TY - JOUR A1 - Dhaliwal, Anand A1 - Zamora, Tomas A1 - Nedopil, Alexander J. A1 - Howell, Stephen M. A1 - Hull, Maury L. T1 - Six commonly used postoperative radiographic alignment parameters do not predict clinical outcome scores after unrestricted caliper-verified kinematically aligned TKA JF - Journal of Personalized Medicine N2 - Background: Unrestricted caliper-verified kinematically aligned (KA) TKA restores patient’s prearthritic coronal and sagittal alignments, which have a wide range containing outliers that concern the surgeon practicing mechanical alignment (MA). Therefore, knowing which radiographic parameters are associated with dissatisfaction could help a surgeon decide whether to rely on them as criteria for revising an unhappy patient with a primary KA TKA using MA principles. Hence, we determined whether the femoral mechanical angle (FMA), hip–knee–ankle angle (HKAA), tibial mechanical angle (TMA), tibial slope angle (TSA), and the indicators of patellofemoral tracking, including patella tilt angle (PTA) and the lateral undercoverage of the trochlear resection (LUCTR), are associated with clinical outcome scores. Methods: Forty-three patients with a CT scan and skyline radiograph after a KA TKA with PCL retention and medial stabilized design were analyzed. Linear regression determined the strength of the association between the FMA, HKA angle, PTS, PTA, and LUCTR and the forgotten joint score (FJS), Oxford knee score (OKS), and KOOS Jr score obtained at a mean of 23 months. Results: There was no correlation between the FMA (range 2° varus to −10° valgus), HKAA (range 10° varus to −9° valgus), TMA (range 10° varus to −0° valgus), TSA (range 14° posterior to −4° anterior), PTA (range, −10° medial to 14° lateral), and the LUCTR resection (range 2 to 9 mm) and the FJS (median 83), the OKS (median 44), and the KOOS Jr (median 85) (r = 0.000 to 0.079). Conclusions: Surgeons should be cautious about using postoperative FMA, HKAA, TMA, TSA, PTA, and LUCTR values within the present study’s reported ranges to explain success and dissatisfaction after KA TKA. KW - total knee arthroplasty KW - kinematic alignment KW - reoperation KW - revision KW - phenotype Y1 - 2022 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-288186 SN - 2075-4426 VL - 12 IS - 9 ER - TY - JOUR A1 - Howell, Stephen M. A1 - Gill, Manpreet A1 - Shelton, Trevor J. A1 - Nedopil, Alexander J. T1 - Reoperations are few and confined to the most valgus phenotypes 4 years after unrestricted calipered kinematically aligned TKA JF - Knee Surgery, Sports Traumatology, Arthroscopy N2 - Purpose The present study determined the postoperative phenotypes after unrestricted calipered kinematically aligned (KA) total knee arthroplasty (TKA), whether any phenotypes were associated with reoperation, implant revision, and lower outcome scores at 4 years, and whether the proportion of TKAs within each phenotype was comparable to those of the nonarthritic contralateral limb. Methods From 1117 consecutive primary TKAs treated by one surgeon with unrestricted calipered KA, an observer identified all patients (N = 198) that otherwise had normal paired femora and tibiae on a long-leg CT scanogram. In both legs, the distal femur–mechanical axis angle (FMA), proximal tibia–mechanical axis angle (TMA), and the hip–knee–ankle angle (HKA) were measured. Each alignment angle was assigned to one of Hirschmann’s five FMA, five TMA, and seven HKA phenotype categories. Results Three TKAs (1.5%) underwent reoperation for anterior knee pain or patellofemoral instability in the subgroup of patients with the more valgus phenotypes. There were no implant revisions for component loosening, wear, or tibiofemoral instability. The median Forgotten Joint Score (FJS) was similar between phenotypes. The median Oxford Knee Score (OKS) was similar between the TMA and HKA phenotypes and greatest in the most varus FMA phenotype. The phenotype proportions after calipered KA TKA were comparable to the contralateral leg. Conclusion Unrestricted calipered KA’s restoration of the wide range of phenotypes did not result in implant revision or poor FJS and OKS scores at a mean follow-up of 4 years. The few reoperated patients had a more valgus setting of the prosthetic trochlea than recommended for mechanical alignment. Designing a femoral component specifically for KA that restores patellofemoral kinematics with all phenotypes, especially the more valgus ones, is a strategy for reducing reoperation risk. KW - phenotype KW - total knee arthroplasty KW - total knee replacement KW - kinematic alignment KW - calipered KW - reoperation Y1 - 2022 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-265291 VL - 30 IS - 3 ER - TY - JOUR A1 - Shekhar, Adithya A1 - Howell, Stephen M. A1 - Nedopil, Alexander J. A1 - Hull, Maury L. T1 - Excellent and good results treating stiffness with early and late manipulation after unrestricted caliper-verified kinematically aligned TKA JF - Journal of Personalized Medicine N2 - Manipulation under anesthesia (MUA) for stiffness within 6 to 12 weeks after mechanically aligned total knee arthroplasty (TKA) generally yields better outcome scores than an MUA performed later. However, the timing of MUA after unrestricted, caliper-verified, kinematically aligned (KA) TKA remains uncertain. A retrospective review identified 82 of 3558 (2.3%) KA TKA patients treated with an MUA between 2010 and 2017. Thirty patients treated with an MUA within 3 months of the TKA (i.e., early) and 24 in the late group (i.e., >3 months) returned a questionnaire after a mean of 6 years and 5 years, respectively. Mean outcome scores for the early vs. late group were 78 vs. 62 for the Forgotten Joint Score (FJS) (p = 0.023) and 42 vs. 39 for the Oxford Knee Score (OKS) (p = 0.037). Subjectively, the early vs. late group responses indicated that 83% vs. 67% walked without a limp, 73% vs. 54% had normal extension, and 43% vs. 25% had normal flexion. An MUA within 3 months after unrestricted KA TKA provided excellent FJS and OKS at final follow-up relative to a late MUA. A late MUA performed after 3 months is worth consideration because of the good FJS and OKS scores, albeit with a risk of a persistent limp and limitation in knee extension and flexion. KW - reoperation KW - revision KW - implant survival KW - forgotten joint score KW - Oxford knee score Y1 - 2022 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-262094 SN - 2075-4426 VL - 12 IS - 2 ER - TY - THES A1 - Erdogan, Ilknur T1 - Evaluation der unterschiedlichen Therapieoptionen beim Rezidiv eines Nebennierenkarzinoms T1 - The role of surgery in the management of recurrent adrenocortical carcinoma N2 - Rezidive eines Nebennierenkarzinoms sind trotz vermeintlich kompletter Tumorresektion im Verlauf der Tumorerkrankung häufig. In der Literatur ist der Stellenwert einer Rezidivoperation bis dato jedoch nicht gut untersucht. Daher wurde in dieser retrospektiven Studie aus den Daten des Deutschen Nebennierenkarzinom-Registers der Einfluss der unterschiedlichen Behandlungen eines Rezidivs auf den weiteren Erkrankungsverlauf bei 154 Patienten untersucht, die nach makroskopisch kompletter Resektion des Primarius im Verlauf ein Rezidiv entwickelt hatten. Das progressionsfreie Überleben und das Gesamtüberleben nach dem Rezidiv wurden mittels Kaplan-Meier-Methode ermittelt. Prognosefaktoren wurden mit Hilfe von der Cox-Regressionsanalyse berechnet. Insgesamt wurden 101 Patienten am Rezidiv operiert und 99 Patienten haben (teils zusätzlich) eine medikamentöse Therapie erhalten. Im Laufe der Nachsorge kam es bei 144 (94%) Patienten zu einem Rezidiv bzw. Tumorprogress (im Median nach einer Zeitspanne von 6 Monaten (1-144 Monate)). In der multivariaten Cox-Regressionsanalyse wurden als Prognosefaktoren Alter, Zeitspanne bis zum Rezidiv, Lokalisation, Anzahl der Läsionen, der Resektionsstatus bei der Rezidivoperation und zusätzliche Therapien einbezogen. Hierbei zeigte sich, dass nur zwei Faktoren unabhängig von den anderen einen signifikanten Einfluss auf die Prognose hatten: die Zeitspanne bis zum ersten Rezidiv und der Resektionsstatus der Rezidivoperation. So hatten Patienten, deren Rezidiv mehr als 12 Monate nach der Erstoperation auftrat ein deutlich niedrigeres adjustiertes Risiko für ein erneutes Rezidiv bzw. Progress als Patienten mit einem früheren Rezidiv (HR 0,56 (95% CI 0,39-0,79); p<0.001). Ähnlich war das Rezidivrisiko bei den Patienten, bei denen eine komplette Resektion erzielt werden konnte deutlich geringer als bei den nicht operierten nur medikamentös behandelten Patienten (HR 0,40 (95% CI 0,17-0,92); p=0,031). Bezüglich des Überlebens nach dem Rezidiv war die Risikoreduktion dieser zwei Prognosefaktoren noch deutlicher: War die Zeitspanne bis zum ersten Rezidiv über 12 Monate, lag die Hazard Ratio für den Nebennierenkarzinom-bedingten Tod bei 0,31 (95% CI 0,20-0,47; p<0,001) und bei der R0-Resektion bei 0,33 (95%CI 0,11-0,96; p=0,042), so dass hier jeweils das Risiko, am NN-Ca zu versterben, um ca. 70% reduziert war. In der homogeneren Subgruppenanalyse aller potentiell resektablen Patienten (n=68) zeigte sich in der multivariaten Auswertung ein ähnliches Ergebnis. Eine RX/R1-Resektion wies im Vergleich zur R0-Resektion ein 2-fach und eine R2-Resektion ein 3-fach höheres Risiko eines erneuten Rezidivs auf. Eine R2-Resektion erhöhte das Sterberisiko durch das Tumorleiden um das 2,8-fache. Die mit Abstand beste Prognose hatten die Patienten, die ihr erstes Rezidiv später als 12 Monate nach der Erstoperation entwickelten und dann komplett reseziert (R0-Resektion) werden konnten. Diese 22 Patienten hatten ein medianes progressionsfreies Überleben von 24 Monate (3-220 Monate) und ein medianes Gesamtüberleben von 58 Monaten (18-220 Monaten). 5 Patienten davon waren zum Zeitpunkt der aktuellen Analyse sogar noch rezidivfrei. Schlussfolgernd lässt sich sagen, dass in der vorliegenden Arbeit die beiden aussagekräftigsten Prädiktoren für die Prognose nach Rezidiv die Zeitspanne bis zum Rezidiv und die komplette Resektabilität sind. Unsere Daten legen nahe, dass Patienten mit Spätrezidiv eine Rezidiv-Operation erhalten sollten, wenn präoperativ eine vollständige Resektion möglich erscheint. Wenn sich ein Frührezidiv (<12 Monate) entwickelt oder eine in-sano-Resektion präoperativ nicht möglich erscheint, profitieren diese Patienten von einer Rezidiv-Operation wahrscheinlich eher nicht. N2 - Context: Even though surgery is most commonly considered as treatment of first choice for localized adrenocortical carcinomas, its role for recurrent disease has not been well defined. Objective: Our aim was to evaluate the clinical outcome after surgery for recurrence. Design: We performed a retrospective analysis of 154 patients with first recurrence after initial radical resection from the German Adrenocortical Carcinoma Registry. Main outcome measures: We applied the progression-free survival (PFS) and the overall survival (OS) method according to Kaplan-Meier and we identifed prognostic factors according to Cox’s regression analysis. Result: 101 patients received repeated surgery (radical resection, n = 78), while 99 obtained (additional) non-surgical therapy. After a median of 6 (1-221) months progression was observed in 144 patients (94%). Multivariate analysis adjusted for age, number of tumoral lesion, time to first recurrence (TTFR), surgery for recurrence (including resection status), and additional therapy indicated that only two factors were significantly associated with longer PFS: TTFR and surgery for recurrence. Hazard ratio for progression: for TTFR > 12 months, 0,56 (95% confidence interval = 0,39-0,79) vs. TTFR ≤ 12 months; for microscopically complete (R0)-resection 0,40 (0,17-0,92) vs. no surgery. As far as OS is concerned, the following two prognostic factors appear to be more distinctive: Hazard ratio for death: for TTFR > 12 months, 0,31 (0,20-0,47) vs. TTFR ≤ 12 months; for R0-resection, 0,33 (0,11-0,96) vs. no surgery. The sub-analysis, which retrospectively regarded patients potentially amenable to radical resection (n=86) revealed similar results: RX/R1-resection showed a 2-fold and R2-resection a 3-fold risk for tumor progression vs. R0-resection. The mortality risk was 2,8-fold higher following a R2-resection as opposed to a R0-resection. Patients fulfilling both criteria, TTFR over 12 months and R0-resection of recurrent tumors (n = 22), seem to have had the best prognosis (median PFS, 24 months; median OS, 58 months). Conclusions: TTFR over 12 months and R0-resection are the best prognostic factors for prolonged survival after first recurrence. Our data suggest that patients with longer TTFR and tumors amenable to radical resection should be recommended surgery, while individualized treatment planning is advisable for patients with shorter TTFR or with incomplete resectable tumors. KW - Nebennierenkarzinom KW - Rezidiv KW - Reoperation KW - Prognosefaktoren KW - ACC KW - adrenal cortical carcinoma KW - recurrence KW - reoperation KW - prognostic factors Y1 - 2012 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-78506 ER -