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Surgical Technology International XXVI contains 50 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
2015 - ISSN:1090-3941
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Orthopaedic Surgery
What’s New in Venous Thromboembolic Prophylaxis Following Total Knee and Total Hip Arthroplasty? An Update
Todd P. Pierce, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Randa K. Elmallah, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Julio J. Jauregui, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Jeffrey J. Cherian, DO, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Director of the Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
643
Venous thromboembolic disease (VTED) (deep venous thrombosis and pulmonary embolism) is a considerable source of morbidity and mortality following lower extremity total joint arthroplasty. The purpose of this review was to: (1) evaluate the most recent updated guidelines on thromboprophylaxis; and to (2) provide an overview and update of current modalities of VTED prophylaxis, such as pharmacological agents and mechanical compression. Although the AAOS and ACCP guidelines have not changed since the last review, the SCIP guidelines have focused on implementing the concepts proposed by each of these organizations. Specifically, the use of aspirin has been highlighted as an acceptable chemoprophylactic agent. Warfarin and low molecular weight heparin remain widely used, but maintaining therapeutic levels of warfarin remains a challenge, and LWMH has not shown itself to be superior to any of the other chemoprophylactic agents. The newer oral anticoagulants, such as factor Xa inhibitors and direct thrombin inhibitors, may have superior efficacy, but their safety profile must be studied further. Additionally, the use of mechanical prophylaxis continues to rise in popularity because of their ability to minimize bleeding complications. Future research should emphasize the development of prophylactic modalities that maximize efficacy while minimizing the risk of adverse events.
A Review of Ligament Augmentation with the InternalBrace™: the Surgical Principle Is Described for the Lateral Ankle Ligament and ACL Repair in Particular, and a Comprehensive Review of Other Surgical Applications and Techniques is Presented
Gordon M. Mackay, MD, FRCS, FFSEM, Professor, University of Stirling, Stirling, Scotland, Mark J.G. Blyth, MBChB, FRCS, Consultant Orthopaedic Surgeon, Glasgow Royal Infirmary, Glasgow, Scotland, Iain Anthony, PhD, Clinical Research Manager, Glasgow Royal Infirmary, Glasgow, Scotland, Graeme P. Hopper, MBChB, MSc, MRCS, Specialty Registrar, West of Scotland Orthopaedics, Glasgow, Scotland, William J. Ribbans, PhD, FRCS, FFSEM, Professor, University of Northampton, Northampton, England
620
This article reviews the surgical decision-making considerations when preparing to undertake an anatomic ligament repair with augmentation using the InternalBrace™. Lateral ankle ligament stabilization of the Broström variety and ACL repair in particular are used to illustrate its application. The InternalBrace™ supports early mobilization of the repaired ligament and allows the natural tissues to progressively strengthen. The principle established by this experience has resulted in its successful application to other distal extremity ligaments including the deltoid, spring, and syndesmosis complex. Knee ligament augmentation with the InternalBrace™ has been successfully applied to all knee ligaments including anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), anterolateral ligament (ALL), and patellofemoral ligament (PFL). The surgical technique and early results will be reviewed including multi-ligament presentations. Upper limb experience with acromioclavicular (AC) joint augmentation and ulnar collateral ligament (UCL) repair of the elbow with the InternalBrace™ will also be discussed. This article points to a change in orthopaedic practice positioning reconstruction as a salvage procedure that has additional surgical morbidity and should be indicated only if the tissues fail to heal adequately after augmentation and repair.
Repeat Manipulation Under Anesthesia For Persistent Stiffness After Total Knee Arthroplasty Achieves Functional Range of Motion
Jason R. Ferrel, MD, PGY-4 Orthopedic Surgery Resident, Department of Orthopedic Surgery, Mount Carmel Health System, Columbus, Ohio, Richard L. Davis II, MD, PGY-4 Orthopedic Surgery Resident, Department of Orthopedic Surgery, Mount Carmel Health System, Columbus, Ohio, Obiajulu A. J. C. Agha, BS, Research Intern, Department of Orthopedic Surgery, The Cardinal Orthopedic Institute/Orthopedic One, Columbus, Ohio, Joel R. Politi, MD, Orthopedic Surgeon, Department of Orthopedic Surgery, Mount Carmel Health System, The Cardinal Orthopaedic Institute/Orthopedic One, Columbus, Ohio
626
Poor range of motion may decrease a patient’s ability to participate in activities of daily living after total knee arthroplasty. Manipulation under anesthesia has been shown to improve range of motion; however, some patients have persistent stiffness even after manipulation. The goal of this study was to evaluate the outcomes and complications of patients who underwent a second manipulation under anesthesia for persistent stiffness after total knee arthroplasty. The review of surgical records of two joint arthroplasty surgeons identified 226 knees in 210 patients who underwent a manipulation under anesthesia for poor range of motion after total knee arthroplasty. Of these patients, 16 patients underwent a second manipulation under anesthesia. For patients undergoing two manipulations under anesthesia procedures, at latest follow up (mean 539 days), mean extension improved from 10.50° to 2.50° (p=0.001) and mean flexion improved from 87.50° to 112.69° (p=0.001) respectively. SF-12 scores were available for 12 of 16 knees with a mean score of 34.42. Two of 16 patients (12.5%) experienced a complication. Three of 16 (18.8%) patients who underwent a second manipulation required a revision arthroplasty procedure. In conclusion, a second manipulation under anesthesia can achieve functional range of motion that is sustained after total knee arthroplasty.
The Use of an Electronic System for Soft Tissue Balancing in Primary Total Knee Arthroplasties: Clinical and Radiological Evaluation
Fabio D’Angelo, MD, Associate Professor, Division of Orthopedics and Traumatology, Department of Biotechnology and Life Sciences, University of Insubria , Varese, Italy, Marco Puricelli, MD, Resident, Division of Orthopedics and Traumatology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy, Tommaso Binda, MD, Orthopedic Surgeon, Division of Orthopedics and Traumatology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy, Michele Francesco Surace, MD, Associate Professor, Division of Orthopedics and Traumatology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy, Chiara Floridi, MD, Radiologist, Department of Radiology, University of Insubria, Varese, Italy, Paolo Cherubino, MD, Full Professor and Chief, Division of Orthopedics and Traumatology, Department of Biology and Life Sciences, University of Insubria, Varese, Italy
545
The eLibra® Dynamic Knee Balancing System (Synvasive Technology, Zimmer, Warsaw, IN) is an instrument designed to address the flexion stability during a TKA. It provides an objective measurement of the soft-tissue forces in the two compartments before the final cuts are made, allowing to obtain patient-specific rotational orientation of the femoral component. Between March 2010 and March 2012, the eLibra® system was used during the implantation of 75 TKAs in 75 patients at the author’s institution. Preoperative and postoperative clinical assessment were evaluated using the Knee Society Score (KSS) and the Visual Analogical Scale (VAS). Radiographic evaluation was performed with weight-bearing radiographs in antero-posterior and lateral views in order to study the presence of radiolucencies. In a sample of 20 patients, representative of the population studied, the rotation of the femoral component was measured by two independent observers using the C-arm Cone Beam CT scan (XperCT/Allura FD20 angiography system; Philips, Best, Netherlands). At a mean follow-up of 42.3 months (29–54 months), three patients died from causes not related to the surgery. We had one case of aseptic loosening three years after surgery. None of the patients reported complications peri- or postoperatively. Clinical evaluation showed an improvement in KSS scoring, from preoperative means of 48.35 and 47.53 points for clinical and functional aspects, respectively, to postoperative means of 88.03 and 91.2 points, respectively (p< 0.001 for both aspects). The current study demonstrates that the use of the eLibra® device is simple and reproducible. It could help surgeons objectively quantify ligament balance and perform soft tissue-guided resection in a reproducible way, resulting in better post-operative stability and reduced complications. The use of the postoperative cone beam computed tomography (CBCT), in a representative sample of patients, revealed a specific and optimal orientation of the femoral component with a mean of 2.18° of external rotation.
What Outcome Metrics Do the Various Knee Rating Systems for Assessment of Outcomes Following Total Knee Arthroplasty Measure? A Systematic Review of Literature
Michael A. Mont, MD, Director, 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, Julio J. Jauregui, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, 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
599
Multiple scoring systems have been developed for the assessment of outcomes following total knee arthroplasty. However, few studies have comprehensively evaluated each scoring system to analyze the various outcome variables and their individual weightings toward generations of the final score. A systematic search of four electronic databases were performed from January 1960 to August, 2013 to identify studies that reported on knee scores and to sub-categorize the outcomes measured based on subjective, objective, rehabilitative, and quality of life outcomes. We also evaluated the outcome metrics that each of these systems measured to identify the relative impact of these variables toward the final score. We identified 45 different outcome metrics in 46 rating scales. Pain (80%), stiffness (13%), and swelling (13%) were the three most common subjective outcomes measured in the scoring systems, while measurements of range-of-motion (57%), flexion contracture (39%), and coronal plane deformity (35%) were the most often reported objective outcome variables. Of all the variables measured, we found that pain (mean weighted score, 26 points; range, 0 to 50 points), range-of-motion (mean weighted score, 11 points; range, 0 to 50 points), distance walked (mean weighted score, 7 points; range, 0 to 30 points), ability to climb stairs (mean weighted score, 6 points; range, 0 to 20 points), ability to rise from sitting position (mean weighted score, 4 points; range, 0 to 20 points), and presence of a flexion contracture (mean weighted score, 4 points, range, 0 to 20 points) had the greatest impact on the final score standardized to 100 points. Currently, few rating scales exist that assess all aspects of functional, rehabilitative, and quality of life outcomes including patient satisfaction within the realms of a single scoring system. Further research is needed to determine the optimal combination and weightings of the individual outcomes metrics to better evaluate overall outcomes following total knee arthroplasty and to develop a more comprehensive scoring system.
Groin Pain in Athletes: A Review of Diagnosis and Management
Matthew Crockett, MB, MChir, Radiology Resident, Mater Misercordiae University Hospital, Dublin, Ireland, Emily Aherne, MB, BCh, Radiology Resident, Mater Misercordiae University Hospital, Dublin, Ireland, Michael O’Reilly, MB, BCh, Radiology Resident, Mater Misercordiae University Hospital, Dublin, Ireland, Gavin Sugrue, MB, BCh, Radiology Resident, Mater Misercordiae University Hospital, Dublin, Ireland, James Cashman, MB, BCh, FRCS,
Consultant Orthopaedic Surgeon, Mater Misercordiae University Hospital, Dublin, Ireland, Eoin Kavanagh, MB, BCh, FFRRCSI, Professor of Radiology, Mater Misercordiae University Hospital, Dublin, Ireland
604
Introduction: Groin pain is a common symptom in athletes, particularly in sports requiring sudden changes in speed and direction and those involving kicking. Despite a high prevalence of groin pain in this patient cohort, the diagnosis and management of the underlying pathological processes remains a challenge for surgeons and radiologists alike. Aim: The aim of this paper is to review the imaging findings and management of the common pathological processes which produce groin pain in athletes. Materials and Methods: The anatomy of the groin region will be defined as a basis for further discussion. The common pathological processes underlying groin pain such as adductor dysfunction, rectus abdominus injury, osteitis pubis, and femuro-acetabular impingement will then be reviewed and correlating radiological imaging findings presented. Current management options will also be considered. Conclusion: This paper will aid surgeons and radiologists in navigating the challenging diagnostic and management dilemma of groin pain in athletes.
Robotic-Arm Assisted Surgery in Total Hip Arthroplasty
Randa K. Elmallah, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Baltimore, MD, Jeffrey J. Cherian, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Baltimore, MD, Julio J. Jauregui, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Baltimore, MD, David A. Padden, MD, Attending Physician, Holy Cross Med Group, Lighthouse Point, FL, Steven F. Harwin, MD, FACS, Chief of Adult Reconstructive Surgery, Mount Sinai Hospital, New York, NY, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD
609
Complications following total hip arthroplasty (THA), such as dislocation, component loosening and wear, continue to be common indications for revision surgery. Multiple studies have attributed some of these problems to poor acetabular cup alignment and placement outside of the purported radiographic safe zone. In addition, it has been shown that conventional manually performed acetabular cup placement may not lead to optimal alignment, regardless of surgical experience. Additionally, incorrect leg length and offset can lead to dissatisfaction and instability. Therefore, robotic-arm assisted surgery has been introduced to improve accuracy of cup placement and leg length, and to offset with the aim of reducing the risk of hip instability and improving satisfaction after primary THA. Our aim was to prospectively review the use of robotic-arm assisted surgery in 224 patients and to assess whether the pre-operatively determined radiographic targets were achieved post-operatively and the proportion of acetabular cups outside of the safe zone. Pre-determined anteversion and inclination were 15 and 40 degrees, respectively. Our results have shown that the use of robotic-arm assisted surgery resulted in a post-operative mean inclination of 40 degrees (range, 34 to 51 degrees) and a mean anteversion of 16 degrees (range, 9 to 25 degrees). Ninety-nine percent of the patients remained within the pre-designated safe zone. Evidence has shown that robotic-arm assisted surgery may have improved accuracy in cup placement when compared to conventional surgery and possibly to computer-assisted surgery. When compared to the literature on robotic-arm assisted surgery, our results were comparable. We believe that this surgical technique may aid in reducing post-operative THA complications, such as aseptic loosening and dislocations, but further prospective studies are needed to evaluate clinical outcomes and long-term results.
Rating Systems to Assess the Outcomes After Total Knee Arthroplasty
Julio J. Jauregui, 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, Jeffrey J. Cherian, DO, Research Fellow,
Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Randa DK Elmallah, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD,
Director, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
611
Introduction: To assess the success of a total knee arthroplasty (TKA), scoring systems have been developed to provide a straightforward method of evaluating the outcomes of patients following surgery. Fully evaluating these outcomes is a challenging and time consuming task, and these simplistic measures often do not provide a complete picture of a patient’s recovery. Therefore, we evaluated different scoring systems to determine the most effective method of assessing the outcomes of patients undergoing total knee arthroplasty. Materials and Methods: We evaluated all knee scoring systems currently available in literature, and a total of 46 questionnaires met our inclusion and exclusion criteria. We then identified all the metrics assessed in the questionnaires (n=48) and subdivided them into objective, subjective, rehabilitative, and quality of life outcome measures. We identified the three most commonly referenced questionnaires (the Knee Society Scores, the Knee Osteoarthritis and Outcomes Scores, and the Western Ontario and McMaster Score—WOMAC) and assessed multiple permutations of these with other scoring systems to identify the combinations that would most comprehensively and efficiently evaluate the outcomes of patients undergoing TKA. Results: Of the 48 metrics, we identified four subjective, eight objective, 20 rehabilitation, and 16 quality of life metrics. On permutation of the three most referenced scoring systems, the KSS and the KOOS together yielded the greatest coverage of the above metrics (79%). When the KSS, KOOS, and WOMAC, respectively, were combined with the Lower Extremity Function Scale (LEFS) and Short Form 36 (SF-36), they yielded 77, 73, and 60% coverage of the metrics and 35, 39, and 37% redundancy, respectively. Conclusion: Surgeons and researchers have attempted to fully evaluate the outcomes of patients undergoing TKA. The proposed combinations may provide a more comprehensive way to cost-effectively evaluate outcomes. Further analysis is required before attempting to create newer knee scoring systems.
Efficacy of Different Rotator Cuff Repair Techniques
Navin Gurnani, MD, Resident, Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands, Derek Friedrich Petrus van Deurzen, MD, Orthopaedic Surgeon, Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands, Mark Flipsen, MD, PhD Candidate , Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands, Eric Ernest Joseph Raven, MD, Orthopaedic Surgeon, Department of Orthopaedic Surgery, Gelre ziekenhuis, Apeldoorn, The Netherlands, Michel Pieter Jozef van den Bekerom, MD, Orthopaedic Surgeon, Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
645
The literature was searched for the different surgical techniques and additional treatment including: [1] full arthroscopic and arthroscopic assisted rotator cuff repair, [2] acromioplasty as an additional treatment to rotator cuff repair, [3] the use of plasma rich platelets (PRP) after rotator cuff repair, [4] the single and double row fixation techniques, [5] long head of the biceps brachii tenotomy or tenodesis with rotator cuff repair, [6] scaffolds in rotator cuff surgery, and [7] early motion or immobilization after rotator cuff repair. The rationale, the results, and the scientific evidence were reported for the eligible procedures.
Standardized Questionnaire Time Burden for Practitioners and Patients
Todd P. Pierce, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Randa D. K. Elmallah, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Jeffrey J. Cherian, DO, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Julio J. Jauregui, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Director, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
612
Introduction: Many questionnaires are used to assess patient-reported outcomes, but there are few studies assessing the time to complete these questionnaires. The purpose of this study was to: (1) evaluate how much time it takes to complete the most commonly used patient-reported outcome questionnaires; (2) calculate the potential variation for time of completion; and (3) assess the potential role of demographics.
Materials and Methods: After literature review, nine different questionnaires were chosen based on the frequency of citation. Each patient was given one questionnaire and time to complete was recorded. Mean times were compared and statistical analysis was performed on patients based on age ≥ 55 years, gender, and education level.
Results: The mean time of completion for each questionnaire is listed from shortest to longest: University of California Los Angeles (UCLA) activity score, Lower Extremity Activity Scale (LEAS), Hospital for Special Surgery Score (HSS), Lower Extremity Functional Scale (LEFS), Oxford Knee Score-12 (OKS-12), Knee Society Scores (KSS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Short Form-36 (SF-36), and the Knee Injury and Osteoarthritis Outcome Score (KOOS). The coefficients of variation were smallest in SF-36 and WOMAC while it was the largest in the UCLA activity score. Age of ≥ 55 years was associated with a longer time to complete the questionnaires. There was no association found between gender or education level.
Discussion: It is possible that if it takes longer to complete certain questionnaires, then the answers given may not accurately reflect the patient’s condition. Future studies should focus on the accuracy of the respondents’ answers to each questionnaire as well as the accuracy after filling out multiple questionnaires at a single patient office visit.
Constrained Implants in Total Knee Replacement
Panagiotis Touzopoulos, MD, Trainee in Orthopaedics, Georgios I. Drosos, MD, PhD, Assistant Professor of Orthopaedics, Athanasios Ververidis, MD, PhD, Assistant Professor of Orthopaedics, Konstantinos Kazakos, MD, PhD, Professor of Orthopaedics, Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
616
Total knee replacement (TKR) is a successful procedure for pain relief and functional restoration in patients with advanced osteoarthritis. The number of TKRs is increasing, and this has led to an increase in revision surgeries. The key to long-term success in both primary and revision TKR is stability, as well as adequate and stable fixation between components and underlying bone. In the vast majority of primary TKRs and in some revision cases, a posterior cruciate retaining or a posterior cruciate substituting device can be used. In some primary cases with severe deformity or ligamentous instability and in most of the revision cases, a more constrained implant is required. The purpose of this paper is to review the literature concerning the use of condylar constrained knee (CCK) and rotating hinge (RH) implants in primary and revision cases focusing on the indications and results. According to this review, although excellent and very good results have been reported, there are limitations of the existing literature concerning the indications for the use of constrained implants, the absence of long-term results, and the limited comparative studies.
Up-to-date Review and Cases Report on Chondral Defects of Knee Treated by ACI Technique: Clinical-instrumental and Histological Results
Giacomo Dell’Osso, MD, Specialist in Orthopedics and, Traumatology, Marco Ghilardi, MD, Specialist in Orthopedics and, Traumatology, Vanna Bottai, MD, Specialist in Orthopedics and, Traumatology, Giulia Bugelli, MD, Resident in Orthopedics and, Traumatology, Giulio Guido, MD, PhD, Ordinary Professor of Orthopedics and, Traumatology, Stefano Giannotti, MD, Specialist in Orthopedics and,
Traumatology,
II Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
617
The limited regenerative potential of a full thickness defect of the knee joint cartilage has certainly conditioned the development of therapeutic strategies that take into account all the aspects of the healing process. The most common treatments to repair chondral and osteochondral lesions are bone marrow stimulation, osteochondral autograft transplantation, autologous matrix-induced chondrogenesis, and autologous chondrocyte implantation. We like to emphasize the difference between a chondral and an osteochondral lesion because the difference is sometimes lost in the literature. In the context of treatment of injuries of the knee joint cartilage, the second-generation autologous chondrocyte transplant is a consolidated surgical method alternative to other techniques. Our experience with the transplantation of chondrocytes has had exceptional clinical results. We report 2 complete cases of a group of 22 in knee and ankle. These 2 cases had histological and instrumental evaluation. We cannot express conclusions, but can only make considerations, stating that, with the clinical functional result being equal, we obtained an excellent macroscopic result in both cases of second look. Autologous chondrocyte implantation (ACI) is a multiple surgical procedure with expensive chondrocyte culture, but even with this limitation, we think that it must be the choice in treating chondral lesions, especially in young patients.
Treatment of Tendon Injuries of the Lower Limb with Growth Factors Associated with Autologous Fibrin Scaffold or Collagenous Scaffold
Stefano Giannotti, MD, Specialist in Orthopedics and Traumatology, Giacomo Dell’Osso, MD, Specialist in Orthopedics and Traumatology, Vanna Bottai, MD, Specialist in Orthopedics and Traumatology, Marco Ghilardi, MD, Specialist in Orthopedics and Traumatology, Giulia Bugelli, MD, Resident in Orthopedics and Traumatology, Ilaria Lazzerini, MD, Resident in Orthopedics and Traumatology, Giulio Guido, MD, PhD, Ordinary Professor of Orthopedics and Traumatology, IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
619
Tendon injuries are an increasing problem in orthopedics as we are faced with a growing demand in sports and recreation and an aging population. Tendons have poor spontaneous regenerative capacity, and often, complete recovery after injury is not achieved. Once injured, tendons do not completely re-acquire the biological and biomechanical properties of normal tendons due to the formation of adhesions and scarring, and often these abnormalities in the arrangement and structure are risk factors for re-injury. These problems associated with the healing of tendon injuries are a challenge for clinicians and surgeons. This study examined 9 cases of subcutaneous injuries including quadriceps tendon (2 cases), patellar tendon (1 case), and Achilles tendon (6 cases), incomplete and complete, treated consecutively. The surgical technique has provided, as appropriate, the termino-terminal tenorraphy, techniques of plastics of rotation flap, reinsertion with suture anchors, and in one case tendon augmentation with cadaver tissue. In cases where we needed mechanical support to the suture, we used preloaded growth factors on porcine collagen scaffold; in cases where we needed only one biological support, we used fibrin scaffold.
Can Sequentially-irradiated and Annealed Highly Cross-linked Polyethylene Inserts Thinner than Eight-millimeters Be Utilized in Total Knee Arthroplasty?
Siraj A. Sayeed, MD, M.Eng, President, Department of Orthopaedic Surgery, South Texas Bone and Joint Institute, San Antonio, Texas, Julio J. Jauregui, MD, Orthopaedic Research Fellow, Department of Orthopaedic Surgery, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Laryssa A. Korduba, MS, Robotics Training Manager, Orthopaedic Department, Stryker Orthopaedics, Mahwah, New Jersey, Aaron Essner, MS, Director Research and Development, Orthopaedic Department, Stryker Orthopaedics, Mahwah, New Jersey, Steven F. Harwin, MD, Chief of Adult Reconstruction and Total Joint Replacement, Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New York, Ronald E. Delanois, MD, Fellowship Director, Department of Orthopaedic Surgery, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Michael A. Mont, MD, Director, Department of Orthopaedic Surgery, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
644
The routine use of highly cross-linked ultra-high molecular weight polyethylene (UHMWPE) has remained controversial secondary to the possibility of decreased material properties when compared to conventional UHMWPE. The aim of the present study was to evaluate if thin, sequentially-irradiated, and annealed highly cross-linked UHMWPE tibial inserts would have improved wear properties, while maintaining mechanical integrity, compared to conventional UHMWPE during biomechanical testing under aligned and malaligned conditions. Polyethylene inserts (4.27 and 6.27mm) manufactured from GUR 1020-UHMWPE were cyclically loaded to analyze for wear. All wear scars were visually examined after loading using scanning electron microscopy (SEM). Volume loss was plotted versus cycle count with linear regression analysis yielding wear rates. There was no statistical difference in wear between both thicknesses for all testing conditions. During aligned condition testing, the volumetric wear rate for sequentially-irradiated and annealed polyethylene thicknesses of 4.27 and 6.27mm was 4.0 and 4.4mm3/million cycles; and during malaligned conditions, it was 13.9 and 15.1mm3/million cycles. For conventional polyethylene during aligned conditions, the volumetric wear rate was 33.0 and 22.8mm3/million cycles; and during malaligned conditions it was 50.0 and 50.8mm3/million cycles. By SEM evaluation, condylar wear surfaces for conventional and sequentially-irradiated and annealed polyethylene displayed surface ripples typical of adhesive wear. There were no observed visible differences between the wear scars for conventional compared to sequentially-irradiated and annealed polyethylene with no evidence of fatigue failure. This study demonstrated no differences between polyethylenes with thicknesses of 4.27 and 6.27mm. This strengthens the conclusion that sequentially-irradiated and annealed highly cross-linked UHMWPE can be utilized in total knee arthroplasty. The successful wear properties of 4.27mm liners could mean that smaller tibial resections leading to bone stock preservation could be utilized in patients undergoing total knee arthroplasty, although further in-vivo studies are needed.
In-Hospital Mortality Following Open and Closed Long Bone Fracture: A Comparative Study
Adam Adler, MD, Orthopaedic Resident, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, Matthew R. Boylan, BS,
Research Associate, Department of Orthopaedic Surgery and the Department of Epidemiology and Biostatistics, SUNY Downstate Medical Center, Brooklyn, NY, Carl Rosenberg, PhD, Clinical Assistant Professor, Department of Epidemiology and Biostatistics, SUNY Downstate School of Public Health, Brooklyn, NY, Robert Pivec, MD, Orthopaedic Resident, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, Bhaveen H. Kapadia, MD,
Orthopaedic Resident, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, Vidushan Nadarajah, BA,
Research Associate, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, Qais Naziri, MD,
Orthopaedic Resident, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, Steven F. Harwin, MD, Chief of Adult Reconstruction and Total Joint Replacement, Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, NY,
Carl B. Paulino, MD,
Program Director, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
625
Background: Open fracture is a serious orthopaedic injury that can lead to significant patient morbidity and mortality. There is limited data on the mortality risk for open compared to closed long bone fracture.
Methods: The Nationwide Inpatient Sample was used to identify all patients who were admitted with a long bone fracture in the United States between 1998 and 2010. Cox proportional hazards regression modeling was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) of mortality.
Results: After adjusting for age, gender, race, insurance, and comorbidities, the HR of mortality was 2.89 (95% CI, 2.56-3.28; p<0.001) for open compared to closed fracture. Stratified by anatomical site, the HR of mortality for open compared to fracture was 3.43 for femur (95% CI, 2.78-4.23; p<0.001), 2.81 for tibia or fibula (95% CI, 2.17-3.64; p<0.001), 2.54 for humerus (95% CI, 1.81-3.56; p<0.001), and 1.56 for radius or ulna (95% CI, 1.10-2.23; p=0.014).
Conclusions: This data suggests that open fracture carries a worse prognosis compared to closed fracture at the same anatomical site.
Molded Articulating Cement Spacers for Two-Stage Treatment of Infected THA and TKA
Keith R. Berend, MD,
Vice President, Joint Implant Surgeons, Inc., New Albany, OH, Clinical Assistant Professor, Department of Orthopaedics, The Ohio State University,
Wexner Medical Center, Columbus, OH, Attending Surgeon, Mount Carmel Health System, Columbus, OH, Nathan J. Turnbull, MD, Fellow, Joint Implant Surgeons, Inc., New Albany, OH, Robert E. Howell, MD, Fellow, Joint Implant Surgeons, Inc., New Albany, OH, Michael J. Morris, MD, Treasurer, Joint Implant Surgeons, Inc., New Albany, OH, Attending Surgeon, Mount Carmel Health System, Columbus, OH, Joanne B. Adams, BFA, CMI, Research Director and Medical Illustrator, Joint Implant Surgeons, Inc., New Albany, OH, Adolph V. Lombardi Jr., MD, FACS, President, Joint Implant Surgeons, Inc., New Albany, OH, Clinical Assistant Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, Attending Surgeon, Mount Carmel Health System, Columbus, OH
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Articulating spacers have been reported to promote greater range of motion, preserve bone, facilitate reimplantation, and enhance functional recovery, as well as provide a vehicle for local administration of antibiotics. The purpose of this study was to review patients treated at our center for deep hip and knee infection with two-staged exchange using molded, articulating antibiotic-laden cement spacers following debridement. A query of our practice registry revealed 84 patients (84 hips) and 177 patients (182 knees) diagnosed with deep infection after THA and TKA respectively, and treated with two-staged exchange using molded articulating cement spacers. Mean follow-up was three years in both groups. Second-stage reimplantation was accomplished in 81 hips, and reinfection occurred in 11 of those (14%), with three responding to a single irrigation and debridement (I&D) procedure, one undergoing two I&Ds, one chronically infected diabetic patient treated with one-stage exchange to cemented components, five patients undergoing multiple procedures including repeat two-staged exchange in four, and one patient declining further treatment. Harris hip score at most recent averaged 69. Second-stage reimplantation was accomplished in 177 knees, and reinfection occurred in 28 of those (16%). Range of motion improved from 93° preoperatively to 101° at most recent, Knee Society clinical scores improved from 46 to 76, and functional scores improved from 32 to 47. Treatment of deep infection after total joint arthroplasty using molded, articulating antibiotic-laden acrylic cement spacers was successful in eradicating infection in 83% of hips (70 of 84) and 82% of knees (149 of 182) at an average of three years after reimplantation.
Patient Compliance with Preoperative Disinfection Protocols for Lower Extremity Total Joint Arthroplasty
Bhaveen H. Kapadia, MD, Orthopedic Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Jeffrey J. Cherian, DO, Orthopedic Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Kimona Issa, MD, Orthopedic Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Sreenath Jagannathan, BS, Medical Student, Lake Erie College of Osteopathic Medicine,
Erie, Pennsylvania, Jacqueline A. Daley, HBSc, MLT, CIC, Director, Infection Prevention and Control, Sinai Hospital of Baltimore, Baltimore, Maryland, 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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Introduction: Infection after total joint arthroplasty has been most attributed to bacterial wound contamination from skin flora. To address this, the CDC recommends bathing with an antiseptic agent the night prior to the operative day. However, despite these measures, the incidence of infections has not been reduced markedly. It is important to have measures in place to ensure proper patient education about infections and disinfection protocols to optimize compliance. Our purpose was to evaluate compliance with preoperative disinfection protocols at our institution and to identify measures which may improve adherence. Materials and Methods: Between 2007 and 2011, we reviewed a database at our institution for all patients who underwent primary or revision total hip (n = 2,458) and knee (n = 2,293) arthroplasty. All of these patients were instructed to follow a chlorhexidine cloth disinfection protocol at the time of surgical scheduling or during their preoperative evaluation. To verify compliance, patients were instructed to remove adhesive stickers from the cloth packages at the time of disinfection and to affix them to the instruction sheet presented on the day of surgery. This was documented in the patient medical records. A database was generated to identify those patients who were compliant (n = 1,035) or non-compliant (n = 3,716). Following this period, if patients did not use chlorhexidine as instructed, the staff ensured one application was received pre-operatively. Results: Approximately 78% of patients (3,716 out of 4,751 patients) were noncompliant. When evaluating the demographic between the two groups, we found that age and gender distributions were not significantly different. Discussion: While preoperative decolonization protocols may reduce surgical site infections, their efficacy is limited by patient compliance and comprehension. Providing patients with thorough instructions about preoperative disinfection protocols and information about the importance of infection burden is more likely to improve patient adherence.
Selective Patellar Resurfacing: A Literature Review
Casey R. Antholz, DO, MS, Orthopaedic Surgery Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Jeffrey J. Cherian, DO, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Randa K. Elmallah, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Julio J. Jauregui, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Todd P. Pierce, MD, Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Director, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Whether to resurface the patella during total knee arthroplasty (TKA) remains a controversial topic among orthopaedic surgeons, and we are still no closer to identifying which technique provides the best outcomes. Advocates for patellar resurfacing have adopted this technique in order to avoid the potential for post-operative anterior knee pain that may be associated with the need for future reoperations. However, reports have indicated that patellar resurfacing may be associated with increased complications such as patellar implant loosening, fracture, osteonecrosis, tendon injury, wear, and instability. More recently, studies have highlighted possible patient-specific and surgical factors, such as weight, body mass index, degree of chondromalacia, and patellar alignment, which may influence functional outcomes, and thus surgical decision making. However, currently there are minimal clear guidelines to help surgeons decide whether or not to resurface the patella. Our aim was to assess the current literature and present the evidence for and against patellar resurfacing, as well as to assess factors that may aid in deciding which procedure is more suitable for the specific patient. Ultimately, we believe there is a need for further research to identify the most appropriate candidates for patellar resurfacing.
