Peri-Operative Urodynamic Assessment has Poor Predictive Value for Developing Post-Operative Urinary Retention

Introduction: Post-operative urinary retention (POUR) following primary total joint arthroplasty (TJA) has a reported prevalence up to 35%. Risk factors for developing POUR have traditionally included surrogate markers such as the presence or absence of urologic disease. However, dynamic measurement of the renal system with post-void residual volumes (PVR) has not been investigated as a tool for assessing POUR risk. Methods: All male TJA patients underwent an pre-operative screen for POUR, including PVR measurements, patient-derived subjective urinary retention scores, and assessment of urologic disease. This was combined with a post-operative monitoring and catheterization protocol developed in partnership with a Urologist. Patient records were retrospectively reviewed and assessed whether pre-operative PVR cutoffs or urinary retention scores were associated with developing POUR. Proportions were evaluated with the chi square test, while continuous variables were evaluated by logistic regression analysis. Receiver-operator characteristic (ROC) curves were utilized to determine the efficacy of using urodynamic variables as a predictor of developing POUR. Results: Two hundred and fifty-two (252) male patients were reviewed who had a mean age of 64.9 years and mean BMI 30.8 kg/m2. The overall rate of POUR was 5.2%; the rate of protocol-driven catheterization was higher (19.8%). Patient urinary retentions scores were not associated with the risk of POUR. Elevated pre-operative PVR (\u3e10 cc) alone and in combination with a history of urologic disease was significantly associated with POUR (p \u3c 0.001 and p = 0.001, respectively). However, both had low positive-predictive values (10.5 and 18.2%, respectively), despite high negative predictive values (99.2 and 97.9%, respectively). Utilization of PVR resulted in moderate sensitivity (91.6%) and low specificity (72.1%) with an AUC of 0.694. Discussion: Urodynamic measurements and patient urinary retention scores, as part of institutional pre-operative screening, have limited value in determining risk of POUR. False-positive rates of up to ~90% were observed with correspondingly low specificity. The authors call into question the utility of obtaining these measurements pre-operatively, particularly as they have no modifiable impact on institutional post-operative catheterization protocol

Limb Salvage Versus Amputation in Conventional Appendicular Osteosarcoma: a Systematic Review.

The overall survivorship in patients with appendicular osteosarcoma has increased in the past few decades. However, controversies and questions about performing an amputation or a limb salvage procedure still remain. Using three peer-reviewed library databases, a systematic review of the literature was performed to evaluate all studies that have evaluated the outcomes of appendicular osteosarcoma, either with limb salvage or amputation. The mean 5-year overall survivorship was 62% for salvage and 58% for amputation (p > 0.05). At mean 6-year follow-up, the local recurrence rates were 8.2% for salvage and 3.0% for amputation (p > 0.05). Additionally, at mean 6-year follow-up, the rate for metastasis was 33% for salvage and 38% for amputation (p > 0.05). The revision rates were higher with salvage (31 vs. 28%), and there were more complications in the salvage groups (52 vs. 34%; p > 0.05). Despite the heterogeneity of studies available for review, we observed similar survival rates between the two procedures. Although there was no significant statistical difference between rates of recurrence and metastasis, the local recurrence rate and risk of complications were higher for limb salvage as compared to amputation. Cosmetic satisfaction is often higher with limb salvage, whereas long-term expense is higher with amputation. Overall, current literature supports limb salvage procedures when wide surgical margins can be achieved while still retaining a functional limb.VoRSUNY DownstateOrthopaedic Surgery & Rehabilitation MedicineN/

Implant fracture after long-stemmed cemented hemiarthroplasty for oncologic indications

© 2015 by Begell House, Inc. Although a long-stemmed cemented hemiarthroplasty is frequently recommended for oncologic lesions of proximal femur, we have observed an alarming number of spontaneous stem fractures. The purpose of this retrospective study was to identify the associated risk factors for stem fractures in a study cohort of 60 (61 prostheses) during 1983–2007. At a mean follow-up of 41 months, 4/61 (6.6%) stems had fractured after a mean of 36 (12–92) months after surgery. All failed implants were Osteonics Omnifit (4/27; 14.8%) and multivariate analysis did not show any correlation with other studied variables. While the failures were successfully salvaged by conversion to a modular proximal femoral replacement, any implant failure in this population is devastating. Spontaneous onset of thigh pain in patients with long stems, particularly if associated with other risk factors, should raise suspicion of a fatigue fracture of the stem