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Surgical Technology International XXVII contains 41 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

Nov, 2015 - ISSN:1090-3941

 

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Orthopaedic Surgery

 

Do Standard Surgical Guides Produce Accurate and Precise Femoral Bone Resections During Total Knee Arthroplasty?
Fatih Küçükdurmaz, MD, Post Doc Research Fellow , Department of Orthopaedic Research , The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, Eric A. Levicoff, MD, Assistant Professor, Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University , Bryn Mawr, PA, Robert P. Good, MD, Clinical Associate Professor, Department of Orthopaedic Surgery , The Rothman Institute at Thomas Jefferson University , Bryn Mawr, PA , Peter F. Sharkey, MD, Associate Professor, Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, King of Prussia, PA

 

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Purpose: Accurate alignment and balanced flexion and extension gaps are critical elements in achieving a successful outcome following total knee arthroplasty (TKA). The ability to make accurate and precise bone cuts is essential in the creation of balanced gaps. We sought to determine if one type of modern-day standard surgical instrument using an intramedullary rod and posterior referencing produces accurate and precise distal and posterior femoral bone resections.
Materials and methods: Seventy-five consecutive patients undergoing TKA were divided into three groups, with 25 patients in each group receiving one of three implant designs: 25 Stryker Triathlon® CR (Stryker, Mahwah, NJ), 25 Zimmer NexGen® Flex CR (Zimmer, Warsaw, IN), and 25 StelKast Proven Gen-FlexTM CR (StelKast, Pittsburgh, PA). Flexion-extension gap matching was determined using only the medial flexion and extension gaps. Accuracy was determined by comparing actual resection thickness to desired resection thickness. “Optimal�? accuracy was considered to be within 1.0mm of desired, and “near-optimal�? accuracy was considered to be within 2.0mm of the desired resection thickness. Precision was determined by the variability of resection thicknesses within each system.
Results: Data demonstrated a lack of accuracy and precision across all three tested systems, with each system resulting in certain unique tendencies. Only one out of 75 cases resulted in optimal resection accuracy with all three cuts (Zimmer). When lowering the threshold to include both optimal and near-optimal (within 2mm of error) with all three cuts, only one third of Stryker and Zimmer cases and two thirds of StelKast cases achieved this threshold, representing 44% of cases (33/75).
Conclusions: Improvements in instrumentation to increase accuracy and precision may be warranted. Errors in fixation may be due to the instrumentation itself, and altering instrumentation to include less modularity, provide more stable fixation, and more reliably seal the implant on the femur may be of benefit.

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Readmission Rates in Patients Who Underwent Total Hip Arthroplasty
Randa K. Elmallah, MD, Research Fellow, Jeffrey J. Cherian, DO, Research Fellow, Hiral Amin, MD, Research Assistant, Julio J. Jauregui, MD, Research Fellow, Todd P. Pierce, MD, Research Fellow, 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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Paravaginal defects, commonly seen in patients with anterior vaginal wall prolapse, are due to the detachment of pubocervical fascia from the arcus tendineus fascia pelvis (ATFP), at or near its lateral attachment. The majority of anterior vaginal wall prolapse is thought to be caused by paravaginal defects. Richardson et al. first described and demonstrated the anatomy of the paravaginal defect, as well as described the initial technique of the abdominal approach to repair. Since that time, the laparoscopic approach for repair has been developed and described with success rates of laparoscopic paravaginal defect repair reported in the range of 60% to 89%. This minimally invasive approach to address anterior wall prolapse eliminates the need for a vaginal incision, reduces risk of vaginal shortening and can be completed at the same time as other laparoscopic procedures, such as hysterectomy, sacralcolpopexy, and/or Burch Urethropexy. Compared to the open abdominal approach, there is improved visualization, less risk of bleeding, and faster recovery with the laparoscopic method. Compared to an anterior colporrhaphy, laparoscopic paravaginal repair is a much more anatomic repair of lateral defects and does not result in vaginal shortening. The laparoscopic paravaginal repair should be considered as the first-line treatment of anterior vaginal wall prolapse caused by lateral defects, including at time of laparoscopic/robotic sacralcolpopexy.

 

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Liposomal Bupivacaine Suspension Can Reduce Length of Stay and Improve Discharge Status of Patients Undergoing Total Hip Arthroplasty
Jeffrey J. Cherian, DO, Resident, Orthopaedic Surgery Department, Philadelphia College of Osteopathic Medicine , Philadelphia, PA, John Barrington, MD, Co-Director , The Joint Replacement Center , Baylor Medical Center of Frisco, Plano, TX, Randa K. Elmallah, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland, Morad Chughtai, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland, Jaydev B. Mistry, 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, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland

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Introduction: To ensure good rehabilitation and improved outcomes following total hip arthroplasty (THA), optimal pain control is necessary. Newer methods of pain control have been advocated, as current modalities have been associated with undesirable side effects and serious complications. One such modality is liposomal bupivacaine, which provides long-acting, slow-release analgesia. The purpose of this study was to evaluate: (1) lengths of hospital stay and (2) the discharge status of patients who underwent THA with liposomal bupivacaine compared to a cohort who received standard analgesic regimens.
Materials and Methods: We utilized a hospital discharge database from July 1, 2013 to June 30, 2014, which included 7,704,919 patients for our analysis. We selected patients aged 18 years or older who had an inpatient stay for THA using ICD-9 procedure code (ICD-9-CM = 81.51), which resulted in 55,129 THA patients. Patients who had a nerve block in the time period from the surgery date to the discharge date were then excluded, which resulted in 54,604 THA patients. The THA cohort who received liposomal bupivacaine suspension consisted of 5,267 patients (2,907 women; 2,360 men) who had a mean age of 64 years, while the THA without injections or nerve block consisted of 49,337 patients who had a mean age of 65 years that consisted of 27,530 women and 21,807 men. We analyzed length-of-stay by controlling for race, region, age, sex, Charlson Index, and operating time using a log link linear model with a negative binomial distribution. The discharge status to home compared to short-term nursing facility or rehabilitation was analyzed using logistic regression while controlling for the aforementioned covariates.
Results: The mean lengths of stay, after adjusting for covariates, for the liposomal bupivacaine cohort was significantly shorter than the no injection cohort. The distribution of patients being discharged to home compared to a short-term nursing facility or a rehabilitation facility was higher in the liposomal bupivacaine cohort compared to the cohort who did not receive liposomal bupivacaine. Multivariate logistic regression analyses demonstrated a higher likelihood of being discharged to home in liposomal bupivacaine cohort when compared to no injection.
Conclusion: Liposomal bupivacaine appears to be an effective pain relief modality that leads to reduced lengths of hospital stay and increased rates of discharge to home. This may be an appropriate addition for the analgesic armamentarium in patients who undergo THA.

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Evaluating the Native Length-Tension Relationship in Arthroscopic, Suprapectoral Biceps Tenodesis: An MRI Assessment of Contralateral Shoulders
John Prodromo, MD, Resident, Department of Orthopedic Surgery, Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, Pennsylvania, Mary K. Mulcahey, MD, Assistant Professor, Department of Orthopedic Surgery, Drexel University College of Medicine/Hahnemann University Hospital , Philadelphia, Pennsylvania, Raymond Hong, MD, Staff Radiologist, Radiology Department, San Diego Imaging, San Diego, California, Tal S. David, MD, Clinical Associate Professor, Department of Orthopedic Surgery, San Diego Arthroscopy and Sports Medicine, San Diego, California

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Background: Successful tenodesis of the proximal biceps relies on accurate reproduction of the native length-tension relationship of the long head of the biceps (LHB). While open tenodesis procedures can reproduce this relationship by referencing the position of the LHB musculotendinous junction (MTJ) to a visible anatomic landmark, arthroscopic suprapectoral tenodesis does not afford such advantage because the MTJ is usually not visible. No studies to date have evaluated the position of the MTJ of the LHB following arthroscopic suprapectoral biceps tenodesis.
Methods: Patients undergoing arthroscopic suprapectoral biceps tenodesis between January 2013 and May 2014 at one center were evaluated for inclusion. Patients included in the study underwent a postoperative MRI of bilateral shoulders. The distance from the superior portion of the humeral head to the LHB MTJ was measured bilaterally. The measurements from each matched pair were compared using a paired t-test to determine if arthroscopic suprapectoral biceps tenodesis anatomically restored the LHB length-tension relationship.
Results: A total of 17 patients met the inclusion criteria. Fourteen of the seventeen patients underwent a postoperative MRI of bilateral shoulders. The distance from the superior portion of the humeral head to the LHB musculotendinous junction was significantly larger on the operative side when compared to the nonsurgical side (operative side mean 98.34mm, standard deviation 13.38mm; nonsurgical mean 87.26mm, standard deviation 9.09; mean difference 11.08mm; p=0.0105).
Conclusion: The musculotendinous junction of the LHB in patients who underwent arthroscopic suprapectoral biceps tenodesis was located significantly more distal than the contralateral control, as measured on MRI.

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Porous Tantalum Buttress Augments for Severe Acetabular Posterior Column Deficiency
R. Michael Meneghini, MD, Associate Professor of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, Jason R. Hull, MD, Virginia Commonwealth University, Richmond, Virginia, Glenn S. Russo, MD, MS, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, Jay R. Lieberman, MD, Chair and Professor of Orthopaedic Surgery, Keck School of Medicine at University of Southern California, Los Angeles, California, William A. Jiranek, MD, Professor of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia

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In revision total hip arthroplasty (THA), consensus is lacking regarding the optimal method for reconstruction of the most severe acetabular defects. Porous tantalum (TM) buttress augments were designed for the most severe postero-superior defects. The purpose of this study was to report the results of a consecutive series of acetabular reconstructions utilizing TM buttress augments. Eight complex acetabular reconstructions utilizing a TM buttress augment were performed at two centers. All were Paprosky 3A or Paprosky 3B bone loss classification, with severe superior and posterior column deficiency where wedge augments were insufficient for mechanical support. The acetabular cup sizes ranged from 64–78, and a buttress shim was used in 7 of 8 cases. Clinical and radiographic follow-up averaged 16.5 months (range, 10–28) and no cases were lost to follow-up. There were no cases of clinical or radiographic loosening, and no case had required reoperation or revision. All patients except one were ambulating with either no assist device or a single cane at final follow-up. There was one complication of an iliac wing fracture noted incidentally on postoperative x-rays in the lone patient in whom a buttress shim was not used. At short-term follow-up, TM acetabular buttress augments appear to effectively substitute for the use of structural allografts or cages, which would otherwise be used in this challenging setting. The potential for biologic fixation is promising for the durability of these reconstructions; however, longer-term follow-up is required for full evaluation.

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Pseudotumor Formation in a Metal-on-polyethylene Total Hip Arthroplasty Due to Trunnionosis at the Head-neck Taper
Jake T. Stahnke, BSc, Medical Scribe, OrthoArizona-Mezona Division, Gilbert, Arizona, Kipling P. Sharpe, MD, FAAOS, Orthopedic Surgeon, OrthoArizona-Mezona Division , Gilbert, Arizona

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We present here a case of pseudotumor formation likely due to metal wear debris generated at the head-neck taper (trunnion) of the femoral stem and head components in a metal-on-polyethylene (MOP) total hip arthroplasty. Over the last few years, this recently described diagnosis, trunnionosis, has been recognized and reported more frequently. This patient presented with a rather large (12-cm diameter) pseudotumor with accompanying loss of abductors and a pelvic discontinuity making reconstruction more challenging. We believe the psuedotumor in this patient developed from trunnionosis. This is an interesting case of aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) in a MOP total hip arthroplasty.

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Prospective Randomized Controlled Trial of Two Different Intramedullary Nails for Pertrochanteric Fractures of the Femur
Lorenzo Andreani, MD, Consultant Orthopaedic Surgeon, Enrico Bonicoli, MD, Consultant Orthopaedic Surgeon, Nicola Piolanti, MD, Consultant Orthopaedic Surgeon, Paolo Parchi, PhD, Consultant, Francesco Niccolai, MD, Resident, Alessandra Carmignani, MD, Resident, Michele Lisanti, MD, Professor, Chief, Orthopaedic Department, University of Pisa, Pisa, Italy

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The purpose of this prospective randomized trial was to assess whether an intramedullary nail is superior or not to another one in the treatment of pertrochanteric fractures. Eighty-one patients with a 31-A1 or A2 Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) pertrochanteric fracture were randomly allocated to fixation with either the Gamma® or the ENDOVIS® nail. In order to estimate the functional outcome the Parker-Palmer mobility score, Barthel Index, and EuroQol-5D (EQ-5D) were used. All patients were followed up at 1, 3, 6, and 12 months postoperatively. There was no statistical difference in Parker mobility score between groups. The statistical analysis revealed that there was no significant difference between the two patient groups as far as the operating time, the amount of blood transfused, and the latest functional outcome. Both kinds of intramedullary nails used in our study provide effective methods of treatment for intertrochanteric fractures in elderly patients. Our data showed slightly worse results for the ENDOVIS nail compared with the Gamma nail, but this did not reach a statistical significance.

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A Comprehensive Assessment of Various Outcome Scores to Evaluate Total Hip Arthroplasties
Julio J. Jauregui, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland, Aaron L. Lerner, BS, Research Volunteer, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland, Jaydev B. Mistry, MD , Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland, Morad Chughtai, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland, Randa K. 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, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement , Sinai Hospital of Baltimore, Baltimore, Maryland

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Introduction: Many scoring systems have been developed that serve to evaluate outcomes following total hip arthroplasty (THA). However, most systems focus on specific aspects of a patient’s recovery rather than investigating a broad spectrum of parameters, which prevent physicians from obtaining a sufficient impression of a patient’s recovery. Therefore, we evaluated existing scoring systems to assess the outcome categories included and parameters of interest.
Materials and Methods: We examined all hip scoring systems currently available in the literature. The outcomes measured in each scoring system were sub-classified into one of four categories; subjective, objective, rehabilitative, and quality of life. We determined the number of scoring systems that incorporated each of these four categories and we assessed the most common parameters in each. The categories and individual parameters were assigned a relative weighted mean score based on how often they were incorporated, in an effort to determine their importance.
Results: We identified 42 hip scoring systems consisting of 44 individual parameters, which were divided into the above four categories. Of the relevant scoring systems, 74% included subjective parameters, 31% included objective parameters, 90% included rehabilitative parameters, and 62% included quality of life parameters. The most commonly assessed subjective parameters include pain, stiffness, and general hip difficulty. The most commonly assessed objective parameters include general/combined ROM, flexion/extension, and abduction/adduction. The most commonly assessed rehabilitative parameters include the ability to walk, the ability to climb stairs, and the ability to reach to the floor. The most commonly assessed quality of life measures include the ability to use a car, performance of light domestic duties, and performance of heavy domestic duties. The category of rehabilitative practices carried the greatest weighted mean (49%) in hip scoring systems, followed by subjective (40%), quality of life (6%), and objective (5%). With regard to individual hip outcome parameters, pain carried the greatest weighted mean (23%), followed by the ability to walk and the ability to perform general activities (11% each).
Conclusion: Patient outcomes can be evaluated by the use of scoring systems in an effort to determine the effectiveness of THA in regaining function and improving quality of life. Determining the frequency and importance of parameters in current scoring systems may allow for a more accurate and purposeful assessment of post-operative function and patient satisfaction. Understanding what is evaluated in existing scoring systems may shed light on the future development of a comprehensive outcome questionnaire.

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The Institutional Costs and Resource Profile of Transfer Patients Into an Arthroplasty Service
Peter Hahn, MD, Resident Physician , Department of Orthopaedic Surgery, University of California, Irvine Medical Center, Orange, CA, Ali Qaderi, BSc, Medical Student, Department of Orthopaedic Surgery, University of California, Irvine Medical Center, Orange, CA, James Jung, MD, Resident Physician , Department of Orthopaedic Surgery, University of California, Irvine Medical Center, Orange CA, Ran Schwarzkopf, MD, MSc, Assistant Professor of Orthopaedic Surgery, Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY

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The decision point with inter-hospital arthroplasty patient transfers and its financial implications have not been well studied. Factors outside of complexity of medical and surgical care are believed to drive the transfer of orthopaedic patients to tertiary care centers. We compared our institutional cost and resource utilization between transfer and elective patients in need of arthroplasty care. We hypothesized that transfer patients will incur a higher direct cost and resource utilization compared to elective patients, and that socioeconomic factors will play a role in the decision of transfer. After analysis of key metrics, transfer patients at our institution did not have any significant differences in insurance types. However, they did incur a longer length of stay (p<0.0001) and incurred greater direct costs (p<0.0001) to the hospital. After analysis of key parameters, transfer patients were more complex and costly to care for compared to our in-system patients.

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Repair of Medial Patellofemoral Ligament Improves Patellar Tracking in Total Knee Replacement
R. Michael Meneghini, MD, Associate Professor of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, Director of Joint Replacement, Orthopedics and Sports Medicine, Indiana University Health Physicians, Fishers, Indiana, Mary Ziemba-Davis, Director of Research for Orthopedics, Academic Health Center, Orthopedics and Sports Medicine, Indiana University Health Physicians, Fishers, Indiana, Shelly Smits, RN, BSN, ONC, Clinical Nurse Coordinator, Orthopedics and Sports Medicine, Indiana University Health Physicians, Fishers, Indiana, James Bicos, MD, Assistant Professor, Oakland University William Beaumont School of Medicine, William Beaumont Hospital, Bingham Farms, Michigan

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The medial patellofemoral ligament (MPFL) is essential to maintain patella stability; however, its role in total knee replacement (TKR) has not been studied. Forty-six consecutive TKRs in 40 patients were reviewed. Standard closure was performed in 29 TKRs. The MPFL was isolated and anatomically re-approximated in 17 subsequent TKRs. Blinded radiographic evaluation of patellar tilt and subluxation was performed preoperatively and 4 months postoperatively. Despite greater preoperative lateral tilt, the MPFL repair group demonstrated greater correction in patellar tilt compared with the standard closure group (p = 0.02). Patellar tracking also was optimized in the MPFL group, despite equivalent preoperative lateral patellar subluxation in the two groups. Simple repair of the MPFL at arthrotomy closure appears to optimize patellar stability radiographically and may improve long-term results by minimizing patellar complications and wear.

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Early Experience with a New Porous Hemispheric Acetabular Component
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, Joanne B. Adams, BFA, CMI, Research Director and Medical Illustrator, 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, 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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A third-generation cementless acetabular system has been designed, building on the successes of a second-generation system that featured good congruity between the liner and hemispheric shell, and proven porous plasma-sprayed coating on titanium alloy substrate, by designing a ringless barb and groove locking mechanism and optimizing range of motion. These design features are amenable to modern, highly crosslinked polyethylenes. A retrospective review was performed to assess early outcomes. A query of our practice registry revealed 534 patients (576 hips) who underwent cementless total hip arthroplasty performed by three surgeons with the G7™ Acetabular System (Biomet, Warsaw, Indiana) between April 2013 and March 2014. All liners were vitamin E infused, highly crosslinked polyethylene with a neutral face. Heads used were 463 BIOLOX® delta (81%; CeramTec AG, Plochingen, Germany) and 112 cobalt-chromium (19%), with diameters of 32mm in 238 (41%), 36mm in 331 (58%), and 40mm in 6. Minimum one-year follow-up was available for 400 hips. Mean follow-up was 15 months (range 10–24, SD 3.0). Harris hip scores improved from 50.7 preoperatively to 86.5 most recently. UCLA activity scale improved from 4.5 preoperatively to 5.4 most recently. Two patients required cup revision secondary to failure of biological fixation at 8.4 and 15.1 months respectively. Radiographic findings in all cases were satisfactory position and alignment with no radiolucencies observed. In this group, with very early follow-up, good results with a low rate of acetabular revision and no dislocations were achieved using a new hemispheric porous shell with ringless barb and groove locking mechanism and geometry.

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Decreased Opioid Utilization and Cost at One Year in Chronic Low Back Pain Patients Treated with Transcutaneous Electric Nerve Stimulation (TENS)
Robert Pivec, MD, Orthopaedic Research Fellow, Michael E. Minshall, MPH, Senior Director, Healthcare Economics & Reimbursement, DJO Global, Vista, California , Jaydev B. Mistry, MD, Orthopaedic Research Fellow, Morad Chughtai, MD, Orthopaedic Research Fellow, Randa K. Elmallah, MD, Orthopaedic Research Fellow, Michael A. Mont, MD, Director, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland

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Introduction: Chronic low back pain (CLBP) may be treated without opioids through the use of transcutaneous electrical nerve stimulation (TENS). However, no study has evaluated its clinical effect and economic impact as measured by opioid utilization and costs. The purpose of this study was to evaluate patients who were given TENS for CLBP compared to a matched group without TENS at one-year follow-up, to determine differences between opioid consumption.
Materials and Methods: Opioid utilization and costs in patients who did and did not receive TENS were extracted from a Medicare supplemental administrative claims database. Patients were selected if they had at least two ICD-9-CM coded claims for low back pain in a three-month period and were then propensity score matched at a 1:1 ratio between patients who received TENS and those who did not. There were 22,913 patients in each group who had a minimum follow-up of one year. There were no significant demographic or comorbidity differences with the exception that TENS patients had more episodes of back pain. Results: Significantly fewer patients in the TENS group required opioids at final follow-up (57.7 vs. 60.3%). TENS patients also had significantly fewer annual per-patient opioid costs compared to non-TENS patients ($169 vs. $192). There were significantly lower event rates in TENS patients compared to non-TENS patients when measured by opioid utilization (characterized by frequency of prescription refills) (3.82 vs. 4.08, respectively) or pharmacy utilization (31.67 vs. 32.25). The TENS group also demonstrated a significantly lower cost of these utilization events ($44 vs. $49) and avoided more opioid events (20.4 events fewer per 100 patients annually).
Discussion: Treatment of CLBP with TENS demonstrated significantly fewer patients requiring opioids, fewer events where a patient required an opioid prescription, and lower per-patient costs. Since TENS is both non-invasive and a non-narcotic, it may potentially allow physicians to be more aggressive in treating CLBP patients.

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Long-Term Bone Remodeling in HA-Coated Stems. A radiographic review of 208 THA with 15 to 20 years follow-up

Dr. Jens G. Boldt MD, Consultant Orthopaedic and Trauma Surgeon, Head of Orthopaedic Department, Klinik Siloah, Guemligen, Switzerland, Jean-Claude Cartillier, MD, Orthopaedic Consultant, Artro Institute, Lyon, France, Alain Machenaud, MD, Orthopaedic, Consultant, Artro Institute, Annecy le Vieux, France, Jean-Pierre Vidalain, MD, Orthopaedic, Consultant, Artro Institute, Annecy le Vieux, France

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We present a prospective study focused on radiographic long-term outcomes and bone remodeling at a mean of 17.0 years (range: 15 to 20) in 208 cementless fully HA-coated femoral stems (Corail, DePuy International Ltd, Leeds, UK). Total hip replacements in this study were performed by three members of the surgeon design group between 1986 and 1991. Radiographic evaluation focused on periprosthetic osteolysis, bone remodeling, osseous integration, subsidence, metaphyseal or diaphyseal load transfer, and femoral stress shielding. The radiographs were digitized and examined with contrast-enhancing software for analysis of the trabecular architecture. Radiographic signs of aseptic stem loosening were visible in two cases (1%). Three stems (1.4%) showed metaphyseal periprosthetic osteolysis in four of seven Gruen zones associated with eccentric polyethylene wear awaiting metaphyseal bone grafting and cup liner exchange. One stem (0.5%) was revised due to infection. No stem altered in varus or valgus alignment more than two degrees, and mean subsidence was 0.1 mm (range: 0 to 2 mm) after a mean of 17.0 years. A total of 5 stems (2.4%) required or are awaiting revision surgery. Trabecular orientation and micro-anatomy suggested main proximal load-transfer patterns in all except 3 cases (98.6%). Combined metaphyseal and diaphyseal osseointegration and bone remodeling were visible in 100 stems (48%). Diaphyseal stress shielding and cortical thickening were observed in 3 stems (1.4%). Other radiographic features are discussed in depth. This long-term study of 208 fully HA-coated Corail stems showed satisfactory osseointegration and fixation in 203 cases (97.6%) after a mean of 17.0 years follow-up. Stem failures were associated with extreme eccentric polyethylene wear.

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Unloader Bracing for Knee Osteoarthritis: A Pilot Study of Gait and Function
Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Jeffrey J. Cherian, DO, Research Fellow, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Anil Bhave, PT, Director of Department of Physical Therapy, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Roland Starr, MS, Director of Gait Lab, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland , Randa K. Elmallah, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Walter B. Beaver, Jr., MD, Medical Director, OrthoCarolina, Charlotte, North Carolina, Steven F. Harwin, MD, FACS, Director, Center of Reconstructive Joint Surgery, Beth Israel Medical Center, New York, New York

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Abstract


Knee osteoarthritis (OA) is increasing in the United States, and some have proposed the use of unloader bracing as an adjunct to current standard treatments. Our purpose was to evaluate outcomes of this brace for the treatment of knee osteoarthritis compared with standard non-operative treatment. Specifically, we evaluated: (1) pain relief, (2) objective functional improvement, (3) subjective functional improvement, (4) quality of life, (5) isokinetic quadriceps muscle strength, and (6) gait changes. A prospective, randomized, study was performed on 18 patients who had Kellgren-Lawrence grade 1 and 2 osteoarthritis. Patients were randomized to receive either standard treatment or an unloader brace. End points evaluated included: functional tests, Knee Society Score, Short Form 36 (SF-36) health survey, Visual Analog Scale (VAS) for pain, Lower Extremity Functional Scale, isokinetic quadriceps and hamstring muscle strength, and 3-dimensional gait analysis. There were no differences between cohorts in evaluation of pain (VAS), objective functional tests, subjective functional outcomes (Knee Society Scores and LEFS), quality of life assessment with SF-36, isokinetic quadriceps and hamstring muscle strength, and gait parameters. The use of unloader brace demonstrated similar improvements compared with standard treatments for knee osteoarthritis, and we believe that it can be a beneficial or equivalent adjunct to continuum of care for the treatment for knee osteoarthritis.

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