Similar Outcomes Achieved Between Anterior and Posterior Approach Total Hip Arthroplasty Using Dual Mobility Implants

BackgroundDual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in high-risk patients; however, their utility in primary THA remains relatively unexplored. No previous reports have described whether surgical approach influences outcomes associated with DM implant systems. This study aims to compare patient reported outcomes and post-operative groin pain between patients undergoing anterior approach versus posterior approach following primary THA with DM implants.MethodsWe retrospectively reviewed all patients who underwent primary THA and received a DM implant between 2011-2021. Patients were stratified into two cohorts based on surgical approach (anterior vs. posterior approach). Primary outcomes included the presence of substantial postoperative groin pain as well as readmission and revision rates. Demographic differences were assessed using chi-square and independent sample t-tests. Outcomes were compared using multilinear and logistic regressions.ResultsOf the 495 patients identified, 55 (11%) underwent THA via the anterior approach and 440 (89%) via the posterior approach. Surgical time (100.24 vs. 109.42 minutes, p=0.070), length of stay (2.19vs.2.67 days,p=0.072), discharge disposition (p=0.151), and significant postoperative groin pain (1.8%vs.0.7%,p=0.966) did not statistically differ between the cohorts. 90-day readmission (9.1%vs.7.7%,p=0.823) and revision rate (0.0%vs.3.0%,p=0.993) did not significantly differ as well. Specifically, readmission (p=0.993) and revision (p=0.998) for instability did not significantly differ between the cohorts. We found no statistical difference in HOOS, JR (p=0.425), VR-12 PCS (p=0.718), and VR-12 MCS (p=0.257) delta score improvement from preoperative to 1-year follow-up between the two groups.ConclusionComparable outcomes following implantation of DM constructs may be achievable irrespective of the surgical approach employed. The incidence of iliopsoas injections for groin pain did not significantly differ between anterior and posterior approaches. Future investigation is needed to determine whether surgical approach influences long-term outcomes in patients receiving DM implants. Level of Evidence: III     

直接前方入路与直接外侧入路人工全髋关节置换术的临床效果比较研究

目的:探讨平卧位直接前方入路(DAA)与侧卧位直接外侧入路(DLA)对行初次全髋关节置换术(THA)患者髋关节功能、平衡功能和步态参数的影响。方法:选取2018年2月～2019年10月期间我院收治的初次THA患者97例,根据入路方式的不同随机分为A组(n=47)和B组(n=50),A组行侧卧位DLA,B组行平卧位DAA,比较两组髋关节功能、影像学参数、平衡功能和步态参数,记录两组术后并发症发生率。结果:术后1周、1个月、3个月及6个月两组髋关节Harris评分(HHS)、Berg平衡量表评分(BBS)依次升高,且B组高于A组(P0.05)。B组手术时间长于A组,术中出血量少于A组,切口长度、初次下床行走时间短于A组(P0.05)。术后3个月、6个月两组步频、步速、步长依次升高,且B组高于A组(P0.05)。两组并发症发生率对比,组间比较未见统计学差异(P0.05)。两组术后6个月髋臼假体外展角、前倾角对比,组间比较无显著差异(P0.05)。结论:与侧卧位DLA相比,初次THA患者行平卧位DAA可获得与其相当的手术效果,同时能更好地改善患者髋关节功能、平衡功能和步态,且安全性有保障。     

Patient Reported Outcomes After Conversion vs. Primary Total Hip Arthroplasty: A Propensity Matched Analysis

BackgroundConversion total hip arthroplasty (cTHA) is increasingly utilized as a salvage procedure for complications associated with fracture fixation around the hip and acetabulum and for failed hip preservation surgery. While primary THA (pTHA) has a high success rate, little is known about outcomes following conversion THA. The purpose of this study is to evaluate patient reported outcomes (PROs) and complication rates following conversion THA compared to primary THA.MethodsPatients that underwent cTHA or pTHA from 2015-2020 at a large tertiary referral academic center were retrospectively identified. THA patients were propensity matched in a 1:1 fashion by age, body mass index (BMI), and sex. Pain scores and PROMIS physical function (PF), pain interference (PI), and depression (DA) scores were compared at preoperative and final postoperative follow up timepoints using independent t-tests. Differences in complication and reoperation rates between cohorts were assessed using chi square analysis.ResultsA total of 118 THAs (59 cTHA, 59 pTHA) were included in this analysis with an average follow up of 21.3 months. cTHAs were most commonly performed following hip fracture fixation (50.8%). The conversion cohort had significantly longer lengths of stay (3.6 days vs 1.9 days, p<0.01) and greater use of revision-type implants (39.0% vs 0.0%, p<0.01) compared to pTHA. There was no significant difference in complication rates (cTHA = 15.3%, pTHA = 8.5%; p=0.26), with intraoperative fracture being the most common for both. Primary and conversion THA groups also experienced similar reoperation rates (cTHA = 5.1%, pTHA = 6.8%; p=0.70). No significant differences in PROs at final follow up were identified between groups.ConclusionPatients undergoing cTHA required increased utilization of revision hip implants and had longer lengths of stay, but had comparable complication and reoperation rates, and ultimately demonstrated similar improvements in PROMIS scores compared to a matched cohort of pTHA patients. Level of Evidence: III     

Time course and extent of functional recovery during the first postoperative year after minimally invasive total hip arthroplasty with two different surgical approaches--a randomized controlled trial

While others have reported short-term comparisons between various minimally invasive surgical (MIS) approaches to total hip arthroplasty (THA) and their conventional analogues, longer-term data is lacking, as is information indicating whether MIS approaches to THA provide a biomechanically complete recovery. Furthermore, different MIS approaches have not been compared. Our approaches of interest were a one-incision modified Watson-Jones, and a two-incision approach. Hypotheses: (1) There are significant differences in gait recovery patterns between the two surgical groups and (2) THA subjects have significant differences in function one year after surgery compared to control subjects. To test these hypotheses, THA candidates (n=26) were randomized to receive one of these MIS approaches and evaluated preoperatively, and postoperatively at 3 weeks, and at 3, 6 and 12 months. Evaluations included three-dimensional gait analysis and 24-hour step-counts. The same data were obtained from 25 control subjects. Recovery time-course was assessed using repeated measures ANOVA. T-tests were used to compare controls with the pooled group of THA subjects. We found no differences between the two THA surgical groups regarding the time-course of recovery (p≥0.591). Although recovery was statistically complete by 3 months postoperatively for all variables, there were significant differences from controls at 12 months. Most notably, the external hip adduction moment, which reflects hip abductor function, was more than one standard deviation below normal (p<0.001). THA subject inactivity could not explain the gait differences, since one year after surgery daily step counts were not significantly different from controls (p=0.346). More work is necessary to determine ways to improve biomechanical outcomes for today's patients with high expectations for function and implant longevity.     

Total Hip Arthroplasty: Direct Anterior Approach Versus Posterior Approach in the First Year of Practice

BackgroundThe direct anterior approach (DAA) for total hip arthroplasty (THA) has been popularized as a less invasive technique, however outcomes within the first year of practice after fellowship have not been investigated. The primary aim was to determine differences in complications and outcomes between DAA and posterior approach (PA) in the first year of practice. The secondary aim was to determine if there was a learning curve factor in DAA and PA after fellowship training.MethodsTHA cases performed by two surgeons during their first year of practice were reviewed. Overall, 181 THAs (91 DAA, 90 PA) in 168 patients, were performed. Intraoperative differences (blood loss, operative time), hospital stay, complications, reoperations, and revisions were compared.ResultsOverall surgical complications were similar between DAA and PA (11% vs. 9%, p=0.64), but complication profiles were different: dislocation (1% vs. 4%, p=0.17), intraoperative femoral fracture (2% vs. 1%, p=0.32), postoperative periprosthetic fractures (2% vs. 3%, p=0.64). neuropraxia (3% vs. 0%, p=0.08). There was no difference in rate of reoperation (1% vs. 3%, p=0.31). There was a difference in rate of revision at final follow-up (0% vs. 6%, p=0.02). DAA consisted of longer operative time (111 vs. 99 minutes; p<0.001), however was only significant in the first 50 cases (p<0.001), while the subsequent cases were similar (p=0.31). There was no difference in the first 50 cases compared to the subsequent cases for either approach regarding blood loss, complications, reoperations, or revisions.ConclusionDAA and PA for THA performed within the first year of practice exhibit similarly low complication rates, but complication profiles are different. In our series, PA did demonstrate a higher risk of revision at final follow-up. A learning curve is not unique to the DAA. Both DAA and PA THA exhibited a learning curve in the first 50 cases performed at the start of a surgeon’s practice. Level of Evidence: III     

不同入路人工全髋关节置换术对髋关节疾病患者康复进程、髋关节功能和生活质量的影响

目的:探讨不同入路人工全髋关节置换术(THA)对髋关节疾病患者康复进程、髋关节功能和生活质量的影响。方法:回顾性分析2016年4月～2018年11月期间到我院行THA治疗的髋关节疾病105例患者的临床资料。根据入路方式的不同将其分为A组(n=54,后外侧入路)和B组(n=51,SuperPATH入路),术后行1年的随访,比较两组患者康复进程、髋关节功能和生活质量,记录两组术后并发症发生情况。结果:B组术中失血量、术后引流量少于A组,切口长度、术后第一次下地时间短于A组(均P0.05);B组手术时间长于A组(P0.05)。两组术后1个月、3个月、6个月、12个月髋关节屈曲活动度、髋关节功能Harris评分、髋关节外展活动度均较术前呈先升高后趋于平稳趋势(P0.05);B组术后1个月髋关节屈曲活动度及外展活动度、髋关节功能Harris评分高于A组(P0.05);B组术后3个月、6个月、12个月髋关节屈曲活动度及外展活动度、髋关节功能Harris评分与A组比较无差异(P0.05)。两组末次随访时SF-36各维度评分均较术前升高,且B组高于A组(P0.05)。两组术后并发症发生率比较无差异(P0.05)。结论:与后外侧入路方式相比,髋关节疾病患者THA中采用SuperPATH入路,可促进患者早日康复,有利于患者早期髋关节功能的恢复,对生活质量的改善更为显著,且不增加并发症发生率。     

全髋关节置换术中直接前入路与后外侧入路的疗效比较及对假体位置和血清疼痛介质的影响

摘要 目的：对比全髋关节置换术（THA）中直接前入路（DAA）与后外侧入路（PLA）的疗效,并分析两种入路方式对假体位置和血清疼痛介质的影响。方法：选取2019年3月-2021年7月我院收治的80例THA患者,据入路方式的不同将患者分为PLA组37例和DAA组43例,对比两组手术相关指标、髋关节功能评分、疼痛评分、影像学指标、步态参数、血清疼痛介质水平、并发症发生率。结果：DAA组的切口长度、术后下地时间短于PLA组,手术时间长于PLA组,术后引流量、术中出血量少于PLA组（P<0.05）。两组术后3个月、术后6个月Harris髋关节功能评分均升高,视觉疼痛模拟评分法（VAS）评分均下降（P<0.05）;DAA组术后3个月、术后6个月Harris 髋关节功能评分高于PLA组,VAS评分低于PLA组（P<0.05）。DAA组臼杯位于安全区的比例高于PLA组（P<0.05）;两组髋臼外展角、髋臼前倾角、股骨假体居中率组间对比无差异（P>0.05）。DAA组的单腿支撑时间长于PLA组,步频大于PLA组,Foot off高于PLA组（P<0.05）。两组术后7 d 5-羟色胺（5-HT）、一氧化氮（NO）、前列腺素E₂（PGE₂）水平均较术前升高（P<0.05）;DAA组术后7 d的5-HT、PGE₂、NO水平低于PLA组（P<0.05）。两组术后并发症发生率对比无差异（P>0.05）。结论：THA患者采用DAA的入路方式,除手术时间较长外,其在手术切口、术中损伤、髋关节功能恢复、步态参数、减轻术后疼痛、臼杯位于安全区的比例等方面均优于PLA,且不会增加并发症发生率。     

Different Approaches for Treating Multilevel Cervical Spondylotic Myelopathy: A Retrospective Study of 153 Cases from a Single Spinal Center

ObjectiveThe optimal surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) remains controversial. This study compared the outcomes of three surgical approaches for MSCM treatment, focusing on the efficacy and safety of a combined approach.MethodsThis retrospective study included 153 consecutive MCSM patients (100 men, 53 women; mean age ± standard deviation, 55.7 ± 9.4 years) undergoing operations involving ≥3 intervertebral segments. The patients were divided into three groups according to surgical approach: anterior (n = 19), posterior (n = 76), and combined (n = 58). We assessed demographic variables, perioperative parameters, and clinical outcomes ≥12 months after surgery (20.5 ± 7.6 months), including Japanese Orthopaedic Association (JOA) score, improvement, recovery rate, and complications.ResultsThe anterior group had the most favorable preoperative conditions, including the highest preoperative JOA score (12.95 ± 1.86, p = 0.046). In contrast, the combined group had the highest occupancy ratio (48.0% ± 11.6%, p = 0.002). All groups showed significant neurological improvement at final follow-ups, with JOA recovery rates of 59.7%, 54.6%, and 68.9% in the anterior, posterior, and combined groups, respectively (p = 0.163). After multivariable adjustments, the groups did not have significantly different clinical outcomes (postoperative JOA score, p = 0.424; improvement, p = 0.424; recovery rate, p = 0.080). Further, subgroup analyses of patients with occupancy ratios ≥50% showed similar functional outcomes following the posterior and combined approaches. Overall complication rates did not differ significantly among the three approaches (p = 0.600). Occupancy ratios did not have a significant negative influence on postoperative recovery following the posterior approach.ConclusionsIf applied appropriately, all three approaches are effective for treating MCSM. All three approaches had equivalent neurological outcomes, even in subgroups with high occupancy ratios. Further investigations of surgical approaches to MCSM are needed, particularly prospective multicenter studies with long-term follow-up.     

Meta-analysis of the clinicopathological characteristics and peri-operative outcomes of colorectal cancer in obese patients

BackgroundThe effect of obesity on the clinicopathological characteristics of colorectal cancer (CRC) has not been clearly characterized. This meta-analysis assesses the pathological and perioperative outcomes of obese patients undergoing surgical resection for CRC.MethodsMeta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were searched for studies reporting outcomes for obese and non-obese patients undergoing primary CRC resection, based on body-mass index measurement. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI).ResultsA total of 2183 citations were reviewed; 29 studies comprising 56,293 patients were ultimately included in the analysis, with an obesity rate of 19.3%. Obese patients with colorectal cancer were more often female (OR 1.2, 95% CI 1.1–1.2, p < 0.001) but there was no difference in the proportion of rectal cancers, T4 tumours, tumour differentiation or margin positivity. Obese patients were significantly more likely to have lymph node metastases (OR 1.2, 95% CI 1.1–1.2, p < 0.001), have a lower nodal yield, were associated with a longer duration of surgery, more blood loss and conversions to open surgery (OR 2.6, 95% CI 1.6–4.0, p < 0.001) but with no difference in length of stay or post-operative mortality.ConclusionThis meta-analysis demonstrates that obese patients undergoing resection for CRC are more likely to have node positive disease, longer surgery and higher failure rates of minimally invasive approaches. The challenges of colorectal cancer resection in obese patients are emphasized.     

Incidence,mortality and outcome of meningiomas: A population-based study from Germany

BackgroundMeningiomas are mostly benign tumors that originate from the coverings of the brain and spinal cord. Compared to malignant glial tumors, meningiomas are relatively understudied with regard to their risk factors and epidemiology. In particular, population-based data on cancer burden and patient outcomes are scant.MethodsPopulation-based data from Saarland, a federal state in South-Western Germany, were used; the data included 992 patients diagnosed with a first meningioma between 2000 and 2015. Incidence and mortality rates—as well as estimates of observed and relative survival and cumulative incidence of tumor recurrence up to 10 years after diagnosis—were derived by sex, age, WHO grade, and whether or not the patient had undergone surgery.ResultsThis population-based study not only included patients treated in the regional university hospital but also those treated elsewhere or patients without any surgical treatment. The mean age of the patients at diagnosis was 63 years, and 70%, 28% and 3% had WHO grade I, II and III meningiomas, respectively. Ten-year observed and relative survival of all patients combined was 72% and 91% respectively. Tumor-related mortality varied by sex and increased with age at diagnosis and the WHO grade of the tumor. The overall 10-year cumulative incidence of meningioma recurrence was 9%.ConclusionThis analysis represents the first modern population-based analysis of meningioma incidence and mortality and outcomes of patients with such neoplasms in Germany. Derived from an unselected sample of patients, this study may fill a hitherto existing gap in the literature on meningiomas.     

Does the Patient-Reported Outcomes Measurement Information System Correlate to Legacy Scores in Measuring Mental Health in Young Total Hip Arthroplasty Patients?

BackgroundMental health is becoming increasingly important in patient outcomes. The patient reported outcome measurement information system (PROMIS) was developed by the NIH to collect outcome data in rapid dynamic fashion on electronic platforms. The potential role of PROMIS in monitoring young total hip arthroplasty (THA) patients is under-investigated. The purpose of this study is to investigate correlations between PROMIS Depression or Anxiety with SF-12 mental component score.MethodsWe identified 223 hips (200 patients) who underwent primary THA over a 30-month period at a single institution. Patients without preoperative PROMIS or SF-12 mental scores, or >50yo were excluded. All data was collected preoperatively and included age, sex, BMI, ASA, PROMIS Depression, PROMIS Anxiety, and SF-12 Mental component score. We considered floor and ceiling effects as significant if >15% of patients responded with the lowest or highest possible score, respectively. Relationships between SF-12 and PROMIS were investigated using correlation (R), and were considered strong if R>0.7.ResultsMean age was 41-years-old, mean ASA category was 2, mean BMI was 30kg/m2, and 54% were female. None of the PROMs showed any floor/ceiling effects at baseline. PROMIS Depression showed a strong correlation to SF-12 Mental (R=-0.72) while PROMIS Anxiety showed a moderate correlation to SF-12 Mental (R=-0.58). Negative linear relationships were observed because a lower PROMIS Depression/Anxiety values indicates less depressive/anxious feelings (inverse of SF-12).ConclusionPROMIS Anxiety and Depression correlate well with SF-12 mental. These PROMIS domains may be attractive alternatives to legacy mental health instruments in young THA patients. Level of Evidence: III     

Economic Evaluation of Interventions for Prevention of Hospital Acquired Infections: A Systematic Review

Objective

This systematic review sought to assess the costs and benefits of interventions preventing hospital-acquired infections and to evaluate methodological and reporting quality.

Methods

We systematically searched Medline via PubMed and the National Health Service Economic Evaluation Database from 2009 to 2014. We included quasi-experimental and randomized trails published in English or German evaluating the economic impact of interventions preventing the four most frequent hospital-acquired infections (urinary tract infections, surgical wound infections, pneumonia, and primary bloodstream infections). Characteristics and results of the included articles were extracted using a standardized data collection form. Study and reporting quality were evaluated using SIGN and CHEERS checklists. All costs were adjusted to 2013 US$. Savings-to-cost ratios and difference values with interquartile ranges (IQRs) per month were calculated, and the effects of study characteristics on the cost-benefit results were analyzed.

Results

Our search returned 2067 articles, of which 27 met the inclusion criteria. The median savings-to-cost ratio across all studies reporting both costs and savings values was US $7.0 (IQR 4.2–30.9), and the median net global saving was US $13,179 (IQR 5,106–65,850) per month. The studies’ reporting quality was low. Only 14 articles reported more than half of CHEERS items appropriately. Similarly, an assessment of methodological quality found that only four studies (14.8%) were considered high quality.

Conclusions

Prevention programs for hospital acquired infections have very positive cost-benefit ratios. Improved reporting quality in health economics publications is required.     

Open Versus Arthroscopic Surgical Management for Recalcitrant Trochanteric Bursitis: A Systematic Review

BackgroundWhile excision of the trochanteric bursae to treat lateral hip pain has increased in popularity, no comparison exists between the surgical outcomes and complications of the open and arthroscopic techniques involving trochanteric bursectomy. The purpose of this study was to determine the efficacies and complication rates of arthroscopic and open techniques for procedures involving trochanteric bursectomy.MethodsThe terms “trochanteric,” “bursectomy,” “arthroscopic,” “open,” “outcomes,” and “hip” were searched in five electronic databases. Fifteen studies from 120 initial results were included. Patient-reported outcomes (PRO), pain, satisfaction, and complications were included for analysis.ResultsFive hundred-two hips in 474 total patients (77.7% female) were included in this study. The average age was 54. The fourteen distinct PRO scores that were reported by the included studies improved significantly from baseline to final mean follow-up (12-70.8 months for open; 12-42 months for arthroscopic) for both approaches, demonstrating statistically significant patient benefit in a variety of hip arthroscopy settings (P > 0.05). The complication rates of all procedures ranged from 0%-33% and failure to improve pain ranged from 0%-8%. Patient satisfaction with surgery was high at 95% and 82% reported a willingness to undergo the same surgery again. No significant mean differences were found between the open and arthroscopic techniques.ConclusionThe open and arthroscopic approaches for trochanteric bursectomy are both safe and effective procedures in treating refractory lateral hip pain. No significant differences in PROs, pain, total complications, severity of complications, and total failures were seen between technique outcomes.Level of Evidence: IV     

Bisphosphonate Use and Risk of Implant Revision after Total Hip/Knee Arthroplasty: A Meta-Analysis of Observational Studies

ObjectiveSeveral studies investigated the association between bisphosphonate use and the risk of implant revision after total hip or knee arthroplasty (THA or TKA); However, the findings were inconsistent. We performed this meta-analysis to evaluate the overall relative risk of such an event.MethodsWe searched the PubMed, EMBASE and Cochrane library databases to identify relevant publications on April 22, 2015. To calculate the pooled risk ratios (RRs) with 95% confidential intervals (CIs), a fixed- or random-effects model was applied based on the heterogeneity across studies.ResultsThree cohort studies and one case-control study were included in this meta-analysis. Compared with the bisphosphonate nonusers, the patients who used bisphosphonates for a long period of time had a significantly decreased risk of implant revision after THA/TKA (summary adjusted RR = 0.48, 95% CI: 0.38–0.61), and the summary adjusted RRs for the users who underwent THA and those who underwent TKA were 0.47 (95% CI: 0.36–0.61) and 0.45 (95% CI: 0.21–0.95), respectively.ConclusionsLong-term use of bisphosphonates is correlated with a significantly decreased risk of implant revision after THA/TKA. However, due to limited number of the included studies, the findings of the present study should be treated with caution. More well-designed studies are required to further confirm our findings.     

Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials

BackgroundHospitals, clinics, and health organizations have provided psychosocial support interventions for medical patients to supplement curative care. Prior reviews of interventions augmenting psychosocial support in medical settings have reported mixed outcomes. This meta-analysis addresses the questions of how effective are psychosocial support interventions in improving patient survival and which potential moderating features are associated with greater effectiveness.Methods and findingsWe evaluated randomized controlled trials (RCTs) of psychosocial support interventions in inpatient and outpatient healthcare settings reporting survival data, including studies reporting disease-related or all-cause mortality. Literature searches included studies reported January 1980 through October 2020 accessed from Embase, Medline, Cochrane Library, CINAHL, Alt HealthWatch, PsycINFO, Social Work Abstracts, and Google Scholar databases. At least 2 reviewers screened studies, extracted data, and assessed study quality, with at least 2 independent reviewers also extracting data and assessing study quality. Odds ratio (OR) and hazard ratio (HR) data were analyzed separately using random effects weighted models. Of 42,054 studies searched, 106 RCTs including 40,280 patients met inclusion criteria. Patient average age was 57.2 years, with 52% females and 48% males; 42% had cardiovascular disease (CVD), 36% had cancer, and 22% had other conditions. Across 87 RCTs reporting data for discrete time periods, the average was OR = 1.20 (95% CI = 1.09 to 1.31, p < 0.001), indicating a 20% increased likelihood of survival among patients receiving psychosocial support compared to control groups receiving standard medical care. Among those studies, psychosocial interventions explicitly promoting health behaviors yielded improved likelihood of survival, whereas interventions without that primary focus did not. Across 22 RCTs reporting survival time, the average was HR = 1.29 (95% CI = 1.12 to 1.49, p < 0.001), indicating a 29% increased probability of survival over time among intervention recipients compared to controls. Among those studies, meta-regressions identified 3 moderating variables: control group type, patient disease severity, and risk of research bias. Studies in which control groups received health information/classes in addition to treatment as usual (TAU) averaged weaker effects than those in which control groups received only TAU. Studies with patients having relatively greater disease severity tended to yield smaller gains in survival time relative to control groups. In one of 3 analyses, studies with higher risk of research bias tended to report better outcomes. The main limitation of the data is that interventions very rarely blinded personnel and participants to study arm, such that expectations for improvement were not controlled.ConclusionsIn this meta-analysis, OR data indicated that psychosocial behavioral support interventions promoting patient motivation/coping to engage in health behaviors improved patient survival, but interventions focusing primarily on patients’ social or emotional outcomes did not prolong life. HR data indicated that psychosocial interventions, predominantly focused on social or emotional outcomes, improved survival but yielded similar effects to health information/classes and were less effective among patients with apparently greater disease severity. Risk of research bias remains a plausible threat to data interpretation.

In a meta-analysis, Timothy Smith and colleagues study trials of the effectiveness of psychosocial support interventions for improving inpatient and outpatient survival.     

Regional trends of minimally invasive radical hysterectomy for cervical cancer and exploration of perioperative outcomes

IntroductionRadical hysterectomy (RH) with bilateral pelvic lymph node dissection is the standard treatment for early stage cervical cancer which can be performed either by an abdominal or a minimally invasive (MIS) approach. In 2018, Ramirez et al. presented their randomized-controlled trial data which demonstrated that patients who were treated with minimally invasive surgical (MIS) radical hysterectomy (RH) had higher rates of locoregional disease recurrence and lower rates of overall survival when compared to patients treated with an abdominal approach. The objective of this study is to examine the trends in management of patients diagnosed with cervical cancer in New York State (NYS) and to analyze their perioperative outcomes.MethodsUsing the Statewide Planning and Research Cooperative System (SPARCS) Database, patients undergoing RH for early stage cervical cancer in NYS between the years of 2007–2015 were identified and categorized based on surgical approach. Demographic information was collected and multivariable regression was conducted to assess the impact of hysterectomy approach on perioperative outcomes.ResultsIn NYS, 5575 patients were treated with RH for early stage cervical cancer with 3257 (58.4%) treated by abdominal RH and 2318 (41.6%) treated with MIS RH. Between the years of 2007 and 2015, patients diagnosed with cervical cancer treated with MIS RH increased from 25.7% to 48.3% respectively. Surgeons performing MIS RH were more likely to be younger (average age 47.1 vs 49.2, p < 0.001) and have less time elapsed from their fellowship graduation (20.37 vs 22.64 years, p < 0.001). Patients who saw high volume doctors (OR 1.95, CI 1.65–2.31) and were seen in high volume facilities (OR 1.40, CI 1.18–1.65) were more likely to undergo MIS RH compared to abdominal RH. Patients who underwent MIS RH were more likely to be discharged home as opposed to acute rehab or nursing facility, when compared to patients treated with abdominal RH (98.5 vs 94.2% p < 0.001). When analyzing perioperativce outcomes, patient undergoing MIS RH had a 85% decrease in length of hospital stay compared to abdominal RH, a 40% reduction in 30-day readmission rates, and a 10% reduction in hospital costs respectively.DiscussionIn our study period, between the years of 2007 and 2015, the number of cervical cancer cases treated with MIS RH increased from 25.7% to 48.3%. MIS techniques led to a reduction in length of hospital stay, patient readmission rates, and hospital costs. Based on recent data from Ramirez et al., preliminary data demonstrated decrease in MIS RH for treatment of cervical cancer after presentation of the LACC trial and our data confirmed these reported trends in NYS. With this change in surgical practice, there will be associated changes in perioperative outcomes. Moreover, for patients diagnosed with cervical cancer with microscopic disease or previous treatment with an excisions procedure, MIS approach should be considered for improvement in perioperative outcomes as long as oncologic outcomes are not compromised.     

Endocystectomy as a conservative surgical treatment for hepatic cystic echinococcosis: A systematic review with single-arm meta-analysis

BackgroundIn patients with hepatic cystic echinococcosis (CE), treatment effectiveness, outcomes, complications, and recurrence rate are controversial. Endocystectomy is a conservative surgical approach that adequately removes cyst contents without loss of parenchyma. This conservative procedure has been modified in several ways to prevent complications and to improve surgical outcomes. This systematic review aimed to evaluate the intraoperative and postoperative complications of endocysectomy for hepatic CE as well as the hepatic CE recurrence rate following endocystectomy.MethodsA systematic search was made for all studies reporting endocystectomy to manage hepatic CE in PubMed, Web of Science, and Cochrane CENTRAL databases. Study quality was assessed using the methodological index for non-randomized studies (MINORS) criteria and the Cochrane revised tool to assess risk of bias in randomized trials (RoB2). The random-effects model was used for meta-analysis and the arscine-transformed proportions were used to determine complication-, mortality-, and recurrence rates. This study is registered with PROSPERO (number CRD42020181732).ResultsOf 3,930 retrieved articles, 54 studies reporting on 4,058 patients were included. Among studies reporting preoperative anthelmintic treatment (31 studies), albendazole was administered in all of them. Complications were reported in 19.4% (95% CI: 15.9–23.2; I² = 84%; p-value <0.001) of the patients; biliary leakage (10.1%; 95% CI: 7.5–13.1; I² = 81%; p-value <0.001) and wound infection (6.6%; 95% CI: 4.6–9; I² = 27%; p-value = 0.17) were the most common complications. The post-endocystectomy mortality rate was 1.2% (95% CI: 0.8–1.8; I² = 21%; p-value = 0.15) and the recurrence rate was 4.8% (95% CI: 3.1–6.8; I² = 87%; p-value <0.001). Thirty-nine studies (88.7%) had a mean follow-up of more than one year after endocystectomy, and only 14 studies (31.8%) had a follow-up of more than five years.ConclusionEndocystectomy is a conservative and feasible surgical approach. Despite previous disencouraging experiences, our results suggest that endocystectomy is associated with low mortality and recurrence.     

Sex Distribution of Study Samples Reported in American Society of Biomechanics Annual Meeting Abstracts

Background

Study samples should be appropriately selected to maximize generalizability of results. Excluding one sex from studies of conditions that affect both sexes is problematic and has received attention as a public policy issue in the United States, resulting in legislation and recommendations made by the National Institutes of Health to address this deficiency of study designs. It is unknown to what extent biomechanical studies have inappropriately excluded one sex. The objective of this study was to provide objective data on this question.

Methods

A retrospective review of random samples of abstracts presented at American Society of Biomechanics annual meetings from 1983 to 2013 was conducted to assess reporting of sex of study samples and whether the study samples were approximately balanced with respect to sex.

Findings

We did not find a statistically significant increasing trend in the percentage of abstracts reporting sex over time. However, increasing trends were noted in the percentage of abstracts including both sexes (p < 0.05) and percentage of abstracts having an “approximately balanced” study sample containing 50 ± 20% females (p > 0.05). In 2013 the percentage of abstracts reporting studies having approximately balanced study samples was only 28%, far from the ideal level of 100%.

Interpretation

While there has been modest change since 1983, there remains significant room for improvement in the reporting and composition of experimental studies reported at American Society of Biomechanics annual meetings.     

Predicting major complications in patients undergoing laparoscopic and open hysterectomy for benign indications

Background:Hysterectomy, the most common gynecological operation, requires surgeons to counsel women about their operative risks. We aimed to develop and validate multivariable logistic regression models to predict major complications of laparoscopic or abdominal hysterectomy for benign conditions.Methods:We obtained routinely collected health administrative data from the English National Health Service (NHS) from 2011 to 2018. We defined major complications based on core outcomes for postoperative complications including ureteric, gastrointestinal and vascular injury, and wound complications. We specified 11 predictors a priori. We used internal–external cross-validation to evaluate discrimination and calibration across 7 NHS regions in the development cohort. We validated the final models using data from an additional NHS region.Results:We found that major complications occurred in 4.4% (3037/68 599) of laparoscopic and 4.9% (6201/125 971) of abdominal hysterectomies. Our models showed consistent discrimination in the development cohort (laparoscopic, C-statistic 0.61, 95% confidence interval [CI] 0.60 to 0.62; abdominal, C-statistic 0.67, 95% CI 0.64 to 0.70) and similar or better discrimination in the validation cohort (laparoscopic, C-statistic 0.67, 95% CI 0.65 to 0.69; abdominal, C-statistic 0.67, 95% CI 0.65 to 0.69). Adhesions were most predictive of complications in both models (laparoscopic, odds ratio [OR] 1.92, 95% CI 1.73 to 2.13; abdominal, OR 2.46, 95% CI 2.27 to 2.66). Other factors predictive of complications included adenomyosis in the laparoscopic model, and Asian ethnicity and diabetes in the abdominal model. Protective factors included age and diagnoses of menstrual disorders or benign adnexal mass in both models and diagnosis of fibroids in the abdominal model.Interpretation:Personalized risk estimates from these models, which showed moderate discrimination, can inform clinical decision-making for people with benign conditions who may require hysterectomy.

Hysterectomy is one of the most frequently performed surgical procedures. Canada has one of the highest rates of hysterectomy globally, with one-third of women undergoing this procedure before 60 years of age.¹ Minimal access approaches are favoured by both clinicians and patients,² and the proportion of hysterectomies being undertaken by a laparoscopic approach has increased substantially in many countries over the last 10 years.^3–7 The evidence-based medicine paradigm for surgical approaches to hysterectomy for benign disease advocates that the chosen surgical approach should be discussed with the patient by their surgeon and decided in light of the relative benefits and risks.² This advice is echoed by national guidelines.^8,9Most clinicians undertaking hysterectomy will intuitively identify patient characteristics that have the potential to increase the complexity and complications of surgery. A 2016 systematic review of studies that reported significant associations between patient characteristics and surgical outcomes for laparoscopic hysterectomy and a 2020 population-based prospective cohort study using data from the Danish hysterectomy database have suggested that older age, race, raised body mass index (BMI), diabetes mellitus, increased uterine weight, fibroids, endometriosis and adhesions are predictors of complications in patients undergoing hysterectomy for benign indications.^10,11 However, assimilating this information to individualize and anticipate the precise risk for each patient if there are multiple factors present can be challenging. A 2020 systematic review reported that surgeons in other specialties were outperformed by risk prediction models in estimating postoperative risk and outcomes; their discriminatory ability showed greater variation (C-statistic 0.51–0.75) than other risk prediction tools.¹²Patients should be given information about potential risks before surgery to manage expectations.¹³ This is especially important when surgery is considered for benign disease because nonsurgical options are often available.Our aim was to generate prediction models that can be used in conjunction with a surgeon’s intuition to enhance preoperative patient counselling and match the advances made in the technical aspects of surgery. We sought to quantify the proportion of patients who underwent hysterectomy for benign disease and will have a major complication, and to develop and validate prognostic models to individualize this risk, using a national data set.