New Online Studies

 

Online First

 

November, 2017

 

The Effect of Preoperative Physical Status on Pain Management in Total Knee Arthroplasty Patients Receiving Adductor Canal Blockade
Chukwuweike U. Gwam, MD, Research Fellow, Jaydev B. Mistry, MD, Research Fellow, Nequesha S. Mohamed, MD, Research Assistant, Nicole E. George, DO, Research Fellow, Jennifer I. Etcheson, MD, MS, Research Fellow, Sana Virani, MD, Research Assistant, Ryan Skalsky, BS, Research Assistant, Shreya Singh BS, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Nicolas S. Piuzzi, MD, Clinical Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 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: Managing postoperative pain can be challenging for arthroplasty surgeons. While pain control modalities, such as adductor canal blockade (ACB), have been proven effective, the multifactorial nature of pain perception may serve as an obstacle for optimizing pain control. This study assesses the effect of patient pre-operative physical status on patient perception of pain. Specifically, we compared 1) lengths of hospital stay (LOS), 2) pain levels, and 3) opioid consumption in patients receiving total knee arthroplasty (TKA) who presented with an American Society of Anesthesiologists physical status score (ASA) of 2 and 3. Materials and Methods: A single hospital, single surgeon database was reviewed for patients who had TKA between January 2015 and April 2016. Only patients with an ASA class of 2 or 3 who received ACB were analyzed. This yielded 106 patients with a mean age of 63 years, comprised of 36 men and 70 women. Patients were stratified into those with an ASA class of 2 (n= 58) and those with an ASA class of 3 (n= 48). Electronic medical records were reviewed to obtain demographic and endpoint data. Pain was quantified using 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: There was no significant difference found between the two groups in LOS (2.25 days vs. 2.19 days; p=0.805), VAS scores (4.95 vs. 5.75; p=0.306), and opioid consumption on day 0 (17.77 morphine eq vs. 23.49 morphine eq; p=0.233) and day 3 (9.11 morphine eq vs. 19.87 morphine eq; p=0.100). However, patients with an ASA score of 2 had a significantly lower opioid consumption on day 1 (32.20 morphine eq vs. 52.70 morphine eq; p=0.049), day 2 (19.21 morphine eq vs. 40.71 morphine eq; p=0.018), and overall (78.30 morphine eq vs. 135.77 morphine eq; p=0.024). Conclusion: Despite the effectiveness of ACB in controlling pain, patient pre-operative status may affect perception of pain. This study demonstrates that patients with a higher ASA physical status classification consumed more opioid medication postoperatively, despite having similar pain scores and lengths of stay to those with a lower classification. Future studies should assess all ASA classifications and stratify for preoperative opioid consumption and tolerance as a possible confounder.

 

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Fluorescent Imaging Evaluation of Lidocaine Distribution Following Bier Block in the Upper Extremity
Andrea L. Gale, MD, Fellow in Orthopedic Surgery, Department of Orthopedics and Sports Medicine, Shari R. Liberman, MD, Board-Certified Orthopedic Surgeon, Department of Orthopedics and Sports Medicine, Suzanne Berry, MD, Board-Certified Anesthesiologist, Department of Anesthesia, Dmitry Zavlin, MD, Postdoctoral Research Fellow in Plastic Surgery, Institute for Reconstructive Surgery, Anthony Echo, MD, Board-Certified Plastic Surgeon, Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas

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Introduction: Bier block regional anesthesia has been used as an alternative to general anesthesia for years. Despite multiple theories and multiple techniques to delineate the location of the action of lidocaine during Bier block anesthesia, there has not been a consensus on the location of action. The purpose of this study was to use fluorescent imaging to further investigate the site of action of lidocaine during Bier block.
Materials and Methods: Three patients with carpal tunnel syndrome underwent open carpal tunnel release with Bier block anesthesia performed in the standard fashion with 1cc of Indocyanine green (IcG) mixed with lidocaine. Fluorescent images were obtained at the time of injection and after 10 minutes to allow patients to reach the level of surgical anesthesia. Repeated imaging was obtained at the time of completion of the procedure or at 30 minutes of tourniquet time.
Results: At time 0, IcG was distributed along the superficial venous system of the hand and forearm. At 10 minutes, the distribution of IcG was within the capillary system and infiltrating the dermis. The distribution later saturated the capillary beds and remained present until release of the tourniquet.
Conclusions: The authors demonstrate that some lidocaine action occurs at the cutaneous level during the administration of a Bier block. Due to limited field depth of view provided by the SPY® Elite System (Novadaq Technologies Inc., Mississauga, Canada), we are unable to draw any conclusions as to the distribution of the IcG or lidocaine at the level of the larger nerves at the site of the tourniquet.

 

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Reproducibility and Reliability of Repeated Quantitative Fluorescence Angiography
Nikolaj Nerup, MD, PhD, PHD-Fellow, Senior Resident, Department of Surgical Gastroenterology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, Kristine Bach Korsholm Knudsen, MD, PhD, PHD-Fellow, Resident, Department of Surgical Gastroenterology, Copenhagen University Hospital Rigshospitalet, Department of Pediatric Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, Rikard Ambrus, MD, PhD, Resident, Department of Surgical Gastroenterology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, Morten Bo Søndergaard Svendsen, MScEng, PhD, Engineer, Copenhagen Academy for Medical Education and Simulation, Copenhagen University Hospital Rigshospitalet , Copenhagen, Denmark, Thomas Thymann, DVM, PhD, Veterinarian, Associate Professor, Section for Comparative Pediatrics and Nutrition, Copenhagen University, Frederiksberg, Denmark, Inge Botker Rasmussen Ifaoui, MD, PhD, Consultant, Department of Pediatric Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, Lars Bo Svendsen, MD, DMSc, Consultant, Professor, Department of Surgical Gastroenterology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, Michael Patrick Achiam, MD, PHD, DMSc, Consultant, Associate Professor, Department of Surgical Gastroenterology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark

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Introduction: When using fluorescence angiography (FA) in perioperative perfusion assessment, repeated measures with re-injections of fluorescent dye (ICG) may be required. However, repeated injections may cause saturation of dye in the tissue, exceeding the limit of fluorescence intensity that the camera can detect. As the emission of fluorescence is dependent of the excitatory light intensity, reduction of this may solve the problem. The aim of the present study was to investigate the reproducibility and reliability of repeated quantitative FA during a reduction of excitatory light.
Materials and Methods: Six preterm piglets were used as a model of humans with compromised liver function and slow ICG clearance, as well as mimicking a situation with close camera tissue distance. In three piglets, FA was performed laparoscopically and in another three, FA was performed after laparotomy. Measurements were performed in the same three regions of interest in each measurement with excitatory light intensities of 100%, 60%, and 20%.
Results: We found an excellent agreement of the normalized slope with an intraclass correlation coefficient of 0.940 (95% CI: 0.870–0.976), and a Cronbach’s alpha of 0.944 indicating high consistency. In addition, Bland Altmann plots found acceptable levels of agreement with minimal proportion bias.
Conclusions: This study indicates that problems with hyper saturation of ICG, when performing repetitive perfusion assessment with FA, may be overcome by using the normalized slope and a reduction of the excitatory light intensity. This may especially be relevant in patients with compromised liver function or when a close camera tissue distance is necessary.

 

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The Use of Acellular Dermal Matrices (ADM) in Breast Reconstruction: A Review
Christian Eichler, MD, Obstetrician/Gynecologist, Breast Center, Department of Gynecology and Obstetrics, Municipal Hospital Holweide, Cologne, Germany, Carolin Schulz, Medical Researcher, Breast Center, Municipal Hospital Holweide, Cologne, Germany, Medical School MD/PhD Program, University of Bonn, Bonn, Germany, Nadine Vogt, MD, Obstetrician/Gynecologist, Breast Center, Municipal Hospital Holweide, Cologne, Germany, Mathias Warm, MD, Obstetrician/Gynecologist/Department Head, Breast Center, Municipal Hospital Holweide, Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany

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The use of acellular dermal matrices (ADM), sometimes referred to as extracellular matrix (ECM), has become an interesting aspect of breast reconstruction. A great deal of literature is available, totaling over 7000 ADM-based reconstructions. Most often, ADMs are used in a skin sparing mastectomy (SSM) scenario, although heterologous breast augmentation with a sub-pectoral fixation may also require an ADM application. Their use has become an attractive, but expensive option. Available data shows head to head comparisons between individual ADMs to be mostly retrospective in nature with only a few prospective trials available. Points of interest include postoperative hematoma, postoperative skin irritation, infection, red breast syndrome, and revision surgery. This work will, therefore, highlight the individual properties of ADMs used in breast reconstruction and compare the available data on complication rates and costs for these devices.

 

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A Pilot Retrospective Study to Evaluate Two Multi-Layer Foam Dressings for the Management of Moderately Exudative Pressure Injuries
Kevin Woo, PhD, RN, FAPWCA, Associate Professor, Queen’s University, Faculty of Health Sciences, School of Nursing, Kingston, Ontario, Jennifer Kasaboski, RN, ET, Queen’s University, Faculty of Health Sciences, School of Nursing, Kingston, Ontario

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Prevention and treatment of pressure injuries (PI) is a standard benchmark for quality of care, performance, risk reduction, and patient safety. Foam dressings are designed to wick away a large volume of exudate with minimal lateral movement to prevent periwound skin maceration; this renders foam dressings a popular choice for the treatment of chronic wounds with high to moderate amounts of exudate. In addition, multi-layer foam dressings may have added benefits to alleviate pressure and minimize shear as the dressing materials slide against each other. The purpose of this retrospective pilot study was to evaluate the effectiveness and safety of two different multi-layer foam dressings (Optifoam® Gentle, Medline Industries, Inc. Northfield, Illinois; Mepilex® Border, Mölnlycke Health Care, Gothenburg, Sweden) for the management of pressure injuries that produce a moderate amount of exudate. A total of 15 patients and 25 wound treatments were reviewed over a period of 12 months in the study. The difference in the mean surface areas at baseline between the two dressings was not statistically significant (p=.38). All wounds improved over time. There was no difference in healing rate (cm2/day) for wounds that were treated with the Mepilex® Border dressing (M=.12 cm2/day, SD=.19) compared to the Optifoam® Gentle dressing (M=.18 cm2/day; SD=.25); t (23)= .85, p=.40. Findings of this study suggest similar clinical performance between the two foam dressings. Foam dressings were used for the management of several shallow stage 3 and 4 PIs in place of packing. Results of this study challenge the commonly accepted notion that wounds with depth should always be packed with dressing material.

 

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AbsorbaSeal™ Vascular Closure Device: A Novel Device for Hemostasis Following Interventional Peripheral Vascular Procedures
Emily Benham, MD, Surgical Resident, Surgery Care Division, Carolinas HealthCare System, Charlotte, North Carolina, Koen Deloose, MD, Head of Vascular Surgery Department, Joren Callaert, MD, Surgeon, Marc Bosiers, MD, Surgeon, Vascular Surgery Department, AZ Sint-Blasius Hospital, Dendermonde, Belgium, Tiffany Cox, MD, Surgical Fellow, Amy Lincourt, PhD, Director of Research, Surgery Care Division, Carolinas HealthCare System, Charlotte, North Carolina, B. Todd Heniford, MD, FACS, Chief, Division of Gastrointestinal and, Minimally Invasive Surgery, Surgery Care Division, Carolinas HealthCare System, Charlotte, North Carolina

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Introduction: Vascular closure devices (VCDs) are designed to achieve rapid hemostasis during percutaneous coronary and peripheral vascular procedures. Studies demonstrate that VCDs improve time to hemostasis (TTH) and time to ambulation (TTA) in comparison to standard manual compression. The available products, however, typically have 13–17 steps in their application, often require hemostatic collagen or other agents as part of the process, and can result in significant scarring at the puncture site that can impact future access. The aim of this study was to investigate the performance of a three-step, novel VCD for access site TTH, short-term and long-term histology, and a first-in-man clinical study.
Materials and Methods: This study evaluated AbsorbaSeal™ (CyndRx, LLC, Brentwood, Tennessee), a simple, three-step, VCD with bio-absorbable components. Following an institutional review board (IRB) approval, a 6-F sheath was placed directly into the porcine aorta, AbsorbaSeal™ was used to seal the puncture site, and a measure of total time of deployment (TTD) and TTH was performed, as well as histologic evaluation at 30, 60, and 180 days.
A complement activation test was performed to determine the potential for activation of the complement system as a mediator of inflammation. The test was performed by directly incubating the VCDs AbsorbaSeal™ and Angio-Seal™ (Terumo Interventional Systems, Tokyo, Japan) in human serum. Serum samples were removed after 30, 60, and 90 minutes and tested for the presence and amount of complement protein SC5b–9.
In the first in-man trial, the device was deployed in anticoagulated patients undergoing interventional vascular procedures. The TTH, estimated blood loss, patient pain scores, and procedural and follow-up complications were recorded.
Results: In the acute and chronic porcine studies, TTD averaged 25 seconds (17–29 seconds). Vascular control was immediate, yielding a TTH of effectively zero seconds. Histologic evaluation demonstrated complete endothelial coverage of the device by 30 days without evidence of bleeding, clotting, or inflammation. At 60 days, the significant mass of the device had dissolved and normal appearing collagen surrounded the devices with essentially no inflammatory response. By six months, all but one microscopic segment of one of the devices had been absorbed with normal appearing vascular endothelium, and no, or minimal, scarring appreciated. The complement test demonstrated that the AbsorbaSeal™ had similar, or lower, complement concentrations than the negative controls and significantly less than Angio-Seal™. This supported the histologic findings of minimal to no inflammation.
The VCD was deployed in 20 patients undergoing interventional vascular procedures. The mean TTH was 2.3 ± 1.5 minutes. Estimated blood loss was 11.7 mL ± 3.5 mL, and no significant hematoma was noted. Post-procedure pain scores were low, with a mean of 1.4 ± 0.8 on a 0–10 pain rating scale. There were no perioperative complications and no adverse events at follow-up.
Conclusions: The AbsorbaSeal™ is safe and simple to use for vascular closure after interventional vascular procedures with favorable outcomes including a short TTH, minimal procedural blood loss, low postoperative pain scores, and no perioperative complications or adverse effects. Histologic evaluation reveals rapid device absorption and little scar formation both short- and long-term. A direct study of complement activation supports that AbsorbaSeal™ evokes a minimal inflammatory response that is significantly less than Angioseal.

 

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Over-Sewing of Staple Line in Laparoscopic Sleeve Gastrectomy: Initial Experience of a Comparative Study
Giorgio Lisi, MD, Resident, Department of General and Pancreatic Surgery, University Hospital of Verona, Verona, Italy, Roberto Rossini, MD, Medical Staff, Department of General Surgery, Don Calabria Hospital, Verona, Italy, Irene Gentile, MD, Medical Staff, Department of General Surgery, Don Calabria Hospital, Verona, Italy, Giacomo Ruffo, MD, Head, Department of General Surgery, Don Calabria Hospital, Verona, Italy

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Introduction: The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. Recently, over-sewing has been proposed as a cost-effective and helpful method for reinforcing the staple line. The purpose of this study was to report our initial experience with LSG comparing over-sewing over the entire staple line with the upper-third staple line.
Materials and Methods: All obese patients seen at Negrar Sacro Cuore, Don Calabria Hospital were entered into our prospective database and were retrospectively evaluated. Complications (divided as major complications: leaks and bleeding; and minor complications: dysphagia, esophagitis, and reflux disease) and reoperations were recorded for all patients. Complications were graded according to the Clavien classification system.
Results: From February 2015 to March 2016, 30 patients underwent LSG. Patients were divided in two groups according to over-sewing: Group A—over-sewing over the entire staple line; and Group B upper-third over-sewing. Mean total operative time was longer in Group A—90 minutes—compared with 85 minutes in Group B. In regard to minor complications, we reported one esophagitis and two cases of dysphagia in Group B and one dysphagia in Group A. Gastroesophageal reflux was higher in Group B than in Group A (3 vs. 1, p=0.149). Three major complications were observed (10%): two bleeding and one hematoma in Group B and no major complications occurred in Group A. All major complications were conservatively treated. No leaks were reported in both groups. No mortality was observed.
Conclusions: Over-sewing of the staple line was associated with fewer leaks but no conclusions can be drawn regarding the effects of over-sewing on staple line bleedings. Before standardizing surgical techniques further, trials are necessary to improve our knowledge about over-sewing in LSG.

 

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Right-Sided versus Left-Sided Colectomies for Cancer: Surgical Outcomes and Novel Considerations
Matteo Lavazza, MD, Consultant General Surgeon, Stefano Rausei, MD, PhD, Consultant General Surgeon, Department of Surgery, University of Insubria, Varese, Italy, Georgios D. Lianos, MD, Consultant General Surgeon, Department of Surgery, Ioannina University Hospital, Ioannina, Greece, Vincenzo Pappalardo, MD, Consultant General Surgeon, Francesco Frattini, MD, Consultant General Surgeon, Department of Surgery, University of Insubria, Varese, Italy, Gianlorenzo Dionigi, MD, FACS, Full Professor in General Surgery, Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood ‘‘G. Barresi’’, University Hospital G. Martino, University of Messina, Italy, Domenico Iovino, MD, Resident Doctor in General Surgery, Francesca Rovera, MD, Associate Professor in General Surgery, Department of Surgery, University of Insubria, Varese, Italy, Luigi Boni, MD, FACS, Associate Professor in General Surgery, Department of General and Emergency Surgery, IRCCS Ca Granda, Policlinico Hospital, University of Milan, Milan, Italy

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Introduction: The aim of this study is to compare short-term outcomes of right versus left colectomies performed as a form of cancer treatment. Materials and Methods: This study includes 305 consecutive patients with adenocarcinoma treated by laparoscopic or open colectomy. Right colectomy has been compared with left colectomy. The study endpoints were the first flatus day, the first evacuation day, the first day of postoperative solid oral diet intake, and the postoperative hospital stay length. Results: There were 140 (45.9%) right colectomies and 165 (54.1%) left colectomies performed. The cut-off values for the considered (median) endpoints were three, five, four, and eight days, respectively. The first day of postoperative solid oral diet intake and the length of postoperative hospital stay are significantly associated with the type of resection. Conclusions: The colon cancer patients treated by right-sided colectomy assumed a solid oral diet and presented a longer postoperative hospital stay compared with the patients treated by left-sided colectomy.

 

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Topographical Variations between Splenic Flexure and Spleen: A Study with CT Image-Based Reconstruction
Dr. Matteo Lavazza, MD, Consultant General Surgeon, 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Dr. Stefano Rausei, MD, PhD, Consultant General Surgeon, Dr. Vincenzo Pappalardo, MD, Consultant General Surgeon, Dr. Davide Inversini, MD, Resident Doctor in General Surgery, Dr. Monica Mangini, MD, Consultant Radiologist, Radiology Division, Department of Surgical Sciences and Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Dr. Anna Maria Ierardi, MD, Consultant Radiologist, Radiology Division, Department of Surgical Sciences and Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Dr. Angkoon Anuwong, MD, Consultant General Surgeon, Department of Surgery, Police General Hospital, Faculty of Medicine, Siam University Pathumwan, Bangkok, Thailand, Dr. Hoon Yub Kim, MD, Consultant General Surgeon, Department of Surgery, Division of Breast and Endocrine Surgery, Minimally Invasive Surgery and Robotic Surgery Center, KUMC Thyroid Center Korea University, Anam Hospital, Seoul, Korea, Prof. Gianpaolo Carrafiello, MD, Full Professor in Radiology, Università degli Studi di Milano, Postgraduation School in Radiodiagnostics, Milan, Italy, Prof. Gianlorenzo Dionigi, MD, FACS, Full Professor in General Surgery, Director of Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood ‘‘G. Barresi’’, University Hospital G. Martino, University of Messina, Messina, Italy

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Introduction: An issue that is seldom seen in the literature relates the detailed relationship of the splenic flexure (SF) and the spleen—both carefully examined—with a prospective approach in patients undergoing computer tomography (CT) scan.
Materials and Methods: SF localization has been searched and examined in 120 consecutive CT scans. Several different variables (age, gender, BMI, indication of CT scan, etc.) have been considered. In cooperation with the Radiology Division, we brought to completion a dedicated topographic outline, with the purpose of providing a detailed classification for SF localization. Results: The SF lies, in 52% of cases, in what we called the inferior (I) position, below the spleen. Other categories of our classification were anterior (A) and posterior (P) positions, which were found respectively in 42% and 8% of analyzed cases. Considering all the variables given, we did not find any significant statistical correlation (p > 0.05).
Conclusions: This study was carried out to classify types of SF in terms of its positional relationship with the spleen. We investigated 120 CT scans and classified the SF into three types, according to its localization: inferior (I), anterior (A), and posterior (P) types. A better understanding of the anatomic variability in SF may be useful for minimizing complications and performing an accurate surgical dissection.

 

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A Simplified Novel Approach for Total Laparoendoscopic Single-Site (LESS) Hysterectomy
Emad Mikhail, MB, ChB, MD, FACOG, FACS, Assistant Professor, Minimally Invasive Gynecologic Surgeon, Elisabeth Sappenfield, MD, Assistant Professor, Allison Wyman, MD, FACOG, Assistant Professor, Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, Stuart Hart, MD, MBA, MS, FACOG, FACS, Voluntary Faculty, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of South Florida/Morsani College of Medicine, Tampa, Florida, Director, Global Medical Affairs, Medical Director, Colorectal & Gynecologic Health, Surgical Innovations/Minimally Invasive Therapies Group, Medtronic PLC, Minneapolis, Minnesota

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Short-Term Results of Eluvia™ Paclitaxel-Eluting Stent in External Iliac and Femoropopliteal Lesions
Maxime Elens, MD, Medical Doctor, Robert Verhelst, PhD, Professor, Julien Possoz, MD, Medical Doctor, Stefano Mastrobuoni, MD, Medical Doctor, Valerie Lacroix, PhD, Professor , Parla Astarci, PhD, Professor, Cardiovascular and Thoracic Surgery Department, St Luc Hospital, Catholic University of Louvain, Brussels, Belgium

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Introduction: The aim of this study was to independently evaluate the real-world performances of Eluvia™ paclitaxel drug-eluting stents (DES) (Boston Scientific, Marlborough, Massachusetts) for the treatment of external iliac and femoropopliteal artery lesions.
Materials and Methods: We prospectively collected, and retrospectively reviewed, data for all patients who underwent an endovascular treatment with an Eluvia™ DES for the treatment of an external iliac or femoropopliteal lesion. Patient demographics, concomitant procedures, arterial lesions characteristics, procedural details, and follow-up were reviewed.
Results: Between April and October 2016, 15 Eluvia™ DES were placed in 15 consecutive adult patients with a technical success of 100%. The treated lesions had a mean length of 93.9 ±58 mm. Sixty percent of the lesions were total occlusions and 13% were restenosis of previous stents. An additional inflow treatment was performed in 40% of the cases. At six months, two patients were lost at follow-up and one had an occluded stent. We had a primary patency rate and freedom from TLR of 92%. All remaining patients had an improved Rutherford class, improved quality of life and wound healing, and an increase in walking distance. Survival and limb salvage rates were 100%.
Conclusions: This study confirms the good result of DES, in general, and of the Eluvia™ stent, in particular, in the treatment of external iliac and femoropopliteal arterial lesions, with a primary patency rate and a freedom from TLR of 92% at six months. A larger number of patients and longer follow-up will be required to determine the true real-world efficacy of the Eluvia™ DES, but short-term experience is encouraging.

 

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Mechanical Strength of the Proximal Tibia Following Total Knee Arthroplasty: A Cadaveric Study of Resection Depth and Bone Density
Tatsuya Sueyoshi, MD, PhD, Orthopedic Surgeon, Department of Orthopedic Surgery, Kobe Medical Center General Hospital, Kobe, Japan, Research Fellow, Joint Replacement Surgeons of Indiana Foundation, Mooresville, Indiana, Scott R. Small, MS, Engineering Director, Orthopedic Biomedical Engineering Laboratory, Joint Replacement Surgeons of Indiana Foundation, Mooresville, Indiana, Jeffrey B Elliott, MS, Research Student, Department of Biology and Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, Indiana, Grace E. Gibbs, BS, Research Student, Department of Biology and Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, Indiana, Ryan B. Seale, MS, Research Student, Department of Biology and Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, Indiana, Merrill A. Ritter, MD, Executive Director, Joint Replacement Surgeons of Indiana Foundation, Mooresville, Indiana

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Background: Tibial component failure has been a problem in total knee arthroplasty, it is still undetermined how tibial resection depth affects the strength to support a tibial component. This study examined the relationship between the resection depth and the bone density and the mechanical strength to support the tibial component.
Materials and Methods: Eight matched pairs of fresh, frozen cadaver lower legs were imaged with computed tomography to assess the bone density. A right tibia was resected at minimum resection level and a left tibia was resected at deep resection level. After the tibial component was implanted with cement on each tibia, it was loaded on a materials testing load frame to measure the stiffness and the load to failure.
Results: The average bone density at the minimum resection level of the tibia was significantly higher than at deep level (p=0.0003). The average stiffness and load to failure of the proximal tibia were 1105 N/mm (range 889 to 1303 N/mm) and 5626 N (range 3360 to 9098 N). There was no statistical correlation between tibial resection depth and the axial stiffness (p=0.4107) or the load to failure (p=0.1487).
Conclusions: Although the bone density at a minimum resection level was higher than that at a deep level, the strength to support the tibial component was not statistically higher at a minimum cutting level than at a deeper cutting level proportionally. Surgeons may not need to minimize a proximal tibial bone resection to maintain a stronger support for a tibial component.

 

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Social Media and Pediatric Scoliosis: An Analysis of Patient and Surgeon Use
Heather S. Haeberle, BS, Medical Student, Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, Anthony C. Egger, MD, Resident, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Sergio M. Navarro, BS, Medical Student, Mary M. Cornaghie, BA, Medical Student, Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, Prem N. Ramkumar, MD, MBA, Resident, Ryan C. Goodwin, MD, Orthopaedic Surgeon, Michael A. Mont, MD, Chairman, Department of Orthopaedics, Cleveland Clinic, Cleveland, Ohio

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Introduction: The purpose of this observational study was to investigate and analyze the social media presence of both patients and surgeons in relation to pediatric scoliosis. First, patient Instagram (Instagram, Inc., San Francisco, California) posts were evaluated for 1) media format; 2) timing in relation to surgery; 3) tone; 4) perspective; 5) content; and 6) subject reference. To analyze reciprocal engagement, the presence and activity of pediatric scoliosis surgeons at five major academic centers were subsequently analyzed on Instagram, Twitter (Twitter Inc., San Francisco, California), and LinkedIn (LinkedIn Corporation, Sunnyvale, California).
Materials and Methods: A search of public Instagram profiles was performed over a one-year period from February 2016 to February 2017. Posts related to pediatric scoliosis were selected for analysis using a hashtag search with 30 related terms. A total of 982 posts were retrieved, with 669 posts meeting the inclusion criteria. Each post was then evaluated for timing, tone, perspective, and content using a categorical scoring system. An additional analysis was performed using academic orthopaedic hospitals’ websites, in which the names of scoliosis surgeons were found and searched for on Instagram, Twitter, and LinkedIn. Their profiles were analyzed for level and length of activity, number of followers or connections, and references to clinical practice.
Results: A total of 669 posts related to scoliosis were analyzed, the majority of which were temporally related to non-operative (74.7%) or post-operative (21.8%) settings. Patients (33.3%), friends and family (34.4%), and professional organizations (23.8%) were the most active contributors. The vast majority of posts were positive in nature (88.9 %) and highlighted the patient experience (79.2%), specifically related to bracing (33.1%), activities of daily living (31.7%), and surgical site or x-rays (25.5%). Of the social media sites analyzed, surgeons were found to have the highest presence on LinkedIn (55% have accounts with a mean of 175 connections) compared to Instagram (8%, 57 followers) and Twitter (33%, 61 followers). Surgeons were also noted to have more information regarding their practice, training, and clinical skills on LinkedIn.
Conclusions: An analysis of Instagram posts related to scoliosis showed that the majority were shared by patients in the non-operative period and overwhelmingly had a positive tone. The content of the posts focused mainly on brace wear, activities of daily living, and post-operative appearance or x-rays. This information provides further insight into what patients deem important regarding pediatric scoliosis care. Analysis of the social media presence of scoliosis surgeons showed that they have an underwhelming presence on Instagram and Twitter, but are more active on LinkedIn, a site geared more toward professional development and networking than other social media options.

 

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Surgical Skills Improvement Using a Low-Cost Laparoscopic Simulator for Ventral Incisional Hernia
Vincenzo Consalvo, MD, General Surgeon Assistant, Clinique Clementville, Montpellier, France, Collaborator, Università degli Studi di Salerno, Fisciano, Italy, Vincenzo Salsano, MD, Director, Bariatric Surgery, Clinique du Parc Montpellier, Clinique Clementville, Montpellier, France

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Introduction: Ventral incisional hernia is one of the most common procedures in laparoscopic surgery, however, it requires proper training before doing it in the operating room. We propose a low-cost mechanical simulator with a new optical system to learn the basic steps of the procedure and improve surgical laparoscopic skill.
Materials and Methods: From November 3, 2014 to January 4, 2015, five residents and five surgeons with no prior laparoscopic experience, as well as two laparoscopic expert surgeons, participated in our study. They repeated the procedure three times per day for seven days. From January 10, 2015 to April 21, 2015, the five trained and five non-trained residents performed (each) five real laparoscopic ventral or median incisional hernia repairs under senior supervision. Operative time, decision making capabilities, number of errors, laparoscopic skill, and depth perception were compared between the two groups.
Results: A multiple regression (R) model was calculated and F-test showed a significant relation between operative time and numbers of procedures with the laparoscopic simulator (p<0.001) for the resident and non-laparoscopic surgeons groups and a multiple R-squared = 0.9974 (highly significant) of the model. No statistical difference was found between residents and non-laparoscopic surgeons (p<0.001), but both groups reached the same level as the expert surgeons after intensive training. Kruskal-Wallis was used to show an increased operative time for non-trained group. Pearson test and t-test showed a lower number of errors and failure in the trained group.
Conclusions: These results indicate that this new model of simulator could shorten the learning curve of surgical trainees for laparoscopic incisional hernia.

 

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Patient Factors Associated with Shorter Length of Stay Following Total Hip Arthroplasty—A Retrospective Cohort Study
Paul A Byrne, MEng, MSc, MBChB, Foundation Doctor, NHS Lothian, Edinburgh, United Kingdom, Sanjay Gupta, MBBS, MRCS (Glas), MSc (Orth), MPhil, FRCS (Tr & Orth), Consultant Orthopaedic Surgeon,  Graeme P. Hopper, MBChB, MSc, MRCS, Speciality Registrar, Trauma & Orthopaedics, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom, Angela H. Deakin, PhD, Orthopaedic Audit and Research Coordinator,  Jason L. Roberts, FRCS (Orth), Consultant Orthopaedic Surgeon,  Andrew W. G. Kinninmonth, FRCS (Ed), Consultant Orthopaedic Surgeon, Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, United Kingdom

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Introduction: Total hip arthroplasty (THA) is an increasingly common procedure in the United Kingdom and incurs vast costs, with a mean length of stay (LOS) of 5.5 days. Reducing LOS plays a key role in improving cost-effectiveness, morbidity, and patient satisfaction following many orthopaedic procedures. The aim of this study was to identify attributes in patients with the shortest LOS following THA, with a view to targeting those with the potential for early discharge.
Materials and Methods: 1280 THA cases over one year at one institution were reviewed in a retrospective case note study. Of these, 131 patients had LOS≤2 days. Various factors (age, gender, American Society of Anesthesiologists (ASA) score, primary diagnosis, body mass index (BMI), socio-economic status) were compared between this group and the rest of the cohort. Further characteristics of the short LOS group were also explored to identify trends for future study.
Results: Lower age, male gender, and low ASA grade were significantly associated with the short LOS group (all p<0.001). BMI, primary diagnosis, and socioeconomic status showed no significant differences. Short LOS patients were also noted to have few comorbidities, family at home, and independent transport.
Conclusion: Younger age, male gender, and lower ASA grade are associated with early discharge following THA, and could be used to identify patients suitable for early discharge.

 

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Total Hip Arthroplasty Dislocation after Cardioversion: A Case Report
Ahmed Siddiqi, DO, Resident, Orthopedic Surgery Department, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Carl T. Talmo, MD, Associate Professor, Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, James V. Bono, MD, Associate Professor, Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts

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New onset postoperative atrial fibrillation (AF) is the most common perioperative arrhythmia in the elderly. The incidence after total joint arthroplasty is much lower than other non-cardiac surgeries. Since postoperative atrial fibrillation can cause increased length of hospital stay, mortality, and healthcare costs, it is critical to focus on prevention and prompt management. New onset atrial fibrillation is treated with rhythm control for patients who demonstrate hemodynamic instability or refractory to rate control measures. Electrical cardioversion is an effective option for unstable patients with known complications. However, there is limited data on orthopedic problems after cardioversion. A unique case is reported presenting postoperative total hip arthroplasty (THA) dislocation after electrical cardioversion for new onset atrial fibrillation in the postanesthesia care unit (PACU).

 

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Cost Analysis of Sending Routine Pathology Specimens following Total Joint Arthroplasty in the Age of Bundled Payments
Hayden S. Holbrook, BS, Department of Orthopaedic Surgery, Medical Student, Wake Forest School of Medicine, Winston-Salem, North Carolina, Johannes F. Plate, MD, PhD, Resident, Physician Scientist, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, Maxwell K. Langfitt, MD, Assistant Professor, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, Jason E. Lang, MD, Orthopaedic Surgeon, Blue Ridge Bone & Joint, Asheville, North Carolina, John S. Shields, MD, Assistant Professor, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina

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Bundled payment plans are being developed as a means to curb healthcare spending. Routine histology following total hip arthroplasties (THA) and total knee arthroplasties (TKA) is standard practice at many institutions. Recently, the value of this practice has been questioned as histologic diagnoses in THA and TKA rarely differ from the clinical diagnoses. The goal of this study is to identify discrepant and discordant diagnoses following THA and TKA at an academic medical center and to calculate the cost-saving potential in the setting of a bundled payment plan. A retrospective chart review was conducted on 1,213 primary THA and TKA performed by two orthopaedic surgeons from 2012 to 2014. The clinical and histologic diagnoses were compared and classified as concordant, discrepant, or discordant. Cost information was obtained from the institutional billing office. One thousand one hundred and sixty-six THA and TKA were analyzed in the final cohort. Nineteen (1.6%) diagnoses were classified as discrepant while none were discordant. The cost of histologic examination per specimen was estimated to be $48.56. The total cost of all arthroplasties was $14,999,512.46, of which histologic examination made up 0.31% of the total cost. The results of this study corroborate the results of previous studies and support the proposition that routine histologic examination is not cost-effective. The cost incurred to perform histologic examination will become a cost deduction from future bundled payments. The practice of sending routine histologic specimens following TJA should be decided upon by the operating orthopaedic surgeon.

 

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Use of an App-Controlled Neuromuscular Electrical Stimulation System for Improved Self-Management of Knee Conditions and Reduced Costs
Morad Chughtai, MD, Resident, PGY-1, Nicholas Piuzzi, MD, Orthopedic Regenerative Medicine and Cellular Therapy Clinical Scholar, George Yakubek, DO, Research Fellow, Anton Khlopas, MD, Research Fellow, Nipun Sodhi, BA, Research Fellow, Assem A. Sultan, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Salahuddin Nasir, BS, Medical Student, American University of Antigua, College of Medicine, Coolidge, Antigua, Benjamin S.T. Yates, BA, Medical Student, American University of Antigua, College of Medicine, Coolidge, Antigua, Anil Bhave, MS, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Patients suffering from quadriceps muscle weakness secondary to osteoarthritis or after surgeries, such as total knee arthroplasty, appear to benefit from the use of neuromuscular electrical stimulation (NMES), which can improve muscle strength and function, range of motion, exercise capacity, and quality of life. Several modalities exist that deliver this therapy. However, with the ever-increasing demand to improve clinical efficiency and costs, digitalize healthcare, optimize data collection, improve care coordination, and increase patient compliance and engagement, newer devices incorporating technologies that facilitate these demands are emerging. One of these devices, an app-controlled home-based NMES therapy system that allows patients to self-manage their condition and potentially increase adherence to the treatment, incorporates a smartphone-based application which allows a cloud-based portal that feeds real-time patient monitoring to physicians, allowing patients to be supported remotely and given feedback. This device is a step forward in improving both patient care and physician efficiency, as well as decreasing resource utilization, which potentially may reduce healthcare costs.

 

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Impact of Physical Activity and Body Mass Index in Cardiovascular and, Musculoskeletal Health: A Review
Morad Chughtai, MD, Resident, PGY-1, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Chukwuweike U. Gwam, MD, Research Fellow, Department of Orthopaedic Surgery, Nequesha Mohamed, MD, Research Fellow, Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland,, Anton Khlopas, MD, Research Fellow, Nipun Sodhi, BA, Research Fellow, Assem A. Sultan, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Anil Bhave, MS, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland,, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Due to an increasing elderly population coupled with a growing obesity epidemic, there has been an increased prevalence in cardiovascular and musculoskeletal diseases. This has led to an increased burden in healthcare expenditures, now estimated to be over 17.8% of gross domestic product. As a result, physical activity has been increasingly encouraged due to its potential prophylactic effects on health. Recent reports have demonstrated a relationship between physical activity and body mass index (BMI) on cardiovascular and musculoskeletal health. However, the effect of the combination of the two have not been reported. Therefore, the purpose of this review was to assess the effect of various levels of physical activity on: 1) cardiovascular disease risk; and 2) the development of musculoskeletal disease (osteoarthritis [OA]) when accounting for various levels of BMIs. A total of 143 abstracts were identified for cardiovascular health and 55 abstracts for musculoskeletal health. Upon review, 11 reports were included for final evaluation. Despite patient BMI, physical activity was associated with a decreased risk of cardiovascular events. Additionally, moderate levels of physical activity were demonstrated to be protective against the development of OA; however, the levels of physical activity necessary to be beneficial were not fully elucidated. This suggests that the prophylactic effects of physical activity were maintained despite patient BMI. Future studies are needed to explore the appropriate levels of physical activity for optimal effectiveness when stratifying by patient BMI.

 

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Quadriceps and Hamstring Muscle Strength Improves After Unicompartmental Knee Arthroplasty
Jennifer Kurowicki, MD, Research Fellow, Department of Orthopedic Surgery, Research Fellow Holy Cross Orthopedic Institute, Fort Lauderdale, Florida,, Anton Khlopas, MD, Research Fellow, Nipun Sodhi, BA, Research Fellow, Jared M. Newman, MD, Research Fellow, Assem A. Sultan, MD, Research Fellow, Morad Chughtai, MD, Resident, PGY-1, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Anil Bhave, MS, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Martin Roche, MD, Chief of Orthopaedics, Department of Orthopedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida, Peter M. Bonutti, MD, Attending Physician, Department of Orthopaedic Surgery, Bonutti Clinic, Effingham, Illinois, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

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Introduction: The ability to reach functional capacity following knee arthroplasty depends on the strength of the quadriceps and hamstring muscles. Following total knee arthroplasty, weakness of these muscles can persist for up to one year postoperatively; however, this phenomenon is not well-studied in unicompartmental knee arthroplasty (UKA) patients. Therefore, we assessed: 1) quadriceps muscle strength; 2) hamstring muscle strength; and 3) correlation to functional outcomes. Materials and Methods: A review of all patients with medial compartment osteoarthritis treated with UKA at a minimum of one-year follow-up was performed. This yielded 26 patients (32 knees), comprising of eight females and 18 males who had a mean age of 67 years (range, 47 to 83 years). Muscle strength was assessed pre-and postoperatively via dynamometer. Functional outcomes were assessed using Knee Society Scores (KSS). Comparisons of groups were performed by paired t-tests. Results: At a minimum one-year postoperatively, quadriceps muscle strength was 27 Nm (range, 13 to 71Nm) and hamstring muscle strength was 19.5Nm (range, 7 to 81Nm). Quadriceps muscle strength increased by 40% (p=0.002) and hamstring muscle strength by 26% (p=0.057). The mean KSS pain was 97 points (range, 85 to 100 points) and mean KSS function was 90 points (range, 45 to 100 points) at the final follow-up. Range of motion was 125° (range, 110° to 135°) at the final follow-up. The Pearson Correlation Coefficient for postoperative extension strength and postoperative flexion strength to postoperative KSS functional scores were 0.268 and 0.220 respectively. Conclusion: Within one-year following UKA, patients can expect restoration of quadriceps and hamstring muscle strength with a corresponding functional improvement. Although long-term follow-up is warranted to determine sustainability, the short-term results demonstrate excellent restoration of function.

 

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