Revision.

Clin Orthop Relat Res 2018 06;476(6):1191-1197

J. J. Yao, H. Maradit Kremers, D. G. Lewallen, D. J. Berry, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA W. K. Kremers, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.

Background: Depression is common in the general population, and so it is likewise common among patients undergoing THA and TKA. Depression is associated with lower perioperative patient-reported outcomes and an increased risk of postoperative complications. Antidepressants are effective in managing symptoms of depression and may potentially contribute to better functional status and better clinical outcomes after THA and TKA.

Questions/purposes: We examined (1) whether perioperative depression is associated with all-cause revisions, revisions for aseptic loosening, revisions without infection, and periprosthetic joint infections (PJIs) in patients undergoing THA and TKA; and (2) whether perioperative antidepressant use reduces the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs in patients undergoing THA and TKA.

Methods: This was a retrospective study of adult patients (≥ 18 years) who underwent 20,112 primary and revision THAs and TKAs from January 1, 2002, through December 31, 2009, at a large US tertiary care hospital. Data on patient and surgery characteristics and outcomes (dates and types of revisions, death) were ascertained through the institutional joint registry. Perioperative antidepressant use was assessed by searching the daily medication administration records beginning at admission and ending at discharge. A diagnosis of depression was present in 4466 (22%), and antidepressants were administered at the time of 5077 (25%) surgical procedures. Multivariable Cox proportional hazard models were used to estimate associations between antidepressant use and the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs.

Results: Depression was associated with an increased risk of all-cause revisions (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.42-2.02; p < 0.001) and PJIs (HR, 2.23; 95% CI, 1.53-3.17; p < 0.001). Overall, perioperative antidepressant use was not associated with the risk of revision or PJI, but selective serotonin reuptake inhibitor (SSRI) users had a lower risk of all-cause revisions (HR, 0.77; 95% CI, 0.61-0.96; p = 0.001) and aseptic revisions (HR, 0.72; 95% CI, 0.56-0.93; p = 0.013).

Conclusions: The presence of a depression diagnosis confers an increased risk of revision and PJI among patients undergoing THA and TKA, yet the risk is lower within the subset of patients who received SSRIs during the perioperative period. Future longitudinal studies with detailed antidepressant medication histories are warranted to better understand the potential biologic effects of SSRI on the risk of revision in patients undergoing THA and TKA.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1007/s11999.0000000000000098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263602PMC
June 2018

Long-term Mortality After Revision THA.

Clin Orthop Relat Res 2018 02;476(2):420-426

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.

Background: Long-term mortality after primary THA is lower than in the general population, but it is unknown whether this is also true after revision THA.

Questions/purposes: We examined (1) long-term mortality according to reasons for revision after revision THA, and (2) relative mortality trends by age at surgery, years since surgery, and calendar year of surgery.

Methods: This retrospective study included 5417 revision THAs performed in 4532 patients at a tertiary center between 1969 and 2011. Revision THAs were grouped by surgical indication in three categories: periprosthetic joint infections (938; 17%); fractures (646; 12%); and loosening, bearing wear, or dislocation (3833; 71%). Patients were followed up until death or December 31, 2016. The observed number of deaths in the revision THA cohort was compared with the expected number of deaths using standardized mortality ratios (SMRs) and Poisson regression models. The expected number of deaths was calculated assuming that the study cohort had the same calendar year, age, and sex-specific mortality rates as the United States general population.

Results: The overall age- and sex-adjusted mortality was slightly higher than the general population mortality (SMR, 1.09; 95% CI, 1.05-1.13; p < 0.001). There were significant differences across the three surgical indication subgroups. Compared with the general population mortality, patients who underwent revision THA for infection (SMR, 1.35; 95% CI, 1.24-1.48; p < 0.001) and fractures (SMR, 1.23; 95% CI, 1.11-1.37; p < 0.001) had significantly increased risk of death. Patients who underwent revision THA for aseptic loosening, wear, or dislocation had a mortality risk similar to that of the general population (SMR, 1.01; 95% CI, 0.96-1.06; p = 0.647). The relative mortality risk was highest in younger patients and declined with increasing age at surgery. Although the relative mortality risk among patients with aseptic indications was lower than that of the general population during the first year of surgery, the risk increased with time and got worse than that of the general population after approximately 8 to 10 years after surgery. Relative mortality risk improved with time after revision THA for aseptic loosening, wear, or dislocation.

Conclusions: Shifting mortality patterns several years after surgery and the excess mortality after revision THA for periprosthetic joint infections and fractures reinforce the need for long-term followup, not only for implant survival but overall health of patients having THA.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1007/s11999.0000000000000030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6259686PMC
February 2018

Local Cellular Responses to Titanium Dioxide from Orthopedic Implants.

Biores Open Access 2017 1;6(1):94-103. Epub 2017 Jul 1.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

We evaluated recently published articles relevant to the biological effects of titanium dioxide (TiO) particles on local endogenous cells required for normal bone homeostasis, repair, and implant osseointegration. Structural characteristics, size, stability, and agglomeration of TiO particles alter the viability and behavior of multiple bone-related cell types. Resulting shifts in bone homeostasis may increase bone resorption and lead to clinical incidents of osteolysis, implant loosening, and joint pain. TiO particles that enter cells (through endocytosis or Trojan horse mechanism) may further disrupt implant retention. We propose that cellular responses to titanium-based nanoparticles contribute to pathological mechanisms underlying the aseptic loosening of titanium-based metal implants.
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http://dx.doi.org/10.1089/biores.2017.0017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5627672PMC
July 2017

Patient-Reported Outcomes Can Be Used to Streamline Post-Total Hip Arthroplasty Follow-Up to High-Risk Patients.

J Arthroplasty 2017 11 24;32(11):3319-3321. Epub 2017 May 24.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Patient-reported outcomes are increasingly used to capture the patients' perspective in total hip arthroplasty (THA). They can potentially be used to streamline post-THA follow-up to high-risk patients. We aimed to determine whether the long-term revision risk in THA relates to patient-reported measures at 2 and 5 years.

Methods: In a single-institution cohort of primary THA procedures, we examined the association between 2-year and 5-year pain and Mayo Hip Scores and the risk of revision.

Results: The absolute scores at 2 and 5 years were both significantly associated with the risk of revisions. Every 10-unit decline in the 2-year Mayo Hip Score <60 was associated with a significant 50% increase in the risk of revision (hazard ratio, 1.5 per 10 units; 95% confidence interval, 1.3-1.8). Similarly, every 10-unit decline in the 5-year Mayo Hip Score <60 was associated with almost doubling of the risk of revision (hazard ratio, 1.9 per 10 units; 95% confidence interval, 1.7-2.1).

Conclusion: We conclude that patient-reported outcomes in THA have prognostic importance and can be taken into account when planning frequency of aftercare. This will improve the efficiency of follow-up in large registry-based follow-up efforts.
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http://dx.doi.org/10.1016/j.arth.2017.05.033DOI Listing
November 2017

Intra-articular injection of a substance P inhibitor affects gene expression in a joint contracture model.

J Cell Biochem 2018 02 20;119(2):1326-1336. Epub 2017 Nov 20.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

Substance P (SP), a neurotransmitter released after injury, has been linked to deregulated tissue repair and fibrosis in musculoskeletal tissues and other organs. Although SP inhibition is an effective treatment for nausea, it has not been previously considered as an anti-fibrotic therapy. Although there are extensive medical records of individuals who have used SP antagonists, our analysis of human registry data revealed that patients receiving these antagonists and arthroplasty are exceedingly rare, thus precluding a clinical evaluation of their potential effects in the context of arthrofibrosis. Therefore, we pursued in vivo studies to assess the effect of SP inhibition early after injury on pro-fibrotic gene expression and contractures in an animal model of post-traumatic joint stiffening. Skeletally mature rabbits (n = 24) underwent surgically induced severe joint contracture, while injected with either fosaprepitant (a selective SP antagonist) or saline (control) early after surgery (3, 6, 12, and 24 h). Biomechanical testing revealed that differences in mean contracture angles between the groups were not statistically significant (P = 0.27), suggesting that the drug neither mitigates nor exacerbates joint contracture. However, microarray gene expression analysis revealed that mRNA levels for proteins related to cell signaling, pro-angiogenic, pro-inflammatory, and collagen matrix production were significantly different between control and fosaprepitant treated rabbits (P < 0.05). Hence, our study demonstrates that inhibition of SP alters expression of pro-fibrotic genes in vivo. This finding will motivate future studies to optimize interventions that target SP to reduce the formation of post-traumatic joint contractures.
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http://dx.doi.org/10.1002/jcb.26256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388635PMC
February 2018

Efficacy of a Four-Hour Drainage Clamping Technique in the Reduction of Blood Loss Following Total Hip Arthroplasty: A Prospective Cohort Study.

Med Sci Monit 2017 Jun 3;23:2708-2714. Epub 2017 Jun 3.

Department of Orthopedic Surgery, The Tenth Peoples' Hospital, Affiliated to Tongji University, Shanghai, China (mainland).

BACKGROUND During total hip arthroplasty (THA) drainage is used by most surgeons. However, the optimal drainage strategy remains controversial. The aim of this prospective cohort study was to determine the safety and efficacy of a four-hour drainage clamping technique in patients undergoing THA. MATERIAL AND METHODS There were 64 patients who underwent THA from March 2012 to December 2015 who were enrolled in the study; 32 patients were randomly assigned to four hours of a drainage clamping technique (clamping group); 32 patients were treated with a non-clamping drainage technique (non-clamping group). All perioperative clinical details were recorded for comparative analysis. RESULTS The postoperative drainage volume and calculated blood loss were significantly greater in the drainage non-clamping group, p<0.001 and p=0.028, respectively. Significantly more patients in the drainage non-clamping group required a blood transfusion, seven cases versus one case (p=0.023). Significantly more units of blood were transfused in the drainage non-clamping group (p=0.001). No significant differences were found for all other clinical outcome factors. CONCLUSIONS The four-hour drainage clamping technique following THA, compared with drainage non-clamping technique reduced blood loss and requirement for blood transfusion. There was no increase in adverse clinical events using the four-hour drainage clamping method. Therefore, four-hour drainage clamping has the potential for routine use in THA.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467705PMC
http://dx.doi.org/10.12659/msm.904864DOI Listing
June 2017

Digital Papillary Adenocarcinoma: Presentation, Natural History and Management.

Rare Tumors 2015 May 25;7(2):5867. Epub 2015 Jun 25.

Department of Surgery, University of Texas Southwestern Medical Center , Dallas, TX ; VA North Texas Health Care System , Dallas, TX, USA.

Digital papillary adenocarcinoma (DPA) is a rare malignant tumor of the sweat glands that often presents as a solitary painless mass on the digits of the hands or feet. We present a rare case of DPA on the ankle in a 54 year-old African American man. Although the most common location for digital papillary adenocarcinoma is on the hands and feet, it can present in other locations. Treatment modalities and concerns such as the level of margin resection, degree of negative margins, and the need for a sentinel lymph node biopsy might be different if the tumor is encountered in locations other than the digits. In the following manuscript, we discuss the natural history of this rare tumor including a review of the current literature with emphasis on documented treatment strategies as well as the approach in treating patients with a unique presentation.
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http://dx.doi.org/10.4081/rt.2015.5867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4508647PMC
May 2015

Predictors of recurrence of umbilical hernias following primary tissue repair in obese veterans.

Am J Surg 2016 Jan 14;211(1):18-23. Epub 2015 May 14.

Department of Surgery, University of Texas Southwestern Medical Center, VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX 75216, USA. Electronic address:

Background: Factors that determine recurrence and complications following primary tissue repair of umbilical hernias (UHs) and the approach to repair UHs in obese patients need further analysis.

Methods: A retrospective review of UH repair (UHR) conducted at our institution was undertaken. Patients were grouped by body mass index (BMI) and compared for recurrence and complications. Univariate and multivariate analyses were performed.

Results: In total, 199 patients (BMI 32.3 kg/m(2), 97% male, 77% Caucasian, American Society of Anesthesiologists class III/IV 59.2%) underwent primary tissue UHR. There were 8 recurrences (4.0%); average follow-up 3.9 ± 2.4 years (range 30 days to 9.2 years). There were no recurrences among normal BMI patients (0/11); 3 in overweight (3/54), 2 in class I obese (2/73), 2 in class II obese (2/47), and 1 in morbidly obese (1/14) patients (P = .84). Albumin and American Society of Anesthesiologists were similar in all groups. Recurrence rates among obese and nonobese patients were not significantly different (3.7% vs 4.6%, P = .72). There were 18 (9.0%) complications. BMI was not associated with complications.

Conclusion: Primary tissue repair is a feasible approach for UHR in obese patients.
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http://dx.doi.org/10.1016/j.amjsurg.2015.03.014DOI Listing
January 2016
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