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Surgical Technology International 29
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Surgical Technology International XXIX contains 49 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
October-2016- ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions.
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Orthopaedic Surgery
Outpatient Robotic-Arm Total Hip Arthroplasty Surgical Technique
Benjamin Domb, MD, Medical Director, Senior Orthopaedic Surgeon, American Hip Institute, Westmont, IL, Stephanie Rabe, ACNP-BC, Nurse Practitioner, American Hip Institute, Westmont, IL, John P. Walsh, MA, Clinical Research Assistant, American Hip Institute, Westmont, IL, Mary R. Close, BS, Clinical Research Assistant, American Hip Institute, Westmont, IL, Edwin O. Chaharbakhshi, BS, Clinical Research Assistant, American Hip Institute, Westmont, IL, Itay Perets, MD, Orthopaedic Surgical Fellow, American Hip Institute, Westmont, IL
733
5-08-2016
ORDER
Outpatient total hip arthroplasty (THA) has remained controversial and challenging. Traditional hospital stays following total joint arthroplasty were substantial and resulted in increased rates of morbidity, significant pain, and severe restriction in mobility. Advancements in the surgical approach, anesthetic regimens, and the initiation of rapid rehabilitation protocols have had an impact on the length of recovery following elective THA. Still, very few studies have specifically outlined outpatient hip arthroplasty and, thus far, none have addressed the use of robotic-arm navigation in outpatient THA. This article describes in detail the technique used to perform outpatient THA with the use of robotic-arm assistance. We believe that outpatient THA using robotic-arm assistance in combination with tissue-preserving surgery, multi-modal pain and nausea management, early rehabilitation, and stringent patient selection yields a suitable alternative to inpatient joint replacement.
Total Shoulder Arthroplasty Demographics, Incidence, and Complications—A Nationwide Inpatient Sample Database Study
Kimona Issa, MD, PGY3 Resident, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ, Casey M. Pierce, MD, PGY5 Resident, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ, Todd P. Pierce, MD, Research Fellow, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ, Matthew R. Boylan, ScB, Medical Student, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, Bashir A. Zikria, MD, MSC, Associate Professor, Department of Orthopaedic Surgery, John Hopkins University Hospital, Baltimore, MD, Qais Naziri, MD, MBA, PGY3 Resident, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, Anthony Festa, MD, Associate Professor, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ, Vincent K. McInerney, MD, Residency Program Director, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ, Anthony J. Scillia, MD, Associate Professor, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ
759
15-07-2016
Introduction: Total shoulder arthroplasty (TSA) has become a popular and successful surgery to treat advanced glenohumeral arthritis, rotator cuff arthropathy, and proximal humerus fractures. Historical data is available investigating the epidemiology of total shoulder arthroplasty with regard to patient characteristics, outcomes, and complications; however, there is a lack of studies investigating the most recent and up to date national trends related to shoulder replacement. The purpose of this study was to evaluate changes in the annual incidence, various demographics, and complications of TSA in America.
Materials and Methods: The Nationwide Inpatient Sample (NIS) was assessed to identify all patients who were admitted for TSA in the United States between 1998 and 2010. National trends in patient demographics, incidence, and length-of-stay (LOS) were analyzed for correlations. The impacts of contributing factors to each outcome were assessed using adjusted multivariable regression analysis. These were used to calculate odds ratios of cohort demographics and their association with complications and LOS.
Results: Admissions for TSA have risen (8,041 to 39,072 admissions). The majority of the cohort consisted of Caucasian men between the ages of 64 and 79 years. The incidence rate of complications has remained consistent. Female gender, age > 80 years, and higher Deyo Comorbidity scores were risk factors for higher complications. The LOS has decreased (2.96 to 2.21 days) during the study time period. Female gender, African-American race, Medicaid insurance, and higher Deyo Comorbidity scores were associated with longer stays. Discussion: Our study demonstrates a rapid increase in incidence rates of TSAs within the 13-year period in the United States. An increased risk of complications was noted with older age, female gender, and increased Deyo score.
Conclusion: Our findings may help health care providers identify ways to better manage this procedure and select patients.
Multiple Small Diameter Drillings Increase Femoral Neck Stability Compared with Single Large Diameter Femoral Head Core Decompression Technique for Avascular Necrosis of the Femoral Head
Philip J. Brown, PhD, Assistant Professor, Virginia Tech-Wake Forest University School of Biomedical Engineering and Sciences, Center for Injury Biomechanics, Winston-Salem, NC, Sandeep Mannava, MD, PhD, Resident, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, Thorsten M. Seyler, MD, PhD, Assistant Professor, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, Johannes F. Plate, MD, PhD, Resident, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, Charles Van Sikes, MD, Surgeon, Department of Orthopaedic Surgery, OrthoCarolina, Mooresville, NC, Joel D. Stitzel, PhD, Professor and Chair, Virginia Tech-Wake Forest University School of Biomedical Engineering and Sciences, Center for Injury Biomechanics, Winston-Salem, NC, Jason E. Lang, MD, Associate Professor, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC
746
2-06-2016
Femoral head core decompression is an efficacious joint-preserving procedure for treatment of early stage avascular necrosis. However, postoperative fractures have been described which may be related to the decompression technique used. Femoral head decompressions were performed on 12 matched human cadaveric femora comparing large 8mm single bore versus multiple 3mm small drilling techniques. Ultimate failure strength of the femora was tested using a servo-hydraulic material testing system. Ultimate load to failure was compared between the different decompression techniques using two paired ANCOVA linear regression models. Prior to biomechanical testing and after the intervention, volumetric bone mineral density was determined using quantitative computed tomography to account for variation between cadaveric samples and to assess the amount of bone disruption by the core decompression. Core decompression, using the small diameter bore and multiple drilling technique, withstood significantly greater load prior to failure compared with the single large bore technique after adjustment for bone mineral density (p<0.05). The 8mm single bore technique removed a significantly larger volume of bone compared to the 3mm multiple drilling technique (p<0.001). However, total fracture energy was similar between the two core decompression techniques. When considering core decompression for the treatment of early stage avascular necrosis, the multiple small bore technique removed less bone volume, thereby potentially leading to higher load to failure.
Novel Sensor Tibial Inserts in Total Knee Arthroplasty: A Review
Ronald E. Delanois, MD, Director, Hip, Knee, and Shoulder Surgery, 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, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Alison K. Klika, MS, Research Program Manager, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Wael K. Barsoum, MD, President, Cleveland Clinic, Weston, Florida, Carlos A. Higuera, MD, Attending Physician, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anil Bhave, PT, Director, Rehabilitation Services, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
781
11-08-2016
Traditional techniques to balance total knee arthroplasties are often subject to variability, as they are usually based on the surgeon’s subjective assessment. Improperly balanced total knee arthroplasties can cause complications such as stiffness, pain, or instability, which may ultimately result in a revision procedure. In an effort to mitigate this, a tibial insert sensor technology has recently been developed to allow for quantifiable, objective measurements of soft-tissue balancing. A systematic review of the current literature was performed, highlighting the utility of this sensor tibial insert with focus on: (1) compartment loading pressures; (2) component orientations; and (3) clinical outcomes.
Ochronosis as Etiology of Requiring Total Knee Arthroplasty—A Case Series
Todd P. Pierce, MD, Research Fellow, Department of Orthopaedics, Seton Hall University, School of Health, and Medical Sciences, South Orange, NJ, Kimona Issa, MD, PGY-2 Resident, Department of Orthopaedics, Seton Hall University, School of Health, and Medical Sciences, South Orange, NJ, Andres Ramirez, BS, Medical Student, New York Medical College, Department of Orthopaedic Surgery, Valhalla, New York, Salvatore Sclafani, BS, Medical Student, Department of Orthopaedic Surgery, Touro College of Osteopathic Medicine, New York, New York, Steven F. Harwin, MD, Chief of Adult Reconstruction and, Total Joint Replacement, Center for Reconstructive Joint Surgery, Mount Sinai Beth Israel Medical Center, New York, New York, Anthony J. Scillia, MD, Associate Professor, Department of Orthopaedics, Seton Hall University, School of Health, and Medical Sciences, South Orange, NJ, Aiman Rifai, DO, Associate Professor, Department of Orthopaedics, Seton Hall University, School of Health, and Medical Sciences, South Orange, NJ, Vincent K. McInerney, MD, Residency Program Director, Department of Orthopaedics, Seton Hall University, School of Health, and Medical Sciences, South Orange, NJ
754
9-06-2016
Alkaptonuria is a rare hereditary metabolic disorder that leads to the accumulation of homogentisic acid accumulation and weakens the collagen, creating fissuring and articular cartilage degeneration. Therefore, we are reporting a multicenter case series of three patients (four arthroplasties) who presented with signs and symptoms of ochronotic arthropathy—and eventually underwent total knee arthroplasty (TKA)—and provide a review of the current literature on total joint arthroplasty in ochronotic osteoarthritis. Each patient achieved excellent Knee Society Scores (KSS) after at least a five-year follow-up—regardless of receiving cemented or cementless prostheses—and suffered no complications. There have been a number of case reports published on patients who had TKA and were found to have a diagnosis of ochronosis. We believe that surgery for symptomatic patients who are surgical candidates for TKA should not be delayed for concerns of complications. However, future studies should compare outcomes to those who undergo TKA without ochronotic arthropathy.
Traumatic Diastasis of the Pubic Symphysis—A Review of Fixation Method Outcomes
Todd P. Pierce, MD, Research Fellow, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ, Kimona Issa, MD, PGY3 Resident, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ, John J. Callaghan, MD, Associate Professor, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ, Craig Wright, MD, Associate Professor, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, NJ
753
10-07-2016
Traumatic pubic symphysis diastases (PSD) are life-threatening injuries that often require operative fixation. The purpose of this review is to evaluate the outcomes of patients following various operative fixation techniques of these particular pelvic ring injuries. Specifically, we will analyze the role of: (1) surgical approach; (2) implant failure; and (3) fixation methods in treating traumatic PSD. They are typically fixed using the Pfannestiel approach, but a midline approach may be used in cases where this is not ideal. These fractures often have implant failure; however, studies have shown this does not impact clinical outcomes. Currently, the gold standard of fixation is multiple-hole plate fixation. There are a number of other surgical fixation methods such as two-hole plating or percutaneous fixation that may be considered as well. Future studies should focus on the long-term outcomes and efficacy of these new innovative techniques for fixation of traumatic PSD.
Peroneal Tubercle Hypertrophy: A Case Report
Giuseppe Restuccia, MD, Specialist in Orthopedics and Traumatology, S.O.D. Ortopedia e Traumatologia AOUP, Pisa, Italy, Alessandro Lippi, MD, Specialist in Orthopedics and Traumatology, S.O.D. Ortopedia e Traumatologia AOUP, Pisa, Italy, Francesco Casella, MD, Resident in Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy, Gisberto Evangelisti, MD, Resident in Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy, Carmine Citarelli, MD, Resident in Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy, Maurizio Benifei, MD, Specialist in Orthopedics and Traumatology, S.O.D. Ortopedia e Traumatologia AOUP, Pisa, Italy
748
26-07-2016
The peroneal tubercle is an osseous prominence present on the calcaneus bone at the junction between the middle and the anterior third of its lateral surface. It is a bony septum which divides the tendons of the peroneus brevis and the peroneus longus and offers insertion to the inferior peroneal retinaculum. A hypertrophy of this prominence causes pain in the lateral and the posterior part of the foot while wearing shoes, rarely peroneal tenosynovitis can even cause it to break. In the following pages, we will describe a case of peroneal tubercle hypertrophy, visible even at clinical examination, in a 26-year-old male patient without apparent causes nor previous trauma.
Anterior Cruciate Ligament Repair with Internal Brace Ligament Augmentation
William T. Wilson, MBChB, Specialty Registrar, Trauma and Orthopaedics Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom, Graeme P. Hopper, MBChB, Specialty Registrar, Trauma and Orthopaedics Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom, Paul A. Byrne, MBChB, Foundation Doctor, Edinburgh Royal Infirmary, Edinburgh, United Kingdom, Gordon M. MacKay, MD, Consultant Orthopaedic Surgeon, Rosshall Hospital, Glasgow, United Kingdom
786
29-09-2016
Background: Anterior cruciate ligament (ACL) reconstruction using tendon or ligament autograft is the gold standard surgical treatment for acute ruptures; however, this is still associated with subsequent problems and variable outcomes. Renewed interest in healing of injured ACL tissue has led to new surgical repair techniques.
Case Description: We report the case of one of the first patients to undergo this novel procedure of ACL repair with internal bracing. An internal brace is a bridging concept using braided suture tape and knotless bone anchors to reinforce ligament strength. We followed the case of one of the first patients to undergo this technique over two years post-operatively.
Outcomes: In this case, we present a good functional outcome along with radiographic and arthroscopic evidence of a healed ACL with normal appearance. The successful application of this technique has been demonstrated.
Discussion: ACL repair techniques are re-emerging as a promising treatment option for acute proximal ruptures. Repair of the ACL can be performed successfully and has the advantage of retaining the natural proprioceptive fibres of the ligament. The internal brace acts as a secondary stabiliser after repair, which may allow accelerated rehabilitation and return to sports, whilst resisting injury recurrence when this is possible.
Conclusions: Repair with internal bracing of the ACL provides an unobtrusive support which allows accelerated recovery. In this case, we demonstrate with radiographic and arthroscopic evidence, a robustly healed ACL after repair with internal bracing. Functional outcomes are excellent over two years following surgery and long term; retained proprioception may prevent re-injury and development of post-traumatic osteoarthritis.
Increased Femoral Component Size Options Improves Manipulation Rate in Females and Knee Society Clinical Scores in Males
Nathan J. Turnbull, MD, Orthopedic Surgeon, Florida Orthopaedic Associates, DeLand, Florida, Keith R. Berend, MD, Vice President, Joint Implant Surgeons, Inc., New Albany, Ohio, Chief Executive Officer and President, White Fence Surgical Suites, New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Vincent Y. Ng, MD, Assistant Professor of Orthopaedic Oncology, Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, Maryland, Joanne B. Adams, BFA, Research Director and Medical Illustrator, Joint Implant Surgeons, Inc., New Albany, Ohio, David A. Crawford, MD, Fellow, Joint Implant Surgeons, Inc., New Albany, Ohio, Adolph V. Lombardi, Jr., MD, FACS, President, Joint Implant Surgeons, Inc., New Albany, Ohio, Clinical Assistant Professor, Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio
787
24-10-2016
Introduction: The gender-specific total knee arthroplasty (TKA) debate focuses on differences in distal femoral mediolateral to anteroposterior aspect ratio between males and females. However, randomized studies have been unable to demonstrate significant differences in outcomes utilizing gender-specific implants. No studies have examined the effect of intermediate femoral component sizes on outcome. We compared outcomes before and after intermediate sizing availability.
Materials and Methods: We identified 331 patients (413 knees) who underwent primary TKA between 2003 and 2004 with a single complete knee system. There were 121 males and 210 females. Three intermediate femoral sizes were added in March 2004 to the six initial options. Patients before March 2004 were assigned to group 1 (n=178), and after to group 2 (n=235).
Results: Follow-up averaged 8.5 years. Preoperative demographics and clinical scores were similar between groups. Knee Society (KS) clinical and functional scores improved in females in both groups, but there was no significant difference. Male patients in group 2 had a significant improvement in KS clinical scores compared to male patients in group 1 (group 1: 33.9, group 2: 41.1; p=0.01). Females in group 2 had significantly less need for manipulation, 1.9%, versus females in group 1, 8.7% (p=0.01). MUA rates were similar for men between groups. Overall, there were 19 revisions (4.6%) with no differences between groups or by genders. Once intermediate sizes were available, they were used in 48% of females and 13% of males. The average femoral component size for females in group 1 was 65 mm and decreased in group 2 to 62.5 mm. The average size of femoral components in males was 70 mm in both groups.
Conclusions: Availability of intermediate size femoral component sizes was associated with a lower rate of manipulation in female patients. Greater KS clinical score improvement was observed in men after availability of additional femoral sizes.
The Reamer-Irrigator-Aspirator System: A Review
Damien Billow, MD, Attending Physician, Anton Khlopas, MD, Research Fellow, Morad Chughtai, MD, Research Fellow, Anas Saleh, MD, Resident, Marcelo B. Siqueira, MD, Resident, Patrick Marinello, MD, Resident, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
784
2-09-2016
The reamer-irrigator-aspirator (RIA) system has been recently developed to decrease the incidence of osseous thermal necrosis and fat embolism associated with intramedullary reaming of long bones in trauma cases. This is achieved by continuous irrigation and suction. Recently, the use of RIA has been expanded to harvest bone graft and debride the medullary canal of long bones in cases of osteomyelitis and intramedullary tumors. Additionally, the collection system of this device has been utilized for its ability to capture bone graft and marrow aspirate. The purpose of this study is to report a comprehensive literature review on the: 1) use of RIA for canal reaming prior to intramedullary nailing; 2) use of RIA for the treatment of intramedullary osteomyelitis of long bones; 3) use of RIA for bone graft harvesting; 4) osteogenic potential of the RIA aspirate; and 5) future applications of the RIA system.
Factors Associated with Range of Motion Recovery Following Manipulation Under Anesthesia
Johannes F. Plate, MD PhD, Resident, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, Andrew D. Wohler, MD, Resident, Department of Orthopaedic Surgery, Carolinas Health Care System, Charlotte, North Carolina, Matthew L Brown, MD, Resident, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, Daniel Sun, MD, Resident, Department of Orthopaedic Surgery, The University of Texas Medical Branch, Galveston, Texas, Nora F. Fino MS, Statistician, Oregon Health and Science University, Portland, Oregon, Jason E. Lang, MD, Associate Professor, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
776
10-09-2016
Introduction: Stiffness and loss of motion following total knee arthroplasty (TKA) is a complex and multifactorial complication that may require manipulation under anesthesia (MUA). However, patient and surgical factors that potentially influence the development of knee stiffness following TKA are not fully understood. The purpose of this study was to identify patient and surgical factors that may influence range of motion loss following TKA by assessing a cohort of patients that underwent MUA and comparing them to a matched cohort of patients without complications.
Materials and Methods: The joints registry was searched for patients who underwent MUA following primary TKA between 2004 and 2013. Demographic and surgical information was obtained from the electronic medical record including range of motion (ROM), comorbidities and timing of MUA. Patients who underwent MUA were then double-matched by baseline (prior to primary TKA) knee ROM to patients who underwent primary TKA with normal postoperative range of motion recovery during the same time period.
Results: Fifty-two patients (fifty-six knees) (66% female, mean BMI 32.4 kg/m2) underwent MUA after TKA during the study period. MUA was performed a mean of 13.6 weeks after primary TKA. Study patients were double-matched by baseline flexion (mean 107º±2º) to 111 patients (112 knees) with a similar mean baseline flexion (104º±2º, p=0.138). Patients requiring MUA were younger (mean age 56 vs. 64 years, p<0.001), had more comorbidities (5 vs. 3, p<0.001), and a higher number of previous knee surgeries (56% vs. 21%, p<0.001) compared with controls. The risk for requiring MUA following primary TKA was significantly higher (2.4, p<0.001) in patients with previous knee surgery (arthroscopy for meniscal pathology, ACL reconstruction, osteotomies). Tourniquet time, length of stay, number of physical therapy sessions, blood loss >50 mL, and any complication during the hospital stay were not found to be associated with an increased risk of requiring MUA.
Conclusion: Younger patients with more comorbidities and a history of previous knee surgery were found to have significantly higher risk for developing stiffness and loss of motion requiring MUA after primary TKA in the current study. Patients with this risk profile need to be counseled regarding the risk for postoperative knee stiffness and range of motion loss possibly requiring MUA after primary TKA.
Improved Functional Outcomes with Robotic Compared with Manual Total Hip Arthroplasty
Brandon R. Bukowski, BSc, Medical Student, Department of Orthopedics and Rehabilitation, The University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, Paul Anderson, MD, Professor of Orthopedic Surgery, Department of Orthopedics and Rehabilitation, The University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Richard L. Illgen II, MD, Professor of Orthopedic Surgery, Department of Orthopedics and Rehabilitation, The University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
785
1-09-2016
Introduction: Functional outcome following total hip arthroplasty (THA) is affected by accurate component positioning and restoration of hip biomechanics. Robotic-assisted THA (rTHA) has been shown to improve accuracy of component positioning, but its impact on functional outcomes has not been demonstrated. The purpose of this study was to compare: 1) operative time; 2) estimated blood loss; 3) postoperative complications; and 4) patient-reported outcome measures (PROMs) between patients who either underwent rTHA or manual THA (mTHA). Materials and Methods: In this retrospective cohort study, a single-center database was used to identify all patients who underwent primary THA since introduction of rTHA at a large academic medical center. Surgical factors including operative time and estimated blood loss as well as postoperative complications were recorded. Validated PROMs following rTHA (n = 100) were compared with consecutive mTHA cases (n = 100) performed by the same fellowship-trained surgeon at a minimum one-year follow-up (24 ± 6 months). PROMs included the Short-Form 12 Health Survey (SF-12), UCLA activity score (UCLA), Western Ontario and McMaster (WOMAC) Osteoarthritis Index, and modified Harris Hip Score (mHHS). A categorical analysis was performed to determine differences in proportions of patients with mHHS scores of 90 to 100, 80 to 89, 70 to 79, and < 70 points between the two groups. Chi-square and two-tailed t-tests were used to compare categorical and continuous data between cohorts. Results: Mean operative time was nine minutes longer for the rTHA group compared with the mTHA group (131 ± 23 min vs. 122 ± 29 min, respectively, p = 0.012). Estimated intraoperative blood loss was significantly reduced for the rTHA group when compared to the mTHA group (374 ± 133 mL vs. 423 ± 186 mL, p = 0.035), and there was no difference in overall complication rates between the two groups (p = 0.101). Robotic-assisted THA demonstrated significantly higher mean postoperative mHHS (92.1 ± 10.5 vs. 86.1 ± 16.2, p = 0.002) and mean UCLA scores (6.3 ± 1.8 vs. 5.8 ± 1.7, p = 0.033) compared with mTHA. The difference between pre- and postoperative mHHS scores was statistically significant when comparing rTHA with mTHA (43.0 ± 18.8 vs. 37.4 ± 18.3, p = 0.035). There were no significant differences in SF-12 or WOMAC scores. There was a significantly higher proportion of patients with mHHS scores between 90 to 100 points (75% vs. 61%, p = 0.034) and a lower percentage with scores < 70 points (6% vs. 19%, p = 0.005) in the rTHA cohort compared with the mTHA cohort. Discussion: The rTHA cohort demonstrated significantly higher mean postoperative UCLA scores, higher mean postoperative mHHS scores, and a greater percentage of patients with mHHS of 90 to 100 points compared with mTHA at a minimum one-year follow-up. To our knowledge, this is the first study to demonstrate that robotic-assisted THA leads to improved patient-reported outcomes. The observed improvement in functional outcomes following rTHA is encouraging and warrants additional multi-center studies to determine if these advantages are maintained at longer follow-up intervals.
Novel Patient-Specific Instruments for Acetabular Preparation and Cup Placement
Ran Schwarzkopf, MD, MSc, Orthopaedic Surgeon, Department of Orthopaedic Surgery, NYU Langone Medical Center Hospital for Joint Diseases, New York, New York, Erik Schnaser, MD, Orthopaedic Surgeon, Desert Orthopedic Center, Eisenhower Medical Center, Rancho Mirage, California, Taiki Nozaki, MD, Radiologist, Department of Radiological Sciences, University of California, Irvine, Orange, California, Yasuhito Kaneko, MD, Radiologist, Department of Radiological Sciences, University of California, Irvine, Orange, California, Michael J. Gillman, MD, Orthopaedic Surgeon, Restore Orthopedics Orange, Orange, California
775
7-09-2016
Introduction: Patient-specific implants and instruments (PSI) have been used in both knee and shoulder replacements due to the perceived benefits of improved surgical accuracy and efficiency. The proposed benefits of using a PSI in total hip arthroplasty (THA) are numerous and include reduction of operative time and improved mechanical and anatomical alignment leading to increased implant longevity, increased stability, and clinical outcomes. We describe a novel patient-specific instrumentation and a surgical method that may improve directed resection of acetabular bone and accurate cup placement during THA.
Materials and Methods: In this cadaveric study, 14 acetabuli were used. Pre-operative CT or MRI scans were obtained as part of the acetabular jigs Bullseye Hip Replacement Instruments® (Bullseye Hip Replacement, LLC, Las Vegas, Nevada) protocol. Two senior hip surgeons performed all the operations in accordance to the PSI technique. Post-operative CT scans were obtained and acetabular cup orientation was measured by two independent radiologists.
Results: Fourteen acetabuli were implanted using the Bullseye Hip Replacement Instruments®. Acetabular cup anteversion angle as measured on post-operative CT images averaged, for all 14 acetabuli, 15.50. Acetabular cup abduction/inclination angle as measured on post-operative CT images averaged 35.9°. All implanted components’ size/diameter matched the preoperative surgical planned implant size.
Conclusion: The Bullseye Hip Replacement Instruments® show good reproducible acetabular cup placement in both anteversion and abduction angles, and accurate sizing of the acetabular component.
Prevention of Dislocation Risk During Hip Revision Surgery with the Dual Mobility Concept; Study of a New Generation of Dual Mobility Cups
Antoine Dangin, Resident, Orthopedic and Trauma Surgery Department, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France, Sandrine Boulat, Resident, Orthopedic and Trauma Surgery Department, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France, Frédéric Farizon, MD, Professor, Orthopedic and Trauma Surgery Department, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France, Rémi Philippot, MD, PhD, Professor, Orthopedic and Trauma Surgery Department, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
791
15-10-2016
Introduction: Total hip arthroplasty (THA) is a common surgery presenting well-known failures that may require surgical revision. To reduce the risk of hip dislocation after revision THA, we hypothesize the interest of the use of a new generation dual mobility cup by evaluating its survival and complication rates.
Materials and Methods: We analyzed the survival and the failures rate of 91 patients who underwent revision THAs with a specific dual mobility cup Novae® E TH (SERF, Décines-Charpieu, France). The surgical indication for revision THAs were: 59 aseptic loosening or insert advanced wear (61.5%), 10 recurrent dislocations (10.9%), and 22 deep infections (24.1%). All patients underwent the same surgical technique and received a clinical and radiological examination. Failure of the cup was defined as an aseptic loosening; all failures were reported.
Results: During the follow up, 17 patients died and five were unaccounted for. The mean follow-up of the 86 patients included was 33 months (0–71) with a mean age of 71 years (41–99) at the time of surgery. The Postel Merle D’Aubigné (PMA) increased by 6.8 points from preoperative until the last consultation. No aseptic loosening was reported. The postoperative dislocation rate was 3.5% and 4.6% for deep infections. The overall rate for re-revision THAs was 8.1%.
Discussion: New choice of design and coating for the cup have demonstrated good results to reduce the rate of aseptic loosening compared to other studies. The three hip dislocations concerned two patients who had a history of recurrent dislocation and psychiatric pathologies. The limit of the study is its short follow-up, partially explained by the occurrence of 10 deaths in the first year of follow-up (lowering the mean).
Conclusion: The use of a cementless dual mobility tripod cup for revision THA confirms its place in the possible therapeutic range by its excellent results at medium term.
Pressure Pain Threshold as a Predictor of Acute Postoperative Pain Following Total Joint Arthroplasty
Brandon A. Haghverdian, BSc, Medical Student, Department of Orthopaedic Surgery, University of California, Irvine School of Medicine, Irvine, CA, David J. Wright, MD, MSc, Resident Physician, Department of Orthopaedic Surgery, University of California, Irvine School of Medicine, Irvine, CA, Ran Schwarzkopf, MD, MSc, Assistant Professor, Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center Hospital, for Joint Diseases, New York, NY
757
3-07-2016
Objectives: Acute pain in the postoperative period after total joint arthroplasty (TJA) has a significant effect on early rehabilitation, hospital length of stay, and the development of chronic pain. Consequently, efforts have been made to predict the occurrence of postoperative pain using preoperative and intraoperative factors. In this study, we tested the usefulness of preoperative pressure pain threshold (PPT) values in the prediction of three outcomes for patients who underwent TJA: visual analog scale pain scores, hospital length of stay, and opioid consumption.
Materials and Methods: Using a digital pressure algometer, we measured the preoperative PPT in 41 patients expected to undergo TJA at three different body sites: the first web space of the hand, the operative joint, and the contralateral joint. We correlated each PPT separately with postoperative visual analog scale pain scores, hospital length of stay, and opioid consumption. Results: No significant correlation was found between preoperative PPT and the three postoperative outcomes. This finding held true when patients were subdivided by surgery type (total knee arthroplasty vs. total hip arthroplasty). There was no significant difference in PPT between the three body testing sites.
Discussion: This study failed to prove the usefulness of PPT in the prediction of acute postoperative pain, pain medication consumption, and length of stay. The pressure algometer has previously found a place in the assessment of pain in a variety of clinical settings, but its utility has not yet been demonstrated in patients undergoing TJA.
Innovative Multi-Modal Physical Therapy Reduces Incidence of Manipulation Under Anesthesia (MUA) in Non-Obese Primary Total Knee Arthroplasty
Tanner McGinn, BS, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anil Bhave, PT, Physical Therapist, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Osman Ali, MD, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Prathik Mudaliar, MD, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Steven F. Harwin, MD, Chief, Adult Reconstruction and, Total Joint Replacement, Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New York, Michael A Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
764
2-08-2016
Introduction: Patients may experience knee stiffness following total knee arthroplasty (TKA). Non-operative measures, such as more physical therapy and special splints are warranted in such cases. In the event of failure of these measures to restore knee range of motion, more invasive procedures with higher risks, such as manipulation under anesthesia (MUA) or repeat surgery, can be utilized. Thus, it becomes essential to optimize their non-operative measures in order to avoid more invasive, riskier options. Therefore, the purpose of this study was to evaluate and compare: 1) range of motion, and 2) the rate of MUA in patients who either underwent a multi-modal physical therapy regimen (IMMPT) or standard-of-care post-operative therapy (standard) following primary total knee arthroplasty.
Materials and Methods: We analyzed all non-obese patients who underwent primary TKAs between January 2013 and December 2014 at our institution who started an outpatient physical therapy program within six weeks of their surgery (n = 127 knees). There were 86 women and 41 men who had a mean age of 67 years (range, 42 to 88 years). This cohort was stratified into those who underwent an IMMPT regimen at our institution (n= 47) and those who underwent standard therapy at an outside institution (N = 80). The range of motion and rate of manipulation between the two groups was compared by using Chi-square and Student’s t-test, as appropriate.
Results: There were similar proportions of those who had an optimal range of motion (≥110 degrees flexion and ≤5 degrees extension) in the IMMPT group as compared to the standard physical therapy cohort (81% vs. 82%). The IMMPT cohort had a significantly lower proportion of patients who underwent MUA as compared to the standard therapy cohort (2% vs. 13%).
Conclusions: This study shows an IMMPT protocol utilizing Astym® therapy (Performance Dynamics, Inc. Muncie, Indiana) is able to significantly reduce the rate of manipulation following a total knee arthroplasty. Furthermore, this IMMPT approach was also able to achieve similar range of motion to the standard physical therapy group while reducing the rate of manipulation, which may indicate similar efficacy in restoring range of motion. Comparative randomized studies are needed to determine the true benefit of this IMMPT protocol.
Early Experience with Vitamin E Antioxidant-Infused Highly Cross-Linked Polyethylene Inserts in Primary Total Knee Arthroplasty
Emilie M. Flament, Pre-medical Y4, Florida Southern College, Lakeland, Florida, Research Intern, Joint Implant Surgeons, Inc., New Albany, Ohio, Keith R. Berend, MD, Vice President, Joint Implant Surgeons, Inc., New Albany, Ohio, Chief Executive Officer and President, White Fence Surgical Suites, New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, OH, Jason M. Hurst, MD, Secretary, Joint Implant Surgeons, Inc., New Albany, Ohio, Chief Operating Officer, White Fence Surgical Suites, New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Michael J. Morris, MD, Treasurer, Joint Implant Surgeons, Inc., New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Joanne B. Adams, BFA, CMI, Research Director and Medical Illustrator, Joint Implant Surgeons, Inc., New Albany, Ohio, Adolph V. Lombardi Jr., MD, FACS, President, Joint Implant Surgeons, Inc., New Albany, Ohio, Clinical Assistant Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio
774
10-10-2016
Background: In past decades, polyethylene wear was a major cause of failure in total knee arthroplasty (TKA). Polyethylene for use in arthroplasty has been vastly improved in recent years, with improved materials as well as manufacturing and sterilization processes. Testing has shown that infusion of vitamin E prevents oxidative degradation of polyethylene without remelting, allowing the material to maintain mechanical properties and wear resistance over time. The purpose of this study is to review the early result of patients undergoing primary TKA with vitamin E antioxidant-infused polyethylene inserts.
Materials and Methods: A query of our practice registry revealed 148 patients (163 knees) who underwent primary cemented TKA using the Vanguard® Complete Knee System and E1® Antioxidant Infused polyethylene bearings (Zimmer Biomet, Warsaw, Indiana) between May 2009 and May 2013. Indications for E1® bearings were younger, more active patients. There were 65 males (44%) and 82 females (56%). Mean age was 50.6 years and mean BMI was 37.3 kg/m2.
Results: At mean follow-up of 3.2 years (range 6 weeks to 6.4 years), there have been seven revisions (4.3%): three two-staged exchanges for infection, two for arthrofibrosis (one insert only, one femoral and tibial), and two (insert only) for late instability with imbalanced tight posteromedial and loose lateral structures. No aseptic loosening has occurred. Mean range of motion improved from 108° preoperatively to 112°, Knee Society clinical scores improved from 36 to 84 and function scores from 56 to 66. Postoperative radiographs, available for 160 TKA, revealed lateral patellar tilt in one knee, and satisfactory position, alignment, and fixation in all others.
Conclusion: At up to 6.4 years’ follow-up, two mechanical failures of the device have occurred and no aseptic loosening. Survival was 100% with aseptic loosening as the endpoint, and 95.7% with revision for any reason as the endpoint.
Do Pre-Operative Glycated Hemoglobin Levels Correlate with the Incidence of Revision in Diabetic Patients that Undergo Total Knee Arthroplasty?
Martin Roche, MD, Chief, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida, Tsun Yee Law, MD, Research Fellow, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Randa K. Elmallah, MD, Resident, Department of Orthopaedic Surgery, University of Mississippi, Jackson, Mississippi, Zachary Hubbard, BS, Research Assistant, University of Miami Miller School of Medicine, Miami, Florida, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
783
21-09-2016
Introduction: The purpose of this study was to: 1) determine the incidence of revision total knee arthroplasty (TKA); 2) correlate the percent of glycated hemoglobin with incidence of revision; and 3) determine the cause of revision in diabetic patients stratified by a glycated hemoglobin level.
Materials and Methods: We analyzed 424,107 patients from a national private payer database from 2007 to 2015 to determine who had diabetes and underwent TKA. We determined the incidence of revision TKA in the overall cohort and stratified it by glycated hemoglobin levels. Correlation analysis between the levels of glycated hemoglobin and the incidence of revision TKA was performed. We performed descriptive statistics of the underlying cause of revision TKA in both the overall and stratified cohorts.
Results: There was a 3.2% incidence of revision in the overall cohort. When stratified by glycated hemoglobin levels, the cohort in the 6.6 to 7.0% category had the lowest incidence of revision (2.9%). The cohorts in the 8.6 to 9% glycated hemoglobin category had the highest revision rate (4.7%). There was a significantly positive correlation between rate of revision and ascending glycated hemoglobin levels, and a significantly negative correlation between descending glycated hemoglobin levels and revision incidence. The most common cause of revision was infection in the overall and stratified groups.
Conclusion: Sub-optimal glycated hemoglobin levels in diabetic patients correlated with increased revision rates in those who underwent TKA. Management of diabetics should be optimized before undergoing TKA to minimize revision surgery risk.
