Therapeutic Level III, comparative series.

Level IV, case series.

Background: Metal component failure in total ankle arthroplasty (TAA) is difficult to treat. Traditionally, conversion to an arthrodesis has been advocated. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. The goal of this study was to analyze the clinical results and patientreported outcomes for patients undergoing revision total ankle arthroplasty. Methods: We retrospectively reviewed prospectively collected data on 52 patients with a mean age of 63.5 + 9.6 years who had developed loosening or collapse of major metal components following primary TAA. These patients were compared to a case-matched control group of 52 primary TAAs performed at the host institution with a minimum of 2 years' follow-up. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and pain scores were prospectively collected. Clinical data was collected through review of the electronic medical record to identify reasons for clinical failure, where clinical failure was defined as second revision or conversion to arthrodesis or amputation. Results: The identified causes of failure of primary TAA were aseptic loosening of both components (42%), talar component subsidence/loosening (36%), coronal talar subluxation (12%), tibial loosening (8%), and talar malrotation (2%). Thirty-one patients (59.5%) underwent revision of all components, 20 (38.5%) just the talar and polyethylene components, and one (2%) the tibial and polyethylene components. The average time to revision was 5.5 years + 5.4 with a follow-up of 3.1 years + 1.5 after revision. Eleven (21.2%) revision arthroplasties required further surgery: 6 required conversion to arthrodesis and 5 required second revision TAA. Pain scores, SF-36 scores, SMFA scores, and AOFAS Hindfoot scores all improved after revision surgery but never reached the same degree of improvement seen after primary TAA. Conclusions: Clinical and patient-reported outcomes of revision ankle arthroplasty after metal component failure significantly improved after surgery, although the recovery time was longer. In this series, 21.2% of revision TAAs required a second revision TAA or arthrodesis surgery. Various prostheses performed similarly when used for revision surgery. Revision TAA can offer significant improvements postoperatively.

BackgroundAdverse events from surgical care are a major cause of death and disability, particularly in low-and-middle-income countries. Metrics for quality of surgical care developed in high-income settings are resource-intensive and inappropriate in most lower resource settings. The purpose of this study was to apply and assess the feasibility of a new tool to measure surgical quality in resource-constrained settings.MethodsThis is a cross-sectional study of surgical quality using a novel evidence-based tool for quality measurement in low-resource settings. The tool was adapted for use at a tertiary hospital in Amazonas, Brazil resulting in 14 metrics of quality of care. Nine metrics were collected prospectively during a 4-week period, while five were collected retrospectively from the hospital administrative data and operating room logbooks.Results183 surgeries were observed, 125 patient questionnaires were administered and patient charts for 1 year were reviewed. All metrics were successfully collected. The study site met the proposed targets for timely process (7 hours from admission to surgery) and effective outcome (3% readmission rate). Other indicators results were equitable structure (1.1 median patient income to catchment population) and equitable outcome (2.5% at risk of catastrophic expenditure), safe outcome (2.6% perioperative mortality rate) and effective structure (fully qualified surgeon present 98% of cases).ConclusionIt is feasible to apply a novel surgical quality measurement tool in resource-limited settings. Prospective collection of all metrics integrated within existing hospital structures is recommended. Further applications of the tool will allow the metrics and targets to be refined and weighted to better guide surgical quality improvement measures.

Background Lack of providers in surgery, anesthesia, and obstetrics (SAO) is a primary driver of limited surgical capacity worldwide. We aimed to identify predictors of entry into Surgery, Anesthesia, and Obstetrics and Gynecology (SAO) fields and preference of working in the public sector in Brazil which may help in profiling medical students for recruitment into these needed areas. Methods A questionnaire was applied to all Brazilian medical graduates registered with a Board of Medicine from 2014 to 2015. Twenty-three characteristics were analyzed. Logistic regression was used to determine predictors’ influence on outcome. Results There were 4601 (28.2%) responders to the survey, of which 40.5% (CI 34.7–46.5%) plan to enter SAO careers. Of the 23 characteristics analyzed, eight differed significantly between those who planned to work in SAO and those who did not. Of those eight characteristics, just three were significant predictors in the regression model: preference for working in the hospital setting, having spent more than 70% of their clinical years in practical activities, and valuing the substantial earning potential. These three factors explained only 6.3% of the variance in SAO preference. Within the graduates who preferred SAO careers, there were only two predictors for working in the public sector (“preparatory time before medical school” and valuing “prestige/status”). Conclusions Factors affecting specialty and sector choice are multifaceted and difficult to predict. Future programs to fill provider gaps should identify methods other than medical student profiling to assure specialty and sector needs are met. Electronic supplementary material The online version of this article (10.1186/s12909-019-1562-6) contains supplementary material, which is available to authorized users.

Category: Ankle Introduction/Purpose: Acute hematogenous periprosthetic joint infection(PJI) is defined in the literature as infection diagnosed and treated within two to four weeks from the onset of symptoms. In total hip and knee arthroplasty, irrigation, debridement(I&D) and polyethylene exchange with component retention is the treatment of choice. There is minimal literature evaluating this treatment method for PJI in total ankle arthroplasty (TAA), however, with four patients being the largest sample size. The purpose of this study was to evaluate both the clinical and patient reported outcomes and survivorship of treating PJI in TAA with I&D and polyethylene exchange in patients with acute hematogenous PJIs. Methods: A single center, retrospective chart review of prospectively collected data in patients with TAA PJI who subsequently underwent I&D and polyethylene exchange with retention of metal components was conducted. The primary outcome was failure rate of I&D and polyethylene exchange where failure was defined as subsequent removal of all components and two-stage revision or arthrodesis. Patient reported outcomes collected before primary arthroplasty, after primary arthroplasty and after polyethylene exchange were also analyzed. Results: We identified 11 patients with acute hematogenous PJI who underwent I&D/ polyethylene exchange with retention of metal components. The average time from onset of symptoms to I&D/ polyethylene exchange was 11.55 days +/-5.57. The mean follow-up after this surgery was 2.8 years +/-1.45. The long-term failure rate was 50%. The most common bacteria isolated in patients who failed was Methicillin Resistant Staphylococcus Aureus (MRSA). The most common bacteria isolated in patients who retained their implants was Methicillin Sensitive Staphylococcus Aureus(MSSA). Visual Analog Scale (VAS), Short Musculoskeletal Function Assessment (SMFA), Short Form-36 (SF36), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale showed significant improvement when compared to preoperative scores in patients who retained their implants both after primary and after I&D and polyethylene exchange. Conclusion: I&D and polyethylene exchange with retention of metal components has comparable long-term survivorship to those reported in the Knee and Hip Arthroplasty literature. Patient reported outcomes after I&D and polyethylene exchange were comparable to those collected after primary arthroplasty in patients who ultimately retained their implants. Two variables which were independent predictors of failure of this surgery include duration of symptoms prior to I&D as well as organism isolated on culture. With a failure rate of 50%, the authors recommend thorough evaluation on a case by case basis prior to indicating a patient for single stage I&D with polyethylene exchange.

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Category: Ankle Arthritis Introduction/Purpose: Metal component failure in total ankle arthroplasty(TAA) is difficult to treat. Traditionally, to an arthrodesis has been advocated. Revision TAA surgery has become more and more common with availability of revision implants and refinement of bone conserving primary implants. It this study, patient reported results and clinical outcomes are analyzed for patients undergoing revision total ankle arthroplasty. Methods: We retrospectively reviewed prospectively collected data on 45 patients (cases) with a mean age of 63.7 +/-10.2 years who developed loosening or collapse of either major metal component in the primary total ankle arthroplasty. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. Prospectively collected patient reported outcomes measures including the American Orthopaedic Foot and Ankle Society(AOFAS) hindfoot score, Visual Analog Scale (VAS), Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and the Foot and Ankle Outcomes Score (FAOS) questionnaires were collected. Clinical data was collected through thorough review of the electronic medical record to identify clinical failure defined as explant and second revision or conversion to arthrodesis or amputation. Results: The causes of failure of primary TAA in this study were aseptic loosening of both components (40%), talar component subsidence/loosening (37.7%), tibial loosening (8.8%), coronal talar subluxation (8.8%) and talar malrotation (2.2%). Twenty-four patients (53.3%) underwent revision of all components, nineteen (42.2%) just the talar and polyethylene components, and two (4.4%) the tibial and polyethylene components. The average time to revision was 5.56 years +/- 5.71 with a follow-up of 3.02 years +/- 1.25 after revision. Ten (22.2%) revision arthroplasties required further surgery; five required conversion to arthrodesis and five required second revision TAA. VAS scores, SF36 scores, SMFA scores, AOFAS Hindfoot scores, and FAOS all improved after revision surgery but took 2 years to reach scores comparable to 1 year after primary TAA. Conclusion: Clinical and patient reported results of revision ankle arthroplasty after metal component failure were comparable to those after primary ankle arthroplasty. In our series, 22.2% of revision TAAs required a second revision TAA or arthrodesis surgery. Various prosthesis performed similarly when used in revision scenarios. Patients recovered faster from primary ankle arthroplasty when compared to revision ankle arthroplasty but all scores were comparable by the two-year follow-up visit after revision arthroplasty surgery.