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Surgical Technology International XXIII contains 44 articles with color illustrations.

 

Universal Medical Press, Inc.

San Francisco, September, 2013

ISBN: 1-890131-19-9

 

1 year Institutional Subscription 

both electronic and print versions.

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Sections

Orthopaedic Surgery

 

Modern Dual-mobility Cup Implanted with an Uncemented Stem: About 100 Cases with 12-year Follow-up

Rémi Philippot, MD, PhD, Assistant Professor of Orthopaedic Surgery, Jean Francois Meucci, MD, Assistant of Orthopaedic Surgery, Bertrand Boyer, MD, Assistant of Orthopaedic Surgery, Frederic Farizon, MD, Professor of Orthopaedic Surgery

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PMID: 23686801

Abstract

We report the results of a 12-year follow-up retrospective series of 100 total hip arthroplasties using cementless, press-fit, dual-mobility acetabular cups. The aim of our study was to evaluate the clinical and radiographic results of this acetabular cup at last follow-up. This continuous and homogeneous series included 100 primary total hip arthroplasties performed during the year 2000. The THA combined a Corail® stem (Corail®, Depuy, Warsaw, IN) with a stainless steel Novae Sunfit® (Serf, Decines, France) acetabular cup. Fifteen patients died and 2 were lost to follow-up. Two cases of early dislocation were observed, and 3 cases of aseptic loosening of the acetabular component were reported. The mean stem subsidence was 0.71 mm, the mean craniopodal acetabular migration was 1.37 mm, and the mean medio-lateral acetabular migration was 1.52 mm.
The 12-year survivorship is comparable to the data from the literature. The low dislocation rate at 12 years confirms the long-term, high stability of dual mobility, which should be recommended in primary THA for patients at risk for postoperative instability. The absence of true intraprosthetic dislocation events at 12-year follow-up provides evidence of the good quality of the latest generation of polyethylene liners and the necessity of combining thin-mirror, polished femoral necks with dual-mobility cups.

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Imaging of Periprosthetic Infection

Fiona Carty, MD, FFRRCSI, Consultant Radiologist, Department of Radiology, Mater Misercordiae University Hospital, Dublin, Ireland, Anne Walsh, MD, Radiology Resident, Department of Radiology, Mater Misercordiae University Hospital, Dublin, Ireland, James Patrick Cashman, MD, FRCS, Consultant Orthopaedic Surgeon, Department of Orthopaedics, Mater Misercordiae University Hospital, Dublin, Ireland

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PMID: 23700179

Abstract

Periprosthetic infection is one of the most challenging and difficult complications in orthopaedics. It can result in significant patient distress and disability, with repeated surgeries, increased cost and utilization of medical resources, and in rare cases even mortality. The biggest challenge to date is the correct diagnosis of periprosthetic infection and implementation of effective treatment regimens capable of eradicating the organism. This article reviews the various modalities used in the imaging of periprosthetic and post-arthroplasty infection.

 

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Does Surgical Approach in Total Hip Arthroplasty Affect Rehabilitation, Discharge Disposition, and Readmission Rate?

Mark L. Schweppe, MD, Resident, Thorsten M. Seyler, MD, Resident, Johannes F. Plate, MD, Resident, Richard D. Swenson, MD, Jason E. Lang, MD, Assistant Professor and Residency Program Director, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina

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PMID: 23700180

Abstract

There is a substantial preoccupation with different surgical approaches and minimally invasive techniques that may improve clinical outcomes for patients who undergo total hip arthroplasty. This study assessed the impact on hospital-related outcomes of the direct anterior approach (DAA) compared with the posterior approach (PA) performed by a single surgeon in 100 consecutive patients in each cohort. Patient age was similar in the DAA (61 ± 1.1 years) compared with the PA (62 ± 1.3, p = 0.733); however, BMI tended to be lower in DAA patients (29.1 ± 0.8) compared with PA patients (31.3 ± 0.7, p = 0.057). The DAA compared with the PA was associated with significantly less blood loss (285 ± 15 vs. 367 ± 21ml, p = 0.002) and transfusions (18 vs. 39 units, p = 0.009), less narcotic usage on postoperative days 1-3 (101 ± 12 vs. 146 ± 12 morphine equivalent dose, p = 0.010), a quicker hospital discharge (70 ± 3.3 vs. 97 ± 5.5 hours, p < 0.001), and a more favorable disposition (97% vs. 84% discharged home, p = 0.003). Thirty-day readmission rate was significantly higher with the PA (9%) compared with the DAA (1%, p = 0.030). The number of cups in the safe zone (5° to 25° anteversion and 30° to 50° inclination) was significantly higher with the DAA (92%) compared with the PA (75%, p = 0.002), possibly attributed to fluoroscopy used with the DAA. The DAA muscle-preservation technique may have led to the benefits observed in this study compared with the muscle-splitting technique associated with the PA.

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Computer Tomography Prototyping and Virtual Procedure Simulation in Difficult Cases of Hip Replacement Surgery

Paolo Domenico Parchi, MD, Consultant Orthopaedic Surgeon, 1st Orthopaedic Department, University of Pisa, Pisa, Italy,  Vincenzo Ferrari , Engineer, Technical/Scientific Coordinator, EndoCAS Center for Computer Assisted Surgery, University of Pisa, Pisa, Italy, Nicola Piolanti, MD, Consultant Orthopaedic Surgeon, 1st Orthopaedic Department, University of Pisa, Pisa, Italy, Lorenzo Andreani, MD, Resident, 1st Orthopaedic Department, University of Pisa, Pisa, Italy, Sara Condino, Engineer, Researcher, EndoCAS Center for Computer Assisted Surgery, University of Pisa, Pisa, Italy, Gisberto Evangelisti, MD, Resident, 1st Orthopaedic Department, University of Pisa, Pisa, Italy, Michele  Lisanti, Professor of Orthopaedic Surgery, Chief of the 1st Orthopaedic Department of Pisa, University of Pisa, Pisa, Italy

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PMID: 23975443

Abstract

Each year approximately 1 million total hip replacements (THR) are performed worldwide. A percentage of failure due to surgical approach and imprecise implant placement still exists. These result in several serious complications. We propose an approach to plan, to simulate, and to assist prosthesis implantation for difficult cases of THR based on 3-D virtual models, generated by segmenting patients’ CT images, 3-D solid models, obtained by rapid prototyping (RP), and virtual procedure simulation. We carried out 8 THR with the aid of 3-D reconstruction and RP. After each procedure a questionnaire was submitted to the surgeon to assess the perceived added value of the technology. In all cases, the surgeon evaluated the 3-D model as useful in order to perform the planning. The clinical results showed a mean increase in the Harris Hip Score of about 42.5 points. The mean time of prototyping was 7.3 hours, (min 3.5 hours, max 9.3 hours). The mean surgery time was 65 minutes (min 50 minutes, max 88 minutes). Our study suggests that meticulous preoperative planning is necessary in front of a great aberration of the joint and in absence of normal anatomical landmarks, CT scan is mandatory, and 3-D reconstruction with solid model is useful.

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Reversed Assembly of Total Hip Arthroplasty Components: A Surgical Tip to Facilitate Implant Reduction During Minimally Invasive Surgery

Yona Kosashvili, MD, Consultant Orthopaedic Surgeon, Specialist in Adult Hip and Knee Arthroplasty and Reconstruction, Division of Arthroplasty, Orthopaedic Department, Rabin Medical Centre, Beilinson Campus, Petach Tikva, Israel, Amir Arami, MD, Resident, Orthopaedic Surgery, Division of Arthroplasty, Orthopaedic Department, Rabin Medical Centre, Beilinson Campus, Petach Tikva, Israel, Snir Heller, MD, Consultant Orthopaedic Surgeon, Division of Arthroplasty, Orthopaedic Department, Rabin Medical Centre, Beilinson Campus, Petach Tikva, Israel, Steven Velkes, MD, Consultant Orthopaedic Surgeon, Specialist in Adult Hip and Knee Arthroplasty and Reconstruction, Head of Orthopaedic Department, Rabin Medical Centre, Beilinson Campus, Petach Tikva, Israel, Jeffery Gollish, MD, FRCSC, Consultant Orthopaedic Surgeon, Specialist in Adult Hip and Knee Arthroplasty and Reconstruction, Holland Orthopaedic and Arthritic Centre, Toronto, Ontario, Canada

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PMID: 23700181

Abstract

Total hip arthroplasty (THA) using minimally invasive surgery (MIS) can result in soft tissue damage during the trial reduction and actual implantation. We present a surgical technique that reduces soft tissue trauma and facilitates implant reduction while protecting the prosthetic head from scratching during MIS THA. Primary THA using MIS was performed in 16 hips through a transgluteul direct lateral approach. Average follow-up was 54 months (range 52-58 months). At latest follow-up there was no evidence for component dissociation or loosening in any of the patients.
Reverse assembly of THA components is a viable option, which may facilitate MIS THA and decrease soft tissue trauma.

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Primary Total Hip Arthroplasty with a Tapered Trabecular Metal™ Coated Femoral Component: Experience with a Minimum 24-Month Follow-up

Nemandra A. Sandiford, MRCS, Fellow, The London Hip Unit, London, England, John A. Skinner, FRCS, Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital, Stanmore, Middlesex, England, Sarah K. Muirhead-Allwood, FRCS, Consultant Orthopaedic Surgeon, The London Hip Unit, London, England, The Royal National Orthopaedic Hospital, Stanmore, Middlesex, England

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PMID: 23860934

Abstract

We prospectively reviewed the clinical and radiological outcome of the first 32 patients (32 hips) undergoing primary total hip arthroplasty using a Trabecular Metal™ coated tapered femoral component. Seventeen males and 15 females were included. Average age was 71.6 years (range 61.5–85 years). Mean duration of follow-up was 34 months (range 24–48 months) Average preoperative Oxford, Harris, and WOMAC scores were 34, 51, and 44, respectively. Mean postoperative scores were 18, 82, and 11, respectively (P < 0.001 for all scores). All patients reported relief of preoperative pain. There were no revisions. These results suggest that the Trabecular Metal™ taper femoral component successfully relieves pain and leads to a significant functional improvement in patients with symptomatic hip arthritis in the early postoperative period.

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Long-Term Results of Femoral Revision With the Wagner Self-Locking Stem
Dario Regis, MD, Assistant Professor of Orthopaedics, Department of Orthopaedic and Trauma Surgery, Integrated University Hospital, Verona, Italy, Andrea Sandri, MD, Assistant Professor of Orthopaedics, Department of Orthopaedic and Trauma Surgery, Integrated University Hospital, Verona, Italy, Ingrid Bonetti, MD, Orthopaedic Surgery Resident, Department of Orthopaedic and Trauma Surgery, Integrated University Hospital, Verona, Italy,

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PMID: 24081844

Abstract

Femoral revision total hip arthroplasty may be a complex procedure due to extensive periprosthetic bone loss. Fluted, tapered stems provide secure axial and rotational stability in the distal femur. We retrospectively evaluated the long-term outcome of the cementless Wagner Self-Locking prosthesis (Sulzer Orthopedics Ltd, Winterthur, Switzerland). From 1992 to 1998, 68 consecutive femoral revisions were performed in 66 patients using the Wagner tapered stem. Twenty-five patients deceased for unrelated causes without additional surgery. The studied group consisted of 41 hips in 41 patients, 12 males and 29 females, aged from 29 to 80 years (mean 61 years). Thirty-five hips (85.4%) included severe deficiency of bone stock. A transfemoral approach was carried out in 32 cases (78%). Bone grafting was never supplemented. Average follow-up was 13.9 years (range 10.4 to 15.8 years). Clinical evaluation was performed using Harris Hip Score (HHS). Osseointegration of the stem and progression of periprosthetic bone remodelling were assessed radiographically. Five stems required rerevision because of deep infection (2), progressive subsidence (2) complicated by hip instability and head-neck disassembly, and old dislocation following acetabular component failure (1). Four hips (9.7%) dislocated, and 8 stems (19.5%) subsided significantly. Average HHS improved from 33 points preoperatively to 75 points at the latest follow-up examination (p < 0.001). Thirty-three of the 36 unrevised stems (91.7%) had radiographic evidence of bone ingrowth. A constant or decreased resorption of the femoral bone was detected in 34/36 patients (94.4%). The cumulative survival rates at 15.8 years with femoral revision for any reason and for stem failure as the end points were 92.0% and 96.6%, respectively. The current study documents the efficacy of distal fixation to the diaphysis in revision of bone-deficient femoral components, supporting the use of tapered, fluted stems. Higher-risk complications (dislocation, subsidence) should be minimized by the development of modular stems.

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The Silicone Ring Tourniquet in Orthopaedic Operations of the Extremities

Georgios I. Drosos, MD, PhD, Assistant Professor of Orthopaedics, Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece, Athanasios Ververidis, MD, PhD, Assistant Professor of Orthopaedics, Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece, Rodion Mavropoulos, MD, Trainee in Orthopaedics, Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece, Georgios Vastardis, MD, Orthopaedic Surgeon, Research and Clinical Fellowship on Spine, Loyola University Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, Musculoskeletal Biomechanics Laboratory, Department of Veterans Affairs, Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, Konstantinos I. Tsioros, MD, Orthopaedic Surgeon, Athens Naval Hospital, Athens, Greece, Konstantinos Kazakos, MD, PhD, Associate Professor of Orthopaedics, Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece

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PMID: 23860930

Abstract

Tourniquets provide a bloodless field in limb operations and their introduction in orthopaedic operative technique has been considered as a landmark. A new tourniquet device, a silicone ring tourniquet (SRT) (HemaClear or S-MART, OHK Medical Devices, Haifa, Israel), was introduced into clinical practice a few years ago. A few clinical studies as well as comparative studies in volunteers have reported its use in a relatively small number of cases.
The aim of this prospective study is to report the clinical use of this device in a large number of patients, including all possible applications of a tourniquet. The SRT was used in 536 cases including 337 male and 119 female patients with a mean age of 43.7 years (range 6 to 87 years). The average tourniquet time was 58.5 minutes (range 6 to 180 minutes). It was applied in 362 (67.5%) elective and in 174 (32.5%) trauma cases including fractures (n:109, 62.6%) and soft-tissue injuries (n:65, 37.4%). The most frequent application site was the femur (n:255, 47.6%), followed by the forearm (n:154, 28.7%), humerus (n:65, 12.1%), and calf (n:62, 11.6%).
Because the device is sterile it was possible to use it in operations in which the pneumatic tourniquet cannot be used, such as open reduction and internal fixation of humeral shaft and femoral supracondylar fractures. In 14 patients (2.6%), the tourniquet failed intraoperatively, and the cause was an unexpected raised blood pressure. The SRT - with a pre-set pressure according to the size and the tension model - is easy to apply. It is sterile, and occupies a narrow area of the limb. Its application combines three functions at the same time: exsanguination, tourniquet, and stockinet application. Although it cannot entirely replace the classic pneumatic tourniquet, it is a safe and useful device in orthopaedic operations because of its advantages.

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Assessing Leg Lengths Intra-operatively in Total Hip Arthroplasty: Comparison of Two Methods

Akshay Mehra, FRCS (Tr&Orth), Alexandra Hospital, UK, Birmingham, UK, Zachary Morison M.Sc, St. Michael’s Hospital, Toronto, Canada, Emil Schemitsch MD, FRCSC, St. Michael’s Hospital, Toronto, Canada, James Waddell MD, FRCSC, St. Michael’s Hospital, Toronto, Canada, , St. Michael’s Hospital, Toronto, Canada, 30 Bond Street, Toronto, Ontario

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PMID: 24081845

Abstract

Leg length discrepancy post total hip arthroplasty surgery is common. Unequal leg lengths after total hip arthroplasty is the single most common reason for litigation against orthopaedic surgeons. Different methods for leg length assessment are used intraoperatively by surgeons, but no one method is 100% reliable and reproducible. The aim of this study was to compare 2 methods of intraoperative leg length assessment. Leg length discrepancy of 5 mm or less was achieved in 72.5% (37/51) of patients using method 1 and in 67% (34/51) of patients using method 2. Both methods assessed produced a discrepancy of greater than 5 mm in about a quarter of the patients. The difference was not found to be statistically significant (p < 0.05). Assessment of leg lengths intraoperatively is challenging even for experienced surgeons. The leg lengths may be better restored if more than one method of assessment is used during surgery.

 

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Preoperative Blood Management , Strategies for Total Hip Arthroplasty
Jeffrey J. Cherian, DO, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Bhaveen H. Kapadia, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Kimona Issa, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Samik Banerjee, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Vincent K. McInerney, MD, Seton Hall University, Director of the Department of Orthopaedics, Saint Joseph Regional Medical Center, Paterson, New Jersey, Steven F. Harwin, MD, Beth Israel Medical Center, Director of Adult Reconstruction and Total Joint Replacement Service, New York, New York, Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland

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PMID: 24085509

Abstract

Total hip arthroplasty is associated with marked blood loss, with the potential for up to 90% of patients requiring allogeneic transfusions. Also, perioperative-induced anemia is associated with lower postoperative functional scores, increased mortality, increased cardiovascular risks, longer hospital stays, and postoperative infections. The purpose of this review was to analyze the recent evidence on preoperative blood management strategies utilized for total hip arthroplasty. Specifically, we evaluated the use of preoperative iron therapy, intravenous erythropoietin, and autologous blood donation. No single strategy was shown to be superior over another in reducing the need for allogeneic transfusions; however, a combination of these blood management strategies may result in improved blood loss outcomes. Larger prospective randomized studies comparing the individual strategies, as well as combination therapies, are needed to develop a concise statement on the most effective and efficient preoperative blood management treatment algorithms for total hip arthroplasty.

 

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Molnlycke
Richard Wolf