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Surgical Technology International 30

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Surgical Technology International Vol. 30 contains 73 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

June-2017- ISSN:1090-3941

 

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Orthopaedic Surgery

Dual Mobility Acetabular Cups in Primary Total Hip Arthroplasty in Patients at High Risk for Dislocation
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, 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, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Chukwuweike Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Jared M. Newman, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Carlos A. Higuera, MD, Attending Physician, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Peter M. Bonutti, MD, Orthopaedic Surgeon, Bonutti Clinic, Effingham, Illinois, Arthur L. Malkani, MD, Professor, Orthopaedic Surgery Department, University of Louisville, Louisville, Kentucky, Frank R. Kolisek, MD, Orthopaedic Surgeon, OrthoIndy, Greenwood, Indiana, 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, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: Postoperative dislocation occurs in approximately 2% of primary total hip arthroplasties (THAs). Risk factors associated with dislocation include: age of 70 years or older, body mass index (BMI) of 30 kg/m2 or greater, alcohol abuse, and neuro-degenerative diseases such as multiple sclerosis or Parkinson’s disease. As a result, dual-mobility articulations, which have been typically used for revision procedures, have become an increasingly popular option for these “at risk�? primary THAs. Few studies have assessed their use in this complex patient population. Therefore, the purpose of this study was to assess: 1) survivorship; 2) radiographic outcomes (cup migration, progressive radiolucencies, and changes in component position); 3) Harris Hip Scores; and 4) complications of the dual-mobility articulation in the setting of primary THA for patients at high risk for dislocation.
Materials and Methods: Five participating surgeons performed 495 primary cementless THAs between January 2011 and December 2013. During this time, four of the five surgeons used dual-mobility articulations whenever the acetabular cup size was 52 mm or greater to allow for a 28 mm head, while one surgeon used it when the cup size was less than 52 mm to allow for an effective head size of 38 mm. The remaining surgeon used it for all THAs. Of the 495 patients, 453 (92%) received dual-mobility articulations, of which, 43 patients (10%) were lost to follow-up before the two year minimum. The remaining 410 patients were further assessed to determine those who were considered high risk for dislocation (age ≥ 70 years, BMI ≥30 kg/m2, had a diagnosis of alcohol abuse, or had a neuro-degenerative disorder). Two hundred forty-nine patients were included in the analysis (103 men, 146 women) who had a mean age of 66 years (range, 24 to 90 years). The mean follow-up was 3.3 years (range, 2 to 5 years). Kaplan-Meier analysis was performed to assess aseptic and all-cause acetabular cup survivorship. Radiographs were evaluated for cup migration, progressive radiolucencies, and any changes in component position. Clinical outcomes were assessed using the Harris Hip Score (HHS), and any surgery-related complications were recorded.
Results: The survivorship to aseptic failure (n= 1) and all-cause (aseptic, n= 1; septic, n= 1) Kaplan-Meier acetabular component survivorships were 99.6% (95% confidence interval [CI], 99.1% to 99.9%) and 99.2% (95% CI, 98.5% to 99.9%), respectively. One hip had impingement of an anteverted cup, resulting in trunnion notching, and required revision of the cup and stem. Another hip had a deep infection, which was treated with a two-stage revision procedure. There were no dislocations in this cohort. No progressive radiolucencies or component positional changes were seen on radiographic assessment. Patients reported a mean HHS of 92.5 (range, 47 to 100 points) at final follow-up. Surgical complications included one polyethylene liner that was incompletely seated, and one loose femoral stem, which required revision of only the femoral component.
Conclusions: At short-term follow-up, dual-mobility articulations in primary THA offer survivorship, outcomes, and complications comparable to conventional THA designs in patients who are at increased risk for postoperative dislocation. Serious complications, such as polyethylene wear and intraprosthetic dislocations, have occasionally been reported with the use of these components. Therefore, future studies should be prospective, multi-center, and have longer-term follow-up to determine the true benefit of modular dual-mobility articulations in patients who are at high risk for dislocation.

 

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A Randomized, Multicenter, Double-Blind Study of Local Infiltration Analgesia with Liposomal Bupivacaine for Postsurgical Pain Following Total Knee Arthroplasty: Rationale and Design of the Pillar Trial

Stan Dysart, MD, Board Certified Orthopaedic Surgeon, Pinnacle Orthopaedics, Marietta, Georgia, Mark A. Snyder, MD, Director of the Orthopaedic Center of Excellence at Good Samaritan Hospital, Wellington Orthopaedics and Sports Medicine, Cincinnati, Ohio, Michael A. Mont, MD, Chairman of the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio

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Introduction: Liposomal bupivacaine, a prolonged-release formulation of bupivacaine hydrochloride, is indicated for infiltration into the surgical site for postsurgical analgesia. Results from previous total knee arthroplasty (TKA) studies suggest that analgesic efficacy associated with liposomal bupivacaine may be impacted by variability in infiltration technique. The PILLAR study is designed to assess liposomal bupivacaine efficacy in TKA using a standardized infiltration protocol.
Materials and Methods/Design: This phase 4, multicenter, randomized, double-blind, controlled, parallel-group study will compare the safety and efficacy of infiltration with liposomal bupivacaine versus standard bupivacaine for postsurgical pain control in adults undergoing primary unilateral TKA. All subjects will receive a standardized pre-surgical analgesic regimen, and will be randomized to receive either liposomal bupivacaine 266 mg/20 mL (admixed with standard bupivacaine 0.5% 20 mL and expanded to a total volume of 120 mL) or bupivacaine 0.5% 20 mL (expanded to a total volume of 120 mL). The study drug will be infiltrated using six syringes (prefilled with 20 mL of study drug solution) to deliver 1-1.5 mL infusions into prespecified periarticular tissues. All subjects will receive standardized postsurgical analgesia and access to rescue medication. The co-primary efficacy endpoints are area under the curve of visual analog scale pain intensity scores from 12–48 hours postsurgery and total postsurgical opioid consumption from 0–48 hours. Secondary efficacy endpoints include other pain assessments, time to first use of rescue medication, discharge readiness, use of skilled nursing facilities, and hospital length of stay. Safety will be evaluated based on adverse events.
Discussion/Conclusion: The use of a standardized protocol comparing infiltration of equal volumes of the study drug, designed by experienced investigators to ensure complete coverage of all areas innervating the surgical site while minimizing leakage of study drug, will help define the role of liposomal bupivacaine in the setting of TKA.

 

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Tranexamic Acid and Computer-Assisted Surgery in Cemented and Cementless Total Knee Arthroplasty: Are the Effects Additive for Blood Conservation?
Michael Fleischman, DO, Orthopedic Surgeon, The Vancouver Clinic, Vancouver, Washington, Mark Hood, Jr., MD, MS, Resident, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, Mary Ziemba-Davis, BA, Director of Research for Orthopedics, Academic Health Center, Indiana University Health Physicians, Fishers, Indiana, R. Michael Meneghini, MD, Associate Professor of Orthopaedic Surgery, Indiana University School of Medicine, Director of Joint Replacement, Indiana University Health Physicians Orthopedics and Sports Medicine, Fishers, Indiana

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Introduction: Efforts continue to minimize blood loss associated with total knee arthroplasty (TKA). The primary objective of this study was to determine whether computer-assisted surgery (CAS) and tranexamic acid (TXA) were additive in minimizing blood loss in cemented TKA. The secondary objective was to assess the combined effectiveness of CAS and TXA in cementless TKA.
Materials and Methods: A retrospective study of 393 consecutive primary TKAs with cemented and cementless fixation was performed. Cemented and cementless fixation TKA cohorts were divided into three subgroups: (1) neither CAS nor TXA was used, (2) CAS alone was used, or (3) CAS plus TXA was used. Three blood loss metrics were calculated: (1) postoperative change in hemoglobin, (2) total drain output, and (3) calculated total blood loss.
Results: After exclusions, 267 cemented TKAs and 35 cementless or hybrid TKAs were available for analysis. In cemented TKAs, the mean postoperative hemoglobin decrease was 2.9 g/dL in patients without CAS or TXA, 2.5 g/dL in the CAS only group, and 2.1 g/dL in the CAS and TXA group (p ≤ 0.001). Median total drain output was lower in the CAS plus TXA group (230 ml) compared to the CAS alone (442.5 ml), and the neither CAS nor TXA group (620 ml) (p ≤ 0.001). Mean calculated total blood loss was 1258.7 ml in the group with neither CAS nor TXA, 1023.8 ml in CAS alone, and 869.1 ml for both the CAS and TXA group (p ≤ 0.001). In cementless TKA, the postoperative hemoglobin drop decreased from 3.3 g/dL in the neither CAS nor TXA group to 2.5 g/dL with CAS alone and 1.9 g/dL in the CAS plus TXA (p = 0.024). Mean total drain output progressively declined with CAS alone and for those with CAS plus TXA compared to those without CAS or TXA (p = 0.004).
Conclusions: An encouraging additive decrease in blood loss after TKA can occur with utilization of both CAS and TXA. The additive effect of both modalities appears to exist in cemented and cementless fixation techniques. Whether this blood conservation will result in improved patient outcomes remains unknown and should be the topic of further study.

 

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Factors Predisposing to Dislocation After Primary Total Hip Arthroplasty: A Multivariate Analysis of Risk Factors at 7 to 10 Years Follow-up
Michele Francesco Surace, MD, Professor and Director of the Residency Program, Orthopedics and Trauma Clinic, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy, Luca Monestier, MD, Orthopedic Surgeon, Orthopedic and Trauma Unit, ASST Sette Laghi, Varese, Italy, Fabio D’Angelo, MD, Professor, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Director Orthopedic and Trauma Unit, ASST Sette Laghi, Varese, Italy, Andrea Bertagnon, MD, Resident, Orthopedics and Trauma Clinic, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy

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Background: Dislocation of primary THA (total hip arthroplasty) is one of the most undesirable complications with an incidence ranging from 2% to 5%. Several risk factors are described, related to the patient, surgery, or prosthetic design. The aim of the study was to assess risk factors and their potential influence on dislocation.
Materials and Methods: 387 primary THA were performed between September 2005 to December 2008 at our institute (Varese, Italy) through a modified posterior-lateral approach. Clinical evaluation was based on range of motion (ROM) and Harris Hip Score; femoral offset, acetabular inclination, and anteversion were measured on plain radiograms. Data were analyzed by SPSS software (SPSS, Inc., Chicago, Illinois).
Results: Excellent ROM and Harris Hip Scores were achieved in more than 95% of patients (p<0.05). The offset was restored in all patients. Most of the cases had their cup positioned in the “safe zone�? (both inclination and anteversion). Six dislocations (1.87%) occurred: significant correlation was found between dislocation and preoperative diagnosis of femoral neck fracture.
Conclusions: THA dislocation rate appears not to be related to patient biometric parameters and prosthesis design. Femoral neck fracture is reported as the major risk factor for this complication, probably caused by higher preoperative activity and lesser compliance of the patient.

 

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Intraarticular Administration of Tranexamic Acid is Safe and Effective in Total Knee Arthroplasty Patients at High-Risk for Thromboembolism
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, Chukwuweike Gwam, 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, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Melbin Thomas, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Prathik P. Mudaliar, BS, 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, Vidur Tangri, BS, Research Assistant, 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

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Introduction: Tranexamic acid (TXA) is an antifibrinolytic agent that can be used to reduce blood loss in total knee arthroplasty (TKA) patients. Due to its thrombogenic properties, intravenous (IV) TXA is contraindicated in patients who have an increased risk of arterial or venous thrombosis. For such patients, intraarticular (IA) TXA may be a safe alternative. In this study, we compare: 1) complication rates; 2) intraoperative blood loss; and 3) need for transfusion in TKA patients who received IA TXA versus patients who used IV TXA.
Materials and Methods: A retrospective chart review of a single surgeon was performed for patients who received a TKA and had either IV TXA or IA TXA (due to increased risk of thrombosis). This yielded 60 patients who had a mean age of 65 years (range, 36 to 84 years). Twenty-six patients received IA TXA as a consequence of being ineligible for IV TXA, because of increased risk for arterial or venous thromboembolism. Thirty-four patients received IV TXA. Complication rates and need for transfusion were evaluated as categorical variables. Amount of blood loss was evaluated as a continuous variable. All categorical variables and continuous variables were analyzed using chi-square test and student’s t-test respectively.
Results: Overall, four patients (7 %) developed complications after the procedure, three of which were in the IA cohort and one in the IV cohort (p= 0.444). In the IA cohort, two patients developed arthrofibrosis and subsequently underwent manipulation under anesthesia. Additionally, one patient in this group developed a hematoma one week after TKA. This patient was managed conservatively until the condition resolved, and no further issues have been reported. One patient in the IV cohort developed a deep vein thrombosis, which was appropriately treated with no further issues. There was no significant difference in mean blood loss or number of transfusions between patients who received IA TXA or IV TXA (289 mL vs. 268 mL, p= 0.503; 3 vs. 4, p= 0.651, respectively).
Conclusion: High-risk patients who have contraindications against intravenous TXA may be good candidates for intraarticular TXA. Our study demonstrated no significant differences in complication rates, blood loss, and transfusion rates in patients who received intravenous TXA as compared to those who received intraarticular TXA during total knee arthroplasty. We conclude that the intraarticular administration of TXA may be a safe and effective alternative for patients who have contraindications against intravenous TXA.

 

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Intrawound Vancomycin Powder Reduces Early Prosthetic Joint Infections in Revision Hip and Knee Arthroplasty
Jeffrey E Otte, MD, Resident, Orthopedic Surgery, Mount Carmel Health Systems, Columbus, Ohio, Joel R. Politi, MD, Associate Faculty Member, Department of Orthopedic Surgery, Mount Carmel Healthy Systems, Columbus, Ohio, Bryan Chambers, MD, Associate Faculty Member, Department of Orthopedic Surgery, Mount Carmel Health Systems, Columbus, Ohio, Craig A. Smith, MD, Resident, Orthopedic Surgery, Mount Carmel Health Systems, Columbus, Ohio

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Intrawound vancomycin powder has shown efficacy and safety in decreasing postoperative spine infections, but its use in arthroplasty has not been well established. The purpose of this study was to compare the rate of early prosthetic joint infections (PJI) with and without the use of intrawound vancomycin powder during joint arthroplasty. A retrospective cohort of all patients who underwent primary or revision hip or knee arthroplasty by two surgeons over a two-year period at a single hospital system was evaluated. The control group received standard systemic prophylaxis only, whereas the treatment group received 1 g of vancomycin powder in the surgical wound in addition to systemic prophylaxis. A statistically significant decrease in the overall PJI rate was found in the treatment group (4/816=0.49%) compared to the control group (13/824=1.57%; p=0.0479). Subgroup analysis demonstrated a trend toward fewer PJIs in the vancomycin group, however, only the revision procedures showed a statistically significant reduction in early PJIs after the initiation of vancomycin (7/180=3.89% to 0/134=0%; p=0.0217). The use of intrawound vancomycin powder was associated with a significant reduction in the overall incidence of early PJIs following joint arthroplasty, however, only the revision procedures demonstrated a significant reduction in the rate of early PJIs.

 

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Early Termination of Randomized Clinical Trials in Orthopaedics
Nicolas Piuzzi, MD, Clinical Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Chukwuweike U. Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, George Muschler, MD, Attending Physician, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Kurt P. Spindler, MD, Director of Research, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Michael A Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Randomized controlled clinical trials (RCTs) in orthopaedics, similar to all medical fields, provide the highest level of clinical data and constitute the cornerstone for evidence-based therapeutic advances. Orthopaedic clinical trials face the same challenges as in other medical fields, such as insufficient recruitment, unforeseen adverse events, and futility. In this article, we highlight the reasons for early termination of clinical trials and provide examples of each type.

 

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Three-Year Results with a Ringless Third-Generation Porous Plasma Sprayed Acetabular Component in Primary Total Hip Arthroplasty

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, Joanne B. Adams, BFA, CMI, Research Director and Medical Illustrator, Joint Implant Surgeons, Inc., New Albany, Ohio, Michael J. Morris, MD, Treasurer, Joint Implant Surgeons, Inc., New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, 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

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Introduction: We previously reported promising early results in patients undergoing primary total hip arthroplasty (THA) with a third-generation cementless acetabular system that has a porous plasma-sprayed coating on a titanium alloy substrate shell, a ringless barb and groove locking mechanism, and a vitamin E-infused highly crosslinked polyethylene insert. The purpose of this study was to examine the outcomes and need for revision in a subset of patients previously reviewed who now have potential for three-year follow-up.
Patients and Methods: A query of our practice registry revealed 235 consented patients (241 hips) who underwent cementless primary THA performed by three surgeons with the G7® Acetabular System (Zimmer Biomet, Warsaw, Indiana) between April 2013 and September 2013. All liners were vitamin E-infused highly crosslinked polyethylene with a neutral face. Mean patient age was 65.8 years and mean BMI was 31.3 kg/m2. Heads used were 179 Biolox® delta (74%; CeramTec AG, Plochingen, Germany) and 62 cobalt-chromium (26%), with diameters of 32mm in 105 (41%) and 36mm in 136 (56%).
Results: A minimum three-year follow-up was available for 152 hips in 146 patients. Harris Hip Scores improved from 47.8 to 88.2, and UCLA activity scale from 3.9 to 5.4. One patient from this study period required cup revision secondary to failure of biological fixation at 15.1 months postoperative. There have been no dislocations or other revisions of the acetabular component. Kaplan-Meier survival with endpoint of acetabular revision was 99.5% (95% CI: 99.0% to 100%) at 3.4 years. Radiographic findings in all cases were satisfactory position and alignment with no radiolucencies observed.
Conclusion: In this study, with minimum three-year follow-up, good results with 99.5% survival were achieved using a third-generation cementless acetabular system with a ringless barb and groove locking mechanism.

 

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Efficacy of Adductor Canal Blockade Compared to Multimodal Peri-Articular Analgesia Following Total Knee Arthroplasty

Chukwuweike U. Gwam, 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, Priya Jha, BS, 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, Melbin Thomas, 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, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, 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

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Introduction: Postoperative pain after total knee arthroplasty (TKA) can be an impediment to patient recovery. Many commonly used pain control modalities are effective, but are also associated with adverse effects. Other modalities, such as adductor canal blocks (ACB) and multimodal periarticular analgesia (MPA), have gained popularity due to their efficacy and high safety profile. However, to the best of our knowledge, there are no published studies indicating if a therapeutic advantage exists between the two pain control modalities. Therefore, the purpose of this study was to assess the: 1) length of stay; 2) level of pain; 3) discharge status; and 4) opioid consumption, in TKA patients who received either ACB or MPA.
Materials and Methods: A single hospital, single surgeon database was reviewed for patients who had a TKA between January 2015 and April 2016, and received either ACB or MPA. This search yielded 98 patients who had a mean age of 63 years (range, 38 to 90 years), comprised of 29 men and 69 women. Patients were divided into those who received ACB alone (n= 54) and those who received MPA alone (n= 44). With the use of electronic medical records, demographic and endpoint data were obtained. Pain was quantified using the Visual Analog Scale (VAS). Continuous variables were compared using the student’s t-test, while categorical variables were compared utilizing a chi-square test.
Results: The mean length of hospital stay (LOS) was significantly shorter for patients who had ACB when compared to patients who had MPA (2.12 days vs. 2.88 days; p = 0.005). There was no significant difference in VAS scores (p= 0.448), proportion of patients discharged home (p= 0.432), or total opioid consumption (p= 0.247) between the two groups.
Conclusion: Total knee arthroplasty patients who received an adductor canal block had shorter lengths of stay when compared to those who received multimodal peri-articular analgesia. Shortened hospital stays may be cost-effective for institutions and providers, however, larger studies are needed to further assess the effect on quality of care provided.

 

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Development of an Encompassing Questionnaire for Evaluating the Outcomes Following Total Knee Arthroplasty

Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Melbin Thomas, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Chukwuweike U. Gwam, 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, Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, Randa K. Elmallah, MD, Resident, Department of Orthopaedic Surgery, University of Mississippi, Jackson, Mississippi, Martin Roche, MD, Chief, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida, Michael A Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: There are many standardized scales and questionnaires used to evaluate TKA patients; however, individually they do not always assess patients adequately. Consequently, many are used in combinations to provide a thorough evaluation. However, this leads to redundancy, confusion, and an excessive patient time-burden. Therefore, the purpose of this study was to develop a usable combined knee questionnaire that combines questions in a non-redundant manner. Specifically, we aimed to: 1) create a combined knee questionnaire that encompasses questions from multiple systems, while eliminating redundancy; 2) correlate the new system with the existing validated questionnaires; and 3) determine the length of time it takes to administer this new questionnaire.
Materials and Methods: In a previous study, it was determined that the six most commonly cited validated systems to assess the knee were the: Knee Society Score (KSS), The Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lower Extremity Functional Scale (LEFS), Activity Rating Scale (ARS), and Short-Form-36 (SF-36). Therefore, we ensured that the new questionnaire encompassed all elements of these systems. After development of the combined questionnaire, we co-administered it to 20 subjects alongside the above validated questionnaires. We then transposed the corresponding answers from the combined questionnaire to each selected validated system to perform an intra-class correlation analysis. In addition, we recorded the length of time it took to administer the new questionnaire and compared it to the time it took to administer the individual validated questionnaires.
Results: Intra-class correlation analysis demonstrated statistically significant positive correlations between the KSS, WOMAC, KOOS, LEFS, ARS, SF-36, and the corresponding questions in the combined questionnaire. The mean length of time it took to administer the combined questionnaire (mean, 10.1 minutes, range, 6.6 to 12.6 minutes) was significantly shorter than the time it took to administer the selected validated questionnaires (mean, 21.3 minutes, range, 17.3 to 24.1 minutes).
Conclusion: We have proposed an all-encompassing combined knee questionnaire that eliminates redundancy and inefficiency during the evaluation of TKA patients. It is a reliable, time-efficient system that can be utilized to fill out the most commonly used questionnaires for assessing TKA. Standardization and uniform use of this questionnaire may simplify future patient assessment following TKA.

 

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The Learning Curve Associated with the Administration of Intra-Articular Liposomal Bupivacaine for Total Knee Arthroplasty: A Pilot Study
Anton Khlopas, 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, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, George A. Yakubek, DO, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Mhamad Faour, 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, Carlos A. Higuera, MD, Attending Physician, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Robert M. Molloy, MD, Director of Adult Reconstruction, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: Liposomal bupivacaine is a long-acting, local, injectable anesthetic that is used to potentially mitigate post-operative pain after total knee arthroplasty (TKA). In addition, it may reduce opioid use in the post-operative period and shorten lengths-of-stay (LOS). There have been mixed results in the literature with regards to its efficacy, which raises questions regarding the injection technique used. Therefore, we evaluated the learning curve associated with injection techniques prior to, and after, formal teaching. Specifically, we compared differences in: 1) opioid use; 2) LOS; 3) pain intensity; and 4) discharge disposition in patients who did not receive liposomal bupivacaine (no infiltration cohort), received liposomal bupivacaine with less optimal technique (subpar infiltration), and received liposomal bupivacaine with appropriate technique (optimal infiltration) during their primary TKA.
Materials and Methods: A 1:1:1 ratio of 54 consecutive cases of patients who had no liposomal bupivacaine infiltration, those who had subpar infiltration, and those who had optimal infiltration were included. To evaluate opioid use, the dosages were obtained and converted to their respective morphine milliequivalents (mEq). The total mEq usage was obtained for the day of surgery through post-operative day (POD) 3. LOS was recorded in days. Pain scores were calculated using the visual analogue scale (VAS), obtained from the first post-operative physical therapy note. Discharge status was recorded as discharged to home or rehabilitation. We used an ANOVA test for continuous and X2-square test for categorical variables.
Results: When compared to patients who had no infiltration, patients who had subpar infiltration had significantly lower opioid use on day 0, while patients who had optimal infiltration had lower opioid use on post-operative day (POD) 0 and 3. When comparing techniques, opioid use was lower on day 3 for patients who had optimal, as compared to subpar technique. However, LOS and VAS were not significantly different among the three groups. The rehab discharge rate was lower for patients who had optimal as compared to subpar technique.
Conclusion: There is a learning curve associated with liposomal bupivacaine use, and incorporating an appropriate technique can markedly affect post-operative outcomes. This should be taken into account when evaluating the potential benefits of this peri-articular injection. It appears that liposomal bupivacaine may decrease opioid use and pain scores when optimal infiltration techniques are used.

 

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Chronic Achilles Tendon Rupture Treated with Allograft: A Case Report
Giuseppe Restuccia, MD, Specialist, Department of Orthopedics and Traumatology, S.O.D Ortopedia e Traumatologia AOUP, Pisa, Italy, Alessandro Lippi, MD, Specialist, Department of Orthopedics and Traumatology, S.O.D Ortopedia e Traumatologia AOUP, Pisa, Italy, Francesco Casella, MD, Resident, Department of Orthopedics and Traumatology, University of Pisa, Pisa, Italy, Carmine Citarelli, MD, Resident, Department of Orthopedics and Traumatology, University of Pisa, Pisa, Italy, Federico Sacchetti, MD, Resident, Department of Orthopedics and Traumatology, University of Pisa, Pisa, Italy, Maurizio Benifei, MD, Specialist, Department of Orthopedics and Traumatology, S.O.D Ortopedia e Traumatologia AOUP, Pisa, Italy

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In clinical practice, chronic Achilles tendon ruptures are uncommon. Usually, these lesions are discovered four to six weeks after injuries. More frequently, Achilles tendon ruptures are acute and treated with tendon sutures.1 Many surgical techniques are available to treat chronic lesions such as sutures or V-Y elongation with or without augments.2-3 Our case is about a chronic Achilles tendon rupture discovered two years after injury. Our patient came to our attention with a 6 cm tendon gap. We performed tendon repair with cadaver allograft. After four years of follow-up, our patient has a complete functional recovery and he can normally perform daily and working tasks without pain.

 

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Achilles Tendon Repair Using the InternalBrace™ Principle

Graeme P. Hopper, MBChB, MSc, MRCS, Speciality Registrar, West of Scotland Orthopaedics, Glasgow, Scotland, UK, Gordon M. Mackay, MD, FRCS(Orth), FFSEM(UK), Professor, University of Stirling, Stirling, Scotland, UK

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Despite extensive research, the management of acute ruptures of the Achilles tendon remains an area of controversy, and there is no consensus regarding the optimal treatment. An InternalBrace™ (Arthrex, Inc., Naples, Florida) is a ligament augmentation repair using high strength sutures/tape and knotless bone anchors which encourages healing and allows early mobilization. This article describes, with video illustration, a knotless Achilles tendon repair technique using the InternalBrace™ principle.

 

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Medical Missions in the Middle East: An Orthopaedic Surgeon’s Experience of a Series of Lower Extremity Cases
Aiman Rifai, DO, Associate Professor, Department of Orthopaedics, Seton Hall University,  School of Health and Medical Sciences, South Orange, New Jersey, Todd P. Pierce, MD, Research Fellow, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey, Kimona Issa, MD, PGY3 Resident, Department of Orthopaedics, Seton Hall University,  School of Health and Medical Sciences, South Orange, New Jersey, Yasmine Rifai, Pre-medical Student, Department of Biological Sciences, Rutgers University, New Brunswick, New Jersey, Bartlomiej Szczech, MD, Adult Joint Reconstruction Fellow, Rubin Institute for Advanced Orthopedics, Sinai Hospital Baltimore, Baltimore, Maryland

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Orthopaedic trauma accounts for a great deal of disability worldwide. There are many impoverished nations affected by war wherein victims suffer blast injuries associated with mines, missiles, high-powered gunshots, and bombings. One way to address this is through international medical missions sponsored by industrialized nations. It is imperative that practitioners have a basic understanding of the type of injuries that may be encountered in these nations impacted by war and conflict. Therefore, we described a small number of various lower extremity injuries seen by one orthopaedic surgeon during his volunteer medical mission to Jordan. Frequently, these injuries did result in the loss of a limb and/or function as the patients were treated without appropriate instrumentation or facilities in a suboptimal environment. Treatment was frequently delayed, and many of the surgeons involved lacked optimal training. It is our hope that this case series will lead to studies which may give guidance regarding how to best treat these complex injuries with optimal outcomes and minimal complications.

 

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Results of a Modular Femoral Revision System Before and After Taper Roller Hardening in Total Hip Arthroplasty
Dean J. Marshall, DO, Associate, Spectrum Orthopedics, North Canton, 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, Ohio, Michael J. Morris, MD, Partner, 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

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Introduction: Modular component options can aid in addressing complex femoral reconstructions in total hip arthroplasty (THA) by allowing for customization of version control and proximal to distal sizing. However, component breakage at the modular junction has occurred, particularly in the presence of poor bone stock. A taper roller hardening (RH) process was developed to strengthen the modular junction to reduce breakage. The purpose of this study is to review THA patients before and after taper roller hardening to compare stem survival and frequency of breakage.
Materials and Methods: A query of our practice registry revealed 183 consented patients (202 THA) who underwent THA with a modular femoral revision component between January 1993 and September 2010. Forty THA were done before (non-RH) and 162 were done after taper roller hardening.
Results: Mean follow-up was seven and 17 years in the RH and non-RH groups respectively. In the non-RH group, 15% were revised for component breakage versus 2% in the RH group. Overall, 35% non-RH versus 8% RH stems have been revised. Kaplan-Meier survival at 10 years with endpoint of stem revision for breakage revealed 84.2% (±6.0%) non-RH compared with 95.5% (±2.2%) RH (p=0.0033), and with endpoint of stem revision for any reason, 65.0% (±7.5%) non-RH compared with 80.3% (±3.7%) RH (p=0.0022).
Conclusions: Results indicate that the taper roller hardening process was successful in improving durability of a modular femoral revision system and reducing frequency of component breakage for patients who require treatment of the deficient femur in complex primary and revision THA.

 

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Does an Anterior-Lipped Tibial Insert Adequately Substitute for a Post-Cam Articulation in Total Knee Arthroplasty
Rahul K. Biyani, MD, Orthopedic Surgeon, Orthopedic One, Upper Arlington, Ohio, Mary Ziemba-Davis, BA, Director of Research for Orthopedics, Indiana University Health Physicians Orthopedics and Sports Medicine, IU Health Saxony Hospital, Fishers, Indiana, Philip H. Ireland, MD, Orthopedic Surgeon, Indiana University Health Physicians Orthopedics and Sports Medicine, IU Health Saxony Hospital, Fishers, Indiana, Assistant Professor of Clinical Orthopaedic Surgery, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, R. Michael Meneghini, MD, Director of Joint Replacement, Indiana University Health Physicians Orthopedics and Sports Medicine, IU Health Saxony Hospital, Fishers, Indiana, Associate Professor, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana

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Introduction: Newer tibial inserts with enhanced conformity (cruciate stabilizing anterior lip; CS) to obviate the need for a posteriorly stabilized (PS) post-cam articulation in posterior cruciate ligament-deficient knees have been recently introduced in modern total knee arthroplasty (TKA). The purpose of this study was to evaluate whether clinical and functional outcomes differ in TKA cohorts without a posterior cruciate ligament (PCL) utilizing either CS anterior-lipped or PS post-cam articulation.
Materials and Methods: Prospectively collected outcomes were compared in matched cohorts of modern TKAs implanted with either CS anterior-lipped tibial inserts or PS post-cam articulations. The PCL was resected in all knees. Modern Knee Society Scores (objective, function, and satisfaction scores), walking and stair pain, EuroQol five dimensions (EQ-5D) health-related quality of life, and UCLA activity level were assessed at minimum one-year follow-up.
Results: Forty-three anterior-lipped and 39 PS TKAs were matched on sex, age, BMI, and ASA classification at the time of surgery and months of follow-up. CS knees had significantly higher preoperative function scores than PS knees (p = 0.033), but both groups had equivalent function scores at minimum follow-up of one-year (p = 0.687). Eight-one percent of patients in each group reported being satisfied or very satisfied with their TKA (X2 = 0.072, p = 0.964).
Conclusions: This study supports the hypothesis that an anterior-lipped insert is an adequate functional substitute for a post-cam articulation in patients undergoing TKA with PCL excision. These findings suggest that a PS post-cam articulation may not be necessary given the introduction, availability, and clinical performance of anterior-lipped and more conforming tibial bearings. Further study and longer term follow-up is warranted.

 

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Evaluation of the Effects of the Metha® Short Stem on Periprosthetic Bone Remodelling in Total Hip Arthroplasties: Results at 48 Months
Paolo D. Parchi, MD, Assistant Professor, 1st Orthopedic Division, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy, Gianluca Ciapini, MD, 1st Orthopedic Division, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy, Iacopo Castellini, MD, 1st Orthopedic Division, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy, Claudia Mannucci, MD, 1st Orthopedic Division, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy, Anna Maria Nucci, MD, 1st Orthopedic Division, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy, Nicola Piolanti, MD, 1st Orthopedic Division, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy, Silvia Maffei, MD, Institute of Clinical Physiology, National Research Council, Pisa, Italy, Michele Lisanti, MD, Full Professor, 1st Orthopedic Division, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy

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Introduction: Total hip arthroplasty is one of the most performed procedures in orthopaedic surgery. Implantation of a prosthesis determines changes in the distribution of loads on the host bone, and this phenomenon, known as stress shielding, is related to the biomechanical characteristics of the implant. Usually stress shielding involves the proximal portion of the femur by reducing the mechanical strength and ability to withstand the transmitted loads. The aim of our study is to demonstrate how the use of a short hip stem reduces the stress shielding phenomenon to the proximal femur.
Materials and Methods: The study analyzed 20 patients undergoing hip prosthesis surgery with a short stem (Metha®, B. Braun Medical, Inc., Bethlehem, Pennsylvania) at the Ist Orthopaedic Division of Pisa University (between December 2008 and January 2010). Each patient was subjected to analysis of periprosthetic bone mineral density by a bone densitometry (dual emission X-ray absorptiometry [DEXA] with the metal removal software) at 0, 6, 12, 18, 24, and 36 months, following a protocol based on the evaluation of the changes of bone density in the seven Gruen zones.
Results: We recorded minimal changes in bone mineral density (BMD) at the level of the greater trochanter (-1.44%) and at the level of the calcar (-3.7%). BMD increased significantly after four years at the level of the lateral distal regions (R2 +9.6% - R3 + 12.4%) and at the level of the distal medial regions (R5 + 8.2% - R6 + 13.1%). We compared the results obtained with the literature data at 12 and 24 months with the same stem (Metha®). At 12 months follow up, we did not see a significant difference between our data and the data published in the literature. However, after 48 months of follow-up, we recorded significant differences in the curves of periprosthetic bone reabsorption at the level of the greater trochanter (Zone 1) and at the level of the calcar (Zone 7).
Discussion: The data obtained from our study are in agreement with other studies in the literature, which demonstrates how the use of short stems preserves the metaphyseal bone stock at the level of the proximal femur, reducing the stress shielding phenomenon. From our data, obtained at 24 months and confirmed at 36, stress shielding seems to minimally occur at the level of the calcar. At the level of the great trochanter, we saw a good load distribution that maintained the baseline BMD; these data are in opposition to the literature data that showed a high increase of BMD at the level of the calcar (+12.9%) and a decrease at the level of the great trochanter. From the analysis of the radiographic images of our cases, and of the cases published with the same stem, these differences in load transfer encountered between the great trochanter and the calcar seems to be related to the level of the femoral neck osteotomy and the consequent stem position (varus/valgus).
Conclusion: We conclude that the amount of periprostetic bone reabsorption around the Metha® stem seems to be strictly related to the surgical technique and the final implant position.

 

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Pain Management with Adductor Canal Blockade or Multimodal Periarticular Analgesia in Elderly Total Knee Arthroplasty Patients
Chukwuweike U. Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Nequesha Mohamed, MD, Research Assistant, 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, Melbin Thomas, 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, Sabahat Khan, 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, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, 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

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Introduction: Post-operative pain management in elderly total knee arthroplasty (TKA) patients has traditionally included opioids, epidurals, and femoral nerve blocks. Although these modalities are effective, they are often associated with adverse side effects, which may have a greater impact on this population. Alternative modalities, such as adductor canal blocks (ACB) and multimodal periarticular analgesia (MPA) have demonstrated great efficacy with a low side effect profile. However, it is unknown if one modality is advantageous over the other in the elderly. Therefore, the purpose of this study is to assess 1) post-operative opioid use, 2) length of stay, 3) pain levels, and 4) discharge status in TKA patients aged 75 years or older who have received either ACB or MPA.
Materials and Methods: A single-hospital, single-surgeon database was reviewed for patients aged 75 years or older who had a TKA with either ACB or MPA between January 2015 and April 2016. This yielded 90 patients with a mean age of 83 years (range, 75 to 90 years) comprised of 31 men and 59 women. Forty-three patients received ACB, whereas 47 patients received MPA. Electronic medical records were reviewed to obtain demographic and endpoint data. Pain was quantified using the visual analog scale (VAS). Continuous variables were compared using the student’s t-test and analysis of variance, while categorical variables were compared using chi-square analysis.
Results: No significant difference was observed in opioid consumption between the two groups at post-operative day 0 (p= 0.832) 1 (p= 0.293), or 3 (p= 0.779). While patients in the ACB group had significantly less opioid consumption on post-operative day 2 (p= 0.005), there was no significant difference between groups in total opioid consumption (p= 0.735). There was no significant difference between groups in lengths of stay (2.8 days vs. 3.0 days, p= 0.627) or VAS scores (3.03 vs. 2.96, p= 0.922). The proportion of patients discharged to home did not yield a significant difference as well (55% vs. 45%; p= 0.331).
Conclusion: Elderly patients may have their post-operative pain well controlled if they receive either ACB or MPA during total knee arthroplasty. Our study demonstrates no significant difference in total opioid consumption, lengths of stay, pain levels, and discharge status between groups. Future studies should utilize larger cohorts and include assessments of post-operative functional recovery.

 

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Opportunities in Total Knee Arthroplasty: Worldwide Surgeons’ Perspective
Michael Dunbar, MD, PhD, Professor of Surgery, Division of Orthopaedic Surgery, Dalhousie University, Nova Scotia, Canada, Jared M. Newman, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, 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, Nick Martinez, MSE, Senior Business Analyst, Stryker Orthopaedics, Mahwah, New Jersey, Manoshi Bhowmik-Stoker, Ph.D., Senior Manager, Research, Stryker Orthopaedics, Mahwah, New Jersey, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: This study surveyed a group of US and international orthopaedic surgeons to prioritize areas of improvement in primary total knee arthroplasty (TKA). Specifically, we assessed surgeon responses regarding the top five areas of TKA needing improvement; which were stratified by: a) US surgeons, b) international surgeons, c) US surgeons’ implant-brand-loyalty, and d) surgeons’ years of experience and case volume.
Materials and Methods: Four hundred and eighteen surgeons who were board-certified, in practice for at least two years, spent 60% of their time in clinical practice, and performed a minimum of 25 lower extremity joint arthroplasties per year were surveyed. They chose the top five areas (among 17) needing improvement for TKA. Results were stratified by surgeons’ location (US and international), implant-brand-loyalty, years of experience, and case volume.
Results: Functional outcomes was the top identified area for improvement (US 63% and international 71%), followed by brand loyalty (Company I 68%, other brand 59%, and multi-brand/no loyalty 66%), years of experience (early-career 64%, mid-career 63%, and late-career 75%) and case volume (low-volume 69%, mid-volume 60%, and high-volume 71%). Following this was costs for US surgeons (47%) and implant survivorship for international surgeons (57%). While costs were the next highest area for specific Company-loyal surgeons (57%), implant survivorship was the next highest area for the other two cohorts. Implant survivorship was the second most important area of improvement regardless of years of experience and for low- and mid-volume surgeons.
Conclusion: Surgeons identified functional outcomes as the most important area needing improvement. Cost of implants was more important for American as compared to international surgeons.

 

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Robotic-Assisted Total Hip Arthroplasty: Outcomes at Minimum Two-Year Follow-Up
Richard L. Illgen II, MD, Professor of Orthopaedic Surgery, Department of Orthopedics and Rehabilitation, The University of Wisconsin School of Medicine and Public Health, UW-Health at The American Center, Madison, Wisconsin, Brandon R. Bukowski, BSc, Medical Student, Department of Orthopedics and Rehabilitation, The University of Wisconsin School of Medicine and Public Health, UW-Health at The American Center, Madison, Wisconsin, Rasheed Abiola, MD, Department of Orthopedics and Rehabilitation, The University of Wisconsin School of Medicine and Public Health, UW-Health at The American Center, Madison, Wisconsin, Paul Anderson, MD, Professor of Orthopaedic Surgery, Department of Orthopedics and Rehabilitation, The University of Wisconsin School of Medicine and Public Health, UW-Health at The American Center, Madison, Wisconsin, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, 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

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Background: Component malposition in total hip arthroplasty (THA) contributes to instability and early failure. Robotic-assisted total hip arthroplasty (rTHA) utilizes CT-based planning with haptically-guided bone preparation and implant insertion to optimize component position accuracy. This study compared acetabular component position and postoperative complications following manual THA (mTHA) with rTHA.
Materials and Methods: Consecutive primary THAs performed by one surgeon at three intervals were analyzed in this retrospective cohort study: the initial 100 consecutive manual THAs (mTHA) in clinical practice (year 2000), the last consecutive 100 mTHA before rTHA introduction (year 2011), and the first consecutive 100 rTHA (year 2012). Acetabular abduction (AAB) and anteversion (AAV) angles were measured using validated software. The Lewinnek safe zone was used to define accuracy (AAB 40°±10° and AAV 15°±10°). Comparisons included operative time, estimated blood loss (EBL), infection rate, and dislocation rate.
Results: The rate of acetabular component placement within Lewinnek safe zone was the highest in the rTHA cohort (77%), followed by late mTHA (45%) and early mTHA (30%) (p<0.001). Robotic-assisted THA resulted in an additional 71% improvement in accuracy in the first year of use (p<0.001). Dislocation rate was 5% with early mTHA, 3% in the late mTHA cohort, and 0% in the rTHA cohort within the first two years postoperatively. There were no statistically significant differences in the rate of infection between groups.
Conclusion: Robotic-assisted THA improved acetabular component accuracy and reduced dislocation rates when compared with mTHA. Further study is needed to determine if similar improvements will be noted in larger multicenter studies using alternative surgical approaches.

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What Influences How Patients with Depression Rate Hospital Stay After Total Joint Arthroplasty?
Chukwuweike Gwam, 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, Nicolas Piuzzi, MD, Clinical Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Melbin Thomas, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Randa K. Elmallah, MD, Resident Physician, Department of Orthopaedic Surgery, University of Mississippi, Jackson, Mississippi, George Muschler, MD, Attending Physician, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, 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, 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

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Background: Recent healthcare reform has spurred important changes to provider reimbursement. With the implementation of the Value Based Purchasing program, significant weight is placed on patient experience of care. The Press Ganey (PG) survey is currently used by over 10,000 hospitals, as it serves to help optimize patient satisfaction. However, confounding factors, such as clinical depression, are not screened against by PG. Thus, arthroplasty surgeons performing lower extremity total joint arthroplasty (TJA) may have difficulty optimizing patient satisfaction while caring for patients with clinical depression. Therefore, we asked: 1) What Press Ganey elements affect the overall hospital rating in patients who suffer from clinical depression? and 2) Are survey responses different between patients who do and do not have clinical depression?
Materials and Methods: We queried our institutional PG database for patients who underwent a TJA from November 2009 to January 2015. Our search yielded 1,454 patients, of which 204 suffered from depression and 1,250 did not. Multiple regression analysis was performed to determine the influence (b weight) of selected PG survey domains on overall hospital rating. The weighted mean for domain was also calculated.
Results: Multiple regression analyses showed that overall hospital ratings were significantly influenced by communication with nurses (b-weight = 0.881, p< 0.001) in post-TJA patients with depression. The remaining domains were not statistically significant. There were no significant differences in individual PG elements for patients who did and did not have depression.
Conclusion: Overall patient satisfaction among patients with depression was greatly influenced by communication with nurses. Understanding these challenges may encourage care coordination across disciplines for the management of patients with depression before and after surgery. As a result, this could optimize orthopedic surgery outcomes, but, more importantly, patient health and satisfaction, while reducing costs of care.

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What is the Impact of Body Mass Index on Cardiovascular and Musculoskeletal Health?
Morad Chughtai, MD, Research Fellow, Anton Khlopas, MD, Research Fellow,  Jared M. Newman, MD, Research Fellow, Gannon L. Curtis, MD, Research Fellow, Nipun Sodhi, BA, Research Fellow, Prem N. Ramkumar, MD, MBA, Orthopaedic Surgey PGY-1 Resident, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Rafay Khan, MD, Internal Medicine Resident, Department of Internal Medicine, Raritan Bay Medical Center, Perth Amboy, New Jersey, Shervin Shaffiy, MD, Post-Graduate, St. Georges University School of Medicine, True Blue, Grenada, West Indies, Ali Nadhim, MD, Internal Medicine Resident, Department of Internal Medicine, Raritan Bay Medical Center, Perth Amboy, New Jersey, Anil Bhave, MS, Director of Physical Therapy, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Obesity has become a major public health concern over the past several decades and has been shown to be associated with type 2 diabetes, cardiovascular diseases, dyslipidemia, hypertension, osteoarthritis (OA), and certain types of cancer. The impact of excess weight on cardiovascular and musculoskeletal health is not well-summarized in the literature, and there are some contradictory reports. Therefore, the purpose of this study was to assess the impact of body mass index (BMI) on: 1) cardiovascular outcomes; 2) osteoarthritis risk and progression; and 3) total knee arthroplasty outcomes (TKA). Three literature searches were performed to identify clinical studies that assessed how BMI affects cardiovascular and musculoskeletal health. We included reports published within last five years. A total of 138 studies on cardiovascular health and 140 studies on musculoskeletal health were identified. After reviewing the abstracts and related citations from the references, there were 29 studies included in the present study. The effect of varying levels of BMI have demonstrated a relationship to cardiovascular disease, osteoarthritis, and TKA outcomes. The evidence suggests that as BMI increases, the chance of developing cardiovascular disease, OA, and negative TKA outcomes also increases. Furthermore, there appears to be a negative effect with being underweight on outcomes as well, suggesting that being at “normal” weight may optimize outcomes. However, there are several reports which make these findings more complicated. Several beneficial factors associated with higher BMI include increased muscle mass and strength, which can potentially be beneficial through better cardiorespiratory fitness or hormonal effects. Additionally, several studies suggest that improving fitness is more important than intentional weight loss for cardiovascular health and osteoarthritis. Therefore, future studies are warranted to assess the combination of BMI and activity to assess the optimal balance and how they affect cardiovascular and musculoskeletal outcomes.

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Does Length of Stay Influence How Patients Rate Their Hospitalization After Total Hip Arthroplasty?
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, Chukwuweike Gwam, 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, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Morad Chughtai, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Prem Ramkumar, MD, Orthopaedic Surgery Resident, Department of Orthopaedic Surgery and Rehabilitation, Cleveland Clinic Foundation, Cleveland, Ohio, Nicolas Piuzzi, MD, Clinical Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Ryan Berger, MD, Orthopaedic Surgery Resident, Department of Orthopaedic Surgery and Rehabilitation, Cleveland Clinic Foundation, Cleveland, Ohio, Peter M. Bonutti, MD, Orthopaedic Surgeon, Bonutti Clinic, Effingham, Illinois, Arthur L. Malkani, MD, Professor, Orthopaedic Surgery Department, University of Louisville, Louisville, Kentucky, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio

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Background: The reimbursement for medical services by Medicare and Medicaid (CMS) has recently changed from fee-for-service to quality-based payments. This is being implemented through the use of patient administered surveys, most commonly Press Ganey. With a recent strive for fast-track total hip arthroplasty (THA), it is important to ascertain whether length-of-stay (LOS) in post-THA patients influences the Press Ganey scores and overall hospital ratings. Therefore, we looked at: 1) Which Press Ganey survey factors affect overall hospital rating in patients who have a short (≤2) or longer (>2) length of stay; and 2) whether hospital satisfaction is different between patients who have varied lengths of stay.
Materials and Methods: A query of the Press Ganey database at our institution was performed between November 2009 and January 2015. We identified 692 patients who had a mean age of 62 years (range, 15 to 91 years). These patients were stratified into two cohorts based on LOS (≤two days, n=403; >two days, n=289). Multiple regression analyses were performed using weighted means of each Press Ganey question category to identify their influence ( b) on hospital ratings. We assessed differences in demographics and survey responses between the two cohorts using x2 tests for categorical data and t-tests for continuous data.
Results: There was no statistically significant difference found between our two cohorts in hospital rating after adjusting for gender and ASA score. In patients who had short lengths-of-stay (LOS≤ two days), the overall hospital rating was most influenced by communication with nurses ( b=0.335, p= 0.004), followed by responsiveness of hospital staff ( b=0.313, p=0.006), and communication with doctors ( b=0.208, p=0.049) after adjusting for gender and ASA score. For patients who stayed longer (LOS>two days), the most important factor in hospital ratings was communication with nurses ( b=0.332, p= 0.007), followed by hospital environment ( b=0.312, p=0.002), communication with doctors ( b=0.233, p=0.013), and staff responsiveness (b=0.223 p=0.042).
Conclusion: Short (LOS≤2) and long (>two days) lengths of stay did not affect overall hospital rating. However, amongst both cohorts, communication with nurses, staff responsiveness, and communication with doctors were positively correlated with hospital ratings. Hospital environment also played a significant role in overall hospital ratings for patients who had an LOS >two days. More studies should be conducted to assess if the use of minimally invasive THA affects overall hospital ratings.

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Effects of Topical Antiseptic Solutions Used During Total Knee Arthroplasty on Suture Tensile Strength
Jared M. Newman, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Jaiben George, MBBS, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Jeffery T. Shepherd, MD, Surgeon, Department of Orthopaedics, Advanced Orthopaedic Associates, Wichita, Kansas, Alison K. Klika, MS, Research Program Manager, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Carlos A. Higuera, MD, Staff Surgeon, Department of Orthopaedic Surgery, Vice Chair, Quality and Patient Safety, Cleveland Clinic, Cleveland, Ohio, Viktor E. Krebs, MD, Vice Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: Irrigating a surgical wound with an antiseptic solution is commonly performed while suturing following a total knee arthroplasty (TKA) to help prevent wound complications. The purpose of this study was to: 1) evaluate the mean load to failure of different sutures, and 2) compare the mean load to failure of the sutures after soaking in four different antiseptic solutions.
Materials and Methods: Load-to-failure tests were conducted on four sets of comparable sutures (eight sutures) from two different companies Ethicon Inc. (Somerville, New Jersey) and Covidien (Mansfield, Massachusetts). The four suture types included: 1) non-absorbable braided polyethylene, 2) absorbable braided glycolide or lactide polymer, 3) absorbable monofilament polydioxanone or polyglyconate, and 4) absorbable monofilament polyglecaprone or gylcomer. Sutures were tested for tensile strength at baseline (i.e., no solution; n=5 per suture), and were then soaked for five minutes in one of four different antiseptic solutions: 0.125% sodium hypochlorite, 4% chlorhexidine gluconate, 10% povidone-iodine, and a 1:1 ratio of 3% hydrogen peroxide and sterile water. Effects of the different solutions on individual sutures were assessed with analysis of variance, and pairwise comparison tests were performed with post-hoc Tukey tests.
Results: For the controls, the mean failure loads for the type 1 sutures were 118.5 N and 120.3 N, for the type 2 sutures, 145.8 N and 155.4 N, the type 3 sutures, 103.8 N and 162.2 N, and the type 4 sutures, 86.9 N and 87.7 N. After being soaked in sodium hypochlorite, the mean failure load decreased for one of the type 2 sutures (mean difference, -12.8 N;p=0.003), while the other type 2 suture had a decreased failure load after soaking in povidone-iodine (mean difference, -10.3 N;p=0.041) and hydrogen peroxide (mean difference, -14.6 N;p=0.001). A type 1 suture had an increased load to failure after soaking in povidone-iodine (mean difference, 13.2 N;p<0.0001) and hydrogen peroxide (mean difference, 10.5 N;p<0.0001).
Conclusion: Certain sutures may have changes in their breaking point depending on what type of antiseptic solution is used for wound irrigation, but due to the small magnitude of change, this may not necessarily be clinically relevant.

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What Influences How Patients Rate Their Hospital Stay After Total Hip Arthroplasty?
Nirav K. Patel, MD, FRCS, Clinical Fellow, Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia, Eric Kim, DO, Resident Physician, Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Anton Khlopas, MD, Research Fellow,  Morad Chughtai, MD, Research Fellow, Chukwuweike Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Randa K. Elmallah, MD, Resident, Department of Orthopaedic Surgery, University of Mississippi, Jackson, Mississippi, Prem Ramkumar, MD, Resident Physician, Nicolas S. Piuzzi, MD, Clinical Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, 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, George Muschler, MD, Orthopaedic Surgeon, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Purpose: Measuring the effect of operative interventions has been a challenge in orthopaedics. The assessment of patient satisfaction, as measured by the Press Ganey (PG) satisfaction surveys, has gained increasing attention. Our purpose was to determine the factors and patient characteristics that influence patient satisfaction after THA.
Materials and Methods: The PG database was queried identifying 692 THA patients (November 2009 to January 2015). A multiple regression analysis was conducted.
Results: Significant influence was found in communication with nurses (p=<0.001), response time of hospital staff (p=0.001), communication with physicians (p=0.002), and hospital environment (p=0.049). Management of pain and communication about medications were not significant for overall hospital rating. There were no differences between PG scores of patients who did and did not have complications.
Conclusions: Hospital rating was significantly influenced by patients’ communication with nurses, response time of hospital staff, and communication with physicians. Recognizing the importance of these elements, can greatly improve patient satisfaction after THA.

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Low Ankle Sprains: A Current Review of Diagnosis and Treatment
Anthony J. Scillia, MD, Associate Professor, Seton Hall University, Todd P. Pierce, MD, Research Fellow, Seton Hall University, Kimona Issa, MD, PGY3 Resident, Department of Orthopaedics, Craig Wright, MD, Associate Professor, Department of Orthopaedics, John J. Callaghan, MD, Associate Professor, Department of Orthopaedics, Anthony Festa, MD, Associate Professor, Department of Orthopaedics, Vincent K. McInerney, MD, Orthopaedic Surgery Residency Program Director, Department of Orthopaedics, Seton Hall University, School of Health, and Medical Sciences, South Orange, New Jersey

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Low ankle sprains are common injuries in young athletes. Hence, it is imperative that low ankle sprains are diagnosed and treated quickly and effectively. We reviewed the: (1) anatomy; (2) imaging; (3) physical exam findings; and (4) treatment modalities regarding these injuries. Plain radiographs are standard of care and routine MRI is not recommended for suspected sprains. However, physical exam findings often may guide management decisions. The majority of patients diagnosed with low ankle sprains are treated with a one- to two-week immobilization period with physical therapy focused on peroneal proprioception and strength. If a prolonged non-operative course fails, or there is gross instability upon physical exam (grade III sprain), surgical reconstruction may be considered and may lead to excellent outcomes. When low ankle sprains do occur, the great majority may be treated non-operatively. In the event that conservative modalities fail, surgical reconstruction may be considered with an open modified Brostrom reconstruction as the current standard of care.

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Cryotherapy Treatment After Arthroscopic Knee Debridement and ACL Reconstruction: A Review
Michael Jawad, BS, Research Fellow, Nipun Sodhi, BA, Research Fellow, Morad Chughtai, MD, Research Fellow, Jared M. Newman, MD, Research Fellow, Anton Khlopas, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Ohio, Cleveland, Ohio, Anil Bhave, MS, Director of Physical Therapy, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland, Timothy Wagner, MD, Resident, Assem A. Sultan, MD, Resident, Martin Roche, MD, Chief, Department of Orthopedic Surgery, Holy Cross Hospital, Fort Lauderdale, Florida, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Pain, swelling, and inflammation of the knee joint and its surrounding soft-tissue structures are common during the postoperative period after arthroscopic knee debridement and anterior cruciate ligament reconstruction. These challenges can make patient recovery difficult immediately after surgery. Several options exist, however, to help patients overcome these challenges. Cryotherapy has been noted to decrease pain, swelling, and inflammation. However, while a number of studies exist characterizing the use of cryotherapy after knee surgery, no definitive cryotherapy devices and modalities have been identified. Therefore, the purpose of this review was to evaluate randomized controlled trials to assess the use of cryotherapy after: 1) arthroscopic debridement; and 2) anterior cruciate ligament reconstruction.

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The Use of Transcutaneous Electrical Nerve Stimulation After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial
Deepak Ramanathan, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anas Saleh, MD, Resident, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Alison K. Klika, MS, Research Program Manager, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Carlos A. Higuera, MD, Staff Surgeon, Department of Orthopaedic Surgery, Vice Chair, Quality and Patient Safety, Cleveland Clinic, Cleveland, Ohio, Wael K. Barsoum, MD, President, Cleveland Clinic Florida, Cleveland Clinic, Cleveland, Ohio

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Introduction: Multimodal pain management is used after total knee arthroplasty (TKA) to reduce opioid intake. Transcutaneous electrical nerve stimulation (TENS) has generated much interest as a non-pharmacologic, patient-controlled therapy. The aims of this study were to evaluate the efficacy of TENS in reducing opioid intake and improving recovery after TKA.
Materials and Methods: This was a prospective, parallel-group, double-blinded, randomized trial of patients receiving femoral nerve catheter block with allocation to either active or placebo TENS device groups. All participants were 18–85 years and underwent unilateral, primary TKA at two academic hospitals. Device usage was monitored during inpatient and outpatient phases. Participants were requested to return at second, fourth, and sixth postoperative weeks for follow-up. The primary endpoint was opioid usage, as indicated by medication intake in equianalgesic equivalents to morphine. Secondary measures included: visual analogue scale (VAS) pain scores; functional assessments as measured from knee joint range of motion (ROM) and Timed Up and Go (TUG) test; and clinical outcomes as defined by modified Knee injury and Osteoarthritis Outcome Scores (KOOS) and the 12-item Short Form Survey Instrument (SF-12).
Results: Among 116 participants, overall withdrawal was 37.9% (44 patients) at similar rates in both study arms. After excluding for non-femoral nerve catheter (FNC) blocks (i.e., protocol deviations), there were 35 patients in the active group and 31 patients in the placebo group whose complete records were analyzed. There were no significant differences between groups in any of the clinical endpoints.

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Transfusion Requirements Following Total Knee Arthroplasty in Patients with Preexisting Blood Dyscrasia
Martin Roche, MD, Director of Robotics, Tsun yee Law, MD, Research Fellow, Department of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida, Samuel Rosas, MD, Research Fellow, Augustus J. Rush III, MD, Resident Physician, Department of Orthopaedic Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida, Anton Khlopas, MD, Research Fellow, Morad Chughtai, MD, Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: There is a paucity of studies investigating the incidence of transfusions in various blood dyscrasias after total knee arthroplasty (TKA). The purpose of this study was: 1) to compare the incidence of transfusion post-TKA in patients with and without blood dyscrasia; 2) to compare the post-TKA transfusion incidence of patients with the various individual blood dyscrasias; and 3) to stratify the findings based on gender and age.
Materials and Methods: A retrospective review of a Medicare database for patients with preexisting blood dyscrasia was conducted. Patients who underwent TKA and had a blood transfusion were identified by current procedural terminology (CPT) and International Classification of Diseases (ICD-9) ninth revision codes. We compared the incidence of transfusion post-TKA in patients with and without blood dyscrasia as well as transfusion incidence for various individual blood dyscrasias. We stratified these findings based on gender and age of the patients.
Results: There was a higher incidence of postoperative transfusion in patients who had a blood dyscrasia, when compared to those who did not (5.8% vs. 2.7%). The most common type of blood dyscrasia was iron deficiency anemia (81,897). Patients who had aplastic anemia had the highest incidence of transfusion (16.9%). Females were more likely to be anemic (69.1%) compared to males (30.1%); however, the incidence of transfusion was significantly higher in males (6.9%) compared with females (5.5%).
Conclusion: The incidence of transfusion was higher in patients with blood dyscrasia. In addition, certain types of blood dyscrasias were associated with higher rates of transfusion. Aplastic anemia had the highest transfusion rate. There was a higher rate of blood transfusions in men when compared to women, although women had a higher prevalence of blood dyscrasias. Future studies need to be conducted to further educate patients and practitioners and optimize TKA blood management care.

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Robotic-Arm Assisted Total Knee Arthroplasty Demonstrated Soft Tissue Protection
Anton Khlopas, MD, Research Fellow, Morad Chughtai, MD, Research Fellow, Emily L. Hampp, PhD, Senior Staff Engineer, Laura Y. Scholl, MS, Staff Engineer, Michael Prieto, BS, Engineer, Ta-Cheng Chang, PhD, Senior Staff Engineer, Abdullah Abbasi, MS, Staff Engineer, Manoshi Bhowmik-Stoker, PhD, Senior Manager, Jason Otto, PhD, Chief Engineer, Robotics System Engineering, Stryker, Mahwah, New Jersey, David J. Jacofsky, MD, Chairman, The Core Institute, Phoenix, Arizona, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: While total knee arthroplasty (TKA) procedures have demonstrated clinical success, occasionally intraoperative complications can occur. Collateral or posterior cruciate ligament injury, instability, extensor mechanism disruption, and tibiofemoral or patellofemoral dislocation are among a few of the intraoperatively driven adverse events prevalently ranked by The Knee Society. Robotic-arm assisted TKA (RATKA) provides a surgeon the ability to three-dimensionally plan a TKA and use intraoperative visual, auditory, and tactile feedback to ensure that only the desired bone cuts are made. The potential benefits of soft tissue protection in these surgeries need to be further evaluated. The purpose of this cadaver study was to assess the a) integrity of various knee soft tissue structures (medial collateral ligament [MCL], lateral collateral ligament [LCL], posterior cruciate ligament [PCL], and the patellar ligament), as well as b) the need for tibial subluxation and patellar eversion during RATKA procedures.
Materials and Methods: Six cadaver knees were prepared using RATKA by a surgeon with no prior clinical robotic experience. These were compared to seven manually performed cases as a control. The mean Kellgren-Lawrence score was 2.8 (range, 0 to 4) in RATKA and 2.6 (range, 1 to 4) in the manual cohort. The presence of soft tissue damage was assessed by having an experienced surgeon perform a visual evaluation and palpation of the PCL, MCL, LCL, and the patellar ligament after the procedures. In addition, leg pose and retraction were documented during all bone resections. The amount of tibial subluxation and patellar eversion was recorded for each case.
Results: For all RATKA-assisted cases, there was no visible evidence of disruption of any of the ligaments. All RATKA cases were left with a bone island on the tibial plateau, which protected the PCL. Tibial subluxation and patella eversion were not required for visualization in any RATKA cases. In two of the seven MTKA cases, there was slight disruption noted of the PCL, although this did not lead to any apparent change in the functional integrity of the ligament. All MTKA cases required tibial subluxation and patellar revision to achieve optimal visualization.
Discussion: Several aspects of soft tissue protection were noted during the study. During bone resections, the tibia in RATKA procedures did not require subluxation, which may reduce ligament stretching or decrease complication rates. Potential patient benefits for short-term recovery and decreased morbidity to reduce operative complications should be studied in a clinical setting. Since RATKA uses a stereotactic boundary to constrain the sawblade, which is generated based on the implant size, shape, and plan, and does not have the ability to track the patient’s soft tissue structures, standard retraction techniques during cutting are recommended. Therefore, the retractor placement and potential for soft tissue protection needs to be further investigated. RATKA has the potential to increase soft tissue protection when compared to manual TKA.

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A Cadaver Study to Evaluate the Accuracy of a New 3D Mini-Optical Navigation Tool for Total Hip Arthroplasty
Jonathan M. Vigdorchik, MD, Assistant Professor, Department of Orthopaedic Surgery, NYU Langone Medical Center-Hospital for Joint Diseases, New York, New York, Michael B. Cross, MD, Assistant Attending Orthopaedic Surgeon, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, Eric A. Bogner, MD, Associate Attending Radiologist, Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, Theodore T. Miller, MD, Attending Radiologist, Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, Jeffrey M. Muir, MSc, DC, MSc (Clin Epi), Clinical Epidemiologist, Clinical Research, Intellijoint Surgical, Waterloo, Canada, Ran Schwarzkopf, MD, MSc, Assistant Professor, Department of Orthopaedic Surgery, NYU Langone Medical Center-Hospital for Joint Diseases, New York, New York

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Background: Accurate measurement of acetabular cup position (CP), changes in leg length (LL), and offset (OS) are paramount in ensuring proper sizing and implantation of components during total hip arthroplasty (THA). LL/OS inaccuracies can cause low back pain, neurological deficits, and patient dissatisfaction, while inaccurate positioning of the acetabular cup can lead to instability, dislocation, and, ultimately, revision surgery. The objective of this study was to evaluate the accuracy of a mini-navigation tool in measuring CP and LL/OS differential during THA.
Materials and Methods: Three board-certified orthopedic surgeons each performed four THA procedures via the posterior approach on six cadavers (12 hips) utilizing a novel mini-navigation tool. Imaging included pre- and post-operative radiographs and post-operative CT scans. Image analysis was performed by two radiologists not involved in the surgical procedures. System accuracy regarding measurement of cup position (anteversion and inclination) was determined by comparing the CT measurement of cup orientation with data gathered intraoperatively by probing the face of the implanted cup with the navigation tool and recording the coordinates.
Results: The mean absolute difference between CT and device measurements of cup position was 0.74° (SD: 0.47, range: 0.19–1.48) for anteversion and 0.97° (SD: 0.67, range: 0.27–2.57) for inclination. The mean difference between device and radiograph measurements of LL changes was 0.27 mm (SD: 3.61, range: -5.20–7.78) (absolute mean: 2.71±2.25 mm), while the mean difference in OS was 1.75 mm (SD: 3.00, range: -2.47–6.65) (absolute mean: 2.37±2.44 mm).
Conclusions: This novel mini-navigation tool measured CP, LL, and OS accurately when compared with implant position measured on imaging.

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Smith & Nephew